A comparison of outcome for stroke patients in Barbados and South London.

BACKGROUND AND AIMS: Little is known about the poststroke outcome in Caribbean populations. We investigated differences in the activities of daily living, level of social activities, living circumstances and survival for stroke patients in Barbados and London. METHODS: Data were collected from the South London Stroke Register and the Barbados Register of Strokes for patients with a first-ever stroke registered between January 2001 and December 2004. The ability to perform activities of daily living was measured by the Barthel Index and level of social activities by the Frenchay Activities Index. Living circumstances were categorised into private household vs. institutional care. Death and dependency, activities of daily living and social activities were assessed at three-months, one- and two-years using logistic regression, adjusted for differences in demographic, socioeconomic and stroke severity characteristics. RESULTS: At three-months, a high level of social activities was more likely for the Barbados Register of Strokes (odds ratio 1.84; 95% confidence interval 1.03-3.29); there were no differences in activities of daily living; and Barbados Register of Strokes patients were less likely to be in institutional care (relative risk ratio 0.38; 95% confidence interval 0.18-0.79). Following adjustment, Barbados Register of Strokes patients had a higher risk of mortality at three-months (relative risk ratio 1.85; 95% confidence interval 1.03-3.30), one-year (relative risk ratio 1.83; 95% confidence interval 1.08-3.09) and two-years (relative risk ratio 1.82; 95% confidence interval 1.08-3.07). This difference was due to early poststroke deaths; for patients alive at four-weeks poststroke, survival thereafter was similar in both settings. CONCLUSIONS: In Barbados, there was evidence for a healthy survivor effect, and short-term social activity was greater than that in the South London Stroke Register.

A comparison of acute and long-term management of stroke patients in Barbados and South London.

BACKGROUND: To compare health care utilisation between stroke patients living in a middle-income country with similar patients in a high-income country in terms of the type and amount of health care received following a stroke. METHODS: Data were collected from the population-based South London Stroke Register (SLSR) and the Barbados Register of Strokes (BROS) from January 2001 to December 2004. Differences in management and diagnostic procedures used in the acute phase were adjusted for age, sex, ethnic group, living conditions pre-stroke and socio-economic status by multivariable logistic regression. Comparison of subsequent management was made for 3 months and 1 year post-stroke. RESULTS: Patients in BROS were less likely to be admitted to a hospital ward (OR 0.22; 95% CI 0.13-0.37), but the difference for the lower use of brain scans in BROS was smaller (OR 0.62; 95% CI 0.25-1.52). Additional adjustment for stroke severity (Glasgow Coma Score) showed that BROS patients were more likely to have a swallow test on admission (OR 2.95; 95% CI 1.17-7.45). BROS patients were less likely to be in nursing care at 3 months (OR 0.37; 95% CI 0.17-0.81), and less likely to be receiving speech and language therapy at 3 months (OR 0.10; 95% CI 0.03-0.33) and 1 year (OR 0.05; 95% CI 0.00-0.55). CONCLUSIONS: The lower use of hospital admission and nursing care at 3 months suggests that in Barbados, family and friends take greater responsibility for patient care around the time of the stroke and in the medium term thereafter.

Differences in risk factors between black Caribbean patients with stroke in Barbados and South london.

BACKGROUND AND PURPOSE: Risk of stroke is higher in black Caribbeans in the United Kingdom compared with black Caribbeans in their country of origin. We investigated if these differences were caused by variations in prior-to-stroke risk factors. SUMMARY OF REPORT: Data were collected from the South London Stroke Register (SLSR) and the Barbados Register of Strokes (BROS). Differences in prevalence and management of stroke risk factors were adjusted for age, sex, living conditions prestroke, stroke subtype, and socioeconomic status by multivariable logistic regression. Patients in BROS were on average older (mean difference 4 years) and more likely to have a nonmanual occupation. They were less likely to have a prestroke diagnosis of myocardial infarction (OR, 0.39; 95% CI, 0.19 to 0.77) or diabetes (OR, 0.65; 95% CI, 0.46 to 0.92) and were less likely to report smoking (OR, 0.31; 95% CI, 0.19 to 0.49). They were also more likely to receive appropriate prestroke antihypertensive (OR, 1.88; 95% CI, 1.21 to 2.92) and antidiabetic treatment (OR, 3.33; 95% CI, 1.44 to 7.70) and less likely to receive cholesterol-lowering drugs (OR, 0.19; 95% CI, 0.05 to 0.71). CONCLUSIONS: The higher risk of stroke in black Caribbeans in the United Kingdom might be caused by a higher prevalence of major prior-to-stroke risk factors, differences in treatment patterns for comorbid conditions, and less healthy lifestyle practices compared with indigenous black Caribbean populations.

Do psychological distress and somatization contribute to misattribution of asthma? A Chilean study.

OBJECTIVE: The aim of this study was to assess the association between asthma and distress by whether symptoms of asthma present alone or are accompanied by atopy or bronchial reactivity to methacholine [bronchial responsiveness (BHR)], hence, to ascertain whether overreporting of asthma symptoms occurs in those with distress. METHODS: We studied 601 young adults in four groups: those with asthma symptoms and atopy or positive BHR, those with asthma symptoms only, those with atopy or positive BHR only, and controls. The main independent variables were the General Health Questionnaire-12 (GHQ-12) and 45 physical symptoms to assess somatization. RESULTS: The somatization score was highly associated with asthma symptoms alone and asthma symptoms with BHR or atopy, GHQ-12 with asthma alone and asthma and BHR or atopy related to a control group. After adjustment for somatization, GHQ-12 was not associated with the asthma outcomes. CONCLUSIONS: Excess asthma symptom reporting due to psychological distress or somatization as a cause of the association is unlikely.

Poststroke survival for black-Caribbean populations in barbados and South london.

BACKGROUND AND PURPOSE: There are variations in mortality rates for stroke in black communities, but the factors associated with survival remain unclear. METHODS: The authors studied population-based stroke registers with follow up in South London (270 participants, 1995 to 2002) and Barbados (578 participants, 2001 to 2003). Differences in sociodemographic factors, stroke risk factors and their management, case severity, and acute management between London and Barbados were studied. Survival analysis used Kaplan-Meier curves, log-rank test, and Cox proportional hazards model with stratification. RESULTS: There were 1411 person-years of follow-up. Patients in Barbados had poorer survival (log-rank test P=0.037), particularly those with a prestroke Barthel index scores between 15 and 20 (1-year survival, 56.4% versus 74.3%; P<0.001). This disadvantage remained significant (hazard ratio [HR], 1.99; 95% CI, 1.23 to 3.21, P=0.005) after adjustment for age and year of stroke and stratification for stroke subtype and socioeconomic status (SES). After stratification by SES, clinical stroke subtype, and Glasgow Coma Score, and adjustment for other potential confounders, additional factors reducing survival were untreated atrial fibrillation (AF; HR, 8.54; 95% CI, 2.14 to 34.08, P=0.002), incontinence after stroke (HR, 2.64; 95% CI, 1.79 to 3.89), and dysphagia (HR, 2.25; 95% CI, 1.57 to 3.24). Patients not admitted to the hospital had improved survival (HR, 0.35; 95% CI, 0.21 to 0.58). Interaction terms between location and Barthel score, location and AF, and location and transient ischemic attack were included in the final model to reflect the greater difference in survival with a high Barthel score of 15 or more, absence of untreated AF, and having untreated transient ischemic attack. CONCLUSIONS: Black-Caribbean people with stroke living in Barbados have worse survival than similar patients in South London, particularly if they have good mobility before the stroke. Further exploration and refinement of measurement of confounding factors such as SES and poststroke management along with exploring the cultural/environmental differences between the communities is required to understand these stark differences.

Estimation of the risk of stroke in black populations in Barbados and South London.

BACKGROUND AND PURPOSE: The incidence of stroke in black populations is a public health issue, but how risk varies between black communities is unclear. METHODS: Population-based registers in South London (SLSR) and Barbados (Barbados Register of Strokes [BROS]). Stroke incidence estimated by age group, gender and stroke subtype from January 1995 to December 2002 (SLSR), and October 2001 to September 2003 (BROS). Incidence rate ratios [IRR] estimated adjusting for age and sex. RESULTS: Two hundred and seventy-one cases registered in SLSR and 628 cases in BROS. Average age of stroke was 66.1 years (SD 13.7) in SLSR and 71.5 years (SD 14.9) in BROS (P<0.001). The incidence rate/1000 population in SLSR was 1.61 (European adjusted; 95% CI, 1.41 to 1.81) and 1.08 (world adjusted; 95% CI, 0.95 to 1.21). For Barbados incidence rates were 1.29 (European adjusted; 95% CI, 1.19 to1.39) and 0.85 (world adjusted; 95% CI, 0.78 to 0.92). Overall IRR for SLSR: BROS adjusted for age and sex was 1.26 (95% CI, 1.09 to 1.46). Statistically significant subtype differences included total anterior cerebral infarction (IRR, 1.82; 95% CI, 1.23 to 2.69), posterior cerebral infarction (IRR, 2.12; 95% CI, 1.28 to 3.53), primary intracerebral hemorrhage (IRR, 1.56; 95% CI, 1.03 to 2.35) and subarachnoid hemorrhage (IRR, 5.04; 95% CI, 2.54 to 9.97). CONCLUSIONS: The risk of stroke in black Caribbeans is higher in South London than Barbados, and particularly so for specific stroke subtypes. The risk in Barbados approaches that in the white population in South London and strokes occur at an older age. Whether environmental factors mediate these differences in migrant populations requires further study.

Agreement between responses to a standardized asthma questionnaire and a questionnaire following a demonstration of asthma symptoms in adults.

Asthma epidemiology relies heavily on standardized questionnaires, but little is known about the understanding of asthma symptoms among adults in the community. In 2004, the authors assessed the level of agreement between responses to a standardized questionnaire and responses to a questionnaire completed by participants after viewing a demonstration of asthma symptoms. The study involved 601 young adults from Chile. The field-workers were trained to explain and demonstrate the asthma symptoms to the participants. The symptoms were wheeze, waking at night with breathlessness, breathlessness following exercise, and waking with cough. The kappa statistic did not exceed 0.4, and the recorded prevalence of asthma symptoms following the demonstration was 30-60% lower than that for the standardized questionnaire. Using bronchial responsiveness as the proxy gold standard, the positive likelihood ratios for wheeze and waking short of breath were higher following symptom demonstration. The low agreement between the standardized questionnaire and the postdemonstration questionnaire and the likelihood ratios' closeness to 1 for the standardized questionnaire decreases the authors' confidence in the appropriateness of this tool for estimating the prevalence of asthma in the community. For etiologic studies of asthma, it may contribute to the lack of consistency between different studies analyzing the same etiologic exposures.

Untreated asthma, final height and sitting height/leg length ratio in Chile.

OBJECTIVE: There is uncertainty as to whether asthma has an effect on final height. We investigated using subjective and objective assessments whether untreated asthma is associated with final height, leg length and sitting height to leg length ratio in an area of Chile in which almost no one received asthma treatment. METHODS: We collected data on 1232 males and females aged 22-28 years in a semi-rural area of Chile. Information on asthma was collected using the European Community Respiratory Health Survey (ECRHS) questionnaire. We assessed sensitisation to eight allergens and bronchial hyper-responsiveness (BHR) to methacholine as a dichotomous variable and as a log slope. Information on possible confounders in terms of smoking, birth weight, number of siblings and socio-economic factors such as household possessions, car ownership and education was available. RESULTS: Regardless of the asthma assessment used, there was no association between asthma symptoms, diagnosis of asthma, atopy, BHR as log slope, binary or categorical and height, leg length or the ratio of sitting height to leg length. The latter was used as a potentially more appropriate measure to assess a detriment of growth. CONCLUSION: Asthma as assessed in community studies is unrelated to final height or body proportions.