Differences in stroke between white, Hispanic, and Native American patients: the Barrow Neurological Institute stroke database

Health Care Disparities in Stroke Rehabilitation

Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.

Vascular Risk Factor Prevalence and Trends in Native Americans with Ischemic Stroke

INTRODUCTION

Native Americans have a higher incidence and prevalence of stroke and the highest stroke-related mortality among race-ethnic groups in the United States. We aimed to analyze trends in the ischemic stroke (IS) vascular risk factor prevalence in Native Americans along with a comparison to the other race-ethnic groups.

METHODS

National Inpatient Sample (NIS) database was used to explore the prevalence of risk factors among hospitalized IS patients during 2000 - 2016. Prevalence estimates were calculated for each risk factor within each race-ethnic group in 6 time periods. Linear trends were explored using linear regression models, with differences in trends between the Native American group and the other race-ethnic groups assessed using interaction terms. The analysis accounted for the complex sampling design, including hospital clusters, NIS stratum, and trend weights for analyzing multiple years of NIS data.

RESULTS

Native Americans constituted 5472 of the 1,278,784 IS patients. The age-and-sex-standardized prevalence of hypertension (slope = 2.24, p < 0.001), hyperlipidemia (slope = 6.29, p < 0.001), diabetes (slope = 2.04, p = 0.005), atrial fibrillation/flutter (trend slope = 0.80, p = 0.011), heart failure (trend slope = 0.73, p = 0.036) smoking (trend slope= 3.65, p < 0.001), and alcohol (slope = 0.60, p = 0.019) increased among Native Americans. They showed larger increases in hypertension prevalence compared to Blacks, Hispanics, and Asian/Pacific Islanders and in smoking prevalence compared to Hispanics and Asian/Pacific Islanders. By the year 2015-2016, Native Americans had the highest overall prevalence of diabetes, coronary artery disease, smoking, and alcohol among all race-ethnic groups.

CONCLUSION

The prevalence of most vascular risk factors among ischemic stroke patients has increased in Native Americans over the last two decades. Significantly larger increases in hypertension and smoking prevalence were seen in Native Americans compared to other groups along with them having the highest prevalence in multiple risk factors in recent years.

Prevalence and predictors of stroke among individuals with prediabetes and diabetes in Florida

Background

The prevalence of both prediabetes and diabetes have been increasing in Florida. These increasing trends will likely result in increases of stroke burden since both conditions are major risk factors of stroke. However, not much is known about the prevalence and predictors of stroke among adults with prediabetes and diabetes and yet this information is critical for guiding health programs aimed at reducing stroke burden. Therefore, the objectives of this study were to estimate the prevalence and identify predictors of stroke among persons with either prediabetes or diabetes in Florida.

Methods

The 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey data were obtained from the Florida Department of Health and used for the study. Weighted prevalence estimates of stroke and potential predictor variables as well as their 95% confidence intervals were computed for adults with prediabetes and diabetes. A conceptual model of predictors of stroke among adults with prediabetes and diabetes was constructed to guide statistical model building. Two multivariable logistic models were built to investigate predictors of stroke among adults with prediabetes and diabetes.

Results

The prevalence of stroke among respondents with prediabetes and diabetes were 7.8% and 11.2%, respectively. The odds of stroke were significantly (p ≤ 0.05) higher among respondents with prediabetes that were ≥ 45 years old (Odds ratio [OR] = 2.82; 95% Confidence Interval [CI] = 0.74, 10.69), had hypertension (OR = 5.86; CI = 2.90, 11.84) and hypercholesterolemia (OR = 3.93; CI = 1.84, 8.40). On the other hand, the odds of stroke among respondents with diabetes were significantly (p ≤ 0.05) higher if respondents were non-Hispanic Black (OR = 1.79; CI = 1.01, 3.19), hypertensive (OR = 3.56; CI = 1.87, 6.78) and had depression (OR = 2.02; CI = 1.14, 3.59).

Conclusions

Stroke prevalence in Florida is higher among adults with prediabetes and diabetes than the general population of the state. There is evidence of differences in the importance of predictors of stroke among populations with prediabetes and those with diabetes. These findings are useful for guiding health programs geared towards reducing stroke burden among populations with prediabetes and diabetes.

Epidemiology of Stroke in Costa Rica: A 7-Year Hospital-Based Acute Stroke Registry of 1319 Consecutive Patients

BACKGROUND

Limited data on stroke exist for Costa Rica. Therefore, we created a stroke registry out of patients with stroke seen in the Acute Stroke Unit of the Hospital Calderon Guardia.

METHODS

We analyzed 1319 patients enrolled over a 7-year period, which incorporated demographic, clinical, laboratory, and neuroimaging data.

RESULTS

The mean age of patients with stroke was 68.0 ± 15.5 years. Seven hundred twenty-five were men and the age range was 13-104 years. The most prevalent risk factors were hypertension (78.8%), dyslipidemia (36.3%), and diabetes (31.9%). Fifteen percent had atrial fibrillation and 24.7% had a previous stroke or transient ischemic attack. Prevalence of hypertension and atrial fibrillation increased with age; however, younger patients were more associated with thrombophilia. We documented 962 (72.9%) ischemic and 270 (20.5%) hemorrhagic strokes. Of the ischemic strokes, 174 (18.1%) were considered secondary to large-artery atherothrombosis, 175 (18.2%) were due to cardiac embolism, 19 (2.0%) were due to lacunar infarcts, and 25 (2.6%) were due to other determined causes. Five hundred sixty-nine (59.1%) remained undetermined. Atherothrombotic strokes were mostly associated with dyslipidemia, diabetes, metabolic syndrome, and obesity, whereas lacunar infarcts were associated with hypertension, smoking, sedentary lifestyle, and previous stroke or transient ischemic attack. Of our patients, 69.9% scored between 0 and 9 in the initial National Institutes of Health Stroke Scale (NIHSS).

CONCLUSIONS

We found differences in sociodemographic features, risk factors, and stroke severity among stroke subtypes. Risk factor prevalence was similar to other registries involving Hispanic populations.

CT Angiographic Evaluation of Pattern and Distribution of Stenosis and its Association with Risk Factors Among Indian Ischemic Stroke Patients

BACKGROUND

Stroke is the major cause of disability and third major cause of death. Ischemia causes about 80% of stroke cases; stenosis and occlusion are the predominant cause of stroke. Our purpose for this study was to evaluate the pattern and distribution of stenosis and its association with risk factors in Indian ischemic stroke patients and in other countries, for comparison.

MATERIAL/METHODS

We evaluated 60 patients after ischemic stroke with CT angiography. The degree of stenosis was measured by the North American Symptomatic Carotid Endarterectomy Trial (NASCET). The results were analyzed by descriptive statistics and chi-square test.

RESULTS

Out of 60 cases, 32 cases were positive for significant stenosis and a total number of stenotic segments was 45. Out of 45 stenotic segments, 29 were single stenotic segments (16 intracranial and 13 extracranial) and 16 were multiple stenotic segments (8 intracranial and 8 extracranial). In the total number of stenotic segments (single and multiple), there were 24 (53.33%) intracranial and 21 (46.67%) extracranial. The most commonly involved intracranial stenosis segment was MCA, present in 10 (41.6%) out of 24 intracranial segments. Most commonly involved extracranial stenosis segment was ICA, present in 14 (66.6%) out of 21 extracranial segments. Diabetes is found to be the most common risk factor of intracranial stenosis while hypertension and hypercholesterolemia are the major risk factors of extracranial stenosis.

CONCLUSIONS

In the Indian population, intracranial stenosis is more common than extracranial one, anterior circulation stenosis is more common than posterior circulation stenosis; single stenosis is more common than multiple stenosis.

Has the aetiology of ischaemic stroke changed in the past decades? Analysis and comparison of data from current and historical stroke databases

OBJECTIVES

We aimed to determine whether the aetiology of ischaemic stroke has changed in recent years and, if so, to ascertain the possible reasons for these changes.

PATIENTS AND METHODS

We analysed the epidemiological history and vascular risk factors of all patients diagnosed with ischaemic stroke at Complejo Hospitalario Universitario de Albacete (CHUA) from 2009 to 2014. Ischaemic stroke subtypes were established using the TOAST criteria. Our results were compared to data from the classic Stroke Data Bank (SDB); in addition, both series were compared to those of other hospital databases covering the period between the two.

RESULTS

We analysed 1664 patients (58% were men) with a mean age of 74 years. Stroke aetiology in both series (CHUA, SDB) was as follows: atherosclerosis (12%, 9%), small-vessel occlusion (13%, 25%), cardioembolism (32%, 19%), stroke of other determined aetiology (3%, 4%), and stroke of undetermined aetiology (40%, 44%). Sixty-three percent of the patients from the CHUA and 42% of the patients from the SDB were older than 70 years. Cardioembolic strokes were more prevalent in patients older than 70 years in both series. Untreated hypertension was more frequent in the SDB (SDB = 31% vs CHUA = 10%). The analysis of other databases shows that the prevalence of cardioembolic stroke is increasing worldwide.

CONCLUSIONS

Our data show that the prevalence of lacunar strokes is decreasing worldwide whereas cardioembolic strokes are increasingly more frequent in both our hospital and other series compared to the SDB. These differences may be explained by population ageing and the improvements in management of hypertension and detection of cardioembolic arrhythmias in stroke units.

Cognitive performance following lacunar stroke in Spanish-speaking patients: results from the SPS3 trial

BACKGROUND

Cognitive impairment is frequent in lacunar stroke patients. The prevalence and pattern among Spanish-speaking patients are unknown and have not been compared across regions or with English-speaking patients.

AIMS

The aim of this study was to characterize cognitive impairment in Spanish-speaking patients and compare it with English-speaking patients.

METHODS

The baseline neuropsychological test performance and the prevalence of mild cognitive impairment, defined as a z-score ≤ -1.5 on memory and/or non-memory tests, were evaluated in Spanish-speaking patients in the Secondary Prevention of Small Subcortical Strokes trial.

RESULTS

Out of 3020 participants, 1177 were Spanish-speaking patients residing in Latin America (n = 693), the United States (n = 121), and Spain (n = 363). Low education (zero- to eight-years) was frequent in Spanish-speaking patients (49-57%). Latin American Spanish-speaking patients had frequent post-stroke upper extremity motor impairment (83%). Compared with English-speaking patients, all Spanish-speaking patient groups had smaller memory deficits and larger non-memory/motor deficits, with Latin American Spanish-speaking patients showing the largest deficits median z-score -1.3 to -0.6 non-memory tests; ≤5.0 for Grooved Pegboard; -0.7 to -0.3 for memory tests). The prevalence of mild cognitive impairment was high and comparable with English-speaking patients in the United States and Latin American Spanish-speaking patients but not the Spanish group: English-speaking patients = 47%, Latin American Spanish-speaking patients = 51%, US Spanish-speaking patients = 40%, Spanish Spanish-speaking patients = 29%, with >50% characterized as non-amnestic in Spanish-speaking patient groups. Older age [odds ratio per 10 years = 1.52, confidence interval = 1.35-1.71), lower education (odds ratio 0-4 years = 1.23, confidence interval = 0.90-1.67), being a Latin American resident (odds ratio = 1.31, confidence interval = 0.87-1.98), and post-stroke disability (odds ratio Barthel Index <95 = 1.89, confidence interval = 1.43-2.50) were independently associated with mild cognitive impairment.

CONCLUSIONS

Mild cognitive impairment in Secondary Prevention of Small Subcortical Strokes Spanish-speaking patients with recent lacunar stroke is highly prevalent but has a different pattern to that observed in English-speaking patients. A combination of socio-demographics, stroke biology, and stroke care may account for these differences.

Stroke in American Indians and Alaska Natives: A Systematic Review

We conducted a systematic review of published studies on stroke epidemiology in American Indians and Alaska Natives (AI/ANs). We used MeSH terms and strict inclusion criteria to search PubMed, identifying a relevant sample of 57 refereed publications. We report a consensus view in which prevalent stroke is more common, and estimates of cerebrovascular risk factors are higher, among AI/ANs than among other US populations. Like other minority groups, AI/ANs suffer stroke at younger ages than do non-Hispanic Whites. However, data on AI/AN stroke mortality are significantly compromised by racial misclassification and nonrepresentative sampling. Studies correcting for these problems have found that stroke mortality rates among AI/ANs are among the highest of all US racial and ethnic groups. As with Black and non-Hispanic White stroke mortality, AI/AN stroke mortality varies by geographic region, with the highest rates in Alaska and the Northwest and the lowest in the Southwest. Our results underscore the need for a concerted national effort to collect accurate cross-sectional and longitudinal data on stroke in AI/ANs.

Meeting the Needs of the Community: A Project to Prevent Stroke in Hispanics

The Hispanic population is the fastest growing minority population in the United States. Little research has been done to address the stroke risk in the Hispanic population that has a higher prevalence of diabetes, alcohol use, and physical inactivity. To change behavior and decrease the risk of stroke, a comprehensive program that combines education, risk identification, and follow-up is needed. The purpose of this article is to identify the increased risk factors of stroke in the Hispanic population, identify the barriers to health care, and outline the development of a stroke education and screening program for Hispanics.

Do Hispanic Children Need to Know About Stroke Prevention?

When compared to Hispanics in their native countries, the frequency of stroke in the Hispanic American population is higher. This has been linked to an increase in smoking, inactivity, and obesity. Initially these health issues were thought to affect only Hispanic adults, but research confirms that first- and second-generation adolescents and young adults continue to demonstrate these habits. Education has been shown to be an effective method of stroke prevention by increasing an individual's knowledge base. As demonstrated in a previous study performed in the Hispanic community, when educational material is presented in a familiar environment and offers lifestyle options that are culturally realistic, there is an increase in knowledge and compliance with lifestyle changes. The focus of education for stroke prevention has always been placed on older adults, but little has been done to alter the cultural risk factors found in the young adult and adolescent population in order to prevent stroke in the future.

Socioeconomic disparities in the utilization of mechanical thrombectomy for acute ischemic stroke

BACKGROUND

Previous studies have demonstrated that socioeconomic disparities in access to treatment of cerebrovascular diseases exist. We studied the Nationwide Inpatient Sample (NIS) to determine if disparities exist in utilization of mechanical thrombectomy for acute ischemic stroke.

METHODS

Using the NIS for the years 2006-2010, we selected all discharges with a primary diagnosis of acute ischemic stroke. Patients who received mechanical thrombectomy for stroke were identified by using the International Classification of Diseases, Ninth Revision, procedure code 39.74. We examined the utilization rates of mechanical thrombectomy by race/ethnicity (white, black, Hispanic, and Asian/Pacific Islander), income quartile (first, second to third, and fourth), and insurance status (Medicare, Medicaid, self-pay, and private). We also studied thrombectomy utilization rates at hospitals that performed thrombectomy.

RESULTS

From 2006 to 2010, 2,087,017 patients were hospitalized with a primary diagnosis of acute ischemic stroke; 8946 patients (.4%) received mechanical thrombectomy. Compared with white patients, black patients had significantly lower rates of overall mechanical thrombectomy utilization (odds ratio [OR] = .59, 95% confidence interval [CI] = .55-.64, P < .0001) and at centers that offered mechanical thrombectomy (OR = .44, 95% CI = .41-.47, P < .0001). Compared with patients in the highest income quartile, patients in the lowest income quartile had significantly lower rates of mechanical thrombectomy utilization both overall (OR = .66, 95% CI = .62-.70, P < .0001) and at centers that offered mechanical thrombectomy (OR = .80, 95% CI = .75-.84, P < .0001). Compared with patients with private insurance, self-pay patients had significantly lower mechanical thrombectomy utilization both overall (OR = .71, 95% CI = .64-.78, P < .0001) and at centers that offered mechanical thrombectomy (OR = .81, 95% CI = .74-.90, P < .0001).

CONCLUSIONS

Significant socioeconomic disparities exist in the utilization of mechanical thrombectomy in the United States.

Socioeconomic disparities in the utilization of mechanical thrombectomy for acute ischemic stroke in US hospitals

BACKGROUND AND PURPOSE

Previous studies have demonstrated that socioeconomic disparities in the treatment of cerebrovascular diseases exist. We studied a large administrative data base to study disparities in the utilization of mechanical thrombectomy for acute ischemic stroke.

MATERIALS AND METHODS

With the utilization of the Perspective data base, we studied disparities in mechanical thrombectomy utilization between patient race and insurance status in 1) all patients presenting with acute ischemic stroke and 2) patients presenting with acute ischemic stroke at centers that performed mechanical thrombectomy. We examined utilization rates of mechanical thrombectomy by race/ethnicity (white, black, and Hispanic) and insurance status (Medicare, Medicaid, self-pay, and private). Multivariate logistic regression analysis adjusting for potential confounding variables was performed to study the association between race/insurance status and mechanical thrombectomy utilization.

RESULTS

The overall mechanical thrombectomy utilization rate was 0.15% (371/249,336); utilization rate at centers that performed mechanical thrombectomy was 1.0% (371/35,376). In the sample of all patients with acute ischemic stroke, multivariate logistic regression analysis demonstrated that uninsured patients had significantly lower odds of mechanical thrombectomy utilization compared with privately insured patients (OR = 0.52, 95% CI = 0.25-0.95, P = .03), as did Medicare patients (OR = 0.53, 95% CI = 0.41-0.70, P < .0001). Blacks had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.35, 95% CI = 0.23-0.51, P < .0001). When considering only patients treated at centers performing mechanical thrombectomy, multivariate logistic regression analysis demonstrated that insurance was not associated with significant disparities in mechanical thrombectomy utilization; however, black patients had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.41, 95% CI = 0.27-0.60, P < .0001).

CONCLUSIONS

Significant socioeconomic disparities exist in the utilization of mechanical thrombectomy in the United States.

Racial-ethnic differences in stroke risk factors and subtypes: results of a prospective hospital-based registry

A majority of stroke research in the United States focuses on Caucasian and African-American populations, limiting the amount of comparative stroke data available on other racial and ethnic groups. The purpose of this research was to examine differences in stroke risk factors/subtypes between minority stroke patient groups in the United States (Asian-Indian, African-American, and Hispanic), using a Caucasian reference group. All patients had a comprehensive stroke work-up to ascertain their stroke risk factors and their stroke etiology applying TOAST criteria. Minority groups were younger compared with the white stroke patients, with the mean age significantly lower in the Asian-Indian and the Hispanic groups. The male:female ratio favored males in the Asian-Indian and Hispanic subgroups and females in the Caucasian and African-American groups. Diabetes was more prevalent in the minority subgroups, with a highest prevalence (55%) noted in the Asian-Indian group. The minority groups had lower prevalence of atrial fibrillation, carotid stenosis (≥70%), CAD, PVD, smoking, and alcohol use. The Asian-Indian stroke group had a higher median fasting plasma homocysteine level compared with the reference white group (12.1 vs. 10.4, p = 0.002). Compared to the reference white stroke group, the Asian-Indian stroke group had fewer strokes related to cardioembolism (7% vs. 25%) and a higher number of strokes related to small vessel occlusive disease (25% vs. 11%). There are some similarities in the stroke risk factors between the minority stroke groups, but the data indicate that there are different trends in stroke risk factors and subtypes.

Racial and ethnic disparities in the use of intravenous recombinant tissue plasminogen activator and outcomes for acute ischemic stroke

Racial and ethnic disparities in acute stroke care in the United States have been previously reported. This study investigated possible racial and ethnic disparities in the administration and outcome of recombinant tissue plasminogen activator (rtPA) therapy for acute ischemic stroke in whites, blacks, Hispanics, and Asian/Pacific Islanders. Using the National Inpatient Sample for 2001-2008, we selected patients with a primary diagnosis of acute ischemic stroke who received treatment with rtPA. Patient data were stratified by race (white, black, Hispanic, and Asian/Pacific Islander). We analyzed the association of patient race on rtPA utilization rate, in-hospital morbidity (ie, discharge to long-term facility), intracranial hemorrhage (ICH) rate, and in-hospital mortality. We performed a multivariate logistic regression analysis to determine independent predictors of poor outcomes. White patients had a higher rate of tPA utilization than black and Hispanic patients (2.3% vs 1.8% and 2.0%, respectively; P < .0001 for both groups). There was no difference in the rate of tPA utilization between whites and Asian/Pacific Islanders (2.3% vs 2.2% P = .07). Multivariate analysis of morbidity, mortality, and ICH rates found that Asian/Pacific Islanders had significantly higher rates of mortality (odds ratio, 1.22, 95% confidence interval, 1.03-1.44; P = .02) and ICH (odds ratio, 2.01; 95% confidence interval, 1.91-2.11; P < .0001) compared with whites. rtPA utilization was greater in white and Asian/Pacific Islander patients than in black and Hispanic patients. Asian/Pacific Islander race was associated with increased risk of ICH and mortality after rtPA administration.

The influence of the level of physical activity and human development in the quality of life in survivors of stroke

Background

The association between physical activity and quality of life in stroke survivors has not been analyzed within a framework related to the human development index. This study aimed to identify differences in physical activity level and in the quality of life of stroke survivors in two cities differing in economic aspects of the human development index.

Methods

Two groups of subjects who had suffered a stroke at least a year prior to testing and showed hemiplegia or hemiparesis were studied: a group from Belo Horizonte (BH) with 48 people (51.5 ± 8.7 years) and one from Montes Claros (MC) with 29 subjects (55.4 ± 8.1 years). Subsequently, regardless of location, the groups were divided into Active and Insufficiently Active so their difference in terms of quality of life could be analyzed.

Results

There were no significant differences between BH and MCG when it came to four dimensions of physical health that were evaluated (physical functioning, physical aspect, pain and health status) or in the following four dimensions of mental health status (vitality, social aspect, emotional aspect and mental health). However, significantly higher mean values were found in Active when compared with Insufficiently Active individuals in various measures of physical health (physical functioning 56.2 ± 4.4 vs. 47.4 ± 6.9; physical aspect 66.5 ± 6.5 vs. 59.1 ± 6.7; pain 55.9 ± 6.2 vs. 47.7 ± 6.0; health status 67.2 ± 4.2 vs. 56.6 ± 7.8) (arbitrary units), and mental health (vitality 60.9 ± 6.8 vs. 54.1 ± 7.2; social aspect 60.4 ± 7.1 vs. 54.2 ± 7.4; emotional aspect 64.0 ± 5.5 vs. 58.1 ± 6.9; mental health status 66.2 ± 5.5 vs. 58.4 ± 7.5) (arbitrary units).

Conclusions

Despite the difference between the cities concerning HDI values, no significant differences in quality of life were found between BH and MCG. However, the Active group showed significantly better results, confirming the importance of active lifestyle to enhance quality of life in stroke survivors.

Stroke epidemiology: advancing our understanding of disease mechanism and therapy

Stroke is the fourth killer and number one cause of adult disability in the United States. The estimated direct and indirect costs of stroke care in this country are $68.9 billion for 2009. The prevalence of stroke and its cost will undoubtedly rise as the aging population increases. In addition, stroke incidence and mortality are increasing in less developed countries in which the lifestyles and population restructuring are rapidly changing. More population-based research to assess incidence, risk factors, and outcomes are needed in these countries. Epidemiologic studies can help identify groups of individuals or regions at higher risk for stroke. They can also help us better understand the natural history of certain conditions and therefore push the direction of therapeutic investigations. Furthermore, the study of trends across different time periods and different populations can help investigators evaluate the effects of stroke care programs and treatment options.

The Secondary Prevention of Small Subcortical Strokes (SPS3) study

BACKGROUND

Small subcortical strokes, also known as lacunar strokes, comprise more than 25% of brain infarcts, and the underlying vasculopathy is the most common cause of vascular cognitive impairment. How to optimally prevent stroke recurrence and cognitive decline in S3 patients is unclear. The aim of the Secondary Prevention of Small Subcortical Strokes study (Trial registration: NCT00059306) is to define strategies for reducing stroke recurrence, cognitive decline, and major vascular events.

METHODS

Secondary Prevention of Small Subcortical Strokes is a randomised, multicentre clinical trial (n = 3000) being conducted in seven countries, and sponsored by the US NINDS/NIH. Patients with symptomatic small subcortical strokes in the six-months before and an eligible lesion on magnetic resonance imaging are simultaneously randomised, in a 2 × 2 factorial design, to antiplatelet therapy--325 mg aspirin daily plus 75 mg clopidogrel daily, vs. 325 mg aspirin daily plus placebo, double-blind--and to one of two levels of systolic blood pressure targets--'intensive' (<130 mmHg) vs. 'usual' (130-149 mmHg). Participants are followed for an average of four-years. Time to recurrent stroke (ischaemic or haemorrhagic) is the primary outcome and will be analysed separately for each intervention. The secondary outcomes are the rate of cognitive decline and major vascular events. The primary and most secondary outcomes are adjudicated centrally by those unaware of treatment assignment.

CONCLUSIONS

Secondary Prevention of Small Subcortical Strokes will address several important clinical and scientific questions by testing two interventions in patients with recent magnetic resonance imaging-defined lacunar infarcts, which are likely due to small vessel disease. The results will inform the management of millions of patients with this common vascular disorder.

Stroke risk factors and outcomes among various Asian ethnic groups in Singapore

Data on interethnic differences in the Asian stroke population are limited. We evaluated the relationships among various cardiovascular risk factors, stroke subtypes, and outcomes in a multiethnic Singaporean population comprising consecutive ischemic stroke patients presenting to our tertiary center over a 1-year period. Strokes were classified based on criteria used in the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Functional independence at hospital discharge was defined as a modified Rankin Scale (mRS) score of 0-2. The ethnic distribution of the study population (n = 481; mean age, 64.1 ± 11.9 years) was 74% Chinese, 17% Malay, and 9% Indian. The prevalence of risk factors was similar in the 3 ethnic groups except for diabetes (Chinese, 39.8%; Malay, 67.5%; Indian, 52.3%; P < .001). Hypertension and hypercholesterolemia were the most common cardiovascular risk factors. Lacunar stroke was the most frequent stroke subtype (47.9%). Large-artery atherosclerotic infarctions were more prevalent in Indians (25.0%), whereas lacunar infarctions occured more frequently in Chinese (51.8%; P < .01). No differences in in-hospital mortality and functional independence at discharge were seen among the 3 ethnic groups. Despite the differences in risk factors and in stroke subtypes classified by location or underlying etiology, short-term outcome measures were similar in the 3 different Asian ethnicities in Singapore.

Ethnic differences in ischemic stroke of working age in northern Israel

BACKGROUND

There are currently no comparative data about ethnic differences in ischemic stroke in Arab and Jewish populations.

METHODS

Data on 727 consecutive Arab and Jewish patients of working age (<or=65 years) with stroke were compared for risk profile, etiology, subtyping, and immediate functional outcome.

RESULTS

The mean age was 59.4 +/- 8.2 years for the Jewish and 53.7 +/- 8.6 years for the Arab patients (P = .03). Higher prevalence of diabetes was found in the Arab patients after adjustment by age, sex, and main vascular risk factors (P < .0001). After adjustment, a higher prevalence of normal transesophageal echocardiography results in the Arab population was found. Small vessel disease-related strokes were significantly more frequent in the Arab patients, whereas large vessel disease-related strokes and strokes resulting from multiple causes were significantly more frequent in the Jewish patients. No correlations were found between the high prevalence of diabetes (or any other examined factor) and the predominance of small vessel disease-related strokes in the Arab patients and large vessel disease-related strokes in the Jewish patients. There was no difference found in treatment or outcome between the Arab and the Jewish patients.

CONCLUSIONS

There are substantial differences in the risk profiles and subtyping of strokes between Arab and Jewish patients of working age.

The economic consequences of diabetes and cardiovascular disease in the United States

Diabetes-related care and complications constitute a significant proportion of the United States' (US) health care expenditure. Of these complications, cardiovascular disease (CVD) is a major component. Higher morbidity and mortality rates translate to higher costs of care in patients with diabetes compared to those who do not have the disease. Minorities bear a disproportionate burden of diabetes and CVD. We review this disparity and examine potential etiologies for it in Hispanics and African-Americans, the two largest minority groups in the US. We examine strategies in these populations that may improve outcomes in diabetes and CVD, potentially decreasing health care costs.

Does race/ethnicity really matter in adult neurogenics?

PURPOSE

Recent evidence suggests that race/ethnicity is a variable that is critical to outcomes in neurological disorders. The purpose of this article was to examine the proportion of studies published in the American Journal of Speech-Language Pathology (AJSLP) and the Journal of Speech, Language, and Hearing Research (JSLHR) that were designed to examine neurologically based disorders of communication in adults and that reported the race/ethnicity of the participants.

METHOD

A review of articles in AJSLP and JSLHR from 1997 through 2007 was completed to determine what proportion of articles in the area of adult neurogenic communication disorders reported the race/ethnicity of the participants.

RESULTS

Between 1997 and 2007, less than 15% of the 116 articles published in the 2 journals reported the race/ethnicity of the participants. The review of studies indicates that the reporting of the race/ethnicity of participants in studies of adult neurogenic communication disorders remains inconsistent.

CONCLUSIONS

Because few studies report race/ethnicity or consider how race/ethnicity has the potential to confound the results and conclusions drawn, the generalization of the reported findings may be limited. Reporting race/ethnicity is likely critical to the external validity of studies in adult neurogenic communication disorders and when available can enhance the relevance of the findings reported.

Effect of race/ethnicity on the efficacy of warfarin: potential implications for prevention of stroke in patients with atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia seen in clinical practice. It affects approximately 6% of persons over 65 years of age and is independently associated with a 4- to 5-fold higher risk of ischaemic stroke and a 2-fold higher risk of death. Randomized controlled trials have shown that treatment with adjusted-dose oral vitamin K antagonists (primarily warfarin with a target international normalized ratio [INR] of 2.0-3.0) reduces the relative risk of ischaemic stroke by two-thirds (an approximately 3% reduction in annual absolute risk), but is associated with a 0.2% excess annual absolute risk of intracranial haemorrhage (ICH). However, in 'real world' studies, the risk reductions in ischaemic stroke with warfarin have been significantly lower (25-50% relative risk reduction) than in selected trial samples. Moreover, more than 90% of patients enrolled in the sentinel trials were White/European. This raises the question of whether the beneficial results of warfarin can be extrapolated to persons of colour. Important differences in stroke risk profile and responsiveness to warfarin exist across racial/ethnic groups, such that one cannot assume a priori that there is a net benefit of warfarin therapy for AF patients of all racial/ethnic groups.Among patients with ischaemic stroke, AF is more likely to be implicated as the cause of stroke in the White population than in other racial/ethnic groups. Furthermore, AF may be a stronger predictor of ischaemic stroke among the White population than in Black or Hispanic/Latino populations. Approximately one-third of strokes in AF patients are noncardioembolic. Warfarin has been shown to be ineffective in preventing recurrent noncardioembolic strokes. Many persons of colour with AF have other risk factors that predispose them to noncardioembolic stroke, which may partially explain why warfarin has been reported to be less efficacious in preventing strokes in non-White patients with AF, even after adjustment for co-morbidities and anticoagulation monitoring. Notably, the background incidence of ICH is higher in Black, Hispanic and Asian patients than in White patients. Any greater than expected increases in bleeding secondary to anticoagulation may potentially offset any benefit gained from cardioembolic stroke reduction, although this has not been fully resolved.Finally, there are racial/ethnic differences in the prevalence of certain polymorphisms in genes that influence warfarin pharmacokinetics and pharmacodynamics (e.g. cytochrome P450 2C9 and vitamin K epoxide reductase). The Asian population generally appear to require the lowest daily dose of warfarin to maintain a given INR target, with the White population requiring an intermediate daily dose and the Black population requiring the highest daily dose. These differences must be taken into account when administering warfarin in order to minimize the risk of under- or over-anticoagulation.In summary, warfarin is highly effective in preventing ischaemic strokes in White patients with AF at a modestly higher risk of ICH. Whether the same net clinical benefit extends to persons of colour is unproven. Given the rapidly changing demographic nationally and internationally, additional research is needed to resolve this important question.

Stroke in minorities

Minorities in the United States have higher stroke risks, stroke occurrence at an earlier age, and for some groups, more severe strokes than non-Hispanic whites. Factors contributing to these disparities are explored. Characteristics of African American, Hispanic, and Native American stroke risk and incidence are reviewed. The authors describe recent interventions to raise the awareness of stroke risk factors and symptoms in minorities. The importance of the problem is highlighted, and the authors suggest ways that stroke in minorities may be reduced.

Incidence and risk factors for stroke in American Indians: the Strong Heart Study

BACKGROUND

There are few published data on the incidence of fatal and nonfatal stroke in American Indians. The aims of this observational study were to determine the incidence of stroke and to elucidate stroke risk factors among American Indians.

METHODS AND RESULTS

This report is based on 4549 participants aged 45 to 74 years at enrollment in the Strong Heart Study, the largest longitudinal, population-based study of cardiovascular disease and its risk factors in a diverse group of American Indians. At baseline examination in 1989 to 1992, 42 participants (age- and sex-adjusted prevalence proportion 1132/100 000, adjusted to the age and sex distribution of the US adult population in 1990) had prevalent stroke. Through December 2004, 306 (6.8%) of 4507 participants without prior stroke suffered a first stroke at a mean age of 66.5 years. The age- and sex-adjusted incidence was 679/100 000 person-years. Nonhemorrhagic cerebral infarction occurred in 86% of participants with incident strokes; 14% had hemorrhagic stroke. The overall age-adjusted 30-day case-fatality rate from first stroke was 18%, with a 1-year case-fatality rate of 32%. Age, diastolic blood pressure, fasting glucose, hemoglobin A(1c,) smoking, albuminuria, hypertension, prehypertension, and diabetes mellitus were risk factors for incident stroke.

CONCLUSIONS

Compared with US white and black populations, American Indians have a higher incidence of stroke. The case-fatality rate for first stroke is also higher in American Indians than in the US white or black population in the same age range. Our findings suggest that blood pressure and glucose control and smoking avoidance may be important avenues for stroke prevention in this population.

Use of a multidisciplinary tool to achieve target outcomes in Native American patients with diabetes: Treat-to-target

Purpose

Our purpose was to test a communication tool used in a multidisciplinary setting to more effectively achieve the recommended goals for glucose, blood pressure, lipids, and prophylactic aspirin use in a Native American population with type 2 diabetes.

Methods

One hundred randomly selected patients were included in this observational, pre-intervention, post-intervention study design. The team began with a chart audit documenting hemoglobin A_1c (Hgb A_1c), blood pressure, cholesterol levels, and aspirin use. The intervention included the development of a one page form used to prompt providers to intensify therapy when the patient was not meeting evidence-based goals. The audit was repeated one year later.

Results

Analysis of 74 patients completing the study showed a decrease in Hgb A1C from 8.812% pre-intervention to a mean 8.214% post-intervention (p < 0.007). At the time of pre-intervention audit, patients were already at target for blood pressure and no significant further decrease was found. Measures of total cholesterol, triglycerides, and aspirin use showed improvement, but statistical significance was not met.

Conclusion

The one-page multidisciplinary tool used to intensify therapy significantly improved glucose control. More consistent interaction of the multidisciplinary team is necessary to reach other desired goals.

Differences in Mexican American and Non-Hispanic White veterans' homocysteine levels

PURPOSE

To compare homocysteine (Hcy) levels and possible modulatory factors, such as nutrient or supplement intake, between Mexican American and Non-Hispanic White (NHW) male military veterans scoring at high- versus low-risk for stroke.

DESIGN

A cross-sectional survey with a high and low stroke risk biomarkers substudy.

METHODS

Voluntary participants were Mexican American (n=109) and NHW (n=120) veteran outpatients 54 to 85 years of age at a Southwestern Veterans Administration (VA) medical center. Measures included food frequency, health history, and stroke risk scale derived from the Framingham Study. Biomarker subgroups, 30 Mexican American and 30 NHW, half of each group scoring high or low on stroke risk, who were tested for morning fasting blood levels of Hcy, B12, and folate.

FINDINGS

In the cross-sectional study (n=229), nutrient intake was comparable between ethnic groups. In the substudy, Mexican Americans (n=30) with high or low stroke risk scores and NHW (n=30) with high stroke risk scores had elevated Hcy levels (12.5; 11.9; 11.4 micromol/L respectively) compared to NHW veterans with low stroke risk scores (7.8 micromol/L) even after controlling for age, education, folate, diabetes, and smoking pack-years (p=.001). Mexican Americans compared to NHW were significantly more likely to be in the preclinical (17% versus 3% >10 micromol/L) and clinical ranges (69% versus 35% >15 micromol/L) for Hcy.

CONCLUSIONS

Mexican Americans showed higher levels of Hcy whether they scored high or low for stroke, and greater representation in clinical and preclinical Hcy ranges compared to NHW veterans. The Framingham-derived, predominantly NHW population-based stroke risk measure might require ethnically relevant stroke risk factors for Mexican Americans.

Carotid stenosis in a multiethnic population

BACKGROUND

Carotid stenosis is an important, treatable cause of stroke. Several population-based studies have shown ethnic differences in the prevalence of carotid atherosclerosis. This study was performed at a large multiethnic hospital to clarify these differences.

METHODS

One thousand six carotid artery ultrasounds performed by the Department of Radiology at Los Angeles County General Hospital over a 4-year period were reviewed. Patients were classified as Caucasian (n=151), Hispanic (n=515), Black (n=173), or Asian (n=167) by self-declaration and birthplace. Carotid stenosis was defined as mild (1% to 39%), moderate (40% to 59%), severe (60% to 79%), critical (80% to 99%), or total (100%).

RESULTS

Twenty and one-half percent of Caucasian patients had greater than 59% stenosis compared with 10.1% of Hispanics, 8.7% of Blacks, and 10.7% of Asians (P<0.001). Nine and two-tenths percent of Caucasians had greater than 79% stenosis compared with 4.3% of Hispanics, 2.9% of Blacks, and 2.8% of Asians (P<0.001). There were no significant differences in age or gender representations between ethnic groups, and the indications for ordering carotid duplex sonography also did not vary by race. Caucasians and Blacks had a higher prevalence of cardiac disease, smoking, and heavy alcohol abuse. Hispanics had higher rates of diabetes.

CONCLUSIONS

These results indicate that significant differences in the degree of carotid stenosis exist among ethnic groups. Caucasian patients in our series showed a statistically higher likelihood of having a severe or critical level of stenosis. These findings may have implications for the allocation of health care resources as ethnic minorities compose a greater proportion of the population.

Safety outcomes of Alteplase among acute ischemic stroke patients with special characteristics

BACKGROUND

Although tissue plasminogen activator (tPA) has been approved for use in acute ischemic stroke, concerns linger regarding its safety. We analyzed whether patients in special subgroups (i.e., age >70 years, baseline National Institute of Health Stroke Scale (NIHSS) score >20, diabetes, congestive heart failure (CHF), and of Hispanic origin) have a higher risk of symptomatic intracerebral hemorrhage (SICH) than patients without these characteristics.

METHODS

Four prospective observational studies of acute ischemic stroke patients treated within 3 h with Alteplase were identified and individual patient data were pooled for this analysis. These included the Standard Treatment with Alteplase to Reverse Stroke Study [STARS, N = 389], Epidemiology Study of Ischemic Stroke [ESIS, N = 236], University Of Texas Houston Stroke Study [UT, N = 241], and Canadian Activase For Stroke Effectiveness Study [CASES, N = 1100]. The risk of SICH was calculated for all patients and for each of five subgroups.

RESULTS

A total of 1966 patients were studied. Overall the risk of symptomatic ICH was 4.7% (95%CI, 3.8-5.8%) and the risk was similar among patients with and without each of the five characteristics. Patients with advanced age, baseline NIHSS score >20, CHF or diabetes had increased mortality and significantly lower rate of functional recovery.

CONCLUSIONS

The present study suggests that these specified subgroups of patients are not at increased risk of SICH after stroke thrombolysis compared to those without these characteristics.

Large and Small Vessels Atherosclerosis: Similarities and Differences

Atherosclerosis is a systemic, multifocal disease leading to a various symptoms and clinical events. Beyond disparities related to the organs involved, some differences might exist according to whether the lesions occur in the large (proximal) or small (distal) arteries. Atherosclerotic lesions occur predominantly in the large vessels first, and more distal lesions occur with aging. Proximal lesions are usually more evolving, especially with higher rates of unstable plaques in the proximal segments of coronary arteries. Racial differences regarding lesion distribution exist, with higher rates of distal lesions observed in races other than caucaians. Despite conflicting results found in each vascular territory, there is a suggestion of a stronger association between large vessel disease and smoking and dyslipidemia, whereas diabetes appears more specific for small vessel disease. Hypertension is more frequently reported in intracranial than in extracranial cerebrovascular disease. Preliminary studies report inflammatory markers preferably associated to large-vessel atherosclerosis. Proximal lesions in 1 territory are more frequently associated with concomitant lesions in other territories. Geometric, hemodynamic, and histologic particularities in large and small vessels may at least partially explain these differences, and some recent data point out different biologic properties of the endothelium according to its location.

Arterial stenosis detected by digital subtraction angiography and its relationship with the Oxfordshire Community Stroke Project classification

The aim of this study was to assess extra-and intracranial arterial stenosis in first-ever stroke patients and to analyse the relationship between arterial stenosis and the Oxfordshire Community Stroke Project (OCSP) classification. Chinese patients (n = 817) were classified according to OCSP criteria, and arterial abnormalities were evaluated in 342 of the patients by digital subtraction angiography. Prevalence of significant stenosis in the extracranial internal carotid artery was highest among total anterior circulation infarct patients and lowest among patients with lacunar infarct. There was no evidence that the frequency of patients with intracranial arterial significant stenosis was different among OCSP subtypes. The results suggest that extracranial internal carotid artery stenosis was significantly related to OCSP subtype and that patients with total anterior circulation infarct were more likely to have extracranial internal carotid artery stenosis than patients having partial anterior circulation infarct, posterior circulation infarct or lacunar infarct.

Stroke: epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management

Cerebrovascular accident, or stroke, refers to an acute onset of neurologic deficits lasting more than 24 hours or culminating in death caused by a sudden impairment of cerebral circulation. Stroke is the third leading cause of death and a major cause of long-term disability in the United States. This article provides the dental community with an up-to-date understanding of the epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management issues pertaining to stroke.

Comorbidity of Alcohol Abuse and Dependence with Medical Conditions in 2 American Indian Reservation Communities

BACKGROUND

The objective was to examine the association of self-reported Diagnostic and Statistical Manual-IV edition alcohol abuse and dependence with medical conditions among American Indians (AIs).

METHODS

We analyzed data previously collected in a large epidemiological study of members of 2 culturally distinct AI tribes from the Southwest (SW; n = 1,446) and the Northern Plains (NP; n = 1,638) living on or near their reservations. Associations of combined self-reported alcohol abuse and alcohol dependence with 19 medical conditions were examined through multinomial logistic regression.

RESULTS

Medical conditions that had significant relationships with alcohol abuse/dependence were sprains and strains [odds ratio (OR) 2.04, p < 0.001], hearing and vision problems (OR 2.05, p < 0.001), kidney and bladder problems (OR 1.55, p < 0.01), head injuries (OR 2.20, p < 0.001), pneumonia/tuberculosis (OR 1.49, p < 0.01), dental problems (OR 1.89, p < 0.001), and liver problems/pancreatitis (OR 2.18, p < 0.001). The total count of medical conditions was also significantly related to alcohol abuse/dependence, with a higher count being associated with the outcome (OR 1.17, p < 0.001).

CONCLUSIONS

In this community-based study of rural AIs, diverse medical conditions were associated with alcohol abuse and dependence. Further research should examine, and confirm, the nature, extent, and tribal variation of the medical consequences of alcohol abuse and dependence in these unique populations.

A possible explanation for the racial difference in distribution of large-arterial cerebrovascular disease: ancestral European settlers evolved genetic resistance to atherosclerosis, but confined to the intracranial arteries

The pattern of cerebral atherosclerosis is not the same among different races. White patients rarely have intracranial large arterial steno-occlusive disease even if their systemic arteries are extensively involved, while non-white patients frequently have their intracranial arteries affected. We postulate that during human population diversification, those who settled in Europe had acquired a stroke-suppressor genotype that increases their resistance against atherogenesis, but with protection confined to the intracranial large arteries. The contemporary affluent lifestyle accelerates the development of atherosclerosis. In the whites, it involves the whole arterial bed except the intracranial vessels. People living in non-Western countries used to have a healthier way of living. They did not develop significant atherosclerotic diseases until recently when a westernised lifestyle was adopted. Unlike the whites, their intracranial arteries will not be spared. Atherosclerosis has become a major cause of premature mortality in the modern world, and an anti-atherogenic mechanism would confer a selection advantage. With further adaptive intensification, this protection may extend to the rest of the arterial bed. As a result, future Homo sapiens will be able to tolerate an affluent lifestyle without much adverse sequel such as premature vascular death. Alternatively, if the mediator of this anti-atherogenic mechanism can be identified and applied therapeutically, we will have an ultimate mean to prevent atherosclerosis.

Epidemiology of stroke in African Americans and Hispanic Americans

Many minorities continue to experience disparities in the level of their personal health and overall health care in the United States. This article explores disparities in stroke as they relate to two minority populations: African Americans and Hispanic Americans. These two groups have been chosen for review and discussion because the available epidemiologic databases are relatively broad, and the authors have personal experience in the conduct of research studies in these populations.

Incidence, 30-day case-fatality rate, and prognosis of stroke in Iquique, Chile: a 2-year community-based prospective study (PISCIS project)

BACKGROUND

The epidemiology of stroke in Latin-American populations and variation of subtypes between communities are unclear. Our aim was to ascertain prospectively the incidence of first-ever stroke in the predominantly Hispanic-Mestizo population of Iquique, a city in the northern desert region of Chile.

METHODS

We prospectively identified all possible cases of stroke and transient ischaemic attacks between July 1, 2000, and June 30, 2002, from several overlapping sources. Patients were rapidly assessed by two field neurologists. Standard definitions for incident cases, stroke, transient ischaemic attack, pathological type, and infarction subtype were used. All cases identified were adjudicated by at least two stroke neurologists and followed up at 6 months. Incidence rates of first-ever strokes were calculated from the population of Iquique (214 526) according to the national census of 2002.

FINDINGS

Of 380 cases of stroke identified, 292 were incident. CT scans were done in 267 (91%) patients and the mean time to scan was 2.2 days. The hospital admission rate was 71% (207/292). The overall age-adjusted incidence rate of first-ever stroke was 140.1 per 100,000 (95% CI 124.0-156.2). The incidence rates per 100,000 according to pathological type were: infarcts 87.3, intracerebral haemorrhage 27.6, and subarachnoid haemorrhage 6.2. The 30 day and 6-month case-fatality rates were 23.3% and 33.0%, respectively.

INTERPRETATION

Our results show incidence rates of stroke similar to those reported in other community studies. Although the proportion of intracerebral haemorrhages was higher than reported in previous studies, the overall incidence was not, which could indicate a slightly lower incidence of ischaemic strokes in this population than in other countries. The prognosis was similar to that found in other population-based studies.

Hospital-based prospective registration of acute ischemic stroke and transient ischemic attack in Japan

The purpose of this study was to obtain fundamental information on patients with acute ischemic stroke and transient ischemic attack (TIA) in Japan. We prospectively registered consecutive stroke and TIA patients who visited 156 participating hospitals within 7 days of onset between May 1, 1999 and April 30, 2000. A total of 16,922 patients with 70.6 +/- 11.5 years old (median 71, range 18-107) were enrolled in the study. TIA was seen in 7% of registered patients, lacunar stroke in 36%, atherothrombotic in 31%, cardioembolic stroke in 20%, and other in 6%. Hypertension was present in 61%, diabetes mellitus in 24%, atrial fibrillation (AF) in 21%, smoking in 18%, and hypercholesterolemia in 17%. Overall, 37% of patients arrived at hospital within 3 hours of symptom onset, and 50% within 6 hours. Among those who visited the hospital within 6 hours, 64% used an ambulance service. Mean NIHSS score was 8.0 +/- 7.9 (median, 5). Only 3% were treated with thrombolytic agents in acute phase of stroke. Only 19% of all patients were treated in stroke care unit or intensive care unit. The modified Rankin Scale score of 0 to 2 at discharge was observed in 61% of the patients, 3 to 5 in 32%, and the mortality rate was 7%. More than half of the acute stroke patients arrived at the hospital after 6 hours of onset, and the stroke care unit was used only in one fifth of all patients. Establishment of ideal emergency system and arrangement of stroke units are also awaited for better management and improvement of patients' outcome.

The effect of diabetes combined with stroke on disability, self-rated health, and mortality in older Mexican Americans: results from the Hispanic EPESE

OBJECTIVE

To examine how diabetes in combination with stroke affects functional activities of daily living (ADLs) and instrumental activities of daily living (IADLs), self-rated health, and 5-year mortality in elderly Mexican Americans with or without other comorbid conditions.

DESIGN

Longitudinal study.

SETTING

Five southwestern states.

PARTICIPANTS

A total of 3050 subjects of age 65 years or older, of whom 23% had diabetes and 6% had a stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

ADL and IADL disabilities, self-rated health, and 5-year mortality.

RESULTS

Subjects with both diabetes and stroke but without other comorbid conditions had almost 18 times higher risk of having any ADL disability (odds ratio [OR]=18.8; 95% confidence interval [CI], 3.3-105.2) and 10 times higher risk of having any IADL disability (OR=10.6; 95% CI, 1.1-101.5), compared with subjects without either of the 2 conditions. The risk of disability was further increased if the subject had a comorbid condition (hypertension, heart attack, cancer, hip fracture, arthritis). The risk of fair or poor self-rated health was 3.5 (95% CI, 1.4-8.6) and the hazard ratio for 5-year mortality was 2.4 (95% CI, 1.7-3.4) in people with both diseases.

CONCLUSIONS

Diabetes and stroke in combination is strongly associated with a higher risk of disabilities, poor self-rated health, and 5-year mortality in elderly Mexican Americans. The effect on outcomes appears to follow an additive model. Information on disability risk and morbidity and mortality should be useful to rehabilitation professionals in discharge planning and allocation of therapy resources.

Management of acute stroke

Stroke ranks as the third leading cause of death and the most common cause of permanent disability in adults. Timely recognition and treatment is imperative to reduce stroke-related morbidity and mortality. Patients with acute ischemic stroke should be evaluated for administration of intravenous tissue plasminogen activator (t-PA); those who do not qualify for t-PA should receive aspirin therapy in the absence of a contraindication. In all stroke patients, intravenous hydration with normal saline should be administered, hypoxia should be corrected with supplemental oxygen, and hyperglycemia and fever should be treated aggressively. Blood pressure management should be individualized on the basis of stroke pathophysiology and specific treatment plan (e.g., planned thrombolysis) following published guidelines. Evaluation of stroke etiology should be undertaken, and the results should be used to guide secondary stroke prevention efforts.

The epidemiology of atherosclerosis and its risk factors among Native Americans

In the past, the rates of risk factors for atherosclerosis and cardiovascular disease (CVD) as well as the manifestations of coronary heart disease, stroke, and peripheral vascular disease in Native Americans have been relatively low compared to the general United States population. However, over the past several decades the rates of these CVD-associated risk factors have markedly increased with the concomitant development of a significant and alarming rise in the manifestations of atherosclerosis.

Neurologic manifestations of cardiogenic embolism: an update

Cardiogenic embolism is increasingly appreciated as an important and preventable cause of stroke. Several potential sources of embolism have been identified with the advent of transoesophageal echocardiography. Their role as independent risk factors for stroke and management implications based on recent evidence, along with characterization of schemes for antithrombotic management of patients with atrial fibrillation are reviewed.

Stroke in Hispanic Americans

The Hispanic American population is the fastest growing minority group with increasing representation among the older age strata. Current ethnic-specific cerebrovascular disease data regarding stroke outcomes and risk factor status reveal significant differences compared with other race/ethnic groups. The authors discuss the literature on stroke incidence and mortality among Hispanic populations. Traditional risk factors, access to care and stroke mechanism differences are also discussed. Advances in Hispanic American specific stroke prevention and treatment efforts demand further investigation to better define Hispanic American stroke prevention and acute treatment strategies.

The Dundee Stroke Register: experience of the first ten years

The objective to establish a register of all patients admitted to Dundee hospitals with acute stroke has been achieved. To do this a computerised database system has been established and a prospective survey has been conducted of clinical data of patients at time of admission, with follow-up at one and three years. All patients with a WHO diagnosis of acute stroke (excluding patients with subarachnoid haemorrhage), from January 1988 have been recorded. By the end of 1998, 3222 patients had been registered. The Dundee Stroke register database is the largest in Scotland and one of the largest in the world. The establishment of the register and database has required substantial investment of resources and the collaboration of the NHS, universities and the private sector. The operation of the register has heightened interest in stroke. It also provides present and future opportunities for clinical research and audit studies and the monitoring of outcomes.