Publications by authors named "Priya Parmar"

43 Publications

Impact and predictors of quality of life in adults diagnosed with a genetic muscle disorder: a nationwide population-based study.

Qual Life Res 2021 Nov 27. Epub 2021 Nov 27.

Neurology Department, Auckland City Hospital, Auckland, New Zealand.

Objectives: To determine the impact of genetic muscle disorders and identify the sociodemographic, illness, and symptom factors influencing quality of life.

Methods: Adults (aged 16-90 years) with a confirmed clinical or molecular diagnosis of a genetic muscle disorder identified as part of a nationwide prevalence study were invited to complete an assessment of the impact of their condition. Quality of life was measured using the World Health Organization Quality of Life questionnaire. Impact was measured via the prevalence of symptoms and comparisons of quality of life against New Zealand norms. Multivariate regression models were used to identify the most significant predictors of quality of life domains.

Results: 490/596 participants completed the assessment (82.2% consent rate). Quality of life was lower than the general population on physical (t = 9.37 p < 0.0001, d = 0.54) social (t = 2.27 p = 0.02, d = 0.13) and environmental domains (t = 2.28 p = 0.02, d = 0.13), although effect sizes were small. No difference was found on the psychological domain (t = - 1.17 p = 0.24, d = 0.07). Multivariate regression models (predicting 42%-64% of the variance) revealed personal factors (younger age, being in employment and in a relationship), symptoms (lower pain, fatigue, and sleep difficulties), physical health (no need for ventilation support, fewer activity limitations and no comorbidities), and psychosocial factors (lower depression, anxiety, behavioural dyscontrol and higher self-efficacy, satisfaction with health care and social support) contributed to improved quality of life.

Conclusions: A range of factors influence the quality of life in adults diagnosed with a genetic muscle disorder and some may serve as targets for multi-faceted intervention.
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http://dx.doi.org/10.1007/s11136-021-03046-2DOI Listing
November 2021

Case-Fatality and Functional Outcome after Subarachnoid Hemorrhage (SAH) in INternational STRoke oUtComes sTudy (INSTRUCT).

J Stroke Cerebrovasc Dis 2022 Jan 15;31(1):106201. Epub 2021 Nov 15.

Clinical Research Development Unit, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.

Background: There are few large population-based studies of outcomes after subarachnoid hemorrhage (SAH) than other stroke types.

Methods: 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.

Results: 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: 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.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106201DOI Listing
January 2022

Which demographic factors influence Pacific women's attendance at colposcopy clinics in New Zealand?

N Z Med J 2021 10 8;134(1543):69-78. Epub 2021 Oct 8.

Emeritus Professor of Pacific Studies, Auckland University of Technology.

Aim: The aim of this study was to examine the demographic factors associated with attendance at colposcopy clinics among Pacific women following a high-grade cytology in New Zealand.

Methods: A retrospective cohort study was undertaken of Pacific women following high-grade cytology between January 2010 and December 2015. Univariate and multivariate binary logistic regression was undertaken to assess whether socioeconomic deprivation, age and Pacific ethnicity were associated with colposcopy attendance.

Results: Colposcopy attendance for Pacific women was 84.9% at 90 days and 93.5% at 180 days following referral. Pacific women residing in the most deprived areas were less likely to attend at both 90 days (OR=0.37 95% CI: 0.21-0.67) and 180 days (OR=0.19 95% CI: 0.60-0.63). Older women were more likely to attend their colposcopy appointment at 90 days when compared to the reference group aged <24-years-old. There was no association between Pacific ethnicity and attendance when adjusting for deprivation and age.

Conclusions: The overall attendance rates for Pacific women were higher than expected. Despite Pacific women engaging with cervical screening, Pacific women living in the most deprived areas were less likely to be seen by colposcopy services following a high-grade cytology. Targeted interventions are required to improve service utilisation and reduce health inequities.
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October 2021

Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses.

Womens Health Rep (New Rochelle) 2020 30;1(1):190-202. Epub 2020 Jun 30.

Menzies Institute for Medical Research Tasmania, University of Tasmania, Hobart, Australia.

To examine sex differences in disease profiles, management, and survival at 1 and 5 years after ischemic stroke (IS) among people with atrial fibrillation (AF). We performed a systematic literature search of reports of AF at IS onset according to sex. We undertook an individual participant data meta-analysis (IPDMA) of nine population-based stroke incidence studies conducted in Australasia, Europe, and South America (1993-2014). Poisson regression was used to estimate women:men mortality rate ratios (MRRs). Study-specific MRRs were combined using random effects meta-analysis. In our meta-analysis based on aggregated data from 101 studies, the pooled AF prevalence was 23% (95% confidence interval [CI]: 22%-25%) in women and 17% (15%-18%) in men. Our IPDMA is of 1,862 IS-AF cases, with women (79.2 ± 9.1, years) being older than men (76.5 ± 9.5, years). Crude pooled mortality rate was greater for women than for men (1-year MRR 1.24; 1.01-1.51; 5-year 1.12; 1.03-1.22). However, the sex difference was greatly attenuated after accounting for age, prestroke function, and stroke severity (1-year 1.09; 0.97-1.22; 5-year 0.98; 0.84-1.16). Women were less likely to have anticoagulant prescription at discharge (odds ratio [OR] 0.94; 95% CI: 0.89-0.98) than men when pooling IPDMA and aggregated data. AF was more prevalent after IS among women than among men. Among IS-AF cases, women were less likely to receive anticoagulant agents at discharge; however, greater mortality rate in women was mostly attributable to prestroke factors. Further information needs to be collected in population-based studies to understand the reasons for lower treatment of AF in women.
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http://dx.doi.org/10.1089/whr.2020.0029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784810PMC
June 2020

New avenue for the geriatric depression scale: Rasch transformation enhances reliability of assessment.

J Affect Disord 2020 03 22;264:7-14. Epub 2019 Nov 22.

Faculty of Health & Environmental Sciences, National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand.

Background: Depression is a common problem in older adults. The 15-item Geriatric Depression Scale (GDS-15) is a widely used psychometric tool for measuring depression in the elderly, but its psychometric properties have not been yet rigorously investigated. The aim was to evaluate psychometric properties of the GDS-15 and improve precision of the instrument by applying Rasch analysis and deriving conversion tables for transformation of raw scores into interval level data.

Methods: The data was extracted from the prospective cohort Sydney Memory and Ageing Study of initially not demented individuals aged 70 years and older. The GDS-15 items scores of 212 participants (47.2% males) were analysed using the dichotomous Rasch model.

Results: Initially poor reliability of the GDS-15, Person Separation Index (PSI) = 0.68, was improved by combining locally dependent items into seven super-items. These modifications improved reliability of the GDS-15 (PSI = 0.78) and resulted in the best Rasch model fit (χ(28)=37.72, p = =0.104), strict unidimensionality and scale invariance across personal factors such as gender, diagnostic and language background.

Limitations: Presence of participants with cognitive impairment may be a potential limitation.

Conclusions: Reliability and psychometric characteristics of the GDS-15 were improved by minor modifications and now satisfy expectations of the unidimensional Rasch model. By using Rasch transformation tables published here psychiatrists, psychologists and researchers can transform GDS raw scores into interval-level data, which improves reliability of the GDS-15 without the need to modify its original response format. These findings increase accuracy of clinical psychometric assessments, leading to more precise diagnosis of depression in the elderly.
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http://dx.doi.org/10.1016/j.jad.2019.11.100DOI Listing
March 2020

The global burden of neurological disorders: translating evidence into policy.

Lancet Neurol 2020 03 5;19(3):255-265. Epub 2019 Dec 5.

Institute for Health Metrics Evaluation, University of Washington, Seattle, WA, USA.

Neurological disorders are the leading cause of disability and the second leading cause of death worldwide. In the past 30 years, the absolute numbers of deaths and people with disabilities owing to neurological diseases have risen substantially, particularly in low-income and middle-income countries, and further increases are expected globally as a result of population growth and ageing. This rise in absolute numbers of people affected suggests that advances in prevention and management of major neurological disorders are not sufficiently effective to counter global demographic changes. Urgent measures to reduce this burden are therefore needed. Because resources for health care and research are already overstretched, priorities need to be set to guide policy makers, governments, and funding organisations to develop and implement action plans for prevention, health care, and research to tackle the growing challenge of neurological disorders.
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http://dx.doi.org/10.1016/S1474-4422(19)30411-9DOI Listing
March 2020

Measuring stroke and transient ischemic attack burden in New Zealand: Protocol for the fifth Auckland Regional Community Stroke Study (ARCOS V).

Int J Stroke 2020 07 24;15(5):573-583. Epub 2019 Oct 24.

Centre for Public Health Research, Massey University, Wellington, New Zealand.

The goal of this paper is to provide a protocol for conducting a fifth population-based Auckland Regional Community Stroke study (ARCOS V) in New Zealand. : In this study, for the first time globally, (1) stroke and TIA burden will be determined using the currently used clinical and tissue-based definition of stroke, in addition to the WHO clinical classifications of stroke used in all previous ARCOS studies, as well as more advanced criteria recently suggested for an "ideal" population-based stroke incidence and outcomes study; and (2) age, sex, and ethnic-specific trends in stroke incidence and outcomes will be determined over the last four decades, including changes in the incidence of acute cerebrovascular events over the last decade. Furthermore, information at four time points over a 40-year period will allow the assessment of effects of recent changes such as implementation of the FAST campaign, ambulance pre-notification, and endovascular treatment. This will enable more accurate projections for health service planning and delivery. The methods of this study will provide a foundation for future similar population-based studies in other countries and populations.
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http://dx.doi.org/10.1177/1747493019884528DOI Listing
July 2020

Sex Differences in Long-Term Quality of Life Among Survivors After Stroke in the INSTRUCT.

Stroke 2019 09 15;50(9):2299-2306. Epub 2019 Aug 15.

From the Menzies Institute for Medical Research Tasmania, University of Tasmania, Hobart, Australia (H.T.P., C.L.B., P.O., S.G.).

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 difference 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.
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http://dx.doi.org/10.1161/STROKEAHA.118.024437DOI Listing
September 2019

Status epilepticus in Auckland, New Zealand: Incidence, etiology, and outcomes.

Epilepsia 2019 08 1;60(8):1552-1564. Epub 2019 Jul 1.

National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand.

Objective: To determine the incidence, etiology, and outcome of status epilepticus (SE) in Auckland, New Zealand, using the latest International League Against Epilepsy (ILAE) SE semiological classification.

Methods: We prospectively identified patients presenting to the public or major private hospitals in Auckland (population = 1.61 million) between April 6, 2015 and April 5, 2016 with a seizure lasting 10 minutes or longer, with retrospective review to confirm completeness of data capture. Information was recorded in the EpiNet database.

Results: A total of 477 episodes of SE occurred in 367 patients. Fifty-one percent of patients were aged <15 years. SE with prominent motor symptoms comprised 81% of episodes (387/477). Eighty-four episodes (18%) were nonconvulsive SE. Four hundred fifty episodes occurred in 345 patients who were resident in Auckland. The age-adjusted incidence of 10-minute SE episodes and patients was 29.25 (95% confidence interval [CI] = 27.34-31.27) and 22.22 (95% CI = 20.57-23.99)/100 000/year, respectively. SE lasted 30 minutes or longer in 250 (56%) episodes; age-adjusted incidence was 15.95 (95% CI = 14.56-17.45) SE episodes/100 000/year and 12.92 (95% CI = 11.67-14.27) patients/100 000/year. Age-adjusted incidence (10-minute SE) was 25.54 (95% CI = 23.06-28.24) patients/100 000/year for males and 19.07 (95% CI = 16.91-21.46) patients/100 000/year for females. The age-adjusted incidence of 10-minute SE was higher in Māori (29.31 [95% CI = 23.52-37.14]/100 000/year) and Pacific Islanders (26.55 [95% CI = 22.05-31.99]/100 000/year) than in patients of European (19.13 [95% CI = 17.09-21.37]/100 000/year) or Asian/other descent (17.76 [95% CI = 14.73-21.38]/100 000/year). Seventeen of 367 patients in the study died within 30 days of the episode of SE; 30-day mortality was 4.6%.

Significance: In this population-based study, incidence and mortality of SE in Auckland lie in the lower range when compared to North America and Europe. For pragmatic reasons, we only included convulsive SE if episodes lasted 10 minutes or longer, although the 2015 ILAE SE classification was otherwise practical and easy to use.
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http://dx.doi.org/10.1111/epi.16277DOI Listing
August 2019

Prevalence of Charcot-Marie-Tooth disease across the lifespan: a population-based epidemiological study.

BMJ Open 2019 06 14;9(6):e029240. Epub 2019 Jun 14.

Auckland City Hospital, Auckland, New Zealand.

Objectives: This population-based study aimed to determine age-standardised prevalence of Charcot-Marie-Tooth disease (CMT) across the lifespan using multiple case ascertainment sources.

Design: Point-prevalence epidemiological study in the Auckland Region of New Zealand (NZ).

Setting: Multiple case ascertainment sources including primary care centres, hospital services, neuromuscular disease registry, community-based organisations and self-referral were used to identify potentially eligible participants.

Participants: Adults (≥16 years, n=207, 87.7%) and children (<16 years, n=29, 12.3%) with a confirmed clinical or molecular diagnosis of CMT, hereditary sensory neuropathy, hereditary motor neuropathy or hereditary neuropathy with liability to pressure palsies who resided in the Auckland Region of NZ on 1 June 2016.

Primary Outcome: Prevalence per 100 000 persons with 95% CIs by subtype, age and sex were calculated and standardised to the world population.

Results: Age-standardised point prevalence of all CMT cases was 15.7 per 100 000 (95% CI 11.6 to 21.0). Highest prevalence was identified in those aged 50-64 years 25.2 per 100 000 (95% CI 19.4 to 32.6). Males had a higher prevalence (16.6 per 100 000, 95% CI 10.9 to 25.2) than females (14.6 per 100 000, 95% CI 9.6 to 22.4). Prevalence of CMT1A was 6.9 per 100 000 (95% CI 5.6 to 8.4). The majority (93.2%) of cases were identified through medical records, with 6.8% of cases uniquely identified through community sources.

Conclusions: A small but significant proportion of people with CMT are not connected to healthcare services. Epidemiological studies using medical records alone to identify cases may risk underestimating prevalence. Further studies using population-based methods and reporting age-standardised prevalence are needed to improve global understanding of the epidemiology of CMT.
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http://dx.doi.org/10.1136/bmjopen-2019-029240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585838PMC
June 2019

Who will redislocate his/her shoulder? Predicting recurrent instability following a first traumatic anterior shoulder dislocation.

BMJ Open Sport Exerc Med 2019 7;5(1):e000447. Epub 2019 Mar 7.

School of Health Sciences, University of Brighton, Brighton, UK.

Objective: To develop a multivariate tool that would predict recurrent instability after a first-time traumatic anterior shoulder dislocation.

Methods: Participants (aged 16-40 years) were recruited across New Zealand into a prospective cohort study. Baseline data were collected during a telephone interview and through examination of radiology records. Variables associated with recurrent instability were selected for the multivariate logistic regression model using backwards selection (p<0.10). Coefficients for those variables retained in the model were used to develop the predictive tool.

Results: Among the 128 participants, 36% had redislocated at least once in the first 12 months. Univariate analysis showed an increased likelihood of recurrent dislocation with bony Bankart lesions (OR=3.65, 95% CI 1.05 to 12.70, p=0.04) and participants who had: not been immobilised in a sling (OR = 0.38, 95% CI 0.15 to 0.98, p=0.05), higher levels of shoulder activity (OR=1.13, 95% CI 1.01 to 1.27, p=0.03), higher levels of pain and disability (OR=1.03, 95% CI 1.01 to 1.06, p=0.02), higher levels of fear of reinjury (OR=1.12, 95% CI 1.01 to 1.26, p=0.04) and decreased quality of life (OR=1.01, 95% CI 1.00 to 1.02, p=0.05). There was no significant difference in those with non-dominant compared with dominant shoulder dislocations (p=0.10) or in those aged 16-25 years compared with 26-40 years (p=0.07).

Conclusion: Six of seven physical and psychosocial factors can be used to predict recurrent shoulder instability following a first-time traumatic anterior shoulder dislocation.
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http://dx.doi.org/10.1136/bmjsem-2018-000447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6407568PMC
March 2019

A Nationwide, Population-Based Prevalence Study of Genetic Muscle Disorders.

Neuroepidemiology 2019 18;52(3-4):128-135. Epub 2019 Jan 18.

Department of Neurology, Auckland City Hospital, Auckland, New Zealand.

Background: Previous epidemiological studies of genetic muscle disorders have relied on medical records to identify cases and may be at risk of selection biases or have focused on selective population groups.

Objectives: This study aimed to determine age-standardised prevalence of genetic muscle disorders through a nationwide, epidemiological study across the lifespan using the capture-recapture method.

Methods: Adults and children with a confirmed clinical or molecular diagnosis of a genetic muscle disorder, resident in New Zealand on April 1, 2015 were identified using multiple overlapping sources. Genetic muscle disorders included the muscular dystrophies, congenital myopathies, ion channel myopathies, GNE myopathy, and Pompe disease. Prevalence per 100,000 persons by age, sex, disorder, ethnicity and geographical region with 95% CIs was calculated using Poisson distribution. Direct standardisation was applied to age-standardise prevalence to the world population. Completeness of case ascertainment was determined using capture-recapture modelling.

Results: Age standardised minimal point prevalence of all genetic muscle disorders was 22.3 per 100,000 (95% CI 19.5-25.6). Prevalence in Europeans of 24.4 per 100,000, (95% CI 21.1-28.3) was twice that observed in NZ's other 3 main ethnic groups; Māori (12.6 per 100,000, 95% CI 7.8-20.5), Pasifika (11.0 per 100,000, 95% CI 5.4-23.3), and Asian (9.13 per 100,000, 95% CI 5.0-17.8). Crude prevalence of myotonic dystrophy was 3 times higher in Europeans (10.5 per 100,000, 9.4-11.8) than Māori and Pasifika (2.5 per 100,000, 95% CI 1.5-4.2 and 0.7 per 100,000, 95% CI 0.1-2.7 respectively). There were considerable regional variations in prevalence, although there was no significant association with social deprivation. The final capture-recapture model, with the least deviance, estimated the study ascertained 99.2% of diagnosed cases.

Conclusions: Ethnic and regional differences in the prevalence of genetic muscle disorders need to be considered in service delivery planning, evaluation, and decision making.
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http://dx.doi.org/10.1159/000494115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518995PMC
December 2019

Secular trends 2013-2017 in overweight and visible dental decay in New Zealand preschool children: influence of ethnicity, deprivation and the Under-5-Energize nutrition and physical activity programme.

J Dev Orig Health Dis 2019 06 31;10(3):345-352. Epub 2018 Oct 31.

Centre for Child Health Research,Faculty of Health and Environmental Sciences,Auckland University of Technology,Auckland 0640,New Zealand.

Early-life intervention to reduce obesity and poor dental health through early-life nutrition will improve health outcomes in later life. This study examined the prevalence of overweight and obesity and visual dental decay in 4-year old children in New Zealand between 2013 and 2017, and the impact of a nutrition and physical activity intervention programme, Under-5-Energize (U5E), on prevalence of these conditions within ethnic groups and by deprivation. The data set included 277,963 4-year-old children, including 25,140 from the Waikato region children of whom 8067 attended one of the 121 early childhood centres (ECC) receiving the U5E programme from 2014. Purposively the U5E-ECC selected were attended by higher proportions of indigenous Māori children and children living in higher deprivation areas than non-U5E-ECC. From 2013 to 2017, the overall prevalence of obesity, as defined by World Health Organisation criteria, declined slightly but rates of dental decay did not change. In the Waikato region, the prevalence of obesity declined in non-Māori children from 2015 to 2017 and children attending U5E-ECC had lower rates of dental decay than non-U5E children. Binary logistic regression showed that between 2015 and 2017 visible dental decay was more likely in children who were Māori (3.06×3.17), living in high deprivation (1.54×1.66) and male (1.10) but less likely if attending an U5E-ECC (0.83×0.79). Early-life intervention had efficacy at reducing dental decay, and demonstrated that the origins of disparities in health such as ethnicity and deprivation need to be addressed further to break the intergenerational cycles of poor health.
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http://dx.doi.org/10.1017/S2040174418000788DOI Listing
June 2019

EpiNet study of incidence of status epilepticus in Auckland, New Zealand: Methods and preliminary results.

Epilepsia 2018 10 29;59 Suppl 2:144-149. Epub 2018 Aug 29.

National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand.

The EpiNet project has been commenced to facilitate investigator-led collaborative research in epilepsy. A new Web-based data collection tool has been developed within EpiNet to record comprehensive data regarding status epilepticus and has been used for a study of status epilepticus in Auckland, New Zealand. All patients aged >4 weeks who presented to any of the five public hospitals and the major private hospital within Auckland city (population = 1.61 million) with an episode of status epilepticus between April 6, 2015 and April 5, 2016 were identified using multiple overlapping sources of information. For this study, status epilepticus was defined as any seizure exceeding 10 minutes in duration, or repeated seizures lasting >10 minutes without recovery between seizures. Patients who had either convulsive or nonconvulsive status epilepticus were included. Episodes of status epilepticus were classified according to the 2015 International League Against Epilepsy ILAE status epilepticus classification. A total of 477 episodes in 367 patients were considered as definite or probable status epilepticus; 285 episodes (62%) lasted >30 minutes, which is the duration that has previously been used for epidemiological studies of status epilepticus.
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http://dx.doi.org/10.1111/epi.14478DOI Listing
October 2018

Trajectories in health recovery in the 12 months following a mild traumatic brain injury in children: findings from the BIONIC Study.

J Prim Health Care 2018 03;10(1):81-89

National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland, New Zealand.

INTRODUCTION There is growing consensus that adverse child outcomes may be evident in the early recovery phase following mild traumatic brain injury (TBI). However, controversy remains around the nature of children's longer-term recovery. AIM To examine child cognitive, behavioural and quality-of-life outcomes over 12 months following mild injury, and to identify prognostic factors associated with outcomes. METHODS A prospective sample of 222 children (aged 2-15 years at injury) with mild TBI was assessed using a cognitive testing battery and parent-report questionnaires at ≤ 14 days, 1, 6 and/or 12-months post-injury. RESULTS Parents reported significant improvements in their child's behavioural adjustment between baseline and 6 months (P = 0.003), with further improvements at 12 months following injury (P = 0.001). Cognitive recovery and quality-of-life improvements were more gradual with minimal changes in the first month (P > 0.05), but significant improvements by 12-months post-injury (P = 0.03, P = 0.02, respectively). Time since injury, male gender, living rurally and parent anxiety were associated with extent of recovery beyond the acute period. CONCLUSIONS Children's recovery from mild TBI continues beyond the initial 6 months following injury. Health-care providers need to be vigilant about the varying trajectories in children's recovery from TBI. On-going monitoring of children following injury will enable timely and proactive responses to persistent difficulties, with a view to minimising longer-term adverse consequences.
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http://dx.doi.org/10.1071/HC17038DOI Listing
March 2018

Determining the feasibility and preliminary efficacy of a stroke instructional and educational DVD in a multinational context: a randomized controlled pilot study.

Clin Rehabil 2018 Aug 30;32(8):1086-1097. Epub 2018 May 30.

1 National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand.

Objective: To assess the feasibility of conducting a randomized controlled trial of an instructional and educational stroke DVD and determine the feasibility and preliminary efficacy of this intervention in a multinational context.

Design: Non-funded, pilot randomized controlled trial of intervention versus usual care.

Setting: International, multicentre, community-based.

Participants: Community-living adults up to three years post stroke with moderate to severe disability and their nominated informal caregivers.

Interventions: Intervention patients viewed and practised rehabilitation techniques demonstrated in the DVD over six weeks.

Main Measures: Trial feasibility by number of active recruitment sites, recruitment efficiency, randomization and follow-up. Intervention feasibility by patient and caregiver impressions. Preliminary efficacy by the quality of life - 5-level EuroQol-5D (EQ-5D) health status measure, General Health Questionnaire and Centre for Epidemiological Studies-Depression at two months.

Results: In total, 14 recruitment sites were established across eight countries. Recruitment was achieved at nine (64%) sites. Over 16 months, 66 participants were recruited (mean (SD) age = 63.5 (12.47) years) and randomized to intervention ( n = 34) and control ( n = 32) groups. In total, 54 (82%) completed a follow-up assessment. Patient and/or caregiver comments about the benefits and barriers to accessing the intervention were mixed. There were no significant between-group differences in outcomes at two months ( P > 0.05).

Conclusion: Conducting a multinational trial of a stroke DVD requires full funding. The intervention was acceptable to some patients and their caregivers, yet a generalized education approach did not fully meet their needs and/or expectations. A more individualized method may be required to meet peoples' changing needs during stroke recovery.
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http://dx.doi.org/10.1177/0269215518777565DOI Listing
August 2018

Factors contributing to sex differences in functional outcomes and participation after stroke.

Neurology 2018 05 27;90(22):e1945-e1953. Epub 2018 Apr 27.

From the Menzies Institute for Medical Research Tasmania (H.T.P., C.L.B., P.O., S.L.G.), University of Tasmania, Hobart, Australia; Department of Health Management and Health Economics (H.T.P.), Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Medicine (A.G.T., D.A.C.), School of Clinical Sciences at Monash Health, Monash University, Clayton; Florey Institute Neuroscience and Mental Health (D.A.C.), Heidelberg, University of Melbourne, Victoria; Faculty of Health and Medicine (J.S.), University of Newcastle; George Institute for Global Health (E.H., C.A.), University of Sydney, New South Wales, Australia; Hellenic Cardiovascular Research Society (K.V.), Athens, Greece; National Institute for Stroke and Applied Neurosciences (P.P., R.K., V.F.), School of Public Health and Psychosocial Studies, Auckland University of Technology; School of Psychology (S.B.-C.), University of Auckland, New Zealand; University of Burgundy (Y.B.), University Hospital of Dijon, France; Clinica Neurológica de Joinville (N.L.C.), Joinville Stroke Registry, University of Joinville Region, Brazil; Department of Biotechnological and Applied Clinical Sciences (A.C., S.S.), Neurological Institute, University of L'Aquila, Italy; Stroke Unit (N.C.), Centre Hospitalier Sud Francilien, Corbeil-Essonnes; Stroke Unit (S.O.), University Hospital of Bordeaux, France; Stroke Prevention Research Unit (P.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK; UNIFAI (C.S., M.C., R.M.), Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal; Department of Neurology (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Neurology and Neurosurgery (J.K., R.V.), University of Tartu, Estonia; and Hospital Carlos Fernando Malzoni and Neurologic Center of Research and Rehabilitation (C.M.), Matão, SP, Brazil.

Objective: To examine factors contributing to the sex differences in functional outcomes and participation restriction after stroke.

Methods: 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.

Results: In unadjusted analyses, women experienced worse functional outcomes after stroke than men (1 year: pooled RR 1.32, 95% confidence interval [CI] 1.18-1.48; 5 years: RR 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: RR 1.08, 95% CI 0.97-1.20; 5 years: RR 1.05, 95% CI 0.94-1.18). Women also had greater participation restriction than men (pooled MD -5.55, 95% CI -8.47 to -2.63), but this difference was again attenuated after adjustment for the aforementioned factors (MD -2.48, 95% CI -4.99 to 0.03).

Conclusions: 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.
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http://dx.doi.org/10.1212/WNL.0000000000005602DOI Listing
May 2018

Determinants, Prevalence, and Trajectory of Long-Term Post-Stroke Cognitive Impairment: Results from a 4-Year Follow-Up of the ARCOS-IV Study.

Neuroepidemiology 2017 16;49(3-4):129-134. Epub 2017 Nov 16.

National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand.

Background: The long-term (>12 months) prevalence, predictors, and trajectory of post-stroke cognitive deficits are not well established, especially at a community level. This study investigated the longitudinal course and prevalence of cognitive impairment in an incidence cohort, identifying factors associated with declining cognition.

Methods: Two hundred fifty-seven participants (mean age = 67.93 ± 13.59) of first-ever stroke survivors, completed cognitive assessments within 2 weeks post stroke, and/or 1, 6, 12, and 48-month. Multivariate linear and logistic models were used to identify baseline predictors (reported as OR with 95% CI) and trajectory of cognitive impairment.

Results: Cognitive functioning significantly declined by 2.8 points by 4 years post stroke. Eighty-four percent of stroke survivors had cognitive impairment indicative of post-stroke dementia (mean Montreal cognitive assessment = 20 ± 4.7) at 4-year. There were significant as-sociations between progressive cognitive decline and the -following factors: male gender (OR 2.9, 95% CI 1.6-5.9, -p = 0.0171), coronary artery disease (OR 2.96, 95% CI 1.35-6.49, p = 0.0070), arrhythmia (OR 2.21, 95% CI 1.07-4.57, p = 0.0317), not in a relationship (OR 2.8, 95% CI 1.4-5.50, p < 0.0001), and not employed (OR 4.9, 95% CI 1.9-12.1, p < 0.0001).

Conclusions: Cognitive deficits remain highly prevalent at 4-year post stroke. Early identification of those at higher risk of declining cognition is vital to target rehabilitation interventions at the acute stage and improve overall outcomes.
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http://dx.doi.org/10.1159/000484606DOI Listing
July 2019

Primary prevention of stroke and cardiovascular disease in the community (PREVENTS): Methodology of a health wellness coaching intervention to reduce stroke and cardiovascular disease risk, a randomized clinical trial.

Int J Stroke 2018 02 13;13(2):223-232. Epub 2017 Sep 13.

2 AUT University, Auckland, New Zealand.

Rationale Stroke is a major cause of death and disability worldwide, yet 80% of strokes can be prevented through modifications of risk factors and lifestyle and by medication. While management strategies for primary stroke prevention in high cardiovascular disease risk individuals are well established, they are underutilized and existing practice of primary stroke prevention are inadequate. Behavioral interventions are emerging as highly promising strategies to improve cardiovascular disease risk factor management. Health Wellness Coaching is an innovative, patient-focused and cost-effective, multidimensional psychological intervention designed to motivate participants to adhere to recommended medication and lifestyle changes and has been shown to improve health and enhance well-being. Aims and/or hypothesis To determine the effectiveness of Health Wellness Coaching for primary stroke prevention in an ethnically diverse sample including Māori, Pacific Island, New Zealand European and Asian participants. Design A parallel, prospective, randomized, open-treatment, single-blinded end-point trial. Participants include 320 adults with absolute five-year cardiovascular disease risk ≥ 10%, calculated using the PREDICT web-based clinical tool. Randomization will be to Health Wellness Coaching or usual care groups. Participants randomized to Health Wellness Coaching will receive 15 coaching sessions over nine months. Study outcomes A substantial relative risk reduction of five-year cardiovascular disease risk at nine months post-randomization, which is defined as 10% relative risk reduction among those at moderate five-year cardiovascular disease risk (10-15%) and 25% among those at high risk (>15%). Discussion This clinical trial will determine whether Health Wellness Coaching is an effective intervention for reducing modifiable risk factors, and hence decrease the risk of stroke and cardiovascular disease.
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http://dx.doi.org/10.1177/1747493017730759DOI Listing
February 2018

The effect of spinal position on sciatic nerve excursion during seated neural mobilisation exercises: an study using ultrasound imaging.

J Man Manip Ther 2017 May 22;25(2):98-105. Epub 2016 Apr 22.

Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.

Objectives: Research has established that the amount of inherent tension a peripheral nerve tract is exposed to influences nerve excursion and joint range of movement (ROM). The effect that spinal posture has on sciatic nerve excursion during neural mobilisation exercises has yet to be determined. The purpose of this research was to examine the influence of different sitting positions (slump-sitting versus upright-sitting) on the amount of longitudinal sciatic nerve movement during different neural mobilisation exercises commonly used in clinical practice.

Methods: High-resolution ultrasound imaging followed by frame-by-frame cross-correlation analysis was used to assess sciatic nerve excursion. Thirty-four healthy participants each performed three different neural mobilisation exercises in slump-sitting and upright-sitting. Means comparisons were used to examine the influence of sitting position on sciatic nerve excursion for the three mobilisation exercises. Linear regression analysis was used to determine whether any of the demographic data represented predictive variables for longitudinal sciatic nerve excursion.

Results: There was no significant difference in sciatic nerve excursion (across all neural mobilisation exercises) observed between upright-sitting and slump-sitting positions ( = 0.26). Although greater body mass index, greater knee ROM and younger age were associated with higher levels of sciatic nerve excursion, this model of variables offered weak predictability ( = 0.22).

Discussion: Following this study, there is no evidence that, in healthy people, longitudinal sciatic nerve excursion differs significantly with regards to the spinal posture (slump-sitting and upright-sitting). Furthermore, although some demographic variables are weak predictors, the high variance suggests that there are other unknown variables that may predict sciatic nerve excursion. It can be inferred from this research that clinicians can individualise the design of seated neural mobilisation exercises, using different seated positions, based upon patient comfort and minimisation of neural mechanosensitivity with the knowledge that sciatic nerve excursion will not be significantly influenced.
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http://dx.doi.org/10.1179/2042618615Y.0000000020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5430455PMC
May 2017

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

Circ Cardiovasc Qual Outcomes 2017 02 22;10(2). Epub 2017 Feb 22.

From the Menzies Institute for Medical Research Tasmania, University of Tasmania, Hobart, Australia (H.T.P., C.L.B., P.O., S.G.); Department of Health Management and Health Economics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam (H.T.P.); Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.); Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Victoria, Australia (D.C.); Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia (J.S.); George Institute for Global Health, University of Sydney, New South Wales, Australia (E.H., C.A.); Hellenic Cardiovascular Research Society, Athens, Greece (V.K.); National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Auckland, New Zealand (P.P., R.K., V.F.); School of Psychology, University of Auckland, New Zealand (S.B.-C.); University of Burgundy, Dijon, France (Y.B.); University Hospital of Dijon, France (Y.B.); Clinica Neurológica de Joinville, Joinville Stroke Registry, University of Joinville Region-Univille, Brazil (N.L.C.); Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy (A.C., S.S.); Stroke Unit, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France (N.C.); Stroke Unit, University Hospital of Bordeaux, France (S.O.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.R.); UNIFAI, Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal (C.S., M.C., R.M.); Department of Neurology, Faculty of Medicine and Health, Örebro University, Sweden (P.A.); Department of Neurology and Neurosurgery, University of Tartu, Estonia (J.K., R.V.); and Departamento de Neurologia, Psicologia e Psiquiatria, Universidade de São Paulo, Ribeirão Preto, Brazil (C.M.).

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.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.116.003436DOI Listing
February 2017

Minding the gap: Subjective relative deprivation and depressive symptoms.

Soc Sci Med 2017 01 16;173:18-25. Epub 2016 Nov 16.

Ryerson University, Canada.

Substantial evidence has linked depressive symptoms to various indices of societal-level inequality and relative deprivation. A larger literature has also addressed cognitive vulnerability and correlates of depression. Despite this evidence, little research to date has examined the relationship of depressive symptoms with such downstream individual-level consequences of inequality as subjective relative deprivation, or whether relative deprivation is associated with cognitive vulnerability in depression. We conducted two investigations among four separate samples (total N = 2999) to examine associations between subjective relative deprivation and depressive symptoms and cognitions. Across our studies and four different self-report measures of depressive symptoms, we found consistent significant positive associations between subjective relative deprivation and depression symptoms. Further, we found that subjective relative deprivation was predictive of depressive symptoms over and above other known vulnerability factors. Finally, we found that the relationship between subjective relative deprivation and depressive symptoms was fully mediated by negative automatic thoughts about self. These results provide further evidence of the importance of subjective deprivation in maintaining negative mental health outcomes.
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http://dx.doi.org/10.1016/j.socscimed.2016.11.021DOI Listing
January 2017

Sleep difficulties and their impact on recovery following mild traumatic brain injury in children.

Brain Inj 2016 8;30(10):1243-8. Epub 2016 Jul 8.

a National Institute for Stroke and Applied Neuroscience , Auckland University of Technology , Auckland , New Zealand.

Objective: To determine the frequency of sleep difficulties in children following mild traumatic brain injury (TBI) over time and explore the role of sleep on recovery and behaviour.

Methods: Longitudinal study of 109 children aged between 8-16 years who had experienced a mild TBI, with an embedded case control study. Parents completed assessments of the child's sleep quality, symptoms and behaviour at baseline, 1, 6 and 12 months post-injury. Regression analyses explored the impact of poor sleep on 12-month outcomes. Healthy control children were assessed at one time point for comparison to determine the longer-term impact of brain injury on sleep.

Results: The number of children experiencing poor sleep quality peaked 1-month post-injury (39%), reducing to 28% 12-months post-injury. Poor sleep quality at 1-month was associated with increased frequency and severity of symptoms and poorer behavioural outcomes 1 year post-TBI. Cases with TBI were significantly more likely to have sleep difficulties 1-year post-injury than controls (Odds ratio = 3.09).

Conclusions: Sleep difficulties are common following mild TBI in children and are predictive of longer-term outcomes. Identifying children with sleep difficulties post-injury and providing support to facilitate sleep may improve their longer-term functioning.
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http://dx.doi.org/10.1080/02699052.2016.1183171DOI Listing
December 2017

Global burden of stroke and risk factors in 188 countries, during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Lancet Neurol 2016 08 9;15(9):913-924. Epub 2016 Jun 9.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.

Background: The contribution of modifiable risk factors to the increasing global and regional burden of stroke is unclear, but knowledge about this contribution is crucial for informing stroke prevention strategies. We used data from the Global Burden of Disease Study 2013 (GBD 2013) to estimate the population-attributable fraction (PAF) of stroke-related disability-adjusted life-years (DALYs) associated with potentially modifiable environmental, occupational, behavioural, physiological, and metabolic risk factors in different age and sex groups worldwide and in high-income countries and low-income and middle-income countries, from 1990 to 2013.

Methods: We used data on stroke-related DALYs, risk factors, and PAF from the GBD 2013 Study to estimate the burden of stroke by age and sex (with corresponding 95% uncertainty intervals [UI]) in 188 countries, as measured with stroke-related DALYs in 1990 and 2013. We evaluated attributable DALYs for 17 risk factors (air pollution and environmental, dietary, physical activity, tobacco smoke, and physiological) and six clusters of risk factors by use of three inputs: risk factor exposure, relative risks, and the theoretical minimum risk exposure level. For most risk factors, we synthesised data for exposure with a Bayesian meta-regression method (DisMod-MR) or spatial-temporal Gaussian process regression. We based relative risks on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks, such as high body-mass index (BMI), through other risks, such as high systolic blood pressure (SBP) and high total cholesterol.

Findings: Globally, 90·5% (95% UI 88·5-92·2) of the stroke burden (as measured in DALYs) was attributable to the modifiable risk factors analysed, including 74·2% (95% UI 70·7-76·7) due to behavioural factors (smoking, poor diet, and low physical activity). Clusters of metabolic factors (high SBP, high BMI, high fasting plasma glucose, high total cholesterol, and low glomerular filtration rate; 72·4%, 95% UI 70·2-73·5) and environmental factors (air pollution and lead exposure; 33·4%, 95% UI 32·4-34·3) were the second and third largest contributors to DALYs. Globally, 29·2% (95% UI 28·2-29·6) of the burden of stroke was attributed to air pollution. Although globally there were no significant differences between sexes in the proportion of stroke burden due to behavioural, environmental, and metabolic risk clusters, in the low-income and middle-income countries, the PAF of behavioural risk clusters in males was greater than in females. The PAF of all risk factors increased from 1990 to 2013 (except for second-hand smoking and household air pollution from solid fuels) and varied significantly between countries.

Interpretation: Our results suggest that more than 90% of the stroke burden is attributable to modifiable risk factors, and achieving control of behavioural and metabolic risk factors could avert more than three-quarters of the global stroke burden. Air pollution has emerged as a significant contributor to global stroke burden, especially in low-income and middle-income countries, and therefore reducing exposure to air pollution should be one of the main priorities to reduce stroke burden in these countries.

Funding: Bill & Melinda Gates Foundation, American Heart Association, US National Heart, Lung, and Blood Institute, Columbia University, Health Research Council of New Zealand, Brain Research New Zealand Centre of Research Excellence, and National Science Challenge, Ministry of Business, Innovation and Employment of New Zealand.
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http://dx.doi.org/10.1016/S1474-4422(16)30073-4DOI Listing
August 2016

Sex Differences in Stroke Incidence, Prevalence, Mortality and Disability-Adjusted Life Years: Results from the Global Burden of Disease Study 2013.

Neuroepidemiology 2015 28;45(3):203-14. Epub 2015 Oct 28.

School of Psychology, The University of Auckland, Auckland, New Zealand.

Background: Accurate information on stroke burden in men and women are important for evidence-based healthcare planning and resource allocation. Previously, limited research suggested that the absolute number of deaths from stroke in women was greater than in men, but the incidence and mortality rates were greater in men. However, sex differences in various metrics of stroke burden on a global scale have not been a subject of comprehensive and comparable assessment for most regions of the world, nor have sex differences in stroke burden been examined for trends over time.

Methods: Stroke incidence, prevalence, mortality, disability-adjusted life years (DALYs) and healthy years lost due to disability were estimated as part of the Global Burden of Disease (GBD) 2013 Study. Data inputs included all available information on stroke incidence, prevalence and death and case fatality rates. Analysis was performed separately by sex and 5-year age categories for 188 countries. Statistical models were employed to produce globally comprehensive results over time. All rates were age-standardized to a global population and 95% uncertainty intervals (UIs) were computed.

Findings: In 2013, global ischemic stroke (IS) and hemorrhagic stroke (HS) incidence (per 100,000) in men (IS 132.77 (95% UI 125.34-142.77); HS 64.89 (95% UI 59.82-68.85)) exceeded those of women (IS 98.85 (95% UI 92.11-106.62); HS 45.48 (95% UI 42.43-48.53)). IS incidence rates were lower in 2013 compared with 1990 rates for both sexes (1990 male IS incidence 147.40 (95% UI 137.87-157.66); 1990 female IS incidence 113.31 (95% UI 103.52-123.40)), but the only significant change in IS incidence was among women. Changes in global HS incidence were not statistically significant for males (1990 = 65.31 (95% UI 61.63-69.0), 2013 = 64.89 (95% UI 59.82-68.85)), but was significant for females (1990 = 64.892 (95% UI 59.82-68.85), 2013 = 45.48 (95% UI 42.427-48.53)). The number of DALYs related to IS rose from 1990 (male = 16.62 (95% UI 13.27-19.62), female = 17.53 (95% UI 14.08-20.33)) to 2013 (male = 25.22 (95% UI 20.57-29.13), female = 22.21 (95% UI 17.71-25.50)). The number of DALYs associated with HS also rose steadily and was higher than DALYs for IS at each time point (male 1990 = 29.91 (95% UI 25.66-34.54), male 2013 = 37.27 (95% UI 32.29-45.12); female 1990 = 26.05 (95% UI 21.70-30.90), female 2013 = 28.18 (95% UI 23.68-33.80)).

Interpretation: Globally, men continue to have a higher incidence of IS than women while significant sex differences in the incidence of HS were not observed. The total health loss due to stroke as measured by DALYs was similar for men and women for both stroke subtypes in 2013, with HS higher than IS. Both IS and HS DALYs show an increasing trend for both men and women since 1990, which is statistically significant only for IS among men. Ongoing monitoring of sex differences in the burden of stroke will be needed to determine if disease rates among men and women continue to diverge. Sex disparities related to stroke will have important clinical and policy implications that can guide funding and resource allocation for national, regional and global health programs.
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http://dx.doi.org/10.1159/000441103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632242PMC
August 2016

Stroke Prevalence, Mortality and Disability-Adjusted Life Years in Children and Youth Aged 0-19 Years: Data from the Global and Regional Burden of Stroke 2013.

Neuroepidemiology 2015 28;45(3):177-89. Epub 2015 Oct 28.

National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand.

Background: There is increasing recognition of stroke as an important contributor to childhood morbidity and mortality. Current estimates of global childhood stroke burden and its temporal trends are sparse. Accurate and up-to-date estimates of childhood stroke burden are important for planning research and the resulting evidence-based strategies for stroke prevention and management.

Objectives: To estimate the prevalence, mortality and disability-adjusted life years (DALYs) for ischemic stroke (IS), hemorrhagic stroke (HS) and all stroke types combined globally from 1990 to 2013.

Methodology: Stroke prevalence, mortality and DALYs were estimated using the Global Burden of Disease 2013 methods. All available data on stroke-related incidence, prevalence, excess mortality and deaths were collected. Statistical models and country-level covariates were employed to produce comprehensive and consistent estimates of prevalence and mortality. Stroke-specific disability weights were used to estimate years lived with disability and DALYs. Means and 95% uncertainty intervals (UIs) were calculated for prevalence, mortality and DALYs. The median of the percent change and 95% UI were determined for the period from 1990 to 2013.

Results: In 2013, there were 97,792 (95% UI 90,564-106,016) prevalent cases of childhood IS and 67,621 (95% UI 62,899-72,214) prevalent cases of childhood HS, reflecting an increase of approximately 35% in the absolute numbers of prevalent childhood strokes since 1990. There were 33,069 (95% UI 28,627-38,998) deaths and 2,615,118 (95% UI 2,265,801-3,090,822) DALYs due to childhood stroke in 2013 globally, reflecting an approximately 200% decrease in the absolute numbers of death and DALYs in childhood stroke since 1990. Between 1990 and 2013, there were significant increases in the global prevalence rates of childhood IS, as well as significant decreases in the global death rate and DALYs rate of all strokes in those of age 0-19 years. While prevalence rates for childhood IS and HS decreased significantly in developed countries, a decline was seen only in HS, with no change in prevalence rates of IS, in developing countries. The childhood stroke DALY rates in 2013 were 13.3 (95% UI 10.6-17.1) for IS and 92.7 (95% UI 80.5-109.7) for HS per 100,000. While the prevalence of childhood IS compared to childhood HS was similar globally, the death rate and DALY rate of HS was 6- to 7-fold higher than that of IS. In 2013, the prevalence rate of both childhood IS and HS was significantly higher in developed countries than in developing countries. Conversely, both death and DALY rates for all stroke types were significantly lower in developed countries than in developing countries in 2013. Men showed a trend toward higher childhood stroke death rates (1.5 (1.3-1.8) per 100,000) than women (1.1 (0.9-1.5) per 100,000) and higher childhood stroke DALY rates (120.1 (100.8-143.4) per 100,000) than women (90.9 (74.6-122.4) per 100,000) globally in 2013.

Conclusions: Globally, between 1990 and 2013, there was a significant increase in the absolute number of prevalent childhood strokes, while absolute numbers and rates of both deaths and DALYs declined significantly. The gap in childhood stroke burden between developed and developing countries is closing; however, in 2013, childhood stroke burden in terms of absolute numbers of prevalent strokes, deaths and DALYs remained much higher in developing countries. There is an urgent need to address these disparities with both global and country-level initiatives targeting prevention as well as improved access to acute and chronic stroke care.
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http://dx.doi.org/10.1159/000441087DOI Listing
August 2016

Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study.

Neuroepidemiology 2015 28;45(3):161-76. Epub 2015 Oct 28.

National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New.

Background: Global stroke epidemiology is changing rapidly. Although age-standardized rates of stroke mortality have decreased worldwide in the past 2 decades, the absolute numbers of people who have a stroke every year, and live with the consequences of stroke or die from their stroke, are increasing. Regular updates on the current level of stroke burden are important for advancing our knowledge on stroke epidemiology and facilitate organization and planning of evidence-based stroke care.

Objectives: This study aims to estimate incidence, prevalence, mortality, disability-adjusted life years (DALYs) and years lived with disability (YLDs) and their trends for ischemic stroke (IS) and hemorrhagic stroke (HS) for 188 countries from 1990 to 2013.

Methodology: Stroke incidence, prevalence, mortality, DALYs and YLDs were estimated using all available data on mortality and stroke incidence, prevalence and excess mortality. Statistical models and country-level covariate data were employed, and all rates were age-standardized to a global population. All estimates were produced with 95% uncertainty intervals (UIs).

Results: In 2013, there were globally almost 25.7 million stroke survivors (71% with IS), 6.5 million deaths from stroke (51% died from IS), 113 million DALYs due to stroke (58% due to IS) and 10.3 million new strokes (67% IS). Over the 1990-2013 period, there was a significant increase in the absolute number of DALYs due to IS, and of deaths from IS and HS, survivors and incident events for both IS and HS. The preponderance of the burden of stroke continued to reside in developing countries, comprising 75.2% of deaths from stroke and 81.0% of stroke-related DALYs. Globally, the proportional contribution of stroke-related DALYs and deaths due to stroke compared to all diseases increased from 1990 (3.54% (95% UI 3.11-4.00) and 9.66% (95% UI 8.47-10.70), respectively) to 2013 (4.62% (95% UI 4.01-5.30) and 11.75% (95% UI 10.45-13.31), respectively), but there was a diverging trend in developed and developing countries with a significant increase in DALYs and deaths in developing countries, and no measurable change in the proportional contribution of DALYs and deaths from stroke in developed countries.

Conclusion: Global stroke burden continues to increase globally. More efficient stroke prevention and management strategies are urgently needed to halt and eventually reverse the stroke pandemic, while universal access to organized stroke services should be a priority. © 2015 S. Karger AG, Basel.
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http://dx.doi.org/10.1159/000441085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4633282PMC
August 2016

Final response to Hippisley-Cox et al.

Int J Stroke 2015 Oct;10(7):E82-5

Auckland University of Technology, Auckland, New Zealand.

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http://dx.doi.org/10.1111/ijs.12606_1DOI Listing
October 2015

30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981-2012): A Multi-Ethnic Population-Based Series of Studies.

PLoS One 2015 20;10(8):e0134609. Epub 2015 Aug 20.

The University of Auckland, Auckland, New Zealand.

Background: Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years.

Methods: Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981-1982, 1991-1992, 2002-2003 and 2011-2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution.

Results: 5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients.

Conclusions: In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0134609PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4546383PMC
May 2016

Sleep difficulties one year following mild traumatic brain injury in a population-based study.

Sleep Med 2015 Aug 15;16(8):926-32. Epub 2015 May 15.

National Institute for Stroke and Applied Neuroscience, Auckland University of Technology, Auckland, New Zealand.

Background: Sleep quality affects all aspects of daily functioning, and it is vital for facilitating recovery from illness and injury. Sleep commonly becomes disrupted following moderate to severe brain injury, yet little is known about the prevalence of sleep disruption over time and how it impacts on recovery following mild injury.

Methods: This was a longitudinal study of 346 adults who experienced a mild brain injury (aged ≥16 years) identified within a population-based incidence sample in New Zealand. The prevalence of sleep difficulties was assessed at baseline (within two weeks), one, six and 12 months, alongside other key outcomes.

Results: One year post injury, 41.4% of people were identified as having clinically significant sleep difficulties, with 21.0% at a level indicative of insomnia. Poor sleep quality at baseline was significantly predictive of poorer post-concussion symptoms, mood, community integration, and cognitive ability one year post injury. The prevalence of insomnia following mild traumatic brain injury (TBI) was more than three times the rate found in the general population. Of those completing a sleep assessment at six and 12 months, 44.9% of the sample showed improvements in sleep quality, 16.2% remained stable, and 38.9% worsened.

Conclusions: Screening for sleep difficulties should occur routinely following a mild brain injury to identify adults potentially at risk of poor recovery. Interventions to improve sleep are needed to facilitate recovery from injury, and to prevent persistent sleep difficulties emerging.
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http://dx.doi.org/10.1016/j.sleep.2015.04.013DOI Listing
August 2015
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