Stroke is still a neglected disease in Brazil

Quality of life: predictors and outcomes after stroke in a Brazilian public hospital

BACKGROUND

Some scales are applied after stroke to measure functional independence but qualify of life (QoL) is sometimes neglected in this scenario.

OBJECTIVE

To analyze predictors and outcomes of QoL after stroke using a validated scale in our population.

METHODS

Our study included patients who had their first ischemic stroke and were followed in the outpatient clinic for at least 6 months from stroke index. Disability status was assessed using the modified Rankin scale (mRS), the Barthel index (BI), and the Lawton and Brody scale. Quality of life was assessed by a stroke-specific QoL (SSQoL) scale. Statistical significance was accepted for p < 0.05. The estimated measure of association was the odds ratio (OR) for which 95% confidence intervals (95%Cis) were presented.

RESULTS

Of 196 patients studied, the median age was 60.4 (±13.4) years, and 89 (45.40%) of the patients were female. In a stepwise model considering risk factors, basic activities of daily living scales, satisfaction with life, and outcomes, we found four independent variables related to a poor QoL after stroke, namely hypertension, non-regular rehabilitation, not returning to work, and medical complications. The National Institutes of Health stroke scale (NIHSS) score at admission ≥ 9 was also an independent clinical marker. Approximately 30% of all participants had a negative score under 147 points in the SSQoL.

CONCLUSIONS

Our results showed that QoL after stroke in a developing country did not seem to differ from those of other countries, although there is a gap in rehabilitation programs in our public system. The functional scales are important tools, but they have failed to predict QoL, in some patients, when compared with specific scales.

Health care professionals' perceptions about atrial fibrillation care in the Brazilian public primary care system: a mixed-methods study

BACKGROUND

Atrial fibrillation (AF) negatively impacts health systems worldwide. We aimed to capture perceptions of and barriers and facilitators for AF care in Brazilian primary care units (PCUs) from the perspective of healthcare professionals (HCPs).

METHODS

This mixed-methods, cross-sectional study utilised an exploratory sequential design, beginning with the quantitative data collection (up to 18 closed questions) immediately followed by a semi-structured interview. HCPs were recruited from 11 PCUs in the Sao Paulo region and included managers, physicians, pharmacists, nurses and community health agents. Descriptive statistics were used to present findings from the quantitative questionnaire and inductive analysis was used to identify themes from the qualitative data.

RESULTS

One hundred seven HCPs were interviewed between September 2019 and May 2020. Three main themes were identified that encapsulated barriers and facilitators to AF care: access to care (appointments, equipment/tests and medication), HCP and patient roles (HCP/patient relationship and patient adherence) and the role of the organisation/system (infrastructure, training and protocols/guidelines). Findings from the qualitative analysis reinforced the quantitative findings, including a lack of AF-specific training for HCPs, protocols/guidelines on AF management, INR tests in the PCUs, patient knowledge of AF management and novel oral anticoagulants (NOACs) as key barriers to optimal AF care.

CONCLUSIONS

Development and implementation of AF-specific training for PCU HCPs are needed in Brazil, along with evidence-based protocols and guidelines, educational programmes for patients, better access to INR tests for patients taking warfarin and availability of NOACs.

Atrial Fibrillation Diagnosis using ECG Records and Self-Report in the Community: Cross-Sectional Analysis from ELSA-Brasil

BACKGROUND

Atrial fibrillation or flutter (AFF) is the most common sustained cardiac arrhythmia. Limited data can be found on AFF epidemiology in South America.

OBJECTIVE

The present study sought to describe the clinical epidemiology of AFF and the use of stroke prevention medication in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline assessment.

METHODS

This study analyzed data from 13,260 ELSA-Brasil participants. AFF was defined according to ECG recording or by self-report. Logistic regression models were built to analyze factors associated with AFF. This study also analyzed if age and sex were associated with anticoagulant use for stroke prevention. Significance level was set at 5%.

RESULTS

Median age was 51 years and 7,213 (54.4%) participants were women. AFF was present in 333 (2.5%) participants. Increasing age (odds ratio [OR]:1.05; 95% confidence interval [95%CI]: 1.04-1.07), hypertension (OR:1.44; 95%CI: 1.14-1.81), coronary heart disease (OR: 5.11; 95%CI: 3.85-6.79), heart failure (OR:7.37; 95%CI: 5.00-10.87), and rheumatic fever (OR:3.38; 95%CI: 2.28-5.02) were associated with AFF. From 185 participants with AFF and a CHA2DS2-VASc score ≥2, only 20 (10.8%) used anticoagulants (50.0% among those with AFF in the baseline ECG). Stroke prevention in this group was associated with a higher age (1.8% vs 17.7% in those aged ≤ 54 and ≥ 65 years, respectively; p=0.013). A trend towards a reduced anticoagulant use was observed in women (7.1% vs. 16.4% in women and men, respectively; p=0.055).

CONCLUSIONS

At the ELSA-Brasil baseline, 2.5% of the participants had AFF. The lack of stroke prevention was common, which is an especially challenging point for healthcare in this setting.

MASPs at the crossroad between the complement and the coagulation cascades - the case for COVID-19

Components of the complement system and atypical parameters of coagulation were reported in COVID-19 patients, as well as the exacerbation of the inflammation and coagulation activity. Mannose binding lectin (MBL)- associated serine proteases (MASPs) play an important role in viral recognition and subsequent activation of the lectin pathway of the complement system and blood coagulation, connecting both processes. Genetic variants of MASP1 and MASP2 genes are further associated with different levels and functional efficiency of their encoded proteins, modulating susceptibility and severity to diseases. Our review highlights the possible role of MASPs in SARS-COV-2 binding and activation of the lectin pathway and blood coagulation cascades, as well as their associations with comorbidities of COVID-19. MASP-1 and/or MASP-2 present an increased expression in patients with COVID-19 risk factors: diabetes, arterial hypertension and cardiovascular disease, chronic kidney disease, chronic obstructive pulmonary disease, and cerebrovascular disease. Based also on the positive results of COVID-19 patients with anti-MASP-2 antibody, we propose the use of MASPs as a possible biomarker of the progression of COVID-19 and the investigation of new treatment strategies taking into consideration the dual role of MASPs, including MASP inhibitors as promising therapeutic targets against COVID-19.

Popular knowledge of stroke in São Paulo: a cross-sectional study within the World Stroke Campaign

BACKGROUND

Stroke is the second leading cause of death in Brazil and the main cause of disability. Inability to identify alarm signals causes delays in seeking emergency services, thereby leading to a worse prognosis.

OBJECTIVES

To assess the population's knowledge of how to recognize and prevent stroke.

DESIGN AND SETTING

Prospective cross-sectional study on data derived from a questionnaire that was administered during the 2016 World Stroke Campaign, launched in the city of São Paulo, Brazil.

METHODS

Data on 806 interviewees were evaluated using descriptive statistics and univariate and multivariate analyses.

RESULTS

Among all the interviewees, 52.1% knew how to conceptualize stroke; 70.07% knew someone who had suffered a stroke; and 29.03% listed three or more risk factors. Only 27.5% mentioned controlling high blood pressure as a preventive measure. In the event of witnessing a stroke, 57.8% would call the emergency service and 2.9% would check the timing. Less educated individuals were 5.6 times more likely (95% confidence interval, CI 3.45-9.02) to have poor knowledge of stroke, compared with the more educated group. Knowing someone who had had a stroke reduced the chances of not knowing the terms relating to the disease (odds ratio, OR = 0.56; 95% CI 0.4-0.78).

CONCLUSIONS

Despite the severity and prevalence of stroke, the population still has little information on this disease. In this context, the importance of mounting campaigns to improve prevention and treatment and to contribute to healthcare policies becomes evident.

Translation and Validation of the TOR-BSST© into Brazilian Portuguese for Adults with Stroke

Brazil has a higher rate of dysphagia in stroke patients compared to developed countries, but does not have a fully validated method for early identification of dysphagia in this population. The aim of this study is to translate the TOR-BSST^© into Brazilian Portuguese and assess the newly translated version for reliability and validity with Brazilian adult patients with stroke. The translation of the TOR-BSST^© followed a multi-step process, according to the International Quality of Life Assessment project. For validation, we included patients with age ≥ 18 years and stroke diagnosis confirmed by neuroimaging and tolerance for videofluoroscopic swallowing assessment. The BR-PT_final TOR-BSST^© was administered by two trained screeners within two hours of videofluoroscopy. All assessors were independent and blinded. Estimates for reliability used the intraclass correlation coefficient (ICC) and for accuracy both sensitivity (SN) and negative predictive (NP) values were used, along with 95% confidence intervals (CI). Sixty patients were enrolled and tested for a mean (SD) of 14.4 (6.9) days from last seen normal. Of all the patients, 41 (68.3%) failed the BR-PT_final TOR-BSST^© and 21 (35%) were scored to have dysphagia on videofluoroscopy, of which 11 (52.4%) had mild dysphagia. The overall reliability between screeners was satisfactory (ICC = 0.59; 95% CI 0.32 to 0.76). The SN and NP values for the BR-PT_final TOR-BSST^© were 85.7% (95% CI 0.62-0.96) and 84.2% (95% CI 0.72-0.95), respectively. The TOR-BSST^© was successfully translated to Brazilian Portuguese with the BR-PT_final TOR-BSST^© proven to have high sensitivity and negative predictive values when compared to gold standard videofluoroscopy.

The impact of acute kidney injury on fatality of ischemic stroke from a hospital-based population in Joinville, Brazil

Introduction:

The occurrence of acute kidney injury (AKI) after ischemic stroke has been associated to a worse prognosis. There is a lack of Brazilian studies evaluating this issue. This study aimed to describe the impact of AKI after a first-ever ischemic stroke in relation to fatality rate in 30 days.

Methods:

This was a retrospective hospital-based cohort. We included patients who had their first ischemic stroke between January to December 2015. AKI was defined by an increase of serum creatinine in relation to baseline value at admission ≥ 0.3 mg/dL or a rise in serum creatinine level by 1.5 times the baseline value at any point in the first week after admission. We performed a univariate and multivariate analysis to evaluate the presence of AKI with fatality in 30 days.

Results:

The final study population (n=214) had mean age of 66.46 ± 13.73 years, 48.1% were men, the mean NIHSS was 6.33 ± 6.27 and 20 (9.3%) presented AKI. Patients with AKI were older, had a higher score on the NIHSS, and had higher creatinine values on hospital discharge. The 30-day mortality was higher in the AKI subgroup compared to non-AKI (35% vs. 6.2%, p < 0.001). AKI was an independent predictor of fatality after an ischemic stroke but limited by severity of stroke (NIHSS).

Conclusion:

The presence of AKI is an important complication after ischemic stroke. Despite its impact on 30-day fatality, the predictive strength of AKI was limited by the severity of stroke.

Hospitalization of the aged due to stroke: An ecological perspective

Contextual variables have been associated with the incidence of stroke, but their association with hospitalization of older persons remains unclear. This study evaluated the association between social context variables and hospitalization of 60 years old and older patients due to stroke in Rio de Janeiro, Brazil. An ecological cross-sectional study was conducted, with secondary data from the Brazilian Hospital Information System from 2006 to 2014. Hospitalization rates were calculated and categorized by tertiles. For subsequent analyzes, the polar extremes method was used to select the groups with extremes values. After that, Student t or Mann-Whitney tests were used to compare the contextual variables and the hospitalization rates clusters. Then, a Binary Logistic Regression analysis was used to assess the association between hospitalization rates clusters and the contextual variables. The total number of hospitalizations was 82 796; the hospitalization rate varied in extremes groups from the lowest (3.49) to the highest (11.95) (p<0.001). The highest rates group was positively associated with the proportion of elderly (p<0.001), the illiteracy rate of the aged (p = 0.01), primary care coverage (p<0.001) and ambulatory care for hypertension and diabetes, while the income ratio showed negative association with the highest rates of hospitalization (p = 0.01). In the multivariate analysis, only the proportion of elderly (OR = 1.55; 95%CI 1.07–2.25), primary care coverage (OR = 1.05; 95%CI 1.01–1.11) and income ratio (OR = 0.82; 95%CI 0.67–0.99) maintained the association. In conclusion, contextual variables in the three dimensions studied were associated with the rate of hospitalization of aged due to stroke in the municipalities in Rio de Janeiro State. Transitional care and other improvements in both the health care and social services are demanded.

Dysphagia and Associated Pneumonia in Stroke Patients from Brazil: A Systematic Review

Dysphagia and its associated complications are expected to be relatively more frequent in stroke patients in Brazil than in similar patients treated in developed countries due to the suboptimal stroke care in many Brazilians medical services. However, there is no estimate of dysphagia and pneumonia incidence for the overall stroke population in Brazil. We conducted a systematic review of the recent literature to address this knowledge gap, first screening citations for relevance and then rating full articles of accepted citations. At both levels, judgements were made by two independent raters according to a priori criteria. Fourteen accepted articles underwent critical appraisal and data extraction. The frequency of dysphagia in stroke patients was high (59% to 76%). Few studies assessed pneumonia and only one study stratified patients by both dysphagia and pneumonia, with an increased Relative Risk for pneumonia in patients with stroke and dysphagia of 8.4 (95% CI 2.1, 34.4). Across all articles, we identified bias related to: heterogeneity in number and type of stroke; no rater blinding; and, assessments that were not reproducible, reliable or validated. Despite the high frequency of dysphagia and associated pneumonia in stroke patients in Brazil, the quality of the available literature is low and that there is little research focused on these epidemiologic data. Future rigorously designed studies are in dire need to accurately determine dysphagia incidence and its impact on stroke patients in Brazil. These data will be critical to properly allocate limited national resources that maximize the quality of stroke care.

Public hospitalizations for stroke in Brazil from 2009 to 2016

Background

Stroke is the third major cause of death in the world and the second in Brazil. The purpose of this work was to assess the stroke-related hospitalization, in-hospital mortality, and case fatality rates under the Brazilian Unified Health System (SUS) from 2009 to 2016.

Methods

We evaluated the hospital admissions for stroke and their associated outcomes using data from the Hospital Information available at the Informatics Department of SUS. We selected hospitalization registries according to stroke diagnosis codes from the International Statistical Classification of Diseases and Related Health Problems (ICD-10). We identified the association of age and sex with patient death through multiple logistic regression and calculated the rates of hospitalization, mortality and case-fatality per 100,000 inhabitants using age-adjustment methodology.

Results

We analyzed 1,113,599 stroke hospitalizations. From 2009 to 2016, the number of admissions increased from 131,122 to 146,950 and the absolute number of in-hospital deaths increased from 28,731 to 31,937. Younger age and male sex were significantly associated with patient survival. Our results showed that the annual age-adjusted hospitalization and in-hospital mortality rates decreased by 11.8% and 12.6%, respectively, but the case fatality rate increased for patients older than 70 years.

Conclusions

Although the age-adjusted hospitalization and in-hospital mortality rates declined, the total number of hospitalization and deaths have increased. It is expected a continuous increase over the next years of stroke admissions with the rapid aging of the Brazilian population. Efforts should be renewed targeting risk factors, access to hospital and rehabilitation in particular for the elderly population.

[Interventions for stroke survivor caregivers: a systematic reviewIntervenciones para los cuidadores de los sobrevivientes de un accidente cerebrovascular: revisión sistemática]

OBJECTIVE

To synthesize and critically review the literature on interventions aimed at decreasing the burden of stroke survivor caregivers and other associated factors.

METHOD

The literature search for the present systematic review was performed in PubMed, SciELO, Coordination for the Improvement of Higher Education Personnel (CAPES) website, and the Virtual Health Library using the following search terms: Stroke AND Caregivers AND Intervention; and Stroke AND Caregivers AND clinical trial. Eight randomized controlled clinical trials (RCT) published between 2008 and 2017 were selected.

RESULTS

The selected studies were performed in Sweden, Taiwan, Germany, China, India, and the United States. Psychoeducational, support, and skill acquisition interventions produced positive results for caregivers - in the psychological, physical, and social domains, in the quality of the care provided, and in the acquisition of knowledge by caregivers - and for stroke survivors - for example, decreased use of health care services and improved capacity for self-care. The critical evaluation of the studies showed that none met all the methodological requirements for RCTs. The main limitations were missing data and the heterogeneity of interventions.

CONCLUSION

The interventions had positive results for caregivers and survivors. However, future studies should consider long term assessments of the outcomes, with detailed description of the baseline needs that guided the study and the sharing of the support materials used to allow the intervention to be reproduced.

Stroke at baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): a cross-sectional analysis

BACKGROUND

Secondary prevention of stroke is a very important goal for achieving continuous reduction in stroke mortality rates over the next decades.

DESIGN AND SETTING

Cross-sectional analysis on the Brazilian Longitudinal Study of Adult Health -(ELSA-Brasil), with data from Salvador, Vitória, Belo Horizonte, Rio de Janeiro, São Paulo and Porto Alegre.

METHODS

This descriptive analysis focused on secondary prevention of stroke among participants who self-reported a medical diagnosis of stroke at the baseline of ELSA-Brasil, and its association with sociodemographic characteristics.

RESULTS

Overall, 197 participants (1.3%) reported a prior medical history of stroke. Participants with stroke were older and less educated and had lower mean monthly family income, compared with non-stroke participants. Among all stroke cases, 23.7% did not use any medication for secondary prevention of stroke. Use of secondary prevention was higher among men than among women (respectively, 59.6% versus 40.4%; P = 0.02 for aspirin; and 71.4% versus 28.6%; P = 0.04 for other antiplatelet drugs). Having private health insurance was associated with greater use of less cost-effective and more expensive medications (like angiotensinogen receptor blockers) and a tendency to use antiplatelet drugs other than aspirin, among participants reporting stroke, compared with others. Use of medication decreased as time passed after suffering a stroke.

CONCLUSIONS

In this sample of individuals with better access to healthcare services, use of secondary prevention for stroke was low, which may suggest that the situation in the general population is worse. Sex was the most important sociodemographic variable associated with low use of secondary prevention.

Cerebrovascular disease in Brazil from 1990 to 2015: Global Burden of Disease 2015

Objective:

To verify the time trends of mortality rates, years of lost life (YLL), and years lived with disability (YLD) caused by cerebrovascular disease in Brazil between 1990 and 2015.

Methods:

The estimates from the Global Burden of Diseases 2015 were used to analyze the magnitude and trends of mortality rates and disability-adjusted life years (DALY) for cerebrovascular disease (ICD-10: I-60-69) in the 27 units of the Federation between 1990 and 2015. The states were analyzed by the social development index (SDI), based on average income per person, educational attainment at 15 years- old and total fertility rate.

Results:

Despite the increase in the absolute number of deaths due to cerebrovascular disease, the proportion of deaths below 70 years of age has been halved between 1990 and 2015. The acceleration of the reduction was higher among women; and increased from 1990 to 2005, when compared to the period from 2005 to 2015. The risk of death has been halved across the country, but states in the lower SDI tertile had less significant reductions (-1.23 and -1.84% a year) compared to the middle tertile (-1.94 and - 2.22%) and the upper tertile (-2.85 and -2.82%) for men and women, respectively. The years lived with disability also presented a reduction among states, but less expressively.

Conclusion:

Despite the reduction of age-adjusted mortality rates throughout the country, cerebrovascular disease still presents a high disease burden, especially in states with lower socioeconomic development.

Hypertension in Latin America: Current perspectives on trends and characteristics

The region of Latin America, which includes Central America, the Caribbean and South America, is one that is rapidly developing. Signified by socio-economic growth, transition and development over the last few decades, living standards in countries like Brazil and Mexico have improved dramatically, including improvements in education and health care. An important marker of socio-economic change has been the epidemiological shift in disease burden. Cardiovascular disease is now the leading cause of death in Latin America, and the drop in prevalence of infectious diseases has been accompanied by a rise in non-communicable diseases. Hypertension is the major risk factor driving the cardiovascular disease continuum. In this article we aim to discuss the epidemiological and management trends and patterns in hypertension that may be specific or more common to Latin-American populations - what we term 'Latin American characteristics' of hypertension - via a review of the recent literature. Recognizing that there may be a specific profile of hypertension for Latin-American patients may help to improve their treatment, with the ultimate goal to reduce their cardiovascular risk. We focus somewhat on the countries of Brazil, Mexico and Venezuela, the experience of which may reflect other Latin American countries that currently have less published data regarding epidemiology and management practices.

Popular stroke knowledge in Brazil: A multicenter survey during "World Stroke Day"

Context and objective

Cerebrovascular disease is one of the most important causes of death and disability worldwide. The patient's inability to identify the warning signs of stroke substantially delays the search for emergency services, which is related directly to a worse outcome. Thus, during the 2011 Stroke Campaign in Brazil, a survey was conducted to identify the lay population's knowledge with regard to the recognition, treatment, and prevention of stroke.

Design and setting

This retrospective, cross-sectional, multicenter study was held in cities throughout southeastern Brazil.

Methods

The campaign was conducted by students of several medical schools under the guidance of neurologists (assistants and professors). The students traveled to various public areas in Sao Paulo, Campinas, Sorocaba, Taubaté, and Pouso Alegre, where information about stroke was distributed and a specific questionnaire was administered.

Results

A total of 1304 people answered the questionnaire: 43.9% claimed to know what a stroke was, 65% knew someone who has had the disease, 35% knew > 3 risk factors for stroke, and 28.8% knew a preventive measure. Further, 17.9% was able to list at least 3 signs or symptoms of a stroke, 33.6% was aware that they should activate the emergency service, and 3.1% would have checked the time at which the signs and symptoms had developed.

Conclusion

Despite the severity of stroke, the population that we analyzed has a low level of knowledge. Campaigns should increase the lay population's understanding of this disease, thus improving its prevention and treatment and contributing to public health politics.

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The delay on search for emergency services is related directly to a worse outcome.

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It is a priority for patients to know the warning signs of stroke.

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A survey was conducted to identify stroke knowledge in lay Brazilian population.

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The analyzed population has a low level of knowledge about stroke.

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Improve the stroke management and contributing to public health politics.

"EMMA Study: a Brazilian community-based cohort study of stroke mortality and morbidity"

CONTEXT AND OBJECTIVE:

Stroke has a high burden of disability and mortality. The aim here was to evaluate epidemiology, risk factors and prognosis for stroke in the EMMA Study (Study of Stroke Mortality and Morbidity).

DESIGN AND SETTINGS:

Prospective community-based cohort carried out in Hospital Universitário, University of São Paulo, 2006-2014.

METHODS:

Stroke data based on fatal and non-fatal events were assessed, including sociodemographic data, mortality and predictors, which were evaluated by means of logistic regression and survival analyses.

RESULTS:

Stroke subtype was better defined in the hospital setting than in the local community. In the hospital phase, around 70% were first events and the ischemic subtype. Among cerebrovascular risk factors, the frequency of alcohol intake was higher in hemorrhagic stroke (HS) than in ischemic stroke (IS) cases (35.4% versus 12.3%, P < 0.001). Low education was associated with higher risk of death, particularly after six months among IS cases (odds ratio, OR, 4.31; 95% confidence interval, CI, 1.34-13.91). The risk of death due to hemorrhagic stroke was greater than for ischemic stroke and reached its maximum 10 days after the event (OR: 3.31; 95% CI: 1.55-7.05). Four-year survival analysis on 665 cases of first stroke (82.6% ischemic and 17.4% hemorrhagic) showed an overall survival rate of 48%. At four years, the highest risks of death were in relation to ischemic stroke and illiteracy (hazard ratio, HR: 1.83; 95% CI: 1.26-2.68) and diabetes (HR: 1.45; 95% CI: 1.07-1.97). Major depression presented worse one-year survival (HR: 4.60; 95% CI: 1.36-15.55).

CONCLUSION:

Over the long term, the EMMA database will provide additional information for planning resources destined for the public healthcare system.