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Background: We examined sex differences in cause of death and cause-specific excess mortality after stroke. Materials and Methods: 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. Results: 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). Conclusions: 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.

Introduction and Aim: Internationally, women are underrepresented as leaders in major scientific organizations and conferences. We aimed to determine gender differences in leadership roles and annual scientific conferences of the Stroke Society of Australasia (SSA). Methods: In a retrospective review of SSA data (2014-2019), committee members were obtained through the SSA Web site, and moderators, speakers, and award recipients were identified from SSA annual scientific conference programs. Gender was determined by name inspection and Web search. Absolute numbers and proportions of women and men were recorded for all roles examined, overall and per year. Associations between representation of women in conferences and percentage of women in speaking roles were tested using multinomial regression. Results: Presidential leadership of the SSA was held by men in 2014-2016 and 2019 and women in 2017-2018. SSA committee membership was predominantly women (55%), being lowest (47%) in 2014 and 2019 and highest (65%) in 2017. There was a wide gender variation at scientific conferences, with 41% of keynote speakers being women overall, from 20% in 2016 to 75% in 2015. From 2014 to 2019, 55% of all speakers were women, ranging from 32% (in 2016) to 71% (in 2015). A higher percentage of women as speakers or moderators was associated with a program committee with over a third of its members composed of women (p ≤ 0.044). Conclusions: Representation of women varied from 2014 to 2019 in the SSA organization and its conferences, although men are more often elected president in the organization and women are less often keynote speakers. When more women were included in the program committee, the representation of women as speakers increased.

Backgrounds: Delays in treatment of aSAH appear common but the causes are not well understood. We explored facilitators and barriers to timely treatment of aSAH. Method(s): We used a mixed-methods multiple case-study approach including in-depth interviews with stakeholders involved in individual aSAH cases, focusing on events from onset to treatment. Quantitative data were extracted from medical records including date and times. Within-case analysis identified barriers and facilitators in 4 phases (pre-hospital, presentation, transfer, in-hospital), which were triangulated with the quantified time in each phase to determine significant influencing factors. Finally, we conducted thematic analysis across cases in early (<12h) and delayed (>12h) treatment group using a case-study matrix. Result(s): Twenty-seven cases (74.1% female) with 89 interviewees were included. Median (IQR) time to treatment was 15.1 (9.0, 24.1) hours. Only 37% of cases had treatment within 12 hours of onset. Rigorous mixed-methods data analysis and synthesis allowed identification of key themes influencing timely treatment of aSAH. Early recognition of aSAH at onset and diagnosis, availability of resources for immediate in-hospital treatment, and good coordination across patients' pathway were key facilitators for treatment within 12 hours from onset. Lack of recognition of aSAH at onset and unavailability of resources for definitive treatment were major barriers implicated in delayed treatment. Conclusion(s): We used a new approach to the analysis and synthesis of data from a clinically focused multiple case study. Using a robust mixed-methods approach, we identified the most significant and potentially modifiable factors affecting more timely treatment of aSAH within 12 hours.

BACKGROUND: Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appear to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH. METHOD(S): This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and was registered in PROSPERO (Reg. No. CRD42019132748). We searched four electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment. RESULT(S): A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories-individual (n=9 factors, e.g. age, sex and clinical characteristics) and health system (n=8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up and type of treatment) were less associated wi

Background and Aims: Delays in treatment of aSAH appear common but the causes are not understood. We explored facilitators and barriers to timely treatment of aSAH. Method(s): We used a mixed-methods multiple case study approach including in-depth interviews with stakeholders involved in individual aSAH cases, focusing on events from onset to treatment. Quantitative data were extracted from medical records including date and times. Within-case analysis identified barriers and facilitators in 4 phases (pre-hospital, presentation, transfer, in-hospital), which were then triangulated with the quantified time in each phase to determine significant influencing factors. Finally, we conducted thematic analysis across cases in early (<12h) and delayed (>12h) treatment group using a case-study matrix. Result(s): Twenty-seven cases (74.1% female) with 89 interviewees were included. Median (IQR) time to treatment was 15.1 (9.0, 24.1) hours. Only 37% of cases had treatment within 12 hours of onset. Rigorous mixed-methods data analysis and synthesis allowed identification of key themes influencing timely treatment of aSAH. Early 'recognition of aSAH' at onset and diagnosis, 'availability of resources' for immediate in-hospital treatment, and good 'coordination' across patients' pathway were key facilitators for treatment within 12 hours from onset. Lack of 'recognition of aSAH' at onset and 'unavailability of resources' for definitive treatment were major barriers implicated in delayed treatment. Conclusion(s): We provided a guidance to a new approach to the analysis and synthesis of data from a clinically focused multiple case study. Using a robust mixed-methods approach, we identified the most significant and potentially modifiable factors affecting more timely treatment of aSAH within 12 hours.

Background: Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appear to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH. Method(s): This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and was registered in PROSPERO (Reg. No. CRD42019132748). We searched four electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment. Result(s): A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories - individual (n = 9 factors, e.g. age, sex and clinical characteristics) and health system (n = 8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up and type of treatment) were less associa

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 Aims: Delays in treatment of aSAH appear common but the causes are not well understood. We explored facilitators and barriers to timely treatment of aSAH. Method(s): We used a mixed-methods multiple case study approach including in-depth interviews with stakeholders involved in individual aSAH cases, focusing on events from onset to treatment. Quantitative data were extracted from medical records including date and times. Within-case analysis identified barriers and facilitators in 4 phases (prehospital, presentation, transfer, in-hospital), which then being triangulated with the quantified time in each phase to determine significant influencing factors. Finally, we conducted thematic analysis across cases in early (<12h) and delayed (>12h) treatment group using a case-study matrix. Result(s): Twenty-seven cases (74.1% female) with 89 interviewees were included. Median (IQR) time to treatment was 15.1 (9.0, 24.1) hours. Only 37% of cases had treatment within 12 hours of onset. Qualitative and quantitative data triangulation identified key themes influencing timely treatment of aSAH. Early recognition of aSAH and good coordination during pre-hospital and diagnosis phases, and availability of resources for treatment during in-hospital period were main facilitators for treatment within 12 hours from onset (Figure 1a). Lack of recognition of aSAH at onset and lack of resources for immediate in-hospital treatment were major barriers for more delayed treatment (Figure 1b). Conclusion(s): Using a robust mixed-methods approach, we identified the most significant factors affecting more timely treatment within 12 hours from onset of aSAH. The factors are potentially modifiable at the patient/health professional and health system level and may improve timely treatment of aSAH.

Background and Aims: Limited evidence exists on clinical management and longer-term survival after aneurysmal subarachnoid hemorrhage (aSAH) including sex differences. We aimed to determine sex differences in the association of optimal evidence-based care with survival. Method(s): We established a retrospective cohort (2010-2016) of all consecutive aSAH cases admitted to two comprehensive cerebrovascular centers in Australia. Survival at one year was obtained by linking cases with the National Death Index. We documented 4 indicators of evidence-based aSAH processes of care: (1) imaging (CTwith CTA/DSA), (2) nimodipine, (3) aneurysm treatment (coiling/clipping) and, (4) antihypertensives in subset with systolic blood pressure (SBP) >=150mmHg and, we calculated 'optimal care' (e.g. received all eligible processes of care).We estimated (1) sex differences in processes of care using t-test/chi-square (2) association between processes of care and sex with 1-year mortality using cox-proportional hazard model adjusting for age, severity, co-morbidities and hospital network. Result(s): Among 575 participants (69% women), only 40% of patients received optimal care. There were no sex differences in processes of care. One-year mortality was 28% with no sex difference. Treatment of the aneurysm, receiving nimodipine and antihypertensive and, receiving 'optimal care' was associated with a lesser hazard of death at 12 months with no differences by sex when adjusted for age, comorbidities and hospital network (fig-1). Conclusion(s): Many people with aSAH do not receive evidence-based care, and this lack of optimal care may impact on their survival.

Background And Aims: Aneurysmal subarachnoid haemorrhage (aSAH) is rare but kills >30% of sufferers within 30-days. Rapid access to specialised care improves outcomes but there is limited evidence on the optimal time-to-treatment. We determined the optimal treatment window that maximised 12-month survival and reduced complications. Method(s): Consecutive patients with first-ever aSAH were identified from clinical, administrative, and radiological sources in two comprehensive cerebrovascular referral centres between 2010-2016. Time delay between aSAH symptom onset and treatment, clinical characteristics, treatment characteristics, and post-treatment complications were extracted from medical records, and survival up to 12 months using data linkage. We estimated the effect of treatment delay on (1) 12-month survival using additive Cox proportional hazard regression and (2) post-treatment complications (rebleed, post treatment stroke, delayed cerebral ischaemia, meningitis, seizure and delayed cerebral injury) using logistic regression. Non-linear 'treatment delay' effects on outcomes were investigated using natural cubic splines. Result(s): Among 482 treated cases, we found a non-linear association between the 12-month all-cause mortality hazard ratio and treatment delay, with the lowest hazard estimated for treatment at 12.25 hours post aSAH onset (p<0.05, figure). Upon adjustment for age and severity (World Federation of Neurosurgeons Scale; modified Fisher grade), the effect was attenuated (p=0.07) providing evidence that severity strongly predicts 12-month survival. We were unable to detect a gender or treatment modality effect on the hazard, or an association between treatment delay and complications. Conclusion(s): The optimal time to treatment associated with the least hazard of 12-month mortality is within 12.25 hours, providing potential guidance for clinical practice. (Figure Presented).

Background: There is limited research on the provision of evidence-based care and its association with outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Aim(s): We examined adherence to evidence-based care after aSAH and associations with survival and discharge destination. Also, factors associated with evidence-based care including age, sex, Charlson comorbidity index, severity scores, and delayed cerebral ischemia and infarction were examined for association with survival and discharge destination. Method(s): In a retrospective cohort (2010-2016) of all aSAH cases across two comprehensive cerebrovascular centres, we extracted 3 indicators of evidence-based aSAH care from medical records: (1) antihypertensives prior to aneurysm treatment, (2) nimodipine, and (3) aneurysm treatment (coiling/clipping). We defined 'optimal care' as receiving all eligible processes of care. Survival at 1 year was obtained by data linkage. We estimated (1) proportion of patients and characteristics associated with receiving processes of care, (2) associations between processes of care with 1-year mortality using cox-proportional hazard model and discharge destination with log binomial regression adjusting for age, sex, severity of aSAH, delayed cerebral ischemia and/or cerebral infarction and comorbidities. Sensitivity analyses explored effect modification of the association between processes of care and outcome by management type (active versus comfort measures). Result(s): Among 549 patients (69% women), 59% were managed according to the guidelines. Individual indicators were associated with lower 1-year mortality but not discharge destination. Optimal care reduced mortality at 1 year in univariable (HR 0.24 95% CI 0.17-0.35) and multivariable analyses (HR 0.51 95% CI 0.34-0.77) independent of age, sex, severity, comorbidities, and hospital network. Conclusion(s): Adherence to processes of care reduced 1-year mortality after aSAH. Many patients with aSAH do not receive evidenc

Background and Aims: Small unruptured intracranial aneurysms (SUIAs) are considered to have low risk of rupture. The proportion of SUIAs that rupture by size threshold when managed without repair is not well known. We aimed to determine the proportion of SUIAs that rupture by size threshold, and to determine the level of precision and sources of heterogeneity in the risk estimate. Method(s): The MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials were searched (inception-August 2020). Studies with longitudinal follow-up of patients with SUIAs (<=10 mm) without endovascular or neurosurgical repair were eligible. The primary outcome was synthesised with random-effects meta-analysis; heterogeneity was explored using meta-regression. PROSPERO registration number CRD42019121522. Result(s): Thirty-one studies that included 13800 SUIAs were eligible for data synthesis. The pooled proportion of <=10 mm SUIAs that ruptured when managed without repair was 1.1% (95%CI 0.8-1.5; I2=52.9%) over mean study follow-up of 3.7 years. Rupture occurred in 1.0% [95%CI 0.8-1.3; I2=0%] of 7280 <=5mm SUIAs and 0.8% [95%CI 0.4-1.5; I2=0%] of 1228 <=3mm SUIAs. In higher quality studies with lower risk of bias, rupture occurred in 1.8% (95%CI 1.5-2.0; I2=0%) over 3.9 years. In meta-regression, neither aneurysm size nor exposure to prior subarachnoid haemorrhage was identified as sources of heterogeneity. Conclusion(s): For every 1000 SUIAs selected for conservative management without repair, between 8 to 15 are estimated to rupture over 3.7 years. Pooled rupture risk estimates are consistent and clinically applicable for <=5mm SUIAs selected for management on the basis of size.

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 Aims: The association between some cardiovascular (CV) risk factors and stroke differs between men and women. We explored sex differences in the association between blood pressure (BP), metabolic markers and smoking in early adulthood with carotid plaques, intima-media thickness (IMT) and distensibility (CD) in mid-adulthood. Method(s): Participants in the Childhood Determinants of Adult Health 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 BP and diastolic BP and carotid ultrasound measures (plaques, IMT and CD) were performed in clinics. We used log binomial and linear regression models with risk factor * gender interactions for predicting these carotid measures. Sexstratified models adjusted for sociodemographic factors were fitted when likelihood ratio tests suggested the effect of risk factors on outcomes differed by sex. Result(s): Among 1,286 participants (53% women), men, compared to women, had higher prevalence of 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). In women but not men, current smoking, greater systolic BP and higher glucose level were associated with significantly greater risk of plaques (Figure 1a) and smaller CD (Figure 1b & 1c). Conclusion(s): CV health was worse in men than women. However, the presence of risk factors such as smoking, elevated systolic BP and glucose in women put them at greater risk of poorer CV health compared to men. (Table Presented).

BACKGROUND: Despite earlier declines, maternal smoking during pregnancy continues to be a public health problem. We examined trends and factors associated with maternal smoking during and between pregnancy over six years. METHODS: Participants were 27 532 pregnant women in Tasmanian public hospitals whose smoking status was gathered by midwives during perinatal care between July 2008 and June 2014. Generalized linear modeling was used to examine the trends in prevalence of maternal smoking over time and factors associated with change in smoking status both within and between pregnancies. RESULTS: Smoking during pregnancy decreased from 25.9% in 2008 to 16.4% in 2014 (57.9% decline). Multivariable regression analysis suggested that maternal alcohol consumption during pregnancy, living in a highly socioeconomically disadvantaged area, and being an Aboriginal or Torres Strait Islander significantly increased the risk of maternal smoking during pregnancy. Being older, married, or in a de facto relationship, and intending to breastfeed were associated with reduced risk of smoking during pregnancy. Between index (first birth recorded in data set) and last pregnancy, 35.1% of smokers quit, but 5.1% of nonsmokers started smoking. Only 8.1% of mothers who smoked during the first half of pregnancy quit by the second half. CONCLUSIONS: Maternal smoking during pregnancy is decreasing. To sustain the decline, preventive efforts must address the role of social determinants of health (eg, mothers who drink alcohol, live in highly disadvantaged areas, are younger and single) among women who smoke during pregnancy.

OBJECTIVE: To compare the processes and outcomes of care in patients who had a stroke treated in urban versus rural hospitals in Australia. DESIGN: Observational study using data from a multicentre national registry. SETTING: Data from 50 acute care hospitals in Australia (25 urban, 25 rural) which participated in the Australian Stroke Clinical Registry during the period 2010-2015. PARTICIPANTS: Patients were divided into two groups (urban, rural) according to the Australian Standard Geographical Classification Remoteness Area classification. Data pertaining to 28 115 patients who had a stroke were analysed, of whom 8159 (29%) were admitted to hospitals located within rural areas. PRIMARY AND SECONDARY OUTCOME MEASURES: Regional differences in processes of care (admission to a stroke unit, thrombolysis for ischaemic stroke, discharge on antihypertensive medication and provision of a care plan), and survival analyses up to 180 days and health-related quality of life at 90-180 days. RESULTS: Compared with those admitted to urban hospitals, patients in rural hospitals less often received thrombolysis (urban 12.7% vs rural 7.5%, p<0.001) or received treatment in stroke units (urban 82.2% vs rural 76.5%, p<0.001), and fewer were discharged with a care plan (urban 61.3% vs rural 44.7%, p<0.001). No significant differences were found in terms of survival or overall self-reported quality of life. CONCLUSIONS: Rural access to recommended components of acute stroke care was comparatively poorer; however, this did not appear to impact health outcomes at approximately 6 months.

OBJECTIVES: Life course exposure to passive smoke may predict health, but there are few validated measures. We tested the reliability and validity of a retrospective life course passive smoking questionnaire. METHODS: Participants from the third follow-up of the Childhood Determinants of Adult Health study (2014-2019, ages 36-49 years) retrospectively reported mother/father/other household member smoking when living at home during childhood, including duration (years) and smoking location (never/sometimes/always inside house). The severity of exposure index (SEI; sum of mother/father/other years smoked multiplied by smoking location), cumulative years of exposure (CYE; sum of mother/father/other years), and total household smokers (THS) were derived. The reliability of retrospective passive smoking reports was examined with intraclass correlation coefficients (ICCs) using household smoking reported 34 years earlier in 1985 by participants when aged 7-15 years. Construct validity was examined by correlating retrospective passive smoking with participants' smoking in adulthood and lung function in childhood and adulthood. RESULTS: Among 2082 participants (mean±standard deviation [SD], 45.0±2.5 years; 55.2% females), THS ranged from 0 to 5 (mean± SD, 0.9±1.0), CYE ranged from 0 to 106 (mean±SD, 10.5±13.9), and SEI ranged from 0 to 318 (mean±SD, 24.4±36.0). Retrospective measures showed moderate agreement with total household smokers reported in childhood (ICC, 0.58 to 0.62). The retrospective measures were weakly but significantly (p<0.05) correlated with participants' smoking (r=0.13 to 0.15) and lung function (r= -0.05 to -0.06). CONCLUSIONS: The retrospective passive smoking questionnaire showed reasonable reliability and validity. This measure may be useful for epidemiological studies.