The incidence of all stroke and stroke subtype in the United Kingdom, 1985 to 2008: a systematic review

<p>Abstract</p> <p>Background</p> <p>There is considerable geographic variation in stroke mortality around the United Kingdom (UK). Whether this is due to geographical differences in incidence or case-fatality is unclear. We conducted a systematic review of high-quality studies documenting the incidence of any stroke and stroke subtypes, between 1985 and 2008 in the UK. We aimed to study geographic and temporal trends in relation to equivalent mortality trends.</p> <p>Methods</p> <p>MEDLINE and EMBASE were searched, reference lists inspected and authors of included papers were contacted. All rates were standardised to the European Standard Population for those over 45, and between 45 and 74 years. Stroke mortality rates for the included areas were then calculated to produce rate ratios of stroke mortality to incidence for each location.</p> <p>Results</p> <p>Five papers were included in this review. Geographic variation was narrow but incidence appeared to largely mirror mortality rates for all stroke. For men over 45, incidence (and confidence intervals) per 100,000 ranged from 124 (109-141) in South London, to 185 (164-208) in Scotland. For men, premature (45-74 years) stroke incidence per 100,000 ranged from 79 (67-94) in the North West, to 112 (95-132) in Scotland. Stroke subtype data was more geographically restricted, but did suggest there is no sizeable variation in incidence by subtype around the country. Only one paper, based in South London, had data on temporal trends. This showed that there has been a decline in stroke incidence since the mid 1990 s. This could not be compared to any other locations in this review.</p> <p>Conclusions</p> <p>Geographic variations in stroke incidence appear to mirror variations in mortality rates. This suggests policies to reduce inequalities in stroke mortality should be directed at risk factor profiles rather than treatment after a first incident event. More high quality stroke incidence data from around the UK are needed before this can be confirmed.</p

Assessing the determinants of stillbirths and early neonatal deaths using routinely collected data in an inner city area

BACKGROUND: Within the UK there is considerable variation in the perinatal mortality rate. The objective of this study was to assess the factors associated with stillbirths and early neonatal deaths (ENND) and the suitability of the available databases in a health authority with one of the highest rates in the country. METHODS: Two case-control studies were carried out in three hospital trusts in the Lambeth, Southwark and Lewisham Health Authority, London, using routinely collected information. In one study, 342 stillbirths and 1,368 controls were included, and in the other study, 205 ENND and 820 controls were included. In the two studies cases and controls were matched for hospital trust. RESULTS: A birthweight below 1.5 kg was found in 54% and 48% of the stillbirths and ENND, respectively. More than 50% of the cases, stillbirths and ENND, had a length of gestation below 32 weeks. Length of gestation, birthweight, emergency caesarean section and age of the mother were associated with stillbirths. Birthweight and Apgar score at 1 minute as a categorical variable were associated with ENND. There was no direct evidence of an effect of social deprivation on the outcomes of interest. CONCLUSION: Birthweight and length of gestation are the most influential factors on an unfavourable outcome. Conception at an older age has a serious impact on stillbirth rates. In our health authority social disadvantage did not have a direct impact on stillbirth and ENND. Maternity information systems should collect routine data on fewer variables, but their quality in terms of value, standardization and completion rates must improve

Parental attitudes towards the management of asthma in ethnic minorities

Objectives: Children from Indian and Pakistani (South Asian) and black minority groups have relatively high rates of attendance at accident and emergency (A&E) departments and admissions to hospital in the UK. We examine parents’ beliefs and management of childhood asthma that possibly contribute to their greater use of hospital services. Design: Questionnaire survey. Setting: Three London hospitals serving multicultural communities with a high proportion of South Asian subjects. Participants: Parent(s) accompanying 150 children aged 3–9 years with asthma attending asthma clinics and A&E departments. Main outcome measures: White, South Asian and ‘‘other’’ ethnic group parents were compared regarding their children’s symptoms and asthma in relation to why their children had developed asthma, use of asthma treatments, views about the prognosis of their children’s asthma, and their feelings associated with stigma. Results: South Asian more often than white parents stated that they did not give preventers to their children (odds ratio (OR) 0.30; 95% confidence interval (CI) 0.12 to 0.75), that most drugs were ‘‘addictive’’ (OR 3.89; 95% CI 1.47 to 10.27), and that medicines could do more harm than good (OR 3.19; 95% CI 1.22 to 8.34). South Asian and ‘‘other’’ ethnic groups were more reluctant to tell others about their children’s asthma (OR 0.11; 95% CI 0.01 to 1.06 and OR 0.06; 95% CI 0.01 to 0.65, respectively). Conclusion: Cultural perspectives related to ethnicity are key factors in the understanding of asthma management. Health staff should give high priority to eliciting parents’ beliefs regarding management of their children’s asthma.Peer reviewe

Survival differences after stroke in a multiethnic population: follow-up study with the south London stroke register

Objectives To identify ethnic differences in survival after stroke and examine the factors that influence survival. Design Population based stroke register with follow-up. Settings South London stroke register. Participants 2321 patients with first stroke registered between January 1995 and December 2002. Main outcome measures Sociodemographic factors, risk factors for stroke and their management, severity of stroke, and acute service provision factors. Survival analysis with Kaplan-Meier curves, log rank test, and Cox's proportional hazard model with stratification. Results In univariable analyses of survival, outcome was better for black people than white people (median 33.7 v 20.0 months). After stratification by socioeconomic status, type of stroke, and Glasgow coma score, and adjustment for other potential confounders, being black was generally associated with better survival, taking into account the interaction between ethnicity and age, and ethnicity and prior Barthel score. Of the risk factors for stroke considered, current smoking (hazard ratio 1.21, 95% confidence interval 1.01 to 1.45, P = 0.044), untreated atrial fibrillation (1.36, 1.08 to 1.72, P = 0.009), untreated diabetes (1.53, 1.05 to 2.22, P = 0.027), and treated diabetes (1.61, 1.27 to 2.03, P < 0.001) were associated with reduced survival. Conclusion In general, black patients in a south London population with first ever stroke are more likely to survive than white patients, the exceptions being in those aged < 65 and those with a prior Barthel score < 15. Some pre-stroke risk factors that have the potential to be modified, including the appropriate treatment of existing health problems, have a strong impact on survival

Outdoor air pollution and incidence of ischemic and hemorrhagic stroke : a small area level ecological study

Background and Purpose—Evidence linking outdoor air pollution and incidence of stroke is limited. We examined effects of outdoor air pollution on the incidence of ischemic and hemorrhagic stroke at the population level focusing on middle-aged and older people. Methods—We used a small-area level ecological study design and a stroke register set up to capture all incident cases of first-ever stroke occurring in a defined geographical area in south London (948 census output areas) where road traffic contributes to spatial variation in air pollution. Population-weighted averages were calculated for output areas using outdoor nitrogen dioxide and PM10 concentrations modeled at a 20-m resolution. Results—There were 1832 ischemic and 348 hemorrhagic strokes in 1995 to 2004 occurring among a resident population of 267 839. Mean (SD) concentration was 25.1 (1.2) μg/m3 (range, 23.3–36.4 μg/m3) for PM10 and 41.4 (3.0) μg/m3 (range, 35.4–68.0 μg/m3) for nitrogen dioxide. For ischemic stroke, adjusted rate ratios per 10-μg/m3 increase, for all ages, 40 to 64 and 65 to 79 years, respectively, were 1.22 (0.77–1.93), 1.12 (0.55–2.28), and 1.86 (1.10–3.13) for PM10 and 1.11 (0.93–1.32), 1.13 (0.86–1.50), and 1.23 (0.99–1.53) for nitrogen dioxide. For hemorrhagic stroke, the corresponding rate ratios were 0.52 (0.20–1.37), 0.78 (0.17–3.51), and 0.51 (0.12–2.22) for PM10 and 0.86 (0.60–1.24), 1.12 (0.66–1.90), and 0.78 (0.44–1.39) for nitrogen dioxide. Conclusions—Although there was no significant association between outdoor air pollutants and ischemic stroke incidence for all ages combined, there was a suggestion of increased risk among people aged 65 to 79 years. There was no evidence of increased incidence in hemorrhagic stroke.Peer reviewe

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.Peer reviewe