Young patients with stroke at the UHWI - the CT findings - Poster presentation

There is not much data on young patients with stroke (< 50 yrs) from the Caribbean. This paper sought to identify the types of stroke seen in young, Caribbean patients, with a view to noting trends and suggesting intervention strategies. The study is a retrospective review of patients (<50 yrs with stroke who had Computerised Tomography (CT scans) of the brain at the UHWI, from January 1, 1998 to December 31, 1998. Data were collated from the CT register of the Xray Department of UHWI. Results were available for 81 patients (43 females and 38 males). Overall, 62 percent of study sample had infarct (71 percent males, 38 percent females), 27 percent intra-cerebral bleed (15 percent males, 34 percent females); 11 percent subarachnoid haemorrhages. In females 11 - 40 yrs, 61 percent of CVAs were on the right and 39 percent on the left; between 41 and 50 yrs. 92 percent of CVAs were left sided and 8 percent on the right. In males 11 - 40 yrs, 66 percent of CVAs were on the right and 33 percent on the left; between 41 and 50 yrs, 45 percent were on the right and 55 percent on the left. This preliminary study suggests that in the population reviewed, there is a similar incidence of CVAs in males and female. Infarcts are the most common results of a CVA followed by intra-cerebral bleed and subarachnoid haemorrhage. Infarcts are more common in males than females whilst intracerebral bleeds are more common in females. Under the age of 41 yrs, CVA is more common on the right than the left whilst between 41 and 50 yrs, they are more common on the left; this is more so in females in whom 92 percent of lesions were on the left in the age group 41 - 50 years.(AU)

Severe neurological complications of post open heart surgery: the Jamaican experience; January, 1994 - August, 1999

Neurological complications after open-heart surgery (OHS) constitute a broad spectrum of injury, and represents the leading cause of morbidity and mortality. The most serious injury is seen in those who remain comatose or never regain meaningful neurologic function. Stroke is another devastating complication that can leave the patient permanently disabled. The incidence of stroke has been documented as ranging from 0.8 - 5.2 percent. Much less information is available on the incidence of the less fatal complications such as delirium, confusion, encephalopathy, developmental delay or other neuropsychiatric disorders. During the period January, 1994 to August, 1999, a total of 360 paitents (adults and children) underwent OHS, at the University Hospital of the West Indies (UHWI), Mona, Jamaica. The types of surgeries performed were: ASD = 53; VSD = 40; valve replacement = 151 (100 MVR, 34 AVR, 17 DVR); valvuloplasty/annuloplasty = 5; CABG = 44; repair of congenital heart abnormalities = 65; other (atrial myxoma) = 2. About eight (8) patients (2.2 percent) developed severe neurological symptoms post-operatively. These ranged from short period (<24 hours) of seizure activities to severe encephalopathy and death, secondary to massive cerebral infarction. Four (4) of these patients died as a result of the neurologic complication. There is no need for avoidance and/or elimination of the factors that increase the risk of post-operative neurologic complications. Unfortunately not all of these can be eliminated. There is also the need for detailed, structured neurological and neuropsychiatric assessments, both pre- and post-operatively. These will enable the early detection of gross, but more importantly the subtle changes and hence prompt institution of counteractive/corrective measure. Detection of markers which will indicate the possible development of severe neurologic injury would also be useful.(AU)

Stroke in Trinidad and Tobago: Burden of illness and risk factors

This study describes the burden of stroke on hospital services in a Caribbean community. The settings are the two main acute general hospitals in Trinidad observed over a 12-month period. All subjects are admitted with a clinical diagnosis of acute stroke. The measures were hospital admission rates, length of hospital stay, case-fatality rates, disability at discharge, and risk factors for stroke. There were 1,105 hospital admissions with a diagnosis of stroke. The median length of stay was 4 days, with an interquartile range of 2 to 9, and stroke accounted for approximately 9,478 bed days per annum. The hospital admission fatality rate was 29 percent. Among surviving patients, 437 (56 percent) were severely disabled at discharge. Age-standardized admission rates for first strokes in persons aged 35-64 years were 114 (95 percent CI: 83 to 145) per 100,000 in Afro-Trinidadian men and 144 (109 to 179) in Indo-Trinidadian men. The equivalent rates for women were 115 (84 to 146) and 152 (118 to 186). Among patients with first strokes, 348/531 (66 percent) reported physician-diagnosed hypertension, but only 226 (65 percent) of these reported being on antihypertensives at admission. Stroke in Trinidad and Tobago is associated with a high case-fatality rate and severe disability in survivors. Modifable risk factors were reported in a majority of stroke cases, and there is a need to develop effective preventive strategies.(AU)

Stroke in Trinidad and Tobago: burden of illness and risk factors

This study describes the burden of stroke on hospital services in a Caribbean community. The settings are the two main acute general hospitals in Trinidad observed over a 12-month period. All subjects were admitted with a clinical diagnosis of acute stroke. The measures were hospital admission rates, length of hospital stay, case-fatality rates, disability at discharge, and risk factors for stroke. There were 1 105 hospital admissions with a diagnosis of stroke. The median length of stay was 4 days, with an interquartile range of 2 to 9, and stroke accounted for approximately 9 478 bed days per annum. The hospital admission fatality rate was 29 percent. Among surviving patients, 437 (56 percent) were severely disabled at discharge. Age-standardized admission rates for first strokes in persons aged 35-64 years were 114 (95 percent CI: 83 to 145) per 100 000 in Afro-Trinidadian men and 144 (109 to 179) in Indo-Trinidadian men. The equivalent rates for women were 115 (84 to 146) and 152 (118 10186). Among patients with first strokes, 348/531 (66 percent) reported physician-diagnosed hypertension, but only 226 (65 percent) of these reported being on antihypertensives at admission. Stroke in Trinidad and Tobago is associated with a high case-fatality rate and severe disability in survivors. Modifiable risk factors were reported in a majority of stroke cases, and there is a need to develop effective preventive strategies (AU)

Ethnicity and excess mortality

The study examines and assesses the excess mortality from cerebrovascular disease, ischaemic heart disease, diabetes, hypertensive disease, injury and poisonings in City and Hackney descendents by country of birth used as proxy of ethnicity. The five year specific death rates for descendents aged 35 to 84 yars for England and Wales during the period 1986-90 was used as the standard to celebrate standardised proportional mortality ratios for these diseases. Mortality odds ratios were computed using the United Kingdom born descendents as the comparison group and all causes of death except genitourinary neoplasms, cirrhosis of the liver and the causes of interest as the auxillary (controls) cause of death. African Caribbean groups contribute 95 percent of the excess mortality from hypertensive disease. Caribbean and Indian groups account for over half the excess deaths from diabetes. All three groups contribute the excess deaths from cerebrovascular disease. Indian females appear to have twice the mortality risk of the England and Wales women, but this excess is hidden by the deficits of the Caribbean, British and younger Indian male groups who show deficit deaths from this cause. Mortality differentials are demonstrable by ethnic group at district level and may be greater than other available sources indicate. Standardised mortality odds ratios may be valuable tool for examining data sets lacking denominator data.(AU)

Risk factors of stroke in a West Indian population, a case control study

Stroke is frequent in Guadeloupe and represents the first cause of mortality in the >35 year age group. A major risk factor of stroke, hypertension, is also very common (23 percent of the adult population). The French West Indies (FWI) has specific demographic characteristics because its population originated from various regions of the world, mainly Africa, and has a higher socioeconomic level than the other tropical regions. These circumstances provide an interesting background for the study of the epidemiology of stroke and its risk factors. A case control study with 90 stroke patients and 77 controls matched for age and ethnicity was carried out during six months at the University Hospital of Pointe-a-Pitre, FWI. A questionnaire was used to collect information on demographics, history of smoking and alcohol use and current medical history. Serum creatinine, C-reactive protein and lipid profile were quantified. Among stroke patients 48/90 (63.6 percent) were ischaemic, and 58/90 (75.3 percent) had previous hypertension. Obesity and diabetes were more frequent in the cases than in the controls. Serum creatinine concentration, serum total cholesterol, and apolipoprotein-B were significantly higher in patients than controls [83 umol/l vs 73 (p<0.0003) for creatinine, 5.7 mmol/l vs 5.2 (p<0.008) for cholesterol, and 1.2 g/l vs 1.0 (p<0.001) for apolipoprotein-B]. A multiple logistic regression analysis revealed that, in addition to hypertension and obesity, a high serum apolipoprotein-B concentration (>75 umol/l), and a high serum apolipoprotein-B concentration (>Ig/I) were independent and significant risk factors of stroke.(AU)

Anticardiolipin antibodies in women with thromboembolic disorders and in primiparae

Our aims were to determine if the presence of anticardiolipin antibodies (aCL) is an independent risk factor for venous thromboembolism (VTE), myocardial infarction (MI) and stroke (CVA) and to estimate the prevalence of aCL among primiparae and its influence on pregnancy outcome. aCL antibody concentration and isotype were measured using an anticardiolipin ELISA. 50 cases of VTE, CVA and MI along with 149 age-matched controls were recruited from a hospital based case control study. Ages ranged from 15 to 49 years. 1,212 primiparae with uncomplicated pregnancies were recruited from clinics in Kingston and St. Andrew. aCL antibodies were present in 16/50 (32 percent) of CVA, VTE and MI cases and in 23/149 (15.4 percent) of the controls (X = 6.5, p = 0.0107). The estimated relative risk for VTE, CVA and MI associated with aCL antibodies is 2.58 (OR = 2.58; 95 percent CI 1.15-5.77). Among the primiparae 137/807 (16.9 percent) were aCL positive. The impact of aCL antibody presence on pregnancy outcomes has not yet been assessed. aCL antibodies confer a significant risk of VTE, CVA, and MI among women 15-49 years old.(AU)

The prevalence of hypertension and the state of cardiovascular health in Venezuela and surrounding nations

This review summarizes the prevalence of hypertension and the state of cardiovascular health in Venezuela and surrounding nations. First, the review discusses the fact that cardiovascular disease (CVD) is the main cause of death in Venezuela, Colombia, Brazil, and Trinidad and Tobago, accounting for 20 percent to 35 percent of all deaths. These data are similar to data from the developed world. Second, prevalence of hypertension in this region varies from 8 percent to 40 percent in the adult population, and, on average, 22 percent of the adult population of this region has an elevated blood pressure. However, prevalence rates very considerably from country to country and within regions of the same country. Although mortality from hypertension as the main cause of death accounts for 1 percent to 4 percent of all deaths, indicating a failure in the treatment of hypertension. In most Latin American countries, the degree of awareness, treatment and control of hypertension is low, necessitating the establishment of programs to prevent, detect and effectively treat hypertension and decrease CVD risk factors.(Au)

Audit of ethnic differences in risk factors and outcomes for diabetic patients attending St. Thomas hospital 1975-1995

Over the past twenty years a computerized record sytem `Diabeta' has been used to collect and collate clinical information on all patients attending the Diabetes Centre. In this time over 8000 patients have been registered, of these 42 percent have been grouped `caucasian' and 32 percent `afro-caribbean' by their own description. These large groups allow us to look at ethnic differences in disease pattern and outcomes, in order to better plan future diabetes health care requirement of different ethnic groups. Specific and significant differences between caucasians and afro-caribbeans are seen in many aspects of disease process and outcome. Age of onset of diabetes in European populations charateristically follows a bi-modal distribution, with peaks around the age of 10 and 60 years, this is mirrored in our own caucasian population in Lambeth. By contrast incidence of diabetes in our afro-Caribbean population is extremely low under the age of 20, but peaks at 50 years. True insulin-dependent diabetes (IDDM) is thus uncommon in afro-Caribbeans whilst non-insulin dependent diabetes (NIDDM) is somewhat more common. Patients with NIDDM have increased risks for cardio-vascular disease and peripheral vascular disease in addition to the specific diabetes-related complications, thus attention is given in the clinic to blood pressure, cholesterol, smoking habits and weight in addition to measures of glycaemic control. Risk factors differ significantly between the two groups, afro-caribbeans having higher blood pressure (despite treatment) but lower rates of smoking. Glycaemic control (percentage of HbALc) is not significantly different between the groups as a mean, but 2/3 of the worst 5 percent of glycaemic control are afro-caribbean. Despite these differences, stroke rates are similar in the two groups, cardiovascular disease higher in caucasians, and almost all specific diabetes complications higher in caucasians. The only major significant outcome that shows higher in afro-caribbeans is the onset of persistent proteinuria (heralding renal failure). Diabetes complications create a large health and financial burden on patients, knowledge of ethnic differences in relative risks of complications will allow us to better tailor the care and health-screening offered in the clinic to the individual needs of our patients. (AU)

South London Community stroke register (SLSR): Stroke incidence in the first two years of the register (1995-1996)

The aim of this project is to determine whether whether there are ethnic differences in the incidence of first-ever stroke and in the frequencies of different subtypes of stroke. SETTING: An inner-city population of 234,533 residents of Lambeth, Brixton and North Southwark, of which 72 percent are Caucasian, 21 percent are Black (11 percent Afro-Caribbean, 7.5 percent West African, and 2.5 percent Black mixed), and 3 percent are Asian, Bangladeshi and Pakistani. METHODS: Using a multi-source, prospective community stroke register, data on incidence and stroke subtype were collected. Ethnic origin was self-reported by the patient or carer using the standardized OPCS census classification of the group. Stroke subtype was classified using brain radiology (computerized tomography or magnetic resonance imaging) or necropsy data. Strokes without pathological confirmation of stroke subtype using either of these methods were unclassified. RESULTS: A total of 596 strokes were registered in 1995-1996 giving a mean overall annual incidence rate of 1.3 strokes per 1,000 population per year (95 percent C.I. 1.1 -1.4). Incidence of stroke was significanlty higher in all ages in blacks compared with whites (p>0.0001), and the mean age of stroke was significantly lower in blacks compared wih whites (63.5 years, 95 percent C.I. 60.1 - 66.9, and 73.9 years. 95 percent C.I. 74.7 - 72.6, respectively, and p>0.0001). Of the first 500 patients registered, classifications of stroke subtype using information from brain radiology or necroscopy was possible in 441 patients (88.2 percent). There were signfificant ethnic differences in the frequencies of the subtypes of stroke between blacks and whites (p 0.015), with an increased proportion of strokes due to intracranial haemorrhage and lacunar infarction in the blacks (28.4 percent and 29.6 percent) compared with whites (16.4 percent and 24.8 percent), and an increased proportion of non-lacunar infarction in the whites compared with blacks (45.5 percent and 36.4 percent respectively). CONCLUSION: These results suggest important ethnic differences in stroke incidence which probably reflect differences in risk factors for stroke between ethnic groups. These need to be examined further in order to develop effective strategies for stroke prevention in multi-ethnic communities.(AU)

Differences in potentially preventable risk factors for stroke amongst ethnic groups

AIM: To assess the prevalence of risk factors for stroke potentially amenable to health service intervention (hypertension, diabetes, smoking, increased alcohol consumption, physical inactivity, atrial fibrillation, cardiac disease, previous TIA) in black Caribbean, black African and white population of an inner-city health authority. METHODS: A cross-sectional survey was conducted, involving 16 GP Practices serving an area with a high proportion of black residents as identified by the 1991 Census. The FHSA list for these practices was used as the sampling frame. A random sample of 8000 residents (45-74 years old) was selected for a postal survey, which collected data on age, sex, occupation and ethnic group. Responders were stratified by ethnic group. A random sample of 450 subjects in white and black Caribbean group was selected, and together with 193 black African responders invited for screening. RESULTS: There were 725 responders: 303 whites (41.8 percent), 316 black Caribbean (43.6 percent) and 106 black Africans (14.6 percent). Black Caribbeans and Africans were less likely to have a normal blood pressure than whites (OR=0.42, p=0.0001, and OR=0.39, p=0.001 respectively.) Black Caribbeans and were also less likely to have a normal ECG (OR=0.55, p=0.0011, and OR=0.41, p=0.007 respectively.) Left ventricular strain was more common in black Caribbeans (OR=15.81, p=0.008) and Africans (OR=19.97, p=0.007), ischaemic changes were more common in black Caribbeans (OR=2.8, p=0.0001) and myocardial infarction in Africans were found in the prevalence of reported risk factors, such as diabetes (5 percent, 15.2 percent, 10.4 percent respectively, p>0.00001), smoking (31.4 percent, 21 percent, 11.3 percent, p<0.00001, alcohol drinking (80.9 percent, 77.8 percent, 61.3 percent, p<0.00001) and physical activity (75.3 percent, 83.2 percent, 79.3 percent, p=0.048). No difference was found in prevalence of atrial fibrillation and previous TIA. CONCLUSION: Black Caribbeans and black Africans have significantly higher prevalence rates of the important risk factors for stroke. This may partially explain higher mortality rates for stroke in these ethnic groups. Strategies for stroke prevention will be considered in the context of the on-going study on cultural attitudes to risk factor reduction. (AU)

Outcome of stroke in patients with sickle cell disease

Cerebral vasculopathy is a major cause of morbidity in sickle cell disease (SCD). We report the first UK population-based study of stroke in SCD. Of 669 SCD patients (HbSS 429, HbSC 193, HbS-thalassaemia 48, HbSO 1) followed at the King's College hospital between 1970 and 1995, 21 (3.1 percent) developed stroke. A further ten patients were referred. 29 had HbSS and 2, HbSC. 3 (10 percent) suffered subarachnoid haemorrhage, the remaining 28 strokes were ischaemic. Median age at initial stroke was 6 years (19 mo- 31 yr) with 24 (80 percent) patients aged >10. Precipitating factors included parvovirus associated aplastic crisis in 2/25 98 percent) evaluable patients and bacterial meningitis in 2 (8 percent). 9 (36 percent) patients experienced transient neurological disturbance prodromally. 27 (87 percent) presented with paresis, 5 (16 percent) cranial nerve defects. 11 (35 percent) dysphasia and 3 (10 percent) seizures. No patient died during the acute episode. Patients with stroke had significantly lower Hb and higher WCC at age 1 compared to matched controls. Exchanged transfusion was performed with 26 patients following which 15 (58 percent) recovered neurologically. 19 patients subsequently entered a transfusion programme to maintain HbS <30 percent. Transfusion was stopped in 10 patients. Of these, 6 (60 percent) had recurrent stroke at a median of 4.5 months. A similar recurrence rate (50 percent) was observed among patients who did not receive regular transfusion whilst no patient maintained on monthly transfusions suffered further stroke. Recurrence was more common in patients suffering initial stroke at an early age and in whom no trigger was identified. Median follow-up after initial stroke is 8 years. 14 (45 percent) patients have no residual neurological deficit, 6 (19 percent) are severely disabled, 13 (42 percent) have learning disabilities and 7 (23 percent) epilepsy. There were two deaths in both patients with recurrent stroke. 1 patient with moyamoya-type disease has undergone extracranial-intracranial bypass and 1 allogeneic-BMT. In conclusion, whilst transfusion is effective in prevention of further stroke, cessation is associated with a high rate of recurrence which frequently results in severe physical and/or neuropsychological disability. The 6.5 percent mortality following stroke supports the rationale for early consideration of allogeneic-BMT in these patients. (AU)

Epidemological transition in Trinidad and Tobago 1953-1992: dissociation of trends in mortality from diabetes mellitus, hypertension, cerebrovascular disease and ischaemic heart disease

This study aims to describe trends in age-specific mortality from diabetes mellitus, hypertension, cerebrovascular disease and ischaemic heart disease in Trinidad and Tobago between 1953 and 1992 and to relate them to earlier changes in infant motality rates. Average annual age-specific mortality rates per 100,000 were calculated for five time periods from 1953-7 to 1988-92 and plotted by mid-year of birth for cohorts born 1874-1882 to 1944-1952. Regression analyses were performed to test associations between adult mortality rates, infant mortality rates for the same birth cohorts, and period of death. Infant mortality declined from 180 per 1000 in 1901 to 10 per 1000 in 1992. Age-standardised mortality from diabetes mellitus increased, in men from 60 in 1958-62 to 278 in 1988-92, in women the increase was from 89 to 303. Mortality from hypertension declined, in men, from 232 in 1953-57 to 73 in 1988-92, in women, from 206 to 67. Cerebrovascular mortality increased, in men from 341 in 1953-57 to 451 in 1963-67 before declining to 224 in 1988-92. In women cerebrovascular mortality increased from 292 in 1953-57 to 361 in 1963-67 before declining to 196 in 1988-92. There was evidence of deceleration in cerebrovascular mortality for cohorts born after 1908 to 1918. Ischeamic heart disease mortality remained constant. Mid-cohort infant mortality rates were not associated with adult mortality after adjusting for age and period of death. Declining infant mortality was subsequently associated with declining mortality from cerebrovascular disease and hypertensive disease and increasing mortality from diabetes mellitus but there was no association with ischaemic heart disease mortality. These relationships were confounded by secular changes associated with year of death. [AU]

Pulse oximetry in a cohort study of sickle cell disease

Oxygen saturation was determined by pulse oximetry in a representative sample of Jamaican patients with steady state sickle cell disease in a cohort study from birth. There were 220 with homozygous sickle cell (SS) disease and 142 with sickle cell-haemoglobin C (SC) disease aged 9-18 years, and 122 with a normal haemoglobin (AA) genotype aged 15-18 years. Pulse oximetry (SpO2) values were lower in SS disease (mean [95 percent confidence interval]), 92.5 [92.0-93.3]. Inhalation of 100 percent oxygen in SS patients with 02 saturations below 90 percent consistency increased saturation to 99-100 percent. In SS disease, Sp02 correlated positively with haemoglobin and fetal haemoglobin and negatively with reticulocyte counts but not MCHC, MCV or bilirubin level. Mean Sp02 in SS subjects with a normal alpha globin gene complement (mean[SD], 91.7 [3.9]percent) was lower than in heterozygotes (93.4 [4.0] percent) or homozygotes (96.1 [3.0] percent) for alpha+thalassaemia, the effects of alpha-thalassaemia not being explained by differences in haemoglobin or MCHC. In SS disease, Sp02 levels were not associated with age (within this age range), sex, number of sick clinic visits or number of hospital admissions. Higher Sp02 levels were associated with greater heights and weights, more frequent painful crises and less frequent acute chest syndrome, but these associations were not significant after adjustment for haemoglobin level. Desaturation is common in steady-state SS disease and knowledge of the individual's steady-state value may be important in the interpreting low value during acute complications.(AU)

Pulse oximetry in cohort study of sickle cell disease

Oxygen saturation was determined by pulse oximetry in a representative sample of Jamaican patients with steady-state sickle cell disease in a cohort study from birth. There were 220 with homozygous sickle cell (SS) disease and 142 with sickle cell- haemoglobin C (SC) disease aged 9-18 years, and 122 with a normal haemoglobin (AA) genotype aged 15-18 years. Pulse oximetry (SpO2) values were lower in SS disease (mean [95 percent confidence interval], 92.5 [92.0-93.0]) than in SC disease (96.7 [96.9-96.9]) or AA controls (97.1 [96.8-97.3]). Inhalation of 100 percent oxygen in SS patients with O2 saturations below 90 percent consistently increased saturation to 99-100 percent. In SS disease, SpO2 correlated positively with haemoglobin and fetal haemoglobin and negatively with reticulocyte counts but not with MCHC, MCV or bilrubin level. Mean SpO2 in SS subjects with a normal alpha globin gene complement (mean [SD], 91.7 [3.9] percent) was lower than in heterozygotes (93.4 [4.0] percent) or homozygotes (96.1 [3.0] percent) for O+ thalassaemia, the effects of O-thalassaemia not being explained by differences in haemoglobin or MCHC. In SS disease, SpO2 levels were not associated with age (within this age range), sex, number of sick clinic visits or number of hospital admissions. Higher SpO2 levels were associated with greater height and weight, more frequent painful crises and less frequent acute chest syndrome, but these associations were not significant after adjustment for haemoglobin level. Desaturation is common in steady-state SS disease and knowledge of the individual's steady-state value may be important in the interpreting low values during acute complications.(AU)

Epidemiological transition in Trinidad and Tobago, West Indies 1953-1992

BACKGROUND: This study aimed to describe trends in age-specific mortality from diabetes mellitus, hypertension, cerebrovascular disease and ischaemic heart disease in Trinidad and Tobago between 1953 and 1992 and to relate them to earlier changes in infant mortality rates. METHODS: Average annual age-specific mortality rates per 100 000 were calculated for 5-year time periods from 1953 -1957 to 1988-1992 and plotted by mid-year of birth for cohorts born 1874-1882 to 1944-1952. Regression analyses were performed to test associations between adult mortality rates, and infant mortality rates for the same birth cohorts and period of death. RESULTS: Infant mortality declined from 180 per 1000 in 1901 to 10 per 1000 in 1992. Age-standardized mortality from diabetes mellitus increased, in men, from 60 in 1958-1962 to 278 in 1988-1992, in women the increase was from 89 to 303. Mortality from hypertension declined, in men, from 232 in 1953-1957 to 73 in 1988-1992, and in women, from 207 to 67. Cerebrovascular mortality increased, in men, from 341 in 1953-1957 to 451 in 1963-1967 before declining to 224 in 1988-1992. In women cerebrovascular mortality increased from 292 in 1953-1957 to 361 in 1963-1967 before declining to 196 in 1988-1992. There was evidence of a deceleration in cebrovascular mortality for cohorts born after 1908-1918. Ischaemic heart disease mortality remained constant. Mid-cohort infant mortality rates were not associated with adult mortality after adjusting for age and period of death. CONCLUSION: Declining infant mortality was subsequently associated with declining mortality from cerebrovascular disease and hypertensive disease and increasing mortality from diabetes mellitus but there was no association with ischaemic heart disease mortality. These relationships were confounded by secular changes associated with year of death.(AU)

Counting the cost of hospital admissions with stroke in the Port-of-Spain and San Fernando, Trinidad

Cerebrovascular disease is one of the leading causes of death in Caribbean countries, but few studies have examined the use of hospital services by people suffering from stroke. We studied all patients admitted to Port-of-Spain and San Fernando hospitals in Trinidad over a twelve-month period. There were 643 admissions at Port-of-Spain Hospital and 462 at San Fernando. There were 823 (74 percent) admissions with first time strokes and 282 (26 percent) admissions with recurrent stroke; 321 (29 percent) were aged 65-74 years and 324 (29 percent) were 75 years of age. Five hundred and nine (46 percent) were Afro-Trinidadian and 418 (38 percent) Indo-Trinidadian but ethnic distribution differed at the two hospitals. There were clinical diagnoses of hypertension in 693 (63 percent) and diabetes mellitus in 355 (32 percent). There were 322 deaths giving a hospital admission fatality rate of 29 percent (95 percent CI, 26-32 percent). Mortality was associated with level of consciousness and degree of impairment of speech, swallowing and continence at the time of first assessment. Hospital mortality was not associated with age, gender, ethnic group or hospital of treatment. Among surviving patients 444 (57 percent) were severely disabled at the time of discharge. The median length of stay was 4 days (interquartile range 2-8 days) at Port-of-Spain and 5(3-9) days at San Fernando. At the two hospitals admissions with stroke accounted for 9088 bed-days annually with a conservatively estimated hospital cost in excess of TT $3.6 million (US$ 0.63). We conclude that stroke imposes a significant burden on hospital services, the hospital mortality rate is high and survivors have significant disability. The high prevalence of hypertension in stroke sufferers points to a strategy for control of stroke (AU)

The role of glutamic acid in the pathogenesis of stroke and the development of neuroprotective drugs

The role of glutamic acid (glutamate) in the pathogenesis of stroke is now fairly well established. As a result, many drugs which act on glutamate receptors are currently under investigation for their ability to prevent the damage induced by glutamate under ischaemic conditions. The efficacy of these compounds in protecting central neurones from the effects of stroke may be indicative of the importance of the role that glutamate plays in this process (AU)