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Melnick KF, Winton J, Corliss BM, Fox WC, Hoh BL, Polifka AJ. Off-Label Utilization of Syphontrak Catheter for Mechanical Thrombectomy in Acute Stroke. World Neurosurg 2020; 143:e106-e111. [PMID: 32653512 DOI: 10.1016/j.wneu.2020.06.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is not known whether aspiration-specific catheters are necessary for successful mechanical thrombectomy, but if not, off-label use of more versatile catheters could offer significant cost savings over specialized aspiration catheters. The Syphontrak (Depuy Synthes, Raynham, MA, USA) support catheter is designed for introduction of devices into distal neurovasculature but is not specifically indicated for use in mechanical thrombectomy. We sought to compare our experience using this catheter to historical controls to show the non-inferiority of aspiration achieved. METHODS Data were collected retrospectively on patients who underwent mechanical thrombectomy using the Syphontrak catheter for aspiration at our institution. Patient demographics, procedure characteristics, and outcome information was recorded. Results were compared to five landmark studies on mechanical thrombectomy: MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA. RESULTS There were 63 patients who underwent mechanical thrombectomy for anterior circulation ischemic stroke. Despite significantly older patients and greater time from symptom onset to groin puncture, Thrombolysis in Cerebral Infarction grade 2B or 3 reperfusion was achieved in significantly more patients than in MR CLEAN, ESCAPE, and REVASCAT. Development of symptomatic intracranial hemorrhage occurred in 6.4% of patients, which was not significantly different from MR CLEAN, ESCAPE, REVASCAT, and EXTEND-IA. Mortality was 19.1%, which was not significantly different from any of the trials. CONCLUSIONS These data support the off-label use of distal intracranial support catheters for this mechanical thrombectomy, which may result in significant cost savings over aspiration-specific catheters, especially in low-volume centers.
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Affiliation(s)
- Kaitlyn F Melnick
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA.
| | - Jesse Winton
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - Brian M Corliss
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - W Christopher Fox
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - Brian L Hoh
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - Adam J Polifka
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
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Xu J, Yalkun G, Wang M, Wang A, Wangqin R, Zhang X, Chen Z, Mo J, Meng X, Li H, Li Z, Wang Y. Impact of Infection on the Risk of Recurrent Stroke Among Patients With Acute Ischemic Stroke. Stroke 2020; 51:2395-2403. [PMID: 32586226 DOI: 10.1161/strokeaha.120.029898] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Infection occurs commonly in patients with acute ischemic stroke. We aimed to investigate the association of infection with short- and long-term risk of recurrent stroke in patients with ischemic stroke. METHODS Data were derived from ischemic stroke patients in 2 stroke registries: the CSCA (Chinese Stroke Center Alliance) program recorded medical data during hospitalization, and the CNSR-III (Third China National Stroke Registry) recorded the medical data during hospitalization and finished 1-year follow-up. Associations of infection (pneumonia or urinary tract infection) during hospitalization with recurrent stroke in short (during hospitalization) and long term (since 30 days to 1 year after stroke onset) were analyzed. Short-term outcomes were analyzed with logistic models and long-term outcomes with Cox models. RESULTS In the CSCA (n=789 596), the incidence of infection during hospitalization reached 9.6%. Patients with infection had a higher risk of stroke recurrence during hospitalization compared with patients without infection (10.4% versus 5.2%; adjusted odds ratio, 1.70 [95% CI, 1.65-1.75]; P<0.0001). In the CNSR-III (n=13 549), the incidence of infection during hospitalization was 6.5%. Infection during hospitalization was significantly associated with short-term risk of recurrent stroke (7.4% versus 3.9%; adjusted odds ratio, 1.40 [95% CI, 1.05-1.86]; P=0.02) but not with long-term risk of recurrent stroke (7.2% versus 5.2%; adjusted hazard ratio, 1.16 [95% CI, 0.88-1.52]; P=0.30). CONCLUSIONS Infection was an independent risk factor for high risk of early stroke recurrence during hospitalization, but we have not found its sustained effect on long-term recurrent risk in patients with acute ischemic stroke.
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Affiliation(s)
- Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Gulbahram Yalkun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Meng Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Runqi Wangqin
- Department of Neurology, Duke University Medical Center, Durham, NC (R.W.)
| | - Xiaoli Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Zimo Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Jinglin Mo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
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Dabilgou AA, Dravé A, Kyelem JMA, Ouedraogo S, Napon C, Kaboré J. Frequency and Mortality Risk Factors of Acute Ischemic Stroke in Emergency Department in Burkina Faso. Stroke Res Treat 2020; 2020:9745206. [PMID: 32577197 PMCID: PMC7305528 DOI: 10.1155/2020/9745206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/26/2020] [Accepted: 05/20/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To determine the prevalence of ischemic stroke deaths and their predictive factors in the Emergency Department at Yalgado Ouedraogo University Teaching Hospital (YOUTH). Methodology. This was a retrospective study with an analytical and descriptive focus over a period of three years from January 1, 2015, to December 31, 2017. RESULTS During the study period, 302 acute ischemic stroke patients with a mean age of 62.2 ± 14.26 years were included. Atrial hypertension was the most common vascular risk factor in 52.5%. On admission, 34.8% of patients had loss of consciousness. The mean time to perform brain CT was 1.5 days. The average length of stay was 4 days. Electrocardiogram, echocardiography, and cervical Doppler were not performed during hospitalization in ED. The mortality rate was 39%, respectively, 37.6% in male and 41.6% in female. The mean age of patients who died in ED was 63.6 ± 13.52 years. Hypertension was the most common vascular risk factors in 54.2% of death. After logistic regression, the predictors of death were past history of heart disease, consciousness disorders, hyperthermia, hyperglycemia on admission, poststroke pneumonia, and urinary tract infection. CONCLUSIONS Acute ischemic stroke was frequent in Emergency Department with high mortality rate. The mortality risk factors were the same than those found in literature. This higher mortality can be avoided by early diagnosis and an adequate management.
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Affiliation(s)
| | - Alassane Dravé
- Department of Neurology, Regional University Hospital of Ouahigouya, Burkina Faso
| | | | - Saïdou Ouedraogo
- Department of Neurology, University Hospital Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Christian Napon
- Department of Neurology, University Hospital of Bogodogo, Ouagadougou, Burkina Faso
| | - Jean Kaboré
- Department of Neurology, University Hospital Yalgado Ouedraogo, Ouagadougou, Burkina Faso
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Man S, Xian Y, Holmes DN, Matsouaka RA, Saver JL, Smith EE, Bhatt DL, Schwamm LH, Fonarow GC. Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke. JAMA 2020; 323:2170-2184. [PMID: 32484532 PMCID: PMC7267850 DOI: 10.1001/jama.2020.5697] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Earlier administration of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is associated with reduced mortality by the time of hospital discharge and better functional outcomes at 3 months. However, it remains unclear whether shorter door-to-needle times translate into better long-term outcomes. OBJECTIVE To examine whether shorter door-to-needle times with intravenous tPA for acute ischemic stroke are associated with improved long-term outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included Medicare beneficiaries aged 65 years or older who were treated for acute ischemic stroke with intravenous tPA within 4.5 hours from the time they were last known to be well at Get With The Guidelines-Stroke participating hospitals between January 1, 2006, and December 31, 2016, with 1-year follow-up through December 31, 2017. EXPOSURES Door-to-needle times for intravenous tPA. MAIN OUTCOMES AND MEASURES The primary outcomes were 1-year all-cause mortality, all-cause readmission, and the composite of all-cause mortality or readmission. RESULTS Among the 61 426 patients treated with tPA within 4.5 hours, the median age was 80 years and 43.5% were male. The median door-to-needle time was 65 minutes (interquartile range, 49-88 minutes). The 48 666 patients (79.2%) who were treated with tPA and had door-to-needle times of longer than 45 minutes, compared with those treated within 45 minutes, had significantly higher all-cause mortality (35.0% vs 30.8%, respectively; adjusted HR, 1.13 [95% CI, 1.09-1.18]), higher all-cause readmission (40.8% vs 38.4%; adjusted HR, 1.08 [95% CI, 1.05-1.12]), and higher all-cause mortality or readmission (56.0% vs 52.1%; adjusted HR, 1.09 [95% CI, 1.06-1.12]). The 34 367 patients (55.9%) who were treated with tPA and had door-to-needle times of longer than 60 minutes, compared with those treated within 60 minutes, had significantly higher all-cause mortality (35.8% vs 32.1%, respectively; adjusted hazard ratio [HR], 1.11 [95% CI, 1.07-1.14]), higher all-cause readmission (41.3% vs 39.1%; adjusted HR, 1.07 [95% CI, 1.04-1.10]), and higher all-cause mortality or readmission (56.8% vs 53.1%; adjusted HR, 1.08 [95% CI, 1.05-1.10]). Every 15-minute increase in door-to-needle times was significantly associated with higher all-cause mortality (adjusted HR, 1.04 [95% CI, 1.02-1.05]) within 90 minutes after hospital arrival, but not after 90 minutes (adjusted HR, 1.01 [95% CI, 0.99-1.03]), higher all-cause readmission (adjusted HR, 1.02; 95% CI, 1.01-1.03), and higher all-cause mortality or readmission (adjusted HR, 1.02 [95% CI, 1.01-1.03]). CONCLUSIONS AND RELEVANCE Among patients aged 65 years or older with acute ischemic stroke who were treated with tissue plasminogen activator, shorter door-to-needle times were associated with lower all-cause mortality and lower all-cause readmission at 1 year. These findings support efforts to shorten time to thrombolytic therapy.
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Affiliation(s)
- Shumei Man
- Department of Neurology and Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ying Xian
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Roland A. Matsouaka
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Eric E. Smith
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Comprehensive Stroke Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Joundi RA, Saposnik G, Martino R, Fang J, Kapral MK. Development and Validation of a Prognostic Tool for Direct Enteral Tube Insertion After Acute Stroke. Stroke 2020; 51:1720-1726. [PMID: 32397928 DOI: 10.1161/strokeaha.120.028949] [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- We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods- We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from July 1, 2003 to June 30, 2010 (derivation cohort) and July 1, 2010 to March 31, 2013 (validation cohort). We used multivariable regression to assign scores to predictor variables for 3 outcomes after tube placement: favorable outcome (discharge modified Rankin Scale score 0-3 and alive at 90 days), poor outcome (discharge modified Rankin Scale score 5 or death at 90 days), and 30-day mortality. Results- Variables associated with a favorable outcome were younger age, preadmission independence, ischemic stroke rather than intracerebral hemorrhage, lower stroke severity, and a shorter time between stroke and tube placement. Variables associated with a poor outcome were older age, preadmission dependence, atrial fibrillation, greater stroke severity, and tracheostomy. Age, preadmission dependence, atrial fibrillation, cancer, chronic obstructive pulmonary disease, and shorter time to tube placement were associated with increased 30-day mortality. Using these variables, we created an online calculator to facilitate estimation of individual patient risk of favorable and poor outcomes. C-statistic in the validation cohort was 0.82 for favorable outcome, 0.65 for poor outcome, and 0.62 for 30-day mortality, and calibration was adequate. Conclusions- We developed risk scores to estimate outcomes after direct enteral tube insertion for acute dysphagic stroke. This information may be useful in discussions with patients and families when there is prognostic uncertainty surrounding outcomes with direct enteral tube placement after stroke.
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Affiliation(s)
- Raed A Joundi
- From the Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary (R.A.J.).,ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Gustavo Saposnik
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), University of Toronto, Canada.,Institute of Health Policy, Management and Evaluation (G.S.), University of Toronto, Canada
| | - Rosemary Martino
- Department of Speech-Language Pathology (R.M.), University of Toronto, Canada.,Graduate Department of Rehabilitation Science (R.M.), University of Toronto, Canada.,Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Canada (R.M.)
| | - Jiming Fang
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Moira K Kapral
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Division of General Internal Medicine, Department of Medicine (M.K.), University of Toronto, Canada.,Institute of Health Policy, Management, and Evaluation (M.K.), University of Toronto, Canada
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Savsin M, Dubourg D, Coppieters Y, Collart P. [Analysis of comorbidities in hospitalized patients for ischemic stroke and their effects on lethality]. Ann Cardiol Angeiol (Paris) 2020; 69:31-36. [PMID: 31542203 DOI: 10.1016/j.ancard.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/07/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The aim of the study consists of analyzing the comorbidities of acute ischemic stroke and those influencing its hospital lethality. METHODS We considered patients from Wallonia aged 25 years or more and admitted to a Belgian hospital for an acute ischemic stroke in 2013 and 2014. The analyzed medico-administrative data are taken from the Minimum Hospital Summary. A factorial correspondence analysis (FCA) was used to demonstrate the comorbidities profiles. A logistic regression was used to analyse the comorbidities influencing hospital lethality by ischemic stroke. RESULTS The stroke risk factors vary according to the age. Cardiac problems are more common in older people aged 85 years or more. High blood pressure, hypercholesterolemia and diabetes are more present between 65- and 84-year-olds. Overweight is more present between 55 and 74-year-olds. People who are addicted to alcohol or tobacco are often 65 years or younger. The logistic regression showed that age and heart problems are the risk factors that increase lethality. However there is a lethality diminution in the presence of high blood pressure, hypercholesterolemia, overweight and addiction to alcohol or tobacco. CONCLUSION This study demonstrates that medico-administrative databases and factorial statistical methods are perfectly adapted to confirm the ischemic stroke risk factors. This type of study will allow to target with more precision the secondary and tertiary prevention actions of stroke.
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Affiliation(s)
- M Savsin
- Centre de recherche épidémiologie, biostatistiques et recherche clinique, école de santé publique, université libre de Bruxelles (U.L.B.), Route de Lennik 808, CP 596, 1070 Brussels, Belgique.
| | - D Dubourg
- Agence pour une vie de qualité, rue de la Rivelaine 21, 6061 Charleroi, Belgique.
| | - Y Coppieters
- Centre de recherche épidémiologie, biostatistiques et recherche clinique, école de santé publique, université libre de Bruxelles (U.L.B.), Route de Lennik 808, CP 596, 1070 Brussels, Belgique.
| | - P Collart
- Centre de recherche épidémiologie, biostatistiques et recherche clinique, école de santé publique, université libre de Bruxelles (U.L.B.), Route de Lennik 808, CP 596, 1070 Brussels, Belgique; Agence pour une vie de qualité, rue de la Rivelaine 21, 6061 Charleroi, Belgique.
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Moalla KS, Damak M, Chakroun O, Farhat N, Sakka S, Hdiji O, Kacem HH, Rekik N, Mhiri C. [Prognostic factors for mortality due to acute arterial stroke in a North African population]. Pan Afr Med J 2020; 35:50. [PMID: 32537055 PMCID: PMC7250234 DOI: 10.11604/pamj.2020.35.50.16287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 12/12/2018] [Indexed: 01/04/2023] Open
Abstract
Introduction cerebrovascular accident (stroke) constitutes a major public health problem due to the number of people affected and to its medical social and economic consequences. This study aims to identify poor vital prognostic factors for survival in patients with acute arterial stroke. Methods we conducted a prospective study of patients with symptoms suggestive of stroke at the two University Hospitals of Sfax, Tunisia over a period of 4 months. Patients were followed-up for a period of 1 month. Results we collected data from 200 patients. After one month of follow-up, mortality was 19.9%. Poor prognostic factors were: male sex, consumption of tobacco, a history of stroke, low Glasgow score, high NIHSS, headaches, acute symptomatic epileptic seizures, Babinski's sign, mydriasis, aphasia, combined deviation of the head and the eyes, high PAS, PAD and PAM, hyperthermia, hyperglycaemia, leukocytosis, high concentration of CRP, creatinine, urea and troponin T, haemorrhagic stroke, perilesional oedema, a mass effect, commitment, total middle cerebral artery topography of ischemia, early signs of ischemia, meningeal hemorrhage, ventricular flood, hydrocephalus, the recourse to respiratory support, to anti-edematous treatment and to antihypertensive therapy, hemorrhagic transformation, vascular epilepsy, infectious, metabolic complications, complications of bed sores. Conclusion the identification of the predictive factors for survival allows for optimisation of therapeutic procedures and better implementation of patient' management. A comparative study will be considered to measure the impact of the corrective measures.
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Affiliation(s)
| | - Mariem Damak
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Olfa Chakroun
- Service des Urgences et du SAMU, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Nouha Farhat
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Salma Sakka
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Olfa Hdiji
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Hanen Haj Kacem
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Noureddine Rekik
- Service des Urgences et du SAMU, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Chokri Mhiri
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
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Yu AYX, Austin PC, Rashid M, Fang J, Porter J, Hill MD, Kapral MK. Deriving a Passive Surveillance Stroke Severity Indicator From Routinely Collected Administrative Data: The PaSSV Indicator. Circ Cardiovasc Qual Outcomes 2020; 13:e006269. [PMID: 32069092 DOI: 10.1161/circoutcomes.119.006269] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Adjusting for stroke severity is crucial for stroke outcomes research. However, this information is not available in administrative healthcare data. We aimed to derive an indicator of baseline stroke severity using these data. METHODS AND RESULTS We identified patients with stroke enrolled in a population-based registry in Ontario, Canada, and used the Canadian Neurological Scale (CNS), documented in the registry, as a measure of stroke severity. We derived an estimated CNS from a linear regression model in which we regressed the observed CNS on predictor variables: age, sex, arrival by ambulance, interhospital transfer, mechanical ventilation, and an emergency department triage score. The effect of stroke severity on the estimated hazard ratios for 30-day mortality was determined in 3 Cox-proportional hazards models with (1) no CNS, (2) observed CNS, and (3) estimated CNS, all adjusted for age, sex, Charlson index, and stroke type. We assessed model discrimination using C statistics. To assess for construct validity, we repeated these analyses in a subset of patients with documented National Institute of Health Stroke Scale and in a cohort of patients with stroke external to the registry. We derived the estimated stroke severity in 41 481 patients (48.7% female, median age of 75 years [interquartile range, 64- 83]). The magnitude of the association between stroke severity and mortality was similar for the observed and estimated CNS. The discriminative ability of the Cox-proportional hazards models to predict mortality was highest when the observed CNS was included (C statistic, 0.82 [95% CI, 0.81-0.82]), moderate with estimated CNS (0.76 [0.75-0.76]), and lowest without CNS (0.69 [0.69-0.70]. Our findings were replicated with the National Institute of Health Stroke Scale and in the external cohort. CONCLUSIONS We derived an estimated measure of stroke severity using administrative data. This can be applied for risk adjustment in population-based stroke outcomes research and in assessments of health system performance.
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Affiliation(s)
- Amy Y X Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, ON, Canada (A.Y.X.Y.).,ICES, Toronto, ON, Canada (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.K.K.)
| | - Peter C Austin
- ICES, Toronto, ON, Canada (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.K.K.)
| | - Mohammed Rashid
- ICES, Toronto, ON, Canada (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, ON, Canada (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.K.K.)
| | - Joan Porter
- ICES, Toronto, ON, Canada (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.K.K.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, AB, Canada (M.D.H.)
| | - Moira K Kapral
- ICES, Toronto, ON, Canada (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.K.K.).,Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, ON, Canada (M.K.K.)
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Freitas-Silva M, Medeiros R, Nunes JPL. Low density lipoprotein cholesterol values and outcome of stroke patients: influence of previous aspirin therapy. Neurol Res 2020; 42:267-274. [PMID: 32024449 DOI: 10.1080/01616412.2020.1724463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: The link between low-density lipoprotein cholesterol (LDL-C) and stroke risk remains controversial and few studies have evaluated the effect of LDL-C after stroke survival.Aims: We assessed the hypothesis proposing the effect of LDL-C on the outcome of stroke patients under the influence of previous Aspirin Therapy.Methods: Associations between LDL-C and outcomes. The effect of LDL cholesterol on stoke outcome was evaluated using Kaplan-Meier methodology, log-rank test, Cox proportional hazard models and Bootstrap Analysis.Results: In a cohort of 342 cases, we observed that among stroke patients with no record of previous aspirin therapy LDL-C levels within recommended range (nLDL-C) are associated to a poor overall survival on (p < 0.001, log-rank test) leading to a 4-fold increased mortality risk in both timeframes of 12 (HR 4.45, 95% CI 1.55-12.71; p = 0.004) or 24 months (HR 4.13, 95%CI 1.62-10.50;p = 0.003) after the first event of stroke. Moreover, modelling the risk of a second event after the first stroke in the timeframe of 24 months demonstrated a predictive capacity for nLDL-C plasmatic levels (HR 3.94, 95%CI 1.55-10.05; p = 0.004) confirmed by Bootstrap analysis (p = 0.003; 1000 replications). In a further step, the inclusion of LDL-C in simulating models equations to predict the risk of a second event in the timeframe of 12 months increased nearly 20% the predictive ability (c-index from 0.763 to 0.956).Conclusion: A worse outcome was seen in stroke patients with normal levels of LDLC, but this finding was restricted to patients not under previous aspirin therapy.
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Affiliation(s)
- Margarida Freitas-Silva
- Department of Medicine, Centro Hospitalar São João, Porto, Portugal.,FMUP, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui Medeiros
- FMUP, Faculty of Medicine, University of Porto, Porto, Portugal.,LPCC, Research Department Portuguese League against Cancer (Liga Portuguesa Contra O Cancro, Núcleo Regional Do Norte), Porto, Portugal.,CEBIMED, Faculty of Health Sciences, Fernando Pessoa University, Porto, Portugal.,Molecular Oncology and Viral Pathology Group, IPO-Porto Research Center (CI-IPOP), Portuguese Institute of Oncology of Porto (Ipo-porto), Porto, Portugal
| | - José Pedro L Nunes
- Department of Medicine, Centro Hospitalar São João, Porto, Portugal.,FMUP, Faculty of Medicine, University of Porto, Porto, Portugal
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Association of Early Oxygenation Levels with Mortality in Acute Ischemic Stroke – A Retrospective Cohort Study. J Stroke Cerebrovasc Dis 2020; 29:104556. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/10/2019] [Accepted: 11/21/2019] [Indexed: 01/05/2023] Open
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Krzhizhanovskaya VV, Závodszky G, Lees MH, Dongarra JJ, Sloot PMA, Brissos S, Teixeira J. Stroke ICU Patient Mortality Day Prediction. LECTURE NOTES IN COMPUTER SCIENCE 2020. [PMCID: PMC7303676 DOI: 10.1007/978-3-030-50423-6_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article presents a study on development of methods for analysis of data reflecting the process of treatment of stroke inpatients to predict clinical outcomes at the emergency care unit. The aim of this work is to develop models for the creation of validated risk scales for early intravenous stroke with minimum number of parameters with maximum prognostic accuracy and possibility to calculate the time of “expected intravenous stroke mortality”. The study of experience in the development and use of medical information systems allows us to state the insufficient ability of existing models for adequate data analysis, weak formalization and lack of system approach in the collection of diagnostic data, insufficient personalization of diagnostic data on the factors determining early intravenous stroke mortality.
In our study we divided patients into 3 subgroups according to the time of death - up to 1 day, 1 to 3 days, and 4 to 10 days. Early mortality in each subgroup was associated with a number of demographic, clinical, and instrumental-laboratory characteristics based on the interpretation of the results of calculating the significance of predictors of binary classification models by machine learning methods from the Scikit-Learn library. The target classes in training were “mortality rate of 1 day”, “mortality rate of 1–3 days”, “mortality rate from 4 days”. AUC ROC of trained models reached 91% for the method of random forest. The results of interpretation of decision trees and calculation of significance of predictors of built-in methods of random forest coincide that can prove to correctness of calculations.
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Du W, Zhao X, Wang Y, Zhang G, Fang J, Pan Y, Liu L, Dong K, Liu G, Wang Y. The PLAN score can predict poor outcomes of intracerebral hemorrhage. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:14. [PMID: 32055605 DOI: 10.21037/atm.2019.11.88] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background For patients hospitalized after acute ischemic stroke (AIS), the preadmission comorbidities, level of consciousness (LOC), age and neurologic deficit (PLAN) score can help to identify those who may have a poor outcome. Implementing the PLAN score in other types of stroke may also have predictive value. Our study aimed to evaluate the PLAN score's prognostic accuracy in predicting 1-year mortality and severe disability after intracerebral hemorrhage (ICH). Methods We analyzed data found in the China National Stroke Registry (CNSR) of 2,453 hospitalized patients in 132 urban Chinese hospitals, diagnosed with ICH from September 2007 to August 2008. The outcomes analysis included 30-day mortality, modified Rankin Scale score (mRS) of 5-6 at discharge, and 1-year mortality. Univariate and multivariate analysis was performed, and we calculated consistency statistics (C statistic). We evaluated the PLAN score performance using area under the curve (AUC) calculations. Results We found that the 30-day mortality was 12.6%, the frequency of a mRS 5-6 at discharge was 20.6%, and 1-year mortality was 21.9%. The PLAN score had good predictive value in 30-day mortality (C statistic, 0.82), death or severe dependence at discharge (0.84), and 1-year mortality (0.82). Conclusions In patients hospitalized for ICH, the 30-day mortality, death or severe dependence at discharge and 1-year mortality can be predicted by the PLAN score. Similarly to patients hospitalized after AIS, the PLAN score can help to identify patients likely to have poor outcomes following hospitalization for ICH.
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Affiliation(s)
- Wanliang Du
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China
| | - Guitao Zhang
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Kehui Dong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing 100070, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
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Kaufman BG, O'Brien EC, Stearns SC, Matsouaka R, Holmes GM, Weinberger M, Song PH, Schwamm LH, Smith EE, Fonarow GC, Xian Y. The Medicare Shared Savings Program and Outcomes for Ischemic Stroke Patients: a Retrospective Cohort Study. J Gen Intern Med 2019; 34:2740-2748. [PMID: 31452032 PMCID: PMC6854149 DOI: 10.1007/s11606-019-05283-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 04/10/2019] [Accepted: 07/25/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care. OBJECTIVE To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke. DESIGN Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605). MAIN MEASURES Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated. KEY RESULTS For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed. CONCLUSIONS Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted. REGISTRATION None.
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Affiliation(s)
- Brystana G Kaufman
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Sally C Stearns
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - G Mark Holmes
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula H Song
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lee H Schwamm
- Neurology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Gregg C Fonarow
- Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC, USA
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Yu AYX, Fang J, Porter J, Austin PC, Smith EE, Kapral MK. Hospital-based cohort study to determine the association between home-time and disability after stroke by age, sex, stroke type and study year in Canada. BMJ Open 2019; 9:e031379. [PMID: 31719083 PMCID: PMC6858198 DOI: 10.1136/bmjopen-2019-031379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Home-time is an emerging patient-centred stroke outcome metric, but it is not well described in the population. We aimed to determine the association between 90-day home-time and global disability after stroke. We hypothesised that longer home-time would be associated with less disability. DESIGN Hospital-based cohort study of patients with ischaemic stroke or intracerebral haemorrhage admitted to an acute care hospital between 1 April 2002 and 31 March 2013. SETTING All regional stroke centres and a simple random sample of patients from all other hospitals across the province of Ontario, Canada. PARTICIPANTS We included 39 417 adult patients (84% ischaemic, 16% haemorrhage), 53% male, with a median age of 74 years. We excluded non-residents of Ontario, patients without a valid health insurance number, patients discharged against medical advice or those who failed to return from a pass, patients living in a long-term care centre at baseline and stroke events occurring in-hospital. PRIMARY OUTCOME MEASURE Association between 90-day home-time, defined as the number of days spent at home in the first 90 days after stroke, obtained using linked administrative data and modified Rankin Scale score at discharge. RESULTS Compared with people with no disability, those with minimal disability had less home-time (adjusted rate ratio (aRR) 0.96, 95% CI 0.93 to 0.98) and those with the most severe disability had the least home-time (aRR 0.05, 95% CI 0.04 to 0.05). We found no clinically relevant modification by stroke type, sex or study year. However, for a given level of disability, older patients experienced less home-time compared with younger patients. CONCLUSIONS Our results provide content validity for home-time to be used to monitor stroke outcomes in large populations or to study temporal trends. Older patients experience less home-time for a given level of disability, suggesting the need for stratification by age.
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Affiliation(s)
- Amy Ying Xin Yu
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Joan Porter
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Moira K Kapral
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine (General Internal Medicine), University of Toronto, Toronto, Ontario, Canada
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Myint PK, Sheng S, Xian Y, Matsouaka RA, Reeves MJ, Saver JL, Bhatt DL, Fonarow GC, Schwamm LH, Smith EE. Shock Index Predicts Patient-Related Clinical Outcomes in Stroke. J Am Heart Assoc 2019; 7:e007581. [PMID: 30371191 PMCID: PMC6222962 DOI: 10.1161/jaha.117.007581] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background The prognostic value of shock index (SI), heart rate divided by systolic blood pressure, in stroke for clinical outcomes other than mortality is not well understood. Methods and Results We examined the Get With The Guidelines–Stroke (GWTG‐Stroke) data to explore the usefulness of SI in predicting in‐hospital outcomes in 425 808 acute stroke cases (mean age: 71.0±14.5 years; 48.8% male; 89.7% ischemic stroke and 10.3% intracerebral hemorrhage) admitted between October 2012 and March 2015. Compared with patients with SI of 0.5 to 0.7, patients with SI >0.7 (13.6% of the sample) had worse outcomes, with adjusted odds ratios of 2.00 (95% confidence interval [CI], 1.92–2.08) for in‐hospital mortality, 1.46 (95% CI, 1.43–1.49) for longer length of hospital stay >4 days, 1.50 (95% CI, 1.47–1.54) for discharge destination other than home, 1.41 (95% CI, 1.38–1.45) for inability to ambulate independently at discharge, and 1.52 (95% CI, 1.47–1.57) for modified Rankin Scale score of 3 to 6 at discharge. Results were similar when analyses were confined to those with available National Institutes of Health Stroke Scale (NIHSS) or within individual stroke subtypes or when SI was additionally included in the models with or without blood pressure components. Every 0.1 increase in SI >0.5 was associated with significantly worse outcomes in linear spline models. The addition of SI to existing GWTG‐Stroke mortality prediction models without NIHSS demonstrated modest improvement, but little to no improvement was noted in models with NIHSS. Conclusions SI calculated at the point of care may be a useful prognostic indicator to identify those with high risk of poor outcomes in acute stroke, especially in hospitals with limited experience with NIHSS assessment.
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Affiliation(s)
- Phyo Kyaw Myint
- Institute of Applied Health SciencesSchool of Medicine, Medical Sciences & NutritionUniversity of AberdeenUnited Kingdom
| | - Shubin Sheng
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Ying Xian
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
- Department of NeurologyDuke University Medical CenterDurhamNC
| | - Roland A. Matsouaka
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
- Department of Biostatistics and BioinformaticsDuke UniversityDurhamNC
| | - Mathew J. Reeves
- Department of Epidemiology and BiostatisticsMichigan State UniversityMichiganMI
| | - Jeffrey L. Saver
- Stroke ProgramDepartment of NeurologyDavid Geffen School of Medicine at UCLALos AngelesCA
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart & Vascular CenterHarvard Medical SchoolHarvard UniversityBostonMA
| | - Gregg C. Fonarow
- Division of CardiologyDavid Geffen School of Medicine at UCLALos AngelesCA
| | - Lee H. Schwamm
- Department of Neurology, Stroke ServiceMassachusetts General HospitalBostonMA
| | - Eric E. Smith
- Calgary Stroke Programme & Department of Clinical NeurosciencesUniversity of CalgaryCalgaryCanada
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Thompson MP, Luo Z, Gardiner J, Burke JF, Nickles A, Reeves MJ. Impact of Missing Stroke Severity Data on the Accuracy of Hospital Ischemic Stroke Mortality Profiling. Circ Cardiovasc Qual Outcomes 2019; 11:e004951. [PMID: 30354572 DOI: 10.1161/circoutcomes.118.004951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services have proposed 30-day ischemic stroke risk-standardized mortality rates that include adjustment for stroke severity using the National Institute of Health Stroke Scale (NIHSS), which is often undocumented. We used simulations to quantify the effect of missing NIHSS data on the accuracy of hospital-level ischemic stroke risk-standardized mortality rate profiling for 100 hypothetical hospitals with different case volumes. METHODS AND RESULTS We generated simulated data sets of patients with NIHSS scores and other predictors of 30-day mortality based on empirical analysis of data from 7654 patients with ischemic stroke in the Michigan Stroke Registry. We assigned and rank-ordered a true (known) 30-day mortality rate to each hospital in the simulated data sets of N=100 hospitals with either low (100 patients with stroke), medium (300), or high (500) case volumes. We then estimated and rank-ordered 30-day risk-standardized mortality rates for the N=100 hospitals in each simulated data set using hierarchical logistic regression models. In each data set, we systematically varied the rate of missing NIHSS data and whether missing NIHSS data was independent (missing completely at random) or dependent (missing not at random) on the NIHSS score. With no missing NIHSS data, the Spearman correlation between the true hospital performance rank order assigned during data set generation and the estimated 30-day risk-standardized mortality rate rank order was 0.72, 0.88, and 0.91 in low, medium, and high volume hospitals, respectively. However, this fell to as low as 0.50, 0.71, and 0.79 as missing NIHSS data reached 70%. CONCLUSIONS Missing NIHSS data had substantial detrimental effects on the accuracy of profiling of ischemic stroke mortality, especially in lower volume hospitals. Even with complete NIHSS documentation, significant limitations in ischemic stroke mortality profiling remain.
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Affiliation(s)
- Michael P Thompson
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.P.T., Z.L., J.G., M.J.R.).,Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI (M.P.T.)
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.P.T., Z.L., J.G., M.J.R.)
| | - Joseph Gardiner
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.P.T., Z.L., J.G., M.J.R.)
| | - James F Burke
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI (J.F.B.)
| | | | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.P.T., Z.L., J.G., M.J.R.)
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Liao PH, Lai CY, Wu CH, Su YC, Wei CW, Kao CH. Central venous catheter use increases ischemic stroke risk: a nationwide population-based study. QJM 2019; 112:771-778. [PMID: 31225600 DOI: 10.1093/qjmed/hcz152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/28/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Central venous catheter (CVC) placement is a common procedure used for the treatment of critically ill patients. However, ischemic stroke is a complication after CVC placement. AIM This study investigated the association between CVC placement and ischemic stroke risk in an Asian population. DESIGN Population-based retrospective study. METHODS We enrolled 37 623 patients who ever-received CVC placement over 2000-10 and propensity score-matched individuals without CVC placement as the comparison cohort from the Taiwan National Health Insurance Research Database. We determined the cumulative incidence rates and adjusted hazard ratios (aHRs) for ischemic stroke. RESULTS We finally identified and enrolled 34 164 propensity score-matched pairs of individuals. Compared with the comparison group, CVC placement increased the average annual ischemic stroke incidence [19.5 vs. 11.6 per 10 000 person-years; crude HR=1.28, 95%, confidence interval (CI)=1.21-1.35; adjusted subhazard ratio (aSHR)=1.4, 95% CI = 1.33-1.47; P<0.001). In addition, compared with those aged >35 years, stroke risk was significantly higher in <35-year-old patients with CVC placement (aSHR=14.3, 95% CI=6.11-33.4; P<0.001). After <1-year follow-up, the ischemic stroke incidence rate in the CVC placement group was ∼3.25-fold higher than that in the comparison group (aHR=3.25, 95% CI=2.9-3.63; P<0.0001). CONCLUSION CVC placement increases ischemic stroke risk, particularly in those aged ≤35 years; this trend warrants further investigation.
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Affiliation(s)
- P-H Liao
- Department of Emergency Medicine, Tungs Taichung Metro Harbor Hospital, Taichung, Taiwan
| | - C-Y Lai
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine
| | - C-H Wu
- Department of Emergency Medicine, Tungs Taichung Metro Harbor Hospital, Taichung, Taiwan
| | - Y-C Su
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
- Health Data Management Office, China Medical University Hospital, Taichung, Taiwan
| | - C-W Wei
- Department of Emergency Medicine, Tungs Taichung Metro Harbor Hospital, Taichung, Taiwan
| | - C-H Kao
- Graduate Institute of Biomedical Sciences and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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68
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Xian Y, Xu H, O’Brien EC, Shah S, Thomas L, Pencina MJ, Fonarow GC, Olson DM, Schwamm LH, Bhatt DL, Smith EE, Hannah D, Maisch L, Lytle BL, Peterson ED, Hernandez AF. Clinical Effectiveness of Direct Oral Anticoagulants vs Warfarin in Older Patients With Atrial Fibrillation and Ischemic Stroke: Findings From the Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study. JAMA Neurol 2019; 76:1192-1202. [PMID: 31329212 PMCID: PMC6647003 DOI: 10.1001/jamaneurol.2019.2099] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/03/2019] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Current guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention in patients with atrial fibrillation (AF) who are at high risk. Despite demonstrated efficacy in clinical trials, real-world data of DOACs vs warfarin for secondary prevention in patients with ischemic stroke are largely based on administrative claims or have not focused on patient-centered outcomes. OBJECTIVE To examine the clinical effectiveness of DOACs (dabigatran, rivaroxaban, or apixaban) vs warfarin after ischemic stroke in patients with AF. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients who were 65 years or older, had AF, were anticoagulation naive, and were discharged from 1041 Get With The Guidelines-Stroke-associated hospitals for acute ischemic stroke between October 2011 and December 2014. Data were linked to Medicare claims for long-term outcomes (up to December 2015). Analyses were completed in July 2018. EXPOSURES DOACs vs warfarin prescription at discharge. MAIN OUTCOMES AND MEASURES The primary outcomes were home time, a patient-centered measure defined as the total number of days free from death and institutional care after discharge, and major adverse cardiovascular events. A propensity score-overlap weighting method was used to account for differences in observed characteristics between groups. RESULTS Of 11 662 survivors of acute ischemic stroke (median [interquartile range] age, 80 [74-86] years), 4041 (34.7%) were discharged with DOACs and 7621 with warfarin. Except for National Institutes of Health Stroke Scale scores (median [interquartile range], 4 [1-9] vs 5 [2-11]), baseline characteristics were similar between groups. Patients discharged with DOACs (vs warfarin) had more days at home (mean [SD], 287.2 [114.7] vs 263.0 [127.3] days; adjusted difference, 15.6 [99% CI, 9.0-22.1] days) during the first year postdischarge and were less likely to experience major adverse cardiovascular events (adjusted hazard ratio [aHR], 0.89 [99% CI, 0.83-0.96]). Also, in patients receiving DOACs, there were fewer deaths (aHR, 0.88 [95% CI, 0.82-0.95]; P < .001), all-cause readmissions (aHR, 0.93 [95% CI, 0.88-0.97]; P = .003), cardiovascular readmissions (aHR, 0.92 [95% CI, 0.86-0.99]; P = .02), hemorrhagic strokes (aHR, 0.69 [95% CI, 0.50-0.95]; P = .02), and hospitalizations with bleeding (aHR, 0.89 [95% CI, 0.81-0.97]; P = .009) but a higher risk of gastrointestinal bleeding (aHR, 1.14 [95% CI, 1.01-1.30]; P = .03). CONCLUSIONS AND RELEVANCE In patients with acute ischemic stroke and AF, DOAC use at discharge was associated with better long-term outcomes relative to warfarin.
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Affiliation(s)
- Ying Xian
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Emily C. O’Brien
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Shreyansh Shah
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Michael J. Pencina
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | | | | | - Lee H. Schwamm
- Harvard Medical School, Massachusetts General Hospital, Boston
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Eric E. Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Deidre Hannah
- Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research Study, Durham, North Carolina
| | - Lesley Maisch
- Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research Study, Durham, North Carolina
| | - Barbara L. Lytle
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Eric D. Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Ali-Ahmed F, Federspiel JJ, Liang L, Xu H, Sevilis T, Hernandez AF, Kosinski AS, Prvu Bettger J, Smith EE, Bhatt DL, Schwamm LH, Fonarow GC, Peterson ED, Xian Y. Intravenous Tissue Plasminogen Activator in Stroke Mimics. Circ Cardiovasc Qual Outcomes 2019; 12:e005609. [PMID: 31412730 PMCID: PMC6699639 DOI: 10.1161/circoutcomes.119.005609] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The necessity for rapid evaluation and treatment of acute ischemic stroke with intravenous tPA (tissue-type plasminogen activator) may increase the risk of administrating tPA to patients presenting with noncerebrovascular conditions that closely resemble stroke (stroke mimics). However, there are limited data on thrombolysis safety in stroke mimics. METHODS AND RESULTS Using data from the Get With The Guidelines-Stroke Registry, we identified 72 582 patients with suspected ischemic stroke treated with tPA from 485 US hospitals between January 2010 and December 2017. We documented the use of tPA in stroke mimics, defined as patients who present with stroke-like symptoms, but after workup are determined not to have suffered from a stroke or transient ischemic attack, and compared characteristics and outcomes in stroke mimics versus those with ischemic stroke. Overall, 3.5% of tPA treatments were given to stroke mimics. Among them, 38.2% had a final nonstroke diagnoses of migraine, functional disorder, seizure, and electrolyte or metabolic imbalance. Compared with tPA-treated true ischemic strokes, tPA-treated mimics were younger (median 54 versus 71 years), had a less severe National Institute of Health Stroke Scale (median 6 versus 8), and a lower prevalence of cardiovascular risk factors, except for a higher prevalence of prior stroke/transient ischemic attack (31.3% versus 26.1%, all P<0.001). The rate of symptomatic intracranial hemorrhage was lower in stroke mimics (0.4%) as compared with 3.5% in ischemic strokes (adjusted odds ratio, 0.29; 95% CI, 0.17-0.50). In-hospital mortality rate was significantly lower in stroke mimics (0.8% versus 6.2%, adjusted odds ratio, 0.31; 95% CI, 0.20-0.49). Patients with stroke mimics were more likely to be discharged to home (83.8% versus 49.3%, adjusted odds ratio, 2.97; 95% CI, 2.59-3.42) and to ambulate independently at discharge (78.6% versus 50.6%, adjusted odds ratio, 1.86; 95% CI, 1.61-2.14). CONCLUSIONS In this large cohort of patients treated with tPA, relatively few patients who received tPA for presumed stroke were ultimately not diagnosed with a stroke or transient ischemic attack. The complication rates associated with tPA in stroke mimics were low. Despite the potential risk of administering tPA to stroke mimics, opportunity remains for continued improvement in the rapid and accurate diagnosis and treatment of ischemic stroke.
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Affiliation(s)
- Fatima Ali-Ahmed
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.).,Department of Cardiology, Beaumont Health, Dearborn, MI (F.A.-A.)
| | - Jerome J Federspiel
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.)
| | - Li Liang
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Theresa Sevilis
- Department of Neurology, Duke University Medical Center, Durham, NC (T.S., Y.X.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Janet Prvu Bettger
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, CA (E.E.S.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Lee H Schwamm
- Division of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California, LA (G.C.F.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.).,Department of Neurology, Duke University Medical Center, Durham, NC (T.S., Y.X.)
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Muñoz Venturelli P, Li X, Middleton S, Watkins C, Lavados PM, Olavarría VV, Brunser A, Pontes-Neto O, Santos TEG, Arima H, Billot L, Hackett ML, Song L, Robinson T, Anderson CS. Impact of Evidence-Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study. J Am Heart Assoc 2019; 8:e012640. [PMID: 31237173 PMCID: PMC6662356 DOI: 10.1161/jaha.119.012640] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence‐based processes of care for acute ischemic stroke (AIS) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke. Methods and Results Use of 8 AIS processes of care were considered: reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0–2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or “defect‐free” care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18–1.65) and better survival (odds ratio, 2.23; 95% CI, 1.62–3.09). Defect‐free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0–1) (odds ratio, 1.22; 95% CI, 1.04–1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates. Conclusions Use of evidence‐based care is associated with improved clinical outcome in AIS. Strategies are required to address regional variation in the use of proven AIS treatments. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique Identifier: NCT02162017.
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Affiliation(s)
- Paula Muñoz Venturelli
- 1 The George Institute for Global Health Faculty of Medicine University of New South Wales Sydney Australia.,2 Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile.,3 Servicio de Neurología Departamento de Neurología y Psiquiatría Alemana de Santiago Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Xian Li
- 1 The George Institute for Global Health Faculty of Medicine University of New South Wales Sydney Australia.,4 The George Institute for Global Health at Peking University Health Science Center Beijing China
| | - Sandy Middleton
- 5 Nursing Research Institute St Vincents Health Australia (Sydney) and Australian Catholic University Sydney Australia.,6 Faculty of Health and Wellbeing University of Central Lancashire Preston United Kingdom
| | - Caroline Watkins
- 6 Faculty of Health and Wellbeing University of Central Lancashire Preston United Kingdom
| | - Pablo M Lavados
- 3 Servicio de Neurología Departamento de Neurología y Psiquiatría Alemana de Santiago Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile.,7 Departamento de Ciencias Neurológicas Facultad de Medicina Universidad de Chile Santiago Chile
| | - Verónica V Olavarría
- 3 Servicio de Neurología Departamento de Neurología y Psiquiatría Alemana de Santiago Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile.,8 Departamento de Paciente Crítico Clínica Alemana de Santiago Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Alejandro Brunser
- 3 Servicio de Neurología Departamento de Neurología y Psiquiatría Alemana de Santiago Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Octavio Pontes-Neto
- 9 Stroke Service Neurology Division Ribeirão Preto Medical School University of São Paulo Ribeirão Preto Brazil
| | - Taiza E G Santos
- 9 Stroke Service Neurology Division Ribeirão Preto Medical School University of São Paulo Ribeirão Preto Brazil
| | - Hisatomi Arima
- 10 Department of Preventive Medicine and Public Health Faculty of Medicine Fukuoka University Fukuoka Japan
| | - Laurent Billot
- 1 The George Institute for Global Health Faculty of Medicine University of New South Wales Sydney Australia
| | - Maree L Hackett
- 1 The George Institute for Global Health Faculty of Medicine University of New South Wales Sydney Australia.,6 Faculty of Health and Wellbeing University of Central Lancashire Preston United Kingdom
| | - Lily Song
- 1 The George Institute for Global Health Faculty of Medicine University of New South Wales Sydney Australia.,4 The George Institute for Global Health at Peking University Health Science Center Beijing China
| | - Thompson Robinson
- 11 Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Center University of Leicester United Kingdom
| | - Craig S Anderson
- 1 The George Institute for Global Health Faculty of Medicine University of New South Wales Sydney Australia.,4 The George Institute for Global Health at Peking University Health Science Center Beijing China
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Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2014.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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72
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Ehrlich ME, Liang L, Xu H, Kosinski AS, Hernandez AF, Schwamm LH, Smith EE, Fonarow GC, Bhatt DL, Peterson ED, Xian Y. Intravenous Tissue-Type Plasminogen Activator in Acute Ischemic Stroke Patients With History of Stroke Plus Diabetes Mellitus. Stroke 2019; 50:1497-1503. [PMID: 31035901 PMCID: PMC6538420 DOI: 10.1161/strokeaha.118.024172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- Acute ischemic stroke patients with history of prior ischemic stroke plus concomitant diabetes mellitus (DM) were excluded from the ECASS III trial (European Cooperative Acute Stroke Study) because of safety concerns. However, there are few data on use of intravenous tissue-type plasminogen activator and symptomatic intracerebral hemorrhage or outcomes in this population. Methods- Using data from the Get With The Guidelines-Stroke Registry between February 2009 and September 2017 (n=1619 hospitals), we examined characteristics and outcomes among patients with acute ischemic stroke treated with tissue-type plasminogen activator within the 3- to 4.5-hour window who had a history of stroke plus diabetes mellitus (HxS+DM) (n=2129) versus those without either history (n=16 690). Results- Compared with patients without either history, those with both prior stroke and DM treated with tissue-type plasminogen activator after an acute ischemic stroke had a higher prevalence of cardiovascular risk factors in addition to history of stroke, DM, and more severe stroke (National Institutes of Health Stroke Scale: median, 8 [interquartile range, 5-15] versus 7 [4-13]). The unadjusted rates of symptomatic intracerebral hemorrhage and in-hospital mortality were 4.3% (HxS+DM) versus 3.8% (without either history; P=0.31) and 6.2% versus 5.5% ( P=0.20), respectively. These differences were not statistically significant after risk adjustment (symptomatic intracerebral hemorrhage: adjusted odds ratio, 0.79 [95% CI, 0.51-1.21]; P=0.28; in-hospital mortality: odds ratio, 0.77 [95% CI, 0.52-1.14]; P=0.19). Unadjusted rate of functional independence (modified Rankin Scale score, 0-2) at discharge was lower in those with HxS+DM (30.9% HxS+DM versus 44.8% without either history; P≤0.0001), and this difference persisted after adjusting for baseline clinical factors (adjusted odds ratio, 0.76 [95% CI, 0.59-0.99]; P=0.04). Conclusions- Among patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator within the 3- to 4.5-hour window, HxS+DM was not associated with statistically significant increased symptomatic intracerebral hemorrhage or mortality risk.
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Affiliation(s)
- Matthew E Ehrlich
- From the Department of Neurology (M.E.E.), Duke University School of Medicine, Durham, NC
| | - Li Liang
- Duke Clinical Research Institute, Durham, NC (L.L., H.X., A.S.K., A.F.H., E.D.P., Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, NC (L.L., H.X., A.S.K., A.F.H., E.D.P., Y.X.)
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics (A.S.K.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute, Durham, NC (L.L., H.X., A.S.K., A.F.H., E.D.P., Y.X.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (L.L., H.X., A.S.K., A.F.H., E.D.P., Y.X.)
| | - Lee H Schwamm
- Department of Neurology, Institute for Heart, Vascular and Stroke Care, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston
| | - Eric E Smith
- Department of Neurosciences, Cumming School of Medicine, University of Calgary, Canada (E.E.S.)
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan University of California, Los Angeles Medical Center (G.C.F.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston
| | - Eric D Peterson
- Department of Medicine (E.D.P.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute, Durham, NC (L.L., H.X., A.S.K., A.F.H., E.D.P., Y.X.)
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC (L.L., H.X., A.S.K., A.F.H., E.D.P., Y.X.)
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73
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Zhou Y, Xu W, Wang W, Yao S, Xiao B, Wang Y, Chen B. Gastrointestinal Hemorrhage is Associated with Mortality after Acute Ischemic Stroke. Curr Neurovasc Res 2019; 16:135-141. [PMID: 30977448 DOI: 10.2174/1567202616666190412160451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 03/14/2019] [Accepted: 03/18/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Gastrointestinal (GI) hemorrhage is serious during the acute phase and is reported to be related to an increased risk of death during the acute phase of acute ischemic stroke in particular. Our study was designed to investigate the relationship between GI hemorrhage and the mortality of acute ischemic stroke, assessing the influence of cerebrovascular risk factors, brain herniation and oral anticoagulation on the onset of GI hemorrhage. The identified risk factors for the occurrence of GI hemorrhage help to elucidate their respective roles in the mortality of acute ischemic stroke. METHODS A total of 15993 consecutive patients with acute ischemic stroke, including 216 cases and 15777 controls, were enrolled in the study from October 2010 to December 2018. Basic clinical and examination data were collected at the time of study enrollment. GI hemorrhage was diagnosed according to the presence of clinical features and endoscopy. Chi-square test and multiple logistic regressions were conducted to explore the associations between the GI hemorrhage occurrence and known risk factors. Kaplan-Meier was used to assess the influence of GI hemorrhage on the age of mortality of acute ischemic stroke. RESULTS GI hemorrhage cases among patients with acute ischemic stroke accounted for 1.35%. Male patients with ischemic stroke were more likely to have GI hemorrhage than their female counterparts (odds ratio (OR): 1.79; P = 0.000). Patients with atrial fibrillation (AF) had a higher incidence of GI hemorrhage than their counterparts without AF (3.03% vs. 1.20%; P < 0.05). Use of oral anticoagulants was related to increased risk for GI hemorrhage (OR: 1.96; P = 0.00). After adjusting for age and sex, both AF and oral anticoagulant use maintained associations with increased risk for GI hemorrhage (2.59-times and 2.02-times risk respectively; P = 0.00). Patients with hyperlipidemia had a lower incidence of GI hemorrhage than their counterparts without hyperlipidemia (0.62% vs. 1.60%; P < 0.05). Hyperlipidemia was associated with a reduced risk of GI hemorrhage (OR: 0.38, 95% confidence interval (CI): 0.25-0.58; P = 0.00), even after adjusting for age and sex (OR: 0.41; P = 0.00). Patients with brain herniation had a 6.54-times increased risk for GI hemorrhage (P = 0.00). GI hemorrhage was associated with 10.98-fold risk for mortality of acute ischemic stroke (P = 0.00). There was an interaction between GI hemorrhage and brain herniation and increased 26.91-fold risk for the mortality after acute ischemic stroke (P = 0.00). CONCLUSION AF, oral anticoagulant use, brain herniation and male sex increase GI hemorrhage risk, while hyperlipidemia reduces risk. GI hemorrhage itself increases the risk for mortality of acute ischemic stroke. The interaction between GI hemorrhage and brain herniation increased the risk for the mortality after acute ischemic stroke.
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Affiliation(s)
- Yongtao Zhou
- The Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China.,Department of Neurobiology, Beijing Institute of Geriatrics, Xuanwu Hospital of Capital Medical University, Beijing, China.,Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Beijing, China
| | - Weihua Xu
- Gastroenterology Department of Traditional Chinese Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Wei Wang
- Gastroenterology Department of Traditional Chinese Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Shukun Yao
- Gastroenterology Department of Traditional Chinese Medicine, China-Japan Friendship Hospital, Beijing, China.,The Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Bei Xiao
- The Department of Medical Record Room, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yuping Wang
- The Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Biao Chen
- The Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China.,Department of Neurobiology, Beijing Institute of Geriatrics, Xuanwu Hospital of Capital Medical University, Beijing, China.,Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Beijing, China
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Cost-Effectiveness of Bridging Anticoagulation Among Patients with Nonvalvular Atrial Fibrillation. J Gen Intern Med 2019; 34:583-590. [PMID: 30623388 PMCID: PMC6445930 DOI: 10.1007/s11606-018-4796-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 06/14/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Bridging anticoagulation is commonly prescribed to patients with atrial fibrillation during initiation and interruption of warfarin. Guidelines recommend bridging patients at high risk of stroke, while a recent randomized trial demonstrated overall harm in a population at comparatively low risk of ischemic stroke. Theory suggests that patients at high risk of stroke and low risk of hemorrhage may benefit from bridging, but data informing patient selection are scant. OBJECTIVE To estimate the utility and cost-effectiveness of bridging anticoagulation among patients with nonvalvular atrial fibrillation, stratified by thromboembolic and hemorrhagic risk DESIGN: Cost-effectiveness analysis with lifelong time horizon, from the perspective of a third-party payer MAIN MEASURES: Quality-adjusted life years (QALYs) per bridged patient; US dollars per QALY gained KEY RESULTS: Unselected patients with nonvalvular atrial fibrillation may be harmed by bridging anticoagulation. Hospital admission for bridging is almost never cost-effective, and generally harmful. Among patients carefully selected by both thromboembolic and hemorrhagic risks, outpatient bridging can be beneficial and cost-effective. Results were sensitive to how effectively heparin products reduce stroke risk. CONCLUSIONS Outpatient bridging anticoagulation can be beneficial and cost-effective for a subset of patients with nonvalvular atrial fibrillation during interruption or initiation of warfarin. Admission for bridging should be avoided.
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75
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Kim P, Langheinrich K, Cristiano B, Grigsby P, Oyoyo U, Kido D, Paul Jacobson J. Low thalamostriate venous quantitative susceptibility measurements correlate with higher presenting NIH stroke scale score in emergent large vessel occlusion stroke. J Int Med Res 2019; 48:300060519832462. [PMID: 30859887 PMCID: PMC7140206 DOI: 10.1177/0300060519832462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objective Hyperacute stroke affects various patient subgroups who may benefit from
different management strategies. Magnetic resonance imaging (MRI)
quantitative susceptibility mapping (QSM) is a recent MRI technique for
measuring deoxyhemoglobin levels. The results of QSM thus have the potential
to act as a quantitative biomarker for predicting the success of
endovascular interventions. Methods Twenty-five patients with M1 occlusions were evaluated retrospectively. QSM
measurements were obtained based on susceptibility-weighted imaging
sequences from the most prominent veins in each of the four standard regions
of interest: the cortical and thalamostriate veins ipsilateral and
contralateral to the side of the stroke. The results were analyzed using
Wilcoxon’s signed rank test and compared with presenting National Institutes
of Health stroke scale (NIHSS) score. Results Cortical veins ipsilateral to the stroke showed the greatest elevation in
susceptibility compared with all other vein groups. Both ipsilateral and
contralateral thalamostriate vein susceptibilities showed strong inverse
correlation with presenting NIHSS score. Conclusion Thalamostriate vein susceptibility shows a strong inverse correlation with
presenting NIHSS in adult patients with hyperacute stroke who are selected
for endovascular intervention by advanced imaging.
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Affiliation(s)
- Paggie Kim
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | - Brian Cristiano
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Phillip Grigsby
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Udo Oyoyo
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Daniel Kido
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - J Paul Jacobson
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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Kaufman BG, O'Brien EC, Stearns SC, Matsouaka RA, Holmes GM, Weinberger M, Schwamm LH, Smith EE, Fonarow GC, Xian Y, Taylor DH. Medicare Shared Savings ACOs and Hospice Care for Ischemic Stroke Patients. J Am Geriatr Soc 2019; 67:1402-1409. [DOI: 10.1111/jgs.15852] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Brystana G. Kaufman
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- Duke Margolis Center for Health Policy Durham North Carolina
| | - Emily C. O'Brien
- Department of Population Health SciencesDuke University Durham North Carolina
| | - Sally C. Stearns
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Roland A. Matsouaka
- Duke Clinical Research Institute Durham North Carolina
- Department of Biostatistics and BioinformaticsDuke University Durham North Carolina
| | - G. Mark Holmes
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Morris Weinberger
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General HospitalHarvard Medical School Boston Massachusetts
| | - Eric E. Smith
- Department of Neurology, Cumming School of MedicineUniversity of Calgary Calgary Canada
| | - Gregg C. Fonarow
- Division of CardiologyDavid Geffen School of Medicine at UCLA Los Angeles California
| | - Ying Xian
- Duke Clinical Research Institute Durham North Carolina
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Gattringer T, Posekany A, Niederkorn K, Knoflach M, Poltrum B, Mutzenbach S, Haring HP, Ferrari J, Lang W, Willeit J, Kiechl S, Enzinger C, Fazekas F. Predicting Early Mortality of Acute Ischemic Stroke. Stroke 2019; 50:349-356. [DOI: 10.1161/strokeaha.118.022863] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose—
Several risk factors are known to increase mid- and long-term mortality of ischemic stroke patients. Information on predictors of early stroke mortality is scarce but often requested in clinical practice. We therefore aimed to develop a rapidly applicable tool for predicting early mortality at the stroke unit.
Methods—
We used data from the nationwide Austrian Stroke Unit Registry and multivariate regularized logistic regression analysis to identify demographic and clinical variables associated with early (≤7 days poststroke) mortality of patients admitted with ischemic stroke. These variables were then used to develop the Predicting Early Mortality of Ischemic Stroke score that was validated both by bootstrapping and temporal validation.
Results—
In total, 77 653 ischemic stroke patients were included in the analysis (median age: 74 years, 47% women). The mortality rate at the stroke unit was 2% and median stay of deceased patients was 3 days. Age, stroke severity measured by the National Institutes of Health Stroke Scale, prestroke functional disability (modified Rankin Scale >0), preexisting heart disease, diabetes mellitus, posterior circulation stroke syndrome, and nonlacunar stroke cause were associated with mortality and served to build the Predicting Early Mortality of Ischemic Stroke score ranging from 0 to 12 points. The area under the curve of the score was 0.879 (95% CI, 0.871–0.886) in the derivation cohort and 0.884 (95% CI, 0.863–0.905) in the validation sample. Patients with a score ≥10 had a 35% (95% CI, 28%–43%) risk to die within the first days at the stroke unit.
Conclusions—
We developed a simple score to estimate early mortality of ischemic stroke patients treated at a stroke unit. This score could help clinicians in short-term prognostication for management decisions and counseling.
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Affiliation(s)
- Thomas Gattringer
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Alexandra Posekany
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria (A.P.)
| | - Kurt Niederkorn
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Birgit Poltrum
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | | | - Hans-Peter Haring
- Department of Neurology 1, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria (H.-P.H.)
| | - Julia Ferrari
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Austria (J.F., W.L.)
| | - Wilfried Lang
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Austria (J.F., W.L.)
| | - Johann Willeit
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Christian Enzinger
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Franz Fazekas
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
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Lichtman JH, Leifheit EC, Wang Y, Goldstein LB. Hospital Quality Metrics: “America's Best Hospitals” and Outcomes After Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:430-434. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/03/2018] [Accepted: 10/13/2018] [Indexed: 11/27/2022] Open
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Sun S, Pan Y, Bai L, Zhao X, Liu L, Li H, Wang Y, Guo L, Wang Y. GWTG Risk Model for All Stroke Types Predicts In-Hospital and 3-Month Mortality in Chinese Patients with Acute Stroke. J Stroke Cerebrovasc Dis 2018; 28:800-806. [PMID: 30553646 DOI: 10.1016/j.jstrokecerebrovasdis.2018.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/01/2018] [Accepted: 11/22/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We aimed to externally validate the Get With the Guidelines (GWTG) risk model for all stroke types to predict in-hospital stroke mortality in Chinese patients and moreover to explore its prognostic value in predicting 3-month mortality after stroke. METHODS The prognostic model was applied to patients with acute stroke from China National Stroke Registry II (CNSR II) to predict in-hospital and 3-month mortality. Model discrimination was estimated by calculating c-statistic and 95% confidence intervals (CIs). Calibration was assessed by Pearson correlation coefficient and Hosmer-Lemeshow test. RESULTS Date from 21,684 stroke patients with complete data for in-hospital mortality prediction and 20,348 stroke patients with complete data for 3-month mortality prediction in the CNSR II were abstracted. The in-hospital and 3-month mortality were 1.4% and 5.6%, respectively. The c-statistics in the CNSR II were .86 (95% CI, .84-.88) and .83 (95% CI, .81-.84) for in-hospital and 3-month mortality, respectively. Calibration plot presented high correlation between the observed and predicted mortality rates (Pearson correlation coefficient, .996 for in-hospital and .998 for 3-month mortality; both P < .001). The Hosmer-Lemeshow statistics for the prediction of in-hospital and 3-month mortality were 0.21 and less than .001, respectively. The model performed nearly as well in each stroke type as in the overall model including all types. CONCLUSIONS The GWTG risk model for all stroke types is a valid clinical tool to predict in-hospital and 3-month mortality in Chinese patients with acute stroke of any type.
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Affiliation(s)
- Shichao Sun
- Department of Neurology, The Second Hospital, Hebei Medical University, Shi Jiazhuang, Hebei Province, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Lei Bai
- Department of Endocrinology, The Fourth Hospital, Hebei Medical University, Shi Jiazhuang, Hebei Province, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Li Guo
- Department of Neurology, The Second Hospital, Hebei Medical University, Shi Jiazhuang, Hebei Province, China.
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Ofori-Asenso R, Zomer E, Chin KL, Si S, Markey P, Tacey M, Curtis AJ, Zoungas S, Liew D. Effect of Comorbidity Assessed by the Charlson Comorbidity Index on the Length of Stay, Costs and Mortality among Older Adults Hospitalised for Acute Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15112532. [PMID: 30424531 PMCID: PMC6267000 DOI: 10.3390/ijerph15112532] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/07/2018] [Accepted: 11/07/2018] [Indexed: 11/16/2022]
Abstract
The burden of comorbidity among stroke patients is high. The aim of this study was to examine the effect of comorbidity on the length of stay (LOS), costs, and mortality among older adults hospitalised for acute stroke. Among 776 older adults (mean age 80.1 ± 8.3 years; 46.7% female) hospitalised for acute stroke during July 2013 to December 2015 at a tertiary hospital in Melbourne, Australia, we collected data on LOS, costs, and discharge outcomes. Comorbidity was assessed via the Charlson Comorbidity Index (CCI), where a CCI score of 0⁻1 was considered low and a CCI ≥ 2 was high. Negative binomial regression and quantile regression were applied to examine the association between CCI and LOS and cost, respectively. Survival was evaluated with the Kaplan⁻Meier and Cox regression analyses. The median LOS was 1.1 days longer for patients with high CCI than for those with low CCI. In-hospital mortality rate was 18.2% (22.1% for high CCI versus 11.8% for low CCI, p < 0.0001). After controlling for confounders, high CCI was associated with longer LOS (incidence rate ratio [IRR]; 1.35, p < 0.0001) and increased likelihood of in-hospital death (hazard ratio [HR]; 1.91, p = 0.003). The adjusted median, 25th, and 75th percentile costs were AUD$2483 (26.1%), AUD$1446 (28.1%), and AUD$3140 (27.9%) higher for patients with high CCI than for those with low CCI. Among older adults hospitalised for acute stroke, higher global comorbidity (CCI ≥ 2) was associated adverse clinical outcomes. Measures to better manage comorbidities should be considered as part of wider strategies towards mitigating the social and economic impacts of stroke.
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Affiliation(s)
- Richard Ofori-Asenso
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
- Epidemiological Modelling Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
- Division of Metabolism, Ageing and Genomics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Ella Zomer
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Ken Lee Chin
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Si Si
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Peter Markey
- Alfred Hospital, Melbourne, VIC 3004, Australia.
| | - Mark Tacey
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Andrea J Curtis
- Division of Metabolism, Ageing and Genomics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Sophia Zoungas
- Division of Metabolism, Ageing and Genomics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Danny Liew
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
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Chauhan N, Ali SF, Hannawi Y, Hinduja A. Utilization of Hospice Care in Patients With Acute Ischemic Stroke. Am J Hosp Palliat Care 2018; 36:28-32. [DOI: 10.1177/1049909118796796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: A significant percentage of terminally ill patients are discharged to hospice care following a devastating stroke. Objective: We sought to determine the factors associated with hospital discharge to hospice care in a large cohort of patients with stroke. Methods: Using the institutional Get With The Guidelines-Stroke database, all consecutive patients with acute ischemic stroke (AIS) who were alive at discharge, from January 2009 until July 2015, were analyzed. Univariate and multivariable statistical analyses were performed to determine the factors associated with discharge to hospice care. Results: Of 2446 patients with AIS, 3.4% died and were excluded of remaining 2363 patients, and 4.2% were discharged to hospice care. Univariate analysis identified patients who were discharged to hospice care to be older, caucasian, Medicare or private insurance, have atrial fibrillation, heart failure and less often had diabetes mellitus or smoked. Altered mentation at presentation and urinary tract infection were more common in patients discharged to hospice. On multivariable analysis, patients transferred to hospice care were older (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.01-1.07; P < .001), had a high National Institute of Health Stroke Scale (NIHSS; OR: 1.15, 95% CI: 1.10-1.20; P < .001), and altered mental status at presentation (OR: 2.42, 95% CI: 1.29-4.55; P < .001). Conclusion: In our study, elderly patients with high NIHSS and altered mental status were identified as factors associated with transition to hospice care following AIS. Prospective studies on the optimal timing of initiation of these consults are needed.
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Affiliation(s)
- Nabeel Chauhan
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Syed F. Ali
- Department of Neurology, University of Arkansas or Medical Sciences, Little Rock, AR, USA
| | - Yousef Hannawi
- Division of Cerebrovascular and Neurocritical Care, Department of Neurology, Ohio State University, Columbus, OH, USA
| | - Archana Hinduja
- Division of Cerebrovascular and Neurocritical Care, Department of Neurology, Ohio State University, Columbus, OH, USA
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Pappas MA, Vijan S, Rothberg MB, Singer DE. Reducing age bias in decision analyses of anticoagulation for patients with nonvalvular atrial fibrillation - A microsimulation study. PLoS One 2018; 13:e0199593. [PMID: 29995900 PMCID: PMC6040745 DOI: 10.1371/journal.pone.0199593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 06/11/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Anticoagulation decreases a patient's risk of ischemic stroke and increases the risk of hemorrhage. Decision analyses regarding anticoagulation therefore require that different outcomes be weighted in comparison to one another. Most decision analyses to date have weighted intracranial hemorrhage (ICH) as 1.5 times worse than ischemic stroke, but because death and disability have lifelong impact, the expected impact should vary by life expectancy. Therefore, a fixed weighting ratio leads to age-related bias decision analyses of anticoagulation. We aimed to quantify the relative impact of ICH and ischemic stroke and derive a ratio that allows decision analysis without microsimulation. METHODS We created a microsimulation model to predict QALYs lost due to ICH and ischemic stroke. We then applied a meta-model to predict the ratio of QALYs lost from ICH relative to ischemic stroke. RESULTS Previously-used weighting ratios (1.5) are close to our derived mean weighting ratio (1.60). However, the weighting ratio of QALYs lost from ICH relative to ischemic stroke is sensitive to age and discount rate. Patients at younger ages have higher mean weighting ratios, as do patients with higher discount rates. CONCLUSIONS The ratio of QALYs lost to ICH relative to ischemic stroke varies with age and discount rate. We present a set of such ratios here for use in decision analyses that do not incorporate full microsimulation models. Use of weighting ratios that vary with age, rather than the current fixed ratios, has the potential to reduce age-based bias in decision-making regarding events with lifelong implications. In this case, use of dynamic ratios may change anticoagulation recommendations for patients with nonvalvular atrial fibrillation at relatively low stroke risk.
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Affiliation(s)
- Matthew A. Pappas
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Sandeep Vijan
- Division of General Internal Medicine, Department of Internal Medicine, The University of Michigan Health System, Ann Arbor, Michigan, United States of America
| | - Michael B. Rothberg
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
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Prevalence of Abnormal Glucose Regulation according to Different Diagnostic Criteria in Ischaemic Stroke without a History of Diabetes. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8358724. [PMID: 29951547 PMCID: PMC5987245 DOI: 10.1155/2018/8358724] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 03/13/2018] [Accepted: 03/26/2018] [Indexed: 12/28/2022]
Abstract
We aimed to investigate the prevalence and distribution of abnormal glucose regulation, including prediabetes and newly diagnosed diabetes, according to different criteria in ischaemic stroke patients without a history of diabetes. Data were derived from a representative cohort across China. Prediabetes was defined as fasting plasma glucose (FPG) 5.6–6.9 mmol/L or 2-hour oral glucose tolerance test (OGTT) 7.8–11.0 mmol/L or haemoglobin A1c (HbA1c) 5.7–6.4%. Newly diagnosed diabetes was defined as FPG ≥ 7.0 mmol/L, 2 h OGTT ≥ 11.1 mmol/L or HbA1c ≥ 6.5%. Among 1251 ischaemic stroke patients, 471 (37.5%) were detected as prediabetes and 539 (43.1%) were detected as newly diagnosed diabetes. Prediabetes was present in 118 (9.4%), 290 (23.2%) and 314 (25.1%) stroke patients, and newly diagnosed diabetes was present in 138 (11.0%), 370 (29.6%), and 365 (29.2%) stroke patients, based on FPG, 2 h OGTT, and HbA1c criteria, respectively. Dependency on FPG alone would have missed 74.9% of patients in the prediabetes range and 74.4% of patients in the diabetes range. Our study demonstrated a high prevalence of prediabetes and diabetes in ischaemic stroke patients without a history of diabetes. OGTT and HbA1c helped detect the majority of prediabetes and newly diagnosed diabetes in ischaemic stroke patients.
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Hastrup S, Johnsen SP, Terkelsen T, Hundborg HH, von Weitzel-Mudersbach P, Simonsen CZ, Hjort N, Møller AT, Harbo T, Poulsen MS, Ruiz de Morales Ayudarte N, Damgaard D, Andersen G. Effects of centralizing acute stroke services: A prospective cohort study. Neurology 2018; 91:e236-e248. [PMID: 29907609 PMCID: PMC6059031 DOI: 10.1212/wnl.0000000000005822] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 04/13/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR). METHODS The CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective "before-and-after" cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014. RESULTS Centralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38-0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark. CONCLUSIONS Centralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.
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Affiliation(s)
- Sidsel Hastrup
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark.
| | - Soren P Johnsen
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Thorkild Terkelsen
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Heidi H Hundborg
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Paul von Weitzel-Mudersbach
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Claus Z Simonsen
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Niels Hjort
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Anette T Møller
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Thomas Harbo
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Marika S Poulsen
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Noella Ruiz de Morales Ayudarte
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Dorte Damgaard
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
| | - Grethe Andersen
- From the Departments of Neurology (S.H., T.T., P.v.W.-M., C.Z.S., N.H., A.T.M., T.H., M.S.P., N.R.d.M.A., D.D., G.A.) and Clinical Epidemiology (S.H., S.P.J., H.H.H.), Aarhus University Hospital; Department of Clinical Medicine, Aarhus University (S.H., C.Z.S., N.H., G.A); and Danish National Registers (H.H.H.), a National Quality Improvement Program (RKKP), Aarhus, Denmark
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Hecht N, Neugebauer H, Fiss I, Pinczolits A, Vajkoczy P, Jüttler E, Woitzik J. Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke. J Cereb Blood Flow Metab 2018; 38:1096-1103. [PMID: 28665171 PMCID: PMC5999005 DOI: 10.1177/0271678x17718693] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The decision to perform decompressive hemicraniectomy (DHC) by default in malignant hemispheric stroke (MHS) remains controversial. Even under ideal conditions, DHC usually results in moderate to severe disability. The present study for the first time uses neuroimaging to identify independent outcome predictors in a prospective cohort of 96 MHS patients undergoing DHC. The primary outcome was functional status according to the modified Rankin Scale (mRS) at 12 months and categorized as favorable (mRS 0-3) or unfavorable (mRS 4-6). At 12 months, 19 patients (20%) reached favorable and 77 patients (80%) unfavorable outcome. The overall mean infarct volume was 328 ± 114 ml. Multivariable logistic regression identified age per year (OR 1.14, 95% CI 1.04-1.24; p = 0.005), infarct volume per cm3 (OR 1.012, 95% CI 1.003-1.022; p = 0.013), thalamic involvement (OR 8.65, 95% CI 1.04-72.15; p = 0.046) and postoperative pneumonia (OR 5.52, 95% CI 1.03-29.57; p = 0.046) as independent outcome predictors, which was confirmed by multivariable ordinal regression for age ( p = 0.004) and infarct volume ( p = 0.015). The infarct volume threshold for reasonable prediction of unfavorable outcome in our patients was 270 cm3, which in the future may help prognostication and development of clinical trials on DHC and outcome in MHS.
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Affiliation(s)
- Nils Hecht
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Ingo Fiss
- 3 Department of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Alexandra Pinczolits
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eric Jüttler
- 2 Department of Neurology, Universitätsklinikum Ulm, Ulm, Germany.,4 Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Johannes Woitzik
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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86
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Impact of smoking on stroke outcome after endovascular treatment. PLoS One 2018; 13:e0194652. [PMID: 29718909 PMCID: PMC5931491 DOI: 10.1371/journal.pone.0194652] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 03/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Recent studies suggest a paradoxical association between smoking status and clinical outcome after intravenous thrombolysis (IVT). Little is known about relationship between smoking and stroke outcome after endovascular treatment (EVT). Methods We analyzed data of all stroke patients treated with EVT at the tertiary stroke centre of Berne between January 2005 and December 2015. Using uni- and multivariate modeling, we assessed whether smoking was independently associated with excellent clinical outcome (modified Rankin Scale (mRS) 0–1) and mortality at 3 months. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage (sICH) and recanalization. Results Of 935 patients, 204 (21.8%) were smokers. They were younger (60.5 vs. 70.1 years of age, p<0.001), more often male (60.8% vs. 52.5%, p = 0.036), had less often from hypertension (56.4% vs. 69.6%, p<0.001) and were less often treated with antithrombotics (35.3% vs. 47.7%, p = 0.004) as compared to nonsmokers. In univariate analyses, smokers had higher rates of excellent clinical outcome (39.1% vs. 23.1%, p<0.001) and arterial recanalization (85.6% vs. 79.4%, p = 0.048), whereas mortality was lower (15.6% vs. 25%, p = 0.006) and frequency of sICH similar (4.4% vs. 4.1%, p = 0.86). After correcting for confounders, smoking still independently predicted excellent clinical outcome (OR 1.758, 95% CI 1.206–2.562; p<0.001). Conclusion Smoking in stroke patients may be a predictor of excellent clinical outcome after EVT. However, these data must not be misinterpreted as beneficial effect of smoking due to the observational study design. In view of deleterious effects of cigarette smoking on cardiovascular health, cessation of smoking should still be strongly recommended for stroke prevention.
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87
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Beslow LA, Dowling MM, Hassanein SMA, Lynch JK, Zafeiriou D, Sun LR, Kopyta I, Titomanlio L, Kolk A, Chan A, Biller J, Grabowski EF, Abdalla AA, Mackay MT, deVeber G. Mortality After Pediatric Arterial Ischemic Stroke. Pediatrics 2018; 141:peds.2017-4146. [PMID: 29695585 DOI: 10.1542/peds.2017-4146] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Cerebrovascular disease is among the top 10 causes of death in US children, but risk factors for mortality are poorly understood. Within an international registry, we identify predictors of in-hospital mortality after pediatric arterial ischemic stroke (AIS). METHODS Neonates (0-28 days) and children (29 days-<19 years) with AIS were enrolled from January 2003 to July 2014 in a multinational stroke registry. Death during hospitalization and cause of death were ascertained from medical records. Logistic regression was used to analyze associations between risk factors and in-hospital mortality. RESULTS Fourteen of 915 neonates (1.5%) and 70 of 2273 children (3.1%) died during hospitalization. Of 48 cases with reported causes of death, 31 (64.6%) were stroke-related, with remaining deaths attributed to medical disease. In multivariable analysis, congenital heart disease (odds ratio [OR]: 3.88; 95% confidence interval [CI]: 1.23-12.29; P = .021), posterior plus anterior circulation stroke (OR: 5.36; 95% CI: 1.70-16.85; P = .004), and stroke presentation without seizures (OR: 3.95; 95% CI: 1.26-12.37; P = .019) were associated with in-hospital mortality for neonates. Hispanic ethnicity (OR: 3.12; 95% CI: 1.56-6.24; P = .001), congenital heart disease (OR: 3.14; 95% CI: 1.75-5.61; P < .001), and posterior plus anterior circulation stroke (OR: 2.71; 95% CI: 1.40-5.25; P = .003) were associated with in-hospital mortality for children. CONCLUSIONS In-hospital mortality occurred in 2.6% of pediatric AIS cases. Most deaths were attributable to stroke. Risk factors for in-hospital mortality included congenital heart disease and posterior plus anterior circulation stroke. Presentation without seizures and Hispanic ethnicity were also associated with mortality for neonates and children, respectively. Awareness and study of risk factors for mortality represent opportunities to increase survival.
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Affiliation(s)
- Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, and Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Michael M Dowling
- Departments of Pediatrics and Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - John K Lynch
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Dimitrios Zafeiriou
- Division of Child Neurology and Developmental Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ilona Kopyta
- Department of Pediatric Neurology, School of Medicine, Medical University of Silesia, Katowice, Poland
| | - Luigi Titomanlio
- Pediatric Emergency Département, Hôpital Robert Debré, Paris, France
| | - Anneli Kolk
- Department of Neuropsychology, University of Tartu, Tartu, Estonia
| | - Anthony Chan
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Canada
| | - Jose Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Eric F Grabowski
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Abdalla A Abdalla
- Department of Neurosciences, Al Jalila Children's Hospital, Dubai, United Arab Emirates
| | - Mark T Mackay
- Department of Neurology, The Royal Children's Hospital, Melbourne, Australia; and
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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88
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Kurmann R, Engelter ST, Michel P, Luft AR, Wegener S, Branscheidt M, Eskioglou E, Sirimarco G, Lyrer PA, Gensicke H, Horvath T, Fischer U, Arnold M, Sarikaya H. Impact of Smoking on Clinical Outcome and Recanalization After Intravenous Thrombolysis for Stroke. Stroke 2018; 49:1170-1175. [DOI: 10.1161/strokeaha.117.017976] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 02/17/2018] [Accepted: 02/23/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The impact of smoking on prognosis after stroke is controversial. We aimed to assess the relationship between smoking status and stroke outcome after intravenous thrombolysis in a large cohort study by adjusting for potential confounders and incorporating recanalization rates.
Methods—
In a prospective observational multicenter study, we analyzed baseline and outcome data of consecutive patients with acute ischemic stroke treated with intravenous thrombolysis. Using uni- and multivariable modeling, we assessed whether smoking was associated with favorable outcome (modified Rankin Scale score of 0–1) and mortality. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage and recanalization of middle cerebral artery. Patients reporting active cigarette use were classified as smokers.
Results—
Of 1865 patients, 19.8% were smokers (n=369). They were younger (mean 63.5 versus 71.3 years), less often women (56% versus 72.1%), and suffered less often from hypertension (61.3% versus 70.1%) and atrial fibrillation (22.7% versus 35.6%) when compared with nonsmokers. Favorable outcome and 3-month mortality were in favor of smokers in unadjusted analyses (45.8% versus 39.5% and 9.3% versus 15.8%, respectively), whereas symptomatic intracranial hemorrhage was comparable in both cohorts. Smoking was not associated with clinical outcome and mortality after adjusting for confounders (odds ratio, 1.20; 95% confidence interval, 0.91–1.61;
P
=0.197 and odds ratio, 1.08; 95% confidence interval, 0.68–1.71;
P
=0.755, respectively). However, smoking still independently predicted recanalization of middle cerebral artery in multivariable analyses (odds ratio, 2.68; 95% confidence interval, 1.11–6.43;
P
=0.028).
Conclusions—
Our study suggests that good outcome in smokers is mainly related to differences in baseline characteristics and not to biological effects of smoking. The higher recanalization rates in smokers, however, call for further studies.
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Affiliation(s)
- Rebekka Kurmann
- From the Department of Neurology, University Hospital Berne, Switzerland (R.K., T.H., U.F., M.A., H.S.)
| | - Stefan T. Engelter
- Stroke Center and Neurology, University Hospital Basel, Switzerland (S.T.E., P.A.L., H.G.)
- Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, University Hospital Basel, Switzerland (S.T.E., H.G.)
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland (P.M., E.E., G.S.)
| | - Andreas R. Luft
- Department of Neurology, University Hospital Zurich, Switzerland (A.R.L., S.W., M.B.)
- cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland (A.R.L.)
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich, Switzerland (A.R.L., S.W., M.B.)
| | - Meret Branscheidt
- Department of Neurology, University Hospital Zurich, Switzerland (A.R.L., S.W., M.B.)
| | - Elissavet Eskioglou
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland (P.M., E.E., G.S.)
| | - Gaia Sirimarco
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland (P.M., E.E., G.S.)
| | - Philippe A. Lyrer
- Stroke Center and Neurology, University Hospital Basel, Switzerland (S.T.E., P.A.L., H.G.)
| | - Henrik Gensicke
- Stroke Center and Neurology, University Hospital Basel, Switzerland (S.T.E., P.A.L., H.G.)
- Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, University Hospital Basel, Switzerland (S.T.E., H.G.)
| | - Thomas Horvath
- From the Department of Neurology, University Hospital Berne, Switzerland (R.K., T.H., U.F., M.A., H.S.)
| | - Urs Fischer
- From the Department of Neurology, University Hospital Berne, Switzerland (R.K., T.H., U.F., M.A., H.S.)
| | - Marcel Arnold
- From the Department of Neurology, University Hospital Berne, Switzerland (R.K., T.H., U.F., M.A., H.S.)
| | - Hakan Sarikaya
- From the Department of Neurology, University Hospital Berne, Switzerland (R.K., T.H., U.F., M.A., H.S.)
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89
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Sico JJ, Myers LJ, Fenton BJ, Concato J, Williams LS, Bravata DM. Association between admission haematocrit and mortality among men with acute ischaemic stroke. Stroke Vasc Neurol 2018; 3:160-168. [PMID: 30294472 PMCID: PMC6169611 DOI: 10.1136/svn-2018-000149] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/20/2018] [Indexed: 12/04/2022] Open
Abstract
Objective Anaemia is associated with higher mortality among patients with non-stroke cardiovascular conditions; less is known regarding the relationship between anaemia and mortality among patients with acute ischaemic stroke. Methods Medical records were abstracted for n=3965 veterans from 131 Veterans Health Administration facilities who were admitted with ischaemic stroke in fiscal year 2007. Haematocrit values within 24 hours of admission were classified as ≤27%, 28%–32%, 33%–37%, 38%–42%, 43%–47% or ≥48%. Multivariate logistic regression was used to examine the relationship between anaemia and in-hospital, 30-day, 6-month and 1-year mortality, adjusting for age, medical comorbidities, modified Acute Physiology and Chronic Health Evaluation-III and stroke severity. Impact factors were calculated to standardise comparisons between haematocrit tier and other covariates. Results Among n=3750 patients included in the analysis, the haematocrit values were ≤27% in 2.1% (n=78), 28%–32% in 6.2% (n=234), 33%–37% in 17.9% (n=670), 38%–42% in 36.4% (n=1366), 43%–47% in 28.2% (n=1059) and ≥48% in 9.1% (n=343). Patients with haematocrit ≤27%, compared with patients in the 38%–42% range, were more likely to have died across all follow-up intervals, with statistically significant adjusted ORs (aORs) ranging from 2.5 to 3.5. Patients with polycythaemia (ie, haematocrit ≥48%) were at increased risk of in-hospital mortality (aOR=2.9; 95% CI 1.4 to 6.0), compared with patients with mid-range admission haematocrits. Pronounced differences between patients receiving and not receiving blood transfusion limited our ability to perform a propensity analysis. Impact factors in the 1-year mortality model were 0.46 (severe anaemia), 0.06 (cancer) and 0.018 (heart disease). Conclusions Anaemia is independently associated with an increased risk of death throughout the first year post stroke; high haematocrit is associated with early poststroke mortality. Severe anaemia is associated with 1-year mortality to a greater degree than cancer or heart disease. These data cannot address the question of whether interventions targeting anaemia might improve patient outcomes.
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Affiliation(s)
- Jason J Sico
- Neurology Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Neurology, Center for NeuroEpidemiological and Clinical Neurological Research, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Laura J Myers
- Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,VA Health Services Research and Development (HSR&D), Center for Healthcare Informatics, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Brenda J Fenton
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Division of Chronic Disease Epidemiology, Yale School of Public Health, West Haven, Connecticut, USA
| | - John Concato
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Medical Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Linda S Williams
- Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,VA Health Services Research and Development (HSR&D), Center for Healthcare Informatics, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dawn M Bravata
- Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,VA Health Services Research and Development (HSR&D), Center for Healthcare Informatics, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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90
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Gao H, Sun X, Li W, Gao Q, Zhang J, Zhang Y, Ma Y, Yang X, Kang X, Jiang W. Development and validation of a risk score to predict 30-day mortality in patients with atrial fibrillation-related stroke: GPS-GF score. Neurol Res 2018; 40:532-540. [PMID: 29544401 DOI: 10.1080/01616412.2018.1451431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Hua Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaolong Sun
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- Department of Rehabilitation Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Wen Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Qiong Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jing Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yi Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yue Ma
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiai Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaogang Kang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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91
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Soriano-Tárraga C, Giralt-Steinhauer E, Mola-Caminal M, Ois A, Rodríguez-Campello A, Cuadrado-Godia E, Fernández-Cadenas I, Cullell N, Roquer J, Jiménez-Conde J. Biological Age is a predictor of mortality in Ischemic Stroke. Sci Rep 2018. [PMID: 29515201 PMCID: PMC5841388 DOI: 10.1038/s41598-018-22579-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Age and stroke severity are the main mortality predictors after ischemic stroke. However, chronological age and biological age are not exactly concordant. Age-related changes in DNA methylation in multiple CpG sites across the genome can be used to estimate biological age, which is influenced by lifestyle, environmental factors, and genetic variation. We analyzed the impact of biological age on 3-month mortality in ischemic stroke. We assessed 594 patients with acute ischemic stroke in a cohort from Hospital del Mar (Barcelona) and validated the results in an independent cohort. Demographic and clinical data, including chronological age, vascular risk factors, initial stroke severity (NIHSS score), recanalization treatment, and previous modified Rankin scale were registered. Biological age was estimated with an algorithm based on DNA methylation in 71 CpGs. Biological age was predictive of 3-month mortality (p = 0.041; OR = 1.05, 95% CI 1.00–1.10), independently of NIHSS score, chronological age, TOAST, vascular risk factors, and blood cell composition. Stratified by TOAST classification, biological age was associated with mortality only in large-artery atherosclerosis etiology (p = 0.004; OR = 1.14, 95% CI 1.04–1.25). As estimated by DNA methylation, biological age is an independent predictor of 3-month mortality in ischemic stroke regardless of chronological age, NIHSS, previous modified Rankin scale, and vascular risk factors.
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Affiliation(s)
- Carolina Soriano-Tárraga
- Department of Neurology, Hospital del Mar; Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques); Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | - Eva Giralt-Steinhauer
- Department of Neurology, Hospital del Mar; Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques); Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | - Marina Mola-Caminal
- Department of Neurology, Hospital del Mar; Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques); Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | - Angel Ois
- Department of Neurology, Hospital del Mar; Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques); Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | - Ana Rodríguez-Campello
- Department of Neurology, Hospital del Mar; Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques); Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Department of Neurology, Hospital del Mar; Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques); Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | - Israel Fernández-Cadenas
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca, MutuaTerrassa, Hospital Mútua de Terrassa, Terrassa, Spain
| | - Natalia Cullell
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca, MutuaTerrassa, Hospital Mútua de Terrassa, Terrassa, Spain
| | - Jaume Roquer
- Department of Neurology, Hospital del Mar; Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques); Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain.
| | - Jordi Jiménez-Conde
- Department of Neurology, Hospital del Mar; Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques); Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain.
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92
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McCall SJ, Alanazi TA, Clark AB, Musgrave SD, Bettencourt-Silva JH, Bachmann MO, Metcalf AK, Bowles KM, Mamas MA, Potter JF, Myint PK. Hyperglycaemia and the SOAR stroke score in predicting mortality. Diab Vasc Dis Res 2018; 15:114-121. [PMID: 29185347 DOI: 10.1177/1479164117743034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We assessed the association between admission blood glucose levels and acute stroke mortality and examined whether there was any incremental value of adding glucose status to the validated acute stroke mortality predictor - the SOAR (stroke subtype, Oxford Community Stroke Project classification, age, and pre-stroke modified Rankin) score. METHODS Data from Norfolk and Norwich University Hospital stroke and Transient Ischaemic Attack register (2003-2013) and Anglia Stroke Clinical Network Evaluation Study (2009-2012) were analysed. Multivariable logistic regression analysis assessed the association between admission blood glucose levels with inpatient and 7-day mortality. The prognostic ability of the SOAR score was then compared with the SOAR with glucose score. RESULTS A total of 5575 acute stroke patients (ischaemic stroke: 89.2%) with mean age (standard deviation) of 76.97 ( ± 11.88 ) years were included. Both borderline hyperglycaemia (7.9-11.0 mmol/L) and hyperglycaemia (>11.0 mmol/L) when compared to normoglycaemia (4.0-7.8 mmol/L) were associated with both 7-day and inpatient mortality after controlling for sex, age, Oxford Community Stroke Project classification and pre-stroke modified Rankin score. Both the SOAR stroke score and SOAR-G score were good predictors of inpatient stroke mortality [area under the curve: 0.82 (95% confidence interval: 0.81-0.84) and 0.83 (95% confidence interval: 0.81-0.84)], respectively. These scores were also good at predicting outcomes in both patients with and without diabetes. CONCLUSION High blood glucose levels at admission were associated with worse acute stroke mortality outcomes. The constituents of the SOAR stroke score were good at predicting mortality after stroke.
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Affiliation(s)
- Stephen J McCall
- 1 Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
- 2 Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Turkiah A Alanazi
- 1 Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
| | - Allan B Clark
- 3 Norwich Medical School, University of East Anglia, Norwich, UK
| | | | | | - Max O Bachmann
- 3 Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Kristian M Bowles
- 3 Norwich Medical School, University of East Anglia, Norwich, UK
- 4 Norfolk and Norwich University Hospital, Norwich, UK
| | - Mamas A Mamas
- 5 Keele Cardiovascular Research Group, Centre for Prognosis Research Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - John F Potter
- 3 Norwich Medical School, University of East Anglia, Norwich, UK
- 4 Norfolk and Norwich University Hospital, Norwich, UK
| | - Phyo K Myint
- 1 Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
- 3 Norwich Medical School, University of East Anglia, Norwich, UK
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93
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de Ridder IR, Dijkland SA, Scheele M, den Hertog HM, Dirks M, Westendorp WF, Nederkoorn PJ, van de Beek D, Ribbers GM, Steyerberg EW, Lingsma HF, Dippel DW. Development and validation of the Dutch Stroke Score for predicting disability and functional outcome after ischemic stroke: A tool to support efficient discharge planning. Eur Stroke J 2018; 3:165-173. [PMID: 29900414 PMCID: PMC5992735 DOI: 10.1177/2396987318754591] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/23/2017] [Indexed: 12/23/2022] Open
Abstract
Introduction We aimed to develop and validate a prognostic score for disability at
discharge and functional outcome at three months in patients with acute
ischemic stroke based on clinical information available on admission. Patients and methods The Dutch Stroke Score (DSS) was developed in 1227 patients with ischemic
stroke included in the Paracetamol (Acetaminophen) In Stroke study.
Predictors for Barthel Index (BI) at discharge (‘DSS-discharge’) and
modified Rankin Scale (mRS) at three months (‘DSS-3 months’) were identified
in multivariable ordinal regression. The models were internally validated
with bootstrapping techniques. The DSS-3 months was externally validated in
the PRomoting ACute Thrombolysis in Ischemic StrokE study (1589 patients)
and the Preventive Antibiotics in Stroke Study (2107 patients). Model
performance was assessed in terms of discrimination, expressed by the area
under the receiver operating characteristic curve (AUC), and
calibration. Results At model development, the strongest predictors of Barthel Index at discharge
were age per decade over 60 (odds ratio = 1.55, 95% confidence interval (CI)
1.41–1.68), National Institutes of Health Stroke Scale (odds ratio = 1.24
per point, 95% CI 1.22–1.26) and diabetes (odds ratio = 1.62, 95% CI
1.32–1.91). The internally validated AUC was 0.76 (95% CI 0.75–0.79). The
DSS-3 months, additionally consisting of previous stroke and atrial
fibrillation, performed similarly at internal (AUC 0.75, 95% CI 0.74–0.77)
and external validation (AUC 0.74 in PRomoting ACute Thrombolysis in
Ischemic StrokE (95% CI 0.72–0.76) and 0.69 in Preventive Antibiotics in
Stroke Study (95% CI 0.69–0.72)). Observed outcome was slightly better than
predicted. Discussion: The DSS had satisfactory performance in predicting
BI at discharge and mRS at three months in ischemic stroke patients. Conclusion If further validated, the DSS may contribute to efficient stroke unit
discharge planning alongside patients' contextual factors and therapeutic
needs.
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Affiliation(s)
- Inger R de Ridder
- 1Department of Neurology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Simone A Dijkland
- 2Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Maaike Scheele
- 1Department of Neurology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Maaike Dirks
- 1Department of Neurology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands.,4Department of Neurology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Willeke F Westendorp
- 5Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Paul J Nederkoorn
- 5Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Diederik van de Beek
- 5Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Gerard M Ribbers
- 6Department of Rehabilitation Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ewout W Steyerberg
- 2Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, Netherlands
| | - Hester F Lingsma
- 2Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Diederik Wj Dippel
- 1Department of Neurology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
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94
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Serum Alkaline Phosphatase, Phosphate, and In-Hospital Mortality in Acute Ischemic Stroke Patients. J Stroke Cerebrovasc Dis 2018; 27:257-266. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/15/2017] [Accepted: 08/25/2017] [Indexed: 11/23/2022] Open
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95
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Harvey D, Butler J, Groves J, Manara A, Menon D, Thomas E, Wilson M. Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations. Br J Anaesth 2018; 120:138-145. [DOI: 10.1016/j.bja.2017.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/20/2017] [Accepted: 10/23/2017] [Indexed: 11/28/2022] Open
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96
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Baker BA, Bailey WL, Bliden KP, Tantry US, Gurbel PA. Unravelling the Smokers’ Paradox: Cigarette smoking, high-risk coronary artery disease and enhanced clinical efficacy of oral P2Y12 inhibitors. Thromb Haemost 2017; 111:1187-90. [DOI: 10.1160/th13-08-0642] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 01/05/2014] [Indexed: 11/05/2022]
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97
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Bei HZ, You SJ, Zheng D, Zhong CK, Du HP, Zhang Y, Lu TS, Cao LD, Dong XF, Cao YJ, Liu CF. Prognostic role of hypochloremia in acute ischemic stroke patients. Acta Neurol Scand 2017; 136:672-679. [PMID: 28613005 DOI: 10.1111/ane.12785] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The impact of electrolyte imbalance on clinical outcomes after acute ischemic stroke (AIS) is still not understood. We investigated the association between hypochloremia and hyponatremia upon hospital admission and in-hospital mortality in AIS patients. MATERIALS AND METHODS A total of 3314 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included in this study. Hypochloremia was defined as having a serum chloride concentration <98 mmol/L and hyponatremia as having a serum sodium concentration <135 mmol/L. The Cox proportional hazard model was used to examine the effect of hypochloremia and hyponatremia on all-cause in-hospital mortality in AIS patients. RESULTS During hospitalization, 118 patients (3.6%) died from all causes. Multivariable model adjusted for age, sex, baseline National Institutes of Health Stroke Scale score, serum sodium, and other potential covariates showed that hypochloremia was associated with a 2.43-fold increase in the risk of in-hospital mortality (hazard ratio [HR] 2.43; 95% confidence interval [CI], 1.41-4.19; P=.001). However, no significant association between hyponatremia (P=.905) and in-hospital mortality was observed. Moreover, the multivariable analysis found that serum chloride (HR=0.92, 95% CI 0.88-0.98; P=.004) but not serum sodium (P=.102) was significantly associated with in-hospital mortality. CONCLUSIONS Hypochloremia at admission was independently associated with in-hospital mortality in AIS patients.
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Affiliation(s)
- H.-Z. Bei
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
- Department of Neurology; The Third Affiliated Hospital of Inner Mongolia Medical University; Baotou China
| | - S.-J. You
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
| | - D. Zheng
- The George Institute for Global Health; The University of New South Wales; Sydney NSW Australia
| | - C.-K. Zhong
- Department of Epidemiology; School of Public Health; Medical College of Soochow University; Suzhou China
| | - H.-P. Du
- Department of Neurology; The Affiliated Wujiang Hospital of Nantong University; Suzhou China
| | - Y. Zhang
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
| | - T.-S. Lu
- Department of Neurology; Changshu First People's Hospital; Suzhou China
| | - L.-D. Cao
- Department of Neurology; Zhangjiagang First People's Hospital; Suzhou China
| | - X.-F. Dong
- Department of Neurology; Suzhou Hospital Affiliated to Nanjing Medical University; Suzhou China
| | - Y.-J. Cao
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
- Institutes of Neuroscience; Soochow University; Suzhou China
| | - C.-F. Liu
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
- Institutes of Neuroscience; Soochow University; Suzhou China
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98
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Dutta D, Cannon A, Bowen E. Validation and comparison of two stroke prognostic models for in hospital, 30-day and 90-day mortality. Eur Stroke J 2017; 2:327-334. [PMID: 31008324 PMCID: PMC6453188 DOI: 10.1177/2396987317703581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/15/2017] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION We aimed to validate and compare two clinical prognostic models for mortality which include the National Institutes of Health Stroke Scale (NIHSS); the Age and NIHSS Score (ANS) and case mix model (CMM) of the Sentinel Stroke National Audit Program (SSNAP). The NIHSS on admission was also tested as a prognostic score. PATIENTS AND METHODS Prospectively collected data from the SSNAP register for a cohort of patients (ischaemic and haemorrhagic stroke) admitted over 1 year to Gloucestershire Royal Hospital, England were accessed. The ANS and CMM were calculated and tested for in hospital, 30-day and 90-day mortality using calibration plots with Hosmer-Lemeshow tests, receiver operating characteristics curves and other measures of prognostic accuracy. RESULTS Of 848 patients, 110 (12.9%) died in hospital, 112 (13.2%) at 30 days and 164 (19.2%) at 90 days. Calibration for all three scores was good, although Hosmer-Lemeshow test p values were <0.05 with the NIHSS alone for in hospital and 30-day deaths, suggesting deviation from good fit. The c-statistics for in hospital, 30-day and 90-day mortality were ANS (0.783, 0.782, 0.779) and CMM (0.783, 0.774, 0.758), respectively. The NIHSS alone showed fair discrimination but performed less well. A NIHSS score ≥6 was associated with significant mortality (p < 0.0001) in comparison to a score <6. CONCLUSION A simple prognostic model containing age and admission NIHSS only, performed as well as a more complex score at predicting in hospital, 30-day and 90-day mortality. Admission NIHSS recording should be encouraged for stroke registries.
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Affiliation(s)
| | | | - Emily Bowen
- Stroke Service, Gloucestershire Royal Hospital,
UK
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99
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Schwartz J, Wang Y, Qin L, Schwamm LH, Fonarow GC, Cormier N, Dorsey K, McNamara RL, Suter LG, Krumholz HM, Bernheim SM. Incorporating Stroke Severity Into Hospital Measures of 30-Day Mortality After Ischemic Stroke Hospitalization. Stroke 2017; 48:3101-3107. [DOI: 10.1161/strokeaha.117.017960] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/08/2017] [Accepted: 08/28/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Jennifer Schwartz
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Yongfei Wang
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Li Qin
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Lee H. Schwamm
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Gregg C. Fonarow
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Nicole Cormier
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Karen Dorsey
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Robert L. McNamara
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Lisa G. Suter
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Harlan M. Krumholz
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
| | - Susannah M. Bernheim
- From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S., Y.W., L.Q., N.C., K.D., R.L.M., L.G.S., H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (J.S., Y.W., R.L.M., H.M.K.), Section of Rheumatology, Department of Medicine (L.G.S.), and Section of General Internal Medicine, Department of Internal Medicine (S.M.B.), Yale University School of Medicine, New Haven, CT; Department of Neurology, Massachusetts General Hospital, Harvard
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100
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Li SS, Yin MM, Zhou ZH, Chen HS. Dehydration is a strong predictor of long-term prognosis of thrombolysed patients with acute ischemic stroke. Brain Behav 2017; 7:e00849. [PMID: 29201550 PMCID: PMC5698867 DOI: 10.1002/brb3.849] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 07/19/2017] [Accepted: 08/06/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Dehydration was found to be involved in the poor prognosis of patients with acute ischemic stroke. It is unclear whether dehydration status before onset is related with prognosis of thrombolysed patients with acute ischemic stroke. If it is the case, quickly hydrating may improve the prognosis. The present study was designed to explore the issue. METHODS Eligible 294 patients with acute ischemic stroke after thrombolysis were enrolled in the present study according to inclusion/exclusion criteria. According to the modified Rankin scale (mRS) 90 days post stroke, the patients were divided into two groups: mRS 0-2 (n = 191) and mRS 3-6 (n = 103). In the present study, BUN/Cr ≥ 15 combined with USG > 1.010 or either of them were chosen as dehydration marker. Clinical data were analyzed between two groups. Univariate and multivariate statistical analyses were carried out. RESULTS Age, fibrinogen, blood glucose, BUN/Cr, NIHSS score at admission, the systolic blood pressure (SBP) before thrombolysis, dehydration status (BUN/Cr ≥ 15 plus USG > 1.010), hyperlipidemia, USG and D-dimer on admission day, and TOAST classification showed significant difference between two groups (p < .05). Further stratification analysis showed that BUN/Cr ≥ 15, NIHSS ≥ 6, blood glucose ≥8, and SBP > 150 were markedly associated with poor outcome (mRS 3-6, p < .05). After adjusting for age, fibrinogen, USG, D-dimer, dehydration status, NIHSS, blood glucose, SBP, hyperlipidemia, and BUN/Cr at admission, multivariate logistic regression showed that dehydration status, higher NIHSS, higher blood glucose, and higher SBP at admission were independent risk factors for predicting the long-term poor prognosis of thrombolysed patients. CONCLUSIONS The present findings suggest that BUN/Cr ≥ 15 combined with USG > 1.010 as a marker of dehydration status was an independent risk factor for long-term poor prognosis of thrombolysed patients with acute ischemic stroke.
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Affiliation(s)
- Sha-Sha Li
- Jinzhou Medical University JinZhou China
| | - Ming-Ming Yin
- Department of Neurology General Hospital of Shenyang Military Region Shen Yang China
| | - Zhong-He Zhou
- Department of Neurology General Hospital of Shenyang Military Region Shen Yang China
| | - Hui-Sheng Chen
- Department of Neurology General Hospital of Shenyang Military Region Shen Yang China
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