Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID-19 Pandemic in the United States.

BACKGROUND: Cardiovascular deaths increased during the early phase of the COVID-19 pandemic in the United States. However, it is unclear whether diverse racial/ethnic populations have experienced a disproportionate rise in heart disease and cerebrovascular disease deaths. METHODS: We used the National Center for Health Statistics to identify heart disease and cerebrovascular disease deaths for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic individuals from March to August 2020 (pandemic period), as well as for the corresponding months in 2019 (historical control). We determined the age- and sex-standardized deaths per million by race/ethnicity for each year. We then fit a modified Poisson model with robust SEs to compare change in deaths by race/ethnicity for each condition in 2020 versus 2019. RESULTS: There were a total of 339 076 heart disease and 76 767 cerebrovascular disease deaths from March through August 2020, compared with 321 218 and 72 190 deaths during the same months in 2019. Heart disease deaths increased during the pandemic in 2020, compared with the corresponding period in 2019, for non-Hispanic White (age-sex standardized deaths per million, 1234.2 versus 1208.7; risk ratio for death [RR], 1.02 [95% CI, 1.02-1.03]), non-Hispanic Black (1783.7 versus 1503.8; RR, 1.19 [95% CI, 1.17-1.20]), non-Hispanic Asian (685.7 versus 577.4; RR, 1.19 [95% CI, 1.15-1.22]), and Hispanic (968.5 versus 820.4; RR, 1.18 [95% CI, 1.16-1.20]) populations. Cerebrovascular disease deaths also increased for non-Hispanic White (268.7 versus 258.2; RR, 1.04 [95% CI, 1.03-1.05]), non-Hispanic Black (430.7 versus 379.7; RR, 1.13 [95% CI, 1.10-1.17]), non-Hispanic Asian (236.5 versus 207.4; RR, 1.15 [95% CI, 1.09-1.21]), and Hispanic (264.4 versus 235.9; RR, 1.12 [95% CI, 1.08-1.16]) populations. For both heart disease and cerebrovascular disease deaths, Black, Asian, and Hispanic populations experienced a larger relative increase in deaths than the non-Hispanic White population (interaction term, P<0.001). CONCLUSIONS: During the COVID-19 pandemic in the United States, Black, Hispanic, and Asian populations experienced a disproportionate rise in deaths caused by heart disease and cerebrovascular disease, suggesting that these groups have been most impacted by the indirect effects of the pandemic. Public health and policy strategies are needed to mitigate the short- and long-term adverse effects of the pandemic on the cardiovascular health of diverse populations.

Progressive multifocal leukoencephalopathy and Creutzfeldt-Jakob disease: population-wide incidences, comorbidities, costs of care, and outcomes.

Neurological disorders associated with chronic infections are often progressive as well as challenging to diagnose and manage. Among 4.4 million persons from 2004 to 2019 receiving universal health, progressive multifocal leukoencephalopathy (PML, n = 58) and Creutzfeldt-Jakob disease (CJD, n = 93) cases were identified, revealing stable yearly incidence rates with divergent comorbidities: HIV/AIDS affected 37.8% of PML cases while cerebrovascular disease affected 26.9% of CJD cases. Most CJD cases died within 1 year (73%) although PML cases lived beyond 5 years (34.1%) despite higher initial costs of care. PML and CJD represent important neurological disorders with evolving risk variables and impact on health care.

Inequalities in premature mortality due to cerebrovascular disease in Europe between 1990 and 2014 / A cerebrovascularis betegségekbol eredo, ido elotti halálozás egyenlotlenségei Európában 1990 és 2014 között.

Összefoglaló. Bevezetés: A cerebrovascularis betegségek népegészségügyi szempontból jelentosek, világszerte a vezeto halálokok között szerepelnek, és a rokkantság egyik fo okát képezik. Célkituzés: Vizsgálatunk célja a cerebrovascularis betegségekbol eredo, ido elotti halálozás hazai és nemzetközi adatainak elemzése régiónkénti bontásban a 45-59 éves korcsoportban. Módszerek: Retrospektív, kvantitatív elemzés keretében vizsgáltuk a cerebrovascularis betegségekbol eredo, korspecifikus, 1990 és 2014 közötti halálozást az Egészségügyi Világszervezet (WHO) Európai Régióján belül kiválasztott nyugat-európai (n = 17), kelet-európai országokban (n = 10) és a volt Szovjetunió utódállamaiban (n = 15), 100 000 fore vetítve, a WHO Európai Halálozási Adatbázisának adatai alapján. Leíró statisztikai módszereket, idosoros kimutatást, Kruskal-Wallis-próbát alkalmaztunk. Eredmények: A cerebrovascularis betegségekbol eredo, 100 000 fore vetített korspecifikus halálozás a nyugat-európai országokban volt a legalacsonyabb (férfiak: 1990: 35,14, 2014: 14,31; nok: 1990: 21,11, 2014: 8,76) és a Szovjetunió utódállamaiban a legmagasabb (férfiak: 1990: 134,19; 2014: 91,13; nok: 1990: 83,62, 2014: 41,83) (p<0,05). A kelet-európai és a nyugat-európai országok, valamint a nyugat-európai országok és a Szovjetunió utódállamainak korspecifikus, cerebrovascularis halálozása között szignifikáns különbséget találtunk mindkét nemben (1990, 2004, 2014: p<0,05). A cerebrovascularis betegségek korspecifikus standardizált halálozása 1990 és 2014 között a nyugat-európai országokban (férfiak: -59,28%, nok: -58,29%) csökkent a legnagyobb mértékben, melyet a vizsgált kelet-európai országok (férfiak: -54,14%, nok: -57,53%), majd a Szovjetunió utódállamai (férfiak: -32,09%, nok: -49,97%) követtek. Következtetések: A korspecifikus, cerebrovascularis halálozás a férfiak és a nok körében egyaránt csökkent az egyes régiókban. Magyarországon a nyugat-európai átlagnál jobban, 62,2%-kal csökkent a férfiak és 59,1%-kal a nok korai cerebrovascularis halálozása 1990 és 2014 között. Orv Hetil. 2021; 162(4): 144-152. INTRODUCTION: Cerebrovascular diseases are a significant public health concern, they are among the leading causes of death worldwide and one of the major causes of disability. OBJECTIVE: Our aim was to analyse national and international data regarding premature, cerebrovascular disease mortality per region in the 45-59 age group. METHODS: We performed a retrospective, quantitative analysis on age-specific, premature cerebrovascular disease mortality between 1990 and 2014 per 100 000 population on data derived from the World Health Organisation, European Mortality Database on Western European (n = 17), Eastern European (n = 10) countries, and countries of the former Soviet Union (n = 15). Descriptive statistics, time series analysis and Kruskal-Wallis test were performed. RESULTS: Age-related, cerebrovascular disease mortality per 100 000 population was the lowest in Western European countries (males: 1990: 35.14, 2014: 14.31; females: 1990: 21.11, 2014: 8.76), and the highest in former Soviet Union countries (males: 1990: 134.19; 2014: 91.13; females: 1990: 83.62, 2014: 41.83) (p<0,05). Significant differences were found in age-specific, cerebrovascular disease mortality in both sexes between Eastern and Western European countries and former Soviet Union countries (1990, 2004, 2014: p<0.05). Between 1990 and 2014, age-specific, standardized cerebrovascular disease mortality showed the biggest decrease in Western European countries (males: -59.28%, females: -58.29%) followed by Eastern European (males: -54.14%, females: -57.53%) and former Soviet Union countries (males: -32.09%, females: -49.97%). CONCLUSIONS: Age-specific, cerebrovascular disease mortality decreased in both sexes in all regions analysed. Hungary was found to have seen a decrease above the Western European average, premature cerebrovascular mortality decreased by 62.2% in males and 59.1% in females between 1990 and 2014. Orv Hetil. 2021; 162(4): 144-152.

Assessment of cerebrovascular disease with computed tomography in COVID-19 patients: correlation of a novel specific visual score with increased mortality risk.

PURPOSE: Cerebrovascular disease (CVD) is considered a major risk factor for fatal outcome in COVID-19. We aimed to evaluate the possible association between computed tomography (CT) signs of chronic CVD and mortality in infected patients. MATERIALS AND METHODS: We performed a double-blind retrospective evaluation of the cerebral CT scans of 83 COVID-19 patients looking for CT signs of chronic CVD. We developed a rapid visual score, named CVD-CT, which summarized the possible presence of parietal calcifications and dolichosis, with or without ectasia, of intracranial arteries, areas of chronic infarction and leukoaraiosis. Statistical analysis was carried out with weighted Cohen's K test for inter-reader agreement and logistic regression to evaluate the association of in-hospital mortality with CVD-CT, chest X-ray (CXR) severity score (Radiographic Assessment of Lung Edema-RALE) for radiological assessment of pulmonary disease, sex and age. RESULTS: CVD-CT (odds ratio 1.6, 95% C.I. 1.2-2.1, p = 0.001) was associated with increased risk of mortality. RALE showed an almost significant association (odds ratio 1.05, 95% C.I. 1-1.1, p 0.06), whereas age and sex did not. CONCLUSION: CVD-CT is associated with risk of mortality in COVID-19 patients. The presence of CT signs of chronic CVD may be correlated to a condition of fragility of the circulatory system, which constitutes a key risk factor for death in infected patients.

China Stroke Statistics 2019: A Report From the National Center for Healthcare Quality Management in Neurological Diseases, China National Clinical Research Center for Neurological Diseases, the Chinese Stroke Association, National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations.

China faces the greatest challenge from stroke in the world. The death rate for cerebrovascular diseases in China was 149.49 per 100 000, accounting for 1.57 million deaths in 2018. It ranked third among the leading causes of death behind malignant tumours and heart disease. The age-standardised prevalence and incidence of stroke in 2013 were 1114.8 per 100 000 population and 246.8 per 100 000 person-years, respectively. According to the Global Burden of Disease Study 2017, the years of life lost (YLLs) per 100 000 population for stroke increased by 14.6%; YLLs due to stroke rose from third highest among all causes in 1990 to the highest in 2017. The absolute numbers and rates per 100 000 population for all-age disability-adjusted life years (DALYs) for stroke increased substantially between 1990 and 2017, and stroke was the leading cause of all-age DALYs in 2017. The main contributors to cerebrovascular diseases include behavioural risk factors (smoking and alcohol use) and pre-existing conditions (hypertension, diabetes mellitus, dyslipidaemia and atrial fibrillation (AF)). The most prevalent risk factors among stroke survivors were hypertension (63.0%-84.2%) and smoking (31.7%-47.6%). The least prevalent was AF (2.7%-7.4%). The prevalences for major risk factors for stroke are high and most have increased over time. Based on the latest national epidemiological data, 26.6% of adults aged ≥15 years (307.6 million adults) smoked tobacco products. For those aged ≥18 years, age-adjusted prevalence of hypertension was 25.2%; adjusted prevalence of hypercholesterolaemia was 5.8%; and the standardised prevalence of diabetes was 10.9%. For those aged ≥40 years, the standardised prevalence of AF was 2.31%. Data from the Hospital Quality Monitoring System showed that 3 010 204 inpatients with stroke were admitted to 1853 tertiary care hospitals during 2018. Of those, 2 466 785 (81.9%) were ischaemic strokes (ISs); 447 609 (14.9%) were intracerebral haemorrhages (ICHs); and 95 810 (3.2%) were subarachnoid haemorrhages (SAHs). The average age of patients admitted was 66 years old, and nearly 60% were male. A total of 1555 (0.1%), 2774 (0.6%) and 1347 (1.4%) paediatric strokes (age <18 years) were identified among IS, ICH and SAH, respectively. Over one-third (1 063 892 (35.3%)) of the patients were covered by urban resident basic medical insurance, followed by urban employee basic medical insurance (699 513 (23.2%)) and new rural cooperative medical schema (489 361 (16.3%)). The leading risk factor was hypertension (67.4% for IS, 77.2% for ICH and 49.1% for SAH), and the leading comorbidity was pneumonia or pulmonary infection (10.1% for IS, 31.4% for ICH and 25.2% for SAH). In-hospital death/discharge against medical advice rate was 8.3% for stroke inpatients, ranging from 5.8% for IS to 19.5% for ICH. The median and IQR of length of stay was 10.0 (7.0-14.0) days, ranging from 10.0 (7.0-13.0) in IS to 14.0 (8.0-22.0) in SAH. Data from the Chinese Stroke Center Alliance demonstrated that the composite scores of guideline-recommended key performance indicators for patients with IS, ICH and SAH were 0.77±0.21, 0.72±0.28 and 0.59±0.32, respectively.

Neurological Morbidity and Mortality in a Neurological Low-Resource Setting: A 2-Year Audit of a Nigerian Hospital.

BACKGROUND: There is still a paucity of information on the burden of neurological disorders particularly in low-resource settings such as sub-Saharan Africa. The objective of this study was to report the burden of neurological disorders, including morbidity and mortality, in adult patients at a Northwestern Nigerian tertiary hospital over a 2-year period. MATERIALS AND METHODS: An audit of adult medical admissions from July 1, 2015, to June 30, 2017, was conducted. Anonymized data on medical admissions were retrieved from admission registries. Primary and secondary outcomes of interest were neurological diagnoses and clinical outcomes, respectively. The Pearson χ and independent t tests were used to test for differences between neurological and general medical proportions and outcomes with a 5% significance level set. RESULTS: Over the 2-year period, 2772 adults were admitted. Neurological morbidity comprised almost a 10th of all adult medical admissions (9.1%), whereas neurological mortality accounted for more than a fifth of all deaths (22.2%). Stroke was the leading cause of neurological morbidity (62.9%) and mortality (79.8%). Infections of the nervous system and epilepsy were other frequent causes of neurological morbidity. Outcomes were poorer for neurological patients (fatality rates: neurological, 55.5%; medical, 19.5%, P<0.001). CONCLUSIONS: Neurological disorders were a significant cause of adult medical morbidity and, to a greater extent, of mortality. Cerebrovascular disease and infections of the nervous system were major drivers of mortality. Cost-effective strategies appropriate for low-resource settings are required to prevent and reverse these negative outcomes.

Outcome differences between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in postoperative ventricular arrhythmia, neurological complications, and in-hospital mortality.

Objective: We study whether the carotid artery stenting (CAS) and carotid endarterectomy (CEA) differ from each other in postoperative ventricular arrhythmia, along with neurological complications (perioperative stroke and transient ischemic attack), in-hospital mortality, and estimated medical cost. Methods: This study used data of patients with carotid artery stenosis from the National Inpatient Sample (NIS) database (2011-2014) from the United States of America. Based on the procedure that patients received, individuals were categorized into groups of CAS and CEA. Multilevel analyses were conducted to examine the difference in the following outcomes: postoperative ventricular arrhythmia, neurological complications, in-hospital mortality, and medical costs between CAS and CEA. The patient age, gender, race, Charlson Comorbidity Index, primary payer, emergency department service record, bed size of hospital, region of the hospital, and location of the hospital were adjusted in each model. In addition, preexisting cardiovascular diseases (CVDs) were adjusted for when predicting postoperative ventricular arrhythmia; postoperative CVDs were adjusted for in the model of in-hospital mortality. Results: A total of 127,321 carotid artery stenosis hospitalizations were included in our analyses (n = 17,074 in CAS, n = 110,247 in CEA). Multivariate logistic regressions showed that compared with patients underwent CAS, those with CEA had a lower odds of postoperative ventricular arrhythmia (odds ratio [OR] = 0.81, 95% confidence interval [CI]: [0.66-0.98]), less neurological complications (OR = 0.55, 95% CI: [0.51-0.59] in general; OR = 0.63, 95% CI: [0.57-0.69] in ischemic stroke; OR = 0.26, 95% CI: [0.20-0.32] in hemorrhagic stroke; and OR = 0.58, 95% CI: [0.47-0.71] in transient ischemic attack), and in-hospital mortality (OR = 0.52, 95% CI: [0.42-0.64]). Generalized linear model indicated patients undergoing CEA had lower medical cost (ß = -4329.99, 95% CI: [-4552.61, -4107.38]) than patients undergoing CAS. Conclusions: In short-term outcomes, CEA was associated with a lower risk of postoperative ventricular arrhythmia, neurological complications, in-hospital mortality, and lower cost as compared with CAS.

[AN ASSESSMENT OF REAL AND POTENTIAL LOSSES DUE TO PREMATURE DEATH FROM CEREBROVASCULAR DISEASES AS A TOOL FOR MANAGEMENT DECISIONS].

Aim -to calculate and estimate the number of years of potential life lost (YPLL) due to premature mortality from cerebrovascular diseases in Ukraine, and its share in the array of losses from all diseases of the circulatory system. The information base of the study was official data of the State Statistics Service of Ukraine on the distribution of the deceased by gender, age groups and causes of death in 2018. A comparative analysis of mortality from cerebrovascular diseases in selected countries was carried out using the European database of mortality (MDB) and the database of the Global Study of Disease Burden, Injuries and Risk Factors. The method of potential demography was used to estimate demographic losses due to premature mortality from cerebrovascular diseases. The number of lost years of potential life due to premature mortality from cerebrovascular diseases in 2018 reached 116,563 thousand man-years (104,355 thousand in 2013), which accounted for more than 18% of similar losses as a result of death from all cardiovascular diseases in Ukraine. Revealed a significant disproportion of losses depending on gender - more than two thirds (69.1%) of the absolute number of lost years accounted for men. Ukraine is losing more significant amounts of potential years of life due to high premature mortality from cerebrovascular diseases compared to the developed countries of the world. Assessing real and potential losses due to premature death from cerebrovascular disease is a useful tool to support management decision making. We can recommend a methodology for arguing the development of strategies and programs aimed at combating cerebrovascular diseases, assessing the dynamics of changes in the process of their implementation, and as an indicator of effectiveness.

[Factors associated with lack of hospital care in deaths from cerebrovascular disease, São Paulo, Brazil: a comparative analysis of 1996-1998 and 2013-2015]. / Fatores associados à falta de assistência hospitalar nos óbitos por doença cerebrovascular, São Paulo, Brasil: análise comparativa entre 1996-1998 e 2013-2015.

The objective was to assess sociodemographic and clinical factors related to the lack of hospital care in deaths from ischemic and hemorrhagic cerebrovascular disease (CVD) in the state of São Paulo, Brazil, in 1996-1998 and 2013-2015. The study used data on deaths from the Mortality Information System. Poisson regression was used to analyze the association between lack of hospital care and the study variables. Of the 127,319 individuals that died of CVD in the two three-years periods, 19,362 (15.2%) had failed to receive hospital care. Lack of hospital care in deaths from CVD remained practically unchanged in relation to sociodemographic and clinical characteristics, except for distributions by sex. The more recent three-year period showed higher risk of death from CVD without hospital care among Asian-descendant individuals (RR = 1.48), while lower risk of death from CVD without hospital care in the more recent period was associated with black color (RR = 0.85), brown color (RR = 0.86), married individuals (RR = 0.70), those living in the capital city of São Paulo (RR = 0.92), those who received medical care (RR = 0.17), and those with hemorrhagic CVD (RR = 0.47). In addition, lack of hospital care in deaths from hemorrhagic CVD was lower among married individuals (RR = 0.67), those living in the capital city of São Paulo (RR = 0.74), and those who received medical care (RR = 0.08). Sociodemographic and clinical characteristics were associated with the lack of hospital care in deaths from ischemic and hemorrhagic CVD, suggesting that there are differences in care for CVD patients.

O objetivo foi avaliar os fatores sociodemográficos e clínicos relacionados à falta de assistência hospitalar em óbitos por doença cerebrovascular (DCV) e DCV hemorrágica, no Estado de São Paulo, Brasil, nos triênios 1996-1998 e 2013-2015. Foram utilizados dados dos óbitos provenientes do Sistema de Informações sobre Mortalidade. Para analisar a associação entre a falta de atendimento hospitalar e as variáveis consideradas no estudo utilizou-se a regressão de Poisson. Dos 127.319 indivíduos que morreram por DCV nos dois triênios, 19.362 (15,2%) não tiveram assistência hospitalar. A falta de atendimento hospitalar em óbitos por DCV manteve-se praticamente inalterada para as características sociodemográficas e clínicas, exceto a distribuição por sexo. No período mais recente, identificou-se maior risco de óbito por DCV sem assistência hospitalar entre indivíduos de cor da pele amarela (RR = 1,48), já em pessoas de cor preta (RR = 0,85), parda (RR = 0,86), nos casados (RR = 0,70), naqueles que residiam no Município de São Paulo (RR = 0,92), nos que tiveram assistência médica (RR = 0,17) e naqueles acometidos pela DCV hemorrágica (RR = 0,47) o risco de óbito sem assistência hospitalar foi menor. Além disso, a falta de atendimento hospitalar em óbitos por DCV hemorrágica foi menor entre os casados (RR = 0,67), naqueles que residiam no Município de São Paulo (RR = 0,74) e nos que tiveram assistência médica (RR = 0,08). As características sociodemográficas e clínicas estiveram associadas com a falta de assistência hospitalar em óbitos por DCV e DCV hemorrágica, sugerindo que há diferenças no atendimento ao paciente com DCV.

El objetivo fue evaluar factores sociodemográficos y clínicos, relacionados con la falta de asistencia hospitalaria en óbitos por enfermedad cerebrovascular (ECV) y ECV hemorrágica, en el Estado de São Paulo, Brasil, durante los trienios 1996-1998 y 2013-2015. Se utilizaron datos de los óbitos procedentes del Sistema de Informaciones sobre Mortalidad. Para analizar la asociación entre la falta de atención hospitalaria y las variables consideradas en el estudio se utilizó la regresión de Poisson. De los 127.319 individuos que murieron por ECV en los dos trienios, 19.362 (15,2%) no tuvieron asistencia hospitalaria. La falta de atención hospitalaria en óbitos por ECV se mantuvo prácticamente inalterada, respecto a las características sociodemográficas y clínicas, excepto en la distribución por sexo. En el período más reciente se identificó un mayor riesgo de óbito por ECV sin asistencia hospitalaria entre individuos de ascendencia asiática (RR = 1,48), mientras que en personas afrodescendientes (RR = 0,85), mestizos (RR = 0,86), casados (RR = 0,70), en aquellos que residían en el municipio de São Paulo (RR = 0,92), en quienes contaron con asistencia médica (RR = 0,17) y en aquellos afectados por la ECV hemorrágica (RR = 0,47), el riesgo de muerte sin asistencia hospitalaria fue menor. Además, la falta de atención hospitalaria en fallecimientos por ECV hemorrágica fue menor entre los casados (RR = 0,67), en aquellos que residían en el municipio de São Paulo (RR = 0,74) y en los que contaron asistencia médica (RR = 0,08). Las características sociodemográficas y clínicas se asociaron con la falta de asistencia hospitalaria en óbitos por ECV y ECV hemorrágica, sugiriendo que existen diferencias en la atención al paciente con una ECV.

Analyses of Mortality and Prevalence of Cerebrovascular Disease in Colombia, South America (2014-2016): A Cross-Sectional and Ecological Study.

BACKGROUND: Stroke is the second cause of death and the first cause of disability worldwide. However, although numerous reports regarding stroke epidemiology in Latin America have been published, they differ widely in terms of employed methods and end points. This is the first of a series of articles that describes the epidemiology of stroke and other cerebrovascular diseases (CVD) in the nation, as well as their correlation with recognized risk factors and social variables. METHODS: Descriptive analyses were performed using the Colombian vital registration system and social security information system as primary data sources. Rates and ratios were calculated, corrected for under-registration, and standardized. Secondary analyses were made using data from national surveys and government organizations on hypertension, diabetes mellitus, sedentarism, obesity, tobacco and alcohol consumption, and unsatisfied basic needs. Factorial multivariate multiple regression analyses were performed to evaluate correlations. Concentration curves and indices were calculated to evaluate for inequities in the distribution of events. RESULTS: Global CVD had a national mortality rate and a prevalence ratio of 28 and 142 per 100,000 persons, respectively. Nontraumatic intracranial hemorrhage had the highest mortality rate (ie, 15 per 100,000), while cerebral infarction and transitory cerebral ischemia had the highest prevalence ratios (ie, 28 and 29 per 100,000, respectively). Hypertension and tobacco use were the most relevant risk factors for most of the simple and multiple models, and cerebral amyloid angiopathy and nonpyogenous intracranial venous thrombosis were the disease categories with the most socially unequal distribution of deaths and cases (ie, concentration indices of .34 and .29, respectively). CONCLUSIONS: CVDs are a cause for concern in Colombia and a marker of healthcare inequality and social vulnerability. Nationwide control of risk factors such as hypertension and tobacco use, as well as the design and conduct of public policy focused on the vulnerable and medically underserved regions and on standardizing mandatory CVD registries might ease its burden.

Fatores associados à falta de assistência hospitalar nos óbitos por doença cerebrovascular, São Paulo, Brasil: análise comparativa entre 1996-1998 e 2013-2015 / Factors associated with lack of hospital care in deaths from cerebrovascular disease, São Paulo, Brazil: a comparative analysis of 1996-1998 and 2013-2015 / Factores asociados a la falta de asistencia hospitalaria en fallecimientos por enfermedad cerebrovascular, São Paulo, Brasil: análisis comparativo entre 1996-1998 y 2013-2015

O objetivo foi avaliar os fatores sociodemográficos e clínicos relacionados à falta de assistência hospitalar em óbitos por doença cerebrovascular (DCV) e DCV hemorrágica, no Estado de São Paulo, Brasil, nos triênios 1996-1998 e 2013-2015. Foram utilizados dados dos óbitos provenientes do Sistema de Informações sobre Mortalidade. Para analisar a associação entre a falta de atendimento hospitalar e as variáveis consideradas no estudo utilizou-se a regressão de Poisson. Dos 127.319 indivíduos que morreram por DCV nos dois triênios, 19.362 (15,2%) não tiveram assistência hospitalar. A falta de atendimento hospitalar em óbitos por DCV manteve-se praticamente inalterada para as características sociodemográficas e clínicas, exceto a distribuição por sexo. No período mais recente, identificou-se maior risco de óbito por DCV sem assistência hospitalar entre indivíduos de cor da pele amarela (RR = 1,48), já em pessoas de cor preta (RR = 0,85), parda (RR = 0,86), nos casados (RR = 0,70), naqueles que residiam no Município de São Paulo (RR = 0,92), nos que tiveram assistência médica (RR = 0,17) e naqueles acometidos pela DCV hemorrágica (RR = 0,47) o risco de óbito sem assistência hospitalar foi menor. Além disso, a falta de atendimento hospitalar em óbitos por DCV hemorrágica foi menor entre os casados (RR = 0,67), naqueles que residiam no Município de São Paulo (RR = 0,74) e nos que tiveram assistência médica (RR = 0,08). As características sociodemográficas e clínicas estiveram associadas com a falta de assistência hospitalar em óbitos por DCV e DCV hemorrágica, sugerindo que há diferenças no atendimento ao paciente com DCV.

The objective was to assess sociodemographic and clinical factors related to the lack of hospital care in deaths from ischemic and hemorrhagic cerebrovascular disease (CVD) in the state of São Paulo, Brazil, in 1996-1998 and 2013-2015. The study used data on deaths from the Mortality Information System. Poisson regression was used to analyze the association between lack of hospital care and the study variables. Of the 127,319 individuals that died of CVD in the two three-years periods, 19,362 (15.2%) had failed to receive hospital care. Lack of hospital care in deaths from CVD remained practically unchanged in relation to sociodemographic and clinical characteristics, except for distributions by sex. The more recent three-year period showed higher risk of death from CVD without hospital care among Asian-descendant individuals (RR = 1.48), while lower risk of death from CVD without hospital care in the more recent period was associated with black color (RR = 0.85), brown color (RR = 0.86), married individuals (RR = 0.70), those living in the capital city of São Paulo (RR = 0.92), those who received medical care (RR = 0.17), and those with hemorrhagic CVD (RR = 0.47). In addition, lack of hospital care in deaths from hemorrhagic CVD was lower among married individuals (RR = 0.67), those living in the capital city of São Paulo (RR = 0.74), and those who received medical care (RR = 0.08). Sociodemographic and clinical characteristics were associated with the lack of hospital care in deaths from ischemic and hemorrhagic CVD, suggesting that there are differences in care for CVD patients.

El objetivo fue evaluar factores sociodemográficos y clínicos, relacionados con la falta de asistencia hospitalaria en óbitos por enfermedad cerebrovascular (ECV) y ECV hemorrágica, en el Estado de São Paulo, Brasil, durante los trienios 1996-1998 y 2013-2015. Se utilizaron datos de los óbitos procedentes del Sistema de Informaciones sobre Mortalidad. Para analizar la asociación entre la falta de atención hospitalaria y las variables consideradas en el estudio se utilizó la regresión de Poisson. De los 127.319 individuos que murieron por ECV en los dos trienios, 19.362 (15,2%) no tuvieron asistencia hospitalaria. La falta de atención hospitalaria en óbitos por ECV se mantuvo prácticamente inalterada, respecto a las características sociodemográficas y clínicas, excepto en la distribución por sexo. En el período más reciente se identificó un mayor riesgo de óbito por ECV sin asistencia hospitalaria entre individuos de ascendencia asiática (RR = 1,48), mientras que en personas afrodescendientes (RR = 0,85), mestizos (RR = 0,86), casados (RR = 0,70), en aquellos que residían en el municipio de São Paulo (RR = 0,92), en quienes contaron con asistencia médica (RR = 0,17) y en aquellos afectados por la ECV hemorrágica (RR = 0,47), el riesgo de muerte sin asistencia hospitalaria fue menor. Además, la falta de atención hospitalaria en fallecimientos por ECV hemorrágica fue menor entre los casados (RR = 0,67), en aquellos que residían en el municipio de São Paulo (RR = 0,74) y en los que contaron asistencia médica (RR = 0,08). Las características sociodemográficas y clínicas se asociaron con la falta de asistencia hospitalaria en óbitos por ECV y ECV hemorrágica, sugiriendo que existen diferencias en la atención al paciente con una ECV.

In-hospital cardiopulmonary resuscitation of patients with cirrhosis: A population-based analysis.

OBJECTIVE: To examine the epidemiology and outcomes of in-hospital cardiopulmonary resuscitation (CPR) among patients with cirrhosis. METHODS: We used the Texas Inpatient Public Use Data File to identify hospitalizations aged ≥ 18 years with and without cirrhosis during 2009-2014 and those in each group who have undergone in-hospital CPR. Short-term survival (defined as absence of hospital mortality or discharge to hospice) following in-hospital CPR was examined. Multivariate logistic regression modeling was used to assess the prognostic impact of cirrhosis following in-hospital CPR and predictors of short-term survival among cirrhosis hospitalizations. RESULTS: In-hospital CPR was reported in 2,511 and 51,969 hospitalizations with and without cirrhosis, respectively. The rate of in-hospital CPR (per 1,000 hospitalizations) was 7.6 and 4.0 among hospitalizations with and without cirrhosis, respectively. The corresponding rate of in-hospital CPR among decedents was 10.7% and 13.4%, respectively. Short-term survival following in-hospital CPR among hospitalizations with and without cirrhosis was 14.9% and 27.3%, respectively, and remained unchanged over time on adjusted analyses among the former (p = 0.1753), while increasing among the latter (p = 0.0404). Cirrhosis was associated with lower odds of short-term survival following in-hospital CPR (adjusted odds ratio [aOR] 0.55 [95% CI: 0.49-0.62]). Lack of health insurance (vs. Medicare) (aOR] 0.47 [95% CI: 0.34-0.67]) and sepsis ([aOR] 0.67 [95% CI: 0.53-85]) were associated with lower odds of short-term survival following in-hospital CPR among cirrhosis hospitalizations. CONCLUSIONS: The rate of in-hospital CPR was nearly 2-fold higher among hospitalizations with cirrhosis than among those without it, though it was used more selectively among the former. Short-term survival following in-hospital CPR remained markedly lower among cirrhosis hospitalizations, while progressively improving among those without cirrhosis. Strategies to increase access to health insurance and improve early identification and control of infection should be explored in future preventive and interventional efforts.

[Association of the Status of Implementation of Nonsmoking at Eating and Drinking Establishments with Prevalence of Persons with Subjective Symptoms, Prevalence of Persons with Diseases under Treatment, Medical Expenses, and Mortality Rate: Examination Using Prefectural Data].

OBJECTIVES: The purpose of this study was to confirm the association of the status of implementation of nonsmoking at eating and drinking establishments with the prevalence of persons with subjective symptoms, the prevalence of persons with diseases under treatment, medical expenses, and mortality rate using prefectural data. METHODS: The prefectural rate of eating and drinking establishments implementing nonsmoking (hereafter, nonsmoking rate) was calculated using the data from "Tabelog®". The variables of interest were the prevalence of persons with subjective symptoms, the prevalence of persons with diseases under treatment, medical expenses (total, hospitalization and nonhospitalization expenses), and the mortality rates of malignant neoplasms (lung cancer, stomach cancer, and colon cancer), heart disease, acute myocardial infarction, cerebrovascular disease, cerebral infarction, and pneumonia in each prefecture. The partial correlation coefficient was estimated between the nonsmoking rate and the variable of interest using the smoking rate by prefectural as the control variable. RESULTS: The nonsmoking rate showed a significantly negative correlation with the medical expenses. When eating and drinking establishments were divided into "restaurant", "café", and "bar", the nonsmoking rate also indicated a significantly negative correlation with the medical expenses in any category. It was negatively related to the mortality rates of cerebrovascular disease, cerebral infarction, and pneumonia. The negative correlation was stronger in females than in males. CONCLUSIONS: These results suggest that the implementation of nonsmoking at eating and drinking establishments may reduce the mortality rates of diseases, such as cerebrovascular disease, cerebral infarction, and pneumonia, and medical expenses. Thus, it is important to implement nonsmoking at eating and drinking establishments in line with the Revised Health Promotion Act.

Exploration of Medical Trajectories of Stroke Patients Based on Group-Based Trajectory Modeling.

A high mortality rate is an issue with acute cerebrovascular disease (ACVD), as it often leads to a high medical expenditure, and in particular to high costs of treatment for emergency medical conditions and critical care. In this study, we used group-based trajectory modeling (GBTM) to study the characteristics of various groups of patients hospitalized with ACVD. In this research, the patient data were derived from the 1 million sampled cases in the National Health Insurance Research Database (NHIRD) in Taiwan. Cases who had been admitted to hospitals fewer than four times or more than eight times were excluded. Characteristics of the ACVD patients were collected, including age, mortality rate, medical expenditure, and length of hospital stay for each admission. We then performed GBTM to examine hospitalization patterns in patients who had been hospitalized more than four times and fewer than or equal to eight times. The patients were divided into three groups according to medical expenditure: high, medium, and low groups, split at the 33rd and 66th percentiles. After exclusion of unqualified patients, a total of 27,264 cases (male/female = 15,972/11,392) were included. Analysis of the characteristics of the ACVD patients showed that there were significant differences between the two gender groups in terms of age, mortality rate, medical expenditure, and total length of hospital stay. In addition, the data were compared between two admissions, which included interval, outpatient department (OPD) visit after discharge, OPD visit after hospital discharge, and OPD cost. Finally, the differences in medical expenditure between genders and between patients with different types of stroke-ischemic stroke, spontaneous intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH)-were examined using GBTM. Overall, this study employed GBTM to examine the trends in medical expenditure for different groups of stroke patients at different admissions, and some important results were obtained. Our results demonstrated that the time interval between subsequent hospitalizations decreased in the ACVD patients, and there were significant differences between genders and between patients with different types of stroke. It is often difficult to decide when the time has been reached at which further treatment will not improve the condition of ACVD patients, and the findings of our study may be used as a reference for assessing outcomes and quality of care for stroke patients. Because of the characteristics of NHIRD, this study had some limitations; for example, the number of cases for some diseases was not sufficient for effective statistical analysis.

Overwork-related disorders and recent improvement of national policy in South Korea.

OBJECTIVES: Recently, overwork-related disorders have become a major public health concern in Korea. This study investigated the current trends of working hours, causes of death in the working population, and compensation rates. METHODS: We reviewed the current trends of working hours, cause of death statistics in the working population, industrial accident compensation insurance (IACI) statistics, issues of compensation and prevention of work-related cerebro-cardio vascular diseases (CCVDs), mental disorders, and suicide. RESULTS: Although weekly working hours and the proportion of long working days have decreased, workers in small companies with fewer than five employees and those in the service sector continue to work long hours. The age standardized mortality due to CCVD and suicide was highest among those with managerial roles. In total, 589 CCVD cases and 104 mental disorder or suicide cases were compensated as occupational diseases in 2017. Between 2016 and 2017, 61% of 59 compensated suicides were related to overwork, specifically: long working hours, increased responsibility, or increased workload. The Korean government has introduced various policies to reduce working hours and to increase compensation approval rate for overwork-related CCVDs. Stakeholders have called for the introduction of independent laws to prevent overwork-related disorders, change organizational culture, and address the blind spots of the IACI Act and Labor Standard Act. CONCLUSIONS: Prevention and compensation policies have improved working conditions in Korea, but there remains much to be done. This review significantly contributes to the understanding of the overall policies and research to prevent overwork-related disorders in Korea.

[Changing trend regarding the burden on cerebrovascular diseases between 1990 and 2016 in China].

Objectives: To analyze the status quo and trends on the burden of cerebrovascular diseases between 1990 and 2016 in China. Methods: Morbidity mortality, years of life lost (YLL), years of lived with disability (YLD) and disability-adjusted life year (DALY) related to cerebrovascular diseases between 1990 and 2016, were collated and analyzed, according to the results of the Global Burden of Diseases Study 2016 (GBD 2016). Numbers on incidence and morbidity were used to assess the incidence of diseases, while the numbers of death and mortality were used to assess the death of diseases. Years of life lost due to premature death (YLL), years lost due to disability (YLD) and disability-adjusted life year (DALY) were used to assess the burden of diseases. Changing trend on the burden of cerebrovascular disease from 1990 to 2016 was also analyzed. Results: In 2016 and 1990, the numbers of new cases/morbidity and the number of deaths/mortality on cerebrovascular diseases in the country showed an upward trend. Rates regarding YLL and DALY on cerebrovascular diseases remained stable from 1990 to 2016, however, the YLD rate showed a slow upward trend. The changing rate of DALY was mainly influenced by YLL. Both DALY and YLL crude rates in males showed a slow upward trend, with the highest DALY rate appearing in the ≥70 age group. Disease burden on males was heavier than that of the females and in the 50-60 age group, which taking the largest proportion. As for the composition in DALY, YLL appearing much larger than YLD and slowly increasing. Analysis on the subtypes of diseases, proportions of YLL and DALY in hemorrhagic stroke were greater than that in ischemic stroke while the proportion of YLD in ischemic stroke was in the opposite. Conclusions: The burden of disease on cerebrovascular diseases remained heavy and the differences appeared in age, gender and subtypes of diseases. Our findings called for the adoption of measures including screening, intervention and rehabilitation to be taken on target populations, in order to reduce the burden on both individuals and the society.

Socioeconomic factors and mortality due to cerebrovascular and hypertensive disease in Brazil.

INTRODUCTION AND OBJECTIVE: Socioeconomic factors may affect mortality due to cerebrovascular diseases (CBVDs), hypertensive diseases (HYPDs), and circulatory system diseases (CSDs). This study aimed to assess the association between the Human Development Index (HDI) and the extent of supplementary health coverage and mortality due to these diseases in the Brazilian Federative Units (FUs) between 2004 and 2013. METHODS: The Municipal HDI (MHDI) scores of each FU for 2000 and 2010 were retrieved from the Atlas Brasil website, and supplementary health coverage data for the period 2004-2013 were obtained from the national regulatory agency for private health insurance. Population and mortality data were obtained from the website of the Department of Information Technology of the Unified Health System (DATASUS). Mortality rates were weighted by ill-defined causes of death and standardized by age. RESULTS: The MHDI increased between 2000 and 2010 in all FUs, in half of which it was 0.7 or higher. Supplementary health coverage increased in the country during the study period and was inversely associated with mortality due to CSDs and CBVDs between 2004 and 2013. Mortality due to CBVDs and HYPD in 2013 showed an inverse linear association with the MHDI in 2000. CONCLUSION: Mortality due to CSDs, CBVDs, and HYPDs was influenced by socioeconomic factors. There was a significant inverse association between socioeconomic factors and mortality due to CSDs, CBVDs, and HYPDs. Plans to reduce mortality due to these diseases should include measures to foster economic development and reduce inequality.

Socioeconomic gap between neighborhoods of Budapest: Striking impact on stroke and possible explanations.

INTRODUCTION: Hungary has a single payer health insurance system offering free healthcare for acute cerebrovascular disorders. Within the capital, Budapest, however there are considerable microregional socioeconomic differences. We hypothesized that socioeconomic deprivation reflects in less favorable stroke characteristics despite universal access to care. METHODS: From the database of the National Health Insurance Fund, we identified 4779 patients hospitalized between 2002 and 2007 for acute cerebrovascular disease (hereafter ACV, i.e. ischemic stroke, intracerebral hemorrhage, or transient ischemia), among residents of the poorest (District 8, n = 2618) and the wealthiest (District 12, n = 2161) neighborhoods of Budapest. Follow-up was until March 2013. RESULTS: Mean age at onset of ACV was 70±12 and 74±12 years for District 8 and 12 (p<0.01). Age-standardized incidence was higher in District 8 than in District 12 (680/100,000/year versus 518/100,000/year for ACV and 486/100,000/year versus 259/100,000/year for ischemic stroke). Age-standardized mortality of ACV overall and of ischemic stroke specifically was 157/100,000/year versus 100/100,000/year and 122/100,000/year versus 75/100,000/year for District 8 and 12. Long-term case fatality (at 1,5, and 10 years) for ACV and for ischemic stroke was higher in younger District 8 residents (41-70 years of age at the index event) compared to D12 residents of the same age. This gap between the districts increased with the length of follow-up. Of the risk diseases the prevalence of hypertension and diabetes was higher in District 8 than in District 12 (75% versus 66%, p<0.001; and 26% versus 16%, p<0.001). DISCUSSION: Despite universal healthcare coverage, the disadvantaged district has higher ACV incidence and mortality than the wealthier neighborhood. This difference affects primarily the younger age groups. Long-term follow-up data suggest that inequity in institutional rehabilitation and home-care should be investigated and improved in disadvantaged neighborhoods.

Cost-effectiveness of home blood pressure telemonitoring and case management in the secondary prevention of cerebrovascular disease in Canada.

Home blood pressure (BP) telemonitoring and pharmacist case management reduce BP, but cost-effectiveness assessments are mixed. We examined the incremental cost-effectiveness of this intervention vs usual care in Canadians with cerebrovascular disease. A Markov decision model cost-utility analysis examining community-residing, high-risk patients with a recent nondisabling cerebrovascular event was created. A lifetime time horizon and health care payer perspective were used. Achieved BP, future cardiovascular risks, and attendant consequences on quality-adjusted life years and Canadian dollar costs were modeled. BP telemonitoring was assumed to occur for 3 months, then quarterly. Life tables were used to determine overall mortality, adjusted by cardiovascular disease mortality. Relative efficacies of intervention-associated BP lowering, resource use, and costs were obtained from Canadian published literature. Reduction in systolic BP of 9.7 mmHg was used in the base case; subsequently, robust sensitivity analyses were conducted. The results showed that, over the lifetime horizon, telemonitoring with case management led to net health care savings of $1929 Canadian and increased per-patient QALYs by 0.83. These findings were robust to sensitivity analysis, with the intervention remaining dominant or highly cost-effective. Increasing telemonitoring costs by 50% still resulted in the intervention being dominant; if the costs of telemonitoring plus case management were 2-3 times base case cost, incremental cost-effectiveness was $1200-$4700 per quality-adjusted life year gained. In conclusion, home BP telemonitoring and pharmacist case management poststroke lowered costs and improved QALYs. Strategies and funding for broad implementation of this dominant strategy should be implemented.

A comparative analysis of long-term mortality after carotid endarterectomy and carotid stenting.

BACKGROUND: The value of carotid intervention is predicated on long-term survival for patients to derive a stroke prevention benefit. Randomized trials report no significant difference in survival after carotid endarterectomy (CEA) vs carotid artery stenting (CAS), whereas observational studies of "real-world" outcomes note that CEA is associated with a survival advantage. Our objective was to examine long-term mortality after CEA vs CAS using a propensity-matched cohort. METHODS: We studied all patients who underwent CEA or CAS within the Vascular Quality Initiative from 2003 to 2013 (CEA, n = 29,235; CAS, n = 4415). Long-term mortality information was obtained by linking patients in the registry to their respective Medicare claims file. We assessed the long-term rate of mortality for CEA and CAS using Kaplan-Meier estimation. We assessed the crude, adjusted, and propensity-matched (total matched pairs, n = 4261) hazard ratio (HR) of mortality for CEA vs CAS using Cox regression. RESULTS: The unadjusted Kaplan-Meier estimated 5-year mortality was 14.0% for CEA and 18.3% for CAS. The crude HR of all-cause mortality for CEA vs CAS was 0.75 (95% confidence interval [CI], 0.70-0.81), indicating that patients who underwent CEA were 25% less likely to die before those who underwent CAS. This survival advantage persisted after adjustment for age, sex, and comorbidities (adjusted HR, 0.75; 95% CI, 0.69-0.82). This effect was confirmed on a propensity-matched analysis, with an HR of 0.76 (95% CI, 0.69-0.85). Finally, these findings were robust to subanalyses that stratified patients by presenting symptoms and were more pronounced in symptomatic patients (adjusted HR, 0.69; 95% CI, 0.61-0.79) than in asymptomatic patients (adjusted HR, 0.80; 95% CI, 0.71-0.90). CONCLUSIONS: During the last 15 years, patients who underwent CEA in the Vascular Quality Initiative have a long-term survival advantage over those who underwent CAS in real-world practice. Despite no difference in long-term survival in randomized trials, our observational study demonstrated a survival benefit for CEA that did not diminish with risk adjustment.