text:
Comparing Stroke Incidence Worldwide
What Makes Studies Comparable?
Jump to
Background Comparing stroke rates in different parts of the world and at different points in time may increase our understanding of the disease. Comparisons are only meaningful if they are based on studies that use similar definitions, methods, and data presentation.
Summary of Review We discuss the criteria that make such studies comparable, drawing on the experiences of recent studies performed around the world. If only those studies that fulfill the proposed criteria for comparison are considered, comparable data do not exist for vast areas of the world, including Africa, Asia, and South America. The importance of complete, community-based case ascertainment, including strokes managed outside the hospital, is emphasized. An approach for measuring and comparing the incidence of the pathological types of stroke (cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage) and subtypes of cerebral infarction is suggested.
Conclusions The "ideal" stroke incidence study does not exist, but studies closely approaching it will reveal the most reliable and comparable results. There is a need for further studies to fill the gaps in our knowledge of the worldwide incidence of stroke, particularly for developing countries.
Comparing stroke incidence in different countries and observing changes in incidence with time in a particular place may increase our understanding of the disease. To be comparable, studies of stroke incidence must use the same definitions, methods, and mode of data presentation. However well-conducted a study may be, unless it conforms in each of these three areas, comparison with other studies is not possible. The ideal approach is to develop standard criteria for these components of a stroke incidence study before establishing a series of comparable studies based on the prespecified criteria.
The first attempt to do this on an international scale is the World Health Organization (WHO) MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) study, primarily designed to monitor trends in the incidence of myocardial infarction and stroke, together with the prevalence of various risk factors, in a number of different countries.1 A comparison of incidence and case-fatality rates from those countries monitoring stroke has recently been published.2 Although clearly a landmark study in international cardiovascular epidemiology, the MONICA study has limitations. The centers monitoring stroke are mainly European, extending into Eastern Europe, Russia, and China. This is the most extensive comparison yet, but large areas of the world were not included. In addition, a limited age range was covered, with most centers monitoring stroke up to age 65 years and none routinely collecting data on those older than 75 years, in whom the incidence (and caseload, at least in the areas studied) of stroke is highest. Finally, the MONICA study concentrates on total strokes and is not specifically designed to examine the incidence of pathological types, although some of the centers do have high enough rates of accurate pathological diagnosis for this.
A large number of independent studies have also measured stroke incidence. Most of them did not have comparative incidence as their sole or even main aim, and only a few are suitable for this purpose. In 1987, Malmgren and colleagues3 reviewed studies of stroke incidence from around the world. Of 65 studies, only nine met a set of standard criteria sufficiently to be considered comparable with each other.4 5 6 7 8 9 10 11 12 13 14 Since that time, several further studies approaching the original criteria of Malmgren et al have been published.15 16 17 18 19 20 21 22 23 24 25 26 27 The area of the world covered by these studies is still very limited, and reliable information remains sparse for nonwhite populations. Despite this deficiency, there is a broadening experience of studying the incidence of stroke in different environments and within different healthcare systems. Thus, an increasing number of studies may provide comparable incidence data to add to our knowledge of stroke incidence worldwide. It is important that these valuable data are not ignored simply because they are from studies that were not established as part of an international effort.
This article aims to extend and refine the original criteria of Malmgren et al in the light of further experiences of measuring stroke incidence, the identification of new problems and possible solutions, and the wider availability of imaging technology, which allows accurate pathological diagnosis. It discusses a set of standards for definitions, methods, and data presentation that individual studies of stroke incidence should fulfill to be considered comparable with one another. It does not attempt to cover all the practicalities of establishing such studies but highlights several important areas that may make comparisons difficult. It is based not only on an extensive review of the literature but also on a series of visits around the world in 1994 to meet with investigators in centers where stroke incidence has been studied for detailed discussions of study methods in the context of the particular local healthcare systems. Considering the successes and problems encountered should increase the ease with which further reliable studies can be established. We hope that this article will encourage those establishing stroke registers to consider the factors that will allow their data to contribute to the accumulating worldwide knowledge of stroke incidence. This is particularly true for the many developing countries for which reliable information simply does not exist.
The main concern of this article is to compare incidence studies in different parts of the world. Many of the issues also relate to studies of time trends in incidence. These may be assessed by continuous registration of strokes or by comparing the incidence measured during two or more discrete periods, separated by a number of years. In either case, internal consistency of methodology is essential so that any change detected is real. For comparison between studies in different locations, external consistency is also necessary.
The wider availability of CT scanning in a number of countries since the 1980s means that many more studies than were published at the time of the review of Malmgren et al can now make a reliable diagnosis of pathological type of stroke during life for the majority of cases. This may allow, for the first time, a reliable international comparison of the incidence of the individual pathological types of stroke (cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage). We include a discussion of the criteria that should make this possible.
Why Measure Stroke Incidence?
Limitations of Mortality Statistics
Mortality is the most readily available variable for comparing stroke rates between countries and monitoring changes with time, so why put enormous efforts into measuring incidence? Official mortality data may be convenient, but they rely on the accuracy of death certificates, which is questionable,28 29 and provide information about fatal cases of stroke only, telling us nothing about the significant proportion of stroke patients who survive, many with major disability. Furthermore, without knowledge of the accuracy of diagnostic methods they cannot tell us about the distribution of the different pathological types of stroke. Several possible explanations exist for the substantial differences in stroke mortality between countries and its trends with time. For example, the apparent recent decline in stroke mortality in many Western countries30 may reflect changes in diagnostic fashions and coding procedures or a real decline, explained by changes in incidence and/or case fatality. The latter may depend on the distribution of pathological types, disease severity, and management. A clearer, more complete picture is only obtained by examining incidence and case-fatality rates separately. If accurate, these measures allow more valid comparisons between countries, may yield data that can be used to follow trends with time, and assist in healthcare planning within communities.
Scope of Stroke Incidence Studies
Another advantage of measuring incidence of stroke is the potential of community-based studies to answer additional questions based on an unbiased sample of incident cases (Table 1⇓). These may include follow-up for outcome in terms of case fatality, recurrence, and disability; case-control studies of various risk factors; and assessment of stroke services. Expanding the yield beyond the mere identification of cases helps to justify the intensive effort put into the case-finding process. Careful study design is crucial to ensure that the identified aims are achieved without the collection of excess, useless data, which simply create extra work for the investigators and may compromise the quality of the study. As for incidence, the measurement of other variables should be standardized for comparison. For case fatality, it is suggested that the MONICA standard of 28-day case fatality be widely adopted.
Measuring Stroke Incidence: A Discussion of Standard Criteria for a Comparable Study (Table 2⇓)
Standard Definitions
WHO Definition of Stroke
The WHO definition of stroke, "rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin,"31 is the broadly accepted standard. Some care is required with its interpretation. First, according to the definition, presentations of subarachnoid hemorrhage with sudden-onset headache, meningism, and no focal or global disturbance of cerebral function should be excluded. However, the definition is generally considered to include all cases of cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage. In practice, most investigators include all subarachnoid hemorrhages, and reports of studies should make this clear.
Second, it is important to rely on the clinical criteria in the definition, with the distinction between stroke and transient ischemic attack (TIA) based on a duration of more (stroke) or less (TIA) than 24 hours. Advances in imaging technology have made us aware that a significant proportion of TIAs are associated with an appropriately located infarct visible on CT or MRI scan. Controversy exists regarding how these "cerebral infarcts with transient signs" should be classified and whether the presence of a visible infarct associated with a TIA alters prognosis.32 33 The availability and sensitivity of imaging technology vary enormously with place and time. Abandoning the clinical distinction between TIA and stroke for one based on imaging would create spurious variability between studies and compound the difficulties in comparing their results.
A similar problem is posed by "silent infarcts"—areas of presumed infarction visible radiologically with no associated symptomatic episode. Again, it would be inappropriate to include these as incident strokes, not only for the reasons outlined in the preceding paragraph but also because, in the absence of symptoms, it is impossible to know when the event leading to the abnormal scan appearance occurred.
First-Ever-in-a-Lifetime Strokes
If we wish comparisons to give us pointers to important determinants of disease etiology, first-ever-in-a-lifetime strokes are the preferred numerator because they most closely reflect these factors. Some studies base their incidence estimates on the number of first stroke events occurring within the study period.31 34 These estimates do not exclude those who had a stroke before the start of the study, thereby including a number of recurrent strokes that are not true incident cases. Others count all strokes within the study period.35 Because there is no consistent relationship between first-ever-in-a-lifetime strokes, first-event strokes, and all strokes,3 it is meaningless to compare incidence measurements based on different definitions (Figure⇓). Including recurrent strokes in the numerator makes sense for assessing the total burden of stroke for local healthcare planning. Thus, studies examining stroke services may also register recurrent strokes but will need available data on first-ever-in-a-lifetime strokes for any etiologic comparisons.
In addition, because many intercurrent illnesses can cause neurological deterioration, defining a recurrent stroke is often difficult in clinical practice, making first-ever-in-a-lifetime stroke a more accurate comparator. Its accuracy requires a careful history and review of all available past records for each potential case to ensure that subjects with previous strokes are not included as incident cases.
Standard Methods
Complete, Community-Based Case Ascertainment
Malmgren et al3 found many studies measuring incidence in hospital-based populations. These never represent the whole community because there will always be some cases not admitted to the hospital (Table 3⇓). Furthermore, they cannot be used for comparisons of place or time: hospitalization rates for stroke vary considerably between and even within countries and are likely to vary with time as management strategies change and new treatments for acute stroke emerge.13 19 36 37 In the Oxfordshire Community Stroke Project, which was performed in the 1980s, 40% of incident stroke patients were not admitted to the hospital.36 This contrasts with the situation in Swedish studies from the same period and later, which demonstrate admission rates of 95% or more.4 13 38 There is also evidence that hospital-based stroke registers are biased toward younger patients with more severe strokes.36 The authors of some community-based studies of stroke incidence were surprised by the significant proportion of cases they found to be managed outside the hospital (eg, 15% in both Warsaw, Poland, and Umbria, Italy19 24 ), demonstrating that such cases must be rigorously searched for without simply assuming that all will be admitted to the hospital. It is because they are entirely hospital based that many of the studies from developing countries are unsuitable for international comparisons.39 40 41
True community-based studies must therefore use several overlapping sources of information to ensure complete case ascertainment. Possible sources are shown in Table 4⇓. The local healthcare system will determine which of these are applicable.
Sources must be surveyed with adequate frequency, covering a broad spectrum of possible presentations of stroke so that cases are not missed. For example, labels such as "collapse," "dizziness," "headache," "fits," or "confusion" may reveal stroke cases. The importance of assessing patients labeled as TIA cases (from both hospital and community) as potential stroke cases is demonstrated by results from the Oxfordshire Community Stroke Project: 7% of incident strokes were initially referred to the investigators as TIAs but in fact had symptoms lasting longer than 24 hours.14
Sources outside the hospital, in particular primary healthcare physicians and nursing institutions, should be involved in the study and contacted regularly to ensure complete referral of community cases. Hospital discharge lists and computer-linked records schemes provide a useful check for patients not identified by admission and ward checks. Reviewing death certificates is the only way of finding patients who die without a referral being made. Their importance, like that of other sources, will depend on local practice and culture. Most studies find death certificates an important contributor of cases. However, a recent study in Okinawa, Japan, which examined death certificates in only one subpopulation of the total, found an insignificant number of cases from this source not already ascertained from others.42 Gathering whatever information is available retrospectively from relatives, attending physicians, medical records, and/or autopsy findings is required before possible death certificate cases can be confirmed (or refuted) as first-ever, WHO-defined strokes.
Assessing Completeness of Case Ascertainment
It would be helpful to have some quantitative way of assessing the completeness of case ascertainment. One approach is to perform a cross-sectional survey of the population, or a sample of it, at intervals (usually every one or few years) during the study to find out whether cases have been missed.6 35 43 Because many stroke cases are among the elderly and disabled, who may be housebound, labor-intensive and therefore expensive survey methods are required to ensure that such cases are not excluded. Cross-sectional surveys may also miss those minor strokes that patients tend to forget with time and that may only be included at all if registered at the time of presentation.
Studies that run for a period of several years can assess their own case-finding efficiency. For example, they may note the number of stroke cases found that are recurrences with a first-ever-in-a-lifetime stroke missed at an earlier stage during the study period. In addition, a surprisingly high or low case-fatality rate may alert investigators to the possibility that either fatal or mild, out-of-hospital cases are being missed. Participating centers in the WHO MONICA study are subject to a number of quality-control procedures to assess the validity of their data. Checks for case ascertainment require centers with case-fatality or out-of-hospital case referral rates falling outside certain arbitrarily determined limits to reexamine their data.44
There is currently no perfect, objective indicator of completeness of case ascertainment. Subjective judgment based on knowledge of the appropriateness of case-finding methods to the study population may be as reliable and less likely to provide false reassurance. No one source of cases will be either infallible or all-encompassing. Multiple overlaps between sources may be regarded as an indication of good case-finding methods as long as multiply referred cases are not registered more than once.10 However, it would be wasteful to concentrate resources on a source with negligible yield. We feel that investigators should identify all possible sources in their location and justify the exclusion of any that are not used. For example, quality-control checks of the WHO MONICA study in northern Sweden, where hospital admission rates are very high, revealed that an intensified effort by general practitioners over a 1-month period to refer all cases did not significantly increase the incidence rates.38 The investigators therefore concentrate on hospital cases and death certificates for case finding.
An interesting possibility is the capture-recapture technique, initially developed for estimating the size of animal populations and now being used in some areas of human disease epidemiology.45 46 It recognizes that no survey has complete coverage and allows an estimate to be made of the number of cases not ascertained, with the use of information from two or more overlapping sources of cases of the disease being counted. Complex adaptations of the technique are required in humans to adjust for the nonindependence of sources and variability between subgroups.45 46 47 The information required to attempt such an analysis is not available for any of the stroke incidence studies of which we are aware, except perhaps the Auckland study.10 11 Until this technique has been developed in stroke epidemiology, we must continue to rely on those methods already in use.
However complete we judge case-finding methods to be, we can only expect to find those cases that are presented to the sources surveyed. The Oxfordshire Community Stroke Project found that of those patients whose stroke was preceded by a TIA, only about half had sought medical attention for their TIA.48 Similarly, some persons with mild strokes might never seek medical attention. This is particularly likely among the elderly, who may attribute symptoms of a stroke to age or some age-associated disease such as osteoarthritis. Any individual study may thus underestimate stroke incidence, and this effect may vary between studies because of differences between study populations in the interpretation of symptoms, perception of their severity, and accessibility and cost of health care. These factors are not easy to control or measure, but their potential contribution to differences in incidence rates between studies, particularly in regard to mild strokes, cannot be ignored.
Importance of Prospective Study Design
Stroke is a clinical diagnosis, making accurate clinical assessment by an appropriately qualified specialist an essential part of any incidence study. There is no "gold standard" diagnostic method superior to clinical judgment. For example, CT or MRI scanning cannot necessarily distinguish between a stroke and the transient focal weakness that may follow a seizure. The rate of error, as judged by CT scanning, in the clinical diagnosis of stroke versus nonstroke varies from 1.5% to 16%19 49 50 51 52 53 and appears to be dependent on the degree of skill and training of the assessor. In community-based stroke registers, in which patients are assessed soon after onset of symptoms by a neurologist or stroke specialist with the specific intent of monitoring stroke incidence, the error rate is below 2%.19 49 Only truly prospective studies that pursue cases as they occur—termed "hot pursuit"—provide this degree of accuracy.
Retrospective collection of information ("cold pursuit") is more liable to cause blurring of the margin between TIAs and strokes than is the hot-pursuit method. One of the reasons for increased accuracy with prospective design is that a clinician managing an individual patient has a different agenda from a study epidemiologist or neurologist measuring incidence in the population. The clinician recognizes that making a precise distinction between a TIA lasting 20 hours and a minor stroke with resolution of symptoms by 30 hours is unnecessary because it will affect neither prognosis nor management. Because this information is not considered relevant, it may either be documented inaccurately or not recorded at all. For the investigator wishing to compare different studies of stroke incidence the distinction, albeit artificial, is important. A further example is the assessment of a patient's history. Previous strokes, minor ones in particular, are much more likely to be ascertained prospectively by a study neurologist or epidemiologist aware of the importance of including only first-ever-in-a-lifetime strokes in the incidence figures.
Many centers in the WHO MONICA study use the cold-pursuit approach, with review of records after hospital discharge and death certificates as the main sources of cases.1 This will provide valuable information about incidence trends as long as diagnostic methods remain constant. Cold-pursuit methods have the advantage of consuming considerably less time and resources than hot-pursuit ones. However, it may be invalid to compare studies using this method with each other or with those using the hot-pursuit method without knowing how overall case ascertainment is affected in any particular center. Centers best suited to cold pursuit will require a very reliable records system and should be able to demonstrate that hot-pursuit methods do not materially alter case ascertainment.
Studies based entirely on retrospective reviews of records depend on complete record ascertainment for the whole community and accurate documentation. These are rarely demonstrated, but exceptions may exist. For example, the Mayo Clinic has a records system that appears to be unique in its complete, reliably documented coverage of the whole Rochester community. In this particular case, as long as the information is appropriately accessed, retrospective methods may be considered as reliable as prospective methods.54
The Study Population
The best populations are well defined (usually, but not always, on a geographic basis) and stable, with limited in- and out-migration. Investigators cannot manipulate populations: they simply have to be opportunistic in selecting what is available. Relatively isolated populations, for example, the inhabitants of Japan's Okinawa islands42 or the Valle d'Aosta in northern Italy,20 are particularly suitable. Such situations limit the "cross-boundary effect" in which cases are either missed, because they occur while a resident is outside the study area, or are included erroneously when they occur in visitors who are not permanent residents. Unstable populations, with frequent permanent changes of residence into and out of the study area, are less reliable. However, the more isolated a population is, the less representative of its country it may be because of the effects of such factors as a restricted gene pool and special dietary habits. A sensibly selected population takes these various opposing factors into account. Populations composed of healthy self-selected volunteers or excluding certain disease states (for example, the Framingham Study55 ) are not really suitable for a comparable incidence study.
The size of the population is important because the larger the population, the more strokes are likely to occur within the monitoring period, and the confidence interval around estimates of incidence is dependent on the number of strokes contributing to the estimate.56 There is no perfect population size. Because most strokes occur in the elderly, populations with a high proportion of older people will yield more strokes for the same total population size than will younger populations. Monitoring too large a population is difficult without extensive resources and may lead to undercounting. Some investigators increase the number of stroke cases by monitoring the same population for several years (but ideally not more than 5; see below) for a single estimate based on the number of person-years observed.15 16 17 18 19 24 57 It is suggested that below approximately 250 cases the confidence interval becomes unacceptably wide. For populations with a Western European type of structure, this will require approximately 100 000 person-years of observation. Estimates of incidence from many cohort studies have limited precision because of small population size.55 58 59 It is emphasized that although they provide an idea of the statistical precision of the estimate, confidence intervals do not allow for methodological flaws such as incomplete case ascertainment.
The accuracy of determining the denominator must also be considered. Investing resources in obsessional case finding is inappropriate unless reliable and up-to-date information on the age and sex structure of the population is also available. For an appropriately large population (see above), minor inaccuracies have little effect on incidence rates but major ones must be avoided. Most studies use official census statistics, which are usually (but not always60 ) reliable in developed countries. Their unreliability in developing countries makes them inappropriate for estimating denominator size. Unfortunately, few populations will have census information for every year. Studies performed during the census year can use the census data as they stand.11 25 Those performed between censuses require an estimate of the denominator. Official updates of the census rely on information about births, deaths, and in- and out-migration.4 13 Because these are often inaccurate (Sweden, with accurate updates fortnightly, is an exception), investigators may prefer to rely on interpolation of census data, based on prior trends.15 The error can be estimated when subsequent census statistics become available. In general, it increases with the time from the last census. In populations in which the vast majority of people are registered with a general practitioner, the denominator may be based on the age/sex registers of general practices.14 One potential problem here is the existence of "ghosts": patients who have died or moved but who have not yet been removed from the practice list.
A further consideration is that incidence measurements should really be based on the population at risk. This implies that we should remove from the denominator any prevalent cases, ie, those who have already suffered a stroke. In practice, the information is simply not available to the vast majority of investigators so that adjustments for prevalence are not made. We can assume that the effect in the younger age groups in whom prevalence is low would be minimal. In older age groups the effect in those populations where it has been assessed appears to be significant (R. Brown, unpublished data, 1995).
Standard Data Presentation
Data collected over complete years avoids confounding from the possible effect of seasonal variations in incidence documented in several community-based studies.61 62 63 From the Rochester group's results, it appears that incidence rates can vary secularly over periods of approximately 5 years.5 This implies that rates should not be averaged over time intervals longer than 5 years and that comparisons between different studies should be confined to similar points in time.
Most stroke epidemiologists use mid-decade 10-year age bands (eg, 45 to 54, 55 to 64 years). It seems reasonable to retain this convention in publications. However, it is helpful to collect data for both numerator and denominator in narrower 5-year bands for two reasons. First, in some other areas of epidemiology the convention is to use 10-year age bands spanning a complete decade (eg, 50 to 59, 60 to 69 years).64 The availability of 5-year age bands allows comparisons between studies presenting data by nonmatching 10-year age bands, including those investigating the incidence of other diseases. Second, the distribution of ages within a 10-year age band may vary considerably between populations. Incidence rates in different studies can be compared either by looking at age-specific rates for a particular age band or by comparing age-standardized rates. The use of narrower age bands (5 rather than 10 years) reduces the effect on age-standardized rates of variability of age distribution within each age band, especially that occurring within the open-ended upper age group. Differences in incidence rates between populations may otherwise simply reflect a different distribution of ages within each age band. This effect was regarded by one reviewer as a potential explanation for the variation in incidence rates with time in the Rochester series.65 Thus, while it would be cumbersome to include rates for 5-year age groups in publications, it is helpful to have them available for comparisons with other studies and time trend studies. The population chosen for age standardization should be appropriate to the study populations. A comparison of stroke incidence rates among countries in Europe might use Segi's notional European population.66 Segi's world population would be more appropriate for a true worldwide comparison. Because of potential differences between the sexes, rates should be sex- as well as age-standardized. Age-specific rates should be presented separately for men and women.
Measuring and Comparing Incidence of Pathological Types of Stroke
Main Pathological Types
The heterogeneity of stroke is a challenge for clinical epidemiologists. The standard WHO definition31 encompasses cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage. Our ability to distinguish the first two pathological types without neuroimaging (usually CT scanning, occasionally MRI) or, in fatal cases, autopsy, is limited.50 It is therefore not possible to draw firm conclusions about the incidence rates of pathological types of stroke in studies using mainly clinical criteria. In the Rochester series, the introduction of CT scanning caused an apparent increase in the rate of intracerebral hemorrhage because of the increased detection rate for small hemorrhages that would previously have been classified as infarcts.67 For many years, particularly high rates of primary intracerebral hemorrhage (22% to 36%) have been reported from countries in the Far East. These reports are from community-based studies with low CT scan rates,6 43 cohort studies with very small study populations,59 or hospital series that have high CT rates but that cannot be assumed to be representative of the whole community.68 69 Newer studies with both high rates of CT scanning and more complete case ascertainment42 are helping to resolve this issue, but there is still a lack of reliable, community-based information on pathological types from this part of the world. It is only when we have confirmation that the apparent excess of cerebral hemorrhages is real that searching for potential causes of this difference will be justified.
Definitions must be standardized for comparisons. We recommend the scheme used in the Oxfordshire Community Stroke Project.57 Appropriately timed CT scan (see below) or autopsy is required to distinguish infarct from intracerebral hemorrhage. The definition of subarachnoid hemorrhage is based on a typical clinical history with CT or lumbar puncture evidence of subarachnoid blood or angiographic demonstration of a source of bleeding. The distribution of pathologies can only be estimated accurately if the proportion with undetermined pathology is small. The problem of falling autopsy rates has been partly overcome in the Dijon Stroke Registry by postmortem CT scans (M. Giroud, unpublished data, 1994). It will never be possible to assign a definite pathological type to every incident case, but an acceptably accurate type can be ascribed to a proportion of cases without CT scan or autopsy. In line with the Oxfordshire Community Stroke Project, we consider it acceptable to use a well-validated clinical scoring system (such as the Guy's Hospital or Siriraj Score) for pathological diagnosis in those cases without CT scan or autopsy, provided the score is at one or the other extreme, giving a diagnostic accuracy for hemorrhage or infarct of 90% or more.70 71 72 For management of individual patients it is often important to be 100% certain about the distinction between infarct and hemorrhage, leading to criticism of these scores in clinical practice.73 However, it seems reasonable to use them for epidemiological studies as long as there is no consistent bias in one direction or the other. Two community-based studies have used clinical scores in combination with high (approximately 70%) CT rates in this way.19 57 Several others have high enough rates of CT scanning (above an arbitrarily selected level of approximately 70%) and autopsy diagnoses to make them suitable for examination of pathological types.16 20 21 23 24
The timing of neuroimaging is important. Several studies consider a CT scan within about 30 days of stroke to be reliable in distinguishing infarct from intracerebral hemorrhage.19 23 57 MR scanning may continue to be helpful after this stage,23 but its availability is often limited. Although it has been demonstrated that a number of small primary intracerebral hemorrhages may be indistinguishable from infarcts on CT scan as early as 2 weeks after onset,74 studies of serially scanned hemorrhages are not large enough to tell us what proportion of hemorrhages we may be misinterpreting as infarcts by performing scans after 2 weeks.75 The 30-day cutoff may still be reasonable for epidemiological purposes, but we do not know. Many centers now scan most cases very early, within 24 hours of onset. However, the issue is important for those countries with many stroke patients managed outside the hospital, with limited scanning facilities and long prescan waiting times.
With early scanning there is concern about misdiagnosis of some cases of hemorrhagic transformation of infarct as primary hemorrhage. There is increasing evidence that such transformation may occur very early, even within hours of stroke onset.76 For the moment this is another unresolved issue but one of which we need to be aware.
The ability of increasing numbers of community-based studies to provide accurate information on pathological types will enhance geographic comparisons. We will be able not only to compare the incidence of these types between countries but also to investigate more closely the difference in incidence between men and women. While it appears that the incidence of myocardial infarction is four to five times greater in men than in women, the incidence of total stroke varies much less between the sexes.77 One reason for this might be that greater differences are hidden until the pathological types are examined separately.
Subtypes of Cerebral Infarction
Cerebral infarction has a number of possible etiologies with differing patterns of clinical presentation and outcome. There is no generally accepted way of classifying these subtypes. We favor the classification developed by Bamford et al,78 dividing cerebral infarction on the basis of simple clinical criteria into four subtypes: total anterior circulation infarction, partial anterior circulation infarction, lacunar infarction, and posterior circulation infarction. This classification is reasonably predictive of etiology,79 prognosis,78 and the size and site of cerebral infarction on CT scanning80 and has reasonable interobserver agreement.81 Furthermore, it is of particular value for epidemiological comparisons because, unlike some classification systems,82 83 it does not require a large number of often invasive investigations. Even in centers with easy access to such investigations, there remain many (40% to 50%) infarcts of undetermined cause. Meticulous searching for a cause may be clinically appropriate in individual cases, but for epidemiological studies the exclusion of a large number of patients from assignment of specific subtypes would make the overall analysis an unrepresentative one.
A few studies fulfilling the core criteria for comparability have been able to apply this classification system to their cases of cerebral infarction.19 78 84 Others have been able to at least define lacunar infarction as a separate group16 24 with the use of the same clinical criteria.
The above discussion is an attempt to create a framework for establishing future studies and for deciding which of the incidence studies performed to date are suitable for international comparisons. The worldwide visits that contributed so much to its content also led to the formation of a collaborative group of comparable studies of stroke incidence. Both qualitative and quantitative data are being collected and will be presented separately.
Table 2⇑ summarizes the major standard criteria that make a study of stroke incidence comparable with others. The ideal study does not exist in reality. However, to make sense of geographic and secular comparisons, we should recognize that the studies that come close to the ideal are the most likely to provide reliable and comparable results. In comparing studies that use standard definitions and make a concerted effort to search for out-of-hospital strokes, the major source of potential error is still likely to be variable case finding. Methods must vary between locations because of differences in healthcare systems. Comparing the relative efficiency of these methods is difficult. The possibility of comparing incidence of accurately assigned pathological types and subtypes of cerebral infarction is an interesting new prospect, based on advances in imaging technology that are becoming increasingly widely available.
Our aim should be to use the lessons from previous incidence studies to design even better ones. The challenge is not only to explain the results that we have but also to find out what we can about stroke incidence in Africa, Asia, South America, and other areas about which so little is known but where so many of the world's people live. In developing countries, we might expect that, as life expectancy increases and the high-risk behaviors (eg, smoking, diet) of the Western lifestyle are increasingly adopted, strokes will be an escalating problem. Governments and makers of health policy are in no position to plan for the prevention of diseases that are an unknown quantity.
The worldwide visits for discussions with international investigators were made possible by the kind hospitality of colleagues and friends in Sweden, Denmark, Poland, Italy, France, Japan, Australia, New Zealand, and the United States, with generous financial support from the Edinburgh Stroke Research Fund, the Guarantors of Brain, the Royal College of Physicians of Edinburgh Myre Sim Bequest, Lilly Industries Limited, Bayer plc, and Boehringer Ingelheim Limited. We thank Martin Dennis, Peter Sandercock, and Mark Sudlow for their helpful comments on the manuscript.
Reprint requests to Dr Cathie Sudlow, Registrar in Medical Neurology, Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, Scotland.
- Received July 20, 1995.
- Revision received December 19, 1995.
- Accepted December 22, 1995.
- Copyright © 1996 by American Heart Association
- ↵
- ↵
Thorvaldsen P, Asplund K, Kuulasmaa K, Rajakangas A, Schroll M, for the WHO MONICA Project. Stroke incidence, case fatality, and mortality in the WHO MONICA Project. Stroke. 1995;26:361-367.
- ↵
- ↵
- ↵
- ↵
Tanaka H, Ueda Y, Date C, Baba T, Yamashita H, Hayashi M, Shoji H, Owada K, Baba K, Shibuya M, Koa T, Detels R. Incidence of stroke in Shibata, Japan: 1976-1978. Stroke. 1981;12:460-466.
- ↵
Herman B, Schulte BP, van Luijk JH, Leyten AC, Frenken CW. Epidemiology of stroke in Tilberg, the Netherlands: the population-based stroke incidence register, I: introduction and preliminary results. Stroke. 1980;11:162-165.
- ↵
Herman B, Leyten AC, van Luijk JH, Frenken CW, Op de Coul AA, Schulte BP. Epidemiology of stroke in Tilberg, the Netherlands: the population-based stroke incidence register, II: incidence, initial clinical picture and medical care, and three week case fatality. Stroke. 1982;13:629-634.
- ↵
Kotila M. Declining incidence and mortality of stroke? Stroke. 1984;15:255-259.
- ↵
- ↵
Bonita R, Beaglehole R, North JD. Event, incidence and case fatality rates of cerebrovascular disease in Auckland, New Zealand. Am J Epidemiol. 1984;120:236-243.
- ↵
Ashok PP, Radhakrishnan K, Sridharan R, el-Mangoush MA. Incidence and pattern of cerebrovascular diseases in Benghazi, Libya. J Neurol Neurosurg Psychiatry. 1986;49:519-523.
- ↵
Terent A. Increasing incidence of stroke among Swedish women. Stroke. 1988;19:598-603.
- ↵
Sandercock PAG, Warlow CP, Price SM. Incidence of stroke in Oxfordshire: first year's experience: Oxfordshire Community Stroke Project. Br Med J. 1983;287:713-717.
- ↵
Broderick JP, Phillips SJ, Whisnant JP, O'Fallon WM, Bergstrahl EJ. Incidence rates of stroke in the eighties: the end of the decline in stroke? Stroke. 1989;20:577-582.
- ↵
Giroud M, Milan C, Beuriat P, Gras P, Essayagh E, Arveux P, Dumas R. Incidence and survival rates during a two-year period of intracerebral and subarachnoid haemorrhages, cortical infarcts, lacunes and transient ischaemic attacks: the stroke registry of Dijon: 1985-1989. Int J Epidemiol. 1991;20:892-899.
- ↵
- ↵
Giroud M, Gras P, Chadan N, Beuriat P. Milan C, Arveux P, Dumas R. Cerebral haemorrhage in a French prospective population study. J Neurol Neurosurg Psychiatry. 1991;54:595-598.
- ↵
Ricci S, Celani MG, La Rosa F, Vitali R, Duca E, Ferraguzzi R, Paolotti M, Seppoloni D, Caputo N, Chirulla C, Scaroni R, Signorini E. SEPIVAC: a community-based study of stroke incidence in Umbria, Italy. J Neurol Neurosurg Psychiatry. 1991;54:695-698.
- ↵
D'Alessandro G, Di Giovanni M, Roveyaz L, Ianizzi L, Compagnoni MP, Blanc S, Bottacchi E. Incidence and prognosis of stroke in the Valle d'Aosta, Italy: first-year results of a community-based study. Stroke. 1992;23:1712-1715.
- ↵
Jorgensen HS, Plesner AM, Hubbe P, Larsen K. Marked increase of stroke incidence in men between 1972 and 1990 in Frederiksberg, Denmark. Stroke. 1992;23:1701-1704.
- ↵
- ↵
- ↵
Czlonkowska A, Ryglewicz D, Weissbein T, Baranska-Gieruszczak M, Hier DB. A prospective community-based study of stroke in Warsaw, Poland. Stroke. 1994;25:547-551.
- ↵
- ↵
- ↵
- ↵
Corwin LE, Wolf PA, Kannel WB, McNamara PM. Accuracy of death certification of stroke: the Framingham Study. Stroke. 1982;13:818-821.
- ↵
- ↵
Bonita R, Stewart A, Beaglehole R. International trends in stroke mortality: 1970-1985. Stroke. 1990;21:989-992.
- ↵
- ↵
- ↵
- ↵
Hansen BS, Marquardsen J. Incidence of stroke in Frederiksberg, Denmark. Stroke. 1977;8:663-665.
- ↵
Yuling H, Bots ML, Pan X, Hofman A, Grobbee DE, Chen H. Stroke incidence and mortality in rural and urban Shanghai from 1984 through 1991. Stroke. 1994;25:1165-1169.
- ↵
Bamford J, Sandercock P, Warlow C, Gray M. Why are patients with acute stroke admitted to hospital? Br Med J. 1986;292:1369-1372.
- ↵
Tuomilehto J, Sarti C, Narva EV, Salmi K, Sivenius J, Kaarsalo E, Salomaa V, Torppa J. The FINMONICA Stroke Register: community-based stroke registration and analysis of stroke incidence in Finland, 1983-1985. Am J Epidemiol. 1992;135:1258-1270.
- ↵
- ↵
Rosman KD. The epidemiology of stroke in an urban black population. Stroke. 1986;17:667-669.
- ↵
Matenga K, Kitai I, Levy L. Strokes among black people in Harare, Zimbabwe: results of computed tomography and associated risk factors. Br Med J. 1986;292:1649-1651.
- ↵
- ↵
- ↵
- ↵
Asplund K, Bonita R, Kuulasmaa K, Rajakangas A, Feigin V, Schaedlich H, Suzuki K, Thorvaldsen P, Tuomilehto J. Multinational comparisons of stroke epidemiology: evaluation of case ascertainment in the WHO MONICA Stroke Study. Stroke. 1995;26:355-360.
- ↵
McCarty DJ, Tull ES, Moy CS, Kwoh CK, LaPorte RE. Ascertainment corrected rates: applications of capture-recapture methods. Int J Epidemiol. 1993;22:559-565.
- ↵
Bruno G, LaPorte RE, Merletti F, Biggeri A, McCarty D, Pagano G. National Diabetes Programs: application of capture-recapture to count diabetes? Diabetes Care. 1994;17:548-556.
- ↵
Hook EB, Regal RR. Effect of variation in probability of ascertainment by sources ('variable catchability') upon 'capture-recapture' estimates of prevalence. Am J Epidemiol. 1993;137:1148-1166.
- ↵
Dennis MS, Bamford JM, Sandercock PA, Warlow CP. Incidence of transient ischemic attacks in Oxfordshire, England. Stroke. 1989;20:333-339.
- ↵
Sandercock P, Molyneux A, Warlow C. Value of computed tomography in patients with stroke: Oxfordshire Community Stroke Project. Br Med J. 1985;290:193-197.
- ↵
Allen C. Clinical diagnosis of acute stroke syndrome. Q J Med. 1983;52:515-523.
- ↵
Britton M, Hindmarsh T, Murray V, Tuden S. Diagnostic errors discovered by CT in patients with suspected stroke. Neurology. 1984;34:1504-1507.
- ↵
Giroud M, Binnert D, Dumas R. Les erreurs diagnostic etiologique corrigees par la scanographie au cours d'une hemiplegie aigue. La Presse Medicale. 1986;15:2061-2063.
- ↵
- ↵
- ↵
Wolf PA, D'Agostino RB, O'Neal A, Sytkowski P, Kase CS, Belanger AJ, Kannel WB. Secular trends in stroke incidence and mortality: the Framingham Study. Stroke. 1992;23:1551-1555.
- ↵
Gardner MJ, Altman DG. Statistics With Confidence. London, England: British Medical Journal Publications; 1989:61-62.
- ↵
Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-1986, II: incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral haemorrhage and subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1990;53:16-22.
- ↵
Lindenstrom E, Boysen G, Nyboe J, Appleyard M. Stroke incidence in Copenhagen, 1976-1988. Stroke. 1992;23:28-32.
- ↵
Hu H, Sheng W, Chu F, Lan C, Chiang B. Incidence of stroke in Taiwan. Stroke. 1992;23:1237-1241.
- ↵
Raleigh VS, Balarajan R. Public health and the 1991 census. Br Med J. 1994;309:287-288.
- ↵
Christie D. Stroke in Melbourne, Australia: an epidemiological study. Stroke. 1981;12:467-469.
- ↵
- ↵
Shinkawa A, Ueda K, Hasuo Y, Kiyohara Y, Fujishima M. Seasonal variation in stroke incidence in Hisayama, Japan. Stroke. 1990;21:1262-1267.
- ↵
- ↵
Kuller LH. Incidence rates of stroke in the eighties: the end of the decline in stroke? Stroke. 1989;20:841-843.
- ↵
Waterhouse J, ed. Cancer Incidence in Five Continents. Lyon, France: IARC; 1976.
- ↵
Drury I, Whisnant JP, Garraway WM. Primary intracerebral haemorrhage: impact of CT on incidence. Neurology. 1984;34:653-657.
- ↵
Suzuki K, Kutsuzawa T, Takita K, Ito M, Sakamoto T, Hirayama A, Ito T, Ishida T, Ooishi H, Kawakami K, Hirota K, Ogasawara T, Toshida J, Tamura T, Hattori S, Iwabuchi S, Karouji Y, Waga T, Oosato Y, Yazaki K, Saito T, Oouchi T, Kojima S. Clinico-epidemiological study of stroke in Akita, Japan. Stroke. 1987;18:402-406.
- ↵
Kay R, Woo J, Kreel L, Wong HY, Tech R, Nicholls MG. Stroke subtypes among Chinese living in Hong Kong: the Shatia Stroke Registry. Neurology. 1992;42:985-987.
- ↵
Sandercock P, Allen C, Corston R, Harrison M, Warlow C. Clinical diagnosis of intracranial haemorrhage using Guy's Hospital Score. Br Med J. 1985;291:1675-1677.
- ↵
Poungvarin N, Viriyavejakul A, Komontri C. Siriraj Stroke Score and validation study to distinguish supratentorial intracerebral haemorrhage from infarction. Br Med J. 1991;302:1565-1567.
- ↵
Celani MG, Righetti E, Migliacci R, Zampolini M, Antoniutti L, Grandi FC, Ricci S. Comparability and validity of two clinical scores in the early differential diagnosis of acute stroke. Br Med J. 1994;308:1674-1676.
- ↵
- ↵
Dennis M, Bamford J, Molyneux A, Warlow C. Rapid resolution of signs of PICH in CT of brain. Br Med J. 1987;95:379-381.
- ↵
- ↵
Bogousslavsky J, Regli F, Uske A, Maeder P. Early spontaneous hematoma in cerebral infarct: is primary cerebral hemorrhage overdiagnosed? Neurology. 1991;41:837-840.
- ↵
Wolf PA, Lewis A. Conner lecture: contributions of epidemiology to the prevention of stroke. Circulation. 1993;88:2471-2478.
- ↵
- ↵
Naylor AR, Sandercock PAG, Sellar RJ, Warlow CP. Patterns of vascular pathology in acute, first-ever cerebral infarction. Scottish Med J. 1993;38:41-44.
- ↵
Wardlaw JM, Dennis MS, Lindley RI, Sellar RJ, Warlow CP. The validity of a simple clinical classification of acute ischaemic stroke. J Neurol. In press.
- ↵
Lindley RI, Warlow CP, Wardlaw JM, Dennis MS, Slattery J, Sandercock PAG. Interobserver reliability of a clinical classification of acute cerebral infarction. Stroke. 1993;24:1801-1804.
- ↵
Adams HP, Bendixen BH, Kappelle J, Biller J, Love BB, Gordon DL, Marsh EE, and the TOAST Investigators. Classification of subtype of ischemic stroke: definitions for use in a multicenter trial. Stroke. 1993;24:35-41.
- ↵
- ↵
Anderson CS, Taylor BV, Hankey GJ, Stewart-Wynne EG, Jamrozik KD. Validation of a clinical classification for subtypes of acute cerebral infarction. Stroke. 1994;57:1173-1179.
This Issue
Jump to
Article Tools
- Comparing Stroke Incidence WorldwideC.L.M. Sudlow and C.P. WarlowStroke. 1996;27:550-558, originally published March 1, 1996http://dx.doi.org/10.1161/01.STR.27.3.550
Citation Manager Formats
Share this Article
- Comparing Stroke Incidence WorldwideC.L.M. Sudlow and C.P. WarlowStroke. 1996;27:550-558, originally published March 1, 1996http://dx.doi.org/10.1161/01.STR.27.3.550
Related Articles
- No related articles found.
Cited By...
- Why do transient ischemic attack patients have higher early stroke recurrence risk than those with ischemic stroke? Influence of patient behavior and other risk factors in the North Dublin Population Stroke Study
- Changes in stroke incidence, outcome, and associated factors in Porto between 1998 and 2011
- Stroke Epidemiology in an Australian Rural Cohort (SEARCH)
- Subarachnoid hemorrhage: Another reason not to smoke
- The epidemiology of stroke in the Middle East
- Cerebrovascular Disease in Rheumatic Diseases: A Systematic Review and Meta-Analysis
- Incidence, short-term outcome, and spatial distribution of stroke patients in Ludhiana, India
- Falls and fractures 2 years after acute stroke: the North Dublin Population Stroke Study
- Countrywide Stroke Incidence, Subtypes, Management and Outcome in a Multiethnic Asian Population: The Singapore Stroke Registry -- Methodology
- Stroke associated with giant cell arteritis: a population-based study
- Hospitalization Within the First Year After Stroke: The Dijon Stroke Registry
- Part I: Frequency of Depression after Stroke: An Updated Systematic Review and Meta-Analysis of Observational Studies
- Mortality following stroke during and after acute care according to neighbourhood deprivation: a disease registry study
- Trends in Incidence and Early Outcomes in a Black Afro-Caribbean Population From 1999 to 2012: Etude Realisee en Martinique et Centree sur l'Incidence des Accidents Vasculaires Cerebraux II Study
- Prevalence and prognostic value of headache on early mortality in acute stroke: The Dijon Stroke Registry
- Incidence and Outcome of Cerebrovascular Events Related to Cervical Artery Dissection: The Dijon Stroke Registry
- Geomagnetic Storms Can Trigger Stroke: Evidence From 6 Large Population-Based Studies in Europe and Australasia
- Trends in the incidence of ischaemic stroke in young adults between 1985 and 2011: the Dijon Stroke Registry
- Clinical Associations and Causes of Convexity Subarachnoid Hemorrhage
- Methodology of a Population-Based Stroke and TIA Incidence and Outcomes Study: The Auckland Regional Community Stroke Study (ARCOS IV) 2011-2012
- Global Stroke Statistics
- Age and Ethnic Disparities in Incidence of Stroke Over Time: The South London Stroke Register
- Stroke Incidence and 30-Day and Six-Month Case Fatality Rates in Udine, Italy: A Population-Based Prospective Study
- Program for the Epidemiological Evaluation of Stroke in Tandil, Argentina (PREVISTA) Study: Rationale and Design
- Epidemiology of stroke and its subtypes in Chinese vs white populations: A systematic review
- Stroke Tracked by Administrative Coding Data: Is it Fair?
- Impact of Completeness of Ascertainment of Minor Stroke on Stroke Incidence: Implications for Ideal Study Methods
- Population-Based Study of Incidence and Outcome of Acute Aortic Dissection and Premorbid Risk Factor Control: 10-Year Results From the Oxford Vascular Study
- Adelaide Stroke Incidence Study: Declining Stroke Rates but Many Preventable Cardioembolic Strokes
- Intracerebral haemorrhage profiles are changing: results from the Dijon population-based study
- Baseline Smoking Status and the Long-Term Risk of Death or Nonfatal Vascular Event in People with Stroke: A 10-Year Survival Analysis
- Incidence, Event Rates, and Early Outcome of Stroke in Dublin, Ireland: The North Dublin Population Stroke Study
- Impact of Thrombolysis on Stroke Outcome at 12 Months in a Population: The Bern Stroke Project
- Factors associated with quality of life in 7-year survivors of stroke
- Incidence and mortality of aneurysmal subarachnoid hemorrhage in two Norwegian cohorts, 1984-2007
- Epidemiology of Stroke in Italy
- Incidence of Stroke and Socioeconomic Neighborhood Characteristics: An Ecological Analysis of Dijon Stroke Registry
- Prevalence of Early Dementia After First-Ever Stroke: A 24-Year Population-Based Study
- Design of the China Epidemiology Research in Subarachnoid Haemorrhage (CHERISH) Study
- Incidence and Case-Fatality of Stroke on the East Border of the European Union: The Grodno Stroke Study
- Auckland Stroke Outcomes Study: Part 1: Gender, stroke types, ethnicity, and functional outcomes 5 years poststroke
- Stroke Incidence and Survival in Ludwigshafen am Rhein, Germany: The Ludwigshafen Stroke Study (LuSSt)
- Disability Burden Due to Stroke in Western Australia: New Insights from Linked Data Sources
- Protocol and Pilot Data for Establishing the Australian Stroke Clinical Registry
- Sex differences in presentation, severity, and management of stroke in a population-based study
- Excessive Incidence of Stroke in Iran: Evidence From the Mashhad Stroke Incidence Study (MSIS), a Population-Based Study of Stroke in the Middle East
- Diagnostic Usefulness of the ABCD2 Score to Distinguish Transient Ischemic Attack and Minor Ischemic Stroke From Noncerebrovascular Events: The North Dublin TIA Study
- Incidence and Case Fatality of Subarachnoid Haemorrhage in Northern Greece: The Evros Registry of Subarachnoid Haemorrhage
- Sociodemographic differences in return to work after stroke: the South London Stroke Register (SLSR)
- Initial management of suspected transient cerebral ischaemia and stroke in primary care: implications of recent research
- Trends in stroke incidence, mortality and case fatality rates in Joinville, Brazil: 1995-2006
- Incidence of stroke subtypes, prognosis and prevalence of risk factors in Joinville, Brazil: a 2 year community based study
- Incidence of Stroke in Europe at the Beginning of the 21st Century
- Sex Differences in Stroke Epidemiology: A Systematic Review
- Differences in the Nature of Stroke in a Multiethnic Urban South African Population: The Johannesburg Hospital Stroke Register
- Epidemiology of ischemic stroke from atrial fibrillation in Dijon, France, from 1985 to 2006
- Ischaemic stroke subtypes and associated risk factors: a French population based study
- Low Incidence of Stroke in Southern Italy: A Population-Based Study
- Ethnic Group Disparities in 10-Year Trends in Stroke Incidence and Vascular Risk Factors: The South London Stroke Register (SLSR)
- Patterns of smoking cessation in the first 3 years after stroke: the South London Stroke Register
- Stroke Incidence and Survival in the Beginning of the 21st Century in Southern Sweden: Comparisons With the Late 20th Century and Projections Into the Future
- Stroke Incidence, Prognosis, 30-Day, and 1-Year Case Fatality Rates in Matao, Brazil: A Population-Based Prospective Study
- Is prestroke use of angiotensin-converting enzyme inhibitors associated with better outcome?
- Surveillance and Measuring Trends of Stroke in Japan: The Takashima Stroke Registry (1988 - Present)
- A Prospective Community-Based Study of Stroke in Kolkata, India
- Prevalence of Depression and Use of Antidepressant Medication at 5-Years Poststroke in the North East Melbourne Stroke Incidence Study
- The Epidemiology of Stroke in the East Asian Region: A Literature-Based Review
- The Neglected Burden of Stroke in Sub-Saharan Africa
- Plasma Fibrinogen Concentrations and Risk of Stroke and Its Subtypes Among Japanese Men and Women
- Frequency, Management, and Predictors of Abnormal Mood After Stroke: The Auckland Regional Community Stroke (ARCOS) Study, 2002 to 2003
- Control of Hypertension 5 Years After Stroke in the North East Melbourne Stroke Incidence Study
- Epidemiology of Aphasia Attributable to First Ischemic Stroke: Incidence, Severity, Fluency, Etiology, and Thrombolysis
- Lifetime Cost of Ischemic Stroke in Germany: Results and National Projections From a Population-Based Stroke Registry: The Erlangen Stroke Project
- Greater Incidence of Both Fatal and Nonfatal Strokes in Disadvantaged Areas: The Northeast Melbourne Stroke Incidence Study
- Trends in Ethnic Disparities in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003
- Transient Ischemic Attacks in Rural and Urban Northern Portugal: Incidence and Short-Term Prognosis
- First-Ever Stroke Incidence and 30-Day Case Fatality in the Sicilian Aeolian Archipelago, Italy
- The Third Stroke Registry in Tartu, Estonia: Decline of Stroke Incidence and 28-Day Case-Fatality Rate Since 1991
- Trends in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003
- Long-Term Outcome in the North East Melbourne Stroke Incidence Study: Predictors of Quality of Life at 5 Years After Stroke
- Community-Based Stroke Incidence in a Scottish Population: The Scottish Borders Stroke Study
- Frequency of Depression After Stroke: A Systematic Review of Observational Studies
- Stroke in South West Nigeria: A 10-Year Review
- Family History of Stroke in Patients With Transient Ischemic Attack in Relation to Hypertension and Other Intermediate Phenotypes
- Stroke Incidence and 30-Day Case-Fatality in a Suburb of Tbilisi: Results of the First Prospective Population-Based Study in Georgia
- Quality of Life After Stroke: The North East Melbourne Stroke Incidence Study (NEMESIS)
- Progressive dementia after first-ever stroke: A community-based follow-up study
- Direct Assessment of Completeness of Ascertainment in a Stroke Incidence Study
- Editorial Comment--Stroke Incidence Studies One Step Closer to the Elusive Gold Standard?
- Prospective Community-Based Study of Stroke in Northern Portugal: Incidence and Case Fatality in Rural and Urban Populations
- Very Long-Term Outcome After Stroke in Auckland, New Zealand
- Increasing Stroke Incidence in Sweden Between 1989 and 2000 Among Persons Aged 30 to 65 Years: Evidence From the Swedish Hospital Discharge Register


text: Rochelle takes baby Alaia to see daddy on JLS tour News & Gossip Celebrity news 0 with our partner Childcare.co.uk I'm looking for a… Please Select All childcare services Parent/family seeking childcare Babysitter Childminder Nanny Au Pair Nursery Private Midwife Nursery Nurse Maternity Nurse Private Tutor School Near the following postcode… The Saturdays singer surprises husband Marvin with a visit to Brighton gig JLS's Goodbye tour is in full swing this week and singer Marvin Humes' wife, Rochelle, brought their baby daughter down to a performance to surprise him. The Saturdays singer Rochelle shared two pics on Instagram, captioning them "family". And Marvin tweeted a photo of himself and his 7-month-old baby Alaia-Mai, saying: "I loved my surprise today!" The JLS boys, Marvin Humes, Aston Merrygold, JB Gill and Oritsé Williams, are on their final tour before the band splits after 6 years together. They were all surprised by their wives and girlfriends before a performance in Brighton. Later, Marvin tweeted about his wife: "So in love with her… When you find ur best friend & soul mate, it's the best feeling in world... I'm a very, very lucky man… Miss her already x" Awww... Read more... Rochelle Humes has norovirus – and worries for baby Alaia-Mai Rochelle "multitasks" with Alaia-Mai at recording studio Rochelle Humes gives birth to baby girl! By Sonali Hindmarch 0 Comments Share Like this article? Showing of Uh-oh! You need to be logged in to do this... Sign In Sign Up Load more posts Write a comment

subset: commoncrawl


text:
Leave a Reply Name (required) Mail (will not be published) (required) Website XHTML: You can use these tags: a href title abbr title acronym title b blockquote cite cite code del datetime em i q cite strike strong WHAT AM I DOING HERE.babyliss paris curl secret precio uruguay You must get supplements with creatine that could support with the lean muscle mass contractions supplied they bring about considerably with your functionality and energy, just in case your purpose as an illustration can be to enhance your vitality and sturdiness. So now you are prepared for enjoyable filled, tension free skiing and snowboarding vacation there is just one thing delegated do have a good time.
Flash Flood should never be used for dumb phones (any regular cell phone) as there are too many holes in the keypads and other areas for you to safely cover and effectively seal.babyliss curl secret comprar maquillalia italia IN NO EVENT WILL RX, ITS AFFILIATES OR LICENSORS BE LIABLE TO YOU OR ANYONE ELSE FOR ANY DECISION MADE OR ACTION TAKEN BY YOU IN RELIANCE ON SUCH INFORMATION. Applications are open until Feburary 2016 and will be considered by a panel of judges including Birkbeck Creative Writing MA Co ordinator Julia Bell, senior lecturer and author Benjamin Wood, professor Russell Ceyln Jones, senior lecturer Toby Litt, and Paul Sherreard from Spread the Word.nouveau boucleur babyliss curl nano
My Abstract Art Series is heavily influenced by nature and the environment and focuses on trying to show the beauty found in the every day and overlooked world we live in. Back in my first year a discussion came up in lecture about web presence of my work, from there Bear hat Illustrations was born. Copyright The Student Room 2016 all rights reserved The Student Room, Get Revising and Marked by Teachers are trading names of The Student Room Group Ltd.babyliss i pro icurl 230 titanium ceramic tile
Again, whether you fully believe Donaghy or not, he does provide a fascinating perspective into the world of refereeing that simply no one else can provide.


text:
Triple is a clever plywood stool with interchangable legs, designed by Chris Hardy.
Classic meets contemporary in the Kruze seating collection, designed by David Fox for Boss Design Group.
Combining digital manufacturing and traditional metalworking techniques, Cinnamon Lee has created an interactive lighting installation for COTA in Sydney.
Husk Armchair
Designed by Patricia Urquiola, the Husk armchair features a recycled plastic shell and soft, quilted cushions.
Vue Chairs
Ross Didier's bespoke furniture pieces, created for Melbourne's revamped Vue de monde, explore the craft of designing with kangaroo skin.
Shortstop child's stool
A bright, versatile and durable collection of children's furniture, designed by In Your Room's Keryn Hughes.
nu – dance with light
ilan.el's nu light is inspired by the movement of the body in Japanese dance, Butoh.
A flexible new ottoman range created by Busk + Hertzog, designed for waiting and reception areas.


text:
Capitol Chevrolet Body Shop
Featured Business
Complete Automotive200 White Park Dr
Dallas, GA 30132-5016
133.9 miles away
10/20/2016 - "The personal touch is amazing!"
"We have been customers for over a decade. I am sorry to say that we left Complete Automotive for a..."
Review for Capitol Chevrolet Body Shop
Mary L. on 11/08/2012
Spoke with Mary's husband. He said everything was great and they did exactly what they said they would do.
Category: Collision
Service Date: 10/31/2012
Review Created: 11/08/2012
This review was collected via phone interview by Customer Research Inc.


text:
- For accurate prices please enter the date of your trip!
- Provision can be requested on the spot
Our best offer
39.60 € / person / night, without provision
Description of the Accommodation
Rooms, services The guests of Santemar Santander may stay in 350 nicely furnished, comfortable rooms in Santander. If you feel like having a meal not included in your chosen type of catering, you can always taste local dishes in the restaurant of the hotel. Should you be arriving by car, parking will be available nearby. Car rental service will help you discover the most important attractions. The fans of actively spent leisure time may take the nearby opportunities to play volleyball, go diving, sailing, surfing and rent a boat. The café and the bar have excellent atmosphere for a relaxed evening talk or a personal meeting. In the safe you can secure your valuables. In case you'd bring your laptop along, you may go online via wireless Internet connection (WiFi) available at the hotel. The exact scope of services offered by Santemar Santander (including those for an extra fee) is available on the information sheet below.
Payment Depeding on the selected room, date and price, you may be asked to provide credit card guarantee or to pay by credit card in advance.
Arrival, opening hours The earliest time to check in at the hotel is 15:00, the latest time to check out is 12:00. The personnel of the hotel can speak in Spanish and English with you.
Santemar Santander reservation, room prices Reservation, room prices
- For accurate prices please enter the date of your trip!
Accommodation services
Parking (19 €/night)
WiFi in shared spaces
Car rental nearby, Volleyball facility nearby, Scuba diving nearby, Sailing nearby, Surfing nearby, Boat rental nearby
- Hairdresser's parlour
Garden, Bar, Cafe, Elevator, Safe deposit box
Own restaurant
Hairdryer, Desk in the room, Mini-bar


text:
Five-time world champion Raymond van Barneveld produced the performance of the tournament thus far as he whitewashed Adrian Lewis in round-two of the World Grand Prix, as world champion Gary Anderson safely progressed to the last eight at the Citywest Hotel, Dublin, on Tuesday evening. 809 more words
Tags » Kyle Anderson
World Grand Prix - Day Three Preview
Day three at the World Grand Prix means it's the start of the second round, half of the field have exited the tournament as we are down to the Last 16. 1,752 more words
World Grand Prix- Day One Report!
Reigning champion Robert Thornton and former winner James Wade were both dumped out on the opening night of the World Grand Prix, as Gary Anderson, Adrian Lewis and Raymond van Barneveld all progressed to round-two at the Citywest Hotel in Dublin on Sunday evening. 735 more words
European Darts Trophy: Day One Report!
Kyle Anderson, Vincent van der Voort, Jamie Caven and Joe Cullen all made it through to the second-round of the European Darts Trophy, whilst Mervyn King, Robbie Green, Max Hopp and Jamie Lewis all suffered early exits at the RWE Arena in Muelheim on Friday. 964 more words
International Darts Open: Day One Report!
Chris Dobey, Joe Cullen, Devon Petersen, Kyle Anderson and Ryan Meikle all impressed on the opening day of action at the International Darts Open in Riesa on Friday afternoon, as Jamie Caven, Brendan Dolan, Andy Hamilton and Kevin Painter all suffered early exits. 16 more words
Big win for Goldeyes over Fargo, but wild card lead falls to 2; by Mickey Steen & Chuck Duboff.
© the ol' professor Mickey Steen and Chuck Duboff
The Winnipeg Goldeyes evened up this 4 game series at 2 & 2 with a convincing 14 to 4 win over Fargo. 264 more words
Taylor averages 112 to dismantle Anderson in Sydney!
Phil Taylor remains on course to win a fourth successive Sydney Darts Masters crown, after producing a majestic performance to dismantle world champion Gary Anderson in the quarter-finals at The Star on Friday night. 737 more words


text:
oh my god this is so cute. and the climax part is so funny and epic. i love it -Anonymous
-> Moar adult games! <-
- Related
- Let's Play ... Let's Play With Konata game
Let's Play With Konata: Hentai sex game. Fuck cute girl.
- Jennybot Jennybot game
Jennybot: My life as a teenage robot adult mini game.
- Hatsune Miku Hatsune Miku game
Hatsune Miku: Hentai mini game by Zone.
- Interactive... Interactive Yoko game
Interactive Yoko: Awwwwww.....:3
- Tsumugi Tsumugi game
Tsumugi: K-On! hentai sex game. Uncensored.
- Johnny Test... Johnny Test: Mary Test And Susan Test game
Johnny Test: Mary Test And Susan Test: Tentacle fucking animation by Zone.
- Princess Clara Princess Clara game
Princess Clara: Adult mini Drawn Together blowjob / dressup game.
- Panty And S... Panty And Stocking With Garterbelt game
Panty And Stocking With Garterbelt: Hentai mini by Zone.
- Hiyake On Top Hiyake On Top game
Hiyake On Top: Hentai sex game.
- Kagamin Kagamin game
Kagamin: Hentai mini game.
- Random
- Space Paws Space Paws game
Space Paws: Adult furry game by Taifun Riders. (0.38.2a)
- Liz Titfuck Liz Titfuck game
Liz Titfuck: Adult game.
- Kelly Is Co... Kelly Is Coming Back Home game
Kelly Is Coming Back Home: Adult game.
- What The Ca... What The Cat Dragged In game
What The Cat Dragged In: Interactive furry sex animation by RenegadeRascal.
- Amy Fuck Amy Fuck game
Amy Fuck: Sonic fucking Amy Rose. Game by NitroTitan.
- Hentai Furr... Hentai Furry Gallery 2 game
Hentai Furry Gallery 2: Gallery for furry lovers.
- Wolf Pack Wolf Pack game
Wolf Pack: Adult cartoon game by Okiyo.
- My Little P... My Little Pony Waifu Simulator game
My Little Pony Waifu Simulator: MLP dating sim by Tiarawhy.
- Pinkie Pie ... Pinkie Pie Clop game
- Hot Cops Hot Cops game
Hot Cops: Adult game.


text:
Popular Now
Popular Now
Popular Now
Popular Now
01803 865913
+44 1803 865913
Edited By: KM Stewart and KL Seymour
675 pages, Figs, tabs
The papers focus on late Cenozoic mammals in North America and Africa, and provide site-specific descriptions of faunas and their associated geological contexts, plus more general syntheses of regional palaeoenvironments and biogeography. The volume contains individual discussions of North American fossil prairie dogs, mastodons, zebras, short-faced bears, sabre cats, lions, giant armadillos, elk-moose, caribou and muskrats, as well as African hyaenas, zebras, hipparion horses, antelopes, rodents and giraffes.
There are currently no reviews for this product. Be the first to review this product!
View all titles in North America (GEN) combined with Palaeozoology & Extinctions
Your orders support book donation projects
NHBS has enriched my life with knowledge for many years now
Search and browse over 110,000 wildlife and science products
Multi-currency. Secure worldwide shipping
Wildlife, science and conservation since 1985


text:
Amateur best movie
Indian gay group movie and best porn movie gay blowjob gallery ebony
best lesbians movie plane action
Still dreaming about this movie of Vintage amateur movie from the forest
The Best of Claudia Grosso (Full movie)
slim cheerleader having the best sex ever movie
viberators are milfs best friend film movie 1
Best Of Alexis Texas Compilation Vol 1.Full Movie
Full Movie BANG.com Best Of Anal Compilation Vol. 1
Best Of Threesomes Compilation Vol 1 Full Movie BANG.com
Best Of Anal Compilation Vol. 1 Full Movie BANG.com
Best Of Squirting Pussy Compilation Vol 1 Full Movie BANG
Best Of Big Tits Compilation Vol 1 Full Movie BANG.com
Best Of Teen Lesbians Compilation Vol 1. Full Movie BANG.com
Gay movie of He's tied to a best post,
Twink movie Gabe in the meantime, was trying his best to linger
Amateur Wife DP in Stockings Best Amateur Sex ever!
Best hot gay sex movie first time Max Martin is upset when he catches
TrafficHolder.com - Buy and Sell Adult Traffic|Trafficshop.com - Let your business grow|Contact Us|Webmaster
All content, including images, text, graphics, video and audio content contained in the website is protected under the laws of copyright, owned or under license to company or its designees,and represents proprietary and valuable intellectual property.
Contact Webmaster 18 U.S.C. 2257 Record-Keeping Requirements Compliance Statement
Powered by Stream Rotator


text:
'Full House' May Be Revived With Original Cast on Board
A "Full House" reunion is happening after all. A new report emerges that Warner Bros. TV is mulling plans to revive the hit ABC sitcom with some of the original cast scheduled to return.
Per TV Guide, John Stamos will be spearheading the project, having an ownership stake in the show. Original executive producer Bob Boyett and creator Jeff Franklin are all on board, with the latter in charge of writing the new version. The main cast Candace Cameron Bure, Jodie Sweetin, and Andrea Barber are all attached while Bob Saget and Dave Coulier are involved in some way.
Over the years, Stamos has been hinting at reunion during his public appearances. "We're sort of working on a twist on a sequel. But we don't know if it's going to happen yet or not," he said during an appearance at "Watch What Happens Live" last winter. Some of the cast members later briefly reunited on "Late Night with Jimmy Fallon" and at Coulier's wedding.
"Full House" repeats are still streaming on Nick at Nite and rakes in high ratings for the network. The series, which originally ran from 1987 to 1995, continued to be a Top 25 show during its run.
- Bob Dylan Called 'Arrogant' for Ignoring Nobel Prize Win
- 'Doctor Strange' Star Tilda Swinton Wants Her Own Marvel Movie
- Jay-Z Makes History as Nominee for 2017 Songwriters Hall of Fame
- Police Called to Larsa and Scottie Pippen's House Before Divorce Announcement
- Did Madonna Just Clap Back at Lady GaGa With This Meme?
- Leonardo DiCaprio to Play the Man Who Invented Rock and Roll in Sam Phillips Biopic
- Brad Pitt and Angelina Jolie to Sell Their Chateau Miraval in France Amid Divorce
- Director Tim Miller Leaves 'Deadpool 2' Due to Creative Differences


text:
Salah's Roma share spoils with Austria Vienna in Europa league
Mohamed Salah came in as a second half substitute but could not help...
Serie A side AS Roma have officially announced that Italian manager Luciano Spalletti is set to have a second coaching spell at the club, naming him the new manager as a replacement for the sacked Rudi Garcia.
Roma have announced they have relieved Rudi Garcia of his job as senior team coach, after spending two and a half years at the club, failing to win any significant title, followed by disappointing performances of the team so far this season.
Spalletti joined Mohamed Salah's Roma on a year and a half contract worth €3m per year, according to Sky Sport Italia. The former Zenit Saint Petersburg coach is set to run his first training session on Thursday ahead of the team's Serie A match against Hellas Verona.
The 56-year-old coach had a previous successful tenure at the eternal city before when he took control of the Giallorossi between 2005 and 2009 where he never won the title and finished second more than once, albeit with much less resources that Garcia had.


text:
- Worldwide Rank #111,191,086
- Follower/Following Ratio 0.06
- Daily New Followers 0
msrrqa Twitter Stats
@00Xzizo - Tracking msrrqa Twitter profile since September 9, 2013
msrrqa Tweets
@00Xzizo has posted 148 tweets in the last 3 days, which translates to an average of 49.3 tweets per day.
msrrqa Twitter Followers
@00Xzizo has 10 followers on Twitter.
This account is #111,191,086 in the worldwide rank of the most popular Twitter users.
msrrqa Following on Twitter
@00Xzizo is following 170 Twitter accounts.
Last month this account followed 106 users.
msrrqa Predictions & Milestones
@00Xzizo will hit 10 followers in the next 3 months, and 10 in one year.
You are on msrrqa's Twitter stats page
We track these Twitter stats since September 9, 2013 . You can see how many followers msrrqa lost or gained and what the prediction is for tomorrow or the next 15 days, together with all kinds of other stats like rank compared to all Twitter users, tweets etc.
Why don't you give it a try and compare msrrqa to yourself ? Or if you are msrrqa get even more feature rich & up-to-date stats with our premium Twitter Stats.
Twitter Counter is the #1 Twitter stats site powered by Twitter. It all started in June 12, 2008 and we grew rather rapidly because of our Twitter Counter badge. The button is a nice small image that shows your visitors how many followers you have on Twitter. Within a year the button was on many many blogs around the world and we displayed more than 100 million buttons in one month. We track follower stats for over 180 million users now.


text:
REAL instagram followers, that are active
This project received 14 bids from talented freelancers with an average bid price of $20 USD.Get free quotes for a project like this
Skills Required
Browse Related Skills
Related Projects
Other things people do on Freelancer
Related Articles
Latest Articles
Project Budget$10 - $30 USD
Total Bids14
Project Description
hello, we need real active instagram followers. we need our page built up to 90K we are currently at 86k real followers and get thousands of likes on our pictures.
we need tons of more likes being retrieved while building our account!
Looking to make some money?
- Set your budget and the timeframe
- Outline your proposal
- Get paid for your work
Hire Freelancers who also bid on this project
Looking for work?
Work on projects like this and make money from home!Sign Up Now
- Forbes
- The New York Times
- Time
- Wall Street Journal
- Times Online


text:
Ericdress Turtleneck Hole Knee-Length Sweater Dress
Ericdress Solid Color Falbala Hollow Lace Dress
Here ericdress.com shows customers a fashion collection of current boots that are in style.You can find many great items. They all have high quality and reasonable price. You can get big discount sometimes, because we always do promotions. If you need boots that are in style,come here to choose. We give you good items and services.
Ericdress Preppy Style Martin Boots
Ericdress Preppy Style Side Zipper Ankle Boots
Ericdress British Style Lace-Up Ankle Boots
Ericdress Korean Style Knee High Boots
Fashion All-matched Roman Style Women Boots
Ericdress Preppy Style High Heel Boots with Bowtie
Ericdress Preppy Style Flat Heel Snow Boots
European Style Fashion Knee High Boots
Euramerican Style Colorful Bracelet
European Style Women's Earrings
Ericdress European Style Hoodie
Ericdress Queen Style Side Zipper High Heel Boots
Ericdress Chic Style Hollow Peep-Toe Knee High Boots
Sexy Trumpet Style Wedding Petticoat
Vogue Leather Retro Style Watch
Ericdress Maximum Style Bohemian Dress
Euramerican Style Concise Open Bracelet
Euramerican Style Unique Alloy Necklace
Ericdress OL Style Chiffon Dress


text:
Rubik's Cube goes touch with TouchCube
Rubik's Cube has announced it has gone "touch" with the introduction of the Rubik's TouchCube, the first completely electronic solvable Cube.
The TouchCube features the same game play of the original Cube that has sold nearly 350 million pieces, but uses "the very latest" in touch and motion technologies.
"We've been working on Rubik's TouchCube for the last three years - with engineering teams on two different continents - and are really excited to share it with the world", says Eric Levin, president, Techno Source.
"Rubik's TouchCube is the 'dream cube' for anyone who's into high-tech gadgets - it combines today's most current technologies with the iconic Rubik's Cube".
The TouchCube features touch sensor technology on all six sides, a motion-detecting accelerometer, and coloured lights in every square.
The next-gen model also features internal memory that allows players to save their current puzzle so they can resume play anytime.
Complete with sound effects and a kind of light show for when its charging in its dock, the TouchCube will launch in autumn 2009 for under $149.99.
At internetmatters.org parents can find all the advice they will need to keep their children safe online. Designed specifically for parents, the site offers a wealth of up-to-date, unbiased information and advice about how to deal with online safety. Parents can learn about the latest issues and technologies, get great tips on how to talk about online safety with their children and get the best advice on dealing with issues and taking action. Created with experts, Internet Matters provides detailed information, but also signposts to best-in-class resources from individual expert organisations. Our goal is to ensure parents can always access the information that they need, in a format that is clear and concise.
Alpha 1S robot review: The dancing robot that offers lots more
Cozmo preview: The Anki robot friend that can do so much
Garmin Vivofit Jnr fitness tracker encourages your kids to keep active
PlayFusion Lightseekers for iOS and Android: Toys to life is not dead, it's...
- Alpha 1S robot review: The dancing robot that offers lots more
- PlayFusion Lightseekers for iOS and Android: Toys to life is not dead, it's only just beginning
- May the Force be with you: Battle worn BB-8 and Force Band let you ditch phone control
- Osmo Coding review: Educational iPad game makes programming fun
- Sky Kids app now has offline viewing to help with school holidays travelling
- Always wanted a Bose speaker? Now you can get your kids to build one
- Cozmo is the tiny robot with the big brain, from the team behind Anki Overdrive
- Infinite Arms for iPad preview: Skylanders for Halo fans
- LeapFrog LeapStart preview: Embracing tech and phyiscal books for kids
- BBC micro:bit now available for pre-order, get your kids into coding
- Best Android Wear smartwatch 2016: The best smartwatches available on Google's platform
- Best smartphones 2016: The best phones available to buy today
- Google Pixel tips and tricks: Getting to grips with Google's phone
- Google Pixel vs Apple iPhone 7: Which should you choose?
- Google Pixel tips: First things to do with your new Google superphone
- Google Pixel XL vs Pixel: Which should you choose?
- Best VR headsets to buy in 2016, whatever your budget
- Here's why you can't access Netflix, Twitter, Spotify, or Reddit
- When is Android 7.1 Nougat coming to my phone?
- Google Pixel XL vs Apple iPhone 7 Plus vs Samsung Galaxy Note 7: What's the difference?


text:
You are a fan of types wars ? Come to discover the best forums types wars on the internet and share your experience with a community fan of types wars . You can also build a forum types wars and create your online discussion.
Home of the best dynasty league in the world.
militaria, world, military, bulletin, board, message, free, iacmc, iacmc-, international, forum, #wars, topics, countries
Not-for-Profit Star Wars Costume Group.
knights, korriban, not-for-profit, star, #wars, costume, group
Deadman Lines is a faction associated with an online MMORPG Star Wars Combine.
deadman, lines, faction, associated, with, online, mmorpg, star, #wars, combine
Home for the Star Wars Battlefront II clan {Dark}!
{dark}, swbf2, clan, star, #wars, force, battlefront, dice, gamespy, gamemaster, gameshare, legitosity, isotopx, dark, trooper, sniper, xbox, forum, home
The city of TumbleWeed located on Tatooine's official forums!
star, #wars, galaxies, tumble, weed, official, city, tumbleweed, located, tatooine's, forums!
The latest and greatest Halo: Reach Clan
halo, reach, clan, xbox, odst, recon, #wars, combat, evolved
A free forum for battlebots enthusiasts, competitors, and fans.
botsiq, battlebots, bots, robotwars, enthusiasts, competitors, fans, engineering, robot, #wars, swpa
A small gaming community of long-time friends
guild, gaming, freelancer, buisnessman, bounty, hunter, senator, galactic, senate, roleplay, applicants, master, knight, padawan, operative, fillorean, society
Free forum : A nice and friendly international place to go and talk about everything comics and comic related areas.
free, forum, alter, comics, corner, nice, friendly, place, talk, about, everything, comic, related, areas, star, #wars, toys, playsets, g.i., transformers, video, games, xbox, playstation, vintage
Free forum : You're taking a risk coming here.
The most elite jedi assault clan in Star Wars Battlefront 2
A forum for friends to role play in Star Wars
After generation of peace in The Old Republic, the Clone Wars have begun. Could you survive this rugged time, or will the darkness consume you.
star, wars:, destiny, force, after, generation, peace, republic, clone, #wars, have, begun, could, survive, this, rugged, time, will, darkness, consume
TIGR Gaming has been apart of the SMITE Community since 10/7/2015 and apart of the Star Wars Battlefront community since 10/9/2015 if you think you have what it takes, then here is your chance!
tigr, esports, swbf, clans, smite, twitch, streamers, rough, ain't
Character Development guild forum for Star Wars The Old Republic game
Ten thousand years after the events of Naruto, space is colonized, conflict is bitter, and darkness is everywhere. Will you join the Great War?
kurayami, naruto, roleplay, anime, role, play, bleach, manga, japan, tokyo, sasuke, itachi, sakura, kakashi, madara, uchiha, konoha, shinobi, ninja, naru, hinata, boruto, gaiden, sarada, orochimaru, star, #wars, starwars, dune, techno, cyber
Forums for a tabletop Star Wars Force & Destiny game.
seeking, force, forums, tabletop, star, #wars, destiny, game
Free forum : SQUAD ON FIRE was a group on the Sony Online Entertainment MMO Game, Clone Wars Adventures. This forum is for the members of SQUAD ON FIRE to connect and socialize.
free, forum, squad, fire, group, sony, online, entertainment, game, clone, #wars, adventures, this, members
Forum for the Omega Force Guild in Star Wars: Galaxy of Heroes.
The Customizers and Builders Guild is a group of Lego enthusiasts specializing in original creations and minifigure customization. Formerly known as the Clone Army Builders Guild.
free, forum, lego, star, #wars, clone, guild, army, builders, legos, clones, customs, legions, troopers, customizers
Free forum : The Official Star Wars BF Elite Squadron Jinx Clan.
free, forum, jinx, clan, official, star, #wars, elite, squadron
Free forum : Once a Toy, Always a Toy
free, forum, sexytoys, branch, network, gamers, community, alliance, game, design, programming, civilization, #wars, empires, devices, computers, drivers, social, events, non-profitabl
Creed Gaming
free, forum, creed, gaming, contract, #wars, begone, games, brotherhood
The executive branch of the secret society of Star Wars debaters.
dark, council, chamber, executive, branch, secret, society, star, #wars, debaters
Free forum : This is a forum for the gmod server Royalty Gaming. It is a serious Star Wars RP server.
royalty, gaming, gmod, server, star, #wars, league, legends, dota
A place for duelist to find there potential while participating in our clan tourneys and wars.
immortal, clan, place, duelist, find, there, potential, while, participating, tourneys, #wars
Our directory helps you find information and reviews about activities from sites around the world that offers different places of interest and types of recreation.
micron, associates, travel, guide, directory, helps, reviews, activities, sites, world, offers, places
This is a place for any type of VW enthusiast, Air or Water Cooled. All Types, Rail Buggy, Baja, Dune Buggy, Kit, etc.
tampa, club, meets, events, volkswagen, rail, buggy, baja, beetle, thing, split, window, type


text:
No. AIIMS/BPL/Peds/INCLEN/Recr/002
Research Assistant/ Research Assistant (Nursing)/ Data Software Manager Job vacancies in All India Institute of Medical Sciences (AIIMS) Bhopal
Project Title : "Evaluation of HBNC-Plus Program at District Level: An INCLEN Study"
Research Assistant
No. of Posts : 09
Qualification : Post graduates in Sociology, Social Work or Anthropology
Salary : Rs, 30,000 (For total ,duration)
Research Assistant (Nursing)
No. of Posts : 03
Qualification : BSc (Nursing)
Salary : Rs. 30,000 (For total ,duration)
Data Software Manager
No. of Post : 01
Qualification : Graduate or Post graduate in Computer Science or relevant field
Salary : Rs. 20,000 per month
AIIMS Bhopal is one of the seven AIIMS apex healthcare institutes being established by the Ministry of Health & Family Welfare, Government of India under the Pradhan Mantri Swasthya Suraksha Yojna(PMSSY). With the aim of correcting regional imbalances in quality tertiary level healthcare in the country, and attaining self sufficiency in graduate and postgraduate medical education and training the PMSSY planned to set up 6 new AIIMS like institutions in under served areas of the country.
Fully solved online mock placement papers with latest test pattern,count down timer,detail test analysis with answer and explanation is available at Power Placement Preparation:P3.
Start your preparation now with P3 and increase your success probabiltiy.
Freshersworld.com is the No.1 Jobsite for Freshers in India with over 1 Crore+ resumes and 60K+ recruiters hiring through us. Apply to Top MNC Jobs / Government jobs by registering now! What's more? Get daily job alert, placement paper and GK updates every day on your email. Freshersworld.com is the only website for applying to Govt Jobs and top MNC Jobs all over India. Register Now to benefit from our unlimited fresher focused services!


text:
New life
Vlada_power, 25 y/o
I can be your sonata of love
Lips4Love, 34 y/o
Do you like to live without love?Let's change it
Ferrero_Lady_Alena, 20 y/o
Catch my sunrays! :D
SunnyIrishka, 44 y/o
your great success
Gods_reward, 39 y/o
Yours_Valentine, 39 y/o
My personality is tender and thoughtful
Irina_Exceptional456, 27 y/o
I am looking for love and you!!!
DelicateMatures, 37 y/o
You will never find more faithful woman
BestChoice_forYou, 63 y/o
In life I go with a smile!
Doctor_Tatiana, 54 y/o


text:
If you log in, you can comment on buildings, submit new photos or update photos that you've already submitted.
We need to upgrade the server that this website runs on. Can you spare a quid to help?.
Description: Row of 8 Headstones and Memorial Cross 15 Metres South of the Church of St Mary of the Purification
Grade: II
Date Listed: 13 May 1986
English Heritage Building ID: 242062
OS Grid Reference: SK5855955603
OS Grid Coordinates: 458559, 355603
Latitude/Longitude: 53.0944, -1.1270
Location: B6020, Blidworth, Nottinghamshire NG21 0QD
Locality: Blidworth
Local Authority: Newark and Sherwood District Council
County: Nottinghamshire
Country: England
Postcode: NG21 0QD
Incorrect location/postcode? Submit a correction!
Explore more of the area around Blidworth, Nottinghamshire at Explore Britain.
(south side)
1/6 Row of 8 headstones
and memorial cross
15 metres south of
the Church of St.
Mary of the Purifi-
Headstones and memorial cross. C14, C17, C18, C19. Ashlar. 8
C17 and C18 headstones with arched or decoratively shaped heads.
Memorial cross shaft comprising part of a C14 octagonal column,
the remainder of the cross being C19.
Listing NGR: SK5855955603
This text is a legacy record and has not been updated since the building was originally listed. Details of the building may have changed in the intervening time. You should not rely on this listing as an accurate description of the building.
Source: English Heritage
Listed building text is © Crown Copyright. Reproduced under licence.


text:
Sign In
See All Brad Paisley Events
Verizon Wireless Arena-NH
February 15, 2014, Saturday @ 7:00pm
With millions of fans nationwide, Ticket Monster
is your destination for exclusive discounts on
sports, concerts, and theater tickets.
Sign up and never miss a deal!
Enter your email address and we will send you an email with instructions on how to reset your password.


text:
Format: Paperback
Language: English
Format: PDF / Kindle / ePub
Size: 11.14 MB
Downloadable formats: PDF
Pages: 240
Publisher: Scarecrow Press (December 7, 2006)
The Imaginary Signifier: Psychoanalysis and the Cinema
Transnational Cinema in a Global North: Nordic Cinema in Transition (Contemporary Approaches to Film and Media Series)
The Battle of the Sexes in French Cinema, 1930–1956
Countervisions (Asian American History & Cultu)
Reframing Difference: Beur and Banlieue Filmmaking in France
Events that occur at the same time for one observer could occur at different times for another Wild Strawberries (BFI Film Classics) Wild Strawberries (BFI Film Classics). When the child is held up to the mirror, it perceives itself being held by the mother, who Metz describes as "its object par excellence." This form of primary identification of self leads the child to form ego, and the mirror image becomes the idealized self download. Mediators need to understand there is a lot that goes into conflict and by understanding these concepts and theories they can mediate the dispute in a more thorough and proper way.... [tags: Mediation, Conflict Resolution ] Stella Ting-Tommey's Toward a Theory of Conflict and Culture - Stella Ting-Tommey's "Toward a Theory of Conflict and Culture" Introduction This research report is based on the article "Toward a Theory of Conflict and Culture" taken from the book Communication, Culture, and Organizational Processes ref.: On the Waterfront (Cambridge read here On the Waterfront (Cambridge Film. Cast: Derek Luke, Joy Bryant, Denzel Washington, Salli Richardson, Earl Billings, Kevin Connolly, Viola Davis, Rainoldo Gooding , cited: Videohound's Groovy Movies: Far-Out Films of the Psychedelic Era http://balancestudios.net/books/videohounds-groovy-movies-far-out-films-of-the-psychedelic-era. There is; and this has spurred much of the recent interest in relativist semantic theories. Relativist semantic theories hold that our indices should include not just a world and (perhaps) a time, but also a context of assessment. Just as propositions can have different truth values with respect to different worlds, so, on this view, they can vary in their truth depending upon features of the conversational setting in which they are considered. (Though this way of putting things assumes that the relativist should be a 'truth relativist' rather than a 'content relativist'; I ignore this in what follows , cited: The Law of the Looking Glass: Cinema in Poland, 1896–1939 (Polish and Polish American Studies) download here.
A View from the Bottom: Asian American Masculinity and Sexual Representation (Perverse Modernities: A Series Edited by Jack Halberstam and Lisa Lowe)
American Animated Cartoons of the Vietnam Era: A Study of Social Commentary in Films And Television Programs, 1961-1973
Ghostly Desires: Queer Sexuality and Vernacular Buddhism in Contemporary Thai Cinema
The French New Wave: Critical Landmarks
Mise-en-scène: Mise-en-scene: Film Style and Interpretation (Short Cuts)
Freedom's Pioneer: John McGrath's Work in Theatre, Film and Television (University of Exeter Press - Exeter Performance Studies)
Cinema and Modernity
Film, History and Cultural Citizenship: Sites of Production (Routledge Studies in Cultural History)
A Critical History and Filmography of Toho's Godzilla® Series
Narration and Spectatorship in Moving Images
A Thinker's Damn: Audie Murphy, Vietnam, and The Making of the Quiet American
The Film Studies Reader
A Cinema Without Walls: Movies and Culture after Vietnam
Shakespeare's comedy of The tempest
Screen Adaptations: Great Expectations: A close study of the relationship between text and film
D.W. Griffith and the Origins of American Narrative Film: THE EARLY YEARS AT BIOGRAPH
British TV and Film Culture in the 1950s: Coming to a TV Near You
Rethinking Occupied Ireland (Irish Studies)
The A List: The National Society Of Film Critics' 100 Essential Films
Bruce McDonald's 'Hard Core Logo' (Canadian Cinema)
Mismatched Women: The Siren's Song Through the Machine (Oxford Music / Media)
Documentary Display: Re-Viewing Nonfiction Film and Video (Nonfictions)
Godard Between Identity and Difference
The Oriental Obscene: Violence and Racial Fantasies in the Vietnam Era