Trends in case-fatality of stroke in Finland during 1983 to 1992.

BACKGROUND AND PURPOSE: Stroke mortality has been declining in Finland during the past 20 years. It is not known, however, whether this favorable development is attributable to the decline in the incidence or case-fatality of stroke. For this reason we examined the trends in case-fatality of stroke, including trends by subtype of stroke. METHODS: The analyses were carried out using data of the community-based FINMONICA Stroke Register, which was operating in three geographic areas of Finland during 1983 to 1992. All stroke events (n = 11,171) in persons aged 35 to 74 years were included in this register. RESULTS: The 28-day case-fatality of stroke fell yearly by 3.6% (P = .01) in men and by 2.6% (P = .2) in women. At the end of the study period, the average 28-day case-fatality of all strokes was 20% in men and 21% in women. Considerable differences by subtype of stroke were observed. The 28-day case-fatalities at the end of the study period were in men-56% for subarachnoid hemorrhage, 42% for intracerebral hemorrhage, and 14% for cerebral infarction. In women, the corresponding figures were 49%, 49%, and 14%. The 28-day case-fatality of subarachnoid hemorrhage did not change during the study period, but for intracerebral hemorrhage, a significant decline was observed in men and there was a declining trend also in women. The 28-day case-fatality of cerebral infarction declined significantly in both genders. CONCLUSIONS: With the exception of subarachnoid hemorrhage, the 28-day case-fatality of stroke has fallen in Finland. It is likely that this fall has contributed to the decline in stroke mortality.

Atrial fibrillation and stroke. Mortality and causes of death after the first acute ischemic stroke.

BACKGROUND AND PURPOSE: Atrial fibrillation (AF) is a risk factor for stroke. This study was undertaken to determine the influence of AF on the mortality of stroke patients and on the causes of death after a stroke event. METHODS: Patients with first ischemic stroke who were .35 to 74 years old and registered in the FINMONICA stroke register during 1982 through 1992 were analyzed (n = 6912). There were 642 patients with AF (9.3%) (mean age, 67 years) and 6270 patients without AF (90.3%) (mean age, 63 years). The association between AF and stroke mortality was investigated by use of logistic regression and Cox proportional hazards models. RESULTS: Mortality was higher in the AF group both at 28 days (19.5% versus 14.4%, P < .001) and 1 year after the attack (30.5% versus 21.8%, P < .001). After adjustment for age and sex, the odds ratio for 28-day case fatality (AF versus non-AF) was 1.27 (95% CI, 1.03 to 1.56; P = .003), and that for 1-year mortality was 1.36 (95% CI, 1.14 to 1.63; P < .001). In the proportional hazards model, AF was a significant independent risk factor for 1-year mortality (hazard ratio, 1.26; 95% CI, 1.09 to 1.46; P = .002). Cardiac causes of death were more common in the AF group at the acute stage. In the course of 1 year, there were no differences in the distributions of causes of death. CONCLUSIONS: Stroke patients with AF are at high risk of death both at the acute phase of stroke and during the subsequent year after the first acute stroke event. Mortality from cardiac diseases prevailed in the AF group during the acute phase of stroke. Careful cardiac evaluation and treatment are essential in patients with AF and stroke.

Seasonal variation in the occurrence of stroke in a Finnish adult population. The FINMONICA Stroke Register. Finnish Monitoring Trends and Determinants in Cardiovascular Disease.

BACKGROUND AND PURPOSE: Seasonal influence on the incidence of and mortality from cerebrovascular disease has been reported during the last three decades, but generally with some discrepancy in results, particularly regarding stroke subtypes. The aim of this study was to examine seasonal variation in the incidence, mortality, and case-fatality rate of stroke in data from the FINMONICA population-based stroke register. METHODS: During 1982 to 1992, 15449 stroke events were registered in the monitored populations aged 25 to 99 years in three geographic areas of Finland: the provinces of Kuopio and North Karelia in eastern Finland and the Turku/Loimaa area in southwestern Finland. We analyzed the seasonal and monthly incidence, mortality, and case-fatality rate of stroke and subtypes of stroke by pooling the data for the three areas and stratifying by sex and age. RESULTS: The rate of occurrence of ischemic stroke events was 12% (95% confidence interval [CI], 5% to 20%) greater in men and 11% (95% CI, 4% to 19%) greater in women in winter than in summer. For intracerebral hemorrhage, we observed a 28% (95% CI, 3% to 58%) greater rate of occurrence in men and a 33% (95% CI, 6% to 66%) greater rate of occurrence in women in winter than in summer. The occurrence of subarachnoid hemorrhage did not vary significantly by season. The greater incidence of ischemic strokes in winter was particularly prominent among men aged 25 to 64 years and less prominent in elderly men and in women. The 28-day case-fatality rate of ischemic stroke showed significant seasonal variation only in women (P = .001), with the lowest rate in summer. CONCLUSIONS: There is a significantly greater incidence of ischemic strokes and intracerebral hemorrhages during winter in Finland. Further research that also takes meteorologic and sociodemographic factors into account is warranted, since it may help to determine new ways to prevent strokes.

Ten-year trends in stroke incidence and mortality in the FINMONICA Stroke Study.

BACKGROUND AND PURPOSE: The trends in stroke incidence reported so far have not been entirely consistent, although declining trends in mortality from stroke have been reported from a number of studies around the world. This study aims to evaluate the 10-year trends (from 1983 through 1992) in incidence, attack rate, and mortality of stroke in the Finnish population. METHODS: A population-based stroke register was set up in the early 1980s to collect data on all suspected events of acute stroke that occurred in the population aged 25 to 74 years permanently residing in three geographic areas of Finland: the provinces of Kuopio and North Karelia in eastern Finland and the Turku-Loimaa area in southwestern Finland. Trends in age-standardized attack rates, incidence, and mortality were calculated for the period studied. RESULTS: During the 10-year study period, 11 392 acute stroke events occurred in the monitored populations. A statistically significant decline was observed in the pooled FINMONICA data, both in the incidence of stroke (-1.7% with 95% confidence interval [CI], -3.0% to -0.5% per year in men; -2.2% with 95% CI, -3.6% to -0.7% per year in women) and in mortality from stroke (-5.2% with 95% CI, -8.2% to -2.2% per year; -4.7% with 95% CI, -8.2% to -1.2% per year). The attack rate of stroke also declined significantly in both sexes. When the areas were considered separately, the declining trends were observed within each area. The decline in incidence of stroke was, however, statistically significant only among men and women in Kuopio and among women in Turku/Loimaa. Mortality declined significantly in all three areas among men but among women only in Kuopio. The incidence to mortality rate ratio increased during the study period, indicating a steeper fall in mortality than in incidence. CONCLUSIONS: A substantial decline in both stroke incidence and mortality was observed in the adult and elderly population in the FINMONICA study areas. Part but not all of the decline in stroke mortality, observed also in the official mortality statistics, can be attributed to the decline in stroke incidence during this 10-year period.

Psychosocial and health status in stroke survivors after 14 years.

BACKGROUND AND PURPOSE: Most studies of long-term survival and assessment of health status in survivors of stroke are hospital based and are often based only on a relatively short follow-up. This study was aimed at evaluating survival of acute stroke after 14 years. We also assessed psychosocial and health status among the long-term stroke survivors. METHODS: This study is a follow-up of the Finnish part of the collaborative World Health Organization Stroke Study that took place during 1972 through 1974. All survivors were interviewed by telephone after being sent a structured questionnaire approximately 14 years after the initial stroke attack. Information on clinical history, socioeconomic situation, self-reported functional capacity, psychosomatic status, perceived mental status, and perceived health was collected. RESULTS: Of the 1241 persons who had been entered in the stroke register from 1972 through 1974, 241 (19.4%) were still alive after 14 years. Participation rate in the telephone interview was 83.4%. Over 80% of all stroke survivors lived at home or with relatives at the time of interview. Functional capacity was good in about two thirds of the stroke survivors. Only 10% to 15% of all respondents felt depressed. About half of both men and women aged 64 years or younger perceived their health as good, while only 25% of men aged 65 years or over did. CONCLUSIONS: Most stroke survivors did not need institutionalized care in the long term. Although a large proportion of them suffered from various somatic diseases, their functional capacity was found to be good.

Declining trends in incidence, case-fatality and mortality of stroke in three geographic areas of Finland during 1983-1989. Results from the FINMONICA stroke register.

Stroke mortality has decreased during the last decade in many industrialized countries, but there has been no clear evidence for a decline in the incidence of stroke. The present study analyzes the trends in the incidence, mortality and case-fatality of stroke in Finland from 1983 to 1989. We used data from the FINMONICA stroke register, a community based register collecting information on all suspected stroke cases aged 25-74 in three geographical areas of Finland. Annual attack rate, incidence, mortality and case-fatality rates were calculated for all strokes and for different subcategories of stroke. A linear regression model was applied to calculate the yearly trends of these rates. In men, the attack rate of stroke was 336/100,000 in 1983 and 310/100,000 in 1989 (-8% during the observation period); incidence declined from 269/100,000 in 1983 to 236/100,000 in 1989 (-12%); mortality declined from 82/100,000 to 64/100,000 (-22%), and case-fatality declined from 25% to 21% (-18%). Also among women similar declining trends were observed (-11%, -13%, -16%, and -10% respectively), but they were not statistically significant. In both incidence and mortality of stroke, the decline was seen in all age groups. Incidence and mortality of cerebral infarction declined similarly to all strokes. A large fall in the incidence (-24% in both men and women) and mortality (-38% in men and -27% in women) of subarachnoid haemorrhage was also observed. An increasing trend, although not significant, was instead observed for cerebral haemorrhage. First stroke and especially first cerebral infarction contributed most to the decline in case-fatality. The availability of computerized brain tomography improved from 18% in 1983 to 60% in 1989. We observed a fall in the incidence, mortality, and case-fatality of stroke during 1983-1989. Among the subtypes of stroke, cerebral infarction contributed most to the decline, but the data suggested also a declining trend in the incidence and mortality of subarachnoid haemorrhage, observed now for the first time in Finland since the 1960s. The fall in the incidence of stroke was not as steep during the 1980s as it was during the 1970s; Finland is anyhow the only European country which has reported a decreasing trend in stroke incidence during the 1980s. We need now to investigate how much the decline in the classical risk factors for stroke observed in Finland during the last two decades predicts the observed trends.

Stroke incidence and case fatality in Finland and in Akita, Japan: a comparative study.

The incidence and case fatality of stroke from 1983 to 1985 from the community-based stroke register of the FINMONICA study in Finland were compared with the corresponding rates in the hospital-based register of Akita in Japan collected during 1984-1986. The comparability of the two registers was assessed, and case fatality was compared only in hospitalized cases. In Akita, the age-standardized incidence of cerebral haemorrhage in people aged 25-74 was twice that in FINMONICA, while the reverse was true for incidence of cerebral infarction. Case fatality from stroke within 48 h of onset was higher in FINMONICA than in Akita in each stroke subtype. The incidence and mortality of subarachnoid haemorrhage were similar in the two populations. The differences in early case fatality are probably due to dissimilarities in the severity of the stroke attacks rather than discrepancies in early treatment. Coding practices and also a more unlikely selection bias due to the differential use of computerized brain tomography in the two countries may play a role in differences in incidence and case fatality between these two countries.

Trends in stroke mortality and incidence in Finland in the 1970s and 1980s.

This article presents trends in stroke mortality and incidence in Finland among people aged 25 to 74 years. Between 1971 and 1980, stroke mortality declined steeply: 4.1% per year among men and 5.5% per year among women. Between 1981 and 1991 the decline was smaller; about 2.2% per year in men and 2.8% per year in women. The North Karelia stroke register showed that stroke mortality declined in men from 155 per 100,000 per year in 1972 to 1973, to 87 per 100,000 per year in 1982 to 1983, and in women from 114 to 44 per 100,000 per year. A slight decline in mortality was observed during the 1980s in men, but not in women. The incidence of stroke also declined in North Karelia during the 1970s, from 328 to 248 per 100,000 per year in men, and from 230 to 141 per 100,000 in women. In the FINMONICA stroke register, the average rate of decline in incidence of stroke between 1983 and 1989 was 1.7% per year in men and 1.8% per year in women. Declines in incidence and mortality from subarachnoid hemorrhage were observed in both men and women; nevertheless it was the decline in cerebral infarction that accounted for most of the changes since about 80% of all strokes are cerebral infarctions. In conclusion, despite steep falls in stroke mortality and incidence in the 1970s, stroke mortality is still high in Finland compared with other nations. During the 1980s, the decline in stroke mortality was less and incidence leveled off until it resumed from 1987 to 1989.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke mortality and case-fatality rates in three geographic areas of Finland from 1983 to 1986.

BACKGROUND AND PURPOSE: Our aim was to describe the mortality and early case-fatality rates of stroke in three geographic areas of Finland during 1983 to 1986 by means of a community-based stroke register and to estimate the accuracy of registration of stroke deaths in the official statistics compared with the FINMONICA stroke register. METHODS: Annual and average mortality and case-fatality rates of stroke were derived from data collected in the FINMONICA stroke register during 1983 to 1986. Age-specific and age-standardized rates were calculated for the three areas, and the results were compared with the official mortality statistics and with the case-fatality figures published previously in the literature for Finland and elsewhere. RESULTS: Mortality from stroke in the three FINMONICA areas was between 73 and 90 per 100,000 per year among men aged 25 to 74 years and between 42 and 55 per 100,000 per year among women in the same age group. Average case-fatality was similar in the three areas and globally high: 20% to 27% in men and 24% to 28% in women. Approximately half of the fatal strokes occurred within less than 2 days from the onset of the attack, and a further 25% within the first week. Hemorrhagic strokes accounted for 54% to 81% of all fatal strokes occurring in less than 2 days among men, while among women the corresponding proportions varied in the three areas between 35% and 74%. Of cerebral infarctions, approximately 28% to 37% among men and 19% to 20% among women were fatal within less than 2 days. Although the number of fatal strokes was similar in both the FINMONICA register and official mortality statistics, only 82% to 85% of the stroke cases were common in both registers; a further 13% to 14% of the cases classified as stroke deaths in the FINMONICA register could also be found in the official mortality statistics, but the underlying cause of death was something other than stroke. CONCLUSIONS: The reliability of the Finnish official mortality statistics with regard to stroke deaths is reasonably good in aggregate numbers, but at the individual level considerable discrepancies seem to occur. Mortality from stroke in Finland has not declined further after 1979 and remains high internationally. Early case-fatality of stroke also seems higher in Finland than in most other countries. We believe that both the high incidence of stroke and the severity of the attacks are contributing to mortality and case-fatality rates of stroke in Finland.

The FINMONICA Stroke Register. Community-based stroke registration and analysis of stroke incidence in Finland, 1983-1985.

In the early 1980s, a standardized community-based stroke register was started in three geographic areas in Finland: North Karelia and Kuopio in eastern Finland and Turku/Loimaa in southwestern Finland. The results from the first 3 years, 1983-1985, confirmed the high incidence of stroke in Finland. The incidence of stroke was higher in eastern Finland than in the southwestern part of the country. The age-standardized annual incidence among men aged 25-74 years varied from 206 per 100,000 population in southwestern Finland to 322 per 100,000 population in the province of Kuopio in eastern Finland. Among women aged 25-74, incidence was 119 and 187 per 100,000 population in these two areas, respectively. The age-standardized male:female ratio in incidence was 1.7, slightly higher than that previously reported in Finland. Out of 3,574 stroke events registered, 78% were first events without a history of previous stroke. People aged 65-74 years accounted for 45% of all events among men and 62% of all events among women. The authors' experience shows that the geographic variation in stroke incidence and attack rates is difficult to assess even within a country with a relatively uniform health care system. Rigorous standardization and quality control is needed for the assessment of long-term trends; this is the primary goal of the FINMONICA Stroke Register. The findings of this study suggest that the incidence of stroke is still high in Finland, although mortality from stroke has steeply declined during the past 15-20 years. The number of stroke survivors in Finland may actually be increasing. Since the occurrence of stroke is high in Finland as compared with other countries, intensified primary and secondary prevention measures are needed to reduce it.

Epidemiology of subarachnoid hemorrhage in Finland from 1983 to 1985.

The age-standardized incidence of subarachnoid hemorrhage was 33/100,000/yr among Finnish men and 25/100,000/yr among Finnish women. Subarachnoid hemorrhage represented 11% of all strokes detected during 1983-1985 in the community-based stroke register in three areas of Finland. Age-standardized mortality from subarachnoid hemorrhage was 18/100,000/yr among men and 12/100,000/yr among women aged 25-74 years, representing in men 22% and in women 23% of all deaths from stroke in the register. The case-fatality rate of subarachnoid hemorrhage was high: 35% among men and 33% among women within 2 days after the onset of the stroke attack and 48% in men and 46% in women at 1 month. Our findings suggest that the incidence and mortality of subarachnoid hemorrhage in Finland are among the highest worldwide, although differences in criteria, study methods, and classification procedures reduce the comparability of studies from different countries. The occurrence of subarachnoid hemorrhage in our present study is also higher than that previously reported in this country. We believe that this is more likely due to changes in diagnostic classification and improvements in detection of the disease than to a real increase in the morbidity and mortality of subarachnoid hemorrhage.

A longitudinal study of occlusal interferences and signs of craniomandibular disorder at the ages of 12 and 15 years.

Occlusal interferences and signs of craniomandibular disorder (CMD) were studied longitudinally in 167 Finnish adolescents at the ages of 12 and 15 years in order to evaluate their importance for orthodontic diagnosis. Of the adolescents sampled 16.8 per cent had received orthodontic treatment. The results showed that occlusal interferences and signs of CMD are quite common. Of the 12-year-olds 25.7 per cent and 30.5 per cent of the 15-year-olds showed palpatory tenderness of the muscles of mastication. Clicking sounds were recorded for 6 per cent of the 15-year-olds. Opening capacity increased with age. Only tow of the adolescents at the age of 12 and none at the age of 15 fulfilled the criteria of functionally optimal occlusion. The number of occlusal interferences increased between 12 and 15 years of age. Both occlusal interferences and clinical signs of CMD were inconsistent in nature. Mediotrusion contracts and protrusion interferences were found to be the most stable occlusal interferences at adolescence. As to pain on mouth opening, the symptom group at the age of 15 consisted of entirely new individuals. No single sign or CMD symptom, nor combination of them, was consistent enough for inclusion in orthodontic screening indices. However, even though the symptomatology changed, only a few of those considered to be symptomatic at the age of 12 were asymptomatic at the age of 15. In accordance with the present state of knowledge, it would thus seem appropriate to add a general statement about the presence or absence of CMD signs and/or symptoms to orthodontic screening indices.(ABSTRACT TRUNCATED AT 250 WORDS)

Symptoms of craniomandibular disorder in a sample of Finnish adolescents at the ages of 12 and 15 years.

Subjective symptoms of craniomandibular disorder (CMD) were studied longitudinally in 167 children at the ages of 12 and 15 in order to investigate their importance for orthodontic diagnosis. The results showed that symptoms are quite common in adolescents (64-67 per cent). However, most of the adolescents experienced their symptoms only occasionally. Frequent occurrence of various, single symptoms of CMD varied from 0 to 7.2 per cent. Recurrent headache was reported by 24 per cent of the adolescents at the age of 12, and by 22 per cent of them at the age of 15. The number of reported symptoms did not increase between the ages of 12 and 15 years, which is in agreement with other studies. The symptoms of CMD did not appear to be consistent. Locking of the joint was found to be the most stable symptom. About 50 per cent of those reporting TMJ-clicking, unexplainable ear symptoms or bruxism at the age of 12, had lost this symptom by the age of 15. For pain on mouth-opening, the symptom group at the age of 15 consisted of entirely new individuals. Because of their inconsistent nature during the final stages of occlusal development, too much attention should not be paid to single occurrences of CMD symptoms. In individual cases, however, important information for diagnosis and treatment planning can be obtained. Symptoms of craniomandibular disorder, recurrent headache, and oral parafunctions should be elicited and recorded at annual dental check-ups of children and adolescents.

Identification of cases requiring orthodontic treatment. A longitudinal study.

The present paper is a report on the second part of a longitudinal study dealing with the identification of children requiring orthodontic treatment. The series consisted of 200 children selected at random. The children were first examined at the age of 7 and next time at the age of 10. At the second examination 38% were found not to need any orthodontic treatment, while it was considered necessary to follow the occlusal development in 19%, and 43% were found to need treatment. The treatment need was urgent in 17%, moderate in 16% and slight in 10%. The re-examination of the untreated children at the age of 10 offered a possibility of checking the orthodontic prognosis made at the age of 7. It was concluded that only children showing cross bites and severe Class II malocclusions can reliably be selected for treatment at the age of 7. At this age misjudgements can be made with regard to dental arch crowding, open bite, deep bite, overjet and distal occlusion. Furthermore, it was concluded that a final decision concerning the need of orthodontic treatment cannot always be made even in 10-year-old children. The study will be continued by examinations at the ages of 12 and 14.