studies have demonstrated that different ethnic groups may have different predisposing risk factors , epidemiologic patterns , and outcomes of stroke .
this has been shown in african americans , caucasians , hispanics , arabs , and asians [ 16 ] .
these differences could be due to differences in demographic or socioeconomic factors or in lifestyle .
although epidemiologic studies on stroke were carried out in different parts of the world , including some arab countries [ 711 ] , there are no published data about palestine .
furthermore , knowledge of the prevalence of stroke - related risk factors can help health decision makers to direct efforts toward reducing stroke - related morbidity and mortality . in palestine
the private sector plays a minor role due to its high cost compared to the average income in palestine .
currently , the palestinian national authority is in charge of west - bank and gaza strip , with a total population of 4,151,668 inhabitants .
nablus district is the second largest district with a population of 362,159 native palestinian inhabitants .
this study was conducted to identify the risk factors , in - hospital mortality , and discharge medications for patients with ischemic stroke admitted to al - watani government hospital , nablus , palestine .
this one - year , retrospective , hospital - based study was conducted between september 01 , 2006 and august 31 , 2007 .
all patients admitted to the hospital with acute ischemic stroke were included in the study .
each diagnosed patient had been followed up until either death at the hospital or discharge .
the data were collected by retrospective review of medical charts included age , gender , medications , serum creatinine ( scr ) level , risk factors , and post - stroke medical complications .
then following were considered risk factors : age , hypertension ( htn ) , diabetes mellitus ( dm ) , congestive heart failure ( chf ) , atrial fibrillation ( af ) , ischemic heart disease ( ihd ) , smoking , previous stroke , and obesity [ 1215 ] .
hyperlipidemia is a risk factor for stroke , but we did not include it because it had not been done routinely at the hospital .
obesity was defined as a body mass index ( bmi ) > 30 for both genders .
creatinine clearance ( crcl ) was calculated by using cokcroft - gault equations , and values for females were obtained by multiplying the result by 0.85 .
the post - stroke complications considered were the presence of one or more of the following : constipation , seizure , depression , infection , limb pain , and gastrointestinal upset .
analysis of data was carried out using the " statistical package for social sciences " ( spss ) program for windows version 15.0 ( spss inc . ,
univariate analysis was carried out using pearson chi - square for categorical variables and student 's t test for continuous variables .
multiple logistic regression analysis was used to find independent predictors of in - hospital mortality .
variables included in the regression model were those that had a significant p value ( p < 0.05 ) in the univariate analysis .
analysis of data was carried out using the " statistical package for social sciences " ( spss ) program for windows version 15.0 ( spss inc . ,
univariate analysis was carried out using pearson chi - square for categorical variables and student 's t test for continuous variables .
multiple logistic regression analysis was used to find independent predictors of in - hospital mortality .
variables included in the regression model were those that had a significant p value ( p < 0.05 ) in the univariate analysis .
we found that 186 stroke patients were admitted to the hospital during the study period ; of these , we studied 153 who were diagnosed with ischemic stroke .
45.8% were males and 54.2% were females , giving a male : female ratio of 0.84:1 .
there was no significant difference between females and males in age . among the patients , 39.9% had previous attack , and 60.1% had a first ever stroke ( fes ) .
patients with fes were younger than those with recurrent stroke ( 67.94  11.66 versus 70.80  10.19 years , respectively ) ; the difference in age between the two groups was not significant ( p = 0.11 ) .
the prevalence of risk factors in the study sample was investigated ( figure 1 ) .
patients had an average of 3.4  1.2 risk factors ( range 1  7 ) before the attack .
htn was the most prevalent risk factor ( 66% ) of the patients , followed by dm ( 45.8% ) .
renal dysfunction was also common : 33.9% of the patients had an estimated crcl < 60 ml / min .
smoking was practiced by 19.6% of the patients , most of whom ( 99% ) were males .
no significant difference was found in the prevalence of risk factors between males and females , with the exception of smoking which was significantly associated with males . however , chf and dm were more common in females , while htn was more common in males .
prevalence of various risk factors in the stroke patients admitted to the hospital during the study period .
htn : hypertension , dm : diabetes mellitus , bmi : body mass index , af : atrial fibrillation , chf : congestive heart failure , ihd : ischemic heart disease twenty - six ( 17% ) of the patients died during hospitalization . of the 127 survivors ,
four variables were significantly associated with in - hospital mortality : history of previous stroke ( p= 0.004 ) , crcl at admission ( p = 0.004 ) , number of post - stroke complications ( p = 0.001 ) , and age ( p = 0.043 ) .
multiple logistic regression analysis indicated that the number of post - stroke complications ( p= 0.001 ) and previous stroke ( p = 0.03 ) were significant independent predictors of in - hospital mortality .
table 1 summarizes the demographic and clinical characteristics of patients who survived versus those who died .
table 2 shows multiple logistic regression model using the enter method for predicting mortality after stroke .
results of univariate analysis of 153 ischemic stroke patients according to vital status at discharge .
htn : hypertension , dm : diabetes mellitus , af : atrial fibrillation , ihd : ischemic heart disease , chf : congestive heart failure .
continuous variables were expressed as mean  sd , while categorical variables were expressed as frequency and percentage .
p value was calculated using independent t test for continuous variables and chi - square test for categorical variables .
multiple logistic regression by the enter method for identifying predictors of mortality after ischemic stroke .
an average of 4.33 medications ( sd = 1.5 , range : 19 ) were prescribed per stroke survivor .
seventy - four ( 92.5% ) stroke survivors with a diagnosis of hypertension were discharged on antihypertensive medications .
ace - i were the most ( n = 62 , 50% ) was the class of antihypertensive agents most frequently prescribed for stroke survivors .
the main exceptions were anti - coagulants , antibiotics , and anti - inflammatory agents , all of which were used at admission but were discontinued at discharge .
there was no difference in the average number of medications prescribed for males and females at discharge ( p= 0.36 ) .
we studied the characteristics of patients with ischemic stroke attacks at al - watani hospital , palestine .
the mean age was higher than that reported in hospital - based studies from some other arab countries but lower than that reported from developed countries [ 16 , 17 ] .
an important observation is the very low percentage ( 1.6% ) of stroke patients who were less than 45 years old .
the prevalence of stroke in young patients seems to vary between different ethnic groups of various geographical areas .
for instance , only 35% of all strokes occurred in individuals under 45 years old in some countries , while in others they constituted as much as 1930% [ 1820 ] .
the male : female ( m : f ) ratio of 0.84:1 in this study was not in agreement with previous studies on stroke from other countries .
one study in a province of saudi arabia found a m : f ratio of 1.8:1 .
a second study among the national guard community in saudi arabia found a m : f ratio of 2.2:1 . a third study in saudi arabia found a ratio of 3.4:1 [ 2123 ] .
however , a hospital - based study in saudi arabia found a 1:1 male : female ratio in stroke patients in general .
the unexpected gender ratio in our study might indicate the presence of undiagnosed or uncontrolled stroke - related risk factors in women in palestine .  
the high prevalence of risk factors among the stroke victims indicates that control of these factors is important for the prevention of stroke .
thus , screening , modification , and better control of existing risk factors , such as htn , dm , and cardiac diseases , should be the primary strategy for prevention of stroke .
prospective observational studies have established that the risk of primary stroke is strongly related to blood pressure ( bp ) .
lowering diastolic bp by 5 mmhg or systolic bp by 10 mmhg reduces the risk of stroke by an estimated 38% . in our study , most patients with htn were given anti - hypertensive agents , particularly ace - i , at discharge .
about one - third of the patients had an estimated crcl < 60 ml / min .
a recent study indicated that mild degrees of renal dysfunction are associated with increased risk of incident ischemic stroke or transient ischemic attack .
recent studies have also established that patients with end stage renal disease ( esrd ) have 510fold higher risk of stroke compared to patients with non - esrd [ 28 , 29 ] .
results of in - hospital mortality among stroke patients in this study were also close to those reported in most arab countries .
four variables were significant risk factors of in - hospital mortality in stroke patients , namely , history of previous stroke , number of post - stroke complications , creatinine clearance , and age .
the influence of age on stroke outcome is still a matter of debate . while several studies showed a negative influence ,
other studies showed no influence [ 3038 ] ; our results resemble those that showed a negative influence of age on stroke outcome .
it is difficult to establish whether age influences stroke outcome itself , or through other factors associated with age .
our finding regarding crcl as an independent predictor of early mortality in stroke patients is endorsed by some studies .
for example , a study by friedman in 1991 indicated that serum creatinine was an independent predictor of mortality among 492 stroke survivors followed up for a mean period of 18 months .
indicated that patients with creatinine clearance calculated at admission of < 51 ml / min had a higher mortality rate .
finally , a recent study by fabjan et al . indicated that in patients with ischemic stroke , decreased crcl was associated with higher in - hospital mortality .
interestingly , we found that prior use of anti - platelets was not associated with decreased risk of mortality . a hospital - based study carried out in kuwait found that non - se of anti - platelets is significantly associated with deleterious 30-day outcome .
one way to reduce early mortality in stroke patients is to develop a stroke unit supervised by a specialized neurologist .
admission of acute stroke patients into specialized hospitals seems to reduce the risk of in - hospital mortality . moreover , academic medical centers with vascular neurologists had lower rates of in - hospital mortality for patients with ischemic stroke .
it seems that mortality in patients with stroke does not depend only on patient - related factors but also on hospital characteristics .
most of the patients in the study had risk factors commonly present in stroke patients .
better control of these risk factors might decrease the future incidence rate of stroke in palestine .
the number of post - stroke complications and previous stroke were significant independent predictors of in - hospital mortality .
medications prescribed at discharge for stroke survivors are consistent with the type of risk factors , especially htn , present in patient 's medical files .
 
 objective : stroke is a major health problem , yet no studies on stroke have been reported from palestine . this one - year , hospital - based study was conducted to determine the prevalence of risk factors and the in - hospital mortality rate in patients with ischemic stroke . 
 method : all patients admitted to al - watani government hospital and diagnosed with ischemic stroke between september 2006 and august 2007 were included in the study . 
 data were obtained by retrospective review of medical charts . 
 pearson chi - square and independent t test were used in the univariate analysis . 
 multiple logistic regression analysis was used to determine the independent predictors of in - hospital mortality rates among the patients . 
 statistical testing and graphics were carried out using spss 15 . 
 results : we identified 153 ischemic stroke patients ( 83 females and 70 males ) of whom 92 were having a first - ever stroke ( fes ) . 
 patients had several prevalent modifiable risk factors such as hypertension ( htn ) ( 66% ) , diabetes mellitus ( dm ) ( 45.8% ) , and renal reduced renal function ( crcl < 60 ml/ min ) ( 33.9% ) . 
 twenty - six ( 17% ) of the patients died during hospitalization . 
 four variables were significantly associated with in - hospital mortality : history of previous stroke ( p= 0.004 ) , crcl at admission ( p = 0.004 ) , number of post - stroke complications ( p = 0.001 ) , and age ( p = 0.043 ) . 
 multiple logistic regression analysis indicated that the number of post - stroke complications ( p= 0.001 ) and previous stroke ( p = 0.03 ) were significant independent predictors of in - hospital mortality . 
 conclusion : screening and better control of risk factors , especially htn , dm and renal dysfunction , are required to decrease the incidence and in - hospital mortality among patients with ischemic stroke . 