Causes and Trends of Disabilities in Community-Dwelling Stroke Survivors: A Population-Based Study

Elevated risk of end-stage kidney disease in stroke patients: A population-based observational study

BACKGROUND

Estimating the incidence of end-stage kidney disease (ESKD) in stroke survivors is important to assess and predict clinical course, improve post-stroke quality of life, and ultimately reduce health burden.

AIM

Our objective was to assess the risk of ESKD in patients compared to a matched stroke-free control cohort.

METHODS

A nationwide retrospective cohort study was conducted in 315,326 stroke subjects and 390,781 matched stroke-free control subjects. Health examination results and claims data were collected from the Korean National Health Insurance Service during 2010-2018. Cox proportional hazard models were used to assess the risk of ESKD in the stroke cohort.

RESULTS

During a mean follow-up period of 4.3 years, the incidence of ESKD was 1.83 per 100,000 person-years in the stroke cohort versus 0.57 per 100,000 person-years in the control cohort. The stroke cohort exhibited a significantly higher risk of developing ESKD compared to the matched control, with an adjusted hazard ratio (aHR) of 1.79 (95% confidence interval (CI) = 1.67-1.93). Stroke survivors were associated with a higher risk of developing ESKD, regardless of the severity of disability (aHRs of 1.93, 95% CI = 1.69-2.21 for severe disability; 1.71, 95% CI = 1.41-2.07 for mild disability; and 1.78, 95% CI = 1.65-1.92 for no disability), compared to the matching control cohort. The elevated risk was observed in both hemorrhagic stroke (aHR = 1.96, 95% CI = 1.73-2.23) and ischemic stroke (aHR = 1.75, 95% CI = 1.62-1.89).

CONCLUSIONS

This study demonstrates that stroke patients have a significantly higher risk of incident ESKD. This highlights the need for heightened clinical awareness and improved monitoring of kidney function in this population.

Trends in stroke incidence, death, and disability outcomes in a multi-ethnic population: Auckland regional community stroke studies (1981-2022)

Background

Reliable data on trends of stroke incidence and outcomes over time are necessary for assessing the effectiveness of public health and clinical strategies, and for allocating healthcare resources. We assessed the levels and trends in incidence, mortality, early case fatality and disability for stroke in a defined, ethnically mixed population over 40 years.

Methods

To analyse data from five population-based stroke incidence studies in adult residents (age ≥15 years) of the Greater Auckland Region of New Zealand (NZ) (1.35 million) over 12-month calendar periods for 1981-1982, 1991-1992, 2002-2003, 2011-2012, and 2021-2022. Fatal and non-fatal, hospitalised and non-hospitalised stroke events (first-ever and recurrent) were identified through multiple overlapping sources using clinical World Health Organization (WHO) diagnostic criteria and neuroimaging to define three major pathological types of stroke: ischaemic stroke (IS), primary intracerebral haemorrhage (PICH), subarachnoid haemorrhage (SAH), and stroke of undetermined type (SUT). Crude and age-standardised annual incidence, mortality, 28-day case fatality and disability level, and 40-year trends were calculated by age, sex, and ethnicity assuming a Poisson distribution. For comparison of our findings, we carried out a pooled analysis of methodologically comparable population-based stroke epidemiology estimates in high-income countries over the last two decades.

Findings

Overall, there were 7462 first-ever strokes (9917 events) over the 40-year period (4,682,012 person-years). From 1981-1982 to 2021-2022, age-standardised stroke incidence rates decreased from 156/100,000 (95% confidence interval [CI] 143; 170) to 124/100,000 (119; 130) and mortality rates from 98/100,000 (88; 110) to 28/100,000 (26; 31) in nearly all age, sex, and ethnic groups. Moreover, from 2002-2003 to 2021-2022, there was an increase in stroke incidence of 1.28% per year (95% CI 0.38-2.17) in people aged 15-54 years, with the mean age of people with stroke decreasing from 73.0 (SD ± 13.8) in 2002-2003 to 71.6 (SD ± 14.9) in 2011-2012 and 70.7 (SD ± 15.2) years in 2021-2022 (p for trend <0.0001). The risk of stroke in Māori and Pacific people in 2021-2022 was almost 1.5 and 2.0 times greater than that in NZ Europeans. Ethnic disparities in the risk of stroke and age of stroke onset remained stable over the study period. From 1981-1982 to 2021-2022, 28-day stroke case fatality declined from 33.1% to 12.1% (p < 0.0001). There was a trend towards reducing 28-day case-fatality (from 31.6% [95% CI 27.6; 35.7] in 1981-1982 to 11.4% [10.0; 12.7] in 2021-2022) and an increasing proportion of stroke survivors with good functional outcome at discharge/28-days post-stroke (increased from 45.7% (95% CI 41.3; 50.0) in 1981-1982 to 60.2% (58.1; 62.3) in 2021-2022).

Interpretation

Stroke incidence, 1-year mortality and 28-day case-fatality and disability have decreased in Auckland, NZ over the last 4 decades. However, over the last decade (2011-2022) there was a stagnation in the decline in the age-standardised stroke incidence rates. The absolute numbers of people with strokes, and those who have died or remained disabled from stroke, have significantly increased from 1981 to 2022. Ethnic disparities in the risk and burden of stroke persist. Effective prevention strategies for stroke must remain a high priority.

Funding

Health Research Council of New Zealand.

Rehabilitation success and related costs following stroke in a regional hospital: a retrospective analysis based on the Australian National Subacute and Non-Acute Patient (AN-SNAP) classification

BACKGROUND

Evidence is limited on the factors influencing successful stroke rehabilitation in regional contexts. Additionally, the relationship between rehabilitation costs following acute stroke, based on Australian National Subacute and Non-Acute Patient (AN-SNAP) casemix classification, and rehabilitation success remains unclear.

OBJECTIVE

This retrospective cohort study investigated the factors contributing to improved functional outcomes following stroke rehabilitation in an Australian regional hospital, also evaluating the respective average daily and total payments.

METHODS

Stroke patients' admission records, during 2010-2020, were linked with rehabilitation registry data. Rehabilitation success was defined as relative functional gain (RFG) ≥ 0.5 and Functional Independence Measure (FIM) efficiency ≥ 1. Multivariate mixed effects logistical regressions modelled the sociodemographic and medical (i.e., comorbidities and stroke type) predictors of rehabilitation success, while logarithms of average daily and total rehabilitation payments were modelled using robust regressions.

RESULTS

Of 582 included patients, 315 (54.1%) achieved RFG ≥ 0.5 and 258 (52.2%) achieved FIM efficiency ≥ 1. A longer delay in starting rehabilitation was associated with a lower likelihood of achieving RFG success [Odds Ratio (OR): 0.85, 95% confidence interval (CI): 0.78-0.93, P < 0.001] and FIM efficiency success (OR: 0.89, 95% CI: 0.82-0.97, P = 0.010). A higher FIM score at admission was associated with decreased odds of FIM efficiency success (OR: 0.35, 95% CI: 0.20-0.60, P < 0.001). The average daily and total rehabilitation payments for inpatients were $AU1,255 (median) [interquartile range (IQR): 1,040, 1,771] and $AU28,363 (median) (IQR: 18,822, 41,815), respectively. FIM efficiency success was positively associated with the average daily payment (Beta: 0.25, 95% CI: 0.20-0.30, P < 0.001), but negatively correlated with the total payment (Beta: -0.18, 95% CI: -0.24-0.13, P < 0.001). No significant associations were found between RFG success and these payments.

CONCLUSION

This study identifies key factors affecting stroke rehabilitation outcomes in a regional Australian setting. Delays in starting rehabilitation were linked to lower success rates, underscoring the importance of timely intervention. While higher average daily costs were associated with better FIM efficiency, total costs did not correlate with relative functional gains. These findings may inform rehabilitation practices and may influence future funding strategies for rehabilitation services.

Expanding Surgical Frontiers Across the Pacific Ocean: Insights from the First Telesurgery Procedures Connecting Orlando with Shanghai in Animal Models

BACKGROUND AND OBJECTIVE

Telesurgery is as a promising solution to support and deliver advanced health care services to underserved areas. The primary endpoint of our study was to prove the concept of low-latency long-distance connectivity and to describe the feasibility of remote surgery.

METHODS

A prospective study was conducted from February 29 to March 1, 2024, in live animal models (porcine) connecting surgeons from Orlando (USA) to the animal laboratory in Shanghai (China) using 5G and Wi-Fi connections, in combination with continental and transpacific fiber. We performed ten radical nephrectomies and two partial nephrectomies in five animals using the MicroPort MedBot robotic platform. Intraoperative and telesurgery connection variables were reported with a descriptive statistical analysis.

KEY FINDINGS AND LIMITATIONS

No complications or conversions were reported. The mean animal weight was 38.2 (35-40) kg, the mean operative time was 32.7 (21-45) min, and the mean blood loss was 23.3 (20-30) ml. The mean latency was 296 (±50) ms. Findings from animal studies may not always translate directly to human outcomes.

CONCLUSIONS AND CLINICAL IMPLICATIONS

We described the feasibility of transpacific low-latency telesurgery in live porcine models with no intraoperative complications. Achieving optimal low-latency connectivity via telecommunication networks was essential for effectively performing the surgical procedures. However, we still need further investigation to achieve even lower latencies for human trials. We found that long-distance telesurgery is safe and feasible in animal models. However, it is a complex practice, and we still need further studies before translating these results to human trials.

PATIENT SUMMARY

Our research has demonstrated the feasibility of low-latency long-distance telesurgery in live animal models. However, this type of telesurgery is a complex procedure, and further work is needed to translate these results to human trials.

Remote delivery of seated exercises transfers to improved balance and mobility after stroke: a case report

INTRODUCTION

Seated exercises can reduce the need for in-person assistance during remote-delivered programs, but its safety implications in stroke are unknown.

OBJECTIVE

This case-report investigates the effect of a novel, remotely delivered 2-week seated exercise program on mobility in a person living with stroke.

CASE DESCRIPTION

A 68-year-old man living with a chronic stroke (>1-year post-stroke) and moderate disability (Modified Rankin Scale = 3) participated in a 2-week seated exercise program delivered remotely through videoconferencing (Zoom). Sessions were 60 min, 3 times per week. The participant worked on average at 37% of heart rate reserve (range: 21-53%).

OUTCOMES

No adverse events were reported during the 2-week intervention. After 2 weeks, Berg Balance Scale score improved by five points. Distance in the six-minute walk test increased from 218 m to 278 m and walking speed increased at self-selected walking (0.18 m/s) and fast-walking (0.28 m/s) pace. Sit-to-stands increased from 5 to 9 sit-to-stands in 30 s. Stroke Impact Scale improved in the following domains: hand function, activities of daily living, mobility, and participation.

DISCUSSION

This novel case-report demonstrated the potential for a 2-week seated exercise program to transfer to meaningful improvements in balance and mobility in a person living with a chronic stroke and mobility impairment. Given the stable seated position, no in-person support was required, while the instructor safely delivered the intervention remotely.

Two-phase therapy for improving neuroprotection and neurogenesis: Preventive use of omega fatty acids plus Copolymer-1 immunization after stroke

Stroke is a major global health issue, ranking as the second leading cause of death and the primary cause of disability worldwide. However, current therapeutic options remain limited. Nutritional supplementation as a form of primary prevention stands as a potential stroke therapeutic. In particular, the intake of omega-3 fatty acids (omega-3FA) exerts anti-inflammatory and neuroprotective effects that help reduce the risk of stroke. In parallel, treatment with Copolymer-1 (COP-1), a peptide with immunomodulatory properties through Th1/Th2/Th3 phenotype switching, similarly affords neuroprotective and neurorestorative effects in stroke models. To investigate the combined effects of these treatments, we designed a two-phase therapy: the first phase involved preventive supplementation with omega-3FA, while the second phase included COP-1 immunization following stroke injury. Sprague-Dawley rats were randomly assigned to one of the four groups: 1) control, 2) omega-3FA, 3) COP-1, and 4) omega-3FA + COP-1. Omega-3FAs were administered for 28 days before inducing stroke. Thirty minutes after reperfusion, the respective groups were immunized with COP-1. Seven days post-stroke, neurological deficits were assessed using the Zea-Longa scale, infarct volumes with 2,3,5-triphenyltetrazolium chloride (TTC) staining, and levels of neurogenesis via immunofluorescence imaging. The results showed that the two-phase therapy produced significant synergistic effects, markedly reducing neurological deficits, and infarct volumes, while enhancing neurogenic activities in neurogenic niches. This combined approach underscores the potential of integrating nutritional and pharmacological strategies to enhance stroke recovery.

The Humanitarian Impact of Telesurgery and Remote Surgery in Global Medicine

Telesurgery is a natural evolution of robotic surgery and has potential to address health care deficiencies in underserved areas of the globe. The same expert can reach more patients on the same day via telesurgery, and emergency procedures for neurovascular and cardiac events could be performed at the appropriate time, reducing deaths and disabilities.

Dynamic changes and lifetime effect of functional disability profiles for stroke patients: real-world evidence from South Korea

PURPOSE

This work aimed to investigate the long-term dynamic changes of functional disabilities and estimate lifetime outcomes of different functional disabilities after a stroke, using real-world data from a nationally representative South Korean cohort.

METHODS

Patients aged 18 and above with ischemic and hemorrhagic strokes were identified from the Korea Health Panel (KHP) data (2008-2018). Functional disabilities were repeatedly measured for patients aged 55 and over for the prevalence of disabilities associated with activities of daily living (ADL), and kernel smoothing means were estimated for each item. The lifetime survival function of stroke patients in Korea was adopted from another study utilizing the National Health Insurance Service of Korea's national sample cohort. By multiplying the disability-free proportion with the survival function throughout life, disability-free life expectancy (DFLE) for each ADL item was estimated. The loss-of-DFLE was calculated by subtracting the DFLE from age-, sex-, and calendar year-matched referents simulated from Korean life tables.

RESULTS

The KHP dataset included 466 stroke patients. The overall functional disability needs increased over time after stroke diagnosis. DFLE was lowest for bathing (10.1 years for ischemic stroke and 12.8 years for hemorrhagic stroke), followed by those for dressing and washing. Loss-of-DFLE was highest for bathing for ischemic and hemorrhagic strokes (7.2 and 10.7 years, respectively), indicating that this task required the most assistance for stroke patients compared with the other tasks. DFLEs were slightly lower than the quality-adjusted life expectancy of stroke patients.

CONCLUSION

Our findings provide valuable insights for resource allocation and policy decisions in long-term stroke care, potentially enhancing the quality of life for stroke survivors and caregivers.

Associated Factors of Time Spent Walking for Community-Dwelling Stroke Survivors

BACKGROUND

This study aimed to investigate the factors associated with the time that community-dwelling stroke survivors spent walking.

METHODS

We analyzed the cross-sectional data of 1534 community-dwelling stroke survivors from the Korean National Health and Nutrition Examination Survey. Complex-sample logistic regression analyses were performed to determine the factors associated with insufficient walking time (<90 min/wk). The mean time spent walking was examined according to age, sex, resistance exercise level, and self-reported disability using complex-sample general linear models.

RESULTS

Women (odds ratio [OR] 1.5; 95% confidence interval [CI], 1.0-2.3), current smokers (OR 1.7; 95% CI, 1.1-2.8), insufficient resistance exercise (OR 2.3; 95% CI, 1.5-3.5), and those with rural residences (OR 1.4; 95% CI, 1.0-1.9) were independently associated with insufficient walking time. The mean time spent walking was significantly lower in older adults aged ≥65 years than in young adults aged <65 years (200.0 ± 42.0 min/wk vs 287.2 ± 36.6 min/wk, P = .002), in women than in men (200.9 ± 44.9 vs 286.2 ± 37.7 min/wk, P = .027), and in individuals engaging in insufficient resistance exercise compared with those engaging in sufficient resistance exercise (203.2 ± 36.2 vs 283.9 ± 43.0 min/wk, P = .008). The mean walking time did not vary according to the presence of self-reported disabilities.

CONCLUSIONS

Environmental and personal factors are associated with insufficient walking time in community-dwelling stroke survivors.

Two stroke education programs designed for older adults

Stroke is an important public health problem worldwide and in Korea causing death and serious long-term disability. This study tested the feasibility, acceptability, and preliminary efficacy of two stroke education programs. The pictogram-based education program was administered to 118 participants, and the PowerPoint-based education program was administered to 108 participants. Stroke knowledge (stroke definition, risk factors, warning signs) and first action knowledge in the event of stroke were assessed among all participants prior to and following completion of their respective programs. Both stroke education programs showed similar, significant improvements in stroke knowledge and first action knowledge from baseline to posttest. Also, feasibility (81-88 % participation and 96 % completion) and acceptability (86-97 % satisfaction) of both stroke education programs were supported. These findings indicate that healthcare professionals can use either of the education programs to improve stroke knowledge and first action knowledge among older adults who are at high risk for stroke.

Association of physical activity, smoking, and socioeconomic factors on health checkup participation in community-dwelling stroke survivors aged 50 years or older

BACKGROUND

We investigated the sociodemographic and health-related factors associated with health checkup participation in community-dwelling stroke survivors.

METHODS

Among participants of the Korea National Health and Nutrition Examination Survey, 642 stroke survivors were included. We investigated the sociodemographic, medical, and health-related quality of life factors-evaluated by the EuroQol 5-Dimension Questionnaire (EQ-5D)-associated with participation in any type of health checkup. To explore the associations between multiple variables and health checkup participation, a multivariable complex-sample logistic regression model was used.

RESULTS

One-third of the community-dwelling stroke survivors did not receive a health checkup in the past two years. Insufficient physical activity (OR: 0.5, 95% CI: 0.3-0.9), current smoking (OR: 0.4, 95% CI: 0.2-0.8), low education level (OR: 0.5, 95% CI: 0.3-0.9), living alone (OR: 0.5, 95% CI: 0.3-0.998), and no occupation (OR: 0.5, 95% CI: 0.3-0.9) showed independent negative associations with health checkup participation. Among the five EQ-5D dimensions, mobility, self-care, usual activities, and pain/discomfort dimensions were associated with health checkup participation rate.

CONCLUSION

Policies and further research are needed to promote health checkups for stroke survivors who are physically inactive, currently smoking, living alone, unemployed, less educated, or having extreme problems in their daily lives.