Exploring dimensions of quality-of-life in survivors of stroke with communication disabilities - a brief report.

BACKGROUND: People with communication disabilities post-stroke have poor quality-of-life. OBJECTIVES: We aimed to explore the association of self-reported communication disabilities with different dimensions of quality-of-life between 90 and 180 days post-stroke. METHODS: Cross-sectional survey data were obtained between 90 and 180 days post-stroke from registrants in the Australian Stroke Clinical Registry recruited from three hospitals in Queensland. The usual follow-up survey included the EQ5D-3L. Responses to the Hospital Anxiety and Depression Scale, and extra questions (e.g. communication disabilities) were also collected. We used χ2 statistics to determine differences. RESULTS: Overall, 244/647 survivors completed the survey. Respondents with communication disabilities (n = 72) more often reported moderate to extreme problems in all EQ5D-3L dimensions, than those without communication disabilities (n = 172): anxiety or depression (74% vs 40%, p < .001), pain or discomfort (58% vs 39%, p = .006), self-care (46% vs 18%, p < .001), usual activities (77% vs 49%, p < .001), and mobility (68% vs 35%, p < .001). Respondents with communication disabilities reported less fatigue (66% vs 89%, p < .001), poorer cognitive skills (thinking) (16% vs 1%, p < .001) and lower social participation (31% vs 6%, p < .001) than those without communication disabilities. CONCLUSIONS: Survivors of stroke with communication disabilities are more negatively impacted across different dimensions of quality-of-life (as reported between 90 and 180 days post-stroke) compared to those without communication disabilities. This highlights the need for timely and on-going comprehensive multidisciplinary person-centered support.

Sex differences in quality of life after stroke were explained by patient factors, not clinical care: evidence from the Australian Stroke Clinical Registry.

BACKGROUND AND PURPOSE: Women may receive stroke care less often than men. We examined the contribution of clinical care on sex differences and health-related quality of life (HRQoL) after stroke. METHODS: We included first-ever strokes registered in the Australian Stroke Clinical Registry (2010-2014) with HRQoL assessed between 90 and 180 days after onset (EQ-5D-3L instrument) that were linked to hospital administrative data (up to 2013). Study factors included sociodemographics, comorbidities, walking ability on admission (stroke severity proxy) and clinical care (e.g. stroke unit care). Responses to the EQ-5D-3L were transformed into a total utility value (-0.516 'worse than death' to 1 'best' health). Quantile regression models, adjusted for confounding factors, were used to determine median differences (MD) in utility scores by sex. RESULTS: Approximately 60% (6852/11 418) of stroke survivors had an EQ-5D-3L assessment (median 139 days; 44% female). Compared with men, women were older (median age 77.1 years vs. men 71.2 years) and fewer could walk on admission (37.9% vs. men 46.1%, P < 0.001). Women had lower utility values than men, and the difference was explained by age and stroke severity, but not clinical care [MDadjusted = -0.039, 95% confidence interval: -0.056, -0.021]. Poorer HRQoL was observed in younger men (aged <65 years), particularly those with more comorbidities, and in older women (aged ≥75 years). CONCLUSIONS: Stroke severity and comorbidities contribute to the poorer HRQoL in young men and older women. Further studies are needed to understand age-sex interaction to better inform treatments for different subgroups and ensure evidence-based treatments to reduce the severity of stroke are prioritized.

Protocol for evaluation of enhanced models of primary care in the management of stroke and other chronic disease (PRECISE): A data linkage healthcare evaluation study.

INTRODUCTION: The growing burden of chronic diseases means some governments have been providing financial incentives for multidisciplinary care and self-management support delivered within primary care. Currently, population-based evaluations of the effectiveness of these policies are lacking. AIM: To outline the methodological approach for our study that is designed to evaluate the effectiveness (including cost) of primary care policies for chronic diseases in Australia using stroke as a case study. METHODS: Person-level linkages will be undertaken between registrants from the Australian Stroke Clinical Registry (AuSCR) and (i) Government-held Medicare Australia claims data, to identify receipt or not of chronic disease management and care coordination primary care items; (ii) state government-held hospital data, to define outcomes; and (iii) government-held pharmaceutical and aged care claims data, to define covariates. N=1500 randomly selected AuSCR registrants will be sent surveys to obtain patient experience information. In Australia, unique identifiers are unavailable. Therefore, personal-identifiers will be submitted to government data linkage units. Researchers will merge the de-identified datasets for analysis using a project identifier. An economic evaluation will also be undertaken. ANALYSIS: The index event will be the first stroke recorded in the AuSCR. Multivariable competing risks Poisson regression for multiple events, adjusted by a propensity score, will be used to test for differences in the rates of hospital presentations and medication adherence for different care (policy) types. Our estimated sample size of 25,000 patients will provide 80% estimated power (ɑ>0.05) to detect a 6-8% difference in rates. The incremental costs per Quality-adjusted life years gained of community-based care following the acute event will be estimated from a health sector perspective. CONCLUSION: Completion of this study will provide a novel and comprehensive evaluation of the effectiveness and cost-effectiveness of Australian primary care policies. Its success will enable us to highlight the value of data-linkage for this type of research.

Effectiveness of a shared team approach between nurses and doctors for improved risk factor management in survivors of stroke: a cluster randomized controlled trial.

BACKGROUND AND PURPOSE: Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack. The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high-risk population was determined. METHODS: This was a prospective, multicentre, cluster-randomized controlled trial with blinded assessment of outcomes and intention-to-treat analysis. Patients hospitalized for stroke/transient ischaemic attack and aged ≥18 years were recruited from four hospitals. General practices treating recruited patients were randomized to provide either usual care or an individualized management programme comprising nurse-led education and review of care plans by stroke specialists in addition to usual care. The primary outcome was a change in cardiovascular Framingham Risk Score between baseline and 12 months. RESULTS: From January 2010 to November 2013, 156 general practices (280 patients) were randomly assigned to usual care (control) and 159 (283 patients) to the intervention. The median age was 70.1 years; 65% were male. Overall, >80% of participants were prescribed recommended secondary prevention therapies at baseline. The primary efficacy analysis comprised 533 participants, with 30 either dying or lost to follow-up. In adjusted analyses, no significant between-group difference was found in the cardiovascular risk score at 12 months (0.04, 95% confidence interval -1.7, 1.8). CONCLUSIONS: The effectiveness of an organized secondary prevention programme for stroke may be limited in patients from high-performing hospitals with regular post-discharge follow-up and communication with general practices.

Factors associated with awareness, treatment and control of hypertension in a disadvantaged rural Indian population.

The aim of this study was to identify factors associated with awareness, treatment and control of hypertension in a rural setting in India. Following screening of the population, all individuals with hypertension (blood pressure (BP) ⩾140/90 mm Hg or taking antihypertensive medications) were invited to participate in this study. We measured BP, height, weight, skinfolds, waist and hip circumference, and administered a questionnaire to obtain information regarding socioeconomic and behavioural characteristics. Multivariable logistic regression was used to determine factors associated with awareness, treatment and control of hypertension. We recruited 277 individuals with hypertension. Awareness (43%), treatment (33%) and control (27%) of hypertension were poor. Greater distance to health services (odds ratio (OR) 0.56 (95% confidence interval (CI)) 0.32-0.98) was associated with poor awareness of hypertension while having had BP measured within the previous year (OR 4.72, 95% CI 2.71-8.22), older age and greater per cent body fat were associated with better awareness. Factors associated with treatment of hypertension were having had BP measured within the previous year (OR 6.18, 95% CI 3.23-11.82), age ⩾65 years, physical inactivity and greater per cent body fat. The only factor associated with control of hypertension was greater per cent body fat (OR 1.05, 95% CI 1.01-1.11). Improving geographic access and utilisation of health services should improve awareness and treatment of hypertension in this rural population. Further research is necessary to determine drivers of control.

Sex differences in presentation, severity, and management of stroke in a population-based study.

OBJECTIVES: Women may have poorer outcomes after stroke than men because of differences in their acute management. We examined sex differences in presentation, severity, in-hospital treatment, and early mortality in a cohort of first-ever-in-a-lifetime stroke patients. METHODS: Data were collected from May 1, 1996, to April 30, 1999, in the North East Melbourne Stroke Incidence Study. Stroke symptoms, prestroke medical history, in-hospital investigations, admission and discharge medications, initial stroke severity, and 28-day mortality were recorded. Multivariable regression was used to estimate sex differences in treatment, investigations, and 28-day mortality. RESULTS: A total of 1,316 patients were included. Women were older (mean age 76 +/- 0.6 vs 72 +/- 0.6, p < 0.01), had more severe strokes (median NIH Stroke Scale score 6 vs 5, p < 0.01), and more likely to experience loss of consciousness (31% vs 23%, p = 0.003) and incontinence (22% vs 11%, p = 0.01) than men. Women were less often on lipid-lowering therapy on admission. Echocardiography and carotid investigations were less frequently performed in women due to greater age and stroke severity. Women had greater 28-day mortality (32% vs 21%, p < 0.001) and stroke severity (44% vs 36%, p = 0.01) than men, but adjustment for age, comorbidities, and stroke severity (for mortality only) completely attenuated these associations. CONCLUSION: Sex differences seen in this study were mostly explained by women's older age, greater comorbidity, and stroke severity. The reasons for differences according to age may need further examination.

Very early mobilisation and complications in the first 3 months after stroke: further results from phase II of A Very Early Rehabilitation Trial (AVERT).

BACKGROUND: Interventions that may reduce the number and severity of potentially harmful post-stroke complications are desirable. This study explored whether very early and frequent mobilisation (VEM) affected complication type (immobility/stroke related), number and severity. METHODS: Secondary analysis from phase II, randomised controlled trial. Patients admitted within 24 h of stroke, whose physiological parameters fell within set limits, were randomised to either VEM, commencing <24 h, or standard care. Complications to 3 months were recorded by a blinded assessor and classified by a neurologist. Analysis was intention to treat. RESULTS: Seventy-one patients were recruited (standard care 33; VEM 38).There were no significant group differences in the number, type or severity of complications by 3 months, and most patients (81.6%) experienced one or more complications. Falls were common, while depression was absent. The multivariate analysis showed older age (OR 1.10, 95% CI: 1.02-1.18, p = 0.009) and longer length of stay (OR 1.18, 95% CI: 1.06-1.32, p = 0.002) were associated with experiencing an immobility-related complication. CONCLUSION: Interventions that promote recovery and reduce complications may consequently reduce length of stay. The larger phase III trial currently underway may shed light on whether increasing mobilisation reduces complications after stroke.

Economic evaluation alongside a phase II, multi-centre, randomised controlled trial of very early rehabilitation after stroke (AVERT).

BACKGROUND/PURPOSE: The effectiveness and costs of very early rehabilitation after stroke are unknown. This study assessed the cost effectiveness of very early mobilisation in addition to standard care (VEM) compared with standard care alone (SC). METHODS: Cost-effectiveness analysis alongside a phase II, multi-centre, randomised controlled trial (RCT) with blinded outcome assessments. Less than 24 h after stroke, patients were recruited from two stroke units and randomised to receive VEM or SC. The intervention continued until discharge or 14 days, whichever was sooner. The efficacy measure was a dichotomised modified Rankin Scale (mRS) at 3 months with mRS < or =2 representing good outcome. Costs were determined from medical records and patient interviews at 3, 6 and 12 months. National average (where available) or local costs were applied for the reference year 2004. Differences in mean total costs at 3 and 12 months were tested using t test assuming unequal variances. An incremental cost-effectiveness ratio was calculated and probabilistic uncertainty analysis was undertaken. RESULTS: The sample consisted of 38 VEM and 33 SC patients. A trend for good outcome with VEM compared to SC was found (adjusted OR 4.10, 95% CI 0.99-16.88, p = 0.051). Patients receiving VEM incurred significantly less costs at 3 months (AUD 13,559) compared with SC (AUD 21,860; p = 0.02). This difference in mean per patient total cost persisted at the 12-month assessment (VEM: AUD 17,564; SC: AUD 29,750; p = 0.03). VEM was found to be a 'dominant' (more effective, less cost) intervention when compared to SC at 3 months. CONCLUSION: These findings provide preliminary evidence that VEM is likely to be cost-effective. A large RCT is currently underway to confirm the cost effectiveness of VEM.

Is prestroke use of angiotensin-converting enzyme inhibitors associated with better outcome?

BACKGROUND: There is evidence that angiotensin-converting enzyme inhibitors (ACEIs) reduce the risk of stroke. However, it is unclear whether ACEI use before stroke provides a vasoprotective effect resulting in less severe stroke. METHODS: We ascertained all strokes occurring in a defined population in Melbourne, Australia. Prestroke use of ACEIs and concomitant medications was obtained from medical records. Initial neurologic deficit was dichotomized according to a NIH Stroke Scale (NIHSS) score < 8 (less severe deficit) or > or = 8 (severe deficit). Logistic regression was used to assess the association between prestroke use of ACEIs and stroke severity (measured by severity of neurologic deficits and death at 28 days). RESULTS: Seven hundred sixteen first-ever ischemic stroke patients were included. Previous use of ACEIs was independently associated with a reduced risk of severe neurologic deficits (odds ratio [OR] 0.56; 95% CI 0.35 to 0.91) and death within 28 days (OR 0.46; 95% CI 0.24 to 0.87). Diuretics were associated with an increased risk of severe neurologic deficits (OR 1.81; 95% CI 1.13 to 2.90). Factors associated with a greater NIHSS score were older age, atrial fibrillation, heart failure, and use of diuretics. These factors and claudication were associated with an increased risk of 28-day mortality, whereas use of anticoagulants was associated with a reduced risk of severe neurologic deficits and death. CONCLUSION: Within this large community-based cohort, prestroke use of angiotensin-converting enzyme inhibitors was associated with a reduced risk of severe stroke.

Progressive dementia after first-ever stroke: a community-based follow-up study.

OBJECTIVES: To examine the risk and determinants of a progressive dementia syndrome and cognitive impairment not dementia (CIND) in community-based nonaphasic first-ever stroke cases 1 year after stroke, relative to a matched community-based stroke-free group. METHODS: Matched cohort design, with cognitive tests given on two occasions 9 months apart to 99 mild-to-moderate first-ever stroke patients and 99 age- and sex-matched people without stroke. At follow-up, progressive dementia or CIND were diagnosed, with judges blinded to stroke/nonstroke status. RESULTS: Progressive dementia was diagnosed in 12.5% of stroke patients and 15.4% of those without strokes (RR 1.1, 95% CI 0.5 to 2.2, p = 0.85). CIND was diagnosed in 37.5% of stroke patients and 17.6% of participants without strokes (RR 2.1, 95% CI 1.2 to 3.4, p = 0.003). In multivariable regression, age (p = 0.04) and baseline cognition (p < 0.001) were independently associated with dementia whereas stroke (p = 0.002), age (p = 0.05), baseline cognition (p = 0.001), and baseline mood (p = 0.03) were independently associated with CIND at follow-up. CONCLUSIONS: In this community-based nonaphasic sample, mild-to moderate first-ever stroke was not associated with the presence of progressive dementia 1 year later, but was clearly associated with a greater risk of cognitive impairment not dementia (CIND). Baseline mood impairment remained independently associated with CIND at 1 year after taking into account stroke, age, and baseline cognitive ability.

Informal care for stroke survivors: results from the North East Melbourne Stroke Incidence Study (NEMESIS).

BACKGROUND AND PURPOSE: Informal caregivers play an important role in the lives of stroke patients, but the cost of providing this care has not been estimated. The purpose of this study was to determine the nature and amount of informal care provided to stroke patients and to estimate the economic cost of that care. METHODS: The primary caregivers of stroke patients registered in the North East Melbourne Stroke Incidence Study (NEMESIS) were interviewed at 3, 6, and 12 months after stroke, and the nature and amount of informal care provided were documented. The opportunity and replacement costs of informal care for all first-ever-in-a-lifetime strokes (excluding subarachnoid hemorrhages) that occurred in 1997 in Australia were estimated. RESULTS: Among 3-month stroke survivors, 74% required assistance with activities of daily living and received informal care from family or friends. Two thirds of primary caregivers were women, and most primary caregivers (>90%) provided care during family or leisure time. Total first-year caregiver time costs for all first-ever-in-a-lifetime strokes were estimated to be A$21.7 million (opportunity cost approach) or A$42.5 million (replacement cost approach), and the present values of lifetime caregiver time costs were estimated to be A$171.4 million (opportunity cost approach) or A$331.8 million (replacement cost approach). CONCLUSIONS: Informal care for stroke survivors represents a significant hidden cost to Australian society. Because our community is rapidly aging, this informal care burden may increase significantly in the future.

Cost of stroke in Australia from a societal perspective: results from the North East Melbourne Stroke Incidence Study (NEMESIS).

BACKGROUND AND PURPOSE: Accurate information about resource use and costs of stroke is necessary for informed health service planning. The purpose of this study was to determine the patterns of resource use among stroke patients and to estimate the total costs (direct service use and indirect production losses) of stroke (excluding SAH) in Australia for 1997. METHODS: An incidence-based cost-of-illness model was developed, incorporating data obtained from the North East Melbourne Stroke Incidence Study (NEMESIS). The costs of stroke during the first year after stroke and the present value of total lifetime costs of stroke were estimated. RESULTS: The total first-year costs of all first-ever-in-a lifetime strokes (SAH excluded) that occurred in Australia during 1997 were estimated to be A$555 million (US$420 million), and the present value of lifetime costs was estimated to be A$1.3 billion (US$985 million). The average cost per case during the first 12 months and over a lifetime was A$18 956 (US$14 361) and A$44 428 (US$33 658), respectively. The most important categories of cost during the first year were acute hospitalization (A$154 million), inpatient rehabilitation (A$150 million), and nursing home care (A$63 million). The present value of lifetime indirect costs was estimated to be A$34 million. CONCLUSIONS: Similar to other studies, hospital and nursing home costs contributed most to the total cost of stroke (excluding SAH) in Australia. Inpatient rehabilitation accounts for approximately 27% of total first-year costs. Given the magnitude of these costs, investigation of the cost-effectiveness of rehabilitation services should become a priority in this community.

Incidence of the major stroke subtypes: initial findings from the North East Melbourne stroke incidence study (NEMESIS).

BACKGROUND AND PURPOSE: Population-based stroke incidence studies are the only accurate way to determine the number of strokes that occur in a given society. Because the major stroke subtypes have different patterns of incidence and outcome, information on the natural history of stroke subtypes is essential. The purpose of the present study was to determine the incidence and case-fatality rate of the major stroke subtypes in a geographically defined region of Melbourne, Australia. METHODS: All suspected strokes that occurred among 133 816 residents of suburbs north and east of Melbourne, Australia, during a 12-month period of 1996 and 1997 were identified and assessed. Multiple overlapping sources were used to ascertain cases, and standard criteria for stroke and case-fatality were used. Stroke subtypes were defined by CT, MRI, and autopsy. RESULTS: Three hundred eighty-one strokes occurred among 353 persons during the study period, with 276 (72%) being first-ever-in-a-lifetime strokes. Of these, 72.5% (95% CI 67.2% to 77.7%) were cerebral infarction, 14.5% (95% CI 10.3% to 18.6%) were intracerebral hemorrhage, 4.3% (95% CI 1.9% to 6.8%) were subarachnoid hemorrhage, and 8.7% (95% CI 5.4% to 12.0%) were stroke of undetermined type. The 28-day case-fatality rate was 12% (95% CI 7% to 16%) for cerebral infarction, 45% (95% CI 30% to 60%) for intracerebral hemorrhage, 50% (95% CI 22% to 78%) for subarachnoid hemorrhage, and 38% (95% CI 18% to 57%) for stroke of undetermined type. CONCLUSIONS: The overall distribution of stroke subtypes and 28-day case-fatality rates are not significantly different from those of most European countries or the United States. There may, however, be some differences in the incidence of subtypes within Australia.

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

BACKGROUND AND PURPOSE: Community-based stroke incidence studies are the most accurate way of explaining mortality trends and developing public health policy. The purpose of this study was to determine the incidence of stroke in a geographically defined region of Melbourne, Australia. METHODS: All suspected strokes occurring in a population of 133 816 residents in suburbs north and east of Melbourne, Australia, during a 12-month period of 1996 and 1997 were found and assessed. Multiple overlapping sources were used to ascertain cases, and standard definitions and criteria for stroke and case fatality were used. RESULTS: A total of 381 strokes occurred among 353 people during the study period, 276 (72%) of which were first-ever-in-a-lifetime strokes. The crude annual incidence rate (first-ever strokes) was 206 (95% CI, 182 to 231) per 100 000 per year overall, 195 (95% CI, 161 to 229) for males, and 217 (95% CI, 182 to 252) for females. The corresponding rates adjusted to the "world" population were 100 (95% CI, 80 to 119) overall, 113 (95% CI, 92 to 134) for males, and 89 (95% CI, 70 to 107) for females. The 28-day case fatality rate for first-ever strokes was 20% (95% CI, 16% to 25%). CONCLUSIONS: The incidence rate of stroke in our population-based study is similar to that of many European studies but is significantly higher than that observed on the west coast of Australia.

Interrater reliability of the National Institutes of Health Stroke Scale: rating by neurologists and nurses in a community-based stroke incidence study.

The reliability of the National Institutes of Health Stroke Scale (NIHSS) for use by trained neurologists in clinical trials of acute stroke has been established in several hospital-based studies. However, it also has the potential for application in community-based settings and to be used by nonneurologists: issues which have not been explored before. Hence, we aimed to determine the reliability of the NIHSS when administered by research nurses within the existing North Eastern Melbourne Stroke Incidence Study. Using the NIHSS, thirty-one consecutively registered stroke patients were assessed by 2 neurologists and 1 of 2 trained research nurses. The interrater reliability of observations was compared using weighted and unweighted kappa statistics and intraclass correlation coefficients (ICC). There was a high level of agreement for total scores between the 2 neurologists (ICC = 0.95) and between each neurologist and research nurse (ICC = 0.92 and 0.96). While there was moderate to excellent agreement among neurologists and research nurse (weighted kappa > 0.4) for the majority of the NIHSS items, there was poor agreement for the component 'limb ataxia'. Overall, agreement between nurse and neurologist for individual items was not significantly different from agreement between neurologists. It appears that in both hospital and community settings, trained research nurses can administer the NIHSS with a reliability similar to stroke-trained neurologists. This ability could be used to advantage in large community-based trials and epidemiological studies.

Heavy drinking, but not moderate or intermediate drinking, increases the risk of intracerebral hemorrhage.

An increased risk of intracerebral hemorrhage among heavy consumers of alcohol has been demonstrated in several epidemiologic studies. The effect of moderate or intermediate intakes is, however, unclear. Although several studies provide evidence for a protective effect, this conclusion may be spurious, resulting from the inclusion, within the zero intake (reference) group, of past drinkers who have recently abstained for health reasons. The present study describes the relation between alcohol consumption and intracerebral hemorrhage among 331 case-control pairs recruited in Melbourne, Australia. Heavy drinking was associated with an increased risk of intracerebral hemorrhage (odds ratio (OR) 3.4, 95% confidence interval (CI) = 1.4-8.4). The odds ratio of intracerebral hemorrhage with moderate drinking, when compared with never drinkers, was 0.7, (95% CI = 0.4-1.2) and was 0.6 (95% CI = 0.4-1.0) when compared with nondrinkers (never drinkers plus past drinkers). Wine drinkers were apparently protected from intracerebral hemorrhage (OR 0.5, 95% CI = 0.2-0.9). These results are consistent with the possibility that moderate drinking may confer protection from intracerebral hemorrhage, but this protection may be less than that previously reported.

Ischemic stroke risk and passive exposure to spouses' cigarette smoking. Melbourne Stroke Risk Factor Study (MERFS) Group.

OBJECTIVES: This study investigated the association between ischemic stroke risk and passive exposure to cigarette smoking. METHODS: Risk factors among 452 hospitalized cases of first-episode ischemic stroke were compared with 452 age- and sex-matched "neighbor-hood" controls. RESULTS: The risk of stroke was twice as high for subjects whose spouses smoked as for those whose spouses did not smoke (95% confidence interval = 1.3, 3.1), after adjustment for the subject's own smoking, heart disease, hypertension, diabetes, and education level. These results were confirmed when analysis was limited to those who never smoked. CONCLUSIONS: These findings provide evidence that spousal smoking may be a significant risk factor for ischemic stroke.

The risk of intracerebral haemorrhage with smoking. The Melbourne Risk Factor Study Group.

To determine whether smoking contributes to the risk of primary intracerebral haemorrhage (ICH) a case-control study was carried out on 331 consecutive cases of first-episode ICH as verified by computed tomography. Patients were age- and sex-matched to 331 community-based controls. Unlike other forms of stroke where smoking is an established risk factor, there was no increase in risk of ICH with smoking in this study (odds ratio, OR, 1.07, 95% confidence interval, CI, 0.631.81). Similar ratios were obtained for past and current smokers. Neither the amount smoked nor the duration of smoking were associated with ICH. Further investigation, however, revealed an interaction between smoking and hypertension on the risk of ICH that was similar regardless of the amount of cigarettes currently smoked and was largely seen to be a phenomenon in men (OR 8.13, 95% CI 2.0432.42). This interaction is a new finding, but the post-hoc nature of this analysis requires that it be further tested, preferably in a large prospective study.

Risk of primary intracerebral haemorrhage associated with aspirin and non-steroidal anti-inflammatory drugs: case-control study.

OBJECTIVE: To examine the association between use of aspirin or other non-steroidal anti-inflammatory drugs and intracerebral haemorrhage. DESIGN: Case-control study. SETTING: 13 major city hospitals in the Melbourne and metropolitan area. SUBJECTS: 331 consecutive cases of stroke verified by computed tomography or postmortem examination, and 331 age (+/- 5 years) and sex matched controls who were community based neighbours. INTERVENTIONS: Questionnaire administered to all subjects either directly or by proxy with the next of kin. Drug use was validated by reviewing prescribing records held by the participants' doctors. MAIN OUTCOME MEASURES: Previous use of aspirin or other non-steroidal anti-inflammatory drugs. RESULTS: Univariate analysis showed no increased risk of intracerebral haemorrhage with low dose aspirin use in the preceding 2 weeks. Using multiple logistic regression to control for possible confounding factors, the odds ratio associated with the use of aspirin was 1.00 (95% confidence interval 0.60 to 1. 66, P=0.998) and the odds ratio associated with the use of other non-steroidal anti-inflammatory drugs was 0.85 (0.45 to 1.61, P=0. 611) compared with respective non-users in the preceding fortnight. Moderate to high doses of aspirin (>1225 mg/week spread over at least three doses) yielded an odds ratio of 3.05 (1.02 to 9.14, P=0. 047). There was no evidence of an increased risk among subgroups defined by age, sex, blood pressure status, alcohol intake, smoking, and the presence or absence of previous cardiovascular disease. CONCLUSIONS: No increase in risk of intracerebral haemorrhage was found among aspirin users overall or among those who took low doses of the drug or other non-steroidal anti-inflammatory drugs. These data provide evidence that doses of aspirin usually used for prophylaxis against vascular disease produce no substantial increase in risk of intracerebral haemorrhage.