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Background: Women are less likely than men to receive some stroke care interventions. It is not known whether gender differences in patient preferences explain some of the observed variations in stroke care delivery.Methods: Outpatients with and without a history of cerebrovascular disease were recruited from stroke, vascular, and general internal medicine ambulatory clinics between September 2002 and October 2003. Self-administered surveys described hypothetical scenarios, and participants were asked if they would accept therapy with thrombolysis for acute ischemic stroke or carotid endarterectomy for secondary stroke prevention. The surveys also included questions on sociodemographic factors and decision-making preferences.Results: A total of 586 patients (45% women) completed the survey. Women were less likely than men to accept thrombolysis (79% vs. 86%, P=0.014), even after adjustment for other factors (adjusted odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37-0.92). Women and men were equally likely to accept carotid endarterectomy (82% vs. 84%, P=0.502), even after adjustment for other factors (adjusted OR 0.94, 95% CI 0.58- 1.53). Women were less confident in their decisions, were more risk averse, and would have preferred more information to assist them in their decision-making.Conclusions: No gender differences were found in patient preferences for carotid surgery. However, we observed gender differences in patient preferences for thrombolysis and in general attitudes toward stroke care decision-making. Health care providers should be aware that, compared with men, women may be more concerned about risks and may require more information before they make a decision. [ABSTRACT FROM AUTHOR]

In clinical and health services research, clustered data (also known as data with a multilevel or hierarchical structure) are frequently encountered. For example, patients may be clustered or nested within hospitals. Understanding when data have a multilevel structure is important because clustering of individuals can induce a homogeneity in outcomes within clusters, so that, even after adjusting for measured covariates, outcomes for 2 individuals in the same cluster are more likely to be similar than outcomes for 2 individuals from different clusters. Using conventional statistical regression models to analyze clustered data can result in incorrect conclusions being drawn. In particular, estimated CIs may be artificially narrow, and significance levels may be artificially low. As a result, one may conclude that there is a statistically significant association when there is none. To avoid this problem, investigators should ensure that their analyses use techniques that account for clustering of data. Generalized linear models estimated using generalized estimating equation (GEE) methods and multilevel regression models (also known as hierarchical regression models, mixed-effects models, or random-effects models) are two such techniques. We provide an introduction to clustered or multilevel data and describe how GEE models or multilevel models can be used for the analysis of multilevel data.

Background: Neighborhood-level income is inversely associated with cardiovascular events; however, it is uncertain whether this association varies with immigration status., Methods and Results: We conducted a population-based cohort study of 5.2 million (53% women, 19% immigrants) urban-dwelling people aged ≥40 years without a prior history of cardiovascular disease in Ontario, Canada. Neighborhood-level income was measured in quintiles from quintile 1 (lowest) to quintile 5 (highest), and immigrants were defined as those born outside of Canada who moved to Canada after 1985. We estimated the association between neighborhood-level income and the rate of incident cardiovascular events (hospitalization for stroke or myocardial infarction, or cardiovascular death) using multivariable cause-specific hazards models and added an interaction term to see if the association varies by immigration status. The absolute difference in the rate of cardiovascular events across income quintiles was less pronounced in immigrants than in long-term residents: age- and sex-adjusted rate per 1000 person-years in quintile 1 versus quintile 5: 5.69 versus 4.10 in immigrants and 8.37 versus 5.87 in long-term residents. In adjusted models, the interaction between immigration status and neighborhoodl evel was significant ( P interaction <0.001). The hazard of cardiovascular events declined with increasing income among long-term residents (hazard ratio [HR] Q1vsQ5 , 1.46 to HR Q4vsQ5 , 1.10) and immigrants, albeit with a smaller gradient (HR Q1vsQ5 , 1.43 to HR Q4vsQ5 , 1.20)., Conclusions: The association between neighborhood-level income and cardiovascular disease incidence varies by immigration status. Understanding the social and structural factors associated with residing in low-income neighborhoods can help with the development of prevention programs that improve health for all.

Objective: Out-of-hospital mortality rates surged during the early COVID-19 pandemic. While expecting a return to pre-pandemic levels, the evolving patterns of out-of-hospital mortality in Canada remain uncertain. We investigated whether these rates returned to pre-pandemic levels., Methods: This retrospective study, employing linked administrative data, analyzed out-of-hospital mortality trends among adult residents in Ontario, Alberta, and Nova Scotia. Interrupted time series analysis assessed trends in age- and sex-standardized rates/100,000/quarter during pre-pandemic (April 2014-March 2020) and pandemic periods (April 2020-March 2022), while considering April to June 2020 as the pandemic onset period. Crude mortality rates were also examined, stratified by sex and age groups., Results: Pre-pandemic, Ontario's standardized out-of-hospital mortality rates were rising, while Alberta's and Nova Scotia's remained stable. At the pandemic onset, all provinces experienced significant increases in standardized out-of-hospital mortality rates/100,000 (Ontario: β 14.6, 95% CI [3.97, 25.22]; Alberta: 21.3, 95% CI [9.26, 33.34]; Nova Scotia: 10.5, 95% CI [1.06, 19.88]). During the pandemic, standardized out-of-hospital mortality rates/100,000/quarter remained above pre-pandemic levels, with no significant departure from the increased pandemic onset levels (Ontario: - 1.6, 95% CI [- 3.63, 0.52]; Alberta: 0.45, 95% CI [- 1.47, 2.36]; Nova Scotia: - 0.06, 95% CI [- 2.18, 2.06]). Crude out-of-hospital mortality rates increased most prominently among individuals aged 18 to 45 in Alberta and Ontario, and among males across all provinces., Conclusion: The sustained increase in out-of-hospital mortality, observed from the pandemic's onset, spanning more than 2 years, potentially suggests its persistent direct and indirect effects on population health in Canada., (© 2024. The Author(s) under exclusive license to The Canadian Public Health Association.)

Cerebral amyloid angiopathy (CAA) is a progressive cerebrovascular and neurodegenerative disorder that is caused by the aberrant accumulation of soluble beta-amyloid isoforms in the small vessel walls of the cerebral and cerebellar cortices and the leptomeninges. Vascular beta-amyloid deposition increases vulnerability to intracerebral hemorrhage (ICH). Clinically, CAA can be the underlying cause of up to half of spontaneous lobar ICHs and can also present with convexity subarachnoid hemorrhage, transient focal neurologic episodes and progressive cognitive decline leading to dementia. The majority of CAA is sporadic, with increasing prevalence with age and often coexists with Alzheimer's Disease (AD). Genetic and iatrogenic etiologies are rare. Cases of CAA and AD have been linked to the use of cadaveric pituitary hormone and later life iatrogenic CAA has also been described following early-life neurosurgical procedures with cadaveric dura grafts. Together these data suggest a capacity of beta-amyloid transmissibility. A recent study found that in over 1 million transfusion recipients from donors who later developed (i) >1 ICH or (ii) one ICH event and dementia, had an elevated risk of developing future ICH. Considering prior reports of transfusion associated variant-Creutzfeldt Jakob Disease in humans and in vivo evidence in sheep, coupled with emerging data supporting beta-amyloid's prion-like properties, raises the question of whether CAA could be transmissible by blood transfusion. This would also have implications for screening, especially in an era of emerging plasma biomarkers of cerebral amyloidosis. Given the public health concerns raised by this biologically plausible question, there is a need for future studies with well-characterized definitions - and temporal ascertainment - of CAA exposure and outcomes to examine whether CAA is transfusion-transmissible, and, if so, with what frequency and timing of onset., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ryan T. Muir: No conflicting interest to report. Jeannie L. Callum: No conflicting interest to report. Amy Y.X Yu: No conflicting interest to report. Moira K. Kapral: No conflicting interest to report. Richard H. Swartz: Acknowledges salary support for research from Sunnybrook Department of Medicine and the Bastable-Potts Chair in stroke research. Sandra E. Black: Reports remuneration for consultation on anti-amyloid immunotherapies for Roche, Biogen, Eisai and Eli Lilly. Bradley J. MacIntosh: No conflicting interest to report. Dean A. Fergusson: No conflicting interest to report. Steven Kleinman: No conflicting interest to report. Andrew D. Demchuk: Under Dr. Demchuk's direction his institution has received funding to perform core laboratory volumetrics for intracerebral hemorrhage research supported by Astra Zeneca, Sense Neuro Diagnostics and SFJ Pharmaceuticals. Dr. Demchuk has received honoraria for consulting and for CME lectures from Astra Zeneca regarding reversal of anticoagulation in intracerebral hemorrhage. Peter K. Stys: No conflicting interest to report. Eric E. Smith: Reports unpaid consulting for Alnylam Pharmaceuticals, Eisai, and Eli Lilly. Michael D. Hill: President, Canadian Neurological Sciences Federation (not-for-profit sector), (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: People with schizophrenia are less likely than those without to be treated for cardiovascular disease. We aimed to evaluate the association between schizophrenia and secondary preventive care after ischemic stroke., Methods and Results: In this retrospective cohort study, we used linked population-based administrative data to identify adults who survived 1 year after ischemic stroke hospitalization in Ontario, Canada between 2004 and 2017. Outcomes were screening, treatment, and control of risk factors, and receipt of outpatient physician services. We used modified Poisson regression to model the relative risk of each outcome among people with and without schizophrenia, adjusting for age and other factors. Among 81 163 people with ischemic stroke, 844 (1.04%) had schizophrenia. Schizophrenia was associated with lower rates of screening for hyperlipidemia (60.5% versus 66.0%, adjusted relative risk [aRR] 0.88 [95% CI, 0.84-0.93]) and diabetes (69.4% versus 73.9%, aRR 0.93 [95% CI, 0.89-0.97]), prescription of antihypertensive medications (91.2% versus 94.7%, aRR 0.96 [95% CI, 0.93-0.99]), achievement of target lipid levels (low-density lipoprotein <2 mmol/L) (30.6% versus 34.6%, aRR 0.86 [95% CI, 0.78-0.96]), and outpatient specialist visits (55.3% versus 67.8%, aRR 0.78 [95% CI, 0.74-0.83]) or primary care physician visits (94.5% versus 98.5%; aRR 0.96 [95% CI, 0.95-0.98]) within 1 year. There were no differences in prescription of antilipemic, antiglycemic, or anticoagulant medications, or in achievement of target hemoglobin A1c ≤7%., Conclusions: People with stroke and schizophrenia are less likely than those without to receive secondary preventive care. This may inform interventions to improve poststroke care and outcomes in those with schizophrenia.

Background: Understanding seasonal variations in stroke can help stakeholders identify underlying causes in seasonal trends, and tailor resources appropriately to times of highest needs. We sought to evaluate the seasonal occurrence of stroke and its subtypes., Methods: We conducted a retrospective cohort study using administrative data from January 1st, 2003, to December 31st, 2017, in Ontario, Canada's most populous province. We evaluated seasonal variations in stroke occurrence by subtype, via age/sex standardized rates and adjusted rate ratios using Poisson regressions. In those with stroke, we evaluated 30-day case fatality risks by season, adjusted for age, sex, stroke type, and comorbid conditions, and then used Cox proportional hazard models to estimate the effect of season on the fatality. The administrative data used in this study were from the Canadian Institute for Health Information's Discharge Abstract Database, the National Ambulatory Care Reporting System Database, the Ontario Registered Persons Database, and the 2006 and 2011 Canada Census and linked administrative databases., Results: During our study period, we observed 394,145 strokes or TIA events, with a decrease in monthly hospitalization/emergency department visits per 100,000 people between January 2003 and December 2017 from 24.22 to 17.43. Compared to the summer, overall stroke occurrence was similar in the spring but slightly lower in the fall (adjusted rate ratio [aRR] 0.97, 95% confidence interval [CI] 0.96-0.98) and winter (aRR 0.94, 95% CI: 0.94-0.95). There were minor variations by stroke subtype. Winter was associated with the highest risk of stroke case fatality compared to the summer (12.4% vs. 11.4%, adjusted hazard ratio 1.10, 95% CI: 1.07-1.13)., Conclusions: We found seasonal variations in stroke occurrence and case fatality, although the absolute differences were small. Further work is needed to better understand how environmental or meteorological factors might affect stroke risk., (© 2024 S. Karger AG, Basel.)

Background and Objectives: Secondary stroke preventive care includes evaluation and control of vascular risk factors to prevent stroke recurrence. Our objective was to evaluate the quality of ambulatory stroke preventive care and its variation by immigration status in adult stroke survivors in Ontario, Canada., Methods: We conducted a population-based administrative database-derived retrospective cohort study in Ontario, Canada. Using immigration records, we defined immigrants as those immigrating after 1985 and long-term residents as those arriving before 1985 or those born in Canada. We included community-dwelling stroke survivors 40 years and older with a first-ever stroke between 2011 and 2017. In the year following their stroke, we evaluated the following metrics of stroke prevention: testing for hyperlipidemia and diabetes; among those with the condition, control of diabetes (hemoglobin A1c ≤7%) and hyperlipidemia (low-density lipoprotein <2 mmol/L); medication use to control hypertension, diabetes, and atrial fibrillation; and visit to a family physician and a specialist (neurologist, cardiologist, or geriatrician). We determined age and sex-adjusted absolute prevalence difference (APD) between immigrants and long-term residents for each metric using generalized linear models with binomial distribution and an identity link function., Results: We included 34,947 stroke survivors (median age 70 years, 46.9% women) of whom 12.4% were immigrants. The receipt of each metric ranged from 68% to 90%. Compared with long-term residents, after adjusting for age and sex, immigrants were slightly more likely to receive screening for hyperlipidemia (APD 5.58%; 95% CI 4.18-6.96) and diabetes (5.49%; 3.76-7.23), have visits to family physicians (1.19%; 0.49-1.90), receive a prescription for antihypertensive (3.12%; 1.76-4.49) and antihyperglycemic medications (9.51%; 6.46-12.57), and achieve control of hyperlipidemia (3.82%; 1.01-6.63). By contrast, they were less likely to achieve diabetes control (-4.79%; -7.86 to -1.72) or have visits to a specialist (-1.68%; -3.12 to -0.24). There was minimal variation by region of origin or time since immigration in immigrants., Discussion: Compared with long-term residents, many metrics of secondary stroke preventive care were better in immigrants, albeit with small absolute differences. However, future work is needed to identify and mitigate the factors associated with the suboptimal quality of stroke preventive care for all stroke survivors.

Background and Objectives: Home-time is a patient-prioritized stroke outcome that can be derived from administrative data linkages. The effect of faster time-to-treatment with endovascular thrombectomy (EVT) on home-time after acute stroke is unknown., Methods: We used the Quality Improvement and Clinical Research registry to identify a cohort of patients who received EVT for acute ischemic stroke between 2015 and 2022 in Alberta, Canada. We calculated days at home in the first 90 days after stroke. We used ordinal regression across 6 ordered categories of home-time to evaluate the association between onset-to-arterial puncture and higher home-time, adjusting for age, sex, rural residence, NIH Stroke Scale, comorbidities, intravenous thrombolysis, and year of treatment. We used restricted cubic splines to assess the nonlinear relationship between continuous variation in time metrics and higher home-time, and also reported the adjusted odds ratios within time categories. We additionally evaluated door-to-puncture and reperfusion times. Finally, we analyzed home-time with zero-inflated models to determine the minutes of earlier treatment required to gain 1 day of home-time., Results: We had 1,885 individuals in our final analytic sample. There was a nonlinear increase in home-time with faster treatment when EVT was within 4 hours of stroke onset or 2 hours of hospital arrival. There was a higher odds of achieving more days at home when onset-to-puncture time was <2 hours (adjusted odds ratio 2.36, 95% CI 1.77-3.16) and 2 to <4 hours (1.37, 95% CI 1.11-1.71) compared with ≥6 hours, and when door-to-puncture time was <1 hour (aOR 2.25, 95% CI 1.74-2.90), 1 to <1.5 hours (aOR 1.89, 95% CI 1.47-2.41), and 1.5 to <2 hours (1.35, 95% CI 1.04-1.76) compared with ≥2 hours. Results were consistent for reperfusion times. For every hour of faster treatment within 6 hours of stroke onset, there was an estimated increase in home-time of 4.7 days, meaning that approximately 1 day of home-time was gained for each 12.8 minutes of faster treatment., Discussion: Faster time-to-treatment with EVT for acute stroke was associated with greater home-time, particularly within 4 hours of onset-to-puncture and 2 hours of door-to-puncture time. Within 6 hours of stroke onset, each 13 minutes of faster treatment is associated with a gain of 1 day of home-time.

Background: Health care teams along the stroke recovery continuum have a responsibility to support care transitions and return to the community. Ideally, individualized care will consider patient and family preferences, best available evidence, and health care professional input. Person-centered care can improve patient-practitioner interactions through shared decision-making in which health professionals and institutions are sensitive to those for whom they provide care. However, it is unclear how the concepts of person-centered care have been described in reports of stroke transitional care interventions., Methods: A secondary analysis of a systematic review and meta-analysis was undertaken. We retrieved all included articles (n=17) and evaluated the extent to which each intervention explicitly addressed 7 domains of person-centered care: alignment of care with patients' values, preferences, and needs; coordination of care; information and education; physical comfort; emotional support; family and friend involvement; and smooth transition and continuity of care., Results: Most of the articles included some aspects of person-centeredness; we found that certain domains were not addressed in the descriptions of transitional care interventions, and no articles mentioned all 7 domains of person-centered care. We identified 3 implications for practice and research: (1) delineating person-centered care components when reporting interventions, (2) elucidating social and cultural factors relevant to the study sample and intervention, and (3) clearly describing the role of family and nonmedical support in the intervention., Conclusions: There is still room for greater consistency in the reporting of person-centeredness in stroke transitions of care interventions, despite a long-standing definition and conceptualization of person-centered care in academic and clinically focused literature.

Background: Risk of recurrence after minor ischemic stroke is usually reported with transient ischemic attack. No previous meta-analysis has focused on minor ischemic stroke alone. The objective was to evaluate the pooled proportion of 90-day stroke recurrence for minor ischemic stroke, defined as a National Institutes of Health Stroke Scale severity score of ≤5., Methods and Results: Published papers found on PubMed from 2000 to January 12, 2021, reference lists of relevant articles, and experts in the field were involved in identifying relevant studies. Randomized controlled trials and observational studies describing minor stroke cohort with reported 90-day stroke recurrence were selected by 2 independent reviewers. Altogether 14 of 432 (3.2%) studies met inclusion criteria. Multilevel random-effects meta-analysis was performed. A total of 6 randomized controlled trials and 8 observational studies totaling 45 462 patients were included. The pooled 90-day stroke recurrence was 8.6% (95% CI, 6.5-10.7), reducing by 0.60% (95% CI, 0.09-1.1;  P =0.02) with each subsequent year of publication. Recurrence was lowest in dual antiplatelet trial arms (6.3%, 95% CI, 4.5-8.0) when compared with non-dual antiplatelet trial arms (7.2%, 95% CI, 4.7-9.6) and observational studies 10.6% (95% CI, 7.0-14.2). Age, hypertension, diabetes, ischemic heart disease, or known atrial fibrillation had no significant association with outcome. Defining minor stroke with a lower National Institutes of Health Stroke Scale threshold made no difference - score ≤3: 8.6% (95% CI, 6.0-11.1), score ≤4: 8.4% (95% CI, 6.1-10.6), as did excluding studies with n<500%-7.3% (95% CI, 5.5-9.0)., Conclusions: The risk of recurrence after minor ischemic stroke is declining over time but remains important.