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Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

Background: Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization-World Health Organization-Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle-income countries (LMICs) compared to high-income countries. Method(s): Using a validated World Stroke Organization comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across World Health Organization regions and economic strata. The World Health Organization also conducted a survey of non-communicable diseases in 194 countries in 2019. Result(s): Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys, and participation in research) were reported in low-income countries than high-income countries. The overall global score for prevention was 40.2%. Stroke units were present in 91% of high-income countries in contrast to 18% of low-income countries (p < 0.001). Acute stroke treatments were offered in ~ 60% of high-income countries compared to 26% of low-income countries (p = 0.009). Compared to high-income countries, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol. Conclusion(s): There is an urgent need to improve access to stroke units and services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.Copyright © 2021 World Stroke Organization.

Background: There are few large population-based studies of outcomes after subarachnoid hemorrhage (SAH) than other stroke types. Method(s): We pooled data from 13 population-based stroke incidence studies (10 studies from the INternational STRroke oUtComes sTudy (INSTRUCT) and 3 new studies; N=657). Primary outcomes were case-fatality and functional outcome (modified Rankin scale score 3-5 [poor] vs. 0-2 [good]). Harmonized patient-level factors included age, sex, health behaviours (e.g. current smoking at baseline), comorbidities (e.g.history of hypertension), baseline stroke severity (e.g. NIHSS >7) and year of stroke. We estimated predictors of case-fatality and functional outcome using Poisson regression and generalized estimating equations using log-binomial models respectively at multiple timepoints. Result(s): Case-fatality rate was 33% at 1 month, 43% at 1 year, and 47% at 5 years. Poor functional outcome was present in 27% of survivors at 1 month and 15% at 1 year. In multivariable analysis, predictors of death at 1-month were age (per decade increase MRR 1.14 [1.07-1.22]) and SAH severity (MRR 1.87 [1.50-2.33]); at 1 year were age (MRR 1.53 [1.34-1.56]), current smoking (MRR 1.82 [1.20-2.72]) and SAH severity (MRR 3.00 [2.06-4.33]) and; at 5 years were age (MRR 1.63 [1.45-1.84]), current smoking (MRR 2.29 [1.54-3.46]) and severity of SAH (MRR 2.10 [1.44-3.05]). Predictors of poor functional outcome at 1 month were age (per decade increase RR 1.32 [1.11-1.56]) and SAH severity (RR 1.85 [1.06-3.23]), and SAH severity (RR 7.09 [3.17-15.85]) at 1 year. Conclusion(s): Although age is a non-modifiable risk factor for poor outcomes after SAH, however, severity of SAH and smoking are potential targets to improve the outcomes.Copyright © 2021 Elsevier Inc.

BACKGROUND AND PURPOSE: Conditions associated with frailty are common in people experiencing stroke and may explain differences in outcomes. We assessed associations between a published, generic frailty risk score, derived from administrative data, and patient outcomes following stroke/transient ischemic attack; and its accuracy for stroke in predicting mortality compared with other measures of clinical status using coded data. METHOD(S): Patient-level data from the Australian Stroke Clinical Registry (2009-2013) were linked with hospital admissions data. We used International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes with a 5-year look-back period to calculate the Hospital Frailty Risk Score (termed Frailty Score hereafter) and summarized results into 4 groups: no-risk (0), low-risk (1-5), intermediate-risk (5-15), and high-risk (>15). Multilevel models, accounting for hospital clustering, were used to assess associations between the Frailty Score and outcomes, including mortality (Cox regression) and readmissions up to 90 days, prolonged acute length of stay (>20 days; logistic regression), and health-related quality of life at 90 to 180 days (quantile regression). The performance of the Frailty Score was then compared with the Charlson and Elixhauser Indices using multiple tests (eg, C statistics) for predicting 30-day mortality. Models were adjusted for covariates including sociodemographics and stroke-related factors. RESULT(S): Among 15 468 adult patients, 15% died <=90 days. The frailty scores were 9% no risk; 23% low, 45% intermediate, and 22% high. A 1-point increase in frailty (continuous variable) was associated with greater length of stay (ORadjusted, 1.05 [95% CI, 1.04 to 1.06), 90-day mortality (HRadjusted, 1.04 [95% CI, 1.03 to 1.05]), readmissions (ORadjusted, 1.02 [95% CI, 1.02 to 1.03]; and worse health-related quality of life (median difference, -0.010 [95% CI -0.012 to -0.010]). Adjusting for the Fra

Background: We examined sex differences in cause of death and cause-specific excess mortality after stroke. Material(s) and Method(s): First-ever strokes (2010-2013; 35 hospitals) participating in the Australian Stroke Clinical Registry were linked to national death registrations and other administrative datasets. One-year cause-specific mortality was categorized as stroke, ischemic heart disease, other cardiovascular disease (CVD; e.g., hypertension), cancer, and other. Specific hazard ratios (sHRs) of death for women compared to men were estimated using competing risk models, with adjustment for factors differing by sex (e.g., age and stroke severity). Age- and sex-specific mortality rates expected in the general population were derived from national data. Standardized mortality ratios (SMRs; observed/expected deaths) were estimated for cause-specific mortality by sex after age standardization. Result(s): Among 9,441 cases (46% women), women were 7 years older than men, had more severe strokes, and received similar patterns of suboptimal secondary prevention medications at discharge. Women had greater mortality associated with stroke (sHRunadjusted 1.65) and other CVD (sHRunadjusted 1.65), which was related to age and stroke severity rather than other factors. Compared to population norms, those surviving to 30 days had eight-fold increased mortality from stroke (primary/recurrent) events irrespective of sex (SMRage-standardised women 8.8; men 8.3). Excess mortality from other CVD was greater in women (SMRage-standardised 3.6 vs. men 2.8; p = 0.026). Conclusion(s): Cause-specific mortality after first-ever stroke differs by sex. The greater death rate attributed to stroke/other CVD in women was mostly explained by age and stroke severity. Greater implementation of secondary stroke prevention is relevant to both sexes.© Copyright 2021, Mary Ann Liebert, Inc., publishers 2021.

Background and aim: We explored sex differences in associations between blood pressure (BP), metabolic markers and smoking in early adulthood with cardiovascular (CV) health in mid-adulthood. Method(s): Participants in the CDAH study at ages 26-36 years were followed-up at ages 39-49 years. Questionnaires measured smoking, while metabolic markers (fasting glucose, insulin, and insulin resistance); systolic and diastolic BP; and CV health (carotid ultrasound for plaques, intima-media thickness [IMT], carotid distensibility [CD]) were measured in clinics.We used log binomial and linear regression models with risk factor*gender interaction predicted CV health. Sex-stratified models adjusted for confounders were fitted when likelihood ratio tests suggested the risk factor*gender interaction was statistically significant. Result(s): Among 1,286 participants (53% women), men more often had carotid plaques (17% vs. 10%), thicker carotid IMT (Mean 0.66+/-0.09 vs. 0.61+/-0.07) and lower CD (Mean 1.87+/-0.60 vs. 2.37 +/-0.77) than women. In women but not men, current smoking (RR men 1.01 95% CI 0.59,1.74; RR women 1.64 95% CI 0.93,2.92; P-interaction=0.133), greater systolic BP (b men -0.006 95% CI -0.012,-0.001; b women -0.016 95% CI -0.023,-0.010; P-interaction=0.029) and higher glucose level (b men 0.019 95% CI -0.100,0.138; b women -0.201 95% CI -0.394,-0.008; P-interaction =0.046) were associated with significantly greater risk of plaques and smaller CD independent of socioeconomic status, behavioural and biomedical risk factors. Conclusion(s): CV health was worse in men than women. However, smoking, elevated systolic BP and glucose in women put them at greater risk of poorer CV health compared to men, which may have implications for stroke prevention.

Background and purpose: Women may receive stroke care less often than men. We examined the contribution of clinical care on sex differences and health-related quality of life (HRQoL) after stroke. Method(s): We included first-ever strokes registered in the Australian Stroke Clinical Registry (2010-2014) with HRQoL assessed between 90 and 180 days after onset (EQ-5D-3L instrument) that were linked to hospital administrative data (up to 2013). Study factors included sociodemographics, comorbidities, walking ability on admission (stroke severity proxy) and clinical care (e.g. stroke unit care). Responses to the EQ-5D-3L were transformed into a total utility value (-0.516 'worse than death' to 1 'best' health). Quantile regression models, adjusted for confounding factors, were used to determine median differences (MD) in utility scores by sex. Result(s): Approximately 60% (6852/11 418) of stroke survivors had an EQ-5D-3L assessment (median 139 days; 44% female). Compared with men, women were older (median age 77.1 years vs. men 71.2 years) and fewer could walk on admission (37.9% vs. men 46.1%, P < 0.001). Women had lower utility values than men, and the difference was explained by age and stroke severity, but not clinical care [MDadjusted = -0.039, 95% confidence interval: -0.056, -0.021]. Poorer HRQoL was observed in younger men (aged <65 years), particularly those with more comorbidities, and in older women (aged >=75 years). Conclusion(s): Stroke severity and comorbidities contribute to the poorer HRQoL in young men and older women. Further studies are needed to understand age-sex interaction to better inform treatments for different subgroups and ensure evidence-based treatments to reduce the severity of stroke are prioritized.Copyright © 2020 European Academy of Neurology

Background: An essential strategy to reduce mortality and disability after stroke is to ensure access to evidence-based care. In developed countries, it has been shown that if hospitals improve the quality of care, the impact of stroke is attenuated. However, in developing countries, data on the processes of care and associated patient outcomes are scarce. We examined the care processes and outcomes among patients with acute stroke from a stroke unit in a major public hospital in Vietnam whereby there are approximately 15,000 hospital admissions for stroke per year. Method(s): We included first-ever strokes admitted to the 115 People's Hospital (June 2017-March 2018). Data were collected in the Registry of Stroke Care Quality which is used in >50 countries. Baseline characteristics, stroke-related factors (e.g., type and severity), processes of care (e.g., thrombolysis), and outcomes at discharge were examined including mortality and functional outcome, assessed as the walking ability without assistance. Result(s): Data were available for 6601 patients with first-ever stroke (44% women, 80% ischemic stroke [IS], median age: 62 years, interquartile range [IQR]: 53-72) who received stroke unit care. The median time from stroke onset to hospital arrival was 15.7 hours (IQR: 5.6-37.5). At admission, the median National Institute of Health Stroke Scale score indicating stroke severity was 7 (IQR: 4-12). Among those with IS, 9% received intravenous thrombolysis. Over 90% of the participants received recommended process of care including dysphasia screening (99%), antihypertensive agents (92%), cholesterol-lowering medication (IS = 99%), and antithrombotic medication (IS = 98%). At discharge (median length of stay: 4 days, IQR: 3-6), 3% of all cases died and 46% were able to walk independently. Advanced age, stroke severity, and not receiving antihypertensive agent(s) were contributing factors to mortality and poorer functional outcome. Conclusion(s): There was a considera

Background and Purpose-Women are reported to have poorer health-related quality of life (HRQoL) after stroke than men, but the underlying reasons are uncertain. We investigated factors contributing to the sex differences. Methods-Individual participant data on 4288 first-ever strokes (1996-2013) were obtained from 4 high-quality population-based incidence studies from Australasia and Europe. HRQoL utility scores among survivors after stroke (range from negative scores=worse than death to 1=perfect health) were calculated from 3 scales including European Quality of Life-5 Dimensions, Short-Form 6-Dimension, and Assessment of Quality of Life at 1 year (3 studies; n=1210) and 5 years (3 studies; n=1057). Quantile regression was used to estimate the median differences in HRQoL for women compared to men with adjustment for covariates. Study factors included sociodemographics, prestroke dependency, stroke-related factors (eg, stroke severity), comorbidities, and poststroke depression. Study-specific median differences were combined into pooled estimates using random-effect meta-analysis. Results-Women had lower pooled HRQoL than men (median differenceunadjusted 1 year,-0.147; 95% CI,-0.258 to-0.036; 5 years,-0.090; 95% CI,-0.119 to-0.062). After adjustment for age, stroke severity, prestroke dependency, and depression, these pooled median differences were attenuated, more greatly at 1 year (-0.067; 95% CI,-0.111 to-0.022) than at 5 years (-0.085; 95% CI,-0.135 to-0.034). Conclusions-Women consistently exhibited poorer HRQoL after stroke than men. This was partly attributable to women's advanced age, more severe strokes, prestroke dependency, and poststroke depression, suggesting targets to reduce the differences. There was some evidence of residual differences in HRQoL between sexes but they were small and unlikely to be clinically significant.Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) disproportionally affects women. The etiology of this is unclear, and the contribution of sex differences in aSAH risk factors is unknown. We aimed to identify sex differences in aSAH risk factors in a systematic review and meta-analysis. Method(s): A systematic search was conducted using the Pubmed, Scopus, Embase, and Medline databases from inception to November 2017 to identify studies that included aSAH risk factors stratified by sex. aSAH risk factors were assessed using meta-analysis with pooled odds ratios (OR) calculated for risk factors with at least 2 studies. Result(s): There were 34 eligible case-control studies; however, 15 did not report sex specific findings with 19 were included. Hypertension (men pooled ORadjusted 3.13 [95% CI 2.26-4.34]; women pooled ORadjusted 3.65 [95% CI 2.87-4.63], p=0.18), smoking (men pooled ORadjusted 2.96 [95% CI 1.68-5.21]; women pooled ORadjusted 3.11 [95% CI 1.21-7.97], p=0.95),family history of aSAH, increased systolic blood pressure, age, angiotensin-converting enzyme gene polymorphism and variation in a protease gene had the same odds for aSAH in both sexes. Alcohol intake (men pooled ORadjusted 1.50 [95% CI 1.04-2.17], women pooled ORadjusted 0.83 [95% CI 0.48-1.45], p=0.003), high alanine aminotransferase levels, and endothelial nitric oxide synthase gene variant were associated with higher odds of aSAH in men than women. Cold temperature, polymorphisms in factor XIII gene and genetic variation on chromosome 9p21 increased the odds of aSAH in women but not men. High aspartate aminotransferase levels were associated with a reduced risk in men while diabetes mellitus decreased the risk in women (men pooled ORadjusted 0.57 [95% CI 0.32- 1.01], women pooled ORadjusted 0.24 [95% CI 0.13-0.43], p=0.017). Conclusion(s): Except for alcohol intake and diabetes mellitus, the magnitude of aSAH risk associated with most common risk factors were similar for both sexes. We adv

Background--Women have worse outcomes after stroke than men, and this may be partly explained by stroke severity. We examined factors contributing to sex differences in severity of acute stroke assessed by the National Institutes of Health Stroke Scale. Methods and Results--We pooled individual participant data with National Institutes of Health Stroke Scale assessment (N=6343) from 8 population-based stroke incidence studies (1996-2014), forming part of INSTRUCT (International Stroke Outcomes Study). Information on sociodemographics, stroke-related clinical factors, comorbidities, and pre-stroke function were obtained. Within each study, relative risk regression using log-binominal modeling was used to estimate the female:male relative risk (RR) of more severe stroke (National Institutes of Health Stroke Scale>7) stratified by stroke type (ischemic stroke and intracerebral hemorrhage). Study-specific unadjusted and adjusted RRs, controlling for confounding variables, were pooled using random-effects meta-analysis. National Institutes of Health Stroke Scale data were recorded in 5326 (96%) of 5570 cases with ischemic stroke and 773 (90%) of 855 participants with intracerebral hemorrhage. The pooled unadjusted female:male RR for severe ischemic stroke was 1.35 (95% CI 1.24-1.46). The sex difference in severity was attenuated after adjustment for age, pre-stroke dependency, and atrial fibrillation but remained statistically significant (pooled RRadjusted 1.20, 95% CI 1.10-1.30). There was no sex difference in severity for intracerebral hemorrhage (RRcrude 1.08, 95% CI 0.97-1.21; RRadjusted 1.08, 95% CI 0.96-1.20). Conclusions--Although women presented with more severe ischemic stroke than men, much although not all of the difference was explained by pre-stroke factors. Sex differences could potentially be ameliorated by strategies to improve pre-stroke health in the elderly, the majority of whom are women. Further research on the potential biological origin of sex dif

Background: Aneurysmal subarachnoid hemorrhage (aSAH) affects women more than men, unlike other stroke types. We completed a systematic review and meta-analysis of risk factors associated with the occurrence of aSAH in women. Method(s): A systematic search was conducted using the Pubmed, Scopus, Embase, and Medline databases from inception to November 2017 to identify studies that included aSAH risk factors among women only or mentioned female sex as a risk factor. The risk factors were assessed using meta-analysis if reported by at least two studies. Result(s): Fourteen studies (10 case-control; 4 cohort) were included. Female sex was associated with higher odds or risk of aSAH in pooled estimates of cohort studies (HRadjusted 1.90, 95% CI 1.47-2.46) but not in case-control studies (ORadjusted 1.44, 95% CI 0.83-2.52). Menarche at an early age (age <12 years HRcrude 1.15 [95% CI 0.52-2.55], age <13 years ORadjusted 3.24 [95% CI 1.25-4.03]), pregnancy at >=26 years (ORadjusted 1.78 [95% CI 1.13-2.80]), use of contraceptive pills (RRcrude range, 5.3-6.5), nulligravidity (ORadjusted 4.23 [95% CI 1.05-7.56]), aSAH predilection area (RRcrude 1.81) and being divorced (RRcrude 1.89) increased the risk for aSAH in women. Parity moderately decreased the risk for aSAH (parity >3 HRcrude 1.21 [95% CI 0.68-2.14], parity=2 ORadjusted 0.87 [95% CI 0.64-1.19], parity >=5, ORadjusted 0.25 [95% CI 0.03-1.89]). Conclusion(s): A number of risk factors, primarily related to reproductive hormones, for aSAH were identified in women. These could be potential causes of higher incidence of aSAH in women compared to men. There is a need for further research focused on aSAH in order to explore the association of these risk factors with aSAH in women.

Introduction: There is some evidence that women receive evidence-based care less often than men, but how this influences long-term mortality after stroke is unclear. We explored this issue using data from a national stroke registry. Material(s) and Method(s): Data are first-ever hospitalized strokes (2010-2014) in the Australian Stroke Clinical Registry from 39 hospitals linked to the national death registrations. Multilevel Poisson regression was used to estimate the women:men mortality rate ratio (MRR), with adjustment for sociodemographics, stroke severity, and processes of care (stroke unit care, intravenous thrombolysis, antihypertensive agent[s], and discharge care plan). Result(s): Among 14,118 events (46% females), women were 7 years older and had greater baseline severity compared to men (29% vs. 37%; p < 0.001), but there were no differences in the four processes of care available across hospitals. In the whole cohort, 1-year mortality was greater in women than men (MRRunadjusted 1.44, 95% confidence interval [CI] 1.34-1.54). However, there were no differences after adjusting for age and stroke severity (MRRadjusted 1.03, 95% CI 0.95-1.10). In analyses of additional processes from Queensland hospitals (n=5224), women were less often administered aspirin <=48 hours (61% vs. men 69%, p < 0.015). In Queensland hospitals, there were no statistically significant sex differences in 1-year mortality after adjusting for age, stroke severity, and early administration of aspirin. Conclusion(s): Greater mortality in women can be explained by differences in age and stroke severity. This highlights the importance of better management of risk factors in the elderly and, potentially, the need for greater access to early aspirin for women with stroke.Copyright © Mary Ann Liebert, Inc., publishers 2019.

Objective: To examine factors contributing to the sex differences in functional outcomes and participation restriction after stroke. Method(s): Individual participant data on long-term functional outcome or participation restriction (i.e., handicap) were obtained from 11 stroke incidence studies (1993-2014). Multivariable log-binomial regression was used to estimate the female:male relative risk (RR) of poor functional outcome (modified Rankin Scale score >2 or Barthel Index score <20) at 1 year (10 studies, n = 4,852) and 5 years (7 studies, n = 2,226). Multivariable linear regression was used to compare the mean difference (MD) in participation restriction by use of the London Handicap Scale (range 0-100 with lower scores indicating poorer outcome) for women compared to men at 5 years (2 studies, n = 617). For each outcome, study-specific estimates adjusted for confounding factors (e.g., sociodemographics, stroke-related factors) were combined with the use of random-effects meta-analysis. Result(s): In unadjusted analyses, women experienced worse functional outcomes after stroke than men (1 year: pooled RRunadjusted 1.32, 95% confidence interval [CI] 1.18-1.48; 5 years: RRunadjusted 1.31, 95% CI 1.16-1.47). However, this difference was greatly attenuated after adjustment for age, prestroke dependency, and stroke severity (1 year: RRadjusted 1.08, 95% CI 0.97-1.20; 5 years: RR adjusted 1.05, 95% CI 0.94-1.18). Women also had greater participation restriction than men (pooled MDunadjusted -5.55, 95% CI -8.47 to -2.63), but this difference was again attenuated after adjustment for the aforementioned factors (MDadjusted -2.48, 95% CI -4.99 to 0.03). Conclusion(s): Worse outcomes after stroke among women were explained mostly by age, stroke severity, and prestroke dependency, suggesting these potential targets to improve the outcomes after stroke in women.Copyright © 2018 American Academy of Neurology.

Introduction: Women appear to experience worse HRQoL after stroke than men. However, women without stroke also report poorer health status than men in all ages. Therefore, it is uncertain whether the sex disparity in HRQoL is caused by stroke or other differences between men and women. Method(s): First-ever strokes admitted to 39 hospitals participating in AuSCR from 2010-2014, had HRQoL assessed at 3-6 months after stroke using EQ-5D-3L and results transformed into utility values for the respondents and among those who died, ranging from -0.516 (worse than death), 0 (death) to 1 (perfect health). Calculated mean EQ5D utility scores for stroke registrants were then stratified by age (<55, 55-64, 65-74 and 75+ years old) and sex. Mean utility (reference) scores of those without stroke in the corresponding age and sex groups were obtained from the South Australian population-based Health Omnibus Survey. We calculated the weighted age-standardized mean difference (MD) scores between those with stroke (AuSCR registrants) and without stroke (population norms), separately for men and women. The difference in weighted MD scores between men and women within the range 0.08-0.12 unit was defined as clinically meaningful. Result(s): After a median follow-up of 139 days, there were 2700 deaths out of 14118 registered cases of stroke. About 60% (6852/11418) of survivors after stroke completed follow-up surveys with EQ5D assessment; 44% being female. In the stroke group, only women aged > 65 years old had significantly lower utility scores than the elderly men of the same age. After standardisation for age, weighted MDs between those with and without stroke were slightly greater for women (MD 0.40 95% CI 0.37, 0.42) compared to men (MD 0.36 95% CI 0.34, 0.38. However, the sex difference in weighted utility scores between those with and without stroke (MD 0.04) was below the clinically meaningful threshold. Conclusion(s): Stroke causes substantial loss of HRQoL in both men and wom

Introduction: Women may receive evidence-based care less often than men after stroke. It is uncertain whether this contributes to sex differences in outcomes. Method(s): We included first-ever strokes admitted to 39 hospitals in the AuSCR during 2010-2014. Mortality 1-year after stroke was obtained from the National Death Index. HRQoL was measured by EQ5D-3L at 3-6 months follow-up. For women compared to men, we estimated the mortality rate ratio (MRR) using multilevel Poisson modelling (accounting for hospital) and the median differences (MD) in HRQoL using quantile regression. Study factors included sociodemographics, stroke type, severity (walking ability on admission) and evidence-based therapies (stroke unit care, thrombolysis, secondary prevention medications, dysphagia screening and mobilisation). Result(s): Data were available for 14,118 strokes (46% women, 81% ischaemic, median age: 75). Women were 7 years older and less able to walk on admission (29% vs 37%, p<0.001) than men. The only difference in evidence-based therapy was that women were less often administered aspirin <=48 hours (51% vs 58%, p=0.014) in a Queensland subset (n=5,224). Mortality was greater in women (MRRcrude 1.45 [95% CI 1.33, 1.59]). Women's lower aspirin administration, advanced age and stroke severity explained the difference (MRRadjusted 1.07 [0.97, 1.17]. About 60% (n=6852) had HRQoL assessments. Only older women compared to older men had poorer EQ5D utility (MD -0.103 [-0.160, -0.047]) independent of severity. The evidence-based care measures did not contribute to the difference. Conclusion(s): Worse outcomes in women were associated with age, severity and aspirin administration suggesting targets to reduce sex differences in outcomes.

Introduction: As women suffer worse functional outcomes of stroke than men, they may also face more challenges with community reintegration but data are scarce. We examined sex differences in participation after stroke and which factors might account for these disparities. Method(s): INSTRUCT is an individual participant data pooling study of incident strokes obtained from 13 population-based cohorts worldwide. Two of the cohorts (Melbourne '96-'99 and Auckland '02-'03) included assessment of participation at 5 years after stroke using the London Handicap Scale (LHS). The LHS is used to assess the individual's perspective of their involvement in life situations including orientation (person's awareness of surroundings), physical independence, mobility, occupation, social interaction and economic self-efficiency. The total score ranges from 0 (worst disadvantage) to 100 (no disadvantage). Linear regression was used to compare LHS total scores and sub-domains for women compared to men. Study-specific multivariable models incorporated adjustment for socio-demographics, stroke-related factors, pre-stroke health and post-stroke factors were combined using random-effects meta-analysis. Result(s): At 5 years after stroke, there were data on participation for 351/592 (59%) of survivors in Melbourne and 266/881 (30%) of survivors in Auckland. Women suffered greater participation restriction than men (total LHS, pooled mean difference, MD-5.55 [95% CI-8.47, 2.63]). The magnitude of the difference attenuated after adjusting for covariates (pooled MD-2.48 [4.99, 0.03]). Significant confounders in study-specific models included age, stroke severity, pre-stroke dependency and pre-stroke dementia for Melbourne; and age, stroke severity and pre-stroke dependency for Auckland. In sub-dimensions, women had greater restriction than men in mobility, physical independence and occupation. Additionally, women in Melbourne experienced poorer social integration and orientation than men. Con

Background - Women are reported to have greater mortality after stroke than men, but the reasons are uncertain. We examined sex differences in mortality at 1 and 5 years after stroke and identified factors contributing to these differences. Methods and Results - Individual participant data for incident strokes were obtained from 13 population-based incidence studies conducted in Europe, Australasia, South America, and the Caribbean between 1987 and 2013. Data on sociodemographics, stroke-related factors, prestroke health, and 1- and 5-year survival were obtained. Poisson modeling was used to estimate the mortality rate ratio (MRR) for women compared with men at 1 year (13 studies) and 5 years (8 studies) after stroke. Study-specific adjusted MRRs were pooled to create a summary estimate using random-effects meta-analysis. Overall, 16 957 participants with first-ever stroke followed up at 1 year and 13 216 followed up to 5 years were included. Crude pooled mortality was greater for women than men at 1 year (MRR 1.35; 95% confidence interval, 1.24-1.47) and 5 years (MRR 1.24; 95% confidence interval, 1.12-1.38). However, these pooled sex differences were reversed after adjustment for confounding factors (1 year MRR, 0.81; 95% confidence interval, 0.72-0.92 and 5-year MRR, 0.76; 95% confidence interval, 0.65-0.89). Confounding factors included age, prestroke functional limitations, stroke severity, and history of atrial fibrillation. Conclusions - Greater mortality in women is mostly because of age but also stroke severity, atrial fibrillation, and prestroke functional limitations. Lower survival after stroke among the elderly is inevitable, but there may be opportunities for intervention, including better access to evidence-based care for cardiovascular and general health.Copyright © 2017 American Heart Association, Inc.

Introduction: Women have been reported to receive evidence-based care less often than men, but it is uncertain whether this contributes to sex differences in outcomes after stroke. We examined this using data obtained from the Australian Stroke Clinical Registry (AuSCR). Method(s): We included first-ever strokes admitted to 40 hospitals participating in the AuSCR during 2010-2013. Mortality one year after stroke was obtained from linkage to the National Death Index. Multilevel Poisson modelling, accounting for hospital, was used to estimate the mortality rate ratio (MRR) for women compared to men. Multivariable models were adjusted for sociodemographics, stroke type, severity (ability to walk on admission) and the provision of evidence-based therapies while in hospital (stroke unit care, thrombolysis, secondary prevention medications, dysphagia screening and mobilization). Result(s): Data were available for 9,549 strokes (47% women, 80% ischaemic stroke). Women, compared to men, were older (mean [SD] 75.0 [15.0] vs 70.3 [13.9], p<0.001) and less able to walk on admission (32% vs 41%, p<0.001). Overall, there were no sex differences in access to evidence-based therapies in hospital, although it appeared that slightly fewer women were admitted to a stroke unit (79% vs 81%, p=0.001). In a subset of patients from Queensland (n=3,013), women were less often mobilised (74% vs 79%, p=0.04) or administered aspirin within 48 hours of stroke onset (66% vs 74%, p<0.001). Mortality was greater in women than men at one year (MRRadjusted 1.42 [95% CI 1.31, 1.55]). This association was attenuated when adjusting for age and severity of stroke (MRRadjusted 1.00 [95% CI 0.92, 1.09] but not by any of the evidence-based therapies. Conclusion(s): Greater mortality in women was associated with differences in age and stroke severity and not differences in access to care. Improvements in care for the elderly and the management of modifiable factors of stroke severity should reduce sex diff

Introduction: It is uncertain why women suffer worse long-term outcomes after stroke than men. We examined sex differences in mortality and disability 1 and 5 years after stroke and identified factors contributing to these differences. Method(s): Individual patient data pooling study of incident strokes (ischemic and hemorrhagic) from 1987-2013 obtained from 12 population-based cohorts from Australasia, Europe, South America and the Caribbean. Data on socio-demographics, stroke-related factors and pre-stroke health were obtained for each patient and harmonized between studies. Poisson modelling estimated the mortality rate ratio (MRR) for women compared to men at 1 year (12 studies) and 5 years (7 studies) post-stroke. Log binomial regression estimated the relative risk (RR) of poor outcome (modified Rankin scale>2 or Barthel Index <20) for women compared to men at 1 year (9 studies) and 5 years (6 studies) after stroke. Multivariable models were adjusted for potential confounders including age, pre-stroke dependency, stroke severity and comorbidities. Result(s): A total of 16557 first-ever-stroke patients with follow-up data to 1 year and 12,839 with follow-up to 5 years were included. The pooled crude mortality was greater in women than men at 1-year (MRR 1.37 95% CI 1.27-1.48) and 5 years (MRR 1.25 95% CI 1.13-1.39). However, these sex differences were reversed after adjustment for confounders at both 1 year (MRR 0.94 95% CI 0.82-1.06) and 5-years post stroke (MRR 0.74 95% CI 0.66-0.84). Similarly, the pooled crude RR for disability after stroke was greater in women than men at 1-year (RR 1.28 95% CI 1.17-1.39 and 5-year (RR 1.32 95% CI 1.18-1.47), but these sex differences disappeared after adjustment at both 1 year (RR 1.08 95%CI 0.98-1.18) and 5-years post stroke (RR 1.08 95% CI 0.97-1.20). The key contributors to worse outcomes in women were greater age, pre-stroke dependency, severe strokes and atrial fibrillation (AF, mortality only) compared with men. Conc

01 maart 2010, Item does not contain fulltext, Lactobacillus plantarum is a ubiquitous microorganism that is able to colonize several ecological niches, including vegetables, meat, dairy substrates and the gastro-intestinal tract. An extensive phenotypic and genomic diversity analysis was conducted to elucidate the molecular basis of the high flexibility and versatility of this species. First, 185 isolates from diverse environments were phenotypically characterized by evaluating their fermentation and growth characteristics. Strains clustered largely together within their particular food niche, but human fecal isolates were scattered throughout the food clusters, suggesting that they originate from the food eaten by the individuals. Based on distinct phenotypic profiles, 24 strains were selected and, together with a further 18 strains from an earlier low-resolution study, their genomic diversity was evaluated by comparative genome hybridization against the reference genome of L. plantarum WCFS1. Over 2000 genes were identified that constitute the core genome of the L. plantarum species, including 121 unique L. plantarum-marker genes that have not been found in other lactic acid bacteria. Over 50 genes unique for the reference strain WCFS1 were identified that were absent in the other L. plantarum strains. Strains of the L. plantarum subspecies argentoratensis were found to lack a common set of 24 genes, organized in seven gene clusters/operons, supporting their classification as a separate subspecies. The results provide a detailed view on phenotypic and genomic diversity of L. plantarum and lead to a better comprehension of niche adaptation and functionality of the organism.