Stroke incidence on the east coast of Australia: the North East Melbourne Stroke Incidence Study (NEMESIS)

Significant Disparity of Access to Stroke Treatment Between the Western Parts and Eastern and Northern Parts of Sydney

Objective To provide an estimate of access times and distances to an endovascular clot retrieval (ECR) service provider for a typical stroke patient in the western part of Sydney and to compare it with the eastern and northern parts. Methods Incidences of stroke were simulated through a population-weighted randomized selection of addresses in the studied western, eastern, and northern areas of Sydney (100,000 times for each). The access times and distances were calculated from those addresses to the closest ECR hub for the eastern and northern parts and to all five ECR hubs, as well as the Nepean Public Hospital (NPH) for the western part. The access times and distance means were compared statistically using ANOVA. Results In the western areas, the estimated average access times and distances to different ECR hubs varied from 38.5 (+/- 15) to 45 (+/- 15) minutes and from 42 (+/- 15.9) to 46.8 (+/- 16) km in working hours and from 45 (+/- 15) to 64 (+/- 15) minutes and 46.8 (+/- 16) to 69.6 (+/- 16) km in after hours. However, the estimated average access times and distances to the local ECR hub were 12.25 (+/- 6) minutes and 9.1 (+/- 5.6) km for northern and 7.5 (+/- 4) minutes and 4.4 (+/- 2.5) km for the eastern areas. The differences between the estimated average access times and distances for a typical stroke patient to an ECR hub in the western areas in comparison with eastern or northern areas were statistically significant (p<0.0001). The average access times and distances in the western part to NPH were 17 (+/- 16) minutes and 15.6 (+/- 16.6) km. Conclusions The patients in the western part of Sydney had significantly longer access times to ECR hubs than those living in comparable areas of the eastern and northern parts. This study supports the Nepean Public Hospital supplying an ECR service to achieve travel times, and, therefore, treatment times for a typical stroke patient in the western parts, similar to patients in the eastern and northern parts of Sydney.

Area-level and individual-level socio-economic differences in health-related quality of life trajectories: Results from a 10-year longitudinal stroke study

BACKGROUND

We examined area-level (aSES) and individual-level (iSES) socio-economic status on trajectories of HRQoL to 10 years following stroke.

METHODS

Participants with strokes between 1/5/1996 and 30/4/1999 completed the Assessment of Quality of Life instrument (AQoL, range: -0.04 [worse than death] to 0 [death] to 1 [full health]) at ≥one of 3month, 6-month, 1-year, 2-year, 3-year, 4-year, 5-year, 7-year and 10-year interviews after stroke. Sociodemographic and health information were collected at baseline. We derived aSES from postcode using the Australian Socio-Economic Indexes For Area (2006) (categories: high, medium, low), and iSES from lifetime occupation (categories: non-manual, manual). Multivariable linear mixed effects modelling was used to estimate trajectories of HRQoL over 10 years, by aSES and iSES, adjusting for age, sex, cardiovascular disease, smoking, diabetes, stroke severity, stroke type, and the time influence on age and health conditions.

RESULTS

Of 1,686 participants enrolled, we excluded 239 with 'possible' stroke and 284 with missing iSES. Among the remaining 1,163 participants, 1,123 (96.6%) had AQoL assessed at ≥3 timepoints. In multivariable analysis, over time, people in the medium aSES group had mean 0.02 (95% CI -0.06, 0.02) greater reduction in AQoL score, and people in the low aSES group had mean 0.04 (95% CI, -0.07, -0.001) greater reduction, than those in the high aSES group. Manual workers had an average 0.04 (95% CI, -0.07, -0.01) greater reduction in AQoL score over time than non-manual workers.

CONCLUSIONS

Over time, HRQoL declines in all people with stroke, declining most rapidly in lower SES groups.

When to initiate palliative care in neurology

Life-limiting and life-threatening neurologic conditions often progress slowly. Patients live with a substantial symptom burden over a long period of time, and there is often a high degree of functional and cognitive impairment. Because of this, the most appropriate time to initiate neuropalliative care is often difficult to identify. Further challenges to the incorporation of neuropalliative care include communication barriers, such as profound dysarthria or language impairments, and loss of cognitive function and decision-making capacity that prevent shared decision making and threaten patient autonomy. As a result, earlier initiation of at least some components of palliative care is paramount to ensuring patient-centered care while the patient is still able to communicate effectively and participate as fully as possible in their medical care. For these reasons, neuropalliative care is also distinct from palliative care in oncology, and there is a growing evidence base to guide timely initiation and integration of neuropalliative care. In this chapter, we will focus on when to initiate palliative care in patients with life-limiting, life-threatening, and advanced neurologic conditions. We will address three main questions, which patients with neurologic conditions will benefit from initiation of palliative care, what aspects of neurologic illness are most amenable to neuropalliative care, and when to initiate neuropalliative care?

Application of Machine Learning Techniques to Identify Data Reliability and Factors Affecting Outcome After Stroke Using Electronic Administrative Records

Aim: To use available electronic administrative records to identify data reliability, predict discharge destination, and identify risk factors associated with specific outcomes following hospital admission with stroke, compared to stroke specific clinical factors, using machine learning techniques. Method: The study included 2,531 patients having at least one admission with a confirmed diagnosis of stroke, collected from a regional hospital in Australia within 2009-2013. Using machine learning (penalized regression with Lasso) techniques, patients having their index admission between June 2009 and July 2012 were used to derive predictive models, and patients having their index admission between July 2012 and June 2013 were used for validation. Three different stroke types [intracerebral hemorrhage (ICH), ischemic stroke, transient ischemic attack (TIA)] were considered and five different comparison outcome settings were considered. Our electronic administrative record based predictive model was compared with a predictive model composed of "baseline" clinical features, more specific for stroke, such as age, gender, smoking habits, co-morbidities (high cholesterol, hypertension, atrial fibrillation, and ischemic heart disease), types of imaging done (CT scan, MRI, etc.), and occurrence of in-hospital pneumonia. Risk factors associated with likelihood of negative outcomes were identified. Results: The data was highly reliable at predicting discharge to rehabilitation and all other outcomes vs. death for ICH (AUC 0.85 and 0.825, respectively), all discharge outcomes except home vs. rehabilitation for ischemic stroke, and discharge home vs. others and home vs. rehabilitation for TIA (AUC 0.948 and 0.873, respectively). Electronic health record data appeared to provide improved prediction of outcomes over stroke specific clinical factors from the machine learning models. Common risk factors associated with a negative impact on expected outcomes appeared clinically intuitive, and included older age groups, prior ventilatory support, urinary incontinence, need for imaging, and need for allied health input. Conclusion: Electronic administrative records from this cohort produced reliable outcome prediction and identified clinically appropriate factors negatively impacting most outcome variables following hospital admission with stroke. This presents a means of future identification of modifiable factors associated with patient discharge destination. This may potentially aid in patient selection for certain interventions and aid in better patient and clinician education regarding expected discharge outcomes.

Intracisternal administration of tanshinone IIA-loaded nanoparticles leads to reduced tissue injury and functional deficits in a porcine model of ischemic stroke

Background

The absolute number of new stroke patients is annually increasing and there still remains only a few Food and Drug Administration (FDA) approved treatments with significant limitations available to patients. Tanshinone IIA (Tan IIA) is a promising potential therapeutic for ischemic stroke that has shown success in pre-clinical rodent studies but lead to inconsistent efficacy results in human patients. The physical properties of Tan-IIA, including short half-life and low solubility, suggests that Poly (lactic-co-glycolic acid) (PLGA) nanoparticle-assisted delivery may lead to improve bioavailability and therapeutic efficacy. The objective of this study was to develop Tan IIA-loaded nanoparticles (Tan IIA-NPs) and to evaluate their therapeutic effects on cerebral pathological changes and consequent motor function deficits in a pig ischemic stroke model.

Results

Tan IIA-NP treated neural stem cells showed a reduction in SOD activity in in vitro assays demonstrating antioxidative effects. Ischemic stroke pigs treated with Tan IIA-NPs showed reduced hemispheric swelling when compared to vehicle only treated pigs (7.85 ± 1.41 vs. 16.83 ± 0.62%), consequent midline shift (MLS) (1.72 ± 0.07 vs. 2.91 ± 0.36 mm), and ischemic lesion volumes (9.54 ± 5.06 vs. 12.01 ± 0.17 cm³) when compared to vehicle-only treated pigs. Treatment also lead to lower reductions in diffusivity (-37.30 ± 3.67 vs. -46.33 ± 0.73%) and white matter integrity (-19.66 ± 5.58 vs. -30.11 ± 1.19%) as well as reduced hemorrhage (0.85 ± 0.15 vs 2.91 ± 0.84 cm³) 24 h post-ischemic stroke. In addition, Tan IIA-NPs led to a reduced percentage of circulating band neutrophils at 12 (7.75 ± 1.93 vs. 14.00 ± 1.73%) and 24 (4.25 ± 0.48 vs 5.75 ± 0.85%) hours post-stroke suggesting a mitigated inflammatory response. Moreover, spatiotemporal gait deficits including cadence, cycle time, step time, swing percent of cycle, stride length, and changes in relative mean pressure were less severe post-stroke in Tan IIA-NP treated pigs relative to control pigs.

Conclusion

The findings of this proof of concept study strongly suggest that administration of Tan IIA-NPs in the acute phase post-stroke mitigates neural injury likely through limiting free radical formation, thus leading to less severe gait deficits in a translational pig ischemic stroke model. With stroke as one of the leading causes of functional disability in the United States, and gait deficits being a major component, these promising results suggest that acute Tan IIA-NP administration may improve functional outcomes and the quality of life of many future stroke patients.

The characteristics of stroke and its rehabilitation in Northern Tanzania

BACKGROUND

Stroke causes great suffering and severe disability worldwide, and rehabilitation following a stroke seeks to restore lost functions. The extent to which stroke patients get access to rehabilitation in Tanzania is not well estimated, and drawing a current picture of the rehabilitation services for these persons is the first step in developing a more effective rehabilitation model in the country.

OBJECTIVE

The objective of this study was to establish the characteristics of stroke and its rehabilitation at the Kilimanjaro Christian Medical Centre (KCMC), a consultant referral hospital in northern Tanzania.

METHODS

This was a records-based descriptive study in which demographic, clinical, and rehabilitation information of stroke patients admitted to the KCMC between January 2012 and December 2015 was collected and audited. The means, percentages, and proportions were used to summarise the demographic, clinical, and rehabilitation patterns using SPSS version 24.0 software. The chi-squared statistic was used to examine the relationships between categorical variables, and a p-value<0.05 was considered statistically significant.

RESULTS

Of the 17,975 patients admitted to the KCMC during the period of the study, 753 (4.2%) had suffered a stroke, with a mean age of 68.8 ± 16.4 years. The predominant cause of stroke was hypertension, which accounted for 546 (72.5%) patients. A total of 357 (47.4%) patients had various forms of rehabilitation during the admission to hospital. Following a discharge home 240 (31.9%) patients did not return to the hospital for the continuation of rehabilitation.

CONCLUSION

Stroke patients at the KCMC lack access to rehabilitation therapies. Insufficient access to rehabilitation therapies may warrant the need to explore alternative approaches such as tele-rehabilitation technologies in Tanzania.

Incidence of Hospitalization for Stroke in Queensland, Australia: Younger Adults at Risk

BACKGROUND

Trends in the incidence of stroke are important for health care planning. Information is particularly scarce in Australia, due to the paucity of studies with access to recent, large-scale, longitudinal datasets. In this paper we investigated the incidence of hospitalization for stroke by sex, age, and subtype in the whole State of Queensland (Australia).

METHODS

We obtained data of all hospital admissions for stroke in Queensland from 2002 to 2015. Age standardized hospitalization rates for first-ever stroke were calculated along with WHO adjusted rates. Poisson regression analyses were conducted to investigate the influence of time and gender on the incidence of subtypes of stroke as well as the total incidence.

RESULTS

Admissions for first-ever stroke were 57,597. Crude hospitalization incidence rose from 87 (95% confidence interval [CI], 84-90) to 108 (95%CI, 105-111) for both sexes. The highest increase was in the age bands 40-49 from 33 (95%CI, 26-40) to 54 (95%CI, 46-62; +62%) and 50-59 from 82 (95%CI, 70-93) to 127 (95%CI, 114-140; +56%) in men and in 60-69 from 118 (95%CI, 100-136) to 159 (95%CI, 143-175; +34%) in women. Ischemic subtype rates appeared to increase more than haemorrhagic rates. Age range, sex, and year reliably predicted incidence rates.

CONCLUSIONS

If these trends are maintained, the data predict further increases, especially in males aged 40-59. With people apparently stroking earlier and mortality rates dropping, the healthcare system in Australia is faced with a rapidly increasing care burden.

How Does Preterm Delivery Contribute to the Increased Burden of Cardiovascular Disease? Quantifying the Economic Impact of Cardiovascular Disease in Women with a History of Preterm Delivery

Background: The association between preterm delivery (PTD) and maternal risk of cardiovascular disease (CVD) was demonstrated, but the economic burden of CVD in these women was unknown. Methods: A Markov microsimulation model, comprising no event, postacute coronary event (ACE, including acute myocardial infarction and unstable angina), poststroke, post-ACE and stroke, postheart failure, and death, was constructed to quantify the CVD burden in women with PTD from 2017 to 2066 using the Australian health care system perspective. Both first-ever and recurrent CVD events were accounted for in the model. Population with PTD histories was sourced from Australian Bureau of Statistics and costs of acute hospitalization and long-term management from government websites. Nonmonetary burden as years of life lost (YLL) was compared between women with and without PTD histories. Both dynamic (i.e., new cohort added every cycle) and static (i.e., population was stabilized) approaches were used to measure the CVD burden, with sensitivity analyses examining the robustness of results. Results: The dynamic model showed the total CVD burden caused by PTD as AUD11.4 billion for the next 50 years and the YLL as 0.34/capita, while the static model generated a cost of AUD4.5 billion and the YLL as 0.52/capita. Long-term management cost was the primary cost determinant (AUD9.4 billion and AUD3.7 billion, respectively) in the two models, with the results most sensitive to the discount rate and time horizon. Conclusions: Considering the substantial economic burden, recognizing PTD as a potential risk factor and encouraging women with PTD histories to participate in primary prevention programs would potentially curb the ever-increasing CVD burden.

An Introduction to Software Tools, Data, and Services for Geospatial Analysis of Stroke Services

Background: There is interest in the use geospatial data for development of acute stroke services given the importance of timely access to acute reperfusion therapy. This paper aims to introduce clinicians and citizen scientists to the possibilities offered by open source softwares (R and Python) for analyzing geospatial data. It is hoped that this introduction will stimulate interest in the field as well as generate ideas for improving stroke services.

Method: Instructions on installation of libraries for R and Python, source codes and links to census data are provided in a notebook format to enhance experience with running the software. The code illustrates different aspects of using geospatial analysis: (1) creation of choropleth (thematic) map which depicts estimate of stroke cases per post codes; (2) use of map to help define service regions for rehabilitation after stroke.

Results: Choropleth map showing estimate of stroke per post codes and service boundary map for rehabilitation after stroke. Conclusions The examples in this article illustrate the use of a range of components that underpin geospatial analysis. By providing an accessible introduction to these areas, clinicians and researchers can create code to answer clinically relevant questions on topics such as service delivery and service demand.

Googling Location for Operating Base of Mobile Stroke Unit in Metropolitan Sydney

Background and purpose: The recent advances in stroke therapy have placed focus on delivering care within the first hour after stroke onset (golden hour), principally through the use of Mobile Stroke Unit (MSU) to bring the hospital to the patient. The aim of this project is to search the location of MSU hub in Sydney, Australia, optimizing for catchment, transport to nearest thrombolysis and endovascular clot retrieval (ECR)/thrombectomy capable hospital and population at risk. Methods: Traveling time was performed using ggmap package in R to interface with Google Maps application program interface (API). This analysis estimates the travel time from the centroids of each suburbs to five potential MSU hubs (Royal Prince Alfred, Prince of Wales, Royal North Shore, Liverpool, and Westmead hospitals) and eight thrombolysis capable hospitals. It is proposed that the MSU should be deployed at ECR hub to cover the suburbs, not well-covered by thrombolysis and ECR capable hospitals. This step was performed by assigning membership to hospitals within 30 min traveling time to the ECR hub. The base hub of the MSU was proposed as the closest hub (providing ECR) to the least well-served suburbs. The population serviceable by MSU was estimated using stroke incidence studies in Melbourne and Adelaide. Results: The largest population, serviceable by MSU within 30 min (4,606 cases), 45 min radius (8,918 cases), and 60 min (10,084 cases), was Royal North Shore followed by Royal Prince Alfred, Liverpool, Westmead, and Prince of Wales hospitals. Prince of Wales hospital has the smallest catchment within 30 min (3,078 cases), 45 min (7,721 cases), and 60 min (9,984 cases). Suburbs at the edge of metropolitan Sydney such as the Northern Suburbs are less well-served by thrombolysis and ECR capable hospitals. There are 10 suburbs within 30 min travel of one hospital. The remainders are within 30 min of two or more hospitals. Conclusions: Any of the five endovascular clot retrieval capable hospitals are capable of serving as a hub for MSU. We provide a method to identify the hub based on location of suburbs less well-served by other hospital.

Googling Service Boundaries for Endovascular Clot Retrieval (ECR) Hub Hospitals in Metropolitan Sydney

Background and Purpose: Endovascular clot retrieval (ECR) has revolutionized acute stroke therapy but is expensive to run and staff with accredited interventional neuroradiologists 24/7; consequently, it is only feasible for each metropolitan city to have a minimum number of hubs that is adequate to service the population. This method is applied to search the minimum number of hospitals to be designated as ECR hubs in Sydney as well as the population at risk of stroke reachable within 30 min. Methods: Traveling time from the centroids of each suburbs to five ECR capable hubs [Royal Prince Alfred/RPA, Prince of Wales/POW, Royal North Shore/RNS, Liverpool/LH and Westmead/WH]. This step was performed using ggmap package in R to interface with Google Map application program interface (API). Next, we calculate the percentage of suburbs within each catchment in which traveling time to the ECR hub is <30 min. This step was performed for all possible combination of ECR hubs. The maps are available at https://gntem3.shinyapps.io/ambsydney/. The population at risk of stroke was estimated using stroke incident studies in Melbourne and Adelaide. Results: The best 3-hospital combinations are LPH/WH/RNS (82.3, 45.7, and 79.7% of suburbs reachable within 30 min or 187 of 226 suburbs) follow by RPA/LPH/RNS (100.0, 80.9, and 73.1% of suburbs) and LPH/POW/RNS (83.3, 90.7, and 76.6% of suburbs). The best 4-hospital model is LPH/WH/POW/RNS (84.2%, 91.1%, 90.7%, 77.8%). In the 5-hospital model, ECR is available for 191 suburbs within 30 min: LPH (83%), RPA (100%), WH (90.2%), RNS (72.7%), POW (88.9%). Based on 3-hospital model and 15% of patient eligible for ECR, the expected number of cases to be handled by each hospital is 465. This number drops down to 374 if a 4-hospital model is preferred. Conclusions: The simulation studies supported a minimum of 4 ECR hubs servicing Sydney. This model provides data on number of suburbs and population at risk of stroke that can reach these hubs within 30 min.

Sex differences in mechanisms of arterial stiffness

Arterial stiffness progressively increases with aging and is an independent predictor of cardiovascular disease (CVD) risk. Evidence supports that there are sex differences in the time course of aging-related arterial stiffness and the associated CVD risk, which increases disproportionately in postmenopausal women. The association between arterial stiffness and mortality is almost twofold higher in women versus men. The differential clinical characteristics of the development of arterial stiffness between men and women indicate the involvement of sex-specific mechanisms. This review summarizes the current literature on sex differences in vascular stiffness induced by aging, obesity, hypertension, and sex-specific risk factors as well as the impact of hormonal status, diet, and exercise on vascular stiffness in males and females. An understanding of the mechanisms driving sex differences in vascular stiffness has the potential to identify novel sex-specific therapies to lessen CVD risk, the leading cause of death in males and females. LINKED ARTICLES: This article is part of a themed section on The Importance of Sex Differences in Pharmacology Research. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.21/issuetoc.

Googling Boundaries for Operating Mobile Stroke Unit for Stroke Codes

Background: Mobile stroke units (MSU) have been proposed to expedite delivery of recombinant tissue plasminogen activator (tPA) and expedite endovascular clot retrieval (ECR). Unexplored questions in the use of MSU include: maximal distance from base, time limit with regards to the use CT imaging, CT Angiography, CT Perfusion, and Telemedicine. We developed a computational model as an app (https://gntem3.shinyapps.io/ambmc/), taking into account traveling time to explore this issue. The aim of this study was to define the operating parameters for an MSU in a large metropolitan city, based on the geography of Melbourne.

Methods: There are 2 hospitals (Royal Melbourne Hospital/RMH, Monash Medical Center/MMC) designated to provide state-wide ECR services. In these spatial simulations, the MSU is based at RMH and delivers tPA at the patient's pick-up address and then takes the patient to the nearest ECR center. We extracted the geocode of suburbs in Melbourne and travel time to each hospital using ggmap, an interface to Google Map API. The app contains widgets for varying the processing time at the patient location (default = 30 min), performing CT angiography (default = 10 min), performing telemedicine consultation (default = 15 min). The data were compared against those for usual ambulance metrics (default traveling time = 15 min, processing time at patient's location = 20 min, door to tPA = 60 min, door to groin = 90 min). Varying the widgets allow the viewer to explore the trade-off between the variable of interest and time to therapy at a suburb level.

Results: The MSU was superior for delivering tPA to all Melbourne suburbs (up to 76 min from RMH). If the CTA times or processing time at location increased by 20 min then it was superior for providing ECR to only 74.9% of suburbs if the return base was RMH. Addition of CT Perfusion or telemedicine consultation affect the ability of a single hospital to provide ECR but not tPA if these additions can be limited to 20 min. Conclusion: The app can help to define how best to deploy the MSU across Melbourne. This app can be modified and used to optimize operating characteristics of MSU in other centers around the world.

Evaluation of adult stroke presentations at an Emergency Department in Queensland Australia

BACKGROUND

Stroke is a leading cause of mortality and morbidity which places high demands on emergency departments (EDs). Currently there is limited data on stroke presentations to Australian EDs and the time performance management of these presentations. Therefore, the aim of this study was to evaluate stroke presentations at an ED in Queensland, Australia in terms of demographics and time performance measures over a five year period.

METHODS

Retrospective analysis of ED presentations by patients ≥18 years with a final diagnosis of stroke between 1 July 2010 and 30 June 2015.

RESULTS

Over the five years there was a 51.4% increase in presentations diagnosed with stroke. The majority of these patients arrived by ambulance (71.0%) and were admitted (94.9%) with death in ED for 1.4% of presentations. From 2010 to 2015 for both haemorrhagic and ischaemic stroke there was a significant decrease in median LOS in ED (435 to 215 min, p < 0.05 and 451 to 238 min, p < 0.001 respectively) and in the proportion of patients in ED greater than four hours (82.4% to 44%, p < 0.05 and 92.4% to 45.8%,p < 0.0001 respectively).

CONCLUSION

Despite increased presentations of stroke, the ED improved in multiple time performance measures. Improving time-based targets in ED is particularly important for stroke presentations given the time critical nature of stroke management.

Sex Differences in Care and Long-Term Mortality After Stroke: Australian Stroke Clinical Registry

Introduction: There is some evidence that women receive evidence-based care less often than men, but how this influences long-term mortality after stroke is unclear. We explored this issue using data from a national stroke registry. Materials and Methods: Data are first-ever hospitalized strokes (2010-2014) in the Australian Stroke Clinical Registry from 39 hospitals linked to the national death registrations. Multilevel Poisson regression was used to estimate the women:men mortality rate ratio (MRR), with adjustment for sociodemographics, stroke severity, and processes of care (stroke unit care, intravenous thrombolysis, antihypertensive agent[s], and discharge care plan). Results: Among 14,118 events (46% females), women were 7 years older and had greater baseline severity compared to men (29% vs. 37%; p < 0.001), but there were no differences in the four processes of care available across hospitals. In the whole cohort, 1-year mortality was greater in women than men (MRR_unadjusted 1.44, 95% confidence interval [CI] 1.34-1.54). However, there were no differences after adjusting for age and stroke severity (MRR_adjusted 1.03, 95% CI 0.95-1.10). In analyses of additional processes from Queensland hospitals (n = 5224), women were less often administered aspirin ≤48 hours (61% vs. men 69%, p < 0.015). In Queensland hospitals, there were no statistically significant sex differences in 1-year mortality after adjusting for age, stroke severity, and early administration of aspirin. Conclusion: Greater mortality in women can be explained by differences in age and stroke severity. This highlights the importance of better management of risk factors in the elderly and, potentially, the need for greater access to early aspirin for women with stroke.

Age, sex, and setting in the etiology of stroke study (ASSESS): Study design and protocol

RATIONALE

Stroke etiology and risk factors vary by age, sex, setting (hospital or community-based) and by region. Identifying these differences would improve our understanding of stroke etiology, diagnosis, and treatment.

AIM

The Age, Sex and Setting in the Etiology of Stroke Study (ASSESS) is a multicenter cohort study to assess differences in stroke etiology.

METHODS AND DESIGN

Data from all centers will be categorized according to age, sex, setting, stroke subtypes. Centers with extensive hospital- or community-based data regarding stroke from Argentina, Australia, Canada, India, Iran, Italy, Ghana, Nigeria, Thailand, the United Kingdom and the United States have agreed to participate so far.

STUDY OUTCOMES

The primary outcome includes differences in stroke etiology in study centers. The secondary outcomes include stroke incidence, risk factors, preventive strategies, and short- and long-term outcomes.

CONCLUSION

ASSESS will enable comparisons of data from different regions to determine the age and sex distribution of the most common causes of stroke in each setting. This will help clinicians to tailor the assessment and treatment of stroke patients on the basis of their specific local characteristics. It will also empower stroke epidemiologists to design preventive measures by targeting the specific characteristics of each population.

Stroke hospital admission rates in Brisbane and Queensland in 2015: Data from 11,072 cases

BACKGROUND AND AIMS

Little data exist on the incidence of stroke in Australia. Our aim was to report age and sex disparities in hospital admission for stroke in Queensland, Australia's most populous northern state.

METHODS

We identified all patients admitted to hospital in Queensland with a diagnosis of stroke from January to December 2015.

RESULTS

Among 25,776 admissions with a diagnosis of stroke or TIA and related sequelae, stroke was the principal diagnosis in 11,072 cases of whom 5270 (47.60%) were first-ever stroke. Based on incidents per 100,000 population per year, the crude annual admission rate for first-ever strokes was 110 (95% CI, 107 to 113), 120 (95% CI, 115 to 124) for men and 101 (95% CI, 97 to 105) for women. The corresponding rates adjusted to the world population were 69 (95% CI, 52 to 85), and 88 (95% CI, 70 to 107) adjusted to the European population. Gender and age-adjusted incidence was greater for men than women in all age-groups, except those aged 30-34 years, where occurrence was 10 for men and 16 for women.

CONCLUSIONS

Based on the outcomes, hospital admission for stroke occurs less frequently in Queensland than in other regions of Australia. Men generally show a higher rate of hospitalization than women, with the notable exception of women aged 30-34, for whom the trend reverses.

Upright activity and higher motor function may preserve bone mineral density within 6 months of stroke: a longitudinal study

PURPOSE

Bone fragility contributes to increased fracture risk, but little is known about the emergence of post-stroke bone loss. We investigated skeletal changes and relationships with physical activity, stroke severity, motor control and lean mass within 6 months of stroke.

METHODS

This is a prospective observational study. Participants were non-diabetic but unable to walk within 2 weeks of first stroke. Distal tibial volumetric bone mineral density (vBMD, primary outcome), bone geometry and microstructure (high-resolution peripheral quantitative computed tomography) were assessed at baseline and 6 months, as were secondary outcomes total body bone mineral content and lean mass (dual energy X-ray absorptiometry), bone metabolism (serum osteocalcin, N-terminal propeptide of type 1 procollagen (P1NP), C-terminal telopeptide of type 1 collagen (CTX)), physical activity (PAL2 accelerometer) and motor control (Chedoke McMaster) which were also measured at 1 and 3 months.

RESULTS

Thirty-seven participants (69.7 years (SD 11.6), 37.8% females, NIHSS 12.6 (SD 4.7)) were included. The magnitude of difference in vBMD between paretic and non-paretic legs increased within 6 months, with a greater reduction observed in paretic legs (mean difference = 1.5% (95% CI 0.5, 2.6), p = 0.007). At 6 months, better motor control was associated with less bone loss since stroke (r = 0.46, p = 0.02). A trend towards less bone loss was observed in people who regained independent walking compared to those who did not (p = 0.053). Higher baseline daily count of standing up was associated with less change in bone turnover over 6 months: osteocalcin (r = -0.51, p = 0.01), P1NP (r = -0.47, p = 0.01), CTX (r = -0.53, p = 0.01).

CONCLUSION

Better motor control and walking recovery were associated with reduced bone loss. Interventions targeting these impairments from early post-stroke are warranted.

CLINICAL TRIAL REGISTRATION

URL: http://www.anzctr.org.au . Unique identifier: ACTRN12612000123842.

Stroke Incidence in Victoria, Australia-Emerging Improvements

Background

Evidence of a decline in the incidence of stroke has emerged from population-based studies. These have included retrospective and prospective cohorts. However, in Australia and other countries, government bodies and stroke foundations predict a rise in the prevalence of stroke that is anticipated to increase the burden of stroke across the entire domain of care. This increase in prevalence must be viewed as different from the decline in incidence being observed, a measure of new stroke cases. In Victoria, all public emergency department visits and public and private hospital admissions are reported to the Department of Health and Human Services and include demographic, diagnostic, and procedural/treatment information.

Methods

We obtained data from financial years 1997/1998 to 2007/2008 inclusive, for all cases with a primary stroke diagnosis (ICD-10-AM categories) with associated data fields. Incident cases were established by using a 5-year clearance period.

Results

From 2003/2004 to 2007/2008 inclusive, there were 53,425 patients with a primary stroke or TIA diagnosis. The crude incident stroke rate for first ever stroke was 211 per 100,000 per year (95% CI 205–217) [females—205 per 100,000 per year (95% CI 196–214) and males—217 per 100,000 per year (95% CI 210–224)]. The overall stroke rates were seen to significantly decline over the period [males (per 100,000 per year) 227 in 2003/2004 to 202 in 2007/2008 (p = 0.0157) and females (per 100,000 per year) 214 in 2003/2004 to 188 in 2007/2008 (p = 0.0482)]. Ischemic stroke rates also appeared to decline; however, this change was not significant.

Conclusion

These results demonstrate a significant decline in stroke incidence during the study period and may suggest evidence for effectiveness of primary and secondary prevention strategies in cerebrovascular risk factor management.

Trajectories of Stroke Care in Ontario: Which Path to Best Care?

BACKGROUND

Few studies have tracked stroke survivors through transitions across the health system and identified the most common trajectories and quality of care received. The objectives of our study were to examine the trajectories that incident stroke patients experience and to quantify the extent to which their care adhered to the best practices for stroke care.

METHODS

A population-based cohort of first-ever stroke/transient ischemic attack (TIA) patients from the 2012/13 Ontario Stroke Audit was linked to administrative databases using an encrypted health card number to identify dominant trajectories (N=12,362). All trajectories began in the emergency department (ED) and were defined by the transitions that followed immediately after the ED. Quality indicators were calculated to quantify best practice adherence within trajectories.

RESULTS

Six trajectories of stroke care were identified with significant variability in patient characteristics and quality of care received. Almost two-thirds (64.5%) required hospital admission. Trajectories that only involved the ED had the lowest rates of brain and carotid artery imaging (91.5 and 44.2%, respectively). Less than 20% of patients in trajectories involving hospital admissions received care on a stroke unit. The trajectory involving inpatient rehabilitation received suboptimal secondary prevention measures.

CONCLUSIONS

There are six main trajectories stroke patients follow, and adherence to best practices varies by trajectory. Trajectories resulting in patients being transitioned to home care following ED management only are least likely and those including inpatient rehabilitation are most likely to receive stroke best practices. Increased time in facility-based care results in greater access to best practices. Stroke patients receiving only ED care require closer follow-up by stroke specialists.

Utility of Ward-Based Retinal Photography in Stroke Patients

BACKGROUND

Improvements in acute care of stroke patients have decreased mortality, but survivors are still at increased risk of future vascular events and mitigation of this risk requires thorough assessment of the underlying factors leading to the stroke. The brain and eye share a common embryological origin and numerous similarities exist between the small vessels of the retina and brain. Recent population-based studies have demonstrated a close link between retinal vascular changes and stroke, suggesting that retinal photography could have utility in assessing underlying stroke risk factors and prognosis after stroke. Modern imaging equipment can facilitate precise measurement and monitoring of vascular features. However, use of this equipment is a challenge in the stroke ward setting as patients are frequently unable to maintain the required seated position, and pupil dilatation is often not feasible as it could potentially obscure important neurological signs of stroke progression.

MATERIALS AND METHODS

This small study investigated the utility of a novel handheld, nonmydriatic retinal camera in the stroke ward and explored associations between retinal vascular features and stroke risk factors. This camera circumvented the practical limitations of conducting retinal photography in the stroke ward setting.

RESULTS

A positive correlation was found between carotid disease and both mean width of arterioles (r = .40, P = .00571) and venules (r = .30, P = .0381).

CONCLUSIONS

The results provide further evidence that retinal vascular features are clinically informative about underlying stroke risk factors and demonstrate the utility of handheld retinal photography in the stroke ward.

Stroke Epidemiology in an Australian Rural Cohort (SEARCH)

Background Stroke rates in Australia and New Zealand have been declining since 1990 but all studies have been completed in large urban centers. Aim We report the first Australasian stroke incidence study in a rural population. Methods The authors applied the principle of complete ascertainment, used the WHO standard definition of stroke and classified ischemic stroke by the TOAST criteria. Data were collected from five rural centers defined by postcode of residence, over a 2-year period with 12 months of follow up of all cases. Results There were 217 strokes in 215 individuals in a population of 96,036 people, over 2 years, giving a crude attack rate of 113 per 100,000 per year. The 181 first-ever strokes (83% of total), standardized to the WHO world population, occurred at a rate of 50/100,000 (95% CI: 43-58). The 28-day fatality for first-ever strokes was 24% (95% CI: 18-31) and 77% (95% CI: 71-83) were classified as ischemic (140/181), 15% (95% CI: 10-21) intracerebral hemorrhage, 3% (95% CI: 1-6) due to subarachnoid hemorrhage and 5% (95% CI: 2-9) were unknown. A high proportion of first-ever ischemic strokes (44%) were cardioembolic, mostly (77%) due to atrial arrhythmias. Of the 38 with known atrial arrhythmias prior to stroke, only six (16%) were therapeutically anticoagulated. Conclusions This rural companion study of a recent Australian urban stroke incidence study confirms the downward trend of stroke incidence in Australia, and reiterates that inadequate anticoagulation of atrial arrhythmia remains a preventable cause of ischemic stroke.

Incidence and Risk Factors for Stroke Among 14 European Countries

Background This study compared the risk factors for and incidence of stroke among 14 European countries by using the Survey of Health, Aging, and Retirement in Europe (SHARE). Methods The analysis was based on data collected during 2006 to 2007 from Wave 2 of SHARE and panel data from respondents interviewed during 2004 to 2005. Results and Conclusion The highest stroke incidence rates were found in Denmark, Poland, and Sweden; these incidence rates were more than double that of Spain. Stroke was mostly associated with elderly people (age, ≥65 years) in Sweden, France, Switzerland, the Czech Republic, and Greece. In addition, stroke incidence was high among young males (age, <65 years) in Italy and elderly males in Germany and Switzerland. A negative association was found between stroke and vigorous exercise for younger people in Sweden and elderly people in Poland, whereas moderate exercise was significantly associated with stroke only for elderly Belgians, Greeks, and Irish.

A model for undertaking effectiveness and cost-effectiveness analyses of primary preventive strategies in cardiovascular disease

BACKGROUND

Clinical trials generally provide strong evidence of the efficacy of cardiovascular preventive strategies, but poor evidence of their 'real-life' utility, in terms of effectiveness and cost-effectiveness.

DESIGN AND METHODS

The Cardiovascular Disease Prevention Model is presented, which represents a means of extrapolating the results of clinical trials to a broader, more relevant context. The model is configured as a decision-analysis tree, and underpinned by life-course analysis and Markov processes. Uncertainty and sensitivity analyses are undertaken by Monte Carlo simulation.

RESULTS

The results of effectiveness and cost-effectiveness analyses of a hypothetical preventive intervention are presented to demonstrate the outputs of the model. The potential impact and efficiency of the intervention are made obvious.

CONCLUSIONS

The Cardiovascular Disease Prevention Model offers a means to translate the results of trials of cardiovascular preventive interventions, in order to inform clinical and public health practice, as well as health policy.

Application of the World Stroke Organization health system indicators and performance in Australia, Singapore, and the USA

Aim

To examine how Australia, Singapore and the United States of America (USA) match to the World Stroke Organization Global Stroke Services health system monitoring indicators (HSI).

Design

Descriptive comparative study

Participants

The health systems of Australia, Singapore, the USA.

Outcome measures

Published data available from each country were mapped to the 10 health system monitoring indicators proposed by the World Stroke Organization.

Results

Most health system monitoring indicators were at least partially met in each country. Thrombolytic agents were available for use in acute stroke. Stroke guidelines and stroke registry data were available in all three countries. Stroke incidence, prevalence, and mortality rates were available but at non-uniform times post-stroke. The International Classification of Disease 9 or 10 coding systems are used in all three countries. Standardized clinical audits are routine in Australia and the USA, but not in Singapore. The use of the modified Rankin Scale is collected sub-acutely but not at one year post-stroke in all three countries.

Conclusions

The three developed countries are performing well against the World Stroke Organization health system monitoring indicators for acute and sub-acute stroke care. However, improvements in stroke risk assessment and at one-year post-stroke outcome measurement are needed.

What Should We Do with Asymptomatic Carotid Stenosis?

The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.

Epidemiological transition and distribution of stroke incidence in Tianjin, China, 1988-2010

OBJECTIVES

To examine the trends in epidemiological transition of stroke over the last two decades in Tianjin, and investigate the subtypes of stroke.

STUDY DESIGN

A population-based epidemiological study using data from the Stroke Incidence Surveillance System of the Tianjin Centres for Disease Control and Prevention from 1988 to 2010.

METHODS

Almost 500,000 cases were analysed to examine changes in the incidence of stroke between 1988 and 2010 by age, sex, subtype, year and urban/rural status.

RESULTS

The incidence of stroke amongst males increased from 136.8/100,000 in 1988 to 387.0/100,000 in 2010, and the incidence amongst females increased from 65.9/100,000 in 1988 to 249.7/100,000 in 2010. Over the study period, the proportion of haemorrhagic strokes decreased and the proportion of ischaemic strokes increased sharply in both men and woman; the differences were significant.

CONCLUSION

The distribution of stroke subtypes changed dramatically over the study period. Changes in trend and subtypes of stroke have raised new challenges and there is a need for adjustment for stroke prevention in Tianjin.

Elevated Intracranial Pressure and Cerebral Edema following Permanent MCA Occlusion in an Ovine Model

INTRODUCTION

Malignant middle cerebral artery (MCA) stroke has a disproportionately high mortality due to the rapid development of refractory space-occupying cerebral edema. Animal models are essential in developing successful anti-edema therapies; however to date poor clinical translation has been associated with the predominately used rodent models. As such, large animal gyrencephalic models of stroke are urgently needed. The aim of the study was to characterize the intracranial pressure (ICP) response to MCA occlusion in our recently developed ovine stroke model.

MATERIALS AND METHODS

30 adult female Merino sheep (n = 8-12/gp) were randomized to sham surgery, temporary or permanent proximal MCA occlusion. ICP and brain tissue oxygen were monitored for 24 hours under general anesthesia. MRI, infarct volume with triphenyltetrazolium chloride (TTC) staining and histology were performed.

RESULTS

No increase in ICP, radiological evidence of ischemia within the MCA territory but without space-occupying edema, and TTC infarct volumes of 7.9+/-5.1% were seen with temporary MCAO. Permanent MCAO resulted in significantly elevated ICP, accompanied by 30% mortality, radiological evidence of space-occupying cerebral edema and TTC infarct volumes of 27.4+/-6.4%.

CONCLUSIONS

Permanent proximal MCAO in the sheep results in space-occupying cerebral edema, raised ICP and mortality similar to human malignant MCA stroke. This animal model may prove useful for pre-clinical testing of anti-edema therapies that have shown promise in rodent studies.

Early mobilization in ischemic stroke: a pilot randomized trial of safety and feasibility in a public hospital in Brazil

Background

The effect of early mobilization after acute stroke is still unclear, although some studies have suggested improvement in outcomes. We conducted a randomized, single-blind, controlled trial seeking to evaluate the feasibility, safety, and benefit of early mobilization for patients with acute ischemic stroke treated in a public teaching hospital in Southern Brazil. This report presents the feasibility and safety findings for the pilot phase of this trial.

Methods

The primary outcomes were time to first mobilization, total duration of mobilization, complications during early mobilization, falls within 3 months, mortality within 3 months, and medical complications of immobility. We included adult patients with CT- or MRI-confirmed ischemic stroke within 48 h of symptom onset who were admitted from March to November 2012 to the acute vascular unit or general emergency unit of a large urban emergency department (ED) at the Hospital de Clínicas de Porto Alegre. The severity of the neurological deficit on admission was assessed by the National Institutes of Health Stroke Scale (NIHSS). The NIHSS and modified Rankin Scale (mRS, functional outcome) scores were assessed on day 14 or at discharge as well as at 3 months. Activities of daily living (ADL) were measured with the modified Barthel Index (mBI) at 3 months.

Results

Thirty-seven patients (mean age 65 years, mean NIHSS score 11) were randomly allocated to an intervention group (IG) or a control group (CG). The IG received earlier (p = 0.001) and more frequent (p < 0.0001) mobilization than the CG. Of the 19 patients in the CG, only 5 (26%) underwent a physical therapy program during hospitalization. No complications (symptomatic hypotension or worsening of neurological symptoms) were observed in association with early mobilization. The rates of complications of immobility (pneumonia, pulmonary embolism, and deep vein thrombosis) and mortality were similar in the two groups. No statistically significant differences in functional independence, disability, or ADL (mBI ≥85) were observed between the groups at the 3-month follow-up.

Conclusions

This pilot trial conducted at a public hospital in Brazil suggests that early mobilization after acute ischemic stroke is safe and feasible. Despite some challenges and limitations, early mobilization was successfully implemented, even in the setting of a large, complex ED, and without complications. Patients from the IG were mobilized much earlier than controls receiving the standard care provided in most Brazilian hospitals.

Moderate agreement between self-reported stroke and hospital-recorded stroke in two cohorts of Australian women: a validation study

BACKGROUND

Conflicting findings on the validity of self-reported stroke from existing studies creates uncertainty about the appropriateness of using self-reported stroke in epidemiological research. We aimed to compare self-reported stroke against hospital-recorded stroke, and investigate reasons for disagreement.

METHODS

We included participants from the Australian Longitudinal Study on Women's Health born in 1921-26 (n = 1556) and 1946-51 (n = 2119), who were living in New South Wales and who returned all survey questionnaires over a defined period of time. We determined agreement between self-reported and hospitalised stroke by calculating sensitivity, specificity and kappa statistics. We investigated whether characteristics including age, education, area of residence, country of birth, language spoken at home, recent mental health at survey completion and proxy completion of questionnaire were associated with disagreement, using logistic regression analysis to obtain odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Agreement between self-report and hospital-recorded stroke was fair in older women (kappa 0.35, 95% CI 0.25 to 0.46) and moderate in mid-aged women (0.56, 95% CI 0.37 to 0.75). There was a high proportion with unverified self-reported stroke, partly due to: reporting of transient ischaemic attacks; strokes occurring outside the period of interest; and possible reporting of stroke-like conditions. In the older cohort, a large proportion with unverified stroke had hospital records of other cerebrovascular disease. In both cohorts, higher education was associated with agreement, whereas recent poor mental health was associated with disagreement.

CONCLUSION

Among women who returned survey questionnaires within the period of interest, validity of self-reported stroke was fair to moderate, but is probably underestimated. Agreement between self-report and hospital-recorded stroke was associated with individual characteristics. Where clinically verified stroke data are unavailable, self-report may be a reasonable alternative method of stroke ascertainment for some epidemiological studies.

Stroke incidence and case-fatality among Indigenous and non-Indigenous populations in the Northern Territory of Australia, 1999-2011

BACKGROUND

Stroke is a leading cause of death and disability in Australia. The impact of stroke on the Australia Indigenous people is, however, unclear.

AIM

This study describes hospital-based stroke incidence and case fatality in the Northern Territory population in Australia.

METHODS

Retrospective study of Northern Territory residents with a first-ever stroke episode and case fatality among Northern Territory residents in 1999-2011.

RESULTS

The rate ratio of age-adjusted stroke incidence between Indigenous and non-Indigenous populations was 2·8 for men and 2·7 for women, similar to those reported elsewhere in Australia. The rate ratio increased to 3·8 (95% confidence interval: 3·4-4·3) after adjusting for multiple risk factors. There was no change in annual incidence between 1999 and 2011 for either non-Indigenous (incidence rate ratio per year 1·01, 95% confidence interval: 1·00-1·03) or Indigenous people (incidence rate ratio: 1·00, 95% confidence interval: 0·98-1·02), although incidence did increase for non-Indigenous people in the 15-39 year age group (incidence rate ratio: 1·09, 95% confidence interval: 1·02-1·17) and for Indigenous people in the 40-64 year age group (incidence rate ratio: 1·03, 95% confidence interva1·00-1·06). The case fatality rate decreased from 22% in 1999 to 12% in 2011. In-hospital deaths were more common among; older and Indigenous people, for those with other chronic diseases, and from haemorrhagic stroke compared with ischemic stroke.

CONCLUSIONS

In the Northern Territory, as elsewhere in Australia, Indigenous Australians are more likely than other Australians to suffer a stroke. Lack of falling in incidence in the Northern Territory population highlights the importance for ongoing comprehensive primary and acute care in reducing risk factors and managing stroke patients.

Prevalence of Cardiovascular Disease and Associated Risk Factors among Adult Population in the Gulf Region: A Systematic Review

Background. CVD is a principal cause of mortality and disability globally.Objective. To analyse the epidemiological data on CHD, strokes, and the associated risk factors among adult population in the Gulf countries.Methods. A systematic review of published articles between 1990 and 2014 was conducted.Results. The analysis included 62 relevant studies. The prevalence of CHD was reported to be 5.5% in Saudi Arabia. The annual incidence of strokes ranged from 27.6 to 57 per 100 000 in the Gulf countries with ischaemic stroke being the most common subtype and hypertension and diabetes being the most common risk factors among stroke and ACS patients. The prevalence of overweight and obesity ranged from 31.2% to 43.3% and 22% to 34.1% in males and from 28% to 34.3% and 26.1% to 44% in females, respectively. In males, the prevalence of hypertension and diabetes ranged from 26.0% to 50.7% and 9.3% to 46.8%, respectively; in females these ranged from 20.9% to 57.2% and 6% to 53.2%, respectively. The prevalence of inactivity was from 24.3% to 93.9% and 56.7% to 98.1% in males and females, respectively. Relatively more males (13.4% to 37.4%) than females (0.5% to 20.7%) were current smokers. Available data indicate poor dietary habits with high consumption of snacks, fatty foods, sugar, and fast food.Conclusion. Effective preventative strategies and education programs are crucial in the Gulf region to reduce the risk of CVD mortality and morbidity in the coming years.

Declining rates of fatal and nonfatal intracerebral hemorrhage: epidemiological trends in Australia

Background

A recent systematic review of epidemiological studies reported intracerebral hemorrhage (ICH) incidence and mortality as unchanged over time; however, comparisons between studies conducted in different health services obscure assessment of trends. We explored trends in ICH rates in a large, representative population in New South Wales, Australia's most populous state (≈7.3 million).

Methods and Results

Adult hospitalizations with a principal ICH diagnosis from 2001 to 2009 were linked to death registrations through to June 30, 2010. Trends for overall, fatal, and nonfatal ICH rates within 30 days and fatal rates for 30‐day survivors at 365 days were calculated. There were 11 332 ICH patient admissions meeting eligibility criteria, yielding a crude hospitalization rate of 25.2 per 100 000 (age‐standardized rate: 17.2). Age‐ and sex‐adjusted overall rates significantly declined by an average of 1.6% per year (P=0.03). Fatal ICH declined by an average of 2.6% per year (P=0.004). For 30‐day survivors, a nonsignificant decline of 2.3% per year in fatal ICH at 365 days was estimated (P=0.17). Male sex and birth in the Oceania region and Asia were associated with an increased ICH risk, although this depended on age. Approximately 12% of ICH admissions would be prevented if the socioeconomic circumstances of the population equated with those of the least disadvantaged.

Conclusions

Overall and fatal ICH rates have fallen in this large Australian population. Improvements in cardiovascular prevention and acute care may explain declining rates. There was no evidence of an increase in devastated survivors because the longer term mortality of 30‐day survivors has not increased over time.

Long-term survival of older Australian women with a history of stroke

BACKGROUND

Although many people survive an initial stroke, little is known about long-term impacts of stroke on survival.

METHODS

Data from the Australian Longitudinal Study on Women's Health were used to compare 12-year survival rates in older women with prevalent stroke, incident stroke, and no stroke. Cox regression models were fitted to assess the effect of lifestyle and demographic characteristics on the relationship between stroke and all-cause mortality. The "no stroke" group was used as the reference category in all statistical models.

RESULTS

At baseline, 4% of the women reported a previous stroke (prevalent stroke). At survey 2 in 1999, a further 3% reported having a stroke between 1996 and 1999 (incident stroke). Stroke was significantly associated with reduced long-term survival. Age-adjusted hazards ratios (HRs) were: 1.64 (1.43-1.89) for the "prevalent stroke" group and 2.29 (1.97-2.66) for the "incident stroke" group. Adjusting for comorbidities reduced the HRs, but the risk of death was still significantly higher in the 2 stroke groups. Adjusting for demographic and lifestyle factors did not make any further difference to the relationship between stroke and survival. However, obesity and past smoking were also risk factors for mortality.

CONCLUSIONS

This study highlights the long-term impacts of stroke on life expectancy and the importance of comorbidities and other lifestyle factors in affecting poststroke survival.

An audit of the pharmacological management of ischaemic stroke patients in a metropolitan Australian hospital

BACKGROUND

According to the Australian Bureau of Statistics, stroke is the second leading cause of death in Australia. The clinical Guidelines for stroke management published by the National Stroke Foundation provide a series of evidence based recommendations to assist clinicians in the management of stroke patients. Appropriate management of patients admitted to stroke units reduces death and disability by 20 %. Moreover, a multidisciplinary team approach also improves patient outcomes.

OBJECTIVE

To retrospectively review the pharmacological management of ischaemic stroke patients in a metropolitan Australian hospital, and to compare adherence with the guidelines for stroke management with the national stroke foundation data with and without pharmacist intervention.

METHOD

A retrospective audit of medical records was undertaken of all patients admitted to a large teaching hospital with the diagnosis of stroke or cerebral infarction from January 2013 to May 2013.

RESULTS

A total of 124 patients were included in the study. Most patients were discharged on appropriate pharmacological intervention for the prevention of secondary stroke: antihypertensive agents (71 %), lipid lowering agents (67 %) and antithrombotic (85 %) medications.

CONCLUSION

The majority of the cohort was discharged on the appropriate evidence based medications for the management of secondary stroke. Further improvement may be achieved by pharmacist intervening as part of a multidisciplinary team.

Estimating the annual number of strokes and the issue of imperfect data: an example from Australia

BACKGROUND

Estimates of strokes in Australia are typically obtained using 1996-1997 age-specific attack rates from the pilot North East Melbourne Stroke Incidence (NEMESIS) Study (eight postcode regions). Declining hospitalizations for stroke indicate the potential to overestimate cases.

AIMS

To illustrate how current methods may potentially overestimate the number of strokes in Australia.

METHODS

Hospital separations data (primary discharge ICD10 codes I60 to I64) and three stroke projection models were compared. Each model had age- and gender-specific attack rates from the NEMESIS study applied to the 2003 population. One model used the 2003 Burden of Disease approach where the ratio of the 1996-1997 NEMESIS study incidence to hospital separation rate in the same year was adjusted by the 2002/2003 hospital separation rate within the same geographic region using relevant ICD-primary diagnosis codes. Hospital separations data were inflated by 12·1% to account for nonhospitalized stroke, while the Burden of Disease model was inflated by 27·6% to account for recurrent stroke events in that year. The third model used 1997-1999 attack rates from the larger 22-postcode NEMESIS study region.

RESULTS

In 2003, Australian hospitalizations for stroke (I60 to I64) were 33,022, and extrapolation to all stroke (hospitalized and nonhospitalized) was 37,568. Applying NEMESIS study attack rates to the 2003 Australian population, 50,731 strokes were projected. Fewer cases for 2003 were estimated with the Burden of Disease model (28,364) and 22-postcode NEMESIS study rates (41,332).

CONCLUSIONS

Estimating the number of strokes in a country can be highly variable depending on the recency of data, the type of data available, and the methods used.

Evidence-to-practice gaps in post-stroke management: a focus on care in a stroke unit and anticoagulation to prevent death, disability and recurrent stroke

ABSTRACT: 

The global burden of stroke is large. Over the last 15 years significant advances have been made to improve acute stroke care and prevention management providing the ability to mitigate much of this burden. In this article, we describe the importance of two main elements of stroke care: stroke units to reduce death and disability and anticoagulation therapy to prevent recurrent, often fatal or disabling, cardioembolic stroke. We also describe the issues related to translating these interventions into practice and the related economic implications. Despite the proven effectiveness and cost–effectiveness of these and other interventions, many people experiencing stroke are not receiving these interventions. Effective evidence translation initiatives and routine monitoring of healthcare is needed to address important gaps in stroke management in promoting societal well-being.

Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010

BACKGROUND

Although stroke is the second leading cause of death worldwide, no comprehensive and comparable assessment of incidence, prevalence, mortality, disability, and epidemiological trends has been estimated for most regions. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to estimate the global and regional burden of stroke during 1990-2010.

METHODS

We searched Medline, Embase, LILACS, Scopus, PubMed, Science Direct, Global Health Database, the WHO library, and WHO regional databases from 1990 to 2012 to identify relevant studies published between 1990 and 2010.We applied the GBD 2010 analytical technique (DisMod-MR), based on disease-specific, pre-specified associations between incidence, prevalence, and mortality, to calculate regional and country-specific estimates of stroke incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) lost by age group (<75 years, ≥ 75 years, and in total)and country income level (high-income, and low-income and middle-income) for 1990, 2005, and 2010.

FINDINGS

We included 119 studies (58 from high-income countries and 61 from low-income and middle-income countries). From 1990 to 2010, the age-standardised incidence of stroke significantly decreased by 12% (95% CI 6-17)in high-income countries, and increased by 12% (-3 to 22) in low-income and middle-income countries, albeit nonsignificantly. Mortality rates decreased significantly in both high income (37%, 31-41) and low-income and middle income countries (20%, 15-30). In 2010, the absolute numbers of people with fi rst stroke (16・9 million), stroke survivors (33 million), stroke-related deaths (5・9 million), and DALYs lost (102 million) were high and had significantly increased since 1990 (68%, 84%, 26%, and 12% increase, respectively), with most of the burden (68・6% incident strokes, 52・2% prevalent strokes, 70・9% stroke deaths, and 77・7% DALYs lost) in low-income and middle-income countries. In 2010, 5・2 million (31%) strokes were in children (aged <20 years old) and young and middle-aged adults(20-64 years), to which children and young and middle-aged adults from low-income and middle-income countries contributed almost 74 000 (89%) and 4・0 million (78%), respectively, of the burden. Additionally, we noted significant geographical differences of between three and ten times in stroke burden between GBD regions and countries. More than 62% of new strokes, 69・8% of prevalent strokes, 45・5% of deaths from stroke, and 71・7% of DALYs lost because of stroke were in people younger than 75 years.

INTERPRETATION

Although age-standardised rates of stroke mortality have decreased worldwide in the past two decades,the absolute number of people who have a stroke every year, stroke survivors, related deaths, and the overall global burden of stroke (DALYs lost) are great and increasing. Further study is needed to improve understanding of stroke determinants and burden worldwide, and to establish causes of disparities and changes in trends in stroke burden between countries of different income levels.

FUNDING

Bill & Melinda Gates Foundation.

Changes to volumetric bone mineral density and bone strength after stroke: a prospective study

RATIONALE AND AIM

Stroke survivors experience accelerated bone loss and increased fracture risk, particularly in paretic weight bearing limbs. Understanding how these changes unfold and their relationship to stroke severity and physical activity could help in the development of targeted interventions to prevent or reduce the severity of these outcomes. The primary aim of this study is to investigate the time course and magnitude of changes in volumetric bone mineral density within the first year after stroke, and to examine relationships with physical activity and motor recovery.

DESIGN

This is a prospective, observational study of 43 nondiabetic, nonambulant adults with first ever hemispheric stroke.

PRIMARY OUTCOME

The primary outcome was the difference in six-month change of total volumetric bone mineral density between paretic and nonparetic distal tibiae, measured at 7% of bone length site using high-resolution peripheral quantitative computed tomography.

SECONDARY OUTCOMES

The secondary outcomes are cortical and trabecular volumetric bone mineral density, cortical thickness, and total and cross-sectional areas of distal tibiae and radii of paretic and nonparetic limbs. Also included are total body and regional bone mineral density derived using dual-energy X-ray absorptiometry, physical activity measured using accelerometry, and motor recovery (Chedoke McMaster Stroke Assessment).

DISCUSSION

Measuring the timing and magnitude of changes to volumetric bone mineral density and bone structure from immediately after stroke, and relationships between these changes with physical activity and motor recovery will provide the basis for targeted interventions to reduce fracture risk in stroke survivors.

Methodology of a population-based stroke and TIA incidence and outcomes study: the Auckland Regional Community Stroke Study (ARCOS IV) 2011-2012

BACKGROUND

Stroke is a leading cause of death and disability worldwide. Stroke burden is immense as it leads to premature deaths, leaves survivors with ongoing disabilities, and has a major financial impact on the individual, their families, and the community. Reliable, high-quality evidence is needed on stroke risk factors, incidence, and outcomes to provide information on how best to reduce this burden. Population-based studies are regarded as the 'gold-standard' of measuring disease burden but are not common due to the logistical and financial challenges they present. The Auckland Regional Community Stroke Studies are among a few in the world that have been carried out at a population level and at regular intervals.

AIM

The aim of the fourth Auckland Regional Community Stroke Studies IV is to examine the current measures of stroke incidence, prevalence, and outcomes as well the trends over four decades. This article describes the methodology of the Auckland Regional Community Stroke Studies IV with stroke and transient ischemic attacks cases registered over a 12-month period from March 1, 2011 to February 29, 2012.

CONCLUSIONS

The methodology described may be used as a guide in order to design similar population-based stroke incidence and outcome studies in other countries and populations, thus facilitating the collection of most consistent and accurate stroke epidemiological data.

Motor recovery monitoring using acceleration measurements in post acute stroke patients

BACKGROUND

Stroke is one of the major causes of morbidity and mortality. Its recovery and treatment depends on close clinical monitoring by a clinician especially during the first few hours after the onset of stroke. Patients who do not exhibit early motor recovery post thrombolysis may benefit from more aggressive treatment.

METHOD

A novel approach for monitoring stroke during the first few hours after the onset of stroke using a wireless accelerometer based motor activity monitoring system is developed. It monitors the motor activity by measuring the acceleration of the arms in three axes. In the presented proof of concept study, the measured acceleration data is transferred wirelessly using iMote2 platform to the base station that is equipped with an online algorithm capable of calculating an index equivalent to the National Institute of Health Stroke Score (NIHSS) motor index. The system is developed by collecting data from 15 patients.

RESULTS

We have successfully demonstrated an end-to-end stroke monitoring system reporting an accuracy of calculating stroke index of more than 80%, highest Cohen's overall agreement of 0.91 (with excellent κ coefficient of 0.76).

CONCLUSION

A wireless accelerometer based 'hot stroke' monitoring system is developed to monitor the motor recovery in acute-stroke patients. It has been shown to monitor stroke patients continuously, which has not been possible so far with high reliability.

Transient ischaemic attack and ischaemic stroke: constructing episodes of care using hospital claims data

Background

Stroke patients may have multiple hospital separations relating to the same stroke. Understanding the pattern of hospitalisations for these patients enables first and recurrent events to be distinguished to better understand care. The aim of this study was to investigate reasons for hospital separations after transient ischaemic attack (TIA) or ischaemic stroke and construct episode of care criteria.

Methods

A retrospective observational study was conducted using the Australian Government Department of Veterans’ Affairs administrative claims database. All patients hospitalised for TIA or ischaemic stroke in 2008–2009 were included. Reasons for hospital separations in the 60 days after TIA or ischaemic stroke were classified by a clinical panel as ‘probably’, ‘possibly’ or ‘unlikely’ to be related to the index separation. Based on panel assessment and time between separations, episode of care criteria for TIA and ischaemic stroke were constructed.

Results

Of the 4520 veterans alive after the index separation, 32% of TIA patients (n=782) and 63% of ischaemic stroke patients (n=1323) had another separation within 60 days. The clinical panel reviewed 460 unique reasons for readmission. Of the 3263 separations, 55% and 85% were classified as related to the index TIA and ischaemic stroke separation, respectively.

Conclusions

Patients hospitalised for ischaemic stroke are likely to have multiple hospital separations for treatment of the same event. Multiple separations for treatment of TIA were less frequent. Consideration of these related separations is recommended when assessing health service utilisation from claims databases.

Triage assessments and the activation of rapid care protocols for acute stroke patients

BACKGROUND

Rapid care protocols developed to reduce in-hospital delay times in the assessment of acute stroke patients are now common in Emergency Departments. Correct triage identification and prioritisation is vital to instigate this process and increase the eligibility of patients for acute stroke treatments.

OBJECTIVE

We set out to examine triage assessments of acute stroke patients and investigate factors associated with the instigation of rapid care protocols (allocation of triage category 1 or 2) for acute stroke patients presenting within 2 h of symptom onset.

METHODS

A retrospective assessment of emergency department records was undertaken for stroke patients presenting to three hospitals in Melbourne over six months in 2010.

RESULTS

798 patients were included in the study. Among acute stroke patients who presented within 2 h (n=185), 173 (94%) were identified as stroke at triage with 10 cases identified as "altered conscious state". In all cases not identified as stroke the patient was diagnosed with intracerebral haemorrhage. 132 cases (71%) were allocated a triage category 1 or 2. Facial weakness (p=0.002) and presentation to Monash Medical Centre (p=<0.001), were significantly associated with triage category 1 or 2.

CONCLUSION

Virtually all acute stroke patients were identified at triage, however 30% were not allocated an urgent triage category (1 or 2). Further education strategies may be required to develop awareness of rapid care protocols for acute stroke patients among triage nurses and ensure the uniform application of Acute Stroke Guidelines and local rapid care pathways.

Recent advances in the management of transient ischaemic attack: a clinical review

Transient ischaemic attack (TIA) if untreated carries a high risk of early stroke and is associated with poorer long-term survival. There have been recent advances in the understanding of TIA, its investigations, management and organisation of services for patient care. Clinically, patients are diagnosed TIA if they have transient sudden-onset focal neurological symptoms which usually completely and rapidly resolve by presentation. Patients with residual symptoms should be evaluated as potentially having stroke, if they present within 4.5 h of onset, should be urgently evaluated for their potential eligibility for thrombolysis. TIA patients should receive rapid attention with essential investigations, including brain imaging, electrocardiograph and carotid ultrasound. Immediate administration of an antiplatelet agent is recommended after brain imaging, with subsequent attention to preventing or treating other mechanistic factors. There is emerging evidence that TIA patients can be managed safely in the outpatient setting after initial rapid management in emergency departments as part of a structured clinical pathway supervised by stroke specialists. Clinical systems of management may require approaches individualised to the healthcare setting, while adopting the central aspects of rapid management.