BACKGROUND:Stroke is a critical public health issue in the United States and globally. System models to optimally capture stroke incidence in rural and culturally diverse communities are needed. The epidemiological transition to a western lifestyle has been associated with an increased burden of vascular risk factors among Alaska Native (AN) people. The burden of stroke in AN communities remains understudied.METHODS:The Alaska Native Stroke Registry (ANSR) was designed to screen and capture all stroke cases between 2005 and 2009 through its integration into the existing single-payer Alaska Tribal Health System infrastructure. Registry staff received notification each time stroke International Classification of Diseases, Ninth Revision codes (430-436) were initiated anywhere in the system. Trained chart abstractors reviewed medical records to document incident strokes among AN patients, which were adjudicated.RESULTS:Between October 2005 and October 2009, over 2100 alerts were screened identifying 514 unique stroke cases, of which 372 were incident strokes. The average annual incidence of stroke (per 100,000) among AN adults was 190.6: 219.2 in men and 164.7 in women. Overall, the ischemic stroke incidence rate was 148.5 per 100,000 with men (184.6) having higher ischemic rates per 100,000 than women (118.3). Men have higher rates of ischemic stroke at all ages, whereas older women experienced higher rates of hemorrhagic strokes over the age of 75 years.CONCLUSIONS:We report a high rate of overall stroke, 190.6 per 100,000. The ANSR methods and findings have implications for other indigenous populations and for global health populations currently undergoing similar epidemiological transitions.

OBJECTIVES:We determined all-cause, cardiovascular disease (CVD), and cancer mortality in western Alaska Native people and examined agreement between death certificate information and adjudicated cause of deaths.METHODS:Data from 4 cohort studies were consolidated. Death certificates and medical records were reviewed and adjudicated according to standard criteria. We compared adjudicated CVD and cancer deaths with death certificates by calculating sensitivity, specificity, predictive values, and κ statistics.RESULTS:Men (n = 2116) and women (n = 2453), aged 18 to 95 years, were followed an average of 6.7 years. The major cause of death in men was trauma (25%), followed by CVD (19%) and cancer (13%). The major cause of death in women was CVD (24%), followed by cancer (19%) and trauma (8%). Stroke rates in both genders were higher than those of US Whites. Only 56% of deaths classified as CVD by death certificate were classified as CVD by standard criteria; discordance was higher among men (55%) than women (32%; κs = 0.4 and 0.7).CONCLUSIONS:We found lower rates for coronary heart disease death but high rates of stroke mortality. Death certificates overestimated CVD mortality; concordance between the 2 methods is better for cancer mortality. The results point to the importance of cohort studies in this population in providing data to assist in health care planning.

OBJECTIVE: To describe the creation of the Alaska Native Stroke Registry (ANSR) and stroke incidence among Alaska Natives between 2005-2009. BACKGROUND: Stroke is emerging as a critical public health issue globally. System models to optimally capture stroke incidence in rural and culturally diverse communities need to be examined. Alaska Native populations are experiencing an increase in CVD risk factors yet the burden of stroke remains understudied. DESIGN/METHODS: ANSR was designed to screen and capture all stroke cases between 2005-2009 through its integration into the existing Alaska Tribal Health System (ATHS) infrastructure. Registry staff received automated notifications every time ICD-9 codes for stroke (430-436) were used anywhere in the health system for any billing purposes (outpatient, inpatient, admission or discharge). Trained chart abstractors pulled medical records to document incident strokes among Alaska Native people which were adjudicated by two neurologists. RESULTS: Between October 2005 and October 2009, we estimate screening over 2100 alerts for 514 unique stroke cases of which 372 were incident strokes. The average annual incidence of stroke (per 100,000) among Alaska Native adults was 190.6: 219.2 in men, and 164.7 in women. The overall ischemic stroke incidence rates was 148.5 per 100,000 with men [184.6] having substantially higher ischemic rates per 100,000 than women [118.3]. Men have higher age-specific rates of total stroke between 45 and 84 years of age whereas women have higher rates among those 85 years of age or older and between 35 and 44 years of age. Men have higher rates of ischemic stroke at all ages whereas women experienced much higher rates of subarachnoid and other hemorrhagic strokes at older ages. CONCLUSIONS: In one of the first ever stroke incidence studies in Alaska Native populations we report high rates of stroke overall and by stroke subtype in both urban and rural communities. Study Supported by: NINDS grant 3U01NS048069-04S3 Disclosure: Dr. Boden-Albala has received personal compensation for activities with the Desmoteplase Advisory Committee. Dr. Roberts has nothing to disclose. Dr. Allen has nothing to disclose. Dr. Bulkow has nothing to disclose. Dr. Trimble has nothing to disclose.

Objectives. We determined all-cause, cardiovascular disease (CVD), and cancer mortality in western Alaska Native people and examined agreement between death certificate information and adjudicated cause of deaths. Methods. Data from 4 cohort studies were consolidated. Death certificates and medical records were reviewed and adjudicated according to standard criteria. We compared adjudicated CVD and cancer deaths with death certificates by calculating sensitivity, specificity, predictive values, and j statistics. Results. Men (n = 2116) and women (n = 2453), aged 18 to 95 years, were followed an average of 6.7 years. The major cause of death in men was trauma (25%), followed by CVD (19%) and cancer (13%). The major cause of death in women was CVD (24%), followed by cancer (19%) and trauma (8%). Stroke rates in both genders were higher than those of US Whites. Only 56% of deaths classified as CVD by death certificate were classified as CVD by standard criteria; discordance was higher among men (55%) than women (32%; js = 0.4 and 0.7). Conclusions. We found lower rates for coronary heart disease death but high rates of stroke mortality. Death certificates overestimated CVD mortality; concordance between the 2 methods is better for cancer mortality. The results point to the importance of cohort studies in this population in providing data to assist in health care planning. (Am J Public Health. 2014;104:1334‐1340. doi:10. 2105/AJPH.2013.301614)

Salvador Cruz-Flores, MD, MPH, FAHA, Chair; Alejandro Rabinstein, MD, Vice Chair; Jose Biller, MD, FAAN, FAHA; Mitchell S.V. Elkind, MD, MS, FAAN; Patrick Griffith, MD, FAAN; Philip B. Gorelick, MD, MPH, FAAN, FAHA; George Howard, DrPH, FAHA; Enrique C. Leira, MD, MS, FAHA; Lewis B. Morgenstern, MD, FAHA, FAAN; Bruce Ovbiagele, MD, MS, FAHA; Eric Peterson, MD, MPH, FAHA; Wayne Rosamond, PhD, MS, FAHA; Brian Trimble, MD; Amy L. Valderrama, PhD, RN; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council on Quality of Care and Outcomes Research

Purpose— Our goal is to describe the effect of race and ethnicity on stroke epidemiology, personal beliefs, access to care, response to treatment, and participation in clinical research. In addition, we seek to determine the state of knowledge on the main factors that may explain disparities in stroke care, with the goal of identifying gaps in knowledge to guide future research. The intended audience includes physicians, nurses, other healthcare professionals, and policy makers. Methods— Members of the writing group were appointed by the American Heart Association Stroke Council Scientific Statement Oversight Committee and represent different areas of expertise in relation to racial-ethnic disparities in stroke care. The writing group reviewed the relevant literature, with an emphasis on reports published since 1972. The statement was approved by the writing group; the statement underwent peer review, then was approved by the American Heart Association Science Advisory and Coordinating Committee. Results— There are limitations in the definitions of racial and ethnic categories currently in use. For the purpose of this statement, we used the racial categories defined by the US federal government: white, black or African American, Asian, American Indian/Alaskan Native, and Native Hawaiian/other Pacific Islander. There are 2 ethnic categories: people of Hispanic/Latino origin or not of Hispanic/Latino origin. There are differences in the distribution of the burden of risk factors, stroke incidence and prevalence, and stroke mortality among different racial and ethnic groups. In addition, there are disparities in stroke care between minority groups compared with whites. These disparities include lack of awareness of stroke symptoms and signs and lack of knowledge about the need for urgent treatment and the causal role of risk factors. There are also differences in attitudes, beliefs, and compliance among minorities compared with whites. Differences in socioeconomic status and insurance coverage, mistrust of the healthcare system, the relatively limited number of providers who are members of minority groups, and system limitations may contribute to disparities in access to or quality of care, which in turn might result in different rates of stroke morbidity and mortality. Cultural and language barriers probably also contribute to some of these disparities. Minorities use emergency medical services systems less, are often delayed in arriving at the emergency department, have longer waiting times in the emergency department, and are less likely to receive thrombolysis for acute ischemic stroke. Although unmeasured factors may play a role in these delays, the presence of bias in the delivery of care cannot be excluded. Minorities have equal access to rehabilitation services, although they experience longer stays and have poorer functional status than whites. Minorities are inadequately treated with both primary and secondary stroke prevention strategies compared with whites. Sparse data exist on racial-ethnic disparities in access to surgical care after intracerebral hemorrhage and subarachnoid hemorrhage. Participation of minorities in clinical research is limited. Barriers to participation in clinical research include beliefs, lack of trust, and limited awareness. Race is a contentious topic in biomedical research because race is not proven to be a surrogate for genetic constitution. Conclusions— There are limitations in the current definitions of race and ethnicity. Nevertheless, racial and ethnic disparities in stroke exist and include differences in the biological determinants of disease and disparities throughout the continuum of care, including access to and quality of care. Access to and participation in research is also limited among minority groups. Acknowledging the presence of disparities and understanding the factors that contribute to them are necessary first steps. More research is required to understand these differences and find solutions.

OBJECTIVES:We aimed to describe the epidemiology of stroke among Alaska Natives, which is essential for designing effective stroke prevention and intervention efforts for this population.METHODS:We conducted an analysis of death certificate data for the state of Alaska for the period 1984 to 2003, comparing age-standardized stroke mortality rates among Alaska Natives residing in Alaska vs US Whites by age category, gender, stroke type, and time.RESULTS:Compared with US Whites, Alaska Natives had significantly elevated stroke mortality from 1994 to 2003 but not from 1984 to 1993. Alaska Native women of all age groups and Alaska Native men younger than 45 years of age had the highest risk, although the rates for those younger than 65 years were statistically imprecise. Over the 20-year study period, the stroke mortality rate was stable for Alaska Natives but declined for US Whites.CONCLUSIONS:Stroke mortality is higher among Alaska Natives, especially women, than among US Whites. Over the past 20 years, there has not been a significant decline in stroke mortality among Alaska Natives.

: This registry initiates a program of epidemiological assessments of PS among Alaska Native people to study the natural history and clinical management of PS, and establishes a database of Alaska native people with PS for public health, research and educational purposes. As feasible, the prevalence of PS in Alaska Native people may be estimated as well. This registry not only would facilitate future research into PS etiology, but also guide health care planning and community education efforts in this population. The proposal takes advantage of a case control study of PS that is ongoing in the same population. The registry is designed in two phases. Phase 1 is a developmental period and is well underway at this time. During this phase, we established the data collection and dissemination protocols, a surveillance protocol received IRB approval but is pending approval by a privacy board, the registry database is complete and a pilot project in Anchorage will be initiated pending approvals. Phase 2 has not yet begun. It is a period of educational outreach and active statewide data collection on prevalent and incident cases of PS. After Phase 2 ends, the registry will be sustained through the Alaska Native Medical Center.

Minorities in the United States have higher stroke risks, stroke occurrence at an earlier age, and for some groups, more severe strokes than non-Hispanic whites. Factors contributing to these disparities are explored. Characteristics of African American, Hispanic, and Native American stroke risk and incidence are reviewed. The authors describe recent interventions to raise the awareness of stroke risk factors and symptoms in minorities. The importance of the problem is highlighted, and the authors suggest ways that stroke in minorities may be reduced.

The Alaska Native people continue to experience high stroke mortality despite a decline in stroke mortality in the general US population. However, the epidemiology of stroke has not been well studied in the Alaska Native population. The aim of the Alaska Native Stroke Registry is to conduct statewide surveillance of stroke to better understand the occurrence and outcome in this population, and to improve the management and care of these stroke patients.

: The intent of this proposal is to conduct a case-control study of Parkinson s disease (PD) among Alaska Natives to determine the association of exposure to polychlorinated biphenyl (PCBs) residues, organochlorine pesticides and methylmercury with PD. The hypothesis is that increased exposure to these compounds will be associated with an increased risk of PD. Exposure will be determined by direct measurement of serum levels, as these compounds are persistent in body tissues. In addition, lifelong exposure will be estimated by structured interview, including a dietary history with specific attention to intake of fish, marine mammals and wild game, known sources of bioconcentration of these environmentally persistent compounds. The project is being conducted in two phases. Phase 1 is a developmental period and is complete for study conduct statewide. The specific aspects of the study design were established, detailed protocols were developed, and Institutional Review Board (IRB) approval was obtained. Phase 2, conduct of the case-control study, is now in progress statewide.

HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is endemic in the Caribbean basin and Japan. Because of the close proximity of the United States to the Caribbean and the presence of HTLV-I-seropositive persons in the United States, we sought reports of patients who were HTLV-I seropositive and had a slowly progressive myelopathy. Over a 2-year period, there were 25 patients reported, 19 of whom were black and 12 of whom had been born in the United States. All patients except two had become symptomatic while living in the United States. Six patients had no apparent risk factor for acquiring HTLV-I. These data demonstrate that HAM/TSP is occurring in the United States and that the diagnosis of HAM/TSP should be considered in patients with a slowly progressive myelopathy regardless of risk factors for acquiring HTLV-I.