Dissertations / Theses on the topic 'Stroke register'

The aim of this thesis was to explore variations in stroke prevention and the effect of prevention on outcome. The studies were based on patients registered in the Swedish Stroke Register between 2001 and 2009 and although used to different extents in each paper, additional information was retrieved through linkage to The National Patient Register, the Cause of Death Register, the Prescribed Drug Register and the Total Population Register. Cardiovascular risk factors were prevalent among ischemic stroke (IS) patients; however, they were not always prescribed the drugs recommended, and increasing age was an important negative predictor (Paper I). After IS, the rate of hemorrhage in patients prescribed antiplatelet agents (2.4 per 100 person-years) was double to results from randomized controlled trails, but was similar for patients prescribed warfarin (2.5 per 100 person-years).  Age ≥75 years and previous hemorrhage were associated with a moderately increased risk of future hemorrhage (Paper II). Among IS patients with atrial fibrillation, one-third was prescribed warfarin and two-thirds were prescribed antiplatelets. After adjustment for a propensity score (used to adjust for the non-randomized design), warfarin was associated with a reduced risk of death (0.67; 95% CI, 0.63-0.71) (Paper III). The rate of subsequent hemorrhagic stroke was 0.4 per 100 person-years and the risk did not change (HR 1.04; 95% CI, 0.73-1.48) when later years of the 2000s (inclusion period 2005-8: follow-up until 2009) was compared with earlier years (inclusion period 2001-4: follow-up until 2005) (Paper IV, cohort). Although the risk of first-ever hemorrhagic stroke more than doubled with warfarin than without, the risk did not change between 2006 and 2009 (Paper IV, case-control). In summary, the prescription of secondary preventive drugs varies with age, even though cardiovascular risk factors are prevalent in all ages. The risk of death and hemorrhage are affected by the type of antithrombotic prescribed. Therefore, it is important individual’s stroke and bleeding risks in stroke prevention are assessed.

Background. Intracerebral hemorrhage (ICH) is the most severe stroke type. Understanding the epidemiology and pathogenesis of ICH is key to design adequate prevention and treatment strategies to improve the dismal prognosis of ICH. Methods. We performed a prospective population-based study in the district of L’Aquila covering the years 2011-2019. ICH incidence, 30-day and 1-year and case-fatality rates (CFRs) were computed in patients residing in the district and suffering a first-ever ICH over the 2011-2017 period (incidence dataset). All the other assessments were performed in residents of the district reporting either a first-ever ICH or an ICH after a stroke during the 2011-2019 period (full dataset). Cases were actively monitored from multiple sources. We classified ICH according to the SMASH-U system. ICH volumes were calculated using the ABC/2 method. The presence of radiological Edinburgh criteria, including associated subarachnoid hemorrhage (aSAH) and finger-like projections (FLPs) was assessed on the first available brain CT of patients with lobar ICH. Crude incidence rates were calculated assuming a Poisson distribution. Incidence rates were also standardized to the European population using the direct method. Univariate comparisons were performed using the chi-square test, t test, ANOVA, Mann-Whitney or Kruskal-Wallis tests, as appropriate. Logistic regression or Cox regression models were used to perform multivariate analyses. Results. We identified 645 patients with ICH (full dataset; 58.6% men; mean age 75.3±13.4 years). The incidence dataset included 514 patients. The crude ICH incidence rate was 24.6 per 100,000 person-years (95% confidence interval [CI] 22.5-26.8); the corresponding rate was 19.4 per 100,000 person-years (95% CI 17.9-20.9) after standardization to the European population. Case-fatality rates were 36.0% at 30 days and 44.6% at 1-year. Compared with the 567 patients with a first-ever ICH, the 78 patients with ICH after a stroke had a higher pre-stroke disability (median modified Rankin Scale score 2, interquartile range [IQR] 1-3, vs 1, IQR 0-2; P<0.001) and higher ICH volume at onset (median 20 cm3, IQR 3-53, vs 8, IQR 2-25; P=0.004), but not higher case-fatality rate. The 34 patients with ICH after hemorrhagic stroke had a higher proportion of lobar location compared with the 44 patients with ICH after ischemic stroke (79.4% vs 40.9%; P=0.009). According to the SMASH-U classification, 39 patients (6.0%) had an ICH attributable to structural lesions, 74 (11.5%) to medication, 41 (6.4%) to systemic or other disease, 217 (33.6%) to amyloid angiopathy, 235 (36.4%) to hypertensive angiopathy, and 39 (6.0%) to undetermined cause. ICH attributable to medication was the only category which independently predicted 30-day (hazard ratio 1.78, 95% CI 1.18-2.67; P=0.006) and 1-year case-fatality (hazard ratio 1.50, 95% CI 1.02-2.19; P=0.038). We included 259 patients with lobar ICH; 87 (33.6%) had both the Edinburgh CT criteria for the classification of probable amyloid angiopathy, i.e. aSAH+FLPs, while 77 (29.7%) had only one and 95 (25.6%) none of the criteria. Patients with aSAH+FLPs also had more severe ICH at onset, higher 30-day (log rank test P=0.009) and 1-year case-fatality (log rank test P=0.003), and higher mRS scores at discharge (P<0.001) as compared to those fulfilling one or none of the Edinburgh criteria. However, the Edinburgh criteria were not independent predictors of case-fatality. Conclusions. In our population-based study, the incidence and outcomes of first-ever ICH were comparable to those reported in similar studies. Applying a classification tool to patients with ICH identified patient categories with different prognosis; however, only ICH attributable to anticoagulant medication was an independent predictor of ICH case-fatality. Besides, the available classification tools are limited by the coexistence of several etiologic factors in the same patient.

BACKGROUND:Stroke is the leading cause of disability and the second most common cause of death worldwide.Stroke registries are important to formulate guidelines and to improve health services and medical assistance. AIM:To obtain recent epidemiological data on first-ever ischemic stroke (FEIS)(Chapter III) and of ischemic stroke etiologic subtypes(Chapter IV);to evaluate the contribution of atrial fibrillation (AF) to the incidence and prognosis of FEIS, and to evaluate possible epidemiological changes over two decades comparing these recent data on AF with those from the 1994-1998 study(Chapter V);to evaluate the contribution of AF diagnosed after stroke onset (newly diagnosed atrial fibrillation; NDAF) to the incidence, and prognosis of FEIS(Chapter VI). METHODS:All the residents in the district of L’Aquila diagnosed with a FEIS in 2011-2013 were included in a prospective population-based registry and were followed up to 5 years. Case-fatality and vascular events were assessed. RESULTS:Among the 1,280 patients with first-ever stroke included in the registry, 919(71.8%)had a FEIS(52.8% women; mean age±SD, 76.5±12.0 years);women were 6.8 years older at FEIS onset as compared with men. The crude incidence rate of FEIS was 102.68 per 100,000 person-years, 93.89 when standardized to 2011 Italian population, and 79.09 when standardized to the 2011 European population. The case-fatality rate (CFR) of FEIS patients was 18.0% at 30 days, 28.2% at 1 year, and 43.4% at 5 years. The 5-year cumulative probability of survival in patients with FEIS was 56.6%.The distribution of etiologic subtypes according to TOAST criteria was as follows: large-artery atherosclerosis (12.8%), cardioembolism (CE; 34.9%), small artery occlusion (11.9%), other causes (4.7%), undetermined causes (35.7%). CE strokes had the highest incidence rate, were more severe and more disabling, had the highest 30-day, 1-year, and 5-year CFRs, and the lowest 5-year survival with respect to those with other etiologic subtypes. The Cox analysis showed that CE was an independent predictor of morality at 1 year, that was mostly driven by the associated higher stroke severity. Among 919 FEIS, 9 patients without ECG evaluation were excluded and AF was documented in 32.3%. Stroke severity, post-stroke disability, and 30-day, 1-year and 5-year CFRs were significantly higher in patients with AF than in those without. The arrhythmia was NDAF in 22.4% and PDAF in 77.6%. Mean age and vascular risk factors profile was similar in patients with NDAF and PDAF. Patients with NDAF had more severe strokes, greater residual disability discharge, and higher CFRs. From 1994-1998 to 2011-2013 there was a decrease from of the relative proportion of FEIS, a 75% decrease of FEIS incidence, and a decrease in 30-day and 1-year mortality. While, there was an overall 31.3% increase of AF prevalence, and a 44% reduction of the incidence rate ratio and a decrease in 30-day and 1-year mortality in patients with and without AF. CONCLUSIONS:We found in our population a fairly low incidence of FEIS, low rates of vascular follow-up events, and similar CFRs compared to concurrent registries. CE is the current most common stroke etiological subtype and AF is the most prevalent risk factor in this group. These results are likely due to effective primary preventive measures, and improved ischemic stroke management during the acute phase, nevetheless, a better diagnosis and management of atherothrombotic vascular risk factors contributed to the reduction of the FEIS incidence over two decades, and to the increase of CE- and AF-related strokes. Given the high burden of stroke due to CE and in particular to AF, primary preventive measures targeting detection and treatment of cardiac risk factors, the implementation of preventive thromboembolic strategies and the education of patients to maintain treatment adherence might contribute to reduce not only stroke occurrence but also its severity and prognosis.

Stroke is the third leading cause of death in the United States, as well as Georgia. In 2003, 23,164 Georgians suffered a stroke and of those 4,285 died. The FDA has currently approved a therapy that must be given within a three hour window. Less than 2% of stroke patients receive this therapy, oftentimes because of delay of hospital arrival. The purpose of this study is to examine the differences in rural and urban Georgia in patients’ times from stroke symptom onset to hospital arrival. Data from hospitals that area a part of the Georgia Coverdell Stroke Registry from 2005-2007 were analyzed. Logistic regression analysis found that arriving to a rural hospital, being of white race, and having an age of over 60 were associated with greater odds of arriving to the hospital within two hours. Arriving at the hospital by EMS transfer from another hospital, arriving by other means (patient arrived in a personal car or was brought by someone) and having undocumented arrival mode were all associated with a greater odds of arriving much later to the hospital. The multivariate logistic regression had similar findings, although having an age of over 60 years was no longer significantly associated with arrival within 120 minutes. Findings show the need for increased educational efforts around signs and symptoms of stroke, and calling 9-1-1 should be a part of all educational campaigns. Recommendations for improved data collection and additional research are made.

O Acidente Vascular Encefálico (AVE) em crianças possui particularidades em relação à faixa etária acometida, apresentação clínica inicial, fatores de risco, etiologias e evolução diferente dos achados de AVE em adultos. O objetivo do presente trabalho é elaborar um protocolo para o registro de Acidente Vascular Encefálico em crianças, adapatado da versão para adultos (REAVER)desenvolvida pelo Professor Octávio Marques Pontes Neto e colaboradores, do Departamento de Neurociências da FMRP-USP,que, consiste em um registro clínico prospectivo de base hospitalar para doenças cerebrovasculares, cada um dos itens foi analisado e adequado à faixa pediátrica sendo fundamentadopor uma revisão bibliográfica de AVE na criança e de um levantamento de casos de AVE tipo isquêmico (AVEi) em crianças e jovens, excetuando a faixa etárianeonatal, atendidos em hospital de nível terciário. Um estudo observacional retrospetivo, secional foi procedido pela revisão de registros médicos de pacientes com menos de 18 anos exceto a idade de neonatal (entre 2 meses e 18 anos), de 1996 a 2014, assistidos no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HCFMRP-USP). Foram incluídas na amostra 89 crianças com um tempo mínimo de acompanhamento de 12 meses e extraídas informações abrangentes quanto à apresentação clínica e fatores associados. Do total de pacientes, 40 (44.94%) pertenciam ao sexo masculino e 49 (55.05%) ao feminino. A média de idade do diagnóstico de AVEi foi de 3,57 ± 0,26 anos. Detectamos 49.43% dos pacientes no período de lactente, 23.59% no período pré-escolar, 17.97% no escolar, e 8.98% dos pacientes no período pré-púbere, não houve nenhum paciente nos grupos púbere e pós púbere. Destes, 77 pacientes (86.51%) eram da raça branca, 11 negros e 1 oriental. Dos pacientes analisados, 24 (26.96%) apresentavam doenças relacionadas ao AVEi, diagnosticadas previamente ao evento. A principal doença previamente diagnosticada foi a cardiopatia complexa ou malformação cardíaca diagnosticadas no período neonatal em 7 (7.86%) pacientes e valvopatia congênita identificada no período de lactente em 1. Em 44 (49,43 %) pacientes houve relato de associação a fatores ambientais, sendo mais prevalente a síndrome febril/infeciosa, precedendo o início dos sintomas do AVEi em até 8 semanas, totalizando 40 (44,94%) casos, com a infecção de vias aéreas superiores mais prevalente, responsável por 27 casos. Na fase aguda, o déficit focal motor esteve presente isoladamente em 28 (31.46%) crianças, crise convulsiva sem outros sinais em 25 (28,08%), e, se contabilizarmos os casos com mais de um sinal clínico (exemplo: crise convulsiva associada a déficit focal) a crise convulsiva foi a principal apresentação clínica, presente em 41 (46.06%) casos. Entre os 56 (62,92%) com etiologia confirmada, relação direta com causas infeciosas foi a mais prevalente totalizando 16 pacientes. Apesar da extensa investigação realizada em 72 (80,89%) pacientes, os quais realizaram protocolo de investigação do AVEi em jovens, 33 (37,07%) permaneceram com etiologia indeterminada. O tempo médio de acompanhamento dos pacientes foi de 5,76 ± 0,37 anos. Vinte (22,47%) pacientes foram a óbito no período de estudo, ocorrendo principalmente dentro do primeiro ano de acompanhamento, ocorrendo em 14 crianças. Embora relativamente raro, comparado com muitas outras doenças de infância, o AVE pediátrico carrega com ele uma morbidez desproporcionalmente alta e o preço pessoal e social de longo prazo.<br>The brain stroke in children has special features regarding age distribution, initial clinical presentation, risk factors, etiology and evolution different from adult stroke. The objective of this study is to develop a protocol for stroke registration in children, anadaptation of adult version (REAVER) developed by Professor Octavio Marques Pontes Neto and colleagues from the Department of Neurosciences of the FMRP-USP consisting of a prospective clinical registry, hospital-based, on cerebrovascular disease. Each item was analyzed and suitable for pediatric patients, with particular focus on environmental factors, comorbidities and the diseases associated with stroke in children.It is grounded bya review of the literature and a survey of cases of ischemic stroke in children and young people, attended at a tertiary care level hospital. A retrospective, cross-sectional observational study was proceded by review of medical records ofpatients aged less than 18 years except for the neonatal age (less than 2 months old), attended at teaching hospital of School of Medicine of Ribeirão Preto, São Paulo University (HCFMRP-USP). Eighty-ninechildren were included with a minimum of 12 months follow-up. Of all patients, 40 (44.94%) were male and 49 (55.05%) female. The mean age of diagnosis of ischemic stroke was 3.57 ± 0.26 years. We detected 44 (49.43%) patients in the infant period, 21 (23:59%) in the preschool period, 16 (17.97%) in the school, and 8 patients (8.98%) in pre-pubertal period, there were no patients in groups pubescent and postpubescent. 77 patients (86.51%) were white, 11 (12:35%) black and 1 (1.12%) eastern patient. Of the patients analyzed 24 (26.96%) were previously diagnosed with a disease known to be related to ischemic stroke. The main previously diagnosed disease was complex heart disease or heart malformation, with 7 (7.86%) patients diagnosed in the neonatal period and 1 (1.12%) Congenital valve disease identified in the infant period. 44 (49.43%) patientshad environmental factorspreceding the stroke. The most prevalent were febrile / infectious syndromes (44.94%), that preceded the stroke up to eight weeks. Among them, upper airway infection, accounted for 27 (30.33%) cases.In the acute phase, the motor focal deficit alone was present in 28 (31.46%) children, seizures without other signs in 25 (28.08%) cases, and if we add cases with more than one clinical signs (example: any focal deficits withseizure) the seizure was the main clinical presentation, present in 41 ( 46.06%) cases. Among the 56 (62.92%) with confirmed etiology, 16 patients had infectious causes directly related tostroke.Despite extensive researchthat has been carried out in 72 (80.89%) patients, 33 (37.07%)remained with undetermined etiology. The mean follow-up of patients was 5.76 ± 0.37 years. Twenty (22.47%) patients died during the study period, occurring mainly within the first year of follow-up, occurring in 14 (15.73%) childrenAlthough relatively uncommon, compared with many other childhood diseases, pediatric stroke carries with it a disproportionately high morbidity and long-term personal and societal cost.

BACKGROUND: Stroke survivors fall 7 times more annually than same-aged healthy adults; and most fall within the first 2 to 6 months post stroke after transition of care home from the acute setting. These falls cause hip fractures and other bodily injury, further compounding post-stroke mobility, fear of falling, social isolation, and social dependence while collectively yielding poorer outcomes at greater financial burden. PROBLEM: To date, no fall prevention program has targeted stroke survivors as they prepare for transition of care home from the acute setting. PURPOSE: The purpose of this practice inquiry is to develop an evidence-based fall prevention program aimed at empowering acute stroke survivors preparing for transition of care home from the acute setting. METHODS: An extensive literature review was synthesized to assess post-stroke falls epidemiology, contributing factors, potential consequences, and the current status of ameliorative interventions. A modified conceptual framework based upon the Science of Unitary Human Beings, theories of health empowerment, cognitive plasticity, and cognitive reserve was created to synergistically inform fall prevention program development. Literature review synthesis and modified conceptual framework collectively informed subsequent construction of a mixed theory-outcome-activities approach logic model to systematically guide proposed program implementation and evaluation plans. RESULTS: A novel evidence-based empowerment-focused fall prevention program was developed for acute stroke survivors preparing for transition of care home from the acute setting. CONCLUSION: The multi-interventional Patient Empowerment at Transitions of Care Fall Prevention Program for Stroke Survivors inspires a paradigm shift in the way stroke professionals and survivors view recovery and inherent survivor potential. The proposed fall prevention program is informed by a solid theoretical foundation and rigorous literature review of high-level evidentiary support. Moreover, existing dynamic funding opportunities promote subsequent program implementation and evaluation facilitated by Patient-Centered Outcome Research Institute grant pursuit.

Les maladies cardiovasculaires sont une cause importante de morbi-mortalité. La surveillance des indicateurs épidémiologiques des Accidents Vasculaires Cérébraux (AVC) et des Syndromes Coronaires Aigus (SCA) au travers de registres de population joue un rôle important dans l'évaluation des politiques publiques. De plus, la prise en charge à la phase aiguë progressant rapidement au cours du temps, il est essentiel de pouvoir surveiller son évolution pour estimer l'impact potentiel des nouveaux traitements dans la vie réelle. Notre objectif était de caractériser le pronostic des AVC et des SCA en population et il s'est ordonné selon 3 axes.Dans une première étude, nous avons étudié la létalité après un AVC dans le registre des AVC de Lille. La létalité à 28 jours, chez les sujets âgés de &gt;=35 ans, était de 48% après un AVC hémorragique, de 3 % après un AVC ischémique des grandes artères ou lacunaires et variait de 15 à 20 % pour les autres sous-types d'AVC ischémiques. A la phase aiguë, les délais entre les premiers symptômes et le contact avec les services de soins étaient dépassés chez 40% des patients, ne permettant pas une revascularisation. L'âge, la gravité et l'étiologie des AVC étaient les principaux prédicteurs de la létalité à 28 jours. La létalité plus élevée, observée chez les femmes par rapport aux hommes, s'expliquait, principalement par leur âge avancé. La FA, une comorbidité sous diagnostiquée, sous-traitée et retrouvée chez 57% des AVC cardioemboliques, était également un facteur de risque de létalité accrue.Dans un second travail nous avons étudié l'évolution de la prise en charge et de la létalité des SCA dans les registres français des SCA entre 2006 et 2016. Chez les patients de 35-74 ans, résidants dans l'une des 3 zones géographiques surveillées par les registres MONICA et hospitalisés pour un SCA, la létalité était de 8% à 28jours. Ces taux variaient selon le type de SCA (9% après un STEMI, 6 % après un NSTEMI à 1 an), mais ne différaient pas entre les hommes et les femmes. Sur le plan thérapeutique, nos résultats montraient une évolution davantage qualitative que quantitative avec une amélioration de l'efficacité de la prise en charge à la phase aiguë et des prescriptions en lien avec les thérapeutiques de nouvelles générations. Cependant, tandis que les caractéristiques des évènements tendent à converger entre les hommes et les femmes, un léger déficit de prise en charge était encore observé chez les femmes par rapport aux hommes.Dans une troisième partie, nous nous sommes intéressés aux patients qui avaient survécu à leur évènement incident pour étudier le risque de récidive après un SCA dans les registres français des SCA. Le taux de récidive après un SCA incident restait élevé (~20 % sur 9 ans), principalement l'année suivant l'évènement incident (6,7%) et ne dépendait pas du type du premier événement (STEMI/NSTEMI/UA), ni du sexe. Une FEVG altérée et les complications de l'évènement incident étaient des facteurs de risque majeurs de récidive. Les taux de récidive diminuaient entre 2009 et 2017.En conclusion, les évènements vasculaires aigus restent des maladies au pronostic grave dont l'étiologie et le mécanisme physiopathologique sont une source importante et indépendante de variabilité pronostique. Il convient de poursuivre l'amélioration de la prise en charge des femmes pour lesquelles la progression n'est pas aussi optimale que pour les hommes et d'apporter une attention particulière aux facteurs de gravité des AVC et des SCA. Ainsi, en fournissant des indicateurs épidémiologiques précis, l'enregistrement en continu des événements vasculaires aigus sur un territoire géographiquement défini, a permis la surveillance de l'état de santé vasculaire en population et nous a permis d'étudier le pronostic des AVC et des SCA selon les caractéristiques précises de l'événement<br>Cardiovascular diseases are an important cause of morbidity and mortality. The monitoring of epidemiological indicators of stroke and Acute Coronary Syndromes (ACS) through population registers plays an important role in the evaluation of public policies. In addition, as acute-phase care progresses rapidly over time, it is essential to be able to monitor its evolution, to estimate the potential impact of new treatments in real life. Our objective was to characterize the prognosis of strokes and ACS in the population and it was organized according to 3 axes.In a first study, we studied lethality after stroke in the Lille stroke registry. Lethality at 28 days, in subjects aged &gt;=35 years, was 48% after hemorrhagic stroke, 3% after large artery atherosclerosis or lacunar stroke and varied from 15 to 20% for the other subtypes of ischemic strokes. In the acute phase, the time between the onset of symptoms and first contact with the care services was exceeded in 40% of patients, not allowing revascularization. Age, severity and stroke etiology were the main predictors of 28-day case fatality. The higher lethality observed in women compared to men was mainly explained by their advanced age. AF, an underdiagnosed and undertreated comorbidity found in 57% of cardioembolic strokes, was also a risk factor associated with lethality.In a second work we studied the evolution of the management and the lethality of ACS in the French registers of ACS between 2006 and 2016. In patients aged 35-74, residing in one of the 3 geographical areas monitored by MONICA registries and hospitalized for an ACS, the lethality was 8% at 28 days. These rates varied by type of ACS (9% after STEMI, 6% after NSTEMI at 1 year), but did not differ between men and women. On the therapeutic level, our results showed a more qualitative than quantitative evolution with an improvement in the effectiveness of management in the acute phase and prescriptions related to new generation therapies. However, while the characteristics of the events tend to converge between men and women, a slight deficit in management was still observed in women compared to men.In a third part, we focused on patients who had survived their incident event to study the risk of recurrence after an ACS in the French ACS registers. The recurrence rate after an incident ACS remained high (~20% over 9 years), mainly the year following the incident event (6.7%) and did not depend on the type of the first event (STEMI/NSTEMI/UA), or sex. Impaired LVEF and complications from the incident event were major risk factors for recurrence. Recurrence rates decreased between 2009 and 2017.In conclusion, acute vascular events remain diseases with a serious prognosis whose etiology and physiopathological mechanism are an important and independent source of prognostic variability. It is important to continue improving the management of women for whom the progression is not as optimal as for men and to pay particular attention to the severity factors of stroke and ACS. Thus, by providing precise epidemiological indicators, the continuous recording of acute vascular events in a geographically defined territory, has enabled the monitoring of the state of vascular health in the population and has enabled us to study the prognosis of strokes and ACS according to the precise characteristics of the event

This diploma thesis deals with the problem of risk analysis of critical applications in banking. The sponsor is the bank operating in the Czech Republic. The thesis is based on the theoretical apparatus in the field of information security and legal normatives of the Czech Republic. The thesis analyzes the laws and directives related to the issue of risk analysis, the bank's internal regulations and the previous analyzes carried out in the bank.

Les maladies non transmissibles et chroniques, et notamment les maladies cardio-vasculaires sont une des principales causes de mortalité. De nombreuses études concernant la prévalence et facteurs de risques des maladies cardiovasculaires sont réalisées à travers le monde. En Guyane, l’accent est souvent porté sur les maladies tropicales et infectieuses dans un contexte amazonien qui fait l’originalité du territoire et permet de nombreuses publications dans le domaine. Cependant la transition épidémiologique est déjà bien entamée et les maladies cardiovasculaires constituent un problème de santé publique majeur en Guyane. Ainsi les accidents vasculaires cérébraux, les maladies coronariennes sont les principales causes de mortalité prématurée après les accidents. Comme ailleurs, l’insuffisance rénale chronique représente également un problème émergent en matière de santé publique en Guyane. Ce département français est complexe avec des populations d’origines diverses, venant souvent de pays pauvres et vivant dans des conditions difficiles, tout en bénéficiant du système de soins français. Il y existe cependant des inégalités de santé prononcées. Le diabète et l’hypertension artérielle sont deux facteurs de risque majeurs de ces complications cardiovasculaires, et sous-tendent la très forte incidence de l’insuffisance rénale chronique terminale. Afin de pallier au manque de données sur ces problèmes de santé en Guyane, ce travail propose d’étudier l’épidémiologie descriptive et analytique au travers des données du programme médicalisé des systèmes d’information (PMSI), des données de la cohorte prospective multicentrique INDIA et des données du registre sur l’insuffisance rénale chronique mis en place par l’Agence de Biomédecine. Les retombées de ces travaux pourraient aider à optimiser l’accès aux soins, à guider le dépistage et la prise en charge thérapeutique pour réduire la mortalité et l’invalidité qui résultent de ces pathologies.La présente thèse montre ainsi les particularités de l’épidémiologie de ces pathologies avec une forte incidence et une létalité élevée. Il montre qu’il existe des inégalités sociales de santé en Guyane, comme pour d’autres pathologies avec les plus vulnérables qui sont malades plus jeunes, avec des atteintes plus graves et un excès de mortalité. L’hypertension artérielle et le diabète sont des cibles d’intervention préventives, avec un effort tout particulier à faire pour atteindre les plus vulnérables<br>Non communicable chronic diseases, notably cardiovascular diseases are one of the main causes of death. Numerous studies have studied risk factors throughout the world. In French Guiana, most research themes focus on tropical infectious diseases. However, the epidemiologic transition is well underway, and cardiovascular diseases represent a major public health problem. Hence strokes and coronary syndrome are the main cause of premature death after accidents. As elsewhere, chronic renal failure also represents a rising problem in French Guiana. French Guiana is an overseas French Territory with a large Afro-caribbean population profile in terms of cultural and socioeconomic aspects with a French health system. Despite the universal healthcare system, there are frequent health inequalities. Diabetes and high blood pressure are 2 major risk factors for cardiovascular diseases and for end stage renal failure. In order to alleviate the lack of epidemiologic data, the present work aims to describe the epidemiology of these diseases in French Guiana using different data sources: the hospital’s « programme médicalisé des systems d’information (PMSI) », the data from the INDIA prospective cohort a collaboration between the clinical investigation center in Cayenne and Dijon hospital, and data from the end stage renal disease registry. These results will hopefully help improve access to care, and reduce mortality.The present thesis thus shows the particularities of the epidemiology of these highly incident and fatal diseases. It also shows the importance of health inequalities in French Guiana, as for other diseases, the more vulnerable populations become sick younger, with more severe diseases, and more deaths. Hypertension and diabetes are prime targets for preventive interventions, with special efforts to reach the most vulnerable social groups

This diploma’s thesis discourses the cryptographic systems and ciphers, whose function, usage and practical implementation are analysed. In the first chapter basic cryptographic terms, symmetric and asymetric cryptographic algorithms and are mentioned. Also usage and reliability are analysed. Following chapters mention substitution, transposition, block and stream ciphers, which are elementary for most cryptographic algorithms. There are also mentioned the modes, which the ciphers work in. In the fourth chapter are described the principles of some chosen cryptographic algorithms. The objective is to make clear the essence of the algorithms’ behavior. When describing some more difficult algorithms the block scheme is added. At the end of each algorithm’s description the example of practical usage is written. The chapter no. five discusses the hardware implementation. Hardware and software implementation is compared from the practical point of view. Several design instruments are described and different hardware design programming languages with their progress, advantages and disadvantages are mentioned. Chapter six discourses the hardware implementation design of chosen ciphers. Concretely the design of stream cipher with pseudo-random sequence generator is designed in VHDL and also in Matlab. As the second design was chosen the block cipher GOST, which was designed in VHDL too. Both designs were tested and verified and then the results were summarized.

碩士<br>亞洲大學<br>生物資訊與醫學工程學系碩士在職專班<br>107<br>Abstract Background and Purpose: This study used Taiwan Stroke Registry System to analyze if choosing of infarction stroke was the main factor for increasing mortality and morbidity of stroke patients. Research Method: The study discussed mortality and survivability of hospitalization in accepting medication for acute ischemic stroke between 2016 and 2019 in comparison. The data was the medical records of 6206 first-time infarction stroke patients from Taiwan Stroke Registry System. It was analyzed by two-sample independent t test and chi-square test separately. Result: The average age of patients of higher mortality in this study was 67.97 years old. Males were more than females, accounted for 61.55%. For the patients of ischemic stroke, taking the medication, such as aspirin, heparin and warfarin, and also trying the treatment, for example, IA (intra-arterial) thrombectomy (thrombolysis), breathing apparatus and indwelling nasogastric tube showed positive association with mortality risk of the patients. It was the important factor for reducing mortality risk. Co-existing diseases, for instance, urinary tract infection, DNR (do not resuscitate), rehabilitation, dysphagia, readmission to intensive care units, and undergone a surgery were the related factors of higher mortality risk for ischemic stroke patients. Conclusion: Analyzed from the emergency treatment of acute ischemic stroke patients, there was a significant neurological recovery after taking aspirin, intravenous thrombolytic therapy (rt-PA), or IA thrombectomy. It was effective and safe for curing acute infarction stroke. The result of the study could provide the reference for medical staff to evaluate clinically the disease progress of infarction stroke patients in the future.

The Georgia Department of Public Health has been engaged in a registry-based quality improvement initiative to monitor and improve the quality of stroke care. It is important to evaluate effectiveness of the quality improvement initiative in order to expand the effort to other sites or disease conditions. The studies, included in this dissertation, addressed whether acute ischemic stroke patients cared for by hospitals participating in the Georgia Coverdell Acute Stroke Registry (GCASR) had a better survival than those treated at other facilities, assessed whether quality of care as measured by nationally accepted ten performance measures is associated with improved patient outcome and evaluated the impact of intravenous alteplase treatment on 1-year mortality. Three data sources – GCASR, Georgia Discharge Data System and the death data – were used for analyses. These data sources were linked applying both a hierarchical deterministic and a probabilistic linkage methods. Survival after stroke incident was analyzed using the extended Cox proportional hazard model. Generalized estimating equation (glimmix procedure) and conditional logistic regression were applied, respectively, to assess the association of quality of care and intravenous alteplase use with 1-year mortality. Acute ischemic stroke patients treated at nonparticipating facilities had a hazard ratio for death of 1.14 (95% confidence interval, 1.03–1.26; p-value = .01) after the first week of admission compared with patients cared for by hospitals participating in the registry. Among patients treated in GCASR-participating hospitals, patients who received the lowest and intermediate quality care respectively had a 3.94 (95%CI: 3.27, 4.75; p-value <0.0001) and a 1.38 (95%CI: 1.12, 1.62; p-value=0.002) times higher odds of dying in one year compared to those who got the best quality stroke care. Patients who were eligible but did not receive IV alteplase had a 1.49 (95%CI: 1.09-2.04; p-value=0.01) times higher odds of dying within one year than those who were treated with the thrombolytic agent. The results strongly suggest that registry-based quality improvement effort has brought significant improvements in ischemic stroke patients’ outcomes. Therefore, it is critical that hospitals adopt a quality improvement strategy to change the process of care delivery for a better patient outcome.

碩士<br>亞洲大學<br>生物資訊與醫學工程學系碩士在職專班<br>107<br>At present, Attention to stroke is getting higher and higher in Taiwan, especially when the stroke is different from other diseases only 65 years old. The above-mentioned elderly population is a high-risk group. It may be because of the changes in the lifestyle of modern people and the convenience of eating habits. The age of stroke-induced acute illness has been decreasing year by year, so the stroke is not only happening to the elderly. Patients suffering from stroke emergency can save their lives in a timely manner, but the characteristics of the brain are damaged by the brain. There may be unilateral paralysis, the life care is close to disability, and the family is caring for and treating. In addition, it takes a huge amount of medical expenses, which causes a burden on the family and society. The purpose of this study is to investigate the association between stroke patients and risk-causing factors in Taiwan. The Taiwan stroke database was used as the source of data. The outpatients were used to find out the stroke patients, and the association between the stroke patients and the risk-inducing factors was calculated by statistical methods. The samples from the stroke database in Taiwan from 2008 to 2017 were adopted as study samples. The relationship between stroke patients and risk-induced factors in the decade was statistically studied. The results indicated that Three High (high blood pressure, high blood fat, diabetes), heart disease, smoking, drinking, obesity, carotid stenosis, and myocardial infarction had higher association with stroke. As the results, active improvement of quality living habits and healthy diet can reduce the incidence. To reduce the risks of stroke can effectively reduce the consumption of medical resources and improve the quality of healthy living.

碩士<br>亞洲大學<br>生物資訊與醫學工程學系碩士在職專班<br>107<br>Abstract Due to the changes in modern people's eating habits and lifestyle, the stroke has gradually become younger, and even the trend of age declines. Therefore, modern people need to adjust their eating habits and life routines to prevent the concept of stroke and replace the treatment of stroke. According to the report of the Statistics Department of the Ministry of Health and Welfare, according to the statistics of the top ten causes of death in 106 years, the fourth is cerebrovascular disease. At present, the Taiwan Brain Stroke Association has a list of Taiwanese strokes and collected the strokes of the Taiwanese people. It can do long-term follow-up studies on the incidence of stroke, and affect the risk factors of stroke, and analyze them with common endocrine and metabolic diseases. Blood pressure, diabetes, heart disease, and high cholesterol are discussed separately. Based on this, this study uses the Taiwan Brain Stroke Registry database as a source of information, uses the public outpatient data to identify patients with stroke, and then uses statistical methods to calculate the gender, education level, occupation, and highness of stroke patients and demographic characteristics. Study on the association of blood pressure, diabetes, high cholesterol, heart disease, age, BMI, etc. Use Taiwan brain stroke to log in the database, as a sample of patients suffering from stroke, statistics on gender, education, occupation, hypertension, diabetes, high cholesterol, heart disease, age, BMI, etc. Relevance, the results of the study pointed out that the risk-induced possible factors including the three high (high blood pressure, high blood lipids, diabetes) ratio is much higher than the average person, so active improvement of quality living habits and healthy diet should reduce the risk of developing a stroke, In the long run, it can effectively reduce the consumption of public medical resources, thereby improving the health of the people and maintaining the quality of life.

博士<br>國立成功大學<br>臨床藥學與藥物科技研究所<br>107<br>Background: Elderly patients are at risk for developing psychosis after stroke, including delusions, hallucinations, agitation, and disorganized behavior. According to previous guidelines, antipsychotics are the first-line pharmacological intervention for psychosis, but elderly patients who are treated with antipsychotics might have an increased risk of mortality based on US FDA safety communications. However, there are limited studies examining mortality risk associated with antipsychotic use in elderly patients who have had a stroke. The major limitations of these studies include selection bias, immortal time bias, and unmeasured confounders, which can lead to bias related to the relative risks of antipsychotic treatment and result in controversial findings. Objectives: To evaluate prescription patterns and comparative mortality risk of antipsychotic use in elderly patients after a stroke by using an active comparator and new user design with an external adjustment method. Methods, design and setting: We conducted a retrospective cohort study to identify patients aged above 65 years old admitted for stroke in the National Health Insurance Database (NHID) from 2002 to 2014. These patients were not prescribed antipsychotics before their discharge date and were followed until they started to receive antipsychotic treatment. The date of antipsychotic use was set as the index date. The covariates were retrieved from claims during the one-year look-back period prior to the index date. We then linked to multi-center stroke registry databases to retrieve additional variables, including smoking history, body mass index, National Institute of Health Stroke Scale (NHISS), the Barthel index, and the modified Rankin Scale (mRS). Exposure: Antipsychotics covered by the NHI program. Main outcome: One-year all-cause mortality. Secondary outcome: One-year cause-specific mortality. Statistical analysis: Descriptive statistics were used to characterize the baseline demographics and antipsychotic prescription patterns. To compare antipsychotics with respect to risk of all-cause and cause-specific mortality, we performed Cox proportional hazard models using the propensity score calibration (PSC) method to adjust for unmeasured confounders in order to estimate the relative risk among antipsychotics in elderly stroke patients. In addition, in order to avoid the surrogacy assumption due to the use of the PSC method, the two-stage calibration (TSC) method (without the surrogacy assumption) was used to adjust unmeasured confounders and to compare the differences between the PSC and TSC methods. Results: There were 72,441 elderly stroke patients who initiated treatment with antipsychotics during the study period. The proportion of incident use of antipsychotics was 26.2% (2002-2015). The majority of the elderly stroke patients had received only a single antipsychotic treatment (99%), and the most commonly used antipsychotic was quetiapine (39.9%). We selected the antipsychotics, including quetiapine, haloperidol and risperidone, which were prescribed for post-stroke psychosis treatment in previous literature on this topic, and compared the mortality risk among these antipsychotics. In the PSC-adjusted intent to treat analyses, haloperidol [adjusted hazard ratio (aHR)=1.22; 95% confidence interval (CI) 1.18-1.27] and risperidone (aHR=1.31; 95% CI 1.24-1.38) users had a higher mortality risk as compared to quetiapine users. Haloperidol and risperidone exhibited a dose-response related to mortality risk after controlling for confounders. The sensitivity analyses assessing the influence of the study population showed similar patterns. In the cause-specific mortality analyses, risperidone (aHR=1.25; 95% CI 1.14-1.38) users had higher cause-specific mortality from cerebro-cardiovascular disease compared to quetiapine users, but there were no significant differences found in the haloperidol (aHR=1.04 95% CI 0.97-1.12) and quetiapine (reference) users. In addition, we found that the surrogacy assumption was not violated. PSC and TSC methods exhibited similar results in terms of mortality risk related to the use of antipsychotics. Conclusions: The significant variations in the differences in mortality risk among antipsychotic agents suggests that antipsychotic selection and dosing may affect survival in elderly stroke patients. In addition, we also found the surrogacy assumption should be tested to determine whether the assumption is violated when the PSC method is performed to adjust for unmeasured confounders. If this assumption is violated, PSC is far less useful and may even increase bias. When the PSC assumption is violated, the TSC method can provide more precise treatment effects than PSC.

The researcher used the integration of both qualitative and quantitative approaches. The respondents were drawn from three district, one regional, one academic and two private hospitals. Data was collected by means of questionnaires. The open-ended questions in the questionnaire allowed the respondents to respond in their own words (“etic” description). This enhanced the organisation and reduction of the relevant data for analysis as well as the validity and trustworthiness of the study. The study revealed that even though most of the South African government health policies were very advanced and among the best in the world, some crucial policies appeared to have encountered problems with implementation, from conflicting ideologies and opinions from hospital management, different unions, professional associations, the provincial government, the South African Nursing Council (SANC) and patients. Too many groups appeared to have discussed nurses‟ issues with government and made decisions for nurses, leaving nurses disillusioned. The majority of the respondents attributed this to poor representation at government level. Furthermore, some decisions, resolutions and strategies agreed upon between the unions and bargaining councils appeared to have worked against nurses, further dividing RNs and failing to accomplish the intended purpose. Although most of the respondents had hoped that the Occupational Specific Dispensation (OSD) for nurses would address chronic low salaries for all nurses in the PHS, it favoured certain specialty qualifications (which were based on the description of post-basic courses in R212 and R48, which were not clearly delineated). In addition, RNs were not informed about the meaning and implications of the OSD prior to implementation. The study thus found an information gap between government and RNs at the production level, which appeared not to be with the government and the nurses, but in between. Most importantly, nurses seemed to be represented more by unions to government and bargaining councils, as opposed to nurses, while most of the respondents did not favour the division of nurses between professional associations and unions. Decisions in the PHS appeared to have been dominated by leaders who had no experience with pragmatic issues of health care services (HCS), particularly at the operational level, and the dynamics of the nursing profession. The study therefore concluded that, if the right people (nurses, doctors and systems) were put in place, and nurses were represented by nurses at government level, bargaining councils and parliament, discontent among RNs in the PHS could be reduced significantly. Existing strategies were found to deal with the symptoms and not the root cause of discontent among RNs in the PHS.<br>Health Studies<br>D. Litt. et Phil. (Health Studies)