Supplementary Material for: Lost Productivity in Stroke Survivors: An Econometrics Analysis

<strong><em>Background:</em></strong> Stroke leads to a substantial societal economic burden. Loss of productivity among stroke survivors is a significant contributor to the indirect costs associated with stroke. We aimed to characterize productivity and factors associated with employability in stroke survivors. <b><i>Methods:</i></b> We used the Canadian Community Health Survey 2011-2012 to identify stroke survivors and employment status. We used multivariable logistic models to determine the impact of stroke on employment and on factors associated with employability, and used Heckman models to estimate the effect of stroke on productivity (number of hours worked/week and hourly wages). <b><i>Results:</i></b> We included data from 91,633 respondents between 18 and 70 years and identified 923 (1%) stroke survivors. Stroke survivors were less likely to be employed (adjusted OR 0.39, 95% CI 0.33-0.46) and had hourly wages 17.5% (95% CI 7.7-23.7) lower compared to the general population, although there was no association between work hours and being a stroke survivor. We found that factors like older age, not being married, and having medical comorbidities were associated with lower odds of employment in stroke survivors in our sample. <b><i>Conclusions:</i></b> Stroke survivors are less likely to be employed and they earn a lower hourly wage than the general population. Interventions such as dedicated vocational rehabilitation and policies targeting return to work could be considered to address this lost productivity among stroke survivors

Five-Year Case Fatality Following First-Ever Stroke in the Mashhad Stroke Incidence Study: A Population-Based Study of Stroke in the Middle East

Background and Purpose: Despite recent declines in stroke mortality in high-income countries, the incidence and mortality of stroke have increased in many low- and middle-income countries. Population-based information on stroke in such countries is a research priority to address this rising trend. This study was designed to evaluate 5-year stroke mortality and its associated factors. Methods: During a 12-month period beginning from November 2006, 624 patients with first-ever stroke (FES) living in Mashhad, Iran, were recruited and followed longitudinally. Kaplan-Meier analyses were used to determine the cumulative risk of death. Prognostic variables associated with death were assessed using a Cox proportional hazard, backward logistic regression model. Results: The 5-year cumulative risk of death was 53.8 for women and 60.5 for men (log rank =.1). The most frequent causes of death were stroke (41.2), myocardial infarction/vascular diseases (16.4), and pneumonia (14.2). In multivariable Cox proportional hazard analysis, male gender (hazard ratio HR: 1.29, 95% confidence interval CI: 1.01-1.64), age (HR: 1.04, 95% CI: 1.03-1.05, per 1-year increase), National Institute of Health Stroke Scale score at admission (HR: 1.11, 95% CI: 1.09-1.12, per 1-point increase), atrial fibrillation (HR: 1.78, CI: 1.24-2.54), and education < 12 years (HR: 1.61, 95% CI: 1.08-2.4) were associated with greater 5-year case fatality. Conclusions: Long-term case fatality following stroke in Iran is greater than that observed in many high-income countries. Targeting strategies to reduce the poor outcome following stroke, such as treating AF, is likely to reduce this disparate outcome. © 2018 National Stroke Associatio

Five-Year Case Fatality Following First-Ever Stroke in the Mashhad Stroke Incidence Study: A Population-Based Study of Stroke in the Middle East

Background and Purpose: Despite recent declines in stroke mortality in high-income countries, the incidence and mortality of stroke have increased in many low- and middle-income countries. Population-based information on stroke in such countries is a research priority to address this rising trend. This study was designed to evaluate 5-year stroke mortality and its associated factors. Methods: During a 12-month period beginning from November 2006, 624 patients with first-ever stroke (FES) living in Mashhad, Iran, were recruited and followed longitudinally. Kaplan-Meier analyses were used to determine the cumulative risk of death. Prognostic variables associated with death were assessed using a Cox proportional hazard, backward logistic regression model. Results: The 5-year cumulative risk of death was 53.8 for women and 60.5 for men (log rank =.1). The most frequent causes of death were stroke (41.2), myocardial infarction/vascular diseases (16.4), and pneumonia (14.2). In multivariable Cox proportional hazard analysis, male gender (hazard ratio HR: 1.29, 95% confidence interval CI: 1.01-1.64), age (HR: 1.04, 95% CI: 1.03-1.05, per 1-year increase), National Institute of Health Stroke Scale score at admission (HR: 1.11, 95% CI: 1.09-1.12, per 1-point increase), atrial fibrillation (HR: 1.78, CI: 1.24-2.54), and education < 12 years (HR: 1.61, 95% CI: 1.08-2.4) were associated with greater 5-year case fatality. Conclusions: Long-term case fatality following stroke in Iran is greater than that observed in many high-income countries. Targeting strategies to reduce the poor outcome following stroke, such as treating AF, is likely to reduce this disparate outcome. © 2018 National Stroke Associatio

Five-Year Recurrence Rate and the Predictors Following Stroke in the Mashhad Stroke Incidence Study: A Population-Based Cohort Study of Stroke in the Middle East

Background: Little is known about the risk of recurrent stroke in low- and middle-income countries. This study was designed to identify the long-term risk of stroke recurrence and its associated factors. Methods: From November 21, 2006 for a period of 1 year, 624 patients with first-ever stroke (FES) were registered from the residents of 3 neighborhoods in Mashhad, Iran. Patients were followed up for the next 5 years after the index event for any stroke recurrence or death. We used competing risk analysis and cause-specific Cox proportional hazard models to estimate the cumulative incidence of stroke recurrence and its associated variables. Results: The cumulative incidence of stroke recurrence was 14.5 by the end of 5 years, with the largest rate during the first year after FES (5.6). Only advanced age (adjusted hazard ratio HR 1.02; 95% CI 1.01-1.04) and severe stroke (National Institutes of Health Stroke Scale score >20; HR 2.23; 95% CI 1.05-4.74) were independently associated with an increased risk of 5-year recurrence. Case fatality at 30 days after first recurrent stroke was 43.2%, which was significantly greater than the case fatality at 30 days after FES of 24.7% (p = 0.001). Conclusion: A substantial number of our patients either died or had stroke recurrences during the study period. Advanced age and the severity of the index stroke significantly increased the risk of recurrence. This is an important finding for health policy makers and for designing preventive strategies in people surviving their stroke. © 2018 S. Karger AG, Basel

Supplementary Material for: Risk of Major Hemorrhage after Kidney Transplantation

<b><i>Background:</i></b> Major hemorrhagic events are associated with significant morbidity and mortality. We examined the three-year cumulative incidence of hospitalization with major nontraumatic hemorrhage after kidney transplantation. <b><i>Methods:</i></b> We performed a retrospective cohort study using healthcare administrative data of all adult-incident kidney-only transplantation recipients in Ontario, Canada from 1994 to 2009. We calculated the three-year cumulative incidence, event rate, and incident rate ratio of hospitalization with major hemorrhage, its subtypes and those undergoing a hemorrhage-related procedure. Results were stratified by patient age and donor type and compared to a random and propensity-score matched sample from the general population. <b><i>Results:</i></b> Among 4,958 kidney transplant recipients, the three-year cumulative incidence of hospitalization with nontraumatic major hemorrhage was 3.5% (95% confidence interval [CI] 3.0-4.1%, 12.7 events per 1,000 patient-years) compared to 0.4% (95% CI 0.4-0.5%) in the general population (RR = 8.2, 95% CI 6.9-9.7). The crude risk of hemorrhage was 3-9-fold higher in all subtypes (upper/lower gastrointestinal, intra-cranial) and 15-fold higher for gastrointestinal endoscopic procedures compared to the random sample from the general population. After propensity score matching, the relative risk for major hemorrhage and its subtypes attenuated but remained elevated. The cumulative incidence of hemorrhage was higher for older individuals and those with a deceased donor kidney. <b><i>Conclusion:</i></b> Kidney transplantation recipients have a higher risk of hospitalization with hemorrhage compared to the general population, with about 1 in 30 recipients experiencing a major hemorrhage in the three years following transplant

Supplementary Material for: Five-Year Recurrence Rate and the Predictors Following Stroke in the Mashhad Stroke Incidence Study: A Population-Based Cohort Study of Stroke in the Middle East

<b><i>Background:</i></b> Little is known about the risk of recurrent stroke in low- and middle-income countries. This study was designed to identify the long-term risk of stroke recurrence and its associated factors. <b><i>Methods:</i></b> From November 21, 2006 for a period of 1 year, 624 patients with first-ever stroke (FES) were registered from the residents of 3 neighborhoods in Mashhad, Iran. Patients were followed up for the next 5 years after the index event for any stroke recurrence or death. We used competing risk analysis and cause-specific Cox proportional hazard models to estimate the cumulative incidence of stroke recurrence and its associated variables. <b><i>Results:</i></b> The cumulative incidence of stroke recurrence was 14.5% by the end of 5 years, with the largest rate during the first year after FES (5.6%). Only advanced age (adjusted hazard ratio [HR] 1.02; 95% CI 1.01–1.04) and severe stroke (National Institutes of Health Stroke Scale score >20; HR 2.23; 95% CI 1.05–4.74) were independently associated with an increased risk of 5-year recurrence. Case fatality at 30 days after first recurrent stroke was 43.2%, which was significantly greater than the case fatality at 30 days after FES of 24.7% (<i>p</i> = 0.001). <b><i>Conclusion:</i></b> A substantial number of our patients either died or had stroke recurrences during the study period. Advanced age and the severity of the index stroke significantly increased the risk of recurrence. This is an important finding for health policy makers and for designing preventive strategies in people surviving their stroke

Statin therapy and outcome after ischemic stroke: Systematic review and meta-analysis of observational studies and randomized trials

BACKGROUND AND PURPOSE - : Although experimental data suggest that statin therapy may improve neurological outcome after acute cerebral ischemia, the results from clinical studies are conflicting. We performed a systematic review and meta-analysis investigating the relationship between statin therapy and outcome after ischemic stroke. METHODS - : The primary analysis investigated statin therapy at stroke onset (prestroke statin use) and good functional outcome (modified Rankin score 0 to 2) and death. Secondary analyses included the following: (1) acute poststroke statin therapy (≤72 hours after stroke), and (2) thrombolysis-treated patients. RESULTS - : The primary analysis included 113 148 subjects (27 studies). Among observational studies, statin treatment at stroke onset was associated with good functional outcome at 90 days (pooled odds ratio [OR], 1.41; 95% confidence interval [CI], 1.29-1.56; P&lt;0.001), but not 1 year (OR, 1.12; 95% CI, 0.9-1.4; P=0.31), and with reduced fatality at 90 days (pooled OR, 0.71; 95% CI, 0.62-0.82; P&lt;0.001) and 1 year (OR, 0.80; 95% CI, 0.67-0.95; P=0.01). In the single randomized controlled trial reporting 90-day functional outcome, statin treatment was associated with good outcome (OR, 1.5; 95% CI, 1.0-2.24; P=0.05). No reduction in fatality was observed on meta-analysis of data from 3 randomized controlled trials (P=0.9). In studies restricted to of thrombolysis-treated patients, an association between statins and increased fatality at 90 days was observed (pooled OR, 1.25; 95% CI, 1.02-1.52; P=0.03, 3 studies, 4339 patients). However, this association was no longer present after adjusting for age and stroke severity in the largest study (adjusted OR, 1.14; 95% CI, 0.90-1.44; 4012 patients). CONCLUSION - : In the largest meta-analysis to date, statin therapy at stroke onset was associated with improved outcome, a finding not observed in studies restricted to thrombolysis-treated patients. Randomized trials of statin therapy in acute ischemic stroke are needed. © 2013 American Heart Association, Inc