Higher Stroke Mortality Research Articles

Abstract TP288: Development and Preliminary Results of a Community Partnered Stroke Preparedness Intervention in Chicago

Objective: Delayed recognition and hospital arrival after acute stroke leads to worse outcomes. Given multi-level barriers to calling 9-1-1 for stroke, we sought to develop a community-partnered stroke preparedness intervention in Chicago’s underserved communities (where EMS use is low, despite high stroke incidence and mortality) tailored to neighborhood and cultural needs and barriers. Methods: As part of the CEERIAS study, we recruited local laypersons to serve as community promoters for a training program that sought to instruct them on delivering targeted messages to their communities. Each half-day training session was facilitated by CEERIAS study investigators, and consisted of a mix of didactic material on stroke statistics relevant to South Side communities, hospital-based tours of the “stroke patient journey,” role playing and tailored strategies for community messaging based on aim 1 focus group findings, and distribution of stroke education materials, “Pact to Act FAST” pledge cards, and website (www.ceerias.com) instructions. Results: We conducted 21 training sessions for 242 community promoters (81 African-American [AA] males, 133 AA females, 4 Hispanic males, 5 Hispanic females, 3 Caucasian males, 16 Caucasian females) between October 2015 and May 2016. Since training, these community promoters have distributed >110,000 educational materials including FAST cards and magnets and participated in 167 community events. A total of 38,221 Pact to Act FAST pledges have been registered (Figure), 80.3% of which registered in South Side Chicago zip codes (Figure). Conclusions: A community-partnered stroke preparedness campaign was effective in increasing stroke awareness in underserved minority communities, as noted by the high volume of Pact to Act FAST pledges. Data on 9-1-1 calls for stroke and early arrival after stroke at neighborhood hospitals will be analyzed to assess effect of the intervention.

Effects of a school-based stroke education program on stroke-related knowledge and behaviour modification―school class based intervention study for elementary school students and parental guardians in a Japanese rural area

ObjectivesThis study aimed to determine the effect of a stroke education programme on elementary school students and their parental guardians in a rural area in Japan that has high stroke...

Depression Is Associated with a Higher Risk of Death among Stroke Survivors

Poststroke depression is common, affecting approximately 1 in 3 stroke survivors. We aimed to evaluate the association between depression and mortality in adults with and without prior stroke. Using the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study (1982-1992), we investigated the association between depression and all-cause mortality among adults aged 25-74 years with and without prior stroke, and stroke mortality among stroke survivors, adjusting for covariates. Among 9919 individuals, 121 (1.2%) reported prior stroke. The adjusted depression prevalence was 37.1% among stroke survivors and 17.3% among individuals without stroke. In persons aged 25-64 years, neither stroke nor depression was associated with all-cause mortality. The combination of depression and stroke was not associated with all-cause mortality (adjusted hazard ratio [HR] 2.83, 95% confidence interval [CI] .67-12.04). Among persons aged 65-74 years, depression alone (adjusted HR 1.24, 95% CI 1.04-1.47), stroke alone (adjusted HR 1.64, 95% CI 1.17-2.32), and the combination of depression and stroke (adjusted HR 2.28, 95% CI 1.79-2.90) were associated with all-cause mortality, consistent with an additive relationship. Among all ages, the combination of depression and stroke was associated with all-cause mortality (adjusted HR 1.93, 95% CI 1.28-2.92). Higher stroke mortality was only observed in those aged 65-74 years (adjusted HR 2.43, 95% CI 1.05-5.60). Compared with stroke survivors without depression, those with depression were ~35 times more likely to die from a stroke (adjusted HR 35.33, 95% CI 7.79-160.32). The combination of prior stroke and depression is associated with higher all-cause mortality than either condition alone. The presence of depression after stroke increases stroke mortality 35-fold, highlighting the importance of identifying and treating depression among stroke survivors.

Association Between Birth in a High Stroke Mortality State, Race, and Risk of Dementia

Birth in a group of predominantly southern US states is robustly linked to increased stroke risk. Given the role of cerebrovascular disease in dementia risk, geographic patterning may also occur for dementia incidence. To determine whether birth in 9 high stroke mortality states (HSMSs) is associated with dementia in a diverse cohort of individuals living in Northern California. An observational cohort study included 7423 members of Kaiser Permanente Northern California (KPNC), an integrated health care delivery system, with health survey and clinical examination data available. Data were collected between 1964 and 1973 when the individuals were middle-aged and 1996 and 2015 when participants were in later life. Self-reported state of birth in an HSMS (top quintile of states for stroke mortality). Dementia diagnoses obtained from electronic health records from January 1, 1996, to October 15, 2015. Place of birth, race, educational level, and midlife vascular risk factors data were collected between 1964 and 1973. Of the 7423 persons included in the analysis, 4049 (54.5%) were women; 1354 (18.2%) were black. The mean (SD) age of study participants at their first visit between 1963 and 1974 was 42.94 (1.73) years and mean (SD) age at the beginning of follow-up for dementia in 1996 was 71.14 (2.72) years. Dementia was diagnosed in 2254 (30.4%) of the participants and was more common among those born in an HSMS than those born outside of one (455 [39.0%] vs 1799 [28.8%]). Birth in an HSMS was 9.6 times more common for black participants (795 [58.7%]) than nonblack participants (371 [6.1%]). Overall, birth in an HSMS was associated with a 28% higher risk of dementia (adjusted hazard ratio [aHR], 1.28; 95% CI, 1.13-1.46) adjusted for age, sex, and race. Compared with nonblack persons born outside of an HSMS, black individuals born in an HSMS had the highest dementia risk (aHR, 1.67; 95% CI, 1.48-1.88), followed by black individuals not born in an HSMS (aHR, 1.48; 95% CI, 1.28-1.72), and nonblack persons born in an HSMS had a 46% increased risk (aHR, 1.46; 95% CI, 1.23-1.74). Cumulative 20-year dementia risks at age 65 years were 30.13% (95% CI, 26.87%-32.93%) and 21.80% (95% CI, 20.51%-22.91%) for individuals born in and outside an HSMS, respectively. To our knowledge, this is the first study to date of place of birth and incident dementia and shows increased risk for individuals born in an HSMS, even though all participants subsequently resided in California. Birth in an HSMS was common among black participants. Place of birth has enduring consequences for dementia risk and may be a major contributor to racial disparities in dementia.

Contributors to the Excess Stroke Mortality in Rural Areas in the United States.

Stroke mortality is 30% higher in the rural United States. This could be because of either higher incidence or higher case fatality from stroke in rural areas. The urban-rural status of 23 280 stroke-free participants recruited between 2003 and 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) was classified using the Rural-Urban Commuting Area scheme as residing in urban, large rural town/city, or small rural town or isolated areas. The risk of incident stroke was assessed using proportional hazards analysis, and case fatality (death within 30 days of stroke) was assessed using logistic regression. Models were adjusted for demographics, traditional stroke risk factors, and measures of socioeconomic status. After adjustment for demographic factors and relative to urban areas, stroke incidence was 1.23-times higher (95% confidence intervals, 1.01-1.51) in large rural town/cities and 1.30-times higher (95% confidence intervals, 1.03-1.62) in small rural towns or isolated areas. Adjustment for risk factors and socioeconomic status only modestly attenuated this association, and the association became marginally nonsignificant (P=0.071). There was no association of rural-urban status with case fatality (P>0.47). The higher stroke mortality in rural regions seemed to be attributable to higher stroke incidence rather than case fatality. A higher prevalence of risk factors and lower socioeconomic status only modestly contributed to the increased risk of incident stroke risk in rural areas. There was no evidence of higher case fatality in rural areas.

Does national expenditure on research and development influence stroke outcomes?

Background Expenditure on research and development is a macroeconomic indicator representative of national investment. International organizations use this indicator to compare international research and development activities. Aim We investigated whether differences in expenditures on research and development at the country level may influence the incidence of stroke and stroke mortality. Methods We compared stroke metrics with absolute amount of gross domestic expenditure on R&D (GERD) per-capita adjusted for purchasing power parity (aGERD) and relative amount of GERD as percent of gross domestic product (rGERD). Sources included official data from the UNESCO, the World Health Organization, the World Bank, and population-based studies. We used correlation analysis and multivariable linear regression modeling. Results Overall, data on stroke mortality rate and GERD were available from 66 countries for two periods (2002 and 2008). Age-standardized stroke mortality rate was associated with aGERD (r = -0.708 in 2002 and r = -0.730 in 2008) or rGERD (r = -0.545 in 2002 and r = -0.657 in 2008) (all p < 0.001). Multivariable analysis showed a lower aGERD and rGERD were independently and inversely associated with higher stroke mortality (all p < 0.05). The estimated prevalence of hypertension, diabetes, or obesity was higher in countries with lower aGERD. The analysis of 27 population-based studies showed consistent inverse associations between aGERD or rGERD and incident risk of stroke and 30-day case fatality. Conclusions There is higher stroke mortality among countries with lower expenditures in research and development. While this study does not prove causality, it suggests a potential area to focus efforts to improve global stroke outcomes.

Abstract MP060: Contributors to the Geographic Disparity in Stroke Incidence in the United States: Results From the Reasons for Geographic and Racial Disparities in Stroke Cohort

Introduction: Geographic disparities in US stroke risk have recently been confirmed by REGARDS, but contributors to this are unknown. Higher prevalence of risk factors (RF) and lower socioeconomic status (SES) may contribute to this geographic disparity. For a RF/SES to contribute to this disparity it must both : 1) have a large geographic difference in prevalence, and 2) be powerfully associated with stroke risk. Methods: The 1,623 counties of residence of 24,863 REGARDS participants were placed in quartiles of Vital Statistics stroke mortality. Logistic regression assessed the geographic difference in prevalence of each RF/SES by quartile of stroke mortality. Proportional hazards was used to calculate HR stroke for each RF/SES. Mediation analysis then estimated the proportion of increased stroke incidence in counties with high stroke mortality explained by each RF/SES. Results: Higher county-level stroke mortality was significantly associated with low neighborhood SES (nSES), and more weakly associated with low education and presence of RFs (left column of table). Over 8-years follow-up there were 1,194 stroke events. Hypertension, diabetes and heart disease were all more strongly associated with higher stroke risk (HR ≥1.59) than nSES (HR = 1.21) (center column of table). The large differences in nSES between regions overcame the somewhat weaker association of nSES with stroke risk, since nSES was the largest single contributor to the geographic disparity in stroke incidence, accounting for 20.5% of the disparity (95% CI: 7.1 - 34.0) (right column in table). In multivariable analysis nSES, hypertension and diabetes collectively mediated27% of the geographic disparity (95% CI: 20.0% - 34.0%), but the association with county-level mortality remained significant (p = 0.006). Conclusion: Lower nSES played the largest role in explaining the county-level geographic disparity in stroke incidence in REGARDS, however, 73% of the excess risk of stroke incidence was not explained by any studied factors.

Abstract 200: Is Risk-standardized In-hospital Stroke Mortality an Adequate Proxy for Risk-standardized 30-day Stroke Mortality Data? Findings From the GWTG-Stroke Program

Background: Hospital profiling is typically undertaken using risk standardized 30-day mortality but obtaining this data is complicated as it requires tracking patients post discharge. We undertook this analysis to determine if risk standardized in-hospital mortality could serve as an adequate proxy for risk standardized 30-day mortality data for the purposes of identifying outlier hospitals with high or low ischemic stroke mortality. Methods: Acute ischemic stroke cases entered into Get With The Guidelines (GWTG)-Stroke between 2003-2013 were linked to fee-for-service Medicare files. Hospitals with fewer than 25 cases were excluded. Risk-standardized mortality rates (RSMR) for both in-hospital and 30-day mortality were generated using a previously developed risk model, and the proportion of hospitals classified as statistical outliers (based on random effects models) were compared between the two. To assess the impact of stroke severity we conducted a sensitivity analysis limiting cases to those with NIHSS data. Results: A total of 535,332 ischemic stroke patients from 1494 GWTG-Stroke hospitals were included; mean age was 80 years, 59% were female, 19% were non-white, NIHSS (mean = 7.7) was recorded in 58%. Average in-hospital and 30-day mortality was 5.7% and 14.5%, respectively. At the hospital level, mean in-hospital RSMR and 30-day RSMR was 6.0% (SD 1.9) and 14.6% (SD 2.0), respectively, but the correlation between the two was only modest (r = 0.53). Overall agreement between the designation of outlier hospitals based on in-hospital and 30-day RSMRs was 78% (Table), but after correcting for chance agreement, concordance was quite modest (Kappa = 0.29). Findings based on models that included NIHSS were similar. Conclusions: When used to identify outlier hospitals with high or low ischemic stroke mortality the agreement between in-hospital mortality and 30-day mortality was only modest. Using in-hospital mortality data proved to be a poor proxy for 30-day mortality.

Countries with women inequalities have higher stroke mortality.

Background Stroke outcomes can differ by women's legal or socioeconomic status. Aim We investigated whether differences in women's rights or gender inequalities were associated with stroke mortality at the country-level. Methods We used age-standardized stroke mortality data from 2008 obtained from the World Health Organization. We compared female-to-male stroke mortality ratio and stroke mortality rates in women and men between countries according to 50 indices of women's rights from Women, Business and the Law 2016 and Gender Inequality Index from the Human Development Report by the United Nations Development Programme. We also compared stroke mortality rate and income at the country-level. Results In our study, 176 countries with data available on stroke mortality rate in 2008 and indices of women's rights were included. There were 46 (26.1%) countries where stroke mortality in women was higher than stroke mortality in men. Among them, 29 (63%) countries were located in Sub-Saharan African region. After adjusting by country income level, higher female-to-male stroke mortality ratio was associated with 14 indices of women's rights, including differences in getting a job or opening a bank account, existence of domestic violence legislation, and inequalities in ownership right to property. Moreover, there was a higher female-to-male stroke mortality ratio among countries with higher Gender Inequality Index (r = 0.397, p < 0.001). Gender Inequality Index was more likely to be associated with stroke mortality rate in women than that in men (p < 0.001). Conclusions Our study suggested that the gender inequality status is associated with women's stroke outcomes.

Increased maximum common carotid intima-media thickness is associated with smoking and hypertension in Tochigi Prefecture residents.

We investigated maximum intima-media thickness of the common carotid artery (IMT-Cmax) in residents of Tochigi Prefecture, who have been reported to have high stroke mortality. Our study included 840 individuals. All participants underwent carotid ultrasonography and answered a questionnaire during participation in a health festival in Tochigi Prefecture. The questionnaire was designed to collect information on age, gender, and risk factors for stroke. IMT-Cmax was measured. Statistical analyses were performed to identify factors contributing to IMT-Cmax values ≥1.1mm. In total, 117 subjects had an IMT-Cmax value ≥1.1mm. IMT-Cmax correlated significantly with age, current smoking, hypertension, diabetes mellitus, heart disease, and previous symptomatic stroke (p<0.05) in univariate analysis. Current smoking (p<0.001, odds ratio 3.88) and hypertension (p=0.0070, odds ratio 1.83) were seen as significant contributing factors to IMT-Cmax ≥1.1mm in logistic regression analysis adjusted by age, gender, and previous symptomatic stroke. We identified current smoking and hypertension as the most significant contributing factors to increased IMT-Cmax in residents of Tochigi Prefecture, emphasizing the importance of routine blood pressure monitoring and anti-smoking education in this population.

Abstract 52: Contributors to the Rural Excess in Stroke Mortality: The REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Introduction: One NIH goal is to investigate the US nationwide rural-urban health disparities; however, few studies provide data to help understand the 30% higher rural stroke mortality. It is unknown if the higher stroke mortality is attributable to a higher incidence of stroke, or to a higher case fatality, in rural regions. Further, the role of risk factors or SES status in higher incidence or case-fatality is unknown. Methods: REGARDS participants stroke-free at baseline (n = 25,090) were stratified by Rural-Urban Commuting Area strata: urban, large rural city/town, or small rural town or isolated region. Participants were followed for incident stroke, and case fatality was defined as death within 30-days of a stroke. Difference in incident stroke was assessed using proportional hazards analysis, and case-fatality by logistic regression, each considered after adjustment for demographic factors, further adjustment for risk factors, and further adjustment for SES. Results: Over an average follow-up of 8.2 years, 1,060 incident strokes occurred, of which 160 died within 30 days. Risk of incident stroke increased with rurality (p = 0.016), with a hazard 1.21-times (95% CI: 1.00 - 1.46) higher in large rural cities/towns, and 1.24-times (95% CI: 1.00 - 1.54) higher in small rural towns or isolated regions (see table). Adjustment for risk factors and SES attenuated the estimated risk by 50%, and the association became non-significant. There was no evidence of a higher case-fatality from stroke in rural regions (p &gt; 0.46). Discussion: The higher stroke mortality in rural regions appears to be attributable to higher stroke incidence, and not to higher case-fatality. Higher stroke incidence in rural regions is partially attributable to a worse risk factor profile and lower SES. Efforts to reduce rural disparity in stroke mortality should focus on preventive strategies, especially those relevant to risk factor development and control, and/or mitigating the impact of lower SES.

Incidence and Case Fatality at the County Level as Contributors to Geographic Disparities in Stroke Mortality

Background: Is the high stroke mortality in the Southeastern parts of the United States driven by differences in stroke incidence or case-fatality? This question remains unanswered. Differences in incidence would underscore the need for stroke prevention, while differences in case fatality would call for improved stroke care. Methods: Quartiles of US counties were defined by stroke mortality, and this gradient was related with stroke incidence and stroke case fatality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, where 1,317 incident stroke events (of which 242 were fatal) occurred among 29,650 participants. Results: There was a significant (p = 0.0025) gradient of fatal stroke events in REGARDS (quartile 4 vs. quartile 1 (Q4/Q1) hazard ratio 1.95, 95% CI 1.35-2.81), demonstrating the consistency of REGARDS with national mortality data. The gradient for incident stroke (fatal + nonfatal) was also significant (p = 0.0023; Q4/Q1 hazard ratio 1.29, 95% CI 1.10-1.52). The gradient for stroke case-fatality was marginally significant (p = 0.058), though the OR for Q4/Q1 (1.71, 95% CI 1.13-2.25) was large. Conclusions: Both stroke incidence and case-fatality in REGARDS appear to be contributing, underscoring the need for strengthening both stroke prevention and acute stroke care in order to reduce the disparity.

Stroke recurrence among South Asians with diabetes in Ontario, Canada.

Background South Asians have more vascular risk factors, earlier cardiovascular disease onset, and higher stroke mortality than non-South Asians. However, ethnic differences in long-term outcomes post-stroke in diabetics are unclear. Aims We compared cardiovascular outcome risk after first ischemic stroke between South Asian and non-South Asian diabetics. Methods Using population-based health care databases in Ontario, Canada, we selected all patients with diabetes hospitalized with first ischemic stroke between 1 April 2002 and 31 March 2012, and assigned South Asian versus non-South Asian ethnicity using a validated surname algorithm. Kaplan-Meier survival analysis estimated survival functions, and competing risk models estimated hazards of death, stroke, and myocardial infarction. The primary predictor was ethnicity, and models were adjusted for demographics and vascular risk factors. Sensitivity analysis including adjustment for medication use was performed in those aged ≥65 years. Results There were 25,495 diabetics with first ischemic stroke; 840 were South Asian. South Asians were younger, more often male, had lower income, and had shorter Ontario residency compared to non-South Asians. South Asians had higher incidence and cumulative risk of recurrent stroke. In fully adjusted competing risk models, recurrent stroke rate was increased among South Asians compared to non-South Asians (HR 1.17 [95% CI 1.00-1.38]) in the whole cohort and in those aged ≥65 years, both with adjustment for medication use (HR 1.23 [1.01-1.50]) and without (1.27 [1.04-1.54]). Conclusions In this large population-based study, South Asian diabetic stroke patients had higher recurrent stroke rates compared to non-South Asians, despite a younger age profile. Further research is needed to reduce stroke burden in South Asians.

Abstract 80: Drive-Time Proximity to Certified Stroke Centers in California, 2015

Introduction: As access to timely, optimal treatment for acute stroke is associated with lower stroke mortality, understanding the relative access to acute stroke care at a certified primary and/or comprehensive stroke center (CPCSC) is essential for the development of a statewide system of care. The present study aims to describe this access, in relation to the relative burden of stroke mortality in California. Hypothesis: It is hypothesized that: (1) Overall, in California, access to CPCSCs is relatively high; and (2) Californians who reside in areas with the highest stroke mortality rates have less access to CPCSCs than do those who reside in areas with the lowest stroke mortality rates. Methods: Using ArcView, a map was created, showing the location of each of the 171 Joint Commission CPCSCs in California, the geographic area within a 40 minute drive-time of each center, and the underlying relative stroke mortality rate in each service area. Results: Overall, 92% of Californians live within a 40 minute drive of a CPCSC. Further, while 98% of those who live in the least burdensome areas (in terms of stroke mortality) have access to such a center, only 65% of those who live in the most burdensome areas have this kind of access. Two geographic examples of this latter situation include California’s Central Valley and the most northern counties. Conclusions: It is incumbent upon California’s public health and emergency medical systems to ensure that all Californians have access to high quality acute stroke care at CPCSCs, especially as clinical standards of care advance. Utilizing GIS technology can help identify potential service gaps and inform ongoing and future efforts to ensure this access.

Abstract TP176: Stroke Recurrence Among South Asians With diabetes in Ontario, Canada

Introduction: South Asians have earlier cardiovascular disease onset and higher stroke mortality than non-South Asians, but disparities in long-term outcomes after stroke in patients with diabetes are not well described. We compared risk of cardiovascular outcomes after first ischemic stroke between South Asian and non-South Asian patients with diabetes. Hypothesis: We hypothesized that South Asian stroke patients with diabetes were younger and had higher stroke recurrence, even accounting for competing risk of death. Methods: Using population-based health care databases in Ontario, Canada, we selected all patients with diabetes hospitalized with first ischemic stroke between April 1, 2002 and March 31, 2012, and assigned South Asian vs. non-South Asian ethnicity using a validated surname algorithm. Kaplan-Meier survival analysis and competing risk models estimated risk of death, stroke, and myocardial infarction. The primary predictor was ethnicity; models were adjusted for demographics and vascular risk factors. Sensitivity analysis including adjustment for medication use was performed in those aged &gt;=65 years. Results: There were 25495 diabetics with first ischemic stroke; 840 were South Asian and were younger, more often male, had lower income, and had shorter Ontario residency compared to non-South Asians. South Asians had higher incidence and cumulative risk of recurrent stroke (Figure). In adjusted competing risk models, recurrent stroke risk was increased among South Asians compared to non-South Asians (HR 1.17 [95% CI 1.00-1.38]) in the whole cohort and in those aged &gt;=65 years, both with adjustment for medication use (HR 1.23 [1.01-1.50]) and without (1.27 [1.04-1.54]). Conclusions: In this large population-based study, South Asian stroke patients with diabetes had higher recurrent stroke risk compared to non-South Asians, despite younger age. Further research and targeted interventions are needed to reduce stroke burden in South Asians.

Paradigms and mechanisms of inhalational anesthetics mediated neuroprotection against cerebral ischemic stroke.

Cerebral ischemic stroke is a leading cause of serious long-term disability and cognitive dysfunction. The high mortality and disability of cerebral ischemic stroke is urging the health providers, including anesthesiologists and other perioperative professioners, to seek effective protective strategies, which are extremely limited, especially for those perioperative patients. Intriguingly, several commonly used inhalational anesthetics are recently suggested to possess neuroprotective effects against cerebral ischemia. This review introduces multiple paradigms of inhalational anesthetic treatments that have been investigated in the setting of cerebral ischemia, such as preconditioning, proconditioning and postconditioning with a variety of inhalational anesthetics. The pleiotropic mechanisms underlying these inhalational anesthetics-afforded neuroprotection against stroke are also discussed in detail, including the common pathways shared by most of the inhalational anesthetic paradigms, such as anti-excitotoxicity, anti-apoptosis and anti-inflammation. There are also distinct mechanisms involved in specific paradigms, such as preserving blood brain barrier integrity, regulating cerebral blood flow and catecholamine release. The ready availability of these inhalational anesthetics bedside and renders them a potentially translatable stroke therapy attracting great efforts for understanding of the underlying mechanisms.

Abstract 10120: Increased Stroke Mortality Among Lean Japanese

Background: Several large cohort studies showed underweight was associated with an increased risk of death in Asians after major methodologic issues were addressed. We examined specific causes of death in lean Japanese of a general population. Methods: We studied 16,461 subjects (mean age 54±13 years, men 26%) who had the annual health checkup offered to adult citizens of Moriguchi city, Osaka, Japan in 1997. The subjects were divided into 5 groups according to body mass index (BMI) presented in the table. Proportional hazards regression analyses adjusted for age, sex, smoking status, drinking habit, history of CV disease, hypertension, diabetes, and hyperlipidemia were used to assess the association of BMI categories with mortality. Results: During a mean follow-up of 14.1±4.4 years, there were 1,939 deaths. Of those, there were 797 cancer deaths, 462 cardiovascular (CV) deaths including 114 coronary deaths, 156 stroke deaths with 88 ischemic stroke deaths. Hazard ratios (HR) relative to the BMI of 22.0-24.9 kg/m 2 group with 95% confidence intervals (CI) were presented in the table. Although underweight (&lt;18.0 kg/m 2 ) was not associated with cancer deaths, it was significantly associated with CV deaths (HR=1.92, 95%CI=1.33 to 2.78, p=0.0005) and stroke deaths (HR=2.02, 95%CI=1.07 to 3.81, p=0.0295). Among stroke deaths, ischemic stroke deaths tended to be higher in the underweight group (HR=1.95, 95%CI=0.90 to 4.26, p=0.0926). Conclusions: In the general Japanese population, underweight was associated with higher stroke mortality.

Georeferencing deaths from stroke in São Paulo: an intra-city stroke belt?

The role of socioeconomic status in the worldwide stroke burden has been studied with various methods using vital statistics and research-generated data. The objective of our study was to describe the stroke mortality rates and the stroke mortality distribution, and to evaluate the association between stroke mortality rates and geographical distribution with the human development index in São Paulo, Brazil. This ecological study evaluated a historical series of stroke mortality in São Paulo, Brazil, from 2004 to 2010. Standard stroke mortality rate per 100 000 inhabitants at each year, the address of residence assumed as the place of living, and the human development index applied as a social indicator were used in order to evaluate if stroke mortality correlated with socioeconomic status. The mean standardized stroke mortality in São Paulo decreased from 66 to 46·7 per 100 000 inhabitants from 2004 to 2010. Stroke mortality differed according to human development index strata with an almost three times higher stroke mortality in the lowest when compared with the highest human development index stratum. Visual inspection of the map of the districts with high stroke mortality disclosed regional clusters with high mortality in the east, northwest, and south regions, a finding suggestive of the presence of a stroke belt inside the city of São Paulo. In conclusion, between 2004 and 2010, stroke mortality rates decreased by 28·5% in São Paulo. A geographical pattern in stroke mortality could be observed, with considerable differences according the human development index level of the place of living.

Opportunities for concurrent transcranial magnetic stimulation and electroencephalography to characterize cortical activity in stroke.

Stroke is the leading cause of disability in the United States. Despite the high incidence and mortality of stroke, sensitive and specific brain-based biomarkers predicting persisting disabilities are lacking. Both neuroimaging techniques like electroencephalography (EEG) and non-invasive brain stimulation (NIBS) techniques such as transcranial magnetic stimulation (TMS) have proven useful in predicting prognosis, recovery trajectories and response to rehabilitation in individuals with stroke. We propose, however, that additional synergetic effects can be achieved by simultaneously combining both approaches. Combined TMS-EEG is able to activate discrete cortical regions and directly assess local cortical reactivity and effective connectivity within the network independent of the integrity of descending fiber pathways and also outside the motor system. Studying cortical reactivity and connectivity in patients with stroke TMS-EEG may identify salient neural mechanisms underlying motor disabilities and lead to novel biomarkers of stroke pathophysiology which can then be used to assess, monitor, and refine rehabilitation approaches for individuals with significant disability to improve outcomes and quality of life after stroke.

American Stroke Association Stroke Council Update

This report represents the Spring 2015 update of the Stroke Council. Much has happened in the last 12 months, and we want to particularly focus on the major developments in acute stroke therapy and their implications, progress in the American Stroke Association (ASA)/American Heart Association (AHA) quality initiatives and tiered systems of stroke care, and the approval of a new code for the National Institutes of Health Stroke Scale (NIHSS). Each Stroke Council Update starts with restating our 2020 Goals: to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%. In December 2014, we had further evidence that our efforts are bearing fruits. In 2011, stroke fell from the number 3 to the number 4 cause of death in the United States, and in December, stroke fell from number 4 to number 5. This development, which reflects the continued decrease in age-adjusted mortality rates for stroke, is a remarkable testament to concerted educational and public health efforts to control blood pressure, decrease tobacco use, appropriately treat atrial fibrillation, educate the public about stroke warning signs, and improve and standardize the neurocritical care of stroke patients. Yet, it is sobering that the actual number of strokes continues to increase as the population ages because the incidence of stroke increases markedly with age. Stroke remains the second leading cause of death worldwide and one of the leading causes of disability worldwide. That is why the ASA/AHA is partnering with the World Stroke Organization and World Health Organization to take best practices and apply them worldwide. We have accomplished much but have more to do. The International Stroke Conference Scientific Sessions and Pre-conference meetings in Nashville was a great success with 4341 attendees, the largest number of attendees ever. The quality of the …