Neurological, functional, and cognitive stroke outcomes in Mexican Americans

Lack of Worsening of Sleep-Disordered Breathing After Recurrent Stroke in the BASIC Project

STUDY OBJECTIVES

To investigate the difference in sleep-disordered breathing (SDB) prevalence and severity after an index and recurrent stroke.

METHODS

In a sample of 40 subjects, home sleep apnea tests were performed a median of 10 days after an index ischemic stroke and 14 days after a recurrent ischemic stroke. A respiratory event index (REI) of ≥ 10 events/h (apneas plus hypopneas per hour of recording) was used to define clinically significant SDB. The relative difference in REI or relative SDB prevalence was used to compare the post-recurrent stroke measurement with that made after the index stroke, and was expressed as a rate ratio (RR) or prevalence ratio (PR). Adjusted regression models (negative binomial for REI and log binomial for SDB) included change in body mass index and time between the events.

RESULTS

The median time from index to recurrent stroke was 330.5 days (interquartile range [IQR]: 103.5, 766.5). The median REI was 17.5 (IQR: 9.0, 32.0) after the index stroke and 18.0 (IQR: 11.0, 25.5) after the recurrent stroke. The within-subject median difference was zero (IQR: -9, 7.5). The relative difference in REI was not significant in unadjusted or adjusted (RR: 0.97 [95% confidence interval: 0.76, 1.24]) models. The prevalence of SDB was not different after the recurrent stroke compared with the index stroke, in unadjusted or adjusted (PR: 1.10 [95% confidence interval: 0.91, 1.32]) models.

CONCLUSIONS

In this within-subject, longitudinal study, neither severity nor prevalence of SDB worsened after recurrent stroke.

Diabetes and ischaemic stroke outcome

AIM

To compare all-cause mortality, stroke recurrence and functional outcomes in people who have experienced stroke, with and without diabetes.

METHODS

We captured data on population-based ischaemic strokes (2006-2012) in Nueces County, Texas. Data were collected from participant interviews and medical records. Differences in cumulative mortality and stroke recurrence risk by diabetes status were estimated at 30 days and 1 year using Cox models. Differences in 90-day functional outcomes (activities of daily living/instrumental activities of daily living score: range 1-4; higher scores worse) by diabetes status were assessed using Tobit regression. Effect modification by ethnicity was examined.

RESULTS

There were 1301 ischaemic strokes, 46% with history of known diabetes. The median (interquartile range) age was 70 (58-81) years and 61% were Mexican American. People with diabetes were younger and more likely to be Mexican American compared with those without diabetes. After adjustment, diabetes predicted mortality (30-day hazard ratio 1.44, 95% CI 0.97-2.12; 1-year hazard ratio 1.47, 95% CI 1.09-1.97) but not stroke recurrence (1-year hazard ratio 1.27, 95% CI 0.78-2.07). People with diabetes had a worse functional outcome score that was explained by cardiovascular risk factors and pre-stroke factors. Diabetes was not associated with functional outcome in the fully adjusted model (final adjusted activities of daily living/instrumental activities of daily living score difference 0.11, 95% CI -0.07 to 0.30). Effect modification by ethnicity was not significant (P>0.3 for all models).

CONCLUSIONS

Diabetes was associated with higher mortality and worse functional outcome but not stroke recurrence. Interventions are needed to decrease the adverse outcomes associated with diabetes, particularly in Mexican-American people.

Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools

Purpose: To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.

Prognosis of Midlife Stroke

OBJECTIVE

To characterize stroke outcomes in a midlife population-based stroke cohort, and to describe comorbidities, quality of care, and risk of recurrence in this age group.

MATERIALS AND METHODS

Ischemic strokes (ISs) were identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2000-2012). Data were from medical records and patient interviews. Ninety-day outcomes (functional, neurologic, cognitive, quality of life [QOL]), prevalence of comorbidities, quality of care, and 1-year recurrence were estimated for those aged 45-64 (midlife) and compared with those aged ≥65 using sex and race-ethnicity adjusted regression models.

RESULTS

Of 4858 ISs, 33% occurred in midlife. On average, the midlife group reported some difficulty with function, favorable neurologic and cognitive outcomes, and moderate QOL scores at 90 days. All outcomes except QOL were better in the midlife group. Prevalent comorbidities in midlife were hypertension (74%), diabetes (51%), hyperlipidemia (34%), heart disease (26%), prior stroke/transient ischemic attack (23%), smoking 37%, excess alcohol 10%, and atrial fibrillation 4%. Median body mass index (BMI) was 30 (interquartile range: 26-35). Diabetes, smoking, and alcohol were more prevalent and BMI higher in the midlife group. Quality of stroke care did not differ by age. One-year recurrence in midlife was 8% (95% confidence interval: 6%-9%) and did not differ by age.

CONCLUSION

While 90-day outcomes were more favorable than in the elderly, midlife stroke survivors faced some disability and did not experience better QOL despite better outcomes. Additional research should identify targets to optimize secondary stroke prevention and improve outcomes in midlife stroke survivors-an understudied group with great potential disability and economic impact.

Sex differences in the impact of acute stroke treatment in a population-based study: a sex-specific propensity score approach

PURPOSE

We investigated whether sex modifies the association of acute stroke treatment on functional outcome using propensity score (PS) methods to minimize confounding and to explore the differential effects of confounders by sex.

METHODS

We included tissue plasminogen activator (tPA) treated (n = 84) and nontreated ischemic stroke cases (n = 143) from a population-based stroke study (2008-2013). The PS model that estimated the probability of receiving tPA included interactions between sex and treatment predictors. The outcome model included sex, tPA, and their interaction. In addition, sex-specific PS values were included as a continuous covariate and modeled using splines. We compared the results with conventional methods of statistical adjustment.

RESULTS

Conventional methods of adjustment suggested that women receive greater benefit from tPA than men. After taking into consideration that the influence of confounders, specifically age and stroke severity, differed by sex, we found no sex difference in the tPA-functional outcome association (P = .94).

CONCLUSIONS

Using PS methods that considered confounding of the sex × treatment interaction, we did not find that the association of tPA with functional outcome differed for women and men. Our findings may have implications for the methodologic approaches used to address confounding in studies that seek to compare stroke treatment effects by sex.

Mexican Americans Receive Less Intensive Stroke Rehabilitation Than Non-Hispanic Whites

BACKGROUND AND PURPOSE

Mexican Americans (MAs) have worse neurological, functional, and cognitive outcomes after stroke. Stroke rehabilitation is important for good outcome. In a population-based study, we sought to determine whether allocation of stroke rehabilitation services differed by ethnicity.

METHODS

Patients with stroke were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project, TX, USA. Cases were validated by physicians using source documentation. Patients were followed prospectively for 3 months after stroke to determine rehabilitation services and transitions. Descriptive statistics were used to depict the study population. Continuous baseline variables were compared using 2 sample t tests or Wilcoxon rank-sum tests by ethnicity. Categorical baseline variables were compared using χ² tests. Ethnic comparisons of rehabilitation services were compared using χ² tests, Fisher's exact tests, and logistic regression.

RESULTS

Seventy-two subjects (50 MA and 22 non-Hispanic white [NHW]) were followed. Mean age, NHW-69 (SD 13), MA-66 (SD 11) years, sex (NHW 55% male, MA 50% male) and median presenting National Institutes of Health Stroke Scale did not differ significantly. There were no ethnic differences among the proportion of patients who were sent home without any rehabilitation services (P=0.9). Among those who received rehabilitation, NHWs were more likely to get inpatient rehabilitation (73%) compared with MAs (30%), P=0.016. MAs (51%) were much more likely to receive home rehabilitation services compared with NHWs (0%) (P=0.0017).

CONCLUSIONS

In this population-based study, MAs were more likely to receive home-based rehabilitation, whereas NHWs were more likely to get inpatient rehabilitation. This disparity may, in part, explain the worse stroke outcome in MAs.

Stroke Quality Measures in Mexican Americans and Non-Hispanic Whites

Mexican Americans (MAs) have been shown to have worse outcomes after stroke than non-Hispanic Whites (NHWs), but it is unknown if ethnic differences in stroke quality of care may contribute to these worse outcomes. We investigated ethnic differences in the quality of inpatient stroke care between MAs and NHWs within the population-based prospective Brain Attack Surveillance in Corpus Christi (BASIC) Project (February 2009- June 2012). Quality measures for inpatient stroke care, based on the 2008 Joint Commission Primary Stroke Center definitions were assessed from the medical record by a trained abstractor. Two summary measure of overall quality were also created (binary measure of defect-free care and the proportion of measures achieved for which the patient was eligible). 757 individuals were included (480 MAs and 277 NHWs). MAs were younger, more likely to have hypertension and diabetes, and less likely to have atrial fibrillation than NHWs. MAs were less likely than NHWs to receive tPA (RR: 0.72, 95% confidence interval (CI) 0.52, 0.98), and MAs with atrial fibrillation were less likely to receive anticoagulant medications at discharge than NHWs (RR 0.73, 95% CI 0.58, 0.94). There were no ethnic differences in the other individual quality measures, or in the two summary measures assessing overall quality. In conclusion, there were no ethnic differences in the overall quality of stroke care between MAs and NHWs, though ethnic differences were seen in the proportion of patients who received tPA and anticoagulant at discharge for atrial fibrillation.

Emerging temporal trends in tissue plasminogen activator use: Results from the BASIC project

OBJECTIVE

To explore temporal trends in tissue plasminogen activator (tPA) administration for acute ischemic stroke (AIS) in a biethnic community without an academic medical center and variation in trends by age, sex, ethnicity, and stroke severity.

METHODS

Cases of AIS were identified from 7 hospitals in the Brain Attack Surveillance in Corpus Christi (BASIC) project, a population-based surveillance study between January 1, 2000, and June 30, 2012. tPA, demographics, and stroke severity as assessed by the NIH Stroke Scale (NIHSS) were ascertained from medical records. Temporal trends were explored using generalized estimating equations, and adjustment made for age, sex, ethnicity, and NIHSS. Interaction terms were included to test for effect modification.

RESULTS

There were 5,277 AIS cases identified from 4,589 unique individuals. tPA use was steady at 2% and began increasing in 2006, reaching 11% in subsequent years. Stroke severity modified temporal trends (p = 0.003) such that cases in the highest severity quartile (NIHSS > 8) had larger increases in tPA use than those in lower severity quartiles. Although ethnicity did not modify the temporal trend, Mexican Americans (MAs) were less likely to receive tPA than non-Hispanic whites (NHWs) due to emerging ethnic differences in later years.

CONCLUSIONS

Dramatic increases in tPA use were apparent in this community without an academic medical center. Primary stroke center certification likely contributed to this rise. Results suggest that increases in tPA use were greater in higher severity patients compared to lower severity patients, and a gap between MAs and NHWs in tPA administration may be emerging.

Living in Latvia after stroke: the association between functional, social and personal factors and the level of self-perceived disability-a cross-sectional study

OBJECTIVE

To investigate how functional, social and personal factors are associated with self-perceived level of disability in the chronic phase of stroke in a Latvian stroke population. The consequences of stroke can vary greatly and often leads to long-term disability that, according to the WHO definitions, depends on the interaction between the person and his/her context.

DESIGN

Cross-sectional study with retrospective data gathering.

SETTING

Community-dwelling persons who received specialised in-patient rehabilitation after stroke in Latvia.

PARTICIPANTS

Of 600 persons after stroke who were identified through hospital register and selected for the study, 255 were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The medical information and discharge data of the Functional Independence Measure (FIM) was extracted from medical records. Participants filled out a questionnaire on sociodemographic information and the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), either in Latvian or Russian, depending on their wish when contacted for their oral agreement to participate. Stepwise multiple regression analysis was conducted to find a model that best explains the variance in WHODAS 2.0 scores.

RESULTS

The models explained 23-43.5% of variance in outcomes. The best explained WHODAS 2.0 domains were 'mobility' and 'self-care'. The significant factors were level of independence in 'self-care', 'locomotion' and 'communication' according to FIM, as well as working status, time since rehabilitation, age, gender, living alone or in family and preferred language.

CONCLUSIONS

Functional, social and personal factors are of similar importance when explaining self-perceived disability in the chronic phase of stroke. Some, but not all, of the factors are modifiable by the healthcare system. Therefore, a complex approach and involvement of medical, social and political systems is needed.

Mexican Americans are Less Likely to Return to Work Following Stroke: Clinical and Policy Implications

BACKGROUND

Greater poststroke disability and U.S. employment policies may disadvantage minority stroke survivors from returning to work. We explored ethnic differences in return to work among Mexican Americans (MAs) and non-Hispanic whites (NHWs) working at the time of their stroke.

METHODS

Stroke patients were identified from the population-based BASIC (Brain Attack Surveillance in Corpus Christi) study from August 2011 to December 2013. Employment status was obtained at baseline and 90-day interviews. Sequential logistic regression models were built to assess ethnic differences in return to work after accounting for the following: (1) age (<65 versus ≥65); (2) sex; (3) 90-day National Institutes of Health Stroke Scale (NIHSS); and (4) education (lower than high school versus high school or higher).

RESULTS

Of the 729 MA and NHW stroke survivors who completed the baseline interview, 197 (27%) were working at the time of their stroke, of which 125 (63%) completed the 90-day outcome interview. Forty-nine (40%) stroke survivors returned to work by 90 days. MAs were less likely to return to work (OR = .45, 95% CI .22-.94) than NHWs. The ethnic difference became nonsignificant after adjusting for NIHSS (OR = .59, 95% CI .24-1.44) and further attenuated after adjusting for education (OR = .85, 95% CI .32- 2.22).

CONCLUSIONS

The majority of stroke survivors did not return to work within 90 days of their stroke. MA stroke survivors were less likely to return to work after stroke than NHW stroke survivors which was due to their greater neurological deficits and lower educational attainment compared with that of NHW stroke survivors. Future work should focus on clinical and policy efforts to reduce ethnic disparities in return to work.

High prevalence of poststroke sleep-disordered breathing in Mexican Americans

OBJECTIVE

The purpose of this study is to compare sleep-disordered breathing (SDB) prevalence and severity after stroke between Mexican Americans (MAs) and non-Hispanic whites (NHWs).

PATIENTS/METHODS

Ischemic stroke (IS) patients within ∼30 days of onset were identified from the population-based BASIC Project (2010-2014) and offered screening with an overnight cardiopulmonary monitoring device, ApneaLink Plus™. The number of apneas and hypopneas per hour, as reflected by the apnea/hypopnea index (AHI), was used to measure SDB severity; SDB was defined as AHI ≥10. Ethnicity, demographics, and risk factors were collected from interviews and medical records. Log and negative-binomial regression models were used to determine prevalence ratios (PRs) and apnea/hypopnea event rate ratios (RRs) comparing MAs with NHWs after adjustment for demographics, risk factors, and stroke severity.

RESULTS

A total of 549 IS cases had AHI data. The median age was 65 years (interquartile range (IQR): 57-76), 55% were men, and 65% were MA. The MAs had a higher prevalence of SDB (68.5%) than NHWs (49.5%) in unadjusted (PR = 1.38; 95% confidence interval (CI): 1.14-1.67) and adjusted analyses (PR = 1.21; 95% CI: 1.01-1.46). The median AHI was 16 (IQR: 7-31) in MAs and nine (IQR: 5-24) in NHWs. The severity of SDB (rate of apneas/hypopneas) was higher in MAs than NHWs in unadjusted (RR = 1.31; 95% CI: 1.09-1.58) but not adjusted analysis (RR = 1.14; 95% CI: 0.95-1.38). There was no ethnic difference in severity among subjects with SDB.

CONCLUSION

More than two-thirds of MA stroke patients had SDB, which was almost 40% more common among MAs than NHWs. Physicians treating MA patients after stroke should have a high index of suspicion for SDB, a treatable condition that could otherwise have adverse impact.

Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers

BACKGROUND

Primary stroke centers (PSCs) utilize more recombinant tissue plasminogen activator (rt-PA) than non-PSCs. The impact of PSCs on racial disparities in rt-PA use is unknown.

METHODS AND RESULTS

We used data from the Nationwide Inpatient Sample from 2004 to 2010, limited to states that publicly reported hospital identity and race. Hospitals certified as PSCs by The Joint Commission were identified. Adults with a diagnosis of ischemic stroke were analyzed. Rt-PA use was defined by the International Classification of Diseases, 9th Revision procedure code 99.10. Discharges (304 152 patients) from 26 states met eligibility criteria, and of these 71.5% were white, 15.0% black, 7.9% Hispanic, and 5.6% other. Overall, 24.7% of white, 27.4% of black, 16.2% of Hispanic, and 29.8% of other patients presented to PSCs. A higher proportion received rt-PA at PSCs than non-PSCs in all race/ethnic groups (white 7.6% versus 2.6%, black 4.8% versus 2.0%, Hispanic 7.1% versus 2.4%, other 7.2% versus 2.5%, all P<0.001). In a multivariable model adjusting for year, age, sex, insurance, medical comorbidities, a diagnosis-related group-based mortality risk indicator, ZIP code median income, and hospital characteristics, blacks were less likely to receive rt-PA than whites at non-PSCs (odds ratio=0.58, 95% CI 0.50 to 0.67) and PSCs (odds ratio=0.63, 95% CI 0.54 to 0.74) and Hispanics were less likely than whites to receive rt-PA at PSCs (odds ratio=0.77, 95% CI: 0.63 to 0.95). In the fully adjusted model, interaction between race and presentation to a PSC for likelihood of receiving rt-PA did not reach significance (P=0.98).

CONCLUSIONS

Racial disparities in intravenous rt-PA use were not reduced by presentation to PSCs. Black patients were less likely to receive thrombolytic treatment than white patients at both non-PSCs and PSCs. Hispanic patients were less likely to be seen at PSCs relative to white patients and were less likely to receive intravenous rt-PA in the fully adjusted model.

Ethnic Differences in Poststroke Quality of Life in the Brain Attack Surveillance in Corpus Christi (BASIC) Project

BACKGROUND AND PURPOSE

Mexican Americans (MAs) have an increased risk of stroke and experience worse poststroke disability than non-Hispanic whites, which may translate into worse poststroke quality of life (QOL). We assessed ethnic differences in poststroke QOL, as well as potential modification of associations by age, sex, and initial stroke severity.

METHODS

Ischemic stroke survivors were identified through the biethnic, population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from medical records, baseline interviews, and 90-day poststroke interviews. Poststroke QOL was measured at ≈90 days by the validated short-form stroke-specific QOL in 3 domains: overall, physical, and psychosocial (range, 0-5; higher scores represent better QOL). Tobit regression was used to model associations between ethnicity and poststroke QOL scores, adjusted for demographics, clinical characteristics, and prestroke cognition and function.

RESULTS

Among 290 eligible stroke survivors (66% MA, 34% non-Hispanic whites, median age=69 years), median scores for overall, physical, and psychosocial poststroke QOL were 3.3, 3.8, and 2.7, respectively. Poststroke QOL was lower for MAs than non-Hispanic whites both overall (mean difference, -0.30; 95% confidence interval, -0.59, -0.01) and in the physical domain (mean difference, -0.47; 95% confidence interval, -0.81, -0.14) after multivariable adjustment. No ethnic difference was found in the psychosocial domain. Age modified the associations between ethnicity and poststroke QOL such that differences were present in older but not in younger ages.

CONCLUSIONS

Disparities exist in poststroke QOL for MAs and seem to be driven by differences in older stroke patients. Targeted interventions to improve outcomes among MA stroke survivors are urgently needed.

Towards an Understanding of Racial Differences in Post-stroke Disability

Due to the aging of the baby boomer generation, the number of stroke survivors is expected to increase from 7 million to over 10 million in 2030. Stroke survivorship will be particularly important for African Americans who have a higher incidence of strokes compared to non-Hispanics whites and greater post stroke disability. Current evidence suggests that the most prominent racial differences in post-stroke disability emerge in the post-stroke period. Further work, with a focus on modifiable factors, is needed to understand which factors in the post-stroke period lead to racial differences in post-stroke disability.

Racial and Ethnic Differences in Mental Distress among Stroke Survivors

OBJECTIVE

African Americans, Hispanics and some Asian subgroups have a higher stroke incidence than non-Hispanic Whites (NHW). Additionally, African Americans and Hispanics have worse stroke outcomes than non-Hispanic Whites. Thus, we explored racial and ethnic differences in mental distress, a known risk factor for post-stroke disability.

METHODS

National Health Interview Survey data from 2000-2010 were used to identify 8,324 community dwelling adults with self-reported stroke. Serious mental distress was identified by the Kessler-6 scale. Logistic regression models assessed racial/ethnic associations with serious mental distress after adjusting for demographics, comorbidities, disability, health care utilization and socioeconomic factors.

RESULTS

Serious mental distress was identified in 9% of stroke survivors. Hispanics (14%) were more likely to have serious mental distress than African Americans (9%), non-Hispanic Whites (9%) and Asians (8%, P = .02). After adjustment, Hispanics (OR = 1.06, 95% CI .76-1.48) and Asians (.84, 95% Cl .37-1.90) had a similar odds of serious mental distress while African Americans had a lower odds of serious mental distress (OR = .61, 95% CI .48-.78) compared with non-Hispanic Whites. Younger age, low levels of education and insurance were important predictors of serious mental distress among Hispanics.

CONCLUSION

Serious mental distress is highly prevalent among US stroke survivors and is more common in Hispanics than NHWs, African Americans and Asians. Further study of the role of mental distress in ethnic differences in post-stroke disability is warranted.

Differences in initial stroke severity between Mexican Americans and non-Hispanic whites vary by age: the Brain Attack Surveillance in Corpus Christi (BASIC) project

BACKGROUND

A wide variety of racial and ethnic disparities in stroke epidemiology and treatment have been reported. Race-ethnic differences in initial stroke severity may be one important determinant of differences in the outcome after stroke. The overall goal of this study was to move beyond ethnic comparisons in the mean or median severity, and instead investigate ethnic differences in the entire distribution of initial stroke severity. Additionally, we investigated whether age modifies the relationship between ethnicity and initial stroke severity as this may be an important determinant of racial differences in the outcome after stroke.

METHODS

Ischemic stroke cases were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project. National Institutes of Health Stroke Scale (NIHSS) was determined from the medical record or abstracted from the chart. Ethnicity was reported as Mexican American (MA) or non-Hispanic white (NHW). Quantile regression was used to model the distribution of NIHSS score by age category (45-59, 60-74, 75+) to test whether ethnic differences exist over different quantiles of NIHSS (5 percentile increments). Crude models examined the interaction between age category and ethnicity; models were then adjusted for history of stroke/transient ischemic attack, hypertension, atrial fibrillation, coronary artery disease, and diabetes. RESULTS were adjusted for multiple comparisons.

RESULTS

There were 4,366 ischemic strokes, with median age 72 (IQR: 61-81), 55% MA, and median NIHSS of 4 (IQR: 2-8). MAs were younger, more likely to have a history of hypertension and diabetes, but less likely to have atrial fibrillation compared to NHWs. In the crude model, the ethnicity-age interaction was not statistically significant. After adjustment, the ethnicity-age interaction became significant at the 85th and 95th percentiles of NIHSS distribution. MAs in the younger age category (45-59) were significantly less severe by 3 and 6 points on the initial NIHSS than NHWs, at the 85th and 95th percentiles, respectively. However, in the older age category (75+), there was a reversal of this pattern; MAs had more severe strokes than NHWs by about 2 points, though not reaching statistical significance.

CONCLUSIONS

There was no overall ethnic difference in stroke severity by age in our crude model. However, several potentially important ethnic differences among individuals with the most severe strokes were seen in younger and older stroke patients that were not explained by traditional risk factors. Age should be considered in future studies when looking at the complex distributional relationship between ethnicity and stroke severity.

Post-stroke cognitive impairment: epidemiology, mechanisms and management

Post-stroke cognitive impairment occurs frequently in the patients with stroke. The prevalence of post-stroke cognitive impairment ranges from 20% to 80%, which varies for the difference between the countries, the races, and the diagnostic criteria. The risk of post-stroke cognitive impairment is related to both the demographic factors like age, education and occupation and vascular factors. The underlying mechanisms of post-stroke cognitive impairment are not known in detail. However, the neuroanatomical lesions caused by the stroke on strategic areas such as the hippocampus and the white matter lesions (WMLs), the cerebral microbleeds (CMBs) due to the small cerebrovascular diseases and the mixed AD with stroke, alone or in combination, contribute to the pathogenesis of post-stroke cognitive impairment. The treatment of post-stroke cognitive impairment may benefit not only from the anti-dementia drugs, but also the manage measures on cerebrovascular diseases. In this review, we will describe the epidemiological features and the mechanisms of post-stroke cognitive impairment, and discuss the promising management strategies for these patients.

Loss of the Mexican American survival advantage after ischemic stroke

BACKGROUND AND PURPOSE

Mexican Americans (MAs) were previously found to have lower mortality after ischemic stroke than non-Hispanic whites. We studied mortality trends in a population-based design.

METHODS

Active and passive surveillance were used to find all ischemic stroke cases from January 2000 to December 2011 in Nueces County, TX. Deaths were ascertained from the Texas Department of Health through December 31, 2012. Cumulative 30-day and 1-year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2011 and to calculate projected ethnic differences.

RESULTS

There were 1974 ischemic strokes among non-Hispanic whites and 2439 among MAs. Between 2000 and 2011, model estimated mortality declined among non-Hispanic whites at 30 days (7.6% to 5.6%; P=0.24) and 1 year (20.8% to 15.5%; P=0.02). Among MAs, 30-day model estimated mortality remained stagnant at 5.1% to 5.2% (P=0.92), and a slight decline from 17.4% to 15.3% was observed for 1-year mortality (P=0.26). Although ethnic differences in 30-day (P=0.01) and 1-year (P=0.06) mortality were apparent in 2000, they were not so in 2011 (30-day mortality, P=0.63; 1-year mortality, P=0.92).

CONCLUSIONS

Overall, mortality after ischemic stroke has declined in the past decade, although significant declines were only observed for non-Hispanic whites and not MAs at 1 year. The survival advantage previously documented among MAs vanished by 2011. Renewed stroke prevention and treatment efforts for MAs are needed.

Impact of state Medicaid coverage on utilization of inpatient rehabilitation facilities among patients with stroke

BACKGROUND AND PURPOSE

Poststroke rehabilitation is associated with improved outcomes. Medicaid coverage of inpatient rehabilitation facility (IRF) admissions varies by state. We explored the role of state Medicaid IRF coverage on IRF utilization among patients with stroke.

METHODS

Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample. Medicaid coverage of IRFs (yes versus no) was ascertained. Primary outcome was discharge to IRF (versus other discharge destinations). We fit a logistic regression model that included patient demographics, Medicaid coverage, comorbidities, length of stay, tissue-type plasminogen activator use, state Medicaid IRF coverage, and the interaction between patient Medicaid status and state Medicaid IRF coverage while accounting for hospital clustering.

RESULTS

Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) of 42 states. The impact of State Medicaid IRF coverage was limited to Medicaid stroke patients (P for interaction <0.01). Compared with Medicaid stroke patients in states with Medicaid IRF coverage, Medicaid stroke patients hospitalized in states without Medicaid IRF coverage were less likely to be discharged to an IRF of 11.6% (95% confidence interval, 8.5%-14.7%) versus 19.5% (95% confidence interval, 18.3%-20.8%), P<0.01 after full adjustment.

CONCLUSIONS

State Medicaid coverage of IRFs is associated with IRF utilization among stroke patients with Medicaid. Given the increasing stroke incidence among the working age and Medicaid expansion under the Affordable Care Act, careful attention to state Medicaid policy for poststroke rehabilitation and analysis of its effects on stroke outcome disparities are warranted.