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Wang JJ, Katz JM, Sanmartin MX, Sinvani LD, Naidich JJ, Rula EY, Sanelli PC. Association between Heat Vulnerability Index and Stroke Severity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:1099. [PMID: 39200708 PMCID: PMC11354810 DOI: 10.3390/ijerph21081099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 08/07/2024] [Accepted: 08/16/2024] [Indexed: 09/02/2024]
Abstract
BACKGROUND Socioeconomically disadvantaged neighborhoods are particularly vulnerable to heat-related illnesses. We aim to investigate the association between the heat vulnerability index (HVI), an established neighborhood-level metric of heat-related mortality risk, and acute ischemic stroke (AIS) severity. METHODS We conducted a retrospective analysis of consecutive AIS admissions to a comprehensive stroke center between 2012 and 2021. Stroke severity was defined upon admission based on the National Institutes of Health Stroke Scale (NIHSS). Demographic, socioeconomic, and clinical characteristics were extracted from electronic health records. HVI status was assigned using residential ZIP codes. Multivariable logistic regression analyses were performed. RESULTS Of 3429 AIS admissions, 1123 (32.8%) were from high-HVI (scores 4-5) neighborhoods and 868 (25.3%) had severe stroke (NIHSS score ≥ 10). In the multivariable regression model with stepwise selection, a high HVI was independently associated with severe stroke (adjusted odds ratio: 1.40 [95% confidence interval 1.16-1.69]). CONCLUSIONS The association between a high HVI and severe stroke underscores the importance of targeting policy interventions to mitigate heat-related illness in socioeconomically disadvantaged neighborhoods.
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Affiliation(s)
- Jason J. Wang
- Northwell Health, New Hyde Park, NY 11040, USA; (J.M.K.); (M.X.S.); (L.D.S.); (P.C.S.)
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
- Departments of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Jeffrey M. Katz
- Northwell Health, New Hyde Park, NY 11040, USA; (J.M.K.); (M.X.S.); (L.D.S.); (P.C.S.)
- Departments of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Departments of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Maria X. Sanmartin
- Northwell Health, New Hyde Park, NY 11040, USA; (J.M.K.); (M.X.S.); (L.D.S.); (P.C.S.)
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
- Departments of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Liron D. Sinvani
- Northwell Health, New Hyde Park, NY 11040, USA; (J.M.K.); (M.X.S.); (L.D.S.); (P.C.S.)
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
- Departments of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Jason J. Naidich
- Northwell Health, New Hyde Park, NY 11040, USA; (J.M.K.); (M.X.S.); (L.D.S.); (P.C.S.)
- Departments of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | | | - Pina C. Sanelli
- Northwell Health, New Hyde Park, NY 11040, USA; (J.M.K.); (M.X.S.); (L.D.S.); (P.C.S.)
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
- Departments of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
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Hall P, Lawrence M, Kroll T, Blake C, Matthews J, Lennon O. Reducing risk behaviours after stroke: An overview of reviews interrogating primary study data using the Theoretical Domains Framework. PLoS One 2024; 19:e0302364. [PMID: 38669261 PMCID: PMC11051587 DOI: 10.1371/journal.pone.0302364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Lifestyle changes, in addition to preventive medications, optimise stroke secondary prevention. Evidence from systematic reviews support behaviour-change interventions post-stroke to address lifestyle-related risk. However, understanding of the theory-driven mediators that affect behaviour-change post-stroke is lacking. METHODS Electronic databases MEDLINE, Embase, Epistemonikos and Cochrane Library of Systematic Reviews were searched to March 2023 for systematic reviews addressing behaviour-change after stroke. Primary studies from identified systematic reviews were interrogated for evidence supporting theoretically-grounded interventions. Data were synthesized in new meta-analyses examining behaviour-change domains of the Theoretical Domains Framework (TDF) and secondary prevention outcomes. RESULTS From 71 identified SRs, 246 primary studies were screened. Only 19 trials (N = 2530 participants) were identified that employed theoretically-grounded interventions and measured associated mediators for behaviour-change. Identified mediators mapped to 5 of 14 possible TDF domains. Trial follow-up ranged between 1-12 months and no studies addressed primary outcomes of recurrent stroke or cardiovascular mortality and/or morbidity. Lifestyle interventions targeting mediators mapped to the TDF Knowledge domain may improve the likelihood of medication adherence (OR 6.08 [2.79, 13.26], I2 = 0%); physical activity participation (OR 2.97 [1.73, 5.12], I2 = 0%) and smoking cessation (OR 10.37 [3.22, 33.39], I2 = 20%) post-stroke, supported by low certainty evidence; Lifestyle interventions targeting mediators mapping to both TDF domains of Knowledge and Beliefs about Consequences may improve medication adherence post-stroke (SMD 0.36 [0.07, 0.64], I2 = 13%, very low certainty evidence); Lifestyle interventions targeting mediators mapped to Beliefs about Capabilities and Emotions domains may modulate low mood post-stroke (SMD -0.70 [-1.28, -0.12], I2 = 81%, low certainty evidence). CONCLUSION Limited theory-based research and use of behaviour-change mediators exists within stroke secondary prevention trials. Knowledge, Beliefs about Consequences, and Emotions are the domains which positively influence risk-reducing behaviours post-stroke. Behaviour-change interventions should include these evidence-based constructs known to be effective. Future trials should address cardiovascular outcomes and ensure adequate follow-up time.
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Affiliation(s)
- Patricia Hall
- School of Public Health, Physiotherapy and Sports Science, Health Science Centre, University College Dublin, Dublin, Ireland
- iPASTAR (Improving Pathways for Acute Stroke and Rehabilitation) Collaborative Doctoral Award, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maggie Lawrence
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow, United Kingdom
| | - Thilo Kroll
- School of Nursing, Midwifery and Health Systems, Health Science Centre, University College Dublin, Dublin, Ireland
| | - Catherine Blake
- School of Public Health, Physiotherapy and Sports Science, Health Science Centre, University College Dublin, Dublin, Ireland
| | - James Matthews
- School of Public Health, Physiotherapy and Sports Science, Health Science Centre, University College Dublin, Dublin, Ireland
| | - Olive Lennon
- School of Public Health, Physiotherapy and Sports Science, Health Science Centre, University College Dublin, Dublin, Ireland
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3
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de Havenon A, Zhou LW, Johnston KC, Dangayach NS, Ney J, Yaghi S, Sharma R, Abbasi M, Delic A, Majersik JJ, Anadani M, Tirschwell DL, Sheth KN. Twenty-Year Disparity Trends in United States Stroke Death Rate by Age, Race/Ethnicity, Geography, and Socioeconomic Status. Neurology 2023; 101:e464-e474. [PMID: 37258298 PMCID: PMC10401675 DOI: 10.1212/wnl.0000000000207446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/07/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In 2017, the Centers for Disease Control and Prevention (CDC) issued an alert that, after decades of consistent decline, the stroke death rate levelled off in 2013, particularly in younger individuals and without clear origin. The objective of this analysis was to understand whether social determinants of health have influenced trends in stroke mortality. METHODS We performed a longitudinal analysis of county-level ischemic and hemorrhagic stroke death rate per 100,000 adults from 1999 to 2018 using a Bayesian spatiotemporally smoothed CDC dataset stratified by age (35-64 years [younger] and 65 years or older [older]) and then by county-level social determinants of health. We reported stroke death rate by county and the percentage change in stroke death rate during 2014-2018 compared with that during 2009-2013. RESULTS We included data from 3,082 counties for younger individuals and 3,019 counties for older individuals. The stroke death rate began to increase for younger individuals in 2013 (p < 0.001), and the slope of the decrease in stroke death rate tapered for older individuals (p < 0.001). During the 20-year period of our study, counties with a high social deprivation index and ≥10% Black residents consistently had the highest rates of stroke death in both age groups. Comparing stroke death rate during 2014-2018 with that during 2009-2013, larger increases in younger individuals' stroke death rate were seen in counties with ≥90% (vs <90%) non-Hispanic White individuals (3.2% mean death rate change vs 1.7%, p < 0.001), rural (vs urban) populations (2.6% vs 2.0%, p = 0.019), low (vs high) proportion of medical insurance coverage (2.9% vs 1.9%, p = 0.002), and high (vs low) substance abuse and suicide mortality (2.8 vs 1.9%, p = 0.008; 3.3% vs 1.5%, p < 0.001). In contrast to the younger individuals, in older individuals, the associations with increased death rates were with more traditional social determinants of health such as the social deprivation index, urban location, unemployment rate, and proportion of Black race and Hispanic ethnicity residents. DISCUSSION Improvements in the stroke death rate in the United States are slowing and even reversing in younger individuals and many US counties. County-level increases in stroke death rate were associated with distinct social determinants of health for younger vs older individuals. These findings may inform targeted public health strategies.
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Affiliation(s)
- Adam de Havenon
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle.
| | - Lily W Zhou
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Karen C Johnston
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Neha S Dangayach
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - John Ney
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Shadi Yaghi
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Richa Sharma
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Mehdi Abbasi
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Alen Delic
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Jennifer Juhl Majersik
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Mohammad Anadani
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - David L Tirschwell
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
| | - Kevin Navin Sheth
- From the Department of Neurology (A.H., R.S., M. Abbasi, K.N.S.), Yale University, New Haven, CT; Department of Neurology (L.Z.), The University of British Columbia, Vancouver; Department of Neurology (K.C.J.), University of Virginia, Charlottesville; Department of Neurology (N.S.D.), Mount Sinai, New York, NY; Department of Neurology (J.N.), Boston University, MA; Department of Neurology (S.Y.), Brown University, Providence, RI; Department of Neurology (A.D., J.J.M.), University of Utah; Department of Neurology (M. Anadani), Medical University of South Carolina, Charleston; and Department of Neurology (D.L.T.), University of Washington, Seattle
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Ohashi K, Osanai T, Fujiwara K, Tanikawa T, Tani Y, Takamiya S, Sato H, Morii Y, Bando K, Ogasawara K. Spatial-temporal analysis of cerebral infarction mortality in Hokkaido, Japan: an ecological study using a conditional autoregressive model. Int J Health Geogr 2022; 21:16. [PMID: 36316770 PMCID: PMC9623919 DOI: 10.1186/s12942-022-00316-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/19/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Accessibility to stroke treatments is a challenge that depends on the place of residence. However, recent advances in medical technology have improved health outcomes. Nevertheless, the geographic heterogeneity of medical resources may increase regional disparities. Therefore, evaluating spatial and temporal influences of the medical system on regional outcomes and advanced treatment of cerebral infarction are important from a health policy perspective. This spatial and temporal study aims to identify factors associated with mortality and to clarify regional disparities in cerebral infarction mortality at municipality level. METHODS This ecological study used public data between 2010 and 2020 from municipalities in Hokkaido, Japan. We applied spatial and temporal condition autoregression analysis in a Bayesian setting, with inference based on the Markov chain Monte Carlo simulation. The response variable was the number of deaths due to cerebral infarction (ICD-10 code: I63). The explanatory variables were healthcare accessibility and socioeconomic status. RESULTS The large number of emergency hospitals per 10,000 people (relative risk (RR) = 0.906, credible interval (Cr) = 0.861 to 0.954) was associated with low mortality. On the other hand, the large number of general hospitals per 10,000 people (RR = 1.123, Cr = 1.068 to 1.178) and longer distance to primary stroke centers (RR = 1.064, Cr = 1.014 to 1.110) were associated with high mortality. The standardized mortality ratio decreased from 2010 to 2020 in Hokkaido by approximately 44%. Regional disparity in mortality remained at the same level from 2010 to 2015, after which it narrowed by approximately 5% to 2020. After mapping, we identified municipalities with high mortality rates that emerged in Hokkaido's central and northeastern parts. CONCLUSION Cerebral infarction mortality rates and the disparity in Hokkaido improved during the study period (2010-2020). This study emphasized that healthcare accessibility through places such as emergency hospitals and primary stroke centers was important in determining cerebral infarction mortality at the municipality level. In addition, this study identified municipalities with high mortality rates that require healthcare policy changes. The impact of socioeconomic factors on stroke is a global challenge, and improving access to healthcare may reduce disparities in outcomes.
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Affiliation(s)
- Kazuki Ohashi
- Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812, Sapporo, Japan
| | - Toshiya Osanai
- Department of Neurosurgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, N15-W7, Kita-ku, 060-8638, Sapporo, Japan
| | - Kensuke Fujiwara
- Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812, Sapporo, Japan
- Graduate School of Commerce, Otaru University of Commerce, 3-5-21, 047-8501, Midori, Otaru, Japan
| | - Takumi Tanikawa
- Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812, Sapporo, Japan
- Faculty of Health Sciences, Hokkaido University of Science, 7-15-4-1, Maeda, Teine-ku, 006-8585, Sapporo, Japan
| | - Yuji Tani
- Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812, Sapporo, Japan
- Department of Medical Informatics and Hospital Management, Asahikawa Medical University, E2-1-1-1, 078-8510, Midorigaoka, Asahikawa, Japan
| | - Soichiro Takamiya
- Department of Neurosurgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, N15-W7, Kita-ku, 060-8638, Sapporo, Japan
- Department of Neurosurgery, Otaru General Hospital, 1-1-1, 047-8550, Wakamatsu, Otaru, Japan
| | - Hirotaka Sato
- Department of Neurosurgery, Kitami Red Cross Hospital, N6-E2, Kitami, 090-8666, Sapporo, Japan
| | - Yasuhiro Morii
- Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812, Sapporo, Japan
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, 2-3-6, 351-0197, Wako, Minami, Japan
| | - Kyohei Bando
- Graduate school of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812, Sapporo, Japan
| | - Katsuhiko Ogasawara
- Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812, Sapporo, Japan.
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