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Abstract
Numerous epidemiological studies have demonstrated stroke disparities across race and ethnic groups. The goal of the NOMAS (Northern Manhattan Study) was to evaluate race and ethnic differences in stroke within a community with 3 different race-ethnic groups. Starting as a population-based incidence and case-control study, the study evolved into a cohort study. Results from NOMAS have demonstrated differences in stroke incidence, subtypes, risk factors, and outcomes. Disparities in ideal cardiovascular health can help explain many differences in stroke incidence and call for tailored risk factor modification through innovative portals to shift more diverse subjects to ideal cardiovascular health. The results of NOMAS and multiple other studies have provided foundational data to support interventions. Conceptual models to address health disparities have called for moving from detecting disparities in disease incidence, to determining the underlying causes of disparities and developing interventions, and then to testing interventions in human populations. Further actions to address race and ethnic stroke disparities are needed including innovative risk factor interventions, stroke awareness campaigns, quality improvement programs, workforce diversification, and accelerating policy changes.
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Affiliation(s)
- Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, FL
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52
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Mukaz DK, Zakai NA, Cruz-Flores S, McCullough LD, Cushman M. Identifying Genetic and Biological Determinants of Race-Ethnic Disparities in Stroke in the United States. Stroke 2020; 51:3417-3424. [PMID: 33104469 PMCID: PMC7594163 DOI: 10.1161/strokeaha.120.030425] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In the United States, causes of racial differences in stroke and its risk factors remain only partly understood, and there is a long-standing disparity in stroke incidence and mortality impacting Black Americans. Only half of the excess risk of stroke in the United States Black population is explained by traditional risk factors, suggesting potential effects of other factors including genetic and biological characteristics. Here, we nonsystematically reviewed candidate laboratory biomarkers for stroke and their relationships to racial disparities in stroke. Current evidence indicates that IL-6 (interleukin-6), a proinflammatory cytokine, mediates racial disparities in stroke through its association with traditional risk factors. Only one reviewed biomarker, Lp(a) (lipoprotein[a]), is a race-specific risk factor for stroke. Lp(a) is highly genetically determined and levels are substantially higher in Black than White people; clinical and pharmaceutical ramifications for stroke prevention remain uncertain. Other studied stroke risk biomarkers did not explain racial differences in stroke. More research on Lp(a) and other biological and genetic risk factors is needed to understand and mitigate racial disparities in stroke.
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Affiliation(s)
- Debora Kamin Mukaz
- Department of Medicine, Vermont Center on Cardiovascular and Brain Health, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Neil A. Zakai
- Department of Medicine, Vermont Center on Cardiovascular and Brain Health, Larner College of Medicine at the University of Vermont, Burlington, VT
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso
| | - Louise D. McCullough
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Mary Cushman
- Department of Medicine, Vermont Center on Cardiovascular and Brain Health, Larner College of Medicine at the University of Vermont, Burlington, VT
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
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53
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Towfighi A, Benson RT, Tagge R, Moy CS, Wright CB, Ovbiagele B. Inaugural Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving Symposium. Stroke 2020; 51:3382-3391. [PMID: 33104474 DOI: 10.1161/strokeaha.120.030423] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Race/ethnic minorities face significant inequities in stroke incidence, prevalence, care, and outcomes. The Health Equity and Actionable Disparities in Stroke: Understanding and Problem-solving symposium, a collaborative initiative of the American Heart Association and National Institute of Neurological Disorders and Stroke, was the first-ever annual multidisciplinary scientific forum focused on race/ethnic inequities in cerebrovascular disease, with the overarching goal of reducing inequities in stroke and accelerating the translation of research findings to improve outcomes for race/ethnic minorities. The symposium featured esteemed invited plenary speakers, lecturing on determinants of race/ethnic inequities in stroke and interventions aimed at redressing the inequities. The Edgar J. Kenton III Award recognized Ralph Sacco, MD, MS, for his lifetime contributions to investigation, management, mentorship, and community service in the field of stroke inequities. Early career investigators were provided with travel awards to attend the symposium; presented their research at moderated poster and Think Tank sessions; received career development advice at the Building Momentum session; and networked with experienced stroke inequities researchers. Future conferences-The Health Equity and Actionable Disparities in Stroke: Understanding and Problem-solving 2021 to 2024-will broaden the focus to include 5 major persistent inequities (race/ethnic, sex, geographic, socioeconomic, and global). Each year will focus on a different theme (community and stakeholder engagement; clinical trials; implementation science; and policy and dissemination). By fostering a community of stroke inequities researchers, we hope to highlight promising work, illuminate research gaps, facilitate networking, inform policy makers, recognize achievement, inspire greater interest among junior investigators to pursue careers in this field, and provide networking opportunities for underrepresented minority scientists.
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Affiliation(s)
- Amytis Towfighi
- Department of Neurology, University of Southern California, Los Angeles (A.T.).,Los Angeles County-Department of Health Services, Los Angeles, CA (A.T.)
| | - Richard T Benson
- Office of Global Health and Health Disparities (R.T.B.), National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | - Raelle Tagge
- Northern California Institute for Research and Education, San Francisco, CA (R.T.)
| | - Claudia S Moy
- Division of Clinical Research (C.S.M., C.B.W.), National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | - Clinton B Wright
- Division of Clinical Research (C.S.M., C.B.W.), National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, CA (B.O.)
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Zhang RV, Ryan KA, Lopez H, Wozniak MA, Phipps MS, Cronin CA, Cole JW, Dutta TM, Mehndiratta P, Motta M, Merino JG, Kittner SJ. Sickle Cell Trait and Risk of Ischemic Stroke in Young Adults. Stroke 2020; 51:e238-e241. [PMID: 32781942 DOI: 10.1161/strokeaha.119.028404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Approximately 8% of Blacks have sickle cell trait (SCT), and there are conflicting reports from recent cohort studies on the association of SCT with ischemic stroke (IS). Most prior studies focused on older populations, with few data available in young adults. METHODS A population-based case-control study of early-onset IS was conducted in the Baltimore-Washington region between 1992 and 2007. From this study, 342 Black IS cases, ages 15 to 49, and 333 controls without IS were used to examine the association between SCT and IS. Each participant's SCT status was established by genotyping and imputation. For analysis, χ2 tests and logistic regression models were performed with adjustment for potential confounding variables. RESULTS Participants with SCT (n=55) did not differ from those without SCT (n=620) in prevalence of hypertension, previous myocardial infarction, diabetes mellitus, and current smoking status. Stroke cases had increased prevalence in these risk factors compared with controls. We did not find an association between SCT and early-onset IS in our overall population (odds ratio=0.9 [95% CI, 0.5-1.7]) or stratified by sex in males (odds ratio=1.26 [95% CI, 0.56-2.80]) and females (odds ratio=0.67 [95% CI, 0.28-1.69]). CONCLUSIONS Our data did not find evidence of increased risk of early-onset stroke with SCT.
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Affiliation(s)
- Rebecca V Zhang
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore
| | - Kathleen A Ryan
- Department of Medicine (K.A.R.), University of Maryland School of Medicine, Baltimore.,VA Maryland Health Care System, Baltimore (K.A.R., H.L., M.A.W., M.S.P., C.A.C., J.W.C., S.J.K.)
| | - Haley Lopez
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore.,VA Maryland Health Care System, Baltimore (K.A.R., H.L., M.A.W., M.S.P., C.A.C., J.W.C., S.J.K.)
| | - Marcella A Wozniak
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore.,VA Maryland Health Care System, Baltimore (K.A.R., H.L., M.A.W., M.S.P., C.A.C., J.W.C., S.J.K.)
| | - Michael S Phipps
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore.,VA Maryland Health Care System, Baltimore (K.A.R., H.L., M.A.W., M.S.P., C.A.C., J.W.C., S.J.K.)
| | - Carolyn A Cronin
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore.,VA Maryland Health Care System, Baltimore (K.A.R., H.L., M.A.W., M.S.P., C.A.C., J.W.C., S.J.K.)
| | - John W Cole
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore.,VA Maryland Health Care System, Baltimore (K.A.R., H.L., M.A.W., M.S.P., C.A.C., J.W.C., S.J.K.)
| | - Tara M Dutta
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore
| | - Prachi Mehndiratta
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore
| | - Melissa Motta
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore
| | - José G Merino
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore
| | - Steven J Kittner
- Department of Neurology (R.V.Z., H.L., M.A.W., M.S.P., C.A.C., J.W.C., T.M.D., P.M., M.M., J.G.M., S.J.K.), University of Maryland School of Medicine, Baltimore.,VA Maryland Health Care System, Baltimore (K.A.R., H.L., M.A.W., M.S.P., C.A.C., J.W.C., S.J.K.)
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55
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Reshetnyak E, Ntamatungiro M, Pinheiro LC, Howard VJ, Carson AP, Martin KD, Safford MM. Impact of Multiple Social Determinants of Health on Incident Stroke. Stroke 2020; 51:2445-2453. [PMID: 32673521 PMCID: PMC9264323 DOI: 10.1161/strokeaha.120.028530] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Social determinants of health (SDOH) have been previously associated with incident stroke. Although SDOH often cluster within individuals, few studies have examined associations between incident stroke and multiple SDOH within the same individual. The objective was to determine the individual and cumulative effects of SDOH on incident stroke. METHODS This study included 27 813 participants from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study, a national, representative, prospective cohort of black and white adults aged ≥45 years. SDOH was the primary exposure. The main outcome was expert adjudicated incident stroke. Cox proportional hazards models examined associations between incident stroke and SDOH, individually and as a count of SDOH, adjusting for potential confounders. RESULTS The mean age was 64.7 years (SD 9.4) at baseline; 55.4% were women and 40.4% were blacks. Over a median follow-up of 9.5 years (IQR, 6.0-11.5), we observed 1470 incident stroke events. Of 10 candidate SDOH, 7 were associated with stroke (P<0.10): race, education, income, zip code poverty, health insurance, social isolation, and residence in one of the 10 lowest ranked states for public health infrastructure. A significant age interaction resulted in stratification at 75 years. In fully adjusted models, among individuals <75 years, risk of stroke rose as the number of SDOH increased (hazard ratio for one SDOH, 1.26 [95% CI, 1.02-1.55]; 2 SDOH hazard ratio, 1.38 [95% CI, 1.12-1.71]; and ≥3 SDOH hazard ratio, 1.51 [95% CI, 1.21-1.89]) compared with those without any SDOH. Among those ≥75 years, none of the observed effects reached statistical significance. CONCLUSIONS Incremental increases in the number of SDOH were independently associated with higher incident stroke risk in adults aged <75 years, with no statistically significant effects observed in individuals ≥75 years. Targeting individuals with multiple SDOH may help reduce risk of stroke among vulnerable populations.
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Affiliation(s)
- Evgeniya Reshetnyak
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY (E.R., L.C.P., M.M.S.)
| | - Mariella Ntamatungiro
- Department of Internal Medicine, Columbia University College of Physicians and Surgeons, New York, NY (M.N.)
| | - Laura C Pinheiro
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY (E.R., L.C.P., M.M.S.)
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (V.J.H., A.P.C., K.D.M.)
| | - April P Carson
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (V.J.H., A.P.C., K.D.M.)
| | - Kimberly D Martin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (V.J.H., A.P.C., K.D.M.)
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY (E.R., L.C.P., M.M.S.)
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56
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Zhang R, Wang Y, Fang J, Yu M, Wang Y, Liu G. Worldwide 1-month case fatality of ischaemic stroke and the temporal trend. Stroke Vasc Neurol 2020; 5:353-360. [PMID: 32665364 PMCID: PMC7804064 DOI: 10.1136/svn-2020-000371] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 01/19/2023] Open
Abstract
Background The 1-month case fatality of ischaemic stroke is an essential epidemiological metric. Whereas the case fatality after ischaemic stroke and the temporal trend is uncertain. We aimed to estimate the 1-month case fatality of ischaemic stroke and its temporal trend, as well as its regional variation. Methods We searched PubMed and Embase to identify the studies for 1-month case fatality of ischaemic stroke. The population-based studies were included. Two investigators extracted the data and assessed the quality independently. One-month case fatality of ischaemic stroke was estimated using a random effects model. The temporal trend was evaluated using a mixed-effect meta-regression model. Results A total of 59 articles with 77 time periods were included. The worldwide 1-month case fatality of ischaemic stroke was 13.5% (95% CI 12.3% to 14.7%). The case fatality was 10.8% (95% CI 8.3% to 13.5%) in Asia, 14.2% (95% CI 12.6% to 15.9%) in Europe, 14.0% (95% CI 11.2% to 17.1%) in South America and Caribbean, 14.0% (95% CI 9.5% to 19.1%) in North America and 12.5% (95% CI 11.1% to 13.9%) in Australia and New Zealand. Overall, there was a non-significant decrease of 0.1% per year in case fatality. It decreased significantly in Europe (−0.2% annually, 95% CI −0.4% to −0.01%) and North America (−0.2% annually, 95% CI −0.4% to −0.04%), increased significantly in Australia and New Zealand (0.2% annually, 95% CI 0.1% to 0.4%), while no evidence of change in other regions. Conclusion The 1-month case fatality of ischaemic stroke and its temporal trend were divergent across regions. Further studies are needed to address the reason of the regional difference, which will be helpful to guide the effort of reducing stroke burden.
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Affiliation(s)
- Runhua Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Miaoxin Yu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China
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57
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Jiang M, Ma C, Li H, Shen H, Li X, Sun Q, Chen G. Sex Dimorphisms in Ischemic Stroke: From Experimental Studies to Clinic. Front Neurol 2020; 11:504. [PMID: 32636794 PMCID: PMC7318992 DOI: 10.3389/fneur.2020.00504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/07/2020] [Indexed: 11/17/2022] Open
Abstract
Sex dimorphisms are important factors that influence the outcomes after ischemic stroke, which include basic health status, cerebrovascular anatomy, hormone levels, and unique factors such as pregnancy and menopause. It is widely recognized that male and female respond differently to stroke. Women aged 45–74 years old showed a lower risk of stroke incidence compared to age-matched man. This kind of protection is lost with aging. Hence, there is increasing requirement to get a more comprehensive understanding of sex-based factors to stroke on stroke incidence, symptoms, and treatments. This review focuses on sex-specific mechanisms in response to stroke based on experimental studies and highlights recent findings in clinical studies including sex-differential evaluation and outcomes of stroke. Sex-based personalized medicine should be promising in stroke therapies.
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Affiliation(s)
- Ming Jiang
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Cheng Ma
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haiying Li
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haitao Shen
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiang Li
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qing Sun
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Gang Chen
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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58
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Jones EM, Okpala M, Zhang X, Parsha K, Keser Z, Kim CY, Wang A, Okpala N, Jagolino A, Savitz SI, Sharrief AZ. Racial disparities in post-stroke functional outcomes in young patients with ischemic stroke. J Stroke Cerebrovasc Dis 2020; 29:104987. [PMID: 32689593 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104987] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND PURPOSE Recent studies show rising incidence of stroke in the young, for which risk factors are not well characterized. There is evidence of increased risk in certain racial and ethnic groups. We assessed racial differences in risk factors, stroke etiology, and outcomes among young stroke patients. METHODS Using data from our inpatient registry for ischemic stroke, we reviewed patients aged 18-50 who were admitted 01/2013 to 04/2018. Race/ethnicity were characterized as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic (HIS). For univariate comparisons Chi-square and Kruskal-Wallis tests were performed as appropriate. Multivariable logistic regression was used to assess impact of race on day seven modified Rankin score (mRS). RESULTS Among 810 patients with race and outcome data who were admitted in the study period, median age was 43, 57.1% were male, and 36.5% NHW, 43.2% NHB, 20.2% HIS. History of hypertension (HTN), type II diabetes (DM II), smoking, heart failure (CHF), prior stroke, and end-stage renal disease varied significantly by race. Compared to NHW, NHB had higher odds of HTN (OR 2.28, 1.65-3.15), CHF (OR 2.17, 1.06-4.46), and DM II 1.92 (1.25-2.94) while HIS had higher odds of DM II (OR 2.52, 1.55-4.10) and lower odds of smoking (OR 0.56, 0.35-0.90). Arrival NIHSS was higher in NHB, but etiology and rates of tpA treatment and thrombectomy did not vary by race. Compared to NHW patients, NHB (OR 0.50 CI (0.31-0.78)) and HIS (OR 0.37 CI (0.21-0.67)) were less likely to have good functional outcome (mRS <2) at day 7 in adjusted analyses. CONCLUSIONS In this study, there was a higher prevalence of several modifiable risk factors in NHB and HIS young stroke patients and early functional outcome was worse in these groups. Our study suggests a need for targeted prevention efforts for younger populations at highest risk for stroke.
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Affiliation(s)
- Erica M Jones
- Institute for Stroke and Cerebrovascular Disease, University Health Sciences Center at Houston, 6431 Fannin Street. MSB 7.044, Houston, TX 77030-1501, United States.
| | - Munachi Okpala
- Institute for Stroke and Cerebrovascular Disease, University Health Sciences Center at Houston, 6431 Fannin Street. MSB 7.044, Houston, TX 77030-1501, United States
| | - Xu Zhang
- Division of Clinical and Translational Sciences, University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Kaushik Parsha
- Institute for Stroke and Cerebrovascular Disease, University Health Sciences Center at Houston, 6431 Fannin Street. MSB 7.044, Houston, TX 77030-1501, United States
| | - Zafer Keser
- McGovern School of Medicine, University of Texas Health Sciences Center at Houston, Houston. TX, United States
| | - Christina Y Kim
- Institute for Stroke and Cerebrovascular Disease, University Health Sciences Center at Houston, 6431 Fannin Street. MSB 7.044, Houston, TX 77030-1501, United States
| | - Austin Wang
- McGovern School of Medicine, University of Texas Health Sciences Center at Houston, Houston. TX, United States
| | - Nnedinma Okpala
- Institute for Stroke and Cerebrovascular Disease, University Health Sciences Center at Houston, 6431 Fannin Street. MSB 7.044, Houston, TX 77030-1501, United States
| | - Amanda Jagolino
- Institute for Stroke and Cerebrovascular Disease, University Health Sciences Center at Houston, 6431 Fannin Street. MSB 7.044, Houston, TX 77030-1501, United States
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University Health Sciences Center at Houston, 6431 Fannin Street. MSB 7.044, Houston, TX 77030-1501, United States
| | - Anjail Z Sharrief
- Institute for Stroke and Cerebrovascular Disease, University Health Sciences Center at Houston, 6431 Fannin Street. MSB 7.044, Houston, TX 77030-1501, United States
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Laurencin CT, McClinton A. The COVID-19 Pandemic: a Call to Action to Identify and Address Racial and Ethnic Disparities. J Racial Ethn Health Disparities 2020. [PMID: 32306369 DOI: 10.1007/2fs40615-020-00756-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic has significantly impacted and devastated the world. As the infection spreads, the projected mortality and economic devastation are unprecedented. In particular, racial and ethnic minorities may be at a particular disadvantage as many already assume the status of a marginalized group. Black Americans have a long-standing history of disadvantage and are in a vulnerable position to experience the impact of this crisis and the myth of Black immunity to COVID-19 is detrimental to promoting and maintaining preventative measures. We are the first to present the earliest available data in the peer-reviewed literature on the racial and ethnic distribution of COVID-19-confirmed cases and fatalities in the state of Connecticut. We also seek to explode the myth of Black immunity to the virus. Finally, we call for a National Commission on COVID-19 Racial and Ethnic Health Disparities to further explore and respond to the unique challenges that the crisis presents for Black and Brown communities.
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Affiliation(s)
- Cato T Laurencin
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, CT, 06030, USA.
- The Africana Studies Institute, University of Connecticut, Storrs, CT, 06269, USA.
| | - Aneesah McClinton
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, CT, 06030, USA
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60
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Rushia SN, Shehab AAS, Motter JN, Egglefield DA, Schiff S, Sneed JR, Garcon E. Vascular depression for radiology: A review of the construct, methodology, and diagnosis. World J Radiol 2020; 12:48-67. [PMID: 32549954 PMCID: PMC7288775 DOI: 10.4329/wjr.v12.i5.48] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/05/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
Vascular depression (VD) as defined by magnetic resonance imaging (MRI) has been proposed as a unique subtype of late-life depression. The VD hypothesis posits that cerebrovascular disease, as characterized by the presence of MRI-defined white matter hyperintensities, contributes to and increases the risk for depression in older adults. VD is also accompanied by cognitive impairment and poor antidepressant treatment response. The VD diagnosis relies on MRI findings and yet this clinical entity is largely unfamiliar to neuroradiologists and is rarely, if ever, discussed in radiology journals. The primary purpose of this review is to introduce the MRI-defined VD construct to the neuroradiology community. Case reports are highlighted in order to illustrate the profile of VD in terms of radiological, clinical, and neuropsychological findings. A secondary purpose is to elucidate and elaborate on the measurement of cerebrovascular disease through visual rating scales and semi- and fully-automated volumetric methods. These methods are crucial for determining whether lesion burden or lesion severity is the dominant pathological contributor to VD. Additionally, these rating methods have implications for the growing field of computer assisted diagnosis. Since VD has been found to have a profile that is distinct from other types of late-life depression, neuroradiologists, in conjunction with psychiatrists and psychologists, should consider VD in diagnosis and treatment planning.
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Affiliation(s)
- Sara N Rushia
- Department of Psychology, The Graduate Center, City University of New York, New York, NY 10016, United States
- Department of Psychology, Queens College, City University of New York, Queens, NY 11367, United States
| | - Al Amira Safa Shehab
- Department of Psychology, The Graduate Center, City University of New York, New York, NY 10016, United States
- Department of Psychology, Queens College, City University of New York, Queens, NY 11367, United States
| | - Jeffrey N Motter
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, NY 10032, United States
- Department of Psychiatry, Columbia University Medical Center, New York, NY 10032, United States
| | - Dakota A Egglefield
- Department of Psychology, The Graduate Center, City University of New York, New York, NY 10016, United States
- Department of Psychology, Queens College, City University of New York, Queens, NY 11367, United States
| | - Sophie Schiff
- Department of Psychology, The Graduate Center, City University of New York, New York, NY 10016, United States
- Department of Psychology, Queens College, City University of New York, Queens, NY 11367, United States
| | - Joel R Sneed
- Department of Psychology, The Graduate Center, City University of New York, New York, NY 10016, United States
- Department of Psychology, Queens College, City University of New York, Queens, NY 11367, United States
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, NY 10032, United States
- Department of Psychiatry, Columbia University Medical Center, New York, NY 10032, United States
| | - Ernst Garcon
- Department of Radiology, Columbia University Medical Center, New York, NY 10032, United States
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Laurencin CT, McClinton A. The COVID-19 Pandemic: a Call to Action to Identify and Address Racial and Ethnic Disparities. J Racial Ethn Health Disparities 2020; 7:398-402. [PMID: 32306369 PMCID: PMC7166096 DOI: 10.1007/s40615-020-00756-0] [Citation(s) in RCA: 442] [Impact Index Per Article: 110.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 11/28/2022]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic has significantly impacted and devastated the world. As the infection spreads, the projected mortality and economic devastation are unprecedented. In particular, racial and ethnic minorities may be at a particular disadvantage as many already assume the status of a marginalized group. Black Americans have a long-standing history of disadvantage and are in a vulnerable position to experience the impact of this crisis and the myth of Black immunity to COVID-19 is detrimental to promoting and maintaining preventative measures. We are the first to present the earliest available data in the peer-reviewed literature on the racial and ethnic distribution of COVID-19-confirmed cases and fatalities in the state of Connecticut. We also seek to explode the myth of Black immunity to the virus. Finally, we call for a National Commission on COVID-19 Racial and Ethnic Health Disparities to further explore and respond to the unique challenges that the crisis presents for Black and Brown communities.
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Affiliation(s)
- Cato T Laurencin
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, CT, 06030, USA. .,The Africana Studies Institute, University of Connecticut, Storrs, CT, 06269, USA.
| | - Aneesah McClinton
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, CT, 06030, USA
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Gardener H, Sacco RL, Rundek T, Battistella V, Cheung YK, Elkind MSV. Race and Ethnic Disparities in Stroke Incidence in the Northern Manhattan Study. Stroke 2020; 51:1064-1069. [PMID: 32078475 PMCID: PMC7093213 DOI: 10.1161/strokeaha.119.028806] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 01/28/2020] [Indexed: 01/01/2023]
Abstract
Background and Purpose- An excess incidence of strokes among blacks versus whites has been shown, but data on disparities related to Hispanic ethnicity remain limited. This study examines race/ethnic differences in stroke incidence in the multiethnic, largely Caribbean Hispanic, NOMAS (Northern Manhattan Study), and whether disparities vary by age. Methods- The study population included participants in the prospective population-based NOMAS, followed for a mean of 14±7 years. Multivariable-adjusted Cox proportional hazards models were constructed to estimate the association between race/ethnicity and incident stroke of any subtype and ischemic stroke, stratified by age. Results- Among 3298 participants (mean baseline age 69±10 years, 37% men, 24% black, 21% white, 52% Hispanic), 460 incident strokes accrued (400 ischemic, 43 intracerebral hemorrhage, 9 subarachnoid hemorrhage). The most common ischemic subtype was cardioembolic, followed by lacunar infarcts, then cryptogenic. The greatest incidence rate was observed in blacks (13/1000 person-years), followed by Hispanics (10/1000 person-years), and lowest in whites (9/1000 person-years), and this order was observed for crude incidence rates until age 75. By age 85, the greatest incidence rate was in Hispanics. Blacks had an increased risk of stroke versus whites overall in multivariable models that included sociodemographics (hazard ratio, 1.51 [95% CI, 1.13-2.02]), and stratified analyses showed that this disparity was driven by women of age ≥70. The increased rate of stroke among Hispanics (age/sex-adjusted hazard ratio, 1.48 [95% CI, 1.13-1.93]) was largely explained by education and insurance status (a proxy for socieoeconomic status; hazard ratio after further adjusting for these variables, 1.17 [95% CI, 0.85-1.62]) but remained significant for women age ≥70. Conclusions- This study provides novel data regarding the increased stroke risk among Caribbean Hispanics in this elderly population. Results highlight the need to create culturally tailored campaigns to reach black and Hispanic populations to reduce race/ethnic stroke disparities and support the important role of low socioeconomic status in driving an elevated risk among Caribbean Hispanics.
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Affiliation(s)
- Hannah Gardener
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | | | - Ying Kuen Cheung
- Department of Biostatistics, Mailman Public School of Health, Columbia University, New York, NY, USA
| | - Mitchell SV Elkind
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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63
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Boot E, Ekker MS, Putaala J, Kittner S, De Leeuw FE, Tuladhar AM. Ischaemic stroke in young adults: a global perspective. J Neurol Neurosurg Psychiatry 2020; 91:411-417. [PMID: 32015089 DOI: 10.1136/jnnp-2019-322424] [Citation(s) in RCA: 118] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/04/2022]
Abstract
Ischaemic stroke at young age is an increasing problem in both developing and developed countries due to rising incidence, high morbidity and mortality and long-term psychological, physical and social consequences. Compared with stroke in older adults, stroke in young adults is more heterogeneous due to the wide variety of possible underlying risk factors and aetiologies. In this review, we will provide an overview of the global variation in the epidemiology of stroke in young adults, with special attention to differences in geography, ethnicity/race and sex, as well as traditional and novel risk factors for early-onset ischaemic stroke, such as air pollution. Understanding global differences is an important prerequisite for better region-specific prevention and treatment of this devastating condition.
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Affiliation(s)
- Esther Boot
- Department of Neurology, Radboud Univerisity Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
| | - Merel Sanne Ekker
- Department of Neurology, Radboud Univerisity Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Steven Kittner
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Frank-Erik De Leeuw
- Department of Neurology, Radboud Univerisity Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
| | - Anil M Tuladhar
- Department of Neurology, Radboud Univerisity Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
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Vagal V, Venema SU, Behymer TP, Mistry EA, Sekar P, Sawyer RP, Gilkerson L, Moomaw CJ, Haverbusch M, Coleman ER, Flaherty ML, Van Sanford C, Stanton RJ, Anderson C, Rosand J, Woo D. White Matter Lesion Severity is Associated with Intraventricular Hemorrhage in Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104661. [PMID: 32122778 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/15/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location. METHODS Utilizing the patient population from 2 large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates. RESULTS Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (P < .0001). Multivariable analysis demonstrated that moderate-severe WML, deep ICH, and increasing ICH volume were independently associated with presence of IVH. We found an increased risk of IVH with moderate-severe WML (OR = 1.38; 95%Cl 1.03-1.86, P = .0328) in the subset of lobar hemorrhages. CONCLUSIONS Moderate to severe WML is a risk for IVH. Even in lobar ICH hemorrhages, severe WML leads to an independent increased risk for ventricular rupture.
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Affiliation(s)
- Vaibhav Vagal
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio.
| | - Simone U Venema
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Tyler P Behymer
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Eva A Mistry
- Vanderbilt University Medical Center, Department of Neurology, Nashville, Tennessee
| | - Padmini Sekar
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Russell P Sawyer
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Lee Gilkerson
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Charles J Moomaw
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Mary Haverbusch
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | | | | | | | - Robert J Stanton
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | | | - Jonathan Rosand
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Daniel Woo
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
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Song S, Liang L, Fonarow GC, Smith EE, Bhatt DL, Matsouaka RA, Xian Y, Schwamm LH, Saver JL. Comparison of Clinical Care and In-Hospital Outcomes of Asian American and White Patients With Acute Ischemic Stroke. JAMA Neurol 2020; 76:430-439. [PMID: 30667466 DOI: 10.1001/jamaneurol.2018.4410] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Although overall stroke incidence and mortality in the United States is improving, little is known about the characteristics and clinical outcomes of acute ischemic stroke in Asian American individuals. Objective To compare the characteristics, care, and outcomes of Asian American and white patients with acute ischemic stroke. Design, Setting, Participants Retrospective analysis of Asian American and white patients admitted with a primary diagnosis of acute ischemic stroke to hospitals participating in the Get With The Guidelines-Stroke (GWTG-Stroke) program between April 1, 2004, and July 31, 2016. The GWTG-Stroke database is a prospectively collected stroke quality improvement registry sponsored by the American Heart Association/American Stroke Association. Main Outcomes and Measures Multivariable logistic regression models assessed the association of Asian American race/ethnicity, clinical outcomes, and quality measures. Results The study population of 1 772 299 patients (mean [SD] age, 72.4 [14.2] years; 51.3% female) consisted of 64 337 Asian American patients (3.6%) and 1 707 962 white patients (96.4%) admitted to 2171 GWTG-Stroke hospitals with acute ischemic stroke. After adjustment for patient and hospital variables, Asian American patients were seen with greater stroke severity compared with white patients (National Institutes of Health Stroke Scale [NIHSS] score ≥16) (odds ratio [OR], 1.35; 95% CI, 1.30-1.40; P < .001), manifested higher in-hospital mortality (OR, 1.14; 95% CI, 1.09-1.19; P < .001), had longer length of stay (OR, 1.17; 95% CI, 1.14-1.20; P < .001), and were less likely to ambulate independently at discharge (OR, 0.84; 95% CI, 0.79-0.90; P < .001). Although Asian American patients had fewer intravenous tissue plasminogen activator (IV tPA) administrations than white patients (OR, 0.95; 95% CI, 0.91-0.98; P = .003), they had more symptomatic hemorrhage after tPA (OR, 1.36; 95% CI, 1.20-1.55; P < .001) and overall post-tPA complications (OR, 1.31; 95% CI, 1.18-1.46; P < .001). Asian American patients had better quality measure adherence overall than white patients, including rehabilitation (OR, 1.27; 95% CI, 1.18-1.36; P < .001), door to tPA within 60 minutes (OR, 1.14; 95% CI, 1.06-1.22; P < .001), and intensive statin therapy (OR, 1.14; 95% CI, 1.10-1.18; P < .001). After adjustment for stroke severity, Asian American patients had lower in-hospital mortality than white patients (OR, 0.95; 95% CI, 0.91-0.99; P = .008). Conclusions and Relevance Asian American patients manifested more severe ischemic strokes, were less likely to receive IV tPA, and had worse functional outcomes than white patients. These findings warrant additional research toward improving clinical outcomes for Asian American patients with acute ischemic stroke.
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Affiliation(s)
- Sarah Song
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
| | - Li Liang
- Duke Clinical Research Institute, Durham, North Carolina
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Ying Xian
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, California
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Boden-Albala B, Goldmann E, Parikh NS, Carman H, Roberts ET, Lord AS, Torrico V, Appleton N, Birkemeier J, Parides M, Quarles L. Efficacy of a Discharge Educational Strategy vs Standard Discharge Care on Reduction of Vascular Risk in Patients With Stroke and Transient Ischemic Attack: The DESERVE Randomized Clinical Trial. JAMA Neurol 2019; 76:20-27. [PMID: 30304326 DOI: 10.1001/jamaneurol.2018.2926] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Despite secondary prevention strategies with proven efficacy, recurrent stroke rates remain high, particularly in racial/ethnic minority populations who are disproportionately affected by stroke. Objective To determine the efficacy of a culturally tailored skills-based educational intervention with telephone follow-up compared with standard discharge care on systolic blood pressure reduction in a multiethnic cohort of patients with mild/moderate stroke/transient ischemic attack. Design, Setting, and Participants Randomized clinical trial with 1-year follow-up. Participants were white, black, and Hispanic patients with mild/moderate stroke/transient ischemic attack prospectively enrolled from 4 New York City, New York, medical centers during hospitalization or emergency department visit between August 2012 and May 2016. Through screening of stroke admissions and emergency department notifications, 1083 eligible patients were identified, of whom 256 declined to participate and 275 were excluded for other reasons. Analyses were intention to treat. Interventions The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) intervention is a skills-based, culturally tailored discharge program with follow-up calls delivered by a community health coordinator. This intervention was developed using a community engagement approach. Main Outcomes and Measures The primary outcome was systolic blood pressure reduction at 12 months postdischarge. Results A total of 552 participants were randomized to receive intervention or usual care (281 women [51%]; mean [SD] age, 64.61 [2.9] years; 180 Hispanic [33%], 151 non-Hispanic white [27%], and 183 non-Hispanic black [33%]). At 1-year follow-up, no significant difference in systolic blood pressure reduction was observed between intervention and usual care groups (β = 2.5 mm Hg; 95% CI, -1.9 to 6.9). Although not powered for subgroup analysis, we found that among Hispanic individuals, the intervention arm had a clinically and statically significant 9.9 mm Hg-greater mean systolic blood pressure reduction compared with usual care (95% CI, 1.8-18.0). There were no significant differences between arms among non-Hispanic white (β = 3.3; 95% CI, -4.1 to 10.7) and non-Hispanic black participants (β = -1.6; 95% CI, -10.1 to 6.8). Conclusions and Relevance Few behavioral intervention studies in individuals who have had stroke have reported clinically meaningful reductions in blood pressure at 12 months, and fewer have focused on a skills-based approach. Results of secondary analyses suggest that culturally tailored, skills-based strategies may be an important alternative to knowledge-focused approaches in achieving sustained vascular risk reduction and addressing racial/ethnic stroke disparities; however, these findings should be tested in future studies. Trial Registration ClinicalTrials.gov identifier: NCT01836354.
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Affiliation(s)
- Bernadette Boden-Albala
- Department of Epidemiology, College of Global Public Health, New York University, New York.,Department of Global Health, College of Global Public Health, New York University, New York.,Department of Neurology, Langone School of Medicine, New York University, New York.,Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York
| | - Emily Goldmann
- Department of Epidemiology, College of Global Public Health, New York University, New York
| | - Nina S Parikh
- Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York
| | - Heather Carman
- Department of Epidemiology, College of Global Public Health, New York University, New York
| | - Eric T Roberts
- Department of Epidemiology, College of Global Public Health, New York University, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Aaron S Lord
- Department of Neurology, Langone School of Medicine, New York University, New York
| | - Veronica Torrico
- Department of Epidemiology, College of Global Public Health, New York University, New York
| | - Noa Appleton
- Department of Epidemiology, College of Global Public Health, New York University, New York
| | - Joel Birkemeier
- Department of Epidemiology, College of Global Public Health, New York University, New York
| | - Michael Parides
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Leigh Quarles
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City
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Roark C, Case D, Gritz M, Hosokawa P, Kumpe D, Seinfeld J, Williamson CA, Libby AM. Nationwide analysis of hospital-to-hospital transfer in patients with aneurysmal subarachnoid hemorrhage requiring aneurysm repair. J Neurosurg 2019; 131:1254-1261. [PMID: 30497228 DOI: 10.3171/2018.4.jns172269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) has devastating consequences. The association between higher institutional volumes and improved outcomes for aSAH patients has been studied extensively. However, the literature exploring patterns of transfer in this context is sparse. Expansion of the endovascular workforce has raised concerns about the decentralization of care, reduced institutional volumes, and worsened patient outcomes. In this paper, the authors explored various patient and hospital factors associated with the transfer of aSAH patients by using a nationally representative database. METHODS The 2013 and 2014 years of the National Inpatient Sample (NIS) were used to define an observational cohort of patients with ruptured brain aneurysms. The initial search identified patients with SAH (ICD-9-CM 430). Those with concomitant codes suggesting trauma or other intracranial vascular abnormalities were excluded. Finally, the patients who had not undergone a subsequent procedure to repair an intracranial aneurysm were excluded. These criteria yielded a cohort of 4373 patients, 1379 of whom had undergone microsurgical clip ligation and 2994 of whom had undergone endovascular repair. The outcome of interest was transfer status, and the NIS data element TRAN_IN was used to define this state. Multiple explanatory variables were identified, including age, sex, primary payer, median household income by zip code, race, hospital size, hospital control, hospital teaching status, and hospital location. These variables were evaluated using descriptive statistics, bivariate correlation analysis, and multivariable logistic regression modeling to determine their relationship with transfer status. RESULTS Patients with aSAH who were treated in an urban teaching hospital had higher odds of being a transfer (OR 2.15, 95% CI 1.71-2.72) than the patients in urban nonteaching hospitals. White patients were more likely to be transfer patients than were any of the other racial groups (p < 0.0001). Moreover, patients who lived in the highest-income zip codes were less likely to be transferred than the patients in the lowest income quartile (OR 0.78, 95% CI 0.64-0.95). Repair type (clip vs coil) and primary payer were not associated with transfer status. CONCLUSIONS A relatively high percentage of patients with aSAH are transferred between acute care hospitals. Race and income were associated with transfer status. White patients are more likely to be transferred than other races. Patients from zip codes with the highest income transferred at lower rates than those from the lowest income quartile. Transfer patients were preferentially sent to urban teaching hospitals. The modality of aneurysm treatment was not associated with transfer status.
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Affiliation(s)
| | | | - Mark Gritz
- 4Division of Health Care Policy and Research
| | - Patrick Hosokawa
- 5Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, Colorado; and
| | | | | | - Craig A Williamson
- 6Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Cruz D, Pinto R, Freitas-Silva M, Nunes JP, Medeiros R. GWAS contribution to atrial fibrillation and atrial fibrillation-related stroke: pathophysiological implications. Pharmacogenomics 2019; 20:765-780. [PMID: 31368859 DOI: 10.2217/pgs-2019-0054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Atrial fibrillation (AF) and stroke are included in a group of complex traits that have been approached regarding of their study by susceptibility genetic determinants. Since 2007, several genome-wide association studies (GWAS) aiming to identify genetic variants modulating AF risk have been conducted. Thus, 11 GWAS have identified 26 SNPs (p < 5 × 10-2), of which 19 reached genome-wide significance (p < 5 × 10-8). From those variants, seven were also associated with cardioembolic stroke and three reached genome-wide significance in stroke GWAS. These associations may shed a light on putative shared etiologic mechanisms between AF and cardioembolic stroke. Additionally, some of these identified variants have been incorporated in genetic risk scores in order to elucidate new approaches of stroke prediction, prevention and treatment.
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Affiliation(s)
- Diana Cruz
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal.,FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Ricardo Pinto
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal
| | - Margarida Freitas-Silva
- FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Department of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - José Pedro Nunes
- FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Department of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal.,FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Research Department, Portuguese League Against Cancer (NRNorte), Estrada Interior da Circunvalação, 6657, 4200-172 Porto, Portugal.,CEBIMED, Faculty of Health Sciences, Fernando Pessoa University, Praça 9 de Abril, 349, 4249-004 Porto, Portugal
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Bhaskar S, Thomas P, Cheng Q, Clement N, McDougall A, Hodgkinson S, Cordato D. Trends in acute stroke presentations to an emergency department: implications for specific communities in accessing acute stroke care services. Postgrad Med J 2019; 95:258-264. [PMID: 31097575 DOI: 10.1136/postgradmedj-2019-136413] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 04/05/2019] [Accepted: 04/27/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE South Western Sydney comprises of a culturally and linguistically diverse (CALD) and lower socioeconomic status population group within the state of New South Wales. Geographic location and sociodemographic factors play important roles in access to healthcare and may be crucial in the success of time-critical acute stroke intervention. The aim of this study was to examine the trends in the delayed presentation to emergency department (ED) and identify factors associated with prehospital delay for an acute stroke/transient ischaemic attack (TIA) at a comprehensive stroke centre. METHODS Patient health-related data were extracted for stroke/TIA discharges for the period 2009-2017. Electronic medical record data were used to determine sociodemographic characteristics and prehospital factors, and their associations with delayed presentation≥4.5 hours from stroke onset were studied. RESULTS During the 9-year period, population-adjusted stroke/TIA discharge rates increased from 540 to 676 per 100 000. A significant reduction in the proportion of patients presenting to ED<4.5 hours (56% in 2009 versus 46% in 2017, p<0.001) was observed. Younger patients aged 55-64 and 65-74 years, those belonging to Polynesia, South Asia and Mainland Southeast Asia, and those not using state ambulance as the mode of arrival to the hospital were at increased risk of prehospital delay. CONCLUSIONS Comprehensive reappraisal of educational programmes for early stroke recognition is required in our region due to delayed ED presentations of younger and specific CALD communities of stroke/TIA patients.
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Affiliation(s)
- Sonu Bhaskar
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia .,Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,South West Sydney Clinical School, School of Medicine, Western Sydney University, Liverpool, NSW, Australia.,The University of New South Wales, Sydney, NSW, Australia
| | - Peter Thomas
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Qi Cheng
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Nik Clement
- Business Intelligence Unit, Liverpool Hospital and South West Sydney Local Health District (SWSLHD), Liverpool, New South Wales, Australia
| | - Alan McDougall
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, NSW, Australia
| | - Suzanne Hodgkinson
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, NSW, Australia
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,South West Sydney Clinical School, School of Medicine, Western Sydney University, Liverpool, NSW, Australia.,The University of New South Wales, Sydney, NSW, Australia
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70
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Pinho J, Costa AS, Araújo JM, Amorim JM, Ferreira C. Intracerebral hemorrhage outcome: A comprehensive update. J Neurol Sci 2019; 398:54-66. [PMID: 30682522 DOI: 10.1016/j.jns.2019.01.013] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 12/22/2018] [Accepted: 01/11/2019] [Indexed: 12/15/2022]
Abstract
Non-traumatic intracerebral hemorrhage (ICH) is associated with a significant global burden of disease, and despite being proportionally less frequent than ischemic stroke, in 2010 it was associated with greater worldwide disability-adjusted life years lost. The focus of outcome assessment after ICH has been mortality in most studies, because of the high early case fatality which reaches 40% in some population-based studies. The most robust and consistent predictors of early mortality include age, severity of neurological impairment, hemorrhage volume and antithrombotic therapy at the time of the event. Long-term outcome assessment is multifaceted and includes not only mortality and functional outcome, but also patient self-assessment of the health-related quality of life, occurrence of cognitive impairment, psychiatric disorders, epileptic seizures, recurrent ICH and subsequent thromboembolic events. Several scores which predict mortality and functional outcome after ICH have been validated and are useful in the daily clinical practice, however they must be used in combination with the clinical judgment for individualized patients. Management of patients with ICH both in the acute and chronic phases, requires health care professionals to have a comprehensive and updated perspective on outcome, which informs decisions that are needed to be taken together with the patient and next of kin.
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Affiliation(s)
- João Pinho
- Neurology Department, Hospital de Braga, Portugal.
| | - Ana Sofia Costa
- Department of Neurology, RWTH Aachen University Hospital, Germany; JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
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71
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Chen LY, Norby FL, Chamberlain AM, MacLehose RF, Bengtson LGS, Lutsey PL, Alonso A. CHA 2DS 2-VASc Score and Stroke Prediction in Atrial Fibrillation in Whites, Blacks, and Hispanics. Stroke 2018; 50:28-33. [PMID: 30580712 DOI: 10.1161/strokeaha.118.021453] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Despite modest predictive ability for ischemic stroke (IS), the CHA2DS2-VASc score is widely used for stroke prediction in atrial fibrillation. Among patients with atrial fibrillation, we aimed to (1) compare the IS or transient ischemic attack (TIA) incidence by CHA2DS2-VASc in blacks and Hispanics versus whites; (2) compare predictive ability of CHA2DS2-VASc score for IS or TIA in blacks and Hispanics versus whites; and (3) determine improvement in predictive ability of CHA2DS2-VASc score from addition of race/ethnicity. Methods- Using data from Optum Clinformatics, a large administrative claims database, we analyzed patients with atrial fibrillation enrolled in commercial and Medicare Advantage health plans from 2009 to 2015. We computed IS or TIA incidence rates, improvement in C statistic, continuous and categorical net reclassification improvement, and relative integrated discrimination improvement from addition of race/ethnicity to CHA2DS2-VASc. Results- A total of 267 419 patients (mean age, 73.1 [SD, 12.3] years; 46.6% women; 84.2% white, 8.5% black, 7.3% Hispanic) were studied. After a mean follow-up of 22 months, there were 6202 IS or TIA events. IS or TIA incidence rates were higher in blacks than Hispanics or whites (1.65, 1.40, and 1.22 cases per 100 person-years, respectively) and increased with higher CHA2DS2-VASc, with no race/ethnicity-based differences (P for interaction=0.17). The CHA2DS2-VASc and CHA2DS2-VASc+race/ethnicity C statistic (95% CI) were 0.679 (0.670-0.686) and 0.679 (0.671-0.688). The CHA2DS2-VASc C statistic in the 3 groups were comparable. With addition of race/ethnicity, the categorical net reclassification improvement, continuous net reclassification improvement, and relative integrated discrimination improvement were -0.045 (95% CI, -0.067 to -0.025), 0.045 (95% CI, 0.025-0.068), and 0.016 (95% CI, 0.014-0.018). Conclusions- The predictive ability of CHA2DS2-VASc for IS or TIA in atrial fibrillation is comparable among whites, blacks, and Hispanics; hence, it can be used in the latter 2 groups. Addition of race/ethnicity to the CHA2DS2-VASc does not improve its predictive ability.
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Affiliation(s)
- Lin Y Chen
- From the Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.)
| | - Faye L Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L.N., R.F.M., P.L.L.)
| | - Alanna M Chamberlain
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN (A.M.C.)
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L.N., R.F.M., P.L.L.)
| | - Lindsay G S Bengtson
- Health Economics and Outcomes Research, Life Sciences, Optum, Eden Prairie, MN (L.G.S.B.)
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L.N., R.F.M., P.L.L.)
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.)
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Thorpe RJ, Wynn AJ, Walker JL, Smolen JR, Cary MP, Szanton SL, Whitfield KE. Relationship Between Chronic Conditions and Disability in African American Men and Women. J Natl Med Assoc 2018; 108:90-8. [PMID: 26928493 DOI: 10.1016/j.jnma.2015.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Race differences in chronic conditions and disability are well established; however, little is known about the association between specific chronic conditions and disability in African Americans. This is important because African Americans have higher rates and earlier onset of both chronic conditions and disability than white Americans. METHODS We examined the relationship between chronic conditions and disability in 602 African Americans aged 50 years and older in the Baltimore Study of Black Aging. Disability was measured using self-report of difficulty in activities of daily living (ADL). Medical conditions included diagnosed self-reports of asthma, depressive symptoms, arthritis, cancer, diabetes, cardiovascular disease (CVD), stroke, and hypertension. RESULTS After adjusting for age, high school graduation, income, and marital status, African Americans who reported arthritis (women: odds ratio (OR)=4.87; 95% confidence interval(CI): 2.92-8.12; men: OR=2.93; 95% CI: 1.36-6.30) had higher odds of disability compared to those who did not report having arthritis. Women who reported major depressive symptoms (OR=2.59; 95% CI: 1.43-4.69) or diabetes (OR=1.83; 95% CI: 1.14-2.95) had higher odds of disability than women who did not report having these conditions. Men who reported having CVD (OR=2.77; 95% CI: 1.03-7.41) had higher odds of disability than men who did not report having CVD. CONCLUSIONS These findings demonstrate the importance of chronic conditions in understanding disability in African Americans and how it varies by gender. Also, these findings underscore the importance of developing health promoting strategies focused on chronic disease prevention and management to delay or postpone disability in African Americans. PUBLICATION INDICES Pubmed, Pubmed Central, Web of Science database.
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Affiliation(s)
- Roland J Thorpe
- Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Center for Biobehavioral Health Disparities Research, Duke University.
| | - Anastasia J Wynn
- Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health
| | | | - Jenny R Smolen
- Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health
| | | | - Sarah L Szanton
- Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Center for Biobehavioral Health Disparities Research, Duke University, Johns Hopkins School of Nursing, Johns Hopkins University
| | - Keith E Whitfield
- Center for Biobehavioral Health Disparities Research, Duke University, Department of Psychology and Neuroscience, Duke University
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Bouslama M, Rebello LC, Haussen DC, Grossberg JA, Anderson AM, Belagaje SR, Bianchi NA, Frankel MR, Nogueira RG. Endovascular Therapy and Ethnic Disparities in Stroke Outcomes. INTERVENTIONAL NEUROLOGY 2018; 7:389-398. [PMID: 30410516 PMCID: PMC6216703 DOI: 10.1159/000487607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/10/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Ethnic disparities in stroke are well described, with a higher incidence of disability and increased mortality in Blacks versus Whites. We sought to compare the clinical outcomes between those ethnic groups after stroke endovascular therapy (ET). METHODS We performed a retrospective review of the prospectively acquired Grady Endovascular Stroke Outcomes Registry between September 1, 2010 and September 30, 2015. Patients were dichotomized into two groups - Caucasians and African-Americans - and matched for age, pretreatment glucose level, and baseline National Institutes of Health Stroke Scale (NIHSS) score. Baseline characteristics as well as procedural and outcome parameters were compared. RESULTS Out of the 830 patients treated with ET, 308 pairs of patients (n = 616) underwent primary analysis. African-Americans were younger (p < 0.01), had a higher prevalence of hypertension (p < 0.01) and diabetes (p = 0.04), and had higher Alberta Stroke Program Early CT Score values (p = 0.03) and shorter times to treatment (p = 0.01). Blacks more frequently had Medicaid coverage and less private insurance (29.6 vs. 11.4% and 41.5 vs. 60.3%, respectively, p < 0.01). The remaining baseline characteristics, including baseline NIHSS score and CT perfusion-derived ischemic core volumes, were well balanced. There were no differences in the overall distribution of 90-day modified Rankin scale scores (p = 0.28), rates of successful reperfusion (84.7 vs. 85.7%, p = 0.91), good outcomes (49.1 vs. 44%, p = 0.24), or parenchymal hematomas (6.5 vs. 6.8%, p = 1.00). Blacks had lower 90-day mortality rates (18 vs. 24.6%, p = 0.04) in univariate analysis, which persisted as a nonsignificant trend after adjustment for potential confounders (OR 0.52, 95% CI 0.26-1.03, p = 0.06). CONCLUSIONS Despite unique baseline characteristics, African-Americans treated with ET for large vessel occlusion strokes have similar outcomes as Caucasians. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Raul G. Nogueira
- Departments of Neurology and Neurosurgery, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, Georgia, USA
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Jacobson LT, Hade EM, Collins TC, Margolis KL, Waring ME, Van Horn LV, Silver B, Sattari M, Bird CE, Kimminau K, Wambach K, Stefanick ML. Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative. J Am Heart Assoc 2018; 7:e008739. [PMID: 30371157 PMCID: PMC6201437 DOI: 10.1161/jaha.118.008739] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/20/2018] [Indexed: 11/16/2022]
Abstract
Background Stroke is the third leading cause of death among US Hispanic and non-Hispanic black women aged 65 and older. One factor that may protect against stroke is breastfeeding. Few studies have assessed the association between breastfeeding and stroke and whether this association differs by race and ethnicity. Methods and Results Data were taken from the Women's Health Initiative Observational Study with follow-up through 2010; adjusted hazard ratios for stroke subsequent to childbirth were estimated with Cox regression models accounting for left and right censoring, overall and stratified by race/ethnicity. Of the 80 191 parous women in the Women's Health Initiative Observational Study, 2699 (3.4%) had experienced a stroke within a follow-up period of 12.6 years. The average age was 63.7 years at baseline. Fifty-eight percent (n=46 699) reported ever breastfeeding; 83% were non-Hispanic white, 8% were non-Hispanic black, 4% were Hispanic, and 5% were of other race/ethnicity. After adjustment for nonmodifiable potential confounders, compared with women who had never breastfed, women who reported ever breastfeeding had a 23% lower risk of stroke (adjusted hazard ratio=0.77; 95% confidence interval 0.70-0.83). This association was strongest for non-Hispanic black women (adjusted hazard ratio=0.52; 95% confidence interval 0.37-0.71). Further, breastfeeding for a relatively short duration (1-6 months) was associated with a 19% lower risk of stroke (adjusted hazard ratios=0.81; 95% confidence interval 0.74-0.89). This association appeared stronger with longer breastfeeding duration and among non-Hispanic white and non-Hispanic black women (test for trend P<0.01). Conclusions Study results show an association and dose-response relationship between breastfeeding and lower risk of stroke among postmenopausal women after adjustment for multiple stroke risk factors and lifestyle variables. Further investigation is warranted.
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Affiliation(s)
- Lisette T. Jacobson
- Department of Preventive Medicine and Public HealthSchool of Medicine‐WichitaUniversity of KansasWichitaKS
| | - Erinn M. Hade
- Center for BiostatisticsDepartment of Biomedical InformaticsThe Ohio State UniversityColumbusOH
| | - Tracie C. Collins
- Department of Preventive Medicine and Public HealthSchool of Medicine‐WichitaUniversity of KansasWichitaKS
| | | | | | | | - Brian Silver
- Department of NeurologyUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Maryam Sattari
- Department of MedicineUniversity of Florida College of MedicineGainesvilleFL
| | | | - Kim Kimminau
- Department of Family MedicineUniversity of Kansas Medical CenterKansas CityKS
| | - Karen Wambach
- School of NursingUniversity of Kansas Medical CenterKansas CityKS
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Racial/ethnic variation in stroke rates and risks among patients with systemic lupus erythematosus. Semin Arthritis Rheum 2018; 48:840-846. [PMID: 30205982 DOI: 10.1016/j.semarthrit.2018.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 06/30/2018] [Accepted: 07/23/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE), which is associated with increased stroke risk, is more prevalent and often more severe among Blacks, Asians, and Hispanics than Whites. We examined racial/ethnic variation in stroke rates and risks, overall and by hemorrhagic versus ischemic subtype, among SLE patients. METHODS Within Medicaid (2000-2010), we identified patients aged 18-65 with SLE (≥ 3 ICD-9 710.0 codes, ≥ 30days apart) and ≥12 months of continuous enrollment. Subjects were followed from index date to first stroke event, death, disenrollment, or end of follow-up. Race/ethnicity-specific annual event rates were calculated for stroke overall and by subtypes (hemorrhagic vs. ischemic). We used Cox proportional hazard models to estimate hazard ratios (HR) of stroke by race/ethnicity, adjusting for comorbidities and the competing risk of death. RESULTS Of 65,788 SLE patients, 93.1% were female. Racial/ethnic breakdown was 42% Black, 38% White, 16% Hispanic, 3% Asian, and 1% American Indian/Alaska Natives. Mean follow-up was 3.7 ± 3.0years. After multivariable adjustment, Blacks were at increased risk of overall stroke (HR 1.34 [95%CI 1.18-1.53), hemorrhagic stroke (HR 1.42 [1.00-2.01]), and ischemic stroke (HR 1.33 [1.15-1.52]) compared to Whites. Hispanics were at increased risk of overall stroke (HR 1.25 [1.06-1.47)] and hemorrhagic stroke (HR 1.79 [95% CI 1.22-2.61]), but not ischemic stroke, compared to Whites. CONCLUSION Among SLE patients enrolled in Medicaid, we observed elevated stroke risk (overall and by subtype) among Blacks and Hispanics compared to Whites, suggesting the importance of early recognition and screening for stroke risk factors among Blacks and Hispanics.
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Mayeda ER, Banack HR, Bibbins-Domingo K, Al Hazzouri AZ, Marden JR, Whitmer RA, Glymour MM. Can Survival Bias Explain the Age Attenuation of Racial Inequalities in Stroke Incidence?: A Simulation Study. Epidemiology 2018; 29:525-532. [PMID: 29621058 PMCID: PMC6289512 DOI: 10.1097/ede.0000000000000834] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In middle age, stroke incidence is higher among black than white Americans. For unknown reasons, this inequality decreases and reverses with age. We conducted simulations to evaluate whether selective survival could account for observed age patterning of black-white stroke inequalities. METHODS We simulated birth cohorts of 20,000 blacks and 20,000 whites with survival distributions based on US life tables for the 1919-1921 birth cohort. We generated stroke incidence rates for ages 45-94 years using Reasons for Geographic and Racial Disparities in Stroke (REGARDS) study rates for whites and setting the effect of black race on stroke to incidence rate difference (IRD) = 20/10,000 person-years at all ages, the inequality observed at younger ages in REGARDS. We compared observed age-specific stroke incidence across scenarios, varying effects of U, representing unobserved factors influencing mortality and stroke risk. RESULTS Despite a constant adverse effect of black race on stroke risk, the observed black-white inequality in stroke incidence attenuated at older age. When the hazard ratio for U on stroke was 1.5 for both blacks and whites, but U only directly influenced mortality for blacks (hazard ratio for U on mortality =1.5 for blacks; 1.0 for whites), stroke incidence rates in late life were lower among blacks (average observed IRD = -43/10,000 person-years at ages 85-94 years versus causal IRD = 20/10,000 person-years) and mirrored patterns observed in REGARDS. CONCLUSIONS A relatively moderate unmeasured common cause of stroke and survival could fully account for observed age attenuation of racial inequalities in stroke.
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Affiliation(s)
- Elizabeth Rose Mayeda
- University of California, Los Angeles Fielding School of Public Health Department of Epidemiology
- University of California, San Francisco Department of Epidemiology and Biostatistics
| | - Hailey R. Banack
- State University of New York at Buffalo Department of Epidemiology and Environmental Health
| | - Kirsten Bibbins-Domingo
- University of California, San Francisco Department of Epidemiology and Biostatistics
- University of California, San Francisco Department of Medicine
| | - Adina Zeki Al Hazzouri
- University of Miami Miller School of Medicine Department of Public Health Sciences, Division of Epidemiology and Population Health
| | | | - Rachel A. Whitmer
- University of California, San Francisco Department of Epidemiology and Biostatistics
- Kaiser Permanente Division of Research
| | - M. Maria Glymour
- University of California, San Francisco Department of Epidemiology and Biostatistics
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MADSEN TE, KHOURY JC, ALWELL KA, MOOMAW CJ, DEMEL SL, FLAHERTY ML, WOO D, MACKEY J, DE LOS RIOS LA ROSA F, MARTINI S, FERIOLI S, ADEOYE O, KHATRI P, KISSELA BM, KLEINDORFER D. Sex differences in cardiovascular risk profiles of ischemic stroke patients with diabetes in the Greater Cincinnati/Northern Kentucky Stroke Study. J Diabetes 2018; 10:496-501. [PMID: 28523847 PMCID: PMC5694383 DOI: 10.1111/1753-0407.12567] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 05/01/2017] [Accepted: 05/15/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The aim of the present study was to compare sex-specific associations between cardiovascular risk factors and diabetes mellitus (DM) among patients with acute ischemic stroke (AIS) in the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS). METHODS The GCNKSS ascertained AIS cases in 2005 and 2010 among adult (age ≥ 20 years) residents of a biracial population of 1.3 million. Past and current stroke risk factors were compared between those with and without DM using Chi-squared tests and multiple logistic regression analysis to examine sex-specific profiles. RESULTS There were 3515 patients with incident AIS; 1919 (55%) were female, 697 (20%) were Black, and 1146 (33%) had DM. Among both women and men with DM, significantly more were obese and had hypertension, high cholesterol, and coronary artery disease (CAD) compared with those without DM. For women with AIS, multivariable sex-specific adjusted analyses revealed that older age was associated with decreased odds of having DM (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.80-0.98). For women with CAD, the odds of DM were increased (aOR 1.76, 95% CI 1.33-2.32). Age and CAD were not significant factors in differentiating the profiles of men with and without DM. CONCLUSIONS Women with DM had strokes at a younger age, whereas no such age difference existed in men. Compared with men, women with DM were also more likely to have CAD than those without DM, suggesting a sex difference in the association between DM and vascular disease. These findings may suggest a need for more aggressive risk factor management in diabetic women.
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Affiliation(s)
- Tracy E. MADSEN
- Division of Sex and Gender in Emergency Medicine, Department of Emergency Medicine, The Alpert Medical School of Brown University, Providence, RI
- Corresponding Author: 55 Claverick Street, 2 floor, 401-489-5275, 401-444-6662,
| | - Jane C. KHOURY
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | | | | | | | - Daniel WOO
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Felipe DE LOS RIOS LA ROSA
- University of Cincinnati College of Medicine, Cincinnati, OH
- Baptist Health Neuroscience Center, Miami, FL
| | | | - Simona FERIOLI
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Opeolu ADEOYE
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Pooja KHATRI
- University of Cincinnati College of Medicine, Cincinnati, OH
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Poledne R, Zicha J. Human genome evolution and development of cardiovascular risk factors through natural selection. Physiol Res 2018; 67:155-163. [PMID: 29726690 DOI: 10.33549/physiolres.933885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Impressive advances in molecular genetic techniques allow to analyze the effects of natural selection on the development of human genome. For example, the trend towards blonde hair and blue eyes was documented. The approach to analyze possible effects of natural selection on the evolution of recent phenotypes with high risk of cardiovascular disease has not been described yet. A possible effect on the evolution of two main risk factors - hypercholesterolemia and hypertension - is presented. The close relationship of non-HDL cholesterol blood concentration to the proportion of pro-inflammatory macrophages in human visceral adipose tissue might be a result of long-lasting natural selection. Individuals with higher proportion of this phenotype might also display a higher ability to fight infection, which was very common in human setting from prehistory until Middle Ages. Successful battle against infections increased the probability to survive till reproductive age. Similar hypothesis was proposed to explain frequent hypertension in African Americans. A long-lasting selection for higher ability to conserve sodium during long-term adaptation to low sodium intake and hot weather was followed by a short-term (but very hard) natural selection of individuals during transatlantic slave transport. Only those with very high capability to retain sodium were able to survive. Natural selection of phenotypes with high plasma cholesterol concentration and/or high blood pressure is recently potentiated by high-fat high-sodium diet and overnutrition. This hypothesis is also supported by the advantage of familial hypercholesterolemia in the 19th century (at the time of high infection disease mortality) in contrast to the disadvantage of familial hypercholesterolemia during the actual period of high cardiovascular disease mortality.
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Affiliation(s)
- R Poledne
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic.
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Combination of Intra-Hematomal Hypodensity on CT and BRAIN Scoring Improves Prediction of Hemorrhage Expansion in ICH. Neurocrit Care 2018; 29:40-46. [DOI: 10.1007/s12028-018-0507-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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80
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Sajatovic M, Tatsuoka C, Welter E, Colon-Zimmermann K, Blixen C, Perzynski AT, Amato S, Cage J, Sams J, Moore SM, Pundik S, Sundararajan S, Modlin C, Sila C. A Targeted Self-Management Approach for Reducing Stroke Risk Factors in African American Men Who Have Had a Stroke or Transient Ischemic Attack. Am J Health Promot 2018; 32:282-293. [PMID: 28530142 PMCID: PMC6241515 DOI: 10.1177/0890117117695218] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE This study compared a novel self-management (TargetEd MAnageMent Intervention [TEAM]) versus treatment as usual (TAU) to reduce stroke risk in African American (AA) men. DESIGN Six-month prospective randomized controlled trial with outcomes evaluated at baseline, 3 months, and 6 months. SETTING Academic health center. PARTICIPANTS Thirty-eight (age < 65) AA men who had a stroke or transient ischemic attack and a Barthel index score of >60 were randomly assigned to TEAM (n = 19) or TAU (n = 19). INTERVENTION Self-management training, delivered in 1 individual and 4 group sessions (over 3 months). MEASURES Blood pressure, glycosylated hemoglobin (HbA1c), lipids, medication adherence, weight, and standardized measures of health behaviors (diet, exercise, smoking, substances), depression, and quality of life. Qualitative assessments evaluated the perspectives of TEAM participants. ANALYSIS T tests for paired differences and nonparametric tests. Thematic content qualitative analysis. RESULTS Mean age was 52.1 (standard deviation [SD] = 7.4) and mean body mass index was 31.4 (SD = 7.4). Compared to TAU, TEAM participants had significantly lower mean systolic blood pressure by 24 weeks, and there was also improvement in HbA1c and high-density lipoprotein cholesterol ( P = .03). Other biomarker and health behaviors were similar between groups. Qualitative results suggested improved awareness of risk factors as well as positive effects of group support.
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Affiliation(s)
- Martha Sajatovic
- Department of Psychiatry, Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Neurology, Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Curtis Tatsuoka
- Department of Neurology, Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Elisabeth Welter
- Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, Cleveland Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kari Colon-Zimmermann
- Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, Cleveland Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Carol Blixen
- Center for Health Care Research and Policy, Case Western Reserve University, Cleveland, OH, USA
- MetroHealth Medical Center, Cleveland, OH, USA
| | - Adam T. Perzynski
- Center for Health Care Research and Policy, Case Western Reserve University, Cleveland, OH, USA
- MetroHealth Medical Center, Cleveland, OH, USA
| | | | - Jamie Cage
- Case Western Reserve University, Cleveland, OH, USA
| | - Johnny Sams
- Case Western Reserve University, Cleveland, OH, USA
| | - Shirley M. Moore
- School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Svetlana Pundik
- Department of Neurology, Cleveland VA Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sophia Sundararajan
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Charles Modlin
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cathy Sila
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Esenwa C, Ilunga Tshiswaka D, Gebregziabher M, Ovbiagele B. Historical Slavery and Modern-Day Stroke Mortality in the United States Stroke Belt. Stroke 2018; 49:465-469. [DOI: 10.1161/strokeaha.117.020169] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 11/29/2017] [Accepted: 12/06/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Charles Esenwa
- From the Department of Neurology, Montefiore Medical Center, New York, NY (C.E.); Department of Public Health, University of West Florida, Pensacola (D.I.T.); Departments of Public Health (M.G.) and Neurology (B.O.), Medical University of South Carolina, Charleston
| | - Daudet Ilunga Tshiswaka
- From the Department of Neurology, Montefiore Medical Center, New York, NY (C.E.); Department of Public Health, University of West Florida, Pensacola (D.I.T.); Departments of Public Health (M.G.) and Neurology (B.O.), Medical University of South Carolina, Charleston
| | - Mulugeta Gebregziabher
- From the Department of Neurology, Montefiore Medical Center, New York, NY (C.E.); Department of Public Health, University of West Florida, Pensacola (D.I.T.); Departments of Public Health (M.G.) and Neurology (B.O.), Medical University of South Carolina, Charleston
| | - Bruce Ovbiagele
- From the Department of Neurology, Montefiore Medical Center, New York, NY (C.E.); Department of Public Health, University of West Florida, Pensacola (D.I.T.); Departments of Public Health (M.G.) and Neurology (B.O.), Medical University of South Carolina, Charleston
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Hurr C, Patik JC, Kim K, Christmas KM, Brothers RM. Tempol augments the blunted cutaneous microvascular thermal reactivity in healthy young African Americans. Exp Physiol 2018; 103:343-349. [PMID: 29271085 DOI: 10.1113/ep086776] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 12/18/2017] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? The purpose was to determine whether there is a difference between African Americans and Caucasians in cutaneous microvascular function and whether this difference is attributable to elevated oxidative stress. What is the main finding and its importance? The main finding is that African Americans have an attenuated cutaneous vasodilatation during local heating relative to Caucasians that is restored with local infusion of the superoxide dismutase mimetic, tempol. This suggests that superoxide mediates microvascular dysfunction and might contribute to the greater prevalence of cardiovascular disease in this population. ABSTRACT African Americans (AA) have elevated risk for cardiovascular disease relative to other populations. We hypothesized that the cutaneous hyperaemic response to local heating is reduced in young AA relative to Caucasian Americans (CA) and that this is attributable to elevated oxidative stress. As such, ascorbic acid (a global antioxidant) and tempol (a superoxide dismutase mimetic) would improve this response in AA. Microdialysis fibres received lactated Ringer solution (control), 10 mm ascorbic acid or 10 μm 4-hydroxy-2,2,6,6-tetramethylpiperidine-1-oxyl (tempol) at a rate of 2.0 μl min-1 . Cutaneous vascular conductance (CVC) was calculated as the red blood cell flux divided by mean arterial pressure. Data were presented as a percentage of maximal CVC (%CVCmax ) induced by 44°C heating plus sodium nitroprusside. Twenty-four (12 AA, 12 CA) young (23 ± 4 years old) subjects participated. During 39°C heating, the %CVCmax was lower in AA at the control (CA, 65 ± 20% versus AA, 47 ± 15%; P < 0.05) and ascorbic acid sites (CA, 73 ± 14% versus AA: 49 ± 17%; P < 0.01). At the tempol site, there were no differences between groups. This was followed by infusion of 10 mm l-NAME at all sites to assess the contribution of nitric oxide to vasodilatation during local heating. The contribution of nitric oxide was lower in AA relative to CA at 39°C; however, this was restored with tempol. These data suggest that: (i) cutaneous vasodilatation in response to local heating is blunted in AA relative to CA; and (ii) elevated superoxide generation attenuates nitric oxide-mediated cutaneous vasodilatation in AA.
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Affiliation(s)
- Chansol Hurr
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, USA.,Department of Pharmacology and Physiology, The George Washington University, Washington, DC, USA
| | - Jordan C Patik
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, USA.,Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, USA
| | - KiYoung Kim
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, USA.,Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin M Christmas
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, USA.,Department of Bioengineering, The University of Washington, Seattle, WA, USA
| | - R Matthew Brothers
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, USA.,Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, USA
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83
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Krishnan K, Beishon L, Berge E, Christensen H, Dineen RA, Ozturk S, Sprigg N, Wardlaw JM, Bath PM. Relationship between race and outcome in Asian, Black, and Caucasian patients with spontaneous intracerebral hemorrhage: Data from the Virtual International Stroke Trials Archive and Efficacy of Nitric Oxide in Stroke trial. Int J Stroke 2017; 13:362-373. [PMID: 29165060 DOI: 10.1177/1747493017744463] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background and purpose Although poor prognosis after intracerebral hemorrhage relates to risk factors and hematoma characteristics, there is limited evidence for the effect of race-ethnicity. Methods Data from 1011 patients with intracerebral hemorrhage enrolled into hyperacute trials and randomized to control were obtained from the Virtual International Stroke Trials Archive and Efficacy of Nitric Oxide in Stroke Trial. Clinical characteristics and functional outcome were compared among three racial groups - Asians, Blacks, and Caucasians. Results The majority of patients were Caucasian (78.1%) followed by Asians (14.5%) and Blacks (5.5%). At baseline, Caucasians were older and had larger hematoma volumes; Blacks had lower Glasgow Coma Scale and higher systolic blood pressure (all p < 0.05). Although the primary outcome of modified Rankin Scale did not differ at 90 days (p = 0.14), there were significant differences in mortality (p < 0.0001) and quality of life (EQ-5D p < 0.0001; EQ-VAS p 0.015). In test of multiple comparisons, Caucasians were more likely to die (p = 0.0003) and had worse quality of life (EQ-5D p = 0.003; EQ-VAS p < 0.0001) as compared to Asians. Conclusion Race-ethnicity appears to explain some of the variation in clinical characteristics and outcomes after acute intracerebral hemorrhage. Factors that explain this variation need to be identified.
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Affiliation(s)
- Kailash Krishnan
- 1 Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lucy Beishon
- 1 Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Eivind Berge
- 2 Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Robert A Dineen
- 4 Radiological Sciences Research Group, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Serefnur Ozturk
- 5 Department of Neurology, Selcuk University Medical Faculty, Konya, Turkey
| | - Nikola Sprigg
- 1 Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- 6 Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, Western General Hospital, Edinburgh, UK
| | - Philip M Bath
- 1 Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Dotson AL, Offner H. Sex differences in the immune response to experimental stroke: Implications for translational research. J Neurosci Res 2017; 95:437-446. [PMID: 27870460 DOI: 10.1002/jnr.23784] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/16/2016] [Indexed: 12/24/2022]
Abstract
Ischemic stroke is a leading cause of death and disability in the United States. It is known that males and females respond differently to stroke. Depending on age, the incidence, prevalence, mortality rate, and disability outcome of stroke differ between the sexes. Females generally have strokes at older ages than males and, therefore, have a worse stroke outcome. There are also major differences in how the sexes respond to stroke at the cellular level. Immune response is a critical factor in determining the progress of neurodegeneration after stroke and is fundamentally different for males and females. Additionally, females respond to stroke therapies differently from males, yet they are often left out of the basic research that is focused on developing those therapies. With a resounding failure to translate stroke therapies from the bench to the bedside, it is clearer than ever that inclusion of both sexes in stroke studies is essential for future clinical success. This Mini-Review examines sex differences in the immune response to experimental stroke and its implications for therapy development. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Abby L Dotson
- Neuroimmunology Research, Veterans Affairs Portland Health Care System, Portland, Oregon
- Department of Neurology, Oregon Health and Science University, Portland, Oregon
| | - Halina Offner
- Neuroimmunology Research, Veterans Affairs Portland Health Care System, Portland, Oregon
- Department of Neurology, Oregon Health and Science University, Portland, Oregon
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
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Abstract
The nitric oxide-cyclic guanosine monophosphate (NO-cGMP) pathway plays a key role in regulating cardiovascular homeostasis, and genetic variants allocated to NO-cGMP pathway genes, leading to NO-cGMP deficiency, may influence the prevalence or course of cardiovascular disease. NO-cGMP deficiency can be caused by nitric oxide synthase substrate deficiency, substrate competition, defects, or uncoupling; endogenous inhibitors of nitric oxide synthase; decreased cGMP production; or increased cGMP degradation. This review presents evidence supporting the role of NO-cGMP deficiency in cardiovascular disease, including findings from genetic association studies for particular polymorphisms, haplotypes, and racial disparities. NO-cGMP pathway components including arginases, guanosine-5'-triphosphate cyclohydrolase 1, nitric oxide synthase, dimethylarginine dimethylaminohydrolases, soluble guanylyl cyclase, protein kinase G, phosphodiesterase 5, and natriuretic peptides will be discussed.
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Affiliation(s)
| | - Sven Moosmang
- Bayer AG, Experimental Medicine CV/HEM, Wuppertal, Germany
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86
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Lee JY, Park KA, Oh SY. Prevalence and incidence of non-arteritic anterior ischaemic optic neuropathy in South Korea: a nationwide population-based study. Br J Ophthalmol 2017; 102:936-941. [DOI: 10.1136/bjophthalmol-2017-311140] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/06/2017] [Accepted: 09/10/2017] [Indexed: 11/04/2022]
Abstract
AimsTo determine the age and sex-specific prevalence and incidence of non-arteritic anterior ischaemic optic neuropathy (NAION) in South Korea.MethodsThis is a nationwide population-based study using data from the Korean national health claims database to identify patients with NAION using the registration programme database, which comprises ophthalmologist-confirmed NAION from 2011 through 2015. We evaluated prevalence and incidence rates using these data.ResultsAmong 25 816 797 of entire population 40 years of age or older, 26 167 patients had NAION (47.8% men) during the 5-year study period. The prevalence in the general population 40 years of age or older was 102.87 (95% CI 95.22 to 110.53) per 100 000 people. In men, it was 111.10 (95% CI 101.19 to 121.02), and in women, it was 94.64 (95% CI 89.25 to 100.03) per 100 000 people. The prevalence increased with advancing age and peaked at 70–74 years in men and 65–69 years in women. The incidence in the general population 40 years of age or older was 11.35 (95% CI 10.37 to 12.33) per 100 000 person-years. In men, it was 14.89 (95% CI 12.26 to 16.91), and in women, it was 9.92 (95% CI 8.85 to 10.99) per 100 000 person-years. The incidence increased with advancing age and peaked at 80–84 years in men and 70–74 years in women.ConclusionsThe prevalence and incidence estimates of NAION are comparable with those of Caucasians. These detailed estimates could promote understanding of the disease’s pathophysiology and allow for appropriate planning within the healthcare system.
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87
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Hospital-Based Study of the Frequency and Risk Factors of Stroke Recurrence in Two Years in China. J Stroke Cerebrovasc Dis 2017; 26:2494-2500. [PMID: 28939046 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/24/2017] [Accepted: 05/17/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Stroke causes death and disability throughout the world and recurrent stroke events are more likely to be disabling or fatal. We conducted a hospital-based study to investigate the frequency and influence factors of stroke recurrence in China. METHODS Data from patients hospitalized with stroke between January 2007 and December 2010 of 109 tertiary hospitals in China were used. Stroke recurrence and associated factors were ascertained. The zero-inflated model was used to evaluate the factors of recurrence. RESULTS Of 101,926 discharged patients, the cumulative 2-year stroke recurrence rate was 3.80% for subarachnoid hemorrhage (SAH), 5.31% for intracerebral hemorrhage (ICH), and 8.71% for ischemic stroke (IS), respectively. Among patients with stroke recurrence, 54.11% with SAH, 60.42% with ICH, and 92.92% with IS relapsed for the same type of the first-onset stroke. For discharged patients with SAH with middle cerebral artery aneurysm clipping or artery aneurysm embolization, it was less likely to stroke relapse, but the times of recurrence would increase if 1 recurrence appeared. Cerebral artery aneurysms and hypertension were risk factors for recurrence frequency. For ICH, protective factors for recurrence were trepanation and drainage of intracranial hematoma, cerebral angiography, puncture and drainage of intracranial hematoma, and length of stay (LOS). But rheumatic heart disease and atrial fibrillation would further the relapse frequency. For IS, age and LOS were protective factors, but recurrence frequency would increase if the first recurrence happened. Cervical spondylopathy, male gender, and diabetes were risk factors for frequency of relapse. CONCLUSIONS Associated factors were different for recurrence frequency among different stroke types.
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88
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James ML, Langefeld CD, Sekar P, Moomaw CJ, Elkind MSV, Worrall BB, Sheth KN, Martini SR, Osborne J, Woo D. Assessment of the interaction of age and sex on 90-day outcome after intracerebral hemorrhage. Neurology 2017; 89:1011-1019. [PMID: 28710330 PMCID: PMC5589792 DOI: 10.1212/wnl.0000000000004255] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 01/25/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Because age affects hormonal production differently in women compared with men, we sought to define sex and age interactions across a multiracial/ethnic population after intracerebral hemorrhage (ICH) to uncover evidence that loss of gonadal hormone production would result in loss of the known neuroprotective effects of gonadal hormones. METHODS Clinical and radiographic data from participants in the Ethnic/Racial Variations of Intracerebral Hemorrhage study and the Genetic and Environmental Risk Factors for Hemorrhagic Stroke study prior to December 2013 were used. Relationships among sex, age, and outcome after ICH in 616 non-Hispanic black, 590 Hispanic, and 868 non-Hispanic white participants were evaluated using multivariable logistic regression analysis. Poor outcome was defined as modified Rankin Scale score ≥3 at 90 days after ICH. RESULTS Sex differences were found in multiple variables among the racial/ethnic groups, including age at onset, premorbid neurologic status, and neurologic outcome after ICH. Overall, no sex-age interaction effect was found for mortality (p = 0.183) or modified Rankin Scale score (p = 0.378) at 90 days after ICH. In racial/ethnic subgroups, only the non-Hispanic black cohort provided possible evidence of a sex-age interaction on 90-day modified Rankin Scale score (p = 0.003). CONCLUSION Unlike in ischemic stroke, there was no evidence that patient sex modified the effect of age on 90-day outcomes after ICH in a large multiracial/ethnic population. Future studies should evaluate biological reasons for these differences between stroke subtypes. CLINICALTRIALSGOV IDENTIFIER NCT01202864.
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Affiliation(s)
- Michael L James
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX.
| | - Carl D Langefeld
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX
| | - Padmini Sekar
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX
| | - Charles J Moomaw
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX
| | - Mitchell S V Elkind
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX
| | - Bradford B Worrall
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX
| | - Kevin N Sheth
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX
| | - Sharyl R Martini
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX
| | - Jennifer Osborne
- From the Brain Injury Translational Research Center, Department of Anesthesiology, and Department of Neurology (M.L.J.), Duke University, Durham; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (P.S., C.J.M., J.O., D.W.), University of Cincinnati, OH; Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University, New Haven, CT; and Department of Neurology (S.R.M.), Baylor College of Medicine, Houston, TX
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Singh N, Moody AR, Zhang B, Kaminski I, Kapur K, Chiu S, Tyrrell PN. Age-Specific Sex Differences in Magnetic Resonance Imaging-Depicted Carotid Intraplaque Hemorrhage. Stroke 2017; 48:2129-2135. [PMID: 28706117 DOI: 10.1161/strokeaha.117.017877] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 05/29/2017] [Accepted: 06/12/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND PURPOSE Stroke rates are higher in men compared with women in the fourth through seventh decades of life, and higher rates may result from differences in carotid intraplaque hemorrhage (IPH), an unstable atherosclerotic plaque component. We report age-specific sex differences in the presence of magnetic resonance imaging-depicted carotid IPH. METHODS Patients (n=1115) underwent magnetic resonance imaging for carotid IPH between 2005 and 2014. Low-grade carotid stenosis patients (n=906) without prior endarterectomy were eligible for this cross-sectional study. RESULTS Of the 906 patients included (mean age±SD in years, 66.98±15.15), 63 (6.95%) had carotid IPH. In men and women, carotid IPH was present in 11.43% (48 of 420) and 3.09% (15 of 486), respectively (P<0.0001). Multivariable logistic regression analysis confirmed greater odds of carotid IPH in men for all ages: 45 to 54 (odds ratio=45.45; 95% confidence interval, 3.43-500), 55 to 64 years (odds ratio=21.74; 95% confidence interval, 3.21-142.86), 65 to 74 years (odds ratio=10.42; 95% confidence interval, 2.91-37.04), and ≥75 years (odds ratio=5.00; 95% confidence interval, 2.31-10.75). Male sex modified the effect of age on the presence of carotid IPH (β=0.074; SE=0.036; P=0.0411). CONCLUSIONS Men have greater age-specific odds of magnetic resonance imaging-depicted carotid IPH compared with women. With increasing age post-menopause, the odds of carotid IPH in women becomes closer to that of men. Delayed onset of carotid IPH in women, an unstable plaque component, may partly explain differential stroke rates between sexes, and further studies are warranted.
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Affiliation(s)
- Navneet Singh
- From the Department of Medical Imaging, Faculty of Medicine (N.S., A.R.M., B.Z., I.K., S.C., P.N.T.) and Department of Statistical Sciences (P.N.T.), University of Toronto, Ontario, Canada; and Department of Neurology, Boston Children's Hospital, Harvard Medical School, MA (K.K.)
| | - Alan R Moody
- From the Department of Medical Imaging, Faculty of Medicine (N.S., A.R.M., B.Z., I.K., S.C., P.N.T.) and Department of Statistical Sciences (P.N.T.), University of Toronto, Ontario, Canada; and Department of Neurology, Boston Children's Hospital, Harvard Medical School, MA (K.K.).
| | - Bowen Zhang
- From the Department of Medical Imaging, Faculty of Medicine (N.S., A.R.M., B.Z., I.K., S.C., P.N.T.) and Department of Statistical Sciences (P.N.T.), University of Toronto, Ontario, Canada; and Department of Neurology, Boston Children's Hospital, Harvard Medical School, MA (K.K.)
| | - Isabella Kaminski
- From the Department of Medical Imaging, Faculty of Medicine (N.S., A.R.M., B.Z., I.K., S.C., P.N.T.) and Department of Statistical Sciences (P.N.T.), University of Toronto, Ontario, Canada; and Department of Neurology, Boston Children's Hospital, Harvard Medical School, MA (K.K.)
| | - Kush Kapur
- From the Department of Medical Imaging, Faculty of Medicine (N.S., A.R.M., B.Z., I.K., S.C., P.N.T.) and Department of Statistical Sciences (P.N.T.), University of Toronto, Ontario, Canada; and Department of Neurology, Boston Children's Hospital, Harvard Medical School, MA (K.K.)
| | - Stephanie Chiu
- From the Department of Medical Imaging, Faculty of Medicine (N.S., A.R.M., B.Z., I.K., S.C., P.N.T.) and Department of Statistical Sciences (P.N.T.), University of Toronto, Ontario, Canada; and Department of Neurology, Boston Children's Hospital, Harvard Medical School, MA (K.K.)
| | - Pascal N Tyrrell
- From the Department of Medical Imaging, Faculty of Medicine (N.S., A.R.M., B.Z., I.K., S.C., P.N.T.) and Department of Statistical Sciences (P.N.T.), University of Toronto, Ontario, Canada; and Department of Neurology, Boston Children's Hospital, Harvard Medical School, MA (K.K.)
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90
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Kabra R, Girotra S, Vaughan Sarrazin M. Refining Stroke Prediction in Atrial Fibrillation Patients by Addition of African-American Ethnicity to CHA2DS2-VASc Score. J Am Coll Cardiol 2017; 68:461-470. [PMID: 27470453 DOI: 10.1016/j.jacc.2016.05.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Prior studies show that African-American patients have a higher risk of stroke compared with Caucasians. OBJECTIVES This study hypothesized addition of African-American ethnicity to CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke, vascular disease, age 65 to 74, and female sex) score might improve stroke prediction in patients with atrial fibrillation (AF). METHODS Medicare claims from January 2010 to December 2012 identified patients with newly diagnosed AF. The CHA2DS2-VASc was calculated on the basis of diagnoses in claims incurred during 12 months before first AF diagnosis. Ethnicity was identified from the Beneficiary Summary File. CHA2DS2-VASc-R score was calculated by giving 1 additional point for African-American ethnicity. The primary outcome was stroke, defined by primary diagnosis on acute inpatient admissions after the initial AF diagnosis. We used proportional hazards regression to determine the relationship between stroke and the CHA2DS2-VASc or a revised CHA2DS2-VASc-R score. RESULTS Of 460,417 patients with AF, 390,590 (85%) were non-Hispanic whites, 31,702 (7%) were non-Hispanic African Americans, and the remainder were other non-white ethnicities. Mean age was 79.2 ± 8.0 years, with 60% females. Overall, 16,703 stroke events occurred, and 151,441 (32.7%) patients died during a mean follow-up period of 18.0 months. Compared with CHA2DS2-VASc, CHA2DS2-VASc-R score improved the fit of the model significantly as measured by the log likelihood ratio statistic (p < 0.001). Among individual risk factors in CHA2DS2-VASc-R score, only prior stroke, age ≥75 years, and female sex had a stronger association with incident stroke than African-American ethnicity. CONCLUSIONS In patients >65 years of age with newly diagnosed AF, the addition of ethnicity to CHA2DS2-VASc score significantly improved stroke prediction.
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Affiliation(s)
- Rajesh Kabra
- Division of Cardiology, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis Tennessee
| | - Saket Girotra
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa
| | - Mary Vaughan Sarrazin
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa; Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.
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91
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Dass N, Kilakkathi S, Obi B, Moosreiner A, Krishnaswami S, Widlansky ME, Kidambi S. Effect of gender and adiposity on in vivo vascular function in young African Americans. ACTA ACUST UNITED AC 2017; 11:246-257. [PMID: 28411075 DOI: 10.1016/j.jash.2017.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/15/2017] [Accepted: 03/02/2017] [Indexed: 01/29/2023]
Abstract
The relationship between obesity and high blood pressure is not as strong among African Americans (AA) as compared to Caucasians. We designed the current study to determine the effect of adiposity on vascular endothelial function (a harbinger of hypertension) among young healthy AA without additional cardiovascular disease risk factors. A total of 108 AA subjects (46 women) between the ages of 18 and 45 years were recruited. All the subjects were normotensive, nonsmokers, and normoglycemic. Anthropometric and cardiovascular disease risk factor measurements (lipid, insulin resistance, and inflammatory markers) were obtained. Vascular endothelial function was measured by brachial artery flow-mediated dilation (FMD). Adiposity distribution was measured by using magnetic resonance imaging scan. There were no gender differences in age and levels of blood pressure, lipids, insulin resistance, and inflammatory markers. Women had higher total body fat percentage and higher peripheral adiposity compared to men. We observed that total and central adiposity did not correlate significantly with brachial artery FMD in women (r = -0.12 and r = 0.23, respectively; P = NS). However, in men, waist circumference was positively associated with FMD (r = 0.3, P ≤ .05). Hyperemic flow was negatively correlated significantly with total and central adiposity in men (r = -0.34 and r = -0.48, respectively; P < .05), but not in women (r = -0.26 and r = 0.03, respectively; P = NS). Our study suggests that increased adiposity may pose greater risk to AA men compared to AA women by adversely affecting resistance vessel function (as measured by hyperemic flow). Larger studies are necessary to validate these findings.
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Affiliation(s)
- Namrata Dass
- Division of Endocrinology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sindhu Kilakkathi
- Division of Endocrinology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Brittaney Obi
- Division of Endocrinology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrea Moosreiner
- Division of Endocrinology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shanthi Krishnaswami
- Division of Endocrinology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael E Widlansky
- Division of Endocrinology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Srividya Kidambi
- Division of Endocrinology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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92
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Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors, Genetics, and Prevention. Circ Res 2017; 120:472-495. [PMID: 28154098 PMCID: PMC5321635 DOI: 10.1161/circresaha.116.308398] [Citation(s) in RCA: 827] [Impact Index Per Article: 118.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/05/2017] [Accepted: 01/05/2017] [Indexed: 12/18/2022]
Abstract
Stroke is a heterogeneous syndrome, and determining risk factors and treatment depends on the specific pathogenesis of stroke. Risk factors for stroke can be categorized as modifiable and nonmodifiable. Age, sex, and race/ethnicity are nonmodifiable risk factors for both ischemic and hemorrhagic stroke, while hypertension, smoking, diet, and physical inactivity are among some of the more commonly reported modifiable risk factors. More recently described risk factors and triggers of stroke include inflammatory disorders, infection, pollution, and cardiac atrial disorders independent of atrial fibrillation. Single-gene disorders may cause rare, hereditary disorders for which stroke is a primary manifestation. Recent research also suggests that common and rare genetic polymorphisms can influence risk of more common causes of stroke, due to both other risk factors and specific stroke mechanisms, such as atrial fibrillation. Genetic factors, particularly those with environmental interactions, may be more modifiable than previously recognized. Stroke prevention has generally focused on modifiable risk factors. Lifestyle and behavioral modification, such as dietary changes or smoking cessation, not only reduces stroke risk, but also reduces the risk of other cardiovascular diseases. Other prevention strategies include identifying and treating medical conditions, such as hypertension and diabetes, that increase stroke risk. Recent research into risk factors and genetics of stroke has not only identified those at risk for stroke but also identified ways to target at-risk populations for stroke prevention.
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Affiliation(s)
- Amelia K Boehme
- From the Department of Epidemiology, Mailman School of Public Health (A.K.B., M.S.V.E.) and Department of Neurology, College of Physicians and Surgeons (A.K.B., C.E., M.S.V.E.), Columbia University, New York, NY
| | - Charles Esenwa
- From the Department of Epidemiology, Mailman School of Public Health (A.K.B., M.S.V.E.) and Department of Neurology, College of Physicians and Surgeons (A.K.B., C.E., M.S.V.E.), Columbia University, New York, NY
| | - Mitchell S V Elkind
- From the Department of Epidemiology, Mailman School of Public Health (A.K.B., M.S.V.E.) and Department of Neurology, College of Physicians and Surgeons (A.K.B., C.E., M.S.V.E.), Columbia University, New York, NY.
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93
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Nguyen-Huynh MN, Hills NK, Sidney S, Klingman JG, Johnston SC. Race-ethnicity on blood pressure control after ischemic stroke: a prospective cohort study. JOURNAL OF THE AMERICAN SOCIETY OF HYPERTENSION : JASH 2017; 11:38-44. [PMID: 27988356 DOI: 10.1016/j.jash.2016.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/18/2016] [Accepted: 11/03/2016] [Indexed: 11/20/2022]
Abstract
Disparities in health care access and socioeconomic status (SES) have been associated with racial-ethnic differences in blood pressure (BP) control. We examined post-ischemic stroke BP in a multiethnic cohort with good health care access. We included all hypertensive patients (n = 2972) from a randomized quality improvement trial on secondary stroke prevention, conducted in 14 Kaiser Permanente hospitals in Northern California from 2004-2006 (QUISP). Average age 73.2 ± 12.2 years; 52% female, 66% non-Hispanic white, 14% African-American, 11% Asian, 8% Hispanic, and 1% other. Demographics, diagnoses, health care utilization, BP measurements, and medications were obtained as part of routine care. We used random effects logistic regression models to examine race as a predictor of blood pressure control (<140/90 mm Hg) at 6 months post-discharge, adjusted for SES, age, gender, dementia, antihypertensive therapy, and attendance at follow-up visits. At 6 months, BP was controlled in 52.7% of blacks compared to 61.4% of whites (OR = 0.63, 95% CI, 0.48-0.82, P = .001). Black race remained independently associated with poorer BP control in adjusted analysis, although blacks were as likely to attend post-discharge visits, and more likely to be on any antihypertensive therapy than whites. Greater difficulty in controlling BP and lifestyle differences may account for this difference.
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Affiliation(s)
- Mai N Nguyen-Huynh
- Kaiser Permanente Division of Research, Oakland, CA, USA; Department of Neurology, Kaiser Permanente Walnut Creek, Walnut Creek, CA, USA.
| | - Nancy K Hills
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Stephen Sidney
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Jeffrey G Klingman
- Department of Neurology, Kaiser Permanente Walnut Creek, Walnut Creek, CA, USA
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Vanderwerf JD, Kumar MA. Management of neurologic complications of coagulopathies. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:743-764. [PMID: 28190445 DOI: 10.1016/b978-0-444-63599-0.00040-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Coagulopathy is common in intensive care units (ICUs). Many physiologic derangements lead to dysfunctional hemostasis; these may be either congenital or acquired. The most devastating outcome of coagulopathy in the critically ill is major bleeding, defined by transfusion requirement, hemodynamic instability, or intracranial hemorrhage. ICU coagulopathy often poses complex management dilemmas, as bleeding risk must be tempered with thrombotic potential. Coagulopathy associated with intracranial hemorrhage bears directly on prognosis and outcome. There is a paucity of high-quality evidence for the management of coagulopathies in neurocritical care; however, data derived from studies of patients with intraparenchymal hemorrhage may inform treatment decisions. Coagulopathy is often broadly defined as any derangement of hemostasis resulting in either excessive bleeding or clotting, although most typically it is defined as impaired clot formation. Abnormalities in coagulation testing without overt clinical bleeding may also be considered evidence of coagulopathy. This chapter will focus on acquired conditions, such as organ failure, pharmacologic therapies, and platelet dysfunction that are associated with defective clot formation and result in, or exacerbate, intracranial hemorrhage, specifically spontaneous intraparenchymal hemorrhage and traumatic brain injury.
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Affiliation(s)
- J D Vanderwerf
- Department of Neurology, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - M A Kumar
- Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Mackey J, Khoury JC, Alwell K, Moomaw CJ, Kissela BM, Flaherty ML, Adeoye O, Woo D, Ferioli S, De Los Rios La Rosa F, Martini S, Khatri P, Broderick JP, Zuccarello M, Kleindorfer D. Stable incidence but declining case-fatality rates of subarachnoid hemorrhage in a population. Neurology 2016; 87:2192-2197. [PMID: 27770074 DOI: 10.1212/wnl.0000000000003353] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 08/11/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize temporal trends in subarachnoid hemorrhage (SAH) incidence and outcomes over 5 time periods in a large population-based stroke study in the United States. METHODS All SAHs among residents of the Greater Cincinnati/Northern Kentucky region at least 20 years of age were identified and verified via study physician review in 5 distinct year-long study periods between 1988 and 2010. We abstracted demographics, care patterns, and outcomes, and we compared incidence and case-fatality rates across the study periods. RESULTS The incidence of SAH in the 5 study periods (age-, race-, and sex-adjusted to the 2000 US population) was 8.8 (95% confidence interval 6.8-10.7), 9.2 (7.2-11.2), 10.0 (8.0-12.0), 9.0 (7.1-10.9), and 7.7 (6.0-9.4) per 100,000, respectively; the trend in incidence rates from 1988 to 2010 was not statistically significant (p = 0.22). Advanced neurovascular imaging, endovascular coiling, and neurologic intensive care unit availability increased significantly over time. All-cause 5-day (32%-18%, p = 0.01; for trend), 30-day (46%-25%, p = 0.001), and 90-day (49%-29%, p = 0.001) case-fatality rates declined from 1988 to 2010. When we included only proven or highly likely aneurysmal SAH, the declines in case-fatality were no longer statistically significant. CONCLUSIONS Although the incidence of SAH remained stable in this population-based region, 5-day, 30-day, and 90-day case-fatality rates declined significantly. Advances in surgical and medical management, along with systems-based changes such as the emergence of neurocritical care units, are potential explanations for the reduced case-fatality.
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Affiliation(s)
- Jason Mackey
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
| | - Jane C Khoury
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Kathleen Alwell
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Charles J Moomaw
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Brett M Kissela
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Matthew L Flaherty
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Opeolu Adeoye
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Daniel Woo
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Simona Ferioli
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Felipe De Los Rios La Rosa
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Sharyl Martini
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Pooja Khatri
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Joseph P Broderick
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Mario Zuccarello
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
| | - Dawn Kleindorfer
- From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX
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96
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Madsen TE, Khoury J, Cadena R, Adeoye O, Alwell KA, Moomaw CJ, McDonough E, Flaherty ML, Ferioli S, Woo D, Khatri P, Broderick JP, Kissela BM, Kleindorfer D. Potentially Missed Diagnosis of Ischemic Stroke in the Emergency Department in the Greater Cincinnati/Northern Kentucky Stroke Study. Acad Emerg Med 2016; 23:1128-1135. [PMID: 27313141 DOI: 10.1111/acem.13029] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 06/04/2016] [Accepted: 06/07/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Missed diagnoses of acute ischemic stroke (AIS) in the ED may result in lost opportunities to treat AIS. Our objectives were to describe the rate and clinical characteristics of missed AIS in the ED, to determine clinical predictors of missed AIS, and to report tissue plasminogen (tPA) eligibility among those with missed strokes. METHODS Among a population of 1.3 million in a five-county region of southwest Ohio and northern Kentucky, cases of AIS that presented to 16 EDs during 2010 were identified using ICD-9 codes followed by physician verification of cases. Missed ED diagnoses were physician-verified strokes that did not receive a diagnosis indicative of stroke in the ED. Bivariate analyses were used to compare clinical characteristics between patients with and without an ED diagnosis of AIS. Logistic regression was used to evaluate predictors of missed AIS diagnoses. Alternative diagnoses given to those with missed AIS were codified. Eligibility for tPA was reported between those with and without a missed stroke diagnosis. RESULTS Of 2,027 AIS cases, 14.0% (n = 283) were missed in the ED. Race, sex, and stroke subtypes were similar between those with missed AIS diagnoses and those identified in the ED. Hospital length of stay was longer in those with a missed diagnosis (5 days vs. 3 days, p < 0.0001). Younger age (adjusted odds ratio [aOR] = 0.94, 95% confidence interval [CI] = 0.89 to 0.98) and decreased level of consciousness (LOC) (aOR = 3.58, 95% CI = 2.63 to 4.87) were associated with higher odds of missed AIS. Altered mental status was the most common diagnosis among those with missed AIS. Only 1.1% of those with a missed stroke diagnosis were eligible for tPA. CONCLUSION In a large population-based sample of AIS cases, one in seven cases were not diagnosed as AIS in the ED, but the impact on acute treatment rates is likely small. Missed diagnosis was more common among those with decreased LOC, suggesting the need for improved diagnostic approaches in these patients.
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Affiliation(s)
- Tracy E. Madsen
- Division of Sex and Gender in Emergency Medicine Department of Emergency Medicine The Alpert Medical School of Brown University Providence RI
| | - Jane Khoury
- Division of Biostatistics and Epidemiology Cincinnati Children's Hospital Medical Center Cincinnati OH
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
| | - Rhonda Cadena
- Department of Neurology and Emergency Medicine UNC School of Medicine Chapel Hill NC
| | - Opeolu Adeoye
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Kathleen A. Alwell
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Charles J. Moomaw
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Erin McDonough
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Matthew L. Flaherty
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Simona Ferioli
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Daniel Woo
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Pooja Khatri
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Joseph P. Broderick
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Brett M. Kissela
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Dawn Kleindorfer
- Neuroscience Institute University of Cincinnati College of Medicine Cincinnati OH
- Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine Cincinnati OH
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97
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Vasudeva E, Moise N, Huang C, Mason A, Penko J, Goldman L, Coxson PG, Bibbins-Domingo K, Moran AE. Comparative Cost-Effectiveness of Hypertension Treatment in Non-Hispanic Blacks and Whites According to 2014 Guidelines: A Modeling Study. Am J Hypertens 2016; 29:1195-205. [PMID: 27172970 PMCID: PMC5018997 DOI: 10.1093/ajh/hpw047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 03/02/2016] [Accepted: 04/14/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND We compared the cost-effectiveness of hypertension treatment in non-Hispanic blacks and non-Hispanic whites according to 2014 US hypertension treatment guidelines. METHODS The cardiovascular disease (CVD) policy model simulated CVD events, quality-adjusted life years (QALYs), and treatment costs in 35- to 74-year-old adults with untreated hypertension. CVD incidence, mortality, and risk factor levels were obtained from cohort studies, hospital registries, vital statistics, and national surveys. Stage 1 hypertension was defined as blood pressure 140-149/90-99mm Hg; stage 2 hypertension as ≥150/100mm Hg. Probabilistic input distribution sampling informed 95% uncertainty intervals (UIs). Incremental cost-effectiveness ratios (ICERs) < $50,000/QALY gained were considered cost-effective. RESULTS Treating 0.7 million hypertensive non-Hispanic black adults would prevent about 8,000 CVD events annually; treating 3.4 million non-Hispanic whites would prevent about 35,000 events. Overall 2014 guideline implementation would be cost saving in both groups compared with no treatment. For stage 1 hypertension but without diabetes or chronic kidney disease, cost savings extended to non-Hispanic black males ages 35-44 but not same-aged non-Hispanic white males (ICER $57,000/QALY; 95% UI $15,000-$100,000) and cost-effectiveness extended to non-Hispanic black females ages 35-44 (ICER $46,000/QALY; $17,000-$76,000) but not same-aged non-Hispanic white females (ICER $181,000/QALY; $111,000-$235,000). CONCLUSIONS Compared with non-Hispanic whites, cost-effectiveness of implementing hypertension guidelines would extend to a larger proportion of non-Hispanic black hypertensive patients.
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Affiliation(s)
- Eshan Vasudeva
- College of Physicians and Surgeons, Columbia University, New York, USA
| | - Nathalie Moise
- Department of General Medicine, Columbia University Medical Center, New York, USA
| | - Chen Huang
- Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China; National Center for Cardiovascular Diseases, Beijing, China
| | - Antoinette Mason
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Joanne Penko
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Lee Goldman
- College of Physicians and Surgeons, Columbia University, New York, USA
| | - Pamela G Coxson
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Kirsten Bibbins-Domingo
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Andrew E Moran
- College of Physicians and Surgeons, Columbia University, New York, USA; Department of General Medicine, Columbia University Medical Center, New York, USA;
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98
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Yoo BR, Yoo CJ, Kim MJ, Kim WK, Choi DH. Analysis of the Outcome and Prognostic Factors of Decompressive Craniectomy between Young and Elderly Patients for Acute Middle Cerebral Artery Infarction. J Cerebrovasc Endovasc Neurosurg 2016; 18:175-184. [PMID: 27847759 PMCID: PMC5104840 DOI: 10.7461/jcen.2016.18.3.175] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 09/05/2016] [Accepted: 09/15/2016] [Indexed: 11/23/2022] Open
Abstract
Objective We compared the effect of decompressive craniectomy between patients < 65 and ≥ 65 years age and investigated prognostics factors that may help predict favorable outcome in acute stroke patients undergoing decompressive surgery. Materials and Methods 52 patients diagnosed with acute middle cerebral artery (MCA) territory infarction that underwent decompressive craniectomy were retrospectively reviewed. The outcome of all patients were evaluated by assessing the Glasgow coma scale, Glasgow outcome scale (GOS), and Modified Rankin scale (mRS) six months after the onset of the disease. 21 patients were preoperatively evaluated with a computed tomography angiography (CTA). Leptomeningeal collateral (LMC) circulation was graded using CTA by experienced neurosurgeons to assess its prognostic value. Results The thirty day mortality for patients ≥ 65 was 35.0% compared to 37.5% in patients < 65. There was no significant difference in the clinical and function outcome between the two groups (4.8 ± 1.2 vs. 4.5 ± 1.5, p = 0.474). Mortality was lower with early surgery (within 24 hours) group for both age groups (25% vs. 37.5% in ≥ 65, 20% vs. 40.7% in < 65). Longer intensive care units stay time and good collateral supply score were correlated with favorable outcome (p = 0.028, p = 0.018). Conclusion Decompressive craniectomy within 24 hours of stroke symptom onset improved survival in both the < 65 and ≥ 65 age groups. There was no significant difference in the functional outcome of both age groups. Unlike previous reports, old age, delayed operation, and multiple of infarct territories were not predictive of poor functional outcome. The presence of good collateral circulation may be a predictor of positive clinical outcome in acute ischemic stroke patients undergoing decompressive craniectomy.
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Affiliation(s)
- Byung Rhae Yoo
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | - Chan Jong Yoo
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | - Myeong Jin Kim
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | - Woo-Kyung Kim
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | - Dae Han Choi
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
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99
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Yeramaneni S, Kleindorfer DO, Sucharew H, Alwell K, Moomaw CJ, Flaherty ML, Woo D, Adeoye O, Ferioli S, de Los Rios La Rosa F, Martini S, Mackey J, Khatri P, Kissela BM, Khoury JC. Hyperlipidemia is associated with lower risk of poststroke mortality independent of statin use: A population-based study. Int J Stroke 2016; 12:152-160. [PMID: 27649737 DOI: 10.1177/1747493016670175] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Although statin therapy is associated with reduced stroke and mortality risk, some studies report that higher lipid levels are associated with improved outcomes following ischemic stroke. Aims We examined the association of hyperlipidemia (HLD) combined with statin therapy on all-cause mortality in stroke patients. Methods All stroke patients in the Greater Cincinnati Northern Kentucky region of ∼1.3 million were identified using ICD-9 discharge codes in 2005 and 2010. Stroke patients with and without HLD were categorized based on their reported statin use at baseline or discharge into three groups: no-HLD/no-statins, HLD/no-statins, and HLD/on-statins. Cox proportional hazards model was used to estimate the risk of mortality at 30 days, 1 year, and 3 years poststroke. Results Overall, 77% (2953) of the 3813 ischemic stroke patients were diagnosed with HLD and 72% ( n = 2123) of those patients were on statin medications. The mean age was 70.0 ± 14.6 years, 56% were women, and 21% were black. In adjusted analyses, the HLD/no-statins group showed 35% (adjusted hazard ratio (aHR) = 0.65, 95% CI: 0.46-0.92), 27% (aHR = 0.73, 95% CI: 0.59-0.90), and 17% (aHR = 0.83, 95% CI: 0.70-0.97) reduced risk of mortality at 30 days, 1 year, and 3 years, respectively, poststroke, compared with no-HLD/no-statins group. The HLD/on-statins group showed an additional 17% significant survival benefit at 3 years poststroke compared with HLD/no-statins group. Conclusions A diagnosis of HLD in ischemic stroke patients is associated with reduced short- and long-term mortality, irrespective of statin use. Statin therapy is associated with significant, additional long-term survival benefit.
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Affiliation(s)
- Samrat Yeramaneni
- 1 Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,2 Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Texas, USA
| | - Dawn O Kleindorfer
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Heidi Sucharew
- 1 Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathleen Alwell
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Charles J Moomaw
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Matthew L Flaherty
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Daniel Woo
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Opeolu Adeoye
- 4 Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Simona Ferioli
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Felipe de Los Rios La Rosa
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.,5 Baptist Health Neuroscience Center, Miami, Florida, USA
| | - Sharyl Martini
- 6 Michael E. DeBakey VA Medical Center, and Department of Neurology, Baylor College of Medicine, Houston Texas, USA
| | - Jason Mackey
- 7 Department of Neurology, Indiana University, Indianapolis, Indiana, USA
| | - Pooja Khatri
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Brett M Kissela
- 3 Department of Neurology and Rehabilitation, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Jane C Khoury
- 1 Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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100
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Racial Differences in Outcomes after Acute Ischemic Stroke Hospitalization in the United States. J Stroke Cerebrovasc Dis 2016; 25:1970-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.049] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/22/2016] [Accepted: 03/27/2016] [Indexed: 11/20/2022] Open
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