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Lim MJR, Zheng H, Zhang Z, Sia CH, Tan BYQ, Hock Ong ME, Nga VDW, Yeo TT, Ho AFW. Trends in hemorrhagic stroke incidence and mortality in a National Stroke Registry of a multi-ethnic Asian population. Eur Stroke J 2024; 9:189-199. [PMID: 37776052 PMCID: PMC10916808 DOI: 10.1177/23969873231202392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023] Open
Abstract
INTRODUCTION High-quality epidemiological data on hemorrhagic stroke (HS) and its subtypes, intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), remains limited in Asian ethnicities. We investigated the trends in HS incidence and 30-day mortality from 2005 to 2019 in a multi-ethnic Asian population from a national registry. PATIENTS AND METHODS Data on all stroke cases from the Singapore Stroke Registry from 2005 to 2019 were collected. Cases were defined using centrally adjudicated review of diagnosis codes. Death outcomes were obtained by linkage with the national death registry. Incidence (per 100,000 people) and 30-day mortality (per 100 people) were measured as crude and age-standardized rates. Trends were analyzed using linear regression. RESULTS We analyzed 19,017 cases of HS (83.9% ICH; 16.1% SAH). From 2005 to 2019, age-standardized incidence rates (ASIR) for HS remained stable from 34.4 to 34.5. However, age-standardized mortality rates (ASMR) decreased significantly from 29.5 to 21.4 (p < 0.001). For ICH, ASIR remained stable while ASMR decreased from 30.4 to 21.3 (p < 0.001); for SAH, ASIR increased from 2.7 to 6.0 (p = 0.006) while ASMR remained stable. In subgroup analyses, HS incidence increased significantly in persons <65 years (from 18.1 to 19.6) and Malays (from 39.5 to 49.7). DISCUSSION From 2005 to 2019, ASIR of HS remained stable while ASMR decreased. Decreasing ASMR reflects improvements in the overall management of HS, consistent with global trends. CONCLUSION Population health efforts to address modifiable risk factors for HS in specific demographic subgroups may be warranted to reduce incidence and mortality of HS.
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Affiliation(s)
| | - Huili Zheng
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - Zheting Zhang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ching Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Yong-Qiang Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, National University Hospital, Singapore
| | | | | | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Hospital, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
- Centre for Population Health Research and Implementation, SingHealth Regional Health System, Singapore
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Ho AFW, Tan BYQ, Zheng H, Leow AST, Pek PP, Liu N, Raju Y, Yeo LLL, Sharma VK, Ong MEH, Aik J. Association of air pollution with acute ischemic stroke risk in Singapore: a time-stratified case-crossover study. Int J Stroke 2022; 17:983-989. [DOI: 10.1177/17474930211066745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Air quality is an important determinant of cardiovascular health such as ischemic heart disease and acute ischemic stroke (AIS) with substantial mortality and morbidity reported across the globe. However, associations between air quality and AIS in the current literature remain inconsistent, with few studies undertaken in cosmopolitan cities located in the tropics. Objectives: We evaluated the associations between individual ambient air pollutants and AIS. Methods: We performed a nationwide, population-based, time-stratified case-crossover analysis on all AIS cases reported to the Singapore Stroke Registry from 2009 to 2018. We estimated the incidence rate ratio (IRR) of AIS across different concentrations of each pollutant by quartiles (referencing the 25th percentile), in single-pollutant conditional Poisson models adjusted for time-varying meteorological effects. We stratified our analysis by predetermined subgroups deemed at higher risk. Results: A total of 51,675 episodes of AIS were included. Ozone (O3) (IRR4th quartile: 1.05, 95% confidence interval (CI): 1.01–1.08) and carbon monoxide (CO) (IRR2nd quartile: 1.05, 95% CI: 1.02–1.08, IRR3rd quartile: 1.07, 95% CI: 1.04–1.10, IRR4th quartile: 1.07, 95% CI: 1.04–1.11) were positively associated with AIS incidence. The increased incidence of AIS due to O3 and CO persisted for 5 days after exposure. Those under 65 years of age were more likely to experience AIS when exposed to CO. Individuals with atrial fibrillation (AF) were more susceptible to exposure from O3, CO, and PM10. Current/ex-smokers were more vulnerable to the effect of O3. Conclusion: Air pollution increases the incidence of AIS, especially in those with AF and in those who are current or ex-smokers.
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Affiliation(s)
- Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital & Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | | | - Huili Zheng
- National Registry of Diseases Office, Health Promotion Board, Singapore
| | | | - Pin Pin Pek
- Pre-hospital & Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Nan Liu
- Pre-hospital & Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yogeswari Raju
- Environmental Quality Monitoring Department, Environmental Monitoring and Modelling Division, National Environment Agency, Singapore
| | - Leonard Leong-Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Marcus Eng-Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital & Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Joel Aik
- Pre-hospital & Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
- Environmental Epidemiology and Toxicology Division, National Environment Agency, Singapore
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Ho AFW, Lim MJR, Zheng H, Leow AST, Tan BYQ, Pek PP, Raju Y, Seow WJ, Yeo TT, Sharma VK, Aik J, Ong MEH. Association of ambient air pollution with risk of hemorrhagic stroke: A time-stratified case crossover analysis of the Singapore stroke registry. Int J Hyg Environ Health 2021; 240:113908. [PMID: 34974273 DOI: 10.1016/j.ijheh.2021.113908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/06/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Haemorrhagic stroke (HS) is a major cause of mortality and disability. Previous studies reported inconsistent associations between ambient air pollutants and HS risk. OBJECTIVE We evaluated the association between air pollutant exposure and the risk of HS in a cosmopolitan city in the tropics. METHODS We performed a nationwide, population-based, time-stratified case-crossover analysis on all HS cases reported to the Singapore Stroke Registry from 2009 to 2018 (n = 12,636). We estimated the risk of HS across tertiles of air pollutant concentrations in conditional Poisson models, adjusting for meteorological confounders. We stratified our analysis by age, atrial fibrillation and smoking status, and investigated the lagged effects of each pollutant on the risk of HS up to 5 days. RESULTS All 12,636 episodes of HS were included. The median (1st-to 3rd-quartile) daily pollutant levels from 22 remote stations deployed across the island were as follows: (PM2.5 = 15.9 (12.7-20.5), PM10 = 27.3 (22.7-33.4), O3 = 22.5 (17.3-29.8), NO2 = 23.3 (18.8-28.4), SO2 = 10.2 (5.6-14.4), CO = 0.5 (0.5-0.6). The median (1st-to 3rd-quartile) temperature (°C) was 27.9 (27.1-28.7), that of relative humidity (%) was 79.4 (75.6-83.2), and that of total rainfall (mm) was 0.0 (0.0-4.2). Higher levels of CO were significantly associated with an increased risk of HS (3rd tertile vs 1st tertile: Incidence Rate Ratio (IRR) = 1.06, 95% CI = 1.01-1.12). The increased risk of HS due to CO persisted for at least 5 days after exposure. Individuals under 65 years old and non-smokers had a higher risk of HS when exposed to CO. O3 was associated with increased risk of HS up to 5 days (3rd tertile vs 1st tertile: IRRday 1 = 1.07, 95% CI = 1.02-1.12; IRRday 5 = 1.07, 95% CI = 1.02-1.13). CONCLUSION Short-term exposure to ambient CO levels was associated with an increased risk of HS. A reduction in CO emissions may reduce the burden of HS in the population.
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Affiliation(s)
- Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore.
| | - Mervyn Jun Rui Lim
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Huili Zheng
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | | | | | - Pin Pin Pek
- Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yogeswari Raju
- Environmental Quality Monitoring Department, Environmental Monitoring and Modelling Division, National Environment Agency, Singapore
| | - Wei-Jie Seow
- National Registry of Diseases Office, Health Promotion Board, Singapore; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joel Aik
- Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore; Environmental Epidemiology and Toxicology Division, National Environment Agency, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Atashzar SF, Carriere J, Tavakoli M. Review: How Can Intelligent Robots and Smart Mechatronic Modules Facilitate Remote Assessment, Assistance, and Rehabilitation for Isolated Adults With Neuro-Musculoskeletal Conditions? Front Robot AI 2021; 8:610529. [PMID: 33912593 PMCID: PMC8072151 DOI: 10.3389/frobt.2021.610529] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Worldwide, at the time this article was written, there are over 127 million cases of patients with a confirmed link to COVID-19 and about 2.78 million deaths reported. With limited access to vaccine or strong antiviral treatment for the novel coronavirus, actions in terms of prevention and containment of the virus transmission rely mostly on social distancing among susceptible and high-risk populations. Aside from the direct challenges posed by the novel coronavirus pandemic, there are serious and growing secondary consequences caused by the physical distancing and isolation guidelines, among vulnerable populations. Moreover, the healthcare system's resources and capacity have been focused on addressing the COVID-19 pandemic, causing less urgent care, such as physical neurorehabilitation and assessment, to be paused, canceled, or delayed. Overall, this has left elderly adults, in particular those with neuromusculoskeletal (NMSK) conditions, without the required service support. However, in many cases, such as stroke, the available time window of recovery through rehabilitation is limited since neural plasticity decays quickly with time. Given that future waves of the outbreak are expected in the coming months worldwide, it is important to discuss the possibility of using available technologies to address this issue, as societies have a duty to protect the most vulnerable populations. In this perspective review article, we argue that intelligent robotics and wearable technologies can help with remote delivery of assessment, assistance, and rehabilitation services while physical distancing and isolation measures are in place to curtail the spread of the virus. By supporting patients and medical professionals during this pandemic, robots, and smart digital mechatronic systems can reduce the non-COVID-19 burden on healthcare systems. Digital health and cloud telehealth solutions that can complement remote delivery of assessment and physical rehabilitation services will be the subject of discussion in this article due to their potential in enabling more effective and safer NMSDK rehabilitation, assistance, and assessment service delivery. This article will hopefully lead to an interdisciplinary dialogue between the medical and engineering sectors, stake holders, and policy makers for a better delivery of care for those with NMSK conditions during a global health crisis including future pandemics.
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Affiliation(s)
- S. Farokh Atashzar
- Department of Electrical and Computer Engineering, Department of Mechanical and Aerospace Engineering, New York University, New York, NY, United States
| | - Jay Carriere
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, AB, Canada
| | - Mahdi Tavakoli
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, AB, Canada
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5
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Cadilhac DA, Kim J, Tod EK, Morrison JL, Breen SJ, Jaques K, Grimley R, Jones B, Cloud GC, Kleinig T, Hillier S, Castley H, Lindley RI, Lannin NA, Middleton S, Yan B, Hill K, Clissold BB, Mitchell PJ, Anderson CS, Faux SG, Campbell BCV. COVID-19 Pandemic Impact on Care for Stroke in Australia: Emerging Evidence From the Australian Stroke Clinical Registry. Front Neurol 2021; 12:621495. [PMID: 33716925 PMCID: PMC7952624 DOI: 10.3389/fneur.2021.621495] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/04/2021] [Indexed: 01/01/2023] Open
Abstract
We present information on acute stroke care for the first wave of the COVID-19 pandemic in Australia using data from the Australian Stroke Clinical Registry (AuSCR). The first case of COVID-19 in Australia was recorded in late January 2020 and national restrictions to control the virus commenced in March. To account for seasonal effects of stroke admissions, patient-level data from the registry from January to June 2020 were compared to the same period in 2019 (historical-control) from 61 public hospitals. We compared periods using descriptive statistics and performed interrupted time series analyses. Perceptions of stroke clinicians were obtained from 53/72 (74%) hospitals participating in the AuSCR (80% nurses) via a voluntary, electronic feedback survey. Survey data were summarized to provide contextual information for the registry-based analysis. Data from the registry covered locations that had 91% of Australian COVID-19 cases to the end of June 2020. For the historical-control period, 9,308 episodes of care were compared with the pandemic period (8,992 episodes). Patient characteristics were similar for each cohort (median age: 75 years; 56% male; ischemic stroke 69%). Treatment in stroke units decreased progressively during the pandemic period (control: 76% pandemic: 70%, p < 0.001). Clinical staff reported fewer resources available for stroke including 10% reporting reduced stroke unit beds. Several time-based metrics were unchanged whereas door-to-needle times were longer during the peak pandemic period (March-April, 2020; 82 min, control: 74 min, p = 0.012). Our data emphasize the need to maintain appropriate acute stroke care during times of national emergency such as pandemic management.
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Affiliation(s)
- Dominique A Cadilhac
- Stroke and Ageing Research School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Joosup Kim
- Stroke and Ageing Research School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Emma K Tod
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Julie L Morrison
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Sibilah J Breen
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Katherine Jaques
- Statewide Stroke Clinical Network, Healthcare Improvement Unit, Clinical Excellence, Queensland Health, Brisbane, QLD, Australia
| | - Rohan Grimley
- Stroke and Ageing Research School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Statewide Stroke Clinical Network, Healthcare Improvement Unit, Clinical Excellence, Queensland Health, Brisbane, QLD, Australia
| | | | - Geoffrey C Cloud
- Department of Neuroscience, Central Clinical School, Monash University, Clayton, VIC, Australia.,Alfred Health, Prahran, VIC, Australia
| | | | - Susan Hillier
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | | | - Richard I Lindley
- Westmead Clinical School, University of Sydney, Darlington, NSW, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Clayton, VIC, Australia.,Alfred Health, Prahran, VIC, Australia
| | - Sandy Middleton
- Nursing Research Institute, Australian Catholic University, Sydney, NSW, Australia.,St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Bernard Yan
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Kelvin Hill
- Stroke Foundation, Melbourne, VIC, Australia
| | - Benjamin B Clissold
- Stroke and Ageing Research School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Monash Health, Clayton, VIC, Australia
| | - Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Craig S Anderson
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,The George Institute for Global Health, Camperdown, NSW, Australia
| | - Steven G Faux
- St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,University of New South Wales, Kensington, NSW, Australia
| | - Bruce C V Campbell
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.,Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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Wu Y, Chen F, Wang Z, Feng W, Liu Y, Wang Y, Song H. Reductions in Hospital Admissions and Delays in Acute Stroke Care During the Pandemic of COVID-19. Front Neurol 2020; 11:584734. [PMID: 33250851 PMCID: PMC7674953 DOI: 10.3389/fneur.2020.584734] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/14/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Rapid and effective medical care for stroke is paramount to achieve maximal functional recovery. Because of the wide spreading of the coronavirus disease in 2019 (COVID-19), acute stroke care is negatively impacted. How much acute care for stroke has been affected during the pandemic remains to be assessed. Methods: The first-level response to major public health was launched from January 24th to April 29th, 2020 in Beijing to contain the spread of COVID-19. Based on a database connecting all 77 stroke centers, the quantity and quality in emergency care for stroke during the 97 lockdown days were compared with the equivalent period in 2019. During the pandemic, 15 of the 77 stroke centers were designated to receive patients sick with COVID-19. Subgroup analyses were carried out by different types of hospitals (designated and undesignated). Results: There were 1,281 and 2,354 stroke emergency hospital admissions in the lockdown period and the parallel period in 2019, respectively. A reduction of 45.6% in admission was shown in the lockdown period, with more reductions for hemorrhagic stroke (69.0%) compared with ischemic stroke (42.9%). More reductions happened in COVID-19 designated hospitals (52.6%) compared with undesignated hospitals (41.8%). The mean NIHSS score at hospital arrival was significantly higher in the lockdown period (9.4 ± 7.7 in 2020 vs. 8.4 ± 7.8 in 2019, P < 0.001). For the metrics measuring the quality of acute stroke care, the onset to door (OTD), onset to needle (ONT), and onset to recanalization (OTR) times didn't change significantly, while significant delays are shown for the door to CT scan (DTC, 1 min delay), door to needle (DTN, 4 min delays), and door to puncture (DTP, 29 min delays) times, which mainly happened in COVID-19 undesignated hospitals. Conclusions: Profound reductions in stroke hospital admissions and significant delays in emergency care for acute ischemic stroke occurred during the pandemic of COVID-19. Engagement and effective communication with all stakeholders including patients, health care providers, governmental policymakers, and other implementation partners are required for future success in similar crises.
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Affiliation(s)
- Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Fei Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zijing Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Ying Liu
- Beijing Municipal Health Commission, Beijing, China
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Stroke Quality Control Center, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Stroke Quality Control Center, Beijing, China
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