Ischemic stroke in Morocco: Prehospital delay and associated factors

ObjectivesThis study aimed to estimate prehospital delay and to identify the factors associated with the late arrival of patients with ischemic stroke at the Souss Massa Regional Hospital Center in Morocco.Patients and methodsAn observational, prospective, cross-sectional study was conducted from March 2019 to September 2019 in the Souss Massa regional hospital center, which is a public hospital structure. A questionnaire was administered to patients with ischemic stroke and to bystanders (family or others), while clinical and paraclinical data were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify the factors associated with delayed arrival at emergency department.ResultsA total of 197 patients and 197 bystanders who fulfilled the criteria for the study were included. The median time from symptom onset to hospital arrival was 6 hours (IQR, 4–16). Multiple regression analysis showed that illiteracy (OR 38.58; CI_95%: 3.40–437.27), waiting for symptoms to disappear (patient behavior) (OR 11.24; CI_95%: 1.57–80.45), deciding to go directly to the hospital (patient behavior) (OR 0.07; CI_95%: 0.01–0.57), bystander's knowledge that stroke is a disease requiring urgent care within a limited therapeutic window (OR 0.005; CI_95%: 0.00–0.36), and direct admission without reference (OR 0.005; CI_95%: 0.00–0.07), were independently associated with late arrival (> 4.5 hours) of patients with acute ischemic stroke. In addition, illiteracy (OR 24.62; CI_95%: 4.37–138.69), vertigo and disturbance of balance or coordination (OR 0.14; CI_95%: 0.03–0.73), the relative's knowledge that stroke is a disease requiring urgent care and within a limited therapeutic window (OR 0.03; CI_95%: 0.00–0.22), calling for an ambulance (relative's behavior) (OR 0.16; CI_95%: 0.03–0.80), distance between 50 and 100 km (OR 10.16; CI_95%: 1.16–89.33), and direct admission without reference (OR 0.03; CI_95%: 0.00–0.14), were independently associated with late arrival (> 6 hours) of patients with acute ischemic stroke.ConclusionPatient behavior, bystander knowledge and direct admission to the competent hospital for stroke care are modifiable factors potentially useful for reducing onset-to-door time, and thereby increasing the implementation rates of acute stroke therapies.     

Ischemic stroke in young adults

Ischemic strokes appear infrequently in young adults before age of 45. It is important to find the etiologic factors and treatment them adequately for preventing the recurrence. Between 1988-1998 eighty-four stroke patients were observed in the authors' clinic. Smoking and hyperlipidemia were the most frequent risk factors. These were different from other studies and they can related to the national eating habits. Atherosclerosis (33.3%), prothrombotic states (15.5%) and cardiogenic embolism (9.5%) were found in the background, but the etiology remained unclear in 17.7% of patients. Neurological signs improved in 77.4% of patients, but deterioration was found in 3.6% and 7% of patients died in spite of appropriate therapy. The frequency of the stroke in young adults and distribution of etiological factors were similar to the other studies. The occurrence of above mentioned risk factors--mainly the frequently observed hyperlipidemia--reflects local feeding features. Because of the limited diagnostic tools some cases remained unclear.     

Ischemic stroke and shift work

OBJECTIVES: This study analyzed the potential association between shift work and ischemic stroke. METHODS: The analysis was carried out using a nested case-control study consisting of 138 shift workers and 469 day workers from the register of the Northern Sweden Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) study and the V?sterbotten Intervention Programme. Logistic regression analysis was used to analyze the risk estimate for day workers in a comparison with shift workers and the risk of ischemic stroke. RESULTS: The crude odds ratio for shift workers' risk of experiencing an ischemic stroke was 1.0 (95% confidence interval 0.6-1.8) for both the men and the women. The risk estimates were consistent despite the introduction of several recognized risk factors for ischemic stroke in the logistic regression models. CONCLUSIONS: In the present study, none of the findings indicated a higher risk of shift workers undergoing an ischemic stroke than day workers.     

Ischemic stroke hospital stay and discharge destination

PURPOSE: Stroke hospitalizations are among the most expensive, with a mean length of stay (LOS) higher than other hospitalizations. This retrospective study assesses factors influencing ischemic stroke LOS taking into consideration the discharge destination of patients. METHODS: Linked hospital separation records between July 1995 and December 1999 were extracted to determine the first admission for ischemic stroke in Western Australia. Multiple hospitalization records for the same patient were screened to obtain the total duration of hospitalization. Demographic characteristics, hospital type, and medical history of patients were also retrieved. In the presence of censoring and without prior assumption on the time-to-discharge distribution, the Cox's proportional hazards model was used to assess the factors affecting LOS. RESULTS: During the study period, 6469 patients with a first-ever admission for ischemic stroke were identified, with average LOS being 28 days (95% CI, 26-30 days). Hospital stays were significantly longer for females and patients directly admitted to hospitals maintaining a specialist stroke unit, whereas patients residing in rural areas had shorter stays. CONCLUSIONS: The impact of stroke severity and placement in nursing homes after discharge need to be understood to manage LOS and the cost of acute care. Accurate diagnosis upon initial presentation would benefit both the efficiency of hospitals and the outcomes of rural ischemic stroke patients.     

Dietary patterns are associated with stroke in Chinese adults

We recently featured Chinese dietary patterns that were associated with obesity, hyperglycemia, hypertension, and metabolic syndrome. In this study, we examined the association of those dietary patterns and risk of stroke among 26,276 Chinese adults aged ≥45 y by using data from the 2002 China National Nutrition and Health Survey and explored whether those associations were mediated by obesity, hypertension, hyperglycemia, and other cardiovascular risk factors. The traditional southern Chinese dietary pattern, characterized by high intakes of rice and vegetables and moderate intakes in animal foods, was related to the lowest prevalence of stroke. Compared to the traditional southern dietary pattern, the traditional northern Chinese dietary pattern, characterized by high intakes of refined cereal products, potatoes, and salted vegetables, was associated with an elevated risk of stroke [OR = 1.96 (95% CI = 1.48-2.60); P < 0.0001]. Adjustment for conventional cardiovascular risk factors did not appreciably change the association [multivariate adjusted OR = 1.59 (95%CI = 1.16-2.17); P = 0.004]. The Western dietary pattern characterized by high consumption of beef, fruit, eggs, poultry, and seafood is also associated with an elevated risk of stroke [OR = 2.36 (95%CI = 1.82-3.06); P < 0.0001], but the associations became nonsignificant after adjustment for obesity, hypertension, hyperglycemia, and dyslipidemia. In conclusion, we found that the traditional southern dietary pattern was related to low prevalence of stroke and the traditional northern dietary pattern was associated with an increased stroke risk. The Western dietary patterns also association with high risk of stroke, which was largely mediated by obesity, hypertension, hyperglycemia, and dyslipidemia.     

Lower ambient temperature was associated with an increased risk of hospitalization for stroke and acute myocardial infarction in young women

OBJECTIVE: Results of investigations into the impact of seasonal variation on the incidence of cardiovascular diseases (CVD) have been inconsistent. Using the WHO Collaborative Study of CVD and Steroid Hormone Contraception database, we attempted to examine the relationship between variation in three climatic variables and risk of hospitalization for venous thromboembolism (VTE), arterial stroke, and acute myocardial infarction (AMI). STUDY DESIGN AND SETTING: We compared the monthly mean temperature, rainfall, and humidity with rates of hospitalized VTE, stroke, and AMI among young women aged 15-49 from 17 different countries in Africa, Asia, Europe, Latin America, and the Caribbean by using a negative binomial regression model. RESULTS: The study included 1146, 2,269, and 369 cases of VTE, stroke, and AMI, respectively. Significant associations between temperature and hospital admission rates of stroke and AMI, but not VTE, were apparent. Lagging the effects of temperature suggested that these effects were relatively acute, within a period of a month. CONCLUSION: These data may help in understanding the mechanisms whereby stroke and AMI events are triggered.     

Dealcoholized red and white wines decrease oxidative stress associated with inflammation in rats

In vitro experiments have demonstrated that polyphenols exhibit antioxidant and anti-inflammatory activities. The present study was designed to test whether dealcoholized red (DRW) and white (DWW) wines can decrease the oxidative stress associated with inflammation in vivo. Rats were fed for 15 d either a control diet or one supplemented with DRW or DWW. Finally, a granuloma was induced by subcutaneous administration of carrageenan. Although DRW showed higher antioxidant activity in vitro than DWW, both wines decreased the number of cells recruited into the granuloma pouch. Malondialdehyde decreased in plasma and inflammatory exudate from rats fed with DRW- and DWW-rich diets. Moreover, the concentration of NO increased in exudate, which correlates with the increase in the citrulline:arginine ratio. Polymorphonuclear leucocytes from the inflammatory exudate of rats fed dealcoholized wines showed decreased superoxide anion (O*2) production and increased NO production ex vivo. This change in NO production resulted from increased expression and activity of inducible NO synthase (EC 1.14.13.39). Moreover, the up regulation of cyclo-oxygenase-2 (EC 1.14.99.1) protein expression observed in rats fed the DRW-rich diet was not related to a direct effect of NO. The present results indicate that the non-alcoholic compounds of wines not only improve antioxidant status in an inflammatory situation, but also limit cell infiltration, possibly through a decrease in O*2 and an increase in NO production.     

Mortality risk associated with temperature and prolonged temperature extremes in elderly populations in Taiwan

Background

This study investigated mortality risks from all causes, circulatory and respiratory diseases for the elderly associated with prolonged exposure to extreme temperatures in four major cities of Taiwan.

Methods

Daily average temperatures at the high 99th, 97th, and 95th percentiles were defined as extreme heat, and those at the low 10th, 5th, and 1st percentiles were defined as extreme cold for each city in 1994–2007. Distributed lag non-linear model was used to estimate the relative risk (RR) of mortality associated with 30-day lag temperature, and heat and cold extremes lasting for 3–5, 6–8, and >8 days. The random-effects meta-analysis summarized the risks of temperature and extreme temperatures events.

Results

The lowest overall mortality among the elderly was when the temperature was 26 °C on average. Low temperatures caused greater adverse effects than high temperatures, particularly for mortality from circulatory diseases. After accounting for the cumulative 30-day temperature effects, meta-analysis showed that mortality risk slightly increased with strengthened and prolonged heat extremes (≥99th and >3 days; ≥97th and >8 days; and ≥ 95th and >8 days) that RRs ranged from 1.04–1.05, 1.01–1.05, and 1.05–1.13 for mortality from all causes and from circulatory and respiratory diseases, respectively. The corresponding RRs ranged from 0.98–1.01, 0.92–1.06, and 0.97–1.03, respectively, for shorter duration of heat extremes. This study did not identify significant effect for stronger or prolonged cold extremes.

Conclusions

Extreme temperatures and their duration cause varied mortality associations in the elderly. Short-term extremely low temperatures exhibit the greatest effect on mortality, and intensified and longer periods of heat extremes also exert a slightly increased effect on mortality.     

深圳市脑卒中发病与气温关系

目的探讨周平均温度与脑卒中发病的关系。方法采用时间序列的广义相加模型(GAM)建模原理,对2003年1月～2005年12月深圳市脑卒中发病与气象资料进行非参数拟合,在控制长期趋势、季节趋势和周平均湿度以后,分析周平均温度与脑卒中发病人数的关系。结果2003～2005年,深圳市脑卒中发病15434例,每周平均(99.00±29.56)例,男性周平均发病(59.52±17.93)例,女性周平均发病(39.42±13.86)例;<65岁周平均发病(54.18±18.00)例,≥65岁周平均发病(44.76±13.72)例。控制长期趋势、季节趋势和周平均湿度等因素影响后,低温是诱发深圳市脑卒中发病的主要气象因素,发病随温度降低而升高。分层分析发现,低温对女性或<65岁者脑卒中发病的影响更大,而男性脑卒中发病与气温降低未见明显影响。结论深圳市脑卒中发病与周平均气温存在线性关系,发病的相对危险度随温度降低而增加;在数据不满足参数拟合条件时,广义相加模型能有效地发现疾病与气象条件的内在关系。     

High free fatty acid levels are associated with stroke recurrence and poor functional outcome in Chinese patients with ischemic stroke

Background

The aim of this study is to investigate whether serum and cerebrospinal fluid (CSF) free fatty acid (FFA) levels are associated with outcome and recurrence in a cohort of patients with an acute ischemic stroke (AIS).

Methods

From December 2013 to May 2015, patients with first-ever AIS were included. FFA level and NIH stroke scale (NIHSS) were measured at the time of admission. Logistic regression analysis was used to evaluate the stroke outcome and recurrence according to FFA level. Clinical follow-up was performed at 6 month.

Results

In our study, we studied 296 patients (52.7% male). We have found a positive correlation between serum and CSF levels of FFA. Patients with a poor outcome and recurrence had significantly increased FFA serum and CSF levels on admission (all p<0.0001). Multivariate logistic regression analysis adjusted for common risk factors showed that FFA was an independent predictor of poor functional outcome and recurrence. Odds ratios (OR) values were more significant for the higher levels of FFA.

Conclusion

In summary, baseline serum and CSF FFA level were associated with stroke poor function outcome and recurrence, suggesting an effect of FFA on disease course in AIS.

     

Obesity and diabetes are jointly associated with functional disability in stroke survivors

BackgroundStroke is the most common cause of complex disability. Obesity and diabetes increase risk for functional disability in the general population, but their contribution to functional disability in stroke survivors is unknown.ObjectiveTo investigate the joint association of obesity and diabetes with functional disability in stroke survivors.MethodsCross-sectional data from 34,376 stroke survivors from the 2015 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys were examined. Weighted and age-adjusted prevalence estimates and adjusted odds ratios (AOR, adjusted for sociodemographic characteristics) with 95% confidence intervals (CIs) were calculated to compare prevalence and odds for self-reported functional disability, stratified by obesity-diabetes status (i.e., neither condition, obesity only, diabetes only, both conditions).ResultsPrevalence of functional disability increased across obesity-diabetes categories in the total sample: neither condition (45.4%, 95% CI: 43.4%–47.4%), obesity only (55.3%, 95% CI: 52.7%–58.0%), diabetes only (60.8%, 95% CI: 57.5%–64.1%), and both conditions (70.3%, 95% CI: 67.7%–72.9%). Compared to respondents with neither condition, those with both obesity and diabetes had 2.62 (95% CI: 2.23–3.08) higher odds for functional disability; odds were also increased for respondents with obesity only (1.52, 95% CI: 1.32–1.76) and diabetes only (1.71, CI: 1.45–2.01).ConclusionsOur findings indicated a joint effect of obesity and diabetes on functional disability that exceeded either condition alone, placing stroke survivors with both health conditions at greatest risk for diminished functional capacity. Recognizing obesity and diabetes as modifiable risk factors may be useful for identifying stroke sub-populations that could benefit from lifestyle intervention.     

Characteristics of stroke victims associated with early cardiovascular mortality in their children

We assessed the relationship between characteristics of stroke victims and the risk of early death from coronary or cerebrovascular disease (CCVD) among their children. For each of 55 stroke patients selected from a registry which enrolled patients between 1969 and 1973, an index of their progeny's survival was calculated using the age in 1987 of 197 surviving children, and the age at and cause of death for 55 deceased children. Increased risk of CCVD death within families was significantly related to parental age at the time of first stroke, and with the parental history of diabetes mellitus. No significant relationship was found between the children's risk of CCVD death and the stroke patient/parent's sex, race, history of hypertension or cardiac disease, stroke diagnosis (infarction vs hemorrhage), or severity upon admission. These results suggest that family histories of cerebrovascular disease may impart differential risks, depending upon a family history of diabetes, and perhaps, the ages at which ancestral strokes first occurred.