Stroke in the very elderly: characteristics and outcome in patients aged ≥85 years with a first-ever ischemic stroke.

BACKGROUND: Epidemiological and clinical features of very elderly patients with stroke are still uncertain. Our aim was to study the patient characteristics and outcomes in the very elderly (aged ≥85 years) with a first-ever ischemic stroke in the National Acute Stroke Israeli Survey (NASIS) registry. METHODS: The NASIS registry is a nationwide prospective hospital-based study performed triennially (2004, 2007, 2010). Patients with ischemic stroke aged ≥85 years were compared with those 65-84 years old regarding their baseline characteristics, stroke severity, etiology of stroke and stroke outcomes. Logistic regression analyses were used to adjust for potential confounders. Stroke severity was determined according to the National Institute of Health Stroke Scale (NIHSS) score. RESULTS: The proportion of very elderly (≥85 years) patients among the NASIS population increased from 18.3% in 2004 to 19.9% in 2007 and 24.5% in 2010 (p for trend = 0.005). The percentage of women was higher in patients aged ≥85 years (p < 0.0001). Atrial fibrillation, congestive heart disease and prior disability were significantly more common, while diabetes, current smoking and dyslipidemia were less frequent in the very elderly. The very elderly presented with more severe strokes: 36.3% of the ≥85-year-old patients had an NIHSS score ≥11 compared with 22.0% in the younger age group (p < 0.05). CONCLUSIONS: There is an increasing proportion of very elderly subjects, mostly women, among first-ever ischemic stroke patients. Current information on age-specific aspects of stroke in the very elderly is crucial to set up successful prevention pathways and implementing well-organized stroke care for this population.

Cerebral artery calcification in patients with acute cerebrovascular diseases: determinants and long-term clinical outcome.

BACKGROUND AND PURPOSE: Coronary artery calcium is an independent predictor of all-cause mortality. We sought to examine the determinants of intracranial cerebral artery calcification (CAC) and its association with long-term outcome in a large prospective cohort of stroke patients. METHODS: Consecutive patients hospitalized because of acute stroke (ischaemic and intracerebral hemorrhage) or TIA throughout a large medical center were systematically assessed and followed up for 1 year. Intracranial CAC was assessed from baseline brain CT blinded to clinical data. Patients were categorized to no, mild, and severe CAC according to their total CAC score. Determinants of CAC were studied with logistic regression analysis. Risk of death, Barthel Index ≤ 60 or death and living in a nursing facility or death were assessed. RESULTS: Amongst 1049 patients (mean age: 70 ± 13 years, 59% males) CAC was present in 727 (69%) patients. The main determinants of CAC were increasing age (OR 1.4, 95% CI 1.3-1.6, per 5 years), diabetes (OR: 2.1, 1.4-3.0), smoking (1.4, 1.0-2.2), hypertension (1.4, 1.0-2.1), and prior coronary heart disease (1.9, 1.3-2.9). CAC was associated with mortality and poor outcome amongst patients with ischaemic stroke; however, after adjusting for age and stroke severity, no significant association was observed. In patients with intracerebral hemorrhage, outcomes were not related to CAC. CONCLUSIONS: Intracranial CAC is highly prevalent in patients with acute stroke and its main determinants are older age, diabetes, smoking, hypertension, and prior coronary heart disease. Associations between CAC and mortality or poor functional outcome in the first year after ischaemic stroke are mainly age- and stroke severity-driven.

Derivation and validation of the prolonged length of stay score in acute stroke patients.

BACKGROUND: Length of stay (LOS) is the main cost-determining factor of hospitalization of stroke patients. Our aim was to derive and validate a simple score for the assessment of the risk of prolonged LOS for acute stroke patients in a national setting. METHODS: Ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients in the National Acute Stroke Israeli Surveys (NASIS 2004 and 2007) were included. Predictors of prolonged LOS (LOS > or =7 days) in the NASIS 2004 (n = 1,700) were identified with logistic regression analysis and used for the derivation of the Prolonged Length of Stay (PLOS) score. The score was validated in the NASIS 2007 (n = 1,648). RESULTS: Median (interquartile range) LOS was 6 (3-10) days in the derivation cohort (42.3% prolonged LOS) and 5 (3-8) in the validation cohort (35.7% prolonged LOS). The derivation cohort included 54.8% men, 90.8% IS and 9.2% ICH, with a mean (SD) age of 71.2 (12.5) years. Stroke severity was the strongest multivariable predictor of prolonged LOS: odds ratio (95% confidence interval [CI]) increased from 2.6 (2.0-3.3) for NIH Stroke Scale score (NIHSS) 6-10 to 4.9 (3.0-8.0) for NIHSS 16-20, compared with NIHSS < or =5. Stroke severity and type, decreased level of consciousness on admission, history of congestive heart failure, and prior atrial fibrillation were used for the derivation of the PLOS score (c statistics 0.692, 95% CI 0.666-0.718). The score performed similarly well in the validation cohort (c statistics 0.680, 95% CI 0.653-0.707). CONCLUSION: A simple prolonged length of stay score, based on available baseline information, may be useful for tailoring policy aimed at better use of resources and optimal discharge planning of acute stroke patients.

Cerebral leukoaraiosis in patients with stroke or TIA: clinical correlates and 1-year outcome.

BACKGROUND AND PURPOSE: Cerebral leukoaraiosis is frequently observed in patients with acute stroke, but its clinical consequences on functional recovery remain incompletely defined. We evaluated the clinical correlates of leukoaraiosis, and its association with stroke-outcome in a cohort of consecutively hospitalized patients. METHODS: One-thousand twenty-four consecutive patients with acute stroke or transient ischemic attack (TIA) undergoing brain CT were included in this single-center study. Patients were systematically evaluated at hospitalization and followed-up for 1 year. Mortality, functional outcome, quality of life (QoL), psychological distress, community integration, and patient perception of recovery were evaluated by leukoaraiosis severity. Adjusted ORs (95%CI) were calculated. RESULTS: Moderate/severe leukoaraiosis was diagnosed in 177 patients (17.3%) and mild leukoaraiosis in 362 patients (35.3%). After 1 year, adjusted ORs for moderate/severe leukoaraiosis compared with no leukoaraiosis were 2.0 (95%CI 1.1-4.0) for Barthel Index

Burden of stroke in Israel.

Stroke is the third most common cause of death in Israel, similar to the United States and Europe. A decline in stroke mortality rates for the Israeli population is evident in the last decades. However, stroke is still a major health and economical burden in Israel and has recently been recognized by the Israeli health-care policy planners as a top priority disease. Action plans are being taken in order to establish a comprehensive infrastructure for the treatment of acute stroke patients.

Performance of the ABCD and ABCD2 scores in TIA patients with carotid stenosis and atrial fibrillation.

BACKGROUND: It has been suggested that scores for risk stratification of TIA patients might not identify patients with carotid stenosis or atrial fibrillation (AF) and that this might undermine the usefulness of such scores. METHODS: In patients with TIA in the Oxford Vascular Study, we studied the associations between ABCD and ABCD2 scores, the presence of > or =50% ipsilateral carotid stenosis or AF, and the risk of stroke at 7 days. RESULTS: Among 285 TIA patients (from 559 referrals of possible TIA), 69 (24.2%) had either > or =50% carotid stenosis (n = 29) or AF (n = 42), or both (n = 2). Although the ABCD and ABCD2 scores were highly predictive of stroke at 7 days (p < 0.0001), there was no clear relationship between either score and the prevalence of > or =50% carotid stenosis or AF. However, the scores did predict the 7-day stroke risk in patients with these pathologies: ABCD score (trend-p = 0.05); ABCD2 (trend-p = 0.03). Five of the 6 patients with AF or symptomatic stenosis who had a stroke within 7 days of their TIA had an ABCD score of > or =5 and all 6 had an ABCD2 score of > or =4. CONCLUSIONS: The ABCD and ABCD2 risk scores appear to identify patients with > or =50% carotid stenosis or AF who are at high risk of stroke. However, these findings should be interpreted with caution due to the small number of outcomes among these subgroups, and further validations are necessary.

Triggering risk factors for ischemic stroke: a case-crossover study.

BACKGROUND: While vascular risk factors for stroke are well established, little is known about factors that may precipitate the acute event. In this study the authors investigated the association between exposure to seven potential triggers during waking hours and acute onset of ischemic stroke. METHODS: In a case-crossover study, 200 consecutive stroke patients were interviewed 1 to 4 days after the event using a validated questionnaire. Reported exposure to potential triggers including negative and positive emotions, anger, sudden posture changes as response to a startling event, heavy physical exertion, heavy eating, and sudden temperature changes during a 2-hour hazard period prior to stroke onset were compared to the same period during the preceding day and to average exposures in the last year. RESULTS: Seventy-six patients (38%) reported exposure to at least one of the study triggers during the 2-hour hazard period. For all factors combined, the OR was 8.4 (95% CI 4.5 to 18.1). The OR for negative emotions was 14.0 (95% CI 4.4 to 89.7), for anger 14.0 (95% CI 2.8 to 253.6), and for sudden changes in body posture in response to a startling event 24.0 (95% CI 5.1 to 428.9). It is important to interpret the reported ORs as estimates of a short-term 2-hour period relative risk and not as cumulative risks. CONCLUSIONS: Negative emotions, anger, and sudden changes in body posture in response to a startling event appear to be independent triggers for ischemic stroke.

Population group differences in trends in stroke mortality in Israel.

BACKGROUND AND PURPOSE: In Israel, stroke is the third most common cause of death. In 1997 stroke accounted for 2905 deaths (8.1% of total), 1390 of them among men (7.5% of total; crude mortality rate of 48.3/100 000) and 1515 among women (8.6% of total; crude rate of 51.7/100 000). This report presents trends on stroke mortality by population group and estimates of morbidity in Israel. METHODS: Data on stroke mortality in Israel during 1969-1997 were obtained from the Israel Central Bureau of Statistics. Age-specific and age-adjusted mortality rates were calculated for the 2 main population groups. Data on morbidity were obtained form the 1996/1997 National Health Survey. Hospitalization rates due to stroke are based on the national hospitalization data. RESULTS: A monotonic decrease in stroke mortality is evident in Jews during 1969-1997 in both sexes. Age-adjusted mortality rates declined by 62.5% for Jewish men and by 73.4% for Jewish women during 1969-1997. Among Arabs, there was a general decreasing trend in the mortality for both sexes during 1973-1997. The main difference in population group mortality trends was found in the group aged >/=75 years: a statistically significant decrease in mortality rates for Jews is evident, while no decrease is apparent for Arabs. On the basis of available data for 1990, an estimated 13 000 patients with stroke were hospitalized during 1997. CONCLUSIONS: During the last 25 years, age-adjusted stroke mortality in Israel has declined substantially, but the decline has been much greater among Jews than Arabs. The group aged >/=75 years shows the greatest difference in trends between Jews and Arabs. This finding may be explained by differences in risk factor distribution and case fatality rates.

Epidemiological characteristics of spotted fever in Israel over 26 years.

During the summer of 1997, 2 confirmed and several suspected fatal cases of spotted fever (SF) occurred in previously healthy young adults in Israel. This unusual cluster of events stimulated the current study. The incidence of SF in Israel from 1971-98 was analyzed. Incidence increased until 1980, declined until 1994, and increased slightly from 1994-97. Incidence was higher during the summer, among children aged 0-9 years, and in rural settlements in central Israel. From 1971-1997, 31 deaths were reported, mostly in the elderly. The deaths that occurred in 1997 are a reminder that, despite the fact that morbidity due to SF is described mainly in children, SF can have a rapidly fatal outcome in healthy young adults. Thus, even during periods of low incidence, careful monitoring and high awareness for prompt diagnosis and treatment are needed.

[Diarrheal disease among caregivers at children's day-care centers. A retrospective and seroepidemiologic study].

Diarrheal disease tends to spread from infected children to their families. Due to the increased risk of exposure, children's caregivers in day-care centers may have a higher incidence of diarrhea, particularly when caring for very young children. We therefore examined the incidence of diarrhea and antibodies to Shigella among caregivers in day-care centers, according to age groups of children in their care (< 18, 18-34, and > 35 months) and in comparison with the general population. 2 studies with a retrospective cohort and seroepidemiological cross-sectional design were carried out. Questionnaires were completed by 401 caregivers in 36% of all WIZO day-care centers. As a measure of past exposure to Shigella, levels of S. sonnei and S. flexneri antibodies were examined in the blood of 110 caregivers (ELISA method). There was a higher incidence of diarrhea among young children, increasing the potential exposure to diarrheal agents among their caregivers. Nevertheless, no statistically significant differences in diarrhea incidence were found among caregivers of the various age groups during the previous year (p = 0.768) and during the previous month (p = 0.319), nor in absenteeism due to diarrhea during the last month (p = 0.761). Levels of Shigella antibodies were similar among caregivers in all 3 groups. Diarrheal incidence was higher among women in the population control group than among caregivers during the previous year (p = 0.005) and month (p = 0.067). No statistically significant differences in levels of S. sonnei and S. flexneri antibodies were found between caregivers and women in the control group. There was no evidence that diarrhea is an occupational hazard for caregivers of young children. An explanation may be the development of protective immunity against common diarrheal agents due to recurrent exposure.

Workers' health in Israel.

BACKGROUND: Occupational hazards are important causes of morbidity, mortality, and disability in the community. This article presents a review of workers' health in Israel. METHODS: Data were collated from the Occupational Health Institute of the University of Tel Aviv, the National Insurance Institute, the Occupational Health Departments of the General Sick Fund, and the Institute of Safety and Hygiene of the Ministry of Labor and Welfare. International comparisons are based on data derived from the WHO Health for All database for the European region. RESULTS: Levels of most biological and chemical exposures in 1996 were found to be in accordance with the standards, except for dust, gases, pesticides, and noise exposure. In 1996, 4.3% of the working population received injury compensation from the National Insurance Institute. 78% of workers' claims approved in 1992-1994 were for injuries to the back and spine. 93% of new cases of occupational diseases and injuries reported in 1996 by the occupational health service of the largest Health Fund were due to noise-induced hearing impairments. In 1996, there were 87 reported deaths following work accidents; about 50% of them were falls that occurred in the construction industry, and 26% of fatalities were among foreign workers. Rates of work accidents, average days of incapacity per accident, and fatalities have been increasing since 1991. Rates of occupational accidents and of occupational fatalities are higher than the European Community average. CONCLUSIONS: Rates of occupational diseases and of injury compensation among workers are increasing, despite the efforts and resources invested in the prevention of work accidents and the promotion of workers' health. These findings indicate the necessity for further research and efforts toward the prevention of injuries and the promotion of occupational health in Israel.