Long-term health sequelae and quality of life at least 6 months after infection with SARS-CoV-2: design and rationale of the COVIDOM-study as part of the NAPKON population-based cohort platform (POP).

PURPOSE: Over the course of COVID-19 pandemic, evidence has accumulated that SARS-CoV-2 infections may affect multiple organs and have serious clinical sequelae, but on-site clinical examinations with non-hospitalized samples are rare. We, therefore, aimed to systematically assess the long-term health status of samples of hospitalized and non-hospitalized SARS-CoV-2 infected individuals from three regions in Germany. METHODS: The present paper describes the COVIDOM-study within the population-based cohort platform (POP) which has been established under the auspices of the NAPKON infrastructure (German National Pandemic Cohort Network) of the national Network University Medicine (NUM). Comprehensive health assessments among SARS-CoV-2 infected individuals are conducted at least 6 months after the acute infection at the study sites Kiel, Würzburg and Berlin. Potential participants were identified and contacted via the local public health authorities, irrespective of the severity of the initial infection. A harmonized examination protocol has been implemented, consisting of detailed assessments of medical history, physical examinations, and the collection of multiple biosamples (e.g., serum, plasma, saliva, urine) for future analyses. In addition, patient-reported perception of the impact of local pandemic-related measures and infection on quality-of-life are obtained. RESULTS: As of July 2021, in total 6813 individuals infected in 2020 have been invited into the COVIDOM-study. Of these, about 36% wished to participate and 1295 have already been examined at least once. CONCLUSION: NAPKON-POP COVIDOM-study complements other Long COVID studies assessing the long-term consequences of an infection with SARS-CoV-2 by providing detailed health data of population-based samples, including individuals with various degrees of disease severity. TRIAL REGISTRATION: Registered at the German registry for clinical studies (DRKS00023742).

Factors associated with smoking cessation in patients with coronary heart disease: a cohort analysis of the German subset of EuroAspire IV survey.

BACKGROUND: Tobacco smoking is one of the most important risk factors of coronary heart disease (CHD). Hence, smoking cessation is considered pivotal in the prevention of CHD. The current study aimed to evaluate smoking cessation patterns and determine factors associated with smoking cessation in patients with established CHD. METHODS: The fourth European Survey of Cardiovascular Disease Prevention and Diabetes investigated quality of CHD care in 24 countries across Europe in 2012/13. In the German subset, smoking cessation patterns and clinical characteristics were repetitively assessed a) during index event due to CHD by medical record abstraction, b) as part of a face-to-face interview 6 to 36 months after the index event (i.e. baseline visit), and c) by telephone-based follow-up interview two years after the baseline visit. Logistic regression analysis was performed to search for factors determining smoking status at the time of the telephone interview. RESULTS: Out of 469 participants available for follow-up, 104 (22.2%) had been classified as current smokers at the index event. Of those, 65 patients (62.5%) had quit smoking at the time of the telephone interview, i.e., after a median observation period of 3.5 years (quartiles 3.0, 4.1). Depressed mood at baseline visit and higher education level were less prevalent amongst quitters vs non-quitters (17.2% vs 35.9%, p = 0.03 and 15.4% vs 33.3%, p = 0.03), cardiac rehabilitation programs were more frequently attended by quitters (83.1% vs 48.7%, p < 0.001), and there was a trend for a higher prevalence of diabetes at baseline visit in quitters (37.5% vs 20.5%, p = 0.07). In the final multivariable model, cardiac rehabilitation was associated with smoking cessation (OR 5.19; 95%CI 1.87 to 14.46; p = 0.002). DISCUSSION: Attending a cardiac rehabilitation program after a cardiovascular event was associated with smoking cessation supporting its use as a platform for smoking cessation counseling and relapse prevention.

[Stroke aftercare : Treatment reality, challenges and future perspectives]. / Schlaganfallnachsorge : Versorgungsrealität, Herausforderungen und Zukunftsperspektiven.

BACKGROUND: Registry data demonstrate a high risk of recurrent stroke and rehospitalization rates after first-time stroke in Germany compared to the international level. Meanwhile, a report of the Institute for Applied Quality Assurance in the Healthcare System (aQua institute) pointed out the potential for improvement of post-stroke care in Germany. OBJECTIVE: To establish perspectives for improvement of outpatient post-stroke care in Germany. METHODS: Critical discussion of important aspects of post-stroke care, presentation of the current structures of healthcare provision and possibilities for improvement of post-stroke care. RESULTS: Post-stroke care in Germany is predominantly carried out by general practitioners. Currently, standard healthcare procedures do not provide a comprehensive supportive system of structured and cross-sectoral aftercare after ischemic stroke. Special attention must be paid to the treatment of cardiovascular risk factors according to the guidelines, a specific and rapid provision of assist devices and physiotherapy as well as prevention and treatment of stroke-associated complications. Previous investigations have revealed sometimes clear deficits in the provision of treatment. The reasons include but are not limited to sectoral barriers that are difficult to overcome. New concepts of post-stroke care for improvement of these deficits are currently undergoing clinical testing. CONCLUSION: Ischemic stroke should be considered as a complex chronic disease and should be treated accordingly after discharge from acute inpatient treatment. Emphasis should be placed on the optimization of interdisciplinary and cross-sectoral cooperation and support for general practitioners in the outpatient post-stroke care. New concepts of post-stroke care have the potential for improvement of the current healthcare structures.

[Quality of care of acute ischemic stroke in Germany 2018]. / Versorgungsqualität des akuten ischämischen Schlaganfalls in Deutschland 2018.

In this overview the current quality of acute in-hospital care of stroke patients in Germany in 2018 is described based on standardized and evidence-based quality indicators. For this purpose the reports of the regional quality assurance projects for stroke care, which collaborated within the German-speaking Stroke Registers Study Group (ADSR) were analyzed. Overall, more than 280,000 acute admissions of stroke patients were documented in the included quality assurance projects. The results regarding the defined 16 quality indicators comprising diagnostics, acute treatment, rehabilitation and secondary prevention showed a high level of acute inpatient treatment of stroke in Germany. Only a few quality indicators, such as early transfer for thrombectomy indicated a great necessity for process optimization.

Microbleeds in ischemic vs hemorrhagic strokes on novel oral anticoagulants.

OBJECTIVES: To identify differences in clinical characteristics and severity of cerebral small vessel disease (CSVD) including cerebral microbleeds (CMBs), between patients suffering ischemic stroke (IS) or intracerebral hemorrhage (ICH) while taking novel (non-vitamin K antagonists) oral anticoagulants (NOACs). METHODS: Multicenter, prospective, observational cohort study performed at 38 centers between 2012 and 2015. We compared demographics, comorbidity, and functional status (before and after stroke) between NOAC-IS and NOAC-ICH patients. Extent of white matter lesions (WML), and location and counts of CMBs were analyzed in a subgroup of patients for whom MRI including hemorrhage-sensitive sequences was available. RESULTS: A total of 351 patients were included (290 NOAC-IS, 61 NOAC-ICH). Functional status was worse in NOAC-ICH patients before and after stroke. No significant differences were found for demographic variables and cardiovascular comorbidity. In the subgroup with available MRI (n = 116), the proportion of patients with at least one CMB was higher in NOAC-ICH than in NOAC-IS (15/19 [79%] vs 36/97 [37%], P < .001), as was the absolute number of CMBs (median 5 [IQR 1-24] vs 0 [0-1], P < .001). WML were more extensive in NOAC-ICH than in NOAC-IS patients. Adjusted for WML, logistic regression analysis showed higher odds of NOAC-ICH in patients with CMB than without (OR 5.60 [1.64-19.14], P = .006). CONCLUSIONS: Patients with NOAC-ICH have similar clinical characteristics but a higher prevalent burden of CSVD compared to NOAC-IS. The role of neuroimaging in selection of patients for anticoagulation with NOAC requires further investigation in longitudinal studies.

[Memorandum 'Development of health services research in Bavaria from the perspective of the Bavarian State Working Group 'Health Services Research (LAGeV)': status quo - potential - strategies']. / Memorandum "Weiterentwicklung der Gesundheitsversorgungsforschung in Bayern aus Sicht der Landesarbeitsgemeinschaft Gesundheitsversorgungsforschung: Status quo - Entwicklungspotenziale - Strategien".

The aim of the memorandum on the development of health services research (HSR) in Bavaria is to operationalise the global objectives of the State Working Group "Health Services Research" (LAGeV) and to collectively define future topics, specific implementation steps, methods as well as ways of working for the future course of the LAGeV. The LAGeV is an expert committee that integrates and links the competencies of different actors from science, politics and health care regarding HSR and facilitates their cooperation. The memorandum is based on an explorative survey among the LAGeV members, which identified the status quo of health services research in Bavaria, potential for development, important constraints, promoting factors, specific recommendations as well as future topics for the further development of HSR in Bavaria. From the perspective of the LAGeV members, the 12 most important future topics are: 1) Interface and networking research, 2) Innovative health care concepts, 3) Health care for multimorbid patients, 4)Health care for chronically ill patients, 5) Evaluation of innovations, processes and technologies, 6) Patient orientation and user focus, 7) Social and regional inequalities in health care, 8) Health care for mentally ill patients, 9) Indicators of health care quality, 10) Regional needs planning, 11) Practical effectiveness of HSR and 12) Scientific use of routine data. Potential for development of HSR in Bavaria lies a) in the promotion of networking and sustainable structures, b) the establishment of an HSR information platform that bundles information and results in regard to current topics and aims to facilitate cooperation as well as c) in the initiation of measures and projects. The latter ought to pinpoint health care challenges and make recommendations regarding the improvement of health care and its quality. The cooperation and networking structures that were established with the LAGeV should be continuously expanded and be used to work on priority topics in order to achieve the global objectives of the LAGeV.

Secondary prevention in diabetic and nondiabetic coronary heart disease patients: Insights from the German subset of the hospital arm of the EUROASPIRE IV and V surveys.

BACKGROUND: Patients with coronary heart disease (CHD) with and without diabetes mellitus have an increased risk of recurrent events requiring multifactorial secondary prevention of cardiovascular risk factors. We compared prevalences of cardiovascular risk factors and its determinants including lifestyle, pharmacotherapy and diabetes mellitus among patients with chronic CHD examined within the fourth and fifth EUROASPIRE surveys (EA-IV, 2012-13; and EA-V, 2016-17) in Germany. METHODS: The EA initiative iteratively conducts European-wide multicenter surveys investigating the quality of secondary prevention in chronic CHD patients aged 18 to 79 years. The data collection in Germany was performed during a comprehensive baseline visit at study centers in Würzburg (EA-IV, EA-V), Halle (EA-V), and Tübingen (EA-V). RESULTS: 384 EA-V participants (median age 69.0 years, 81.3% male) and 536 EA-IV participants (median age 68.7 years, 82.3% male) were examined. Comparing EA-IV and EA-V, no relevant differences in risk factor prevalence and lifestyle changes were observed with the exception of lower LDL cholesterol levels in EA-V. Prevalence of unrecognized diabetes was significantly lower in EA-V as compared to EA-IV (11.8% vs. 19.6%) while the proportion of prediabetes was similarly high in the remaining population (62.1% vs. 61.0%). CONCLUSION: Between 2012 and 2017, a modest decrease in LDL cholesterol levels was observed, while no differences in blood pressure control and body weight were apparent in chronic CHD patients in Germany. Although the prevalence of unrecognized diabetes decreased in the later study period, the proportion of normoglycemic patients was low. As pharmacotherapy appeared fairly well implemented, stronger efforts towards lifestyle interventions, mental health programs and cardiac rehabilitation might help to improve risk factor profiles in chronic CHD patients.

Peripheral endothelial function and arterial stiffness in women with migraine with aura: a case-control study.

BACKGROUND: Vascular dysfunction may be involved in migraine pathophysiology and contribute to the increased risk of ischemic stroke in migraine, particularly in women with migraine with aura (MA). However, data on endothelial function in MA are controversial. Here, we investigated whether systemic endothelial function and arterial stiffness are altered in women with MA, using a novel peripheral arterial tonometry device for the first time. METHODS: Twenty-nine female MA patients without comorbidities and 30 healthy women were included, and carotid intima-media thickness was assessed by a standardized procedure. Endothelial function was assessed using peripheral arterial tonometry. Reactive hyperaemic response of digital pulse amplitude was measured following 5 minutes of forearm occlusion of the brachial artery. Arterial stiffness was assessed by fingertip tonometry derived and heart-rate-adjusted augmentation index. RESULTS: No differences were found in peripheral arterial tonometry ratio (2.3 ± 0.6 vs 2.2 ± 0.8; p = 0.58) and left carotid intima-media thickness (in µm: 484 ± 119 vs 508 ± 60; p = 0.37). Women with MA had higher heart-rate-averaged augmentation index [median (interquartile range, IQR) of 5 (IQR 0.5 to 18) vs -5 (IQR -16.8 to 8.3), p = 0.005] and heart-rate-adjusted augmentation index [1 (IQR -6 to 12.5) vs -8 (IQR -20.3 to 2.5), p = 0.008] than healthy controls. CONCLUSION: Peripheral endothelial function is not impaired in women with MA, but they have greater arterial stiffness. This may contribute to the increased stroke risk in women with MA.

Clinical and radiological differences in posterior reversible encephalopathy syndrome between patients with preeclampsia-eclampsia and other predisposing diseases.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a serious maternal complication in pregnancy, but data on the clinicoradiological differences to other etiologies of PRES are scarce. In this study, we aimed to investigate the clinical and imaging characteristics of PRES in preeclampsia-eclampsia patients compared with other predisposing diseases in a large cohort. METHODS: We retrospectively reviewed the radiological report data bases between January 1999 and August 2010 for patients with PRES. Patients fulfilling the criteria for PRES after detailed investigation of clinical charts and imaging studies were separated into patients with eclampsia-preeclampsia and other predisposing causes. Various imaging features at onset of symptoms and on follow-up as well as clinical and paraclinical data were analyzed. RESULTS: A total of 24 patients with preeclampsia-eclampsia associated PRES and 72 patients with PRES of other predisposing causes were included into the study. In preeclampsia-eclampsia patients, headaches were significantly more frequent as initial PRES-related symptom (P < 0.001), whereas altered mental state was significantly less frequent (P = 0.001). Thalamus, midbrain, and pons affection was significantly less frequent in preeclampsia-eclampsia associated PRES (P = 0.01). Preeclampsia-eclampsia patients had significantly less severe edema, less cytotoxic edema, hemorrhage and contrast enhancement, while more frequent complete resolution of edema and less frequent residual structural lesions were seen on follow-up imaging. CONCLUSION: In our PRES cohort, we found major clinicoradiological differences between preeclampsia-eclampsia and other predisposing causes pointing toward a less severe course of disease in preeclampsia-eclampsia.

[Rivermead assessment of somatosensory performance: validation of a German version (RASP-DT)]. / Rivermead Assessment of Somatosensory Performance : Validierung einer deutschen Version (RASP DT).

BACKGROUND: Sensory deficits after stroke are common and impact motor regeneration and the total length of hospital stay as well as quality of life factors including the independence to conduct daily life activities. There is currently no existing reliable and standardized assessment tool to measure somatosensory performance in the German language. The aim of our study was to translate the original version of the Rivermead assessment for somatosensory performance (RASP) into German and to study its reliability in a German-speaking population sample. METHODS: The translation of the English original version followed the protocol of the Medical Outcomes Trust. The German version was assessed with 60 patients with first time presentation of subacute stroke and AC1 coefficients were calculated to measure interrater reliability for the different subtests. RESULTS: The mean AC1 value was 0.75 (range 0.58-0.81). The interrater reliability was good to excellent for all subtests. CONCLUSION: The German version of the RASP (RASP-DT) developed in this study is a reliable assessment instrument for sensory deficits after stroke.

Changes in cognitive function over 3 years after first-ever stroke and predictors of cognitive impairment and long-term cognitive stability: the Erlangen Stroke Project.

BACKGROUND AND PURPOSE: Cognitive impairment (CI) is frequent after stroke, but data from population-based stroke cohorts on the natural course of CI are limited. The purpose of this study was to determine changes in cognitive status over 3 years after stroke. METHODS: Data were collected from the Erlangen Stroke Project, an ongoing population-based stroke registry. The Mini-Mental State Examination (MMSE) for assessing global cognitive function was used; CI was defined as an MMSE score <24. RESULTS: From February 1998 to January 2006, 630 patients with first-ever stroke were included. Prevalence rates of CI at 3 months, 1 and 3 years were 15, 13, and 12%. In multivariable analysis, stroke severity, i.e. Barthel index (p < 0.001), age (OR = 1.03; 95% CI = 1.00-1.05) and diabetes mellitus (OR = 2.03; 95% CI = 1.13-3.67) were associated with CI at 3 months. Recovery rate from CI at 3 months after stroke was found to be 31% over the following 3 years. Intact cognitive function rate was 71% over 3 years and inversely associated with age (OR = 0.96; 95% CI = 0.96-0.94) and stroke severity (p < 0.001). CONCLUSION: CI is frequent among stroke survivors and associated with age, stroke severity, and diabetes mellitus, but recovery occurs in approximately one third of the patients over the course of 3 years. Factors affecting intact cognitive function over time are increasing age and stroke severity.

[Development of mortality and morbidity of vascular diseases: variations between coronary heart disease and stroke]. / Entwicklung von Mortalität und Morbidität vaskulärer Erkrankungen : Unterschiede zwischen koronarer Herzerkrankung und Schlaganfall.

INTRODUCTION: Cardiovascular diseases represent a central challenge for our health care system because of their individual and societal consequences. The manuscript compares the current development of mortality and morbidity of coronary heart disease and stroke in Germany. RESULTS: Coronary heart diseases are one of the leading causes of death and one of the major causes for adult disability. In Germany the average life expectancy has increased by more then 2 years per decade within recent years. The greatest contribution to the increase in life expectancy between 1980 and 2002 in Germany was attributed in previous studies to the decline in mortality rates of cardiovascular diseases; for example in Germany 134,648 persons died in 2008 from coronary heart disease (ICD-10 I20-I25) and 63,060 persons from stroke (ICD-10 I60-I64) compared to 178,759 persons and 90,241 persons in 1998, respectively. Statistical models from other countries estimated that the decrease in coronary heart disease mortality is attributed by about 40% to better treatment and by about 60% to changes in risk factors in the population. Comparable data for stroke are lacking. CONCLUSION: Despite the substantial knowledge on cardiovascular diseases in Germany a continuous and timely documentation of their determinants, time trends of risk factors and impact regarding mortality and morbidity is compulsory to assess the effectiveness of initiated population health measures and to identify future options for improving prevention and treatment of cardiovascular diseases in Germany.

Patient-specific recovery patterns over time measured by dependence in activities of daily living after stroke and post-stroke care: the South London Stroke Register (SLSR).

BACKGROUND AND PURPOSE: Data on patient-specific recovery after stroke are lacking and the effects of complex healthcare interventions on the course of recovery were not reported. To quantify the recovery pattern up to 1 year post-stroke and assess effects of evidence-based treatments on the patient-specific course of recovery allowing its prediction. METHODS: A total of 355 patients after first-ever stroke from the population-based South London Stroke Register (source population >270,000) participated in a substudy between August 2002 and October 2004. At 1, 2, 3, 4, 6, 8, 12, 26, and 52 weeks post-stroke, Barthel Index (BI; ranging from 0 to 20) was documented. Multilevel growth models allowing predictions for patients with specific characteristics were calculated. RESULTS: Mean age was 70 years, 48% were male and 23% died within the first year. The age-, gender- and stroke subtype-adjusted BI curve sharply increased until week 8 to 24 depending on patient characteristics and subsequently plateaued. Multivariable analysis identified stroke unit care, appropriate secondary prevention and physiotherapy for those with disabilities as independent predictors of improved functional ability over time (P < 0.05). Patients receiving stroke unit care additionally gained 4 BI points within 6 months compared with their counterparts (P = 0.004). CONCLUSIONS: Functional outcome in the general population showed an increase followed by a plateau. Care parameters reflecting guideline treatment independently improved recovery illustrating the beneficial effects of evidence-based interventions on recovery in an unbiased population.

[The German version of the satisfaction with stroke care questionnaire (SASC) for stroke patients]. / Entwicklung der deutschen Version der Patientenzufriedenheits-Skala (SASC) für den Einsatz bei Patienten nach Schlaganfall.

BACKGROUND AND PURPOSE: Patient satisfaction is an important objective to achieve in all parts of the health-care system. Patient satisfaction probably effects adherence to therapy. Until now, German-speaking countries were lacking a reliable instrument to investigate patient satisfaction. The aim of this study was to translate the English Satisfaction with Stroke Care Questionnaire (SASC), validated and created specifically for patients who had a stroke, and to assess the test-retest reliability of the German version. METHODS: The translation of the satisfaction questionnaire followed the protocol of the Medical Outcome Trust. The validation was carried out with continuously admitted inpatients who had suffered an acute stroke and were able to give written consent. Patients received two questionnaires for self-administration three months after hospital admission. The two questionnaires were compared for test-retest reliability. Reliability was measured using AC 1 values. RESULTS: Out of 202 patients continuously admitted to our hospital with the diagnosis of stroke, 33 could not give written informed consent due to aphasia (N = 29) or foreign-language (N = 4) or refused written consent (N = 8) or died during the following 3 months after the event (N = 14). Recall rate at three months was 71 % with 104 of the remaining 147 patients sending both questionnaires back. (Characteristics of responders: NIHSS = 3 [0 - 26], age = 71.5 [31 - 89] years, 40 % female, 48 % with five or more years of secondary school, 66 % paretic, 17 % with aphasia, 26 % with atrial fibrillation). The test-retest reliability of the German version of the self-administered satisfaction questionnaire was substantial (mean AC 1 = 0.612; range from 0.307 to 0.789). CONCLUSION: The German version of the SASC is a reliable tool to test patient satisfaction in stroke patients in the German language.

Sociodemographic differences in return to work after stroke: the South London Stroke Register (SLSR).

BACKGROUND: Loss of employment contributes significantly to the burden of stroke on individuals and society. There is limited information on factors influencing return to work after stroke. OBJECTIVES: To investigate the frequency and determinants of return to paid work after stroke in a multi-ethnic urban population. METHODS: Patterns of return to work were examined among people with first ever stroke registered in the population based South London Stroke Register. Employment status and functional outcome (Barthel Index (BI), Frenchay Activity Index (FAI)) were assessed 1 year after stroke. Associations between baseline characteristics and return to paid work were analysed by multivariable logistic regression analysis. RESULTS: Among 2874 patients with first ever strokes in 1995-2004, 400 (15%) were working before the stroke. At 1 year, 94 (35%) of 266 survivors had returned to paid work. Black ethnicity (OR 0.41; 95% CI 0.19 to 0.88), female sex (0.43; 0.21 to 0.91), older age (p<0.001), diabetes (0.25; 0.08 to 0.79) and dependence (BI < or = 19) in the acute phase (0.24; 0.11 to 0.49) were independently associated with lower odds of return to work in multivariable analysis. Better functional outcome at 1 year was associated with return to paid work (p<0.001) but 53% of 161 independent (BI > 19) and 39% of 96 very active (FAI > 30/45) individuals had not resumed work. CONCLUSIONS: There were important sociodemographic differences in return to work after stroke that were independent of clinical and service use variables included in the analysis. A large proportion of patients did not resume work despite excellent functional outcome.

Frequency and predictors for the risk of stroke recurrence up to 10 years after stroke: the South London Stroke Register.

BACKGROUND: Data estimating the risk of, and predictors for, long-term stroke recurrence are lacking. METHODS: Data were collected from the population-based South London Stroke Register. Patients were followed up for a maximum of 10 years. Kaplan-Meier estimates and Cox proportional hazards models were used to assess the cumulative risk of and predictors for first stroke recurrence. Variables analysed included sociodemographic factors, stroke subtype (defined as cerebral infarction, intracerebral haemorrhage and subarachnoid haemorrhage), stroke severity markers and prior-to-stroke risk factors. RESULTS: Between 1995 and 2004, 2874 patients with first-ever stroke were included. The mean follow-up period was 2.9 years. During 8311 person-years of follow-up, 303 recurrent events occurred. The cumulative risk of stroke recurrence at 1 year, 5 years and 10 years was 7.1%, 16.2% and 24.5% respectively. No differences in stroke recurrence were noted between the stroke subtypes. Factors increasing the risk of recurrence at 1 year were previous myocardial infarction (HR 1.73; 95% CI 1.08 to 2.78) and atrial fibrillation (HR 1.61; 95% CI 1.04 to 4.27); at 5 years, hypertension (HR 1.47; 95% CI 1.08 to 1.99) and atrial fibrillation (HR 1.79; 95% CI 1.29 to 2.49); and at 10 years, older age (p = 0.04), and hypertension (HR 1.38, 95% CI 1.04 to 1.82), myocardial infarction (HR 1.50, 95% CI 1.06 to 2.11) and atrial fibrillation (HR 1.51, 95% CI 1.09 to 2.09). CONCLUSIONS: Very-long-term risk of stroke recurrence is substantial. Different predictors for stroke recurrence were identified throughout the follow-up period. Risk factors prior to initial stroke have a significant role in predicting stroke recurrence up to 10 years.

Predictors of survival after haemorrhagic stroke in a multi-ethnic population: the South London Stroke Register (SLSR).

OBJECTIVES: To identify the predictors of long-term survival after haemorrhagic stroke. METHODS: Data were collected within the population-based South London Stroke Register covering a multiethnic source population of 271,817 inhabitants (2001) in South London. Death data were collected at post-stroke follow-up. The impact of patients' demographic and clinical characteristics, ethnic origin, pre-stroke risk factors and acute treatment on long-term survival were investigated. Survival methods included Kaplan-Meier curves and Cox's proportional hazards model. RESULTS: Between January 1995 and December 2004, a total of 566 patients with first-ever haemorrhagic stroke (395 primary intracerebral haemorrhage; 171 subarachnoid haemorrhage) were registered. Mean age was 62.3 years; 365 (64.5%) were white, 132 (23.3%) were black and 69 (12.2%) were other or unknown ethnic origin; there were 1340 person-years of follow-up. After multivariable adjustment, age (p<0.001) and having diabetes (hazard ratio (HR), 1.69; 95% CI 1.06-2.70) were associated with increased risk of death. Patients with severe stroke (Glasgow Coma Scale (GCS) <9) had an increased risk of death (HR 6.5; 95% CI 4.68 to 8.90) compared with those with mild stroke (GCS >12). Treatment on a stroke unit reduced the long-term risk of death (HR 0.70; 95% CI 0.50 to 0.98). Black patients had a reduced risk of death (HR 0.62; 95% CI 0.42 to 0.92) compared with white patients. CONCLUSIONS: Age, diabetes, stroke severity and stroke unit care influenced the long-term risk of death after haemorrhagic stroke. An independent survival advantage was observed in black patients. These factors can be utilised for clinical predictions but the cause of the observations in black patients remains unclear.

Standard method for developing stroke registers in low-income and middle-income countries: experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS Stroke).

BACKGROUND: Stroke is a leading global cause of death, with an estimated 5.8 million fatal events in 2005, two-thirds of which happened in low-income and middle-income countries. In these regions, epidemiological methods to establish hospital-based stroke registers for clinical audit or studies to estimate incidence are scarce. Our aim was to ascertain whether stroke registers could be set up in geographically diverse populations in low-income and middle-income countries, using standardised data-collection manuals and methods, before recommending their wider use. METHODS: WHO's stepwise approach to stroke surveillance (STEPS Stroke) offers an entry point for countries to register stroke patients in health-information systems. The methods proposed in this strategy were tested in a feasibility study, which focused on hospitalised stroke patients in nine different surveillance sites located in five low-income and middle-income countries. Data collection was for a median of 12 months. Observed differences between men and women were adjusted for age and surveillance site with logistic-regression analyses. FINDINGS: A total of 5557 stroke patients were registered; 91 people whose age was missing or younger than 15 years were excluded from the analyses. Mean age was 64.2 years (SD 14.6), and 2484 (45%) participants were women. Ischaemic stroke accounted for about two-thirds of events. Half of all patients were hospitalised the same day. Stroke subtype was verified in 4913 (90%) participants by diagnostic techniques. Women had lower odds of verification of stroke subtype compared with men after adjustment for age and surveillance site (odds ratio 0.69 [95% CI 0.56-0.86]; p=0.0006). INTERPRETATION: STEPS Stroke can be used in diverse populations to provide data in a standardised manner in countries with little or no previous records of stroke. Future studies should concentrate on expansion beyond hospital case series by adding information for stroke patients treated outside the hospital, linked to census data for the source population from which the cases come.

Variations in the use of diagnostic procedures after acute stroke in Europe: results from the BIOMED II study of stroke care.

Valid classification of stroke is essential to initiate effective acute management and early secondary prevention strategies. To accurately evaluate stroke subtype a number of diagnostic procedures have to be performed. This study sought to investigate variations in use of diagnostic procedures across selected European hospitals. First-ever stroke patients were sampled over a 1-year period through 11 hospital-based registers across 10 European countries. We defined a diagnostic standard for valid aetiological classification of ischemic stroke including brain imaging, vascular imaging and echocardiography. The impact of socio-demographic, clinical and structural characteristics on performance of the diagnostic standard was assessed using multivariate logistic regression analyses. A total of 1721 patients were included in the study. 83.1% received brain imaging, ranging from 32.8% to 100%. The diagnostic standard was performed in 40.4% of stroke patients, ranging from 0% to 77.2%. Patients with increasing age (P < 0.001) and with more severe strokes (P = 0.001) were less probably to receive the diagnostic standard. Patients treated in stroke units and neurological departments were more frequently investigated with the diagnostic standard (P < 0.001). Less than half of hospitalized stroke patients across Europe underwent diagnostic procedures to allow for aetiological classification of stroke, which may hamper the initiation of effective early management and secondary prevention.