Riina Vibo

The Third Stroke Registry in Tartu, Estonia: Decline of Stroke Incidence and 28-Day Case-Fatality Rate Since 1991

Background and Purpose— The purpose of the present study was to estimate the time trends of stroke during the last 10 years in an Estonian population by comparison of the results from the 2 previous stroke registries from Tartu. Methods— The Third Stroke Registry in Tartu was conducted from January 12, 2001, to November 30, 2003. The previous registry was composed from January 1, 1991, to December 31, 1993. The design of both studies is similar, using the same study criteria and classification schemes. Results— A total of 1280 patients with first-ever stroke were registered during the 5-year study period. The overall incidence rate of 230 per 100 000 declined between the studies to 188 per 100 000 age-standardized to the European standard population. The age-adjusted incidence rate for women decreased from 204 to 164 per 100 000 between the 2 periods. In most of the age groups, the overall case-fatality rates declined during the second period; the trend in the age group 75 to 84 years was statistically significant. Conclusions— The incidence of first-ever stroke in Tartu has declined significantly during the past decade and reached the level of the first registry. The 28-day case-fatality rate has declined from 30% to 26%. The prevalence of cardiovascular risk factors, incidence of stroke, and ischemic heart disease has been high in Eastern European countries. Our data show that the situation has improved.

One‐year outcome after first‐ever stroke according to stroke subtype, severity, risk factors and pre‐stroke treatment. A population‐based study from Tartu, Estonia

The aim of the current study was to evaluate the outcome at 1 year following a first‐ever stroke based on a population‐based registry from 2001 to 2003 in Tartu, Estonia. The outcome of first‐ever stroke was assessed in 433 patients by stroke risk factors, demographic data and stroke severity at onset using the Barthel Index (BI) score and the modified Rankin Score (mRS) at seventh day, 6 months and 1 year. Female sex, older age, blood glucose value >10 mmol/l on admission and more severe stroke on admission were the best predictors of dependency 1 year following the first‐ever stroke. At 1 year, the percentage of functionally dependent patients was 20% and the survival rate was 56%. The use of antihypertensive/antithrombotic medication prior to stroke did not significantly affect the outcome. The survival rate of stroke patients in Tartu is lower compared with other studied populations. The outcome of stroke was mainly determined by the initial severity of stroke and by elevated blood glucose value on admission. Patients with untreated hypertension had more severe stroke and trend for unfavourable outcome compared with those who were on treatment.

Acute phase proteins and oxidised low-density lipoprotein in association with ischemic stroke subtype, severity and outcome.

Objectives: The goal of our study was to investigate the associations of oxidized LDL (apoB100 aldehyde-modified form) and acute phase proteins (fibrinogen, CRP) with acute ischemic stroke severity and outcome. Materials and Methods: The study included 61 ischemic stroke patients and 64 controls. Strokes were subtyped according to TOAST criteria, the severity and outcome of stroke (at 1 year) were measured. Results: The mean triglyceride, fibrinogen, CRP and glucose values were significantly higher among cases. The median oxLDL value for patients with large artery atherosclerosis (LAA) type of stroke was significantly higher than for other subtypes. The oxLDL values did not correlate with age, stroke severity and outcome. Conclusions: Inflammatory markers (fibrinogen and CRP) predicted the stroke severity and outcome whereas elevation of oxLDL levels did not. Our data refer to possibility that there may exist some links between the LAA subtype of stroke and elevated oxLDL (apoB100 aldehyde-modified form).

Sex Differences in Long-Term Mortality After Stroke in the INSTRUCT (INternational STRoke oUtComes sTudy): A Meta-Analysis of Individual Participant Data

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.

The Third Stroke Registry in Tartu, Estonia, from 2001 to 2003

Objectives –  The main goal of the Third Stroke Registry in Tartu was to determine the incidence and 28‐day case‐fatality of first‐ever stroke in an Estonian population.

First-Year Results of the Third Stroke Registry in Tartu, Estonia

Background: The main goal of the Third Stroke Registry in Tartu was to determine the incidence and 28-day case-fatality rates for first-ever stroke in an Estonian population. Methods: The data collection started on 01.12.2001. All patients with first-ever stroke living in Tartu were registered. Results: During the first year, 234 first-ever stroke cases were registered. The incidence rate of first-ever stroke age-standardised to the European population was 195/100,000, 214 (95% CI, 185–243) for men and 181 (95% CI, 155–208) per 100,000 for women. Sixty-eight patients (29%) died within 28 days of stroke onset. Conclusions: The incidence and 28-day case-fatality rate of stroke in Estonia are high compared to other countries. It might be related to higher risk factor prevalence, stress and socioeconomic status.

The Mannheim Declaration of Stroke in Eastern Europe

Accessible online at: www.karger.com/ced Stroke is the most devastating cause of morbidity and mortality in the Eastern European countries. In this region, stroke is more frequent and the victims are younger than in Western Europe. Moreover, the incidence of stroke is significantly higher in social classes with low income, which represents a higher percentage of the Eastern European populations. Stroke is still one of the most important contributors to the mortality gap between East and West. The socioeconomic impact of stroke further weakens the economic development of these societies. The frequency of stroke is partly dependent on modifiable risk factors. In Eastern Europe, relatively more high-risk patients (hypertension + diabetes + smoking) live in worse environmental conditions compared with Western individuals. The positive tendency of decreasing mortality and morbidity could not be seen in the majority of Eastern countries, therefore urgent and efficient steps should be done to improve the situation. To avoid death and permanent disability caused by stroke in Eastern Europe, a specialised action plan has been established. This action plan is based on the Helsingborg Declaration and the 10-Point Action Plan to Tackle Stroke summarised by the European Parliament in June, 2003. The governments of these countries should elaborate a countryspecific programme based on the following elements. 1 Highlight the link between stroke and risk factors to physicians, emergency medical personnel, other health care professionals and the general public by facilitating education programmes. Recognition of symptoms of stroke is the cornerstone of successful stroke management. 2 Health care budgets should be allocated considering stroke prevention and therapy as a priority. 3 In specialised stroke units, widespread application of diagnostic interventions, pharmacological and surgical treatments should be available for all patients with stroke. The prevention and treatment of stroke should be based on the principle of evidence-based medicine. There is a pressing need for further randomised and placebo-controlled trials. 4 Stroke patients should receive an individual, patient-centred rehabilitation treatment carried out by an interdisciplinary team and involving the family. 5 Ensure the timely prevention of stroke by adequately treated modifiable risk factors such as hypertension, diabetes, hyperlipidaemia and atrial fibrillation by helping physicians making their treatment decisions using swiftly adoptable guidelines. 6 Because stroke is an emergency and efficient therapy is possible only in a limited time window, simplify the transport of acute stroke patients from their home to the stroke units and try to shorten the stroke-to-needle time. 7 Persuade people of the importance of changing their lifestyle including smoking, heavy alcohol and calorie intake, lack of physical activity, mental and emotional stress, which are very common, but also modifiable risk factors of stroke in Eastern Europe. 8 Encourage active and establish new patients’ associations. Patient groups play an important role in health policy and are able to coordinate actions to promote better rehabilitation and social support for people with stroke and their families. 9 Set realistic, time-based targets for stroke management and produce population-based monitoring systems covering incidence, prevalence, mortality and disability to provide an Eastern European picture of stroke management. 10 Foundation of an East and West European Stroke Forum to share all information between Western and Eastern European stroke professionals by identifying and disseminating the best practices in stroke prevention and treatment.

Stroke Awareness in Two Estonian Cities: Better Knowledge in Subjects with Advanced Age and Higher Education

Objectives: This study was undertaken to assess stroke awareness of the Estonian population. Methods: Investigators were asked to fill in an original, closed-ended multiple-choice questionnaire about the definition, risk factors, symptoms and behavior at the onset of stroke by randomly selected subjects in public places of the two biggest cities in Estonia (Tallinn and Tartu). Results: The study included 355 persons. Most of the respondents knew that stroke is an acute disease and that one should call the ambulance at the onset of a stroke. Speech disorder and paresis were the best known symptoms, while hypertension was the best known risk factor. There were no differences between the sexes, but advanced age and higher level of education were related to higher awareness. Conclusions: The overall knowledge was better compared to many other studies. Future awareness campaigns should be addressed to younger subjects with lower education.

Acute stroke: why do some patients arrive in time and others do not?

The aim of this study was to evaluate which factors are associated with early hospital arrival and help-seeking delays in acute stroke. All consecutive eligible patients were interviewed face-to-face within 72 h of admission. Factors associated with early arrival were assessed by univariate and multivariate analysis. The data of 195 patients were analysed. The patients who first called the emergency medical services rather than the family physician arrived earlier (odds ratio 15.9, 95% confidence interval 3.23–78.3, P<0.01). Those who contacted the emergency medical services within 30 min of symptom onset were more likely to receive thrombolysis (odds ratio 6.9, 95% confidence interval 2.6–18.4, P<0.01). The most common reasons for delaying seeking help were the hope for spontaneous recovery and perceiving the elapsed time as insignificant. The patients who call their family physician lose valuable time and their chance for thrombolysis. Many patients probably neglect symptoms because of stroke itself and therefore do not act fast enough.

IgG from patients with liver diseases inhibit mitochondrial respiration in permeabilized oxidative muscle cells: impaired function of intracellular energetic units?

The effect of IgG purified from the sera of healthy persons and patients with primary biliary cirrhosis (PBC) and chronic hepatitis (CH) on ADP dependent respiration (oxidative phosphorylation) in skinned muscle fibers from rat oxidative muscles (heart and M. soleus) and glycolytic skeletal muscle (M. gastrocnemius) was studied. The results show that IgG from three different sources inhibited the rate of respiration by 13, 44 and 42%, respectively, these effects being equally expressed in both types of oxidative muscles, whereas no inhibition was observed in glycolytic muscle. The following washout of unbound IgG did not abolish the inhibition of respiration suggesting that the specific interaction of IgG with antigens had taken place. Laser confocal analysis revealed binding of IgG predominantly to the sarcomeric structures such as Z-disk and M-lines in the cardiomyocytes. The staining of IgG within Z-disks and intermitochondrial space coincided throughout the muscle cells so that transversally serial spaces, each containing mitochondria and adjacent sarcomere, became clearly visible. When the IgG from a CH patient was incubated with the skinned myocardial fibers of the desmin knockout mice, its binding to Z-disks and the sarcomeric area was found to be similar to that in normal cardiac muscle. However, the transversal staining pattern was disintegrated, because of the slippage of the myofibrils in relation to each other and accumulation of mitochondria between them. These observations support the recent hypothesis that in oxidative muscles the mitochondria and adjacent sarcomeres form complexes, termed as the intracellular energetic units, ICEUs. Moreover, they indicate that human autoantibodies can be useful tools for localizing the proteins responsible for formation of ICEUs and modulation of their function. Thus, it appears that the proteins associated with the Z-disks and M-lines may participate in formation of ICEUs and that binding of IgG to these proteins decreases the access of exogenous adenine nucleotides to mitochondria, which manifests as decreased rate of ADP-dependent respiration.