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Chung D, Lee JS, Oh MS, Park JM, Chung JW, Bang OY, Kim GM, Seo WK. Temporal trends of sex differences in acute reperfusion therapy and early outcomes of acute ischemic stroke in South Korea: 10-year analysis of the nationwide stroke registry. Int J Stroke 2024; 19:1028-1037. [PMID: 38836445 DOI: 10.1177/17474930241261877] [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] [Indexed: 06/06/2024]
Abstract
BACKGROUND Sex differences in stroke outcomes are notable, with women experiencing higher incidence rates, greater disability-adjusted life years, and poorer recovery compared to men, even after adjusting for age and comorbidities. Despite the disproportionate burden in women, studies have reported that women are less likely to receive appropriate stroke treatment than men. AIM This study investigated temporal trends of sex differences in acute reperfusion therapy and early outcomes in patients with acute ischemic stroke over 10 years in South Korea. METHODS A retrospective analysis of Korean Stroke Registry included patients with acute ischemic stroke from 2012 to 2021. The study outcomes were the temporal trends of acute reperfusion therapy and early outcomes over 10 years in men and women, respectively. In addition, this study analyzed the temporal trends of sex differences in these parameters during the same period. Early outcomes include the proportions of favorable functional outcomes at discharge, discharge patterns, and in-hospital mortality. RESULTS A total of 93,692 patients (68.4 years, 40.1% women) with acute ischemic stroke were finally enrolled. Women had a higher age at stroke onset, a higher prevalence of atrial fibrillation, and more severe strokes than men. Women had lower proportion of favorable functional outcomes at discharge and higher proportion of in-hospital mortality compared to men each year. The proportion of patients who received intravenous thrombolysis was lower or similar in women compared to men in most years, and the proportion of patients who received endovascular thrombectomy did not significantly differ between sexes annually. Sex differences in acute reperfusion therapy remained unchanged over 10 years. CONCLUSION Women have received acute reperfusion therapy at similar or lower rates than men and experienced poorer outcomes, despite having more stroke risk factors and often more severe strokes.
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Affiliation(s)
- Darda Chung
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Ji Sung Lee
- Department of Clinical Research Center, Asan Medical Center, College of Medicine, University of Ulsan, Ulsan, Republic of Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon-si, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, School of Medicine, Eulji University, Daejeon, Republic of Korea
| | - Jong-Won Chung
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Oh Young Bang
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Gyeong-Moon Kim
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
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Ali M, van der Meij A, van Os HJA, Ali M, Van Zwet EW, Spaander FHM, Hofmeijer J, Nederkoorn PJ, van den Wijngaard IR, Majoie CBLM, van Es ACGM, Schonewille WJ, van Walderveen MAA, Dippel DWJ, Visser MC, Kruyt ND, Wermer MJH. Sex differences in onset to hospital arrival time, prestroke disability, and clinical symptoms in patients with a large vessel occlusion: a MR CLEAN Registry substudy. J Neurointerv Surg 2023; 15:e255-e261. [PMID: 36379704 DOI: 10.1136/jnis-2022-019670] [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: 09/21/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women have been reported to have worse outcomes after endovascular treatment (EVT), despite a similar treatment effect in non-clinical trial populations. We aimed to assess sex differences at hospital presentation with respect to workflow metrics, prestroke disability, and presenting clinical symptoms. METHODS We included consecutive patients from the Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in The Netherlands (MR CLEAN) Registry (2014-2018) who received EVT for anterior circulation large vessel occlusion (LVO). We assessed sex differences in workflow metrics, prestroke disability (modified Rankin Scale (mRS) score ≥1), and stroke severity and symptoms according to the National Institutes of Health Stroke Scale (NIHSS) score on hospital admission with logistic and linear regression analyses and calculated the adjusted OR (aOR). RESULTS We included 4872 patients (47.6% women). Compared with men, women were older (median age 76 vs 70 years) and less often achieved good functional outcome at 90 days (mRS ≤2: 35.2% vs 46.4%, aOR 0.70, 95% CI 0.60 to 0.82). Mean onset-to-door time was longer in women (2 hours 16 min vs 2 hours 7 min, adjusted delay 9 min, 95% CI 4 to 13). This delay contributed to longer onset-to-groin times (3 hours 26 min in women vs 3 hours 13 min in men, adjusted delay 13 min, 95% CI 9 to 17). Women more often had prestroke disability (mRS ≥1: 41.1% vs 29.1%, aOR 1.57, 95% CI 1.36 to 1.82). NIHSS on admission was essentially similar in men and women (mean 15±6 vs 15±6, NIHSS <10 vs ≥10, aOR 0.91, 95% CI 0.78 to 1.06). There were no clear sex differences in the occurrence of specific stroke symptoms. CONCLUSION Women with LVO had longer onset-to-door times and more often prestroke disability than men. Raising awareness of these differences at hospital presentation and investigating underlying causes may help to improve outcome after EVT in women.
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Affiliation(s)
- Mariam Ali
- Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Anne van der Meij
- Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Mahsoem Ali
- Surgery, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Erik W Van Zwet
- Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jeanette Hofmeijer
- Neurology, Rijnstate Hospital, Arnhem, The Netherlands
- University of Twente Faculty of Science and Technology, Enschede, The Netherlands
| | | | - Ido R van den Wijngaard
- Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Neurology, HMC Westeinde, The Hague, The Netherlands
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Adriaan C G M van Es
- Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | - Marieke C Visser
- Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Nyika D Kruyt
- Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Silva Y, Sánchez-Cirera L, Terceño M, Dorado L, Valls A, Martínez M, Abilleira S, Rubiera M, Quesada H, Llull L, Rodríguez-Campello A, Martí-Fàbregas J, Seró L, Purroy F, Payo I, García S, Cánovas D, Krupinski J, Mas N, Palomeras E, Cocho D, Font MÀ, Catena E, Puiggròs E, Pedroza C, Marín G, Carrión D, Costa X, Almendros MC, Torres I, Colom C, Velasquez JA, Diaz G, Jiménez X, Subirats T, Deulofeu A, Hidalgo V, Salvat-Plana M, Pérez de la Ossa N. Sex and gender differences in acute stroke care: metrics, access to treatment and outcome. A territorial analysis of the Stroke Code System of Catalonia. Eur Stroke J 2023; 8:557-565. [PMID: 37231687 PMCID: PMC10334164 DOI: 10.1177/23969873231156260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/23/2023] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Previous studies have reported differences in the management and outcome of women stroke patients in comparison with men. We aim to analyze sex and gender differences in the medical assistance, access to treatment and outcome of acute stroke patients in Catalonia. PATIENTS AND METHODS Data were obtained from a prospective population-based registry of stroke code activations in Catalonia (CICAT) from January/2016 to December/2019. The registry includes demographic data, stroke severity, stroke subtype, reperfusion therapy, and time workflow. Centralized clinical outcome at 90 days was assessed in patients receiving reperfusion therapy. RESULTS A total of 23,371 stroke code activations were registered (54% men, 46% women). No differences in prehospital time metrics were observed. Women more frequently had a final diagnosis of stroke mimic, were older and had a previous worse functional situation. Among ischemic stroke patients, women had higher stroke severity and more frequently presented proximal large vessel occlusion. Women received more frequently reperfusion therapy (48.2% vs 43.1%, p < 0.001). Women tended to present a worse outcome at 90 days, especially for the group receiving only IVT (good outcome 56.7% vs 63.8%; p < 0.001), but not for the group of patients treated with IVT + MT or MT alone, although sex was not independently associated with clinical outcome in logistic regression analysis (OR 1.07; 95% CI, 0.94-1.23; p = 0.27) nor in the analysis after matching using the propensity score (OR 1.09; 95% CI, 0.97-1.22). DISCUSSION AND CONCLUSION We found some differences by sex in that acute stroke was more frequent in older women and the stroke severity was higher. We found no differences in medical assistance times, access to reperfusion treatment and early complications. Worse clinical outcome at 90 days in women was conditioned by stroke severity and older age, but not by sex itself.
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Affiliation(s)
| | | | | | - Laura Dorado
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Adrián Valls
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marina Martínez
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Marta Rubiera
- Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Helena Quesada
- Hospital Universitari de Bellvitge, L’Hospitalet de llobregat, Spain
| | - Laura Llull
- Hospital Clínic of Barcelona, Barcelona, Spain
| | | | | | - Laia Seró
- Hospital Universitari Joan XXIII, Tarragona, Spain
| | | | - Iago Payo
- Hospital Verge de la Cinta, Tortosa, Spain
| | - Sònia García
- Complex Hospitalari Moisès Broggi, Sant Joan Despí, Spain
| | | | | | | | | | | | | | - Esther Catena
- Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedès, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mercè Salvat-Plana
- Pla Director de les Malalties Vasculars Cerebrals. Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS) CIBER en Epidemiolgia i Salut Pública (CBERESP), Departament de Salut, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Pla Director de les Malalties Vasculars Cerebrals. Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS) CIBER en Epidemiolgia i Salut Pública (CBERESP), Departament de Salut, Barcelona, Spain
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Ouyang M, Shajahan S, Liu X, Sun L, Carcel C, Harris K, Anderson CS, Woodward M, Wang X. Sex differences in the utilization and outcomes of endovascular treatment after acute ischemic stroke: A systematic review and meta-analysis. Front Glob Womens Health 2023; 3:1032592. [PMID: 36741299 PMCID: PMC9889638 DOI: 10.3389/fgwh.2022.1032592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/22/2022] [Indexed: 01/20/2023] Open
Abstract
Background Studies of sex differences in the use and outcomes of endovascular treatment (EVT) for acute ischemic stroke report inconsistent results. Methods We systematically searched PubMed and Embase databases for studies examining sex-specific utilization of EVT for acute ischemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT use. To estimate sex differences in functional outcome on the modified Rankin scale after EVT, the female:male ratio of ORs and 95% confidence intervals (CIs) were obtained from ordinal or binary analysis. Results 6,396 studies were identified through database searching, of which 594 qualified for a full review. A total of 51 studies (36 non-RCT and 15 RCTs) reporting on sex-specific utilization of EVT were included, and of those 10 estimated the sex differences of EVT on functional outcomes. EVT use was similar in women and men both in non-RCTs (OR: 1.03, 95% CI: 0.96-1.11) and RCTs (1.02, 95% CI: 0.89-1.16), with consistent results across years of publication and regions of study, except that in Europe EVT treatment was higher in women than men (1.15, 95% CI: 1.13-1.16). No sex differences were found in the functional outcome by either ordinal and binary analyses (ORs 0.95, 95% CI: 0.68-1.32] and 0.90, 95% CI: 0.65-1.25, respectively). Conclusions No sex differences in EVT utilization or on functional outcomes were evident after acute ischemic stroke from large-vessel occlusion. Further research may be required to examine sex differences in long-term outcomes, social domains, and quality of life. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=226100, identifier: CRD42021226100.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Sultana Shajahan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Liu
- Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Lingli Sun
- Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Katie Harris
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Correspondence: Xia Wang
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Agarwal MA, Dhaliwal JS, Yang EH, Aksoy O, Press M, Watson K, Ziaeian B, Fonarow GC, Moriarty JM, Saggar R, Channick R. Sex Differences in Outcomes of Percutaneous Pulmonary Artery Thrombectomy in Patients With Pulmonary Embolism. Chest 2023; 163:216-225. [PMID: 35926721 DOI: 10.1016/j.chest.2022.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/27/2022] [Accepted: 07/18/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The sex differences in use, safety outcomes, and health-care resource use of patients with pulmonary embolism (PE) undergoing percutaneous pulmonary artery thrombectomy are not well characterized. RESEARCH QUESTION What are the sex differences in outcomes for patients diagnosed with PE who undergo percutaneous pulmonary artery thrombectomy? STUDY DESIGN AND METHODS This retrospective cross-sectional study used national inpatient claims data to identify patients in the United States with a discharge diagnosis of PE who underwent percutaneous thrombectomy between January 2016 and December 2018. We evaluated the demographics, comorbidities, safety outcomes (in-hospital mortality), and health-care resource use (discharge to home, length of stay, and hospital charges) of patients with PE undergoing percutaneous thrombectomy. RESULTS Among 1,128,904 patients with a diagnosis of PE between 2016 and 2018, 5,160 patients (0.5%) underwent percutaneous pulmonary artery thrombectomy. When compared with male patients, female patients showed higher procedural bleeding (16.9% vs 11.2%; P < .05), required more blood transfusions (11.9% vs 5.7%; P < .05), and experienced more vascular complications (5.0% vs 1.5%; P < .05). Women experienced higher in-hospital mortality (16.9% vs 9.3%; adjusted OR, 1.9; 95% CI, 1.2-3.0; P = .003) when compared with men. Although length of stay and hospital charges were similar to those of men, women were less likely to be discharged home after surviving hospitalization (47.9% vs 60.3%; adjusted OR, 0.7; 95% CI, 0.50-0.99; P = .04). INTERPRETATION In this large nationwide cohort, women with PE who underwent percutaneous thrombectomy showed higher morbidity and in-hospital mortality compared with men.
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Affiliation(s)
- Manyoo A Agarwal
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Jasmeet S Dhaliwal
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Eric H Yang
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Olcay Aksoy
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Marcella Press
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Karol Watson
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Boback Ziaeian
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Gregg C Fonarow
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - John M Moriarty
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Sex Differences in Ischemic Cerebral Infarction: A Nationwide German Real-Life Analysis from 2014 to 2019. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2022. [DOI: 10.3390/ctn6030023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Female sex has been shown to be associated with an unfavorable outcome after ischemic stroke. In this nationwide analysis, we evaluate a large dataset of patients suffering from acute ischemic stroke to elucidate the factors associated with an increased risk of mortality after stroke in women. We analyzed a nationwide dataset from the German Federal Bureau of Statistics including 1,577,884 (761,537 female sex, 48.3%) in-hospital cases admitted between 1 January 2014 and 31 December 2019 with a primary diagnosis of acute ischemic cerebral infarction. Patients were analyzed regarding morbidity, treatments and in-hospital mortality. A multiple logistic regression analysis was performed, adjusted by patients’ risk profile including age, to evaluate the association of sex and in-hospital mortality. According to the median, women were older than men (79 years vs. 73 years). The multiple logistic regression analysis however revealed female sex remained an independent factor for an increased in-hospital mortality (odds ratio [OR] 1.12; 95% confidence interval [CI] 1.11–1.14; p < 0.001). Women had a higher prevalence of relevant risk factors, namely arterial hypertension (77.0% vs. 74.7%), arterial fibrillation (33.3% vs. 25.6%), chronic heart failure (12.3% vs. 9.7%), chronic kidney disease (15.6% vs. 12.9%) and dementia (6.6% vs. 4.1%), but were less affected with respect to other relevant co-morbidities such as cerebrovascular disease (11.7% vs. 15.1%), coronary heart disease (11.7% vs. 18.8%), diabetes mellitus (26.4% vs. 29.6%), dyslipidemia (38.1% vs. 42.0%), ischemic heart disease (12.3% vs. 19.3%) and previous coronary artery bypass grafting (1.1% vs. 3.2%). Overall, therapeutic interventions were performed less frequently in women such as carotid endarterectomy (1.1% vs. 2.3%), carotid stent (0.7% vs. 1.4%), as well as hematoma drainage (0.1% vs. 0.2%), and renal replacement therapy (0.4% vs. 0.6%). Conclusions: Our nationwide analysis revealed a higher mortality rate after stroke in women. Nevertheless, women had fewer in-hospital complications and were also less likely to experience the severe effects of some important co-morbidities. The dataset, however, showed that women received surgical or interventional carotid treatments after stroke less often. It is important for research on sex disparities in stroke to keep these treatment frequency differences in mind.
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Demel SL, Reeves M, Xu H, Xian Y, Mac Grory B, Fonarow GC, Matsouaka R, Smith EE, Saver J, Schwamm L. Sex Differences in Endovascular Therapy for Ischemic Stroke: Results From the Get With The Guidelines-Stroke Registry. Stroke 2022; 53:3099-3106. [PMID: 35880521 DOI: 10.1161/strokeaha.122.038491] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2015, endovascular therapy (EVT) for large vessel occlusions became standard of care for acute ischemic stroke. Lower utilization of IV alteplase has been reported in women, but whether sex differences in EVT use in the United States exists has not been established. METHODS We identified all acute ischemic stroke discharges from Get With The Guidelines-Stroke hospitals between 2012 and 2019 who were potentially eligible for EVT, based on National Institutes of Health Stroke Scale score ≥6 and arrival <6 hours, according to 2018 American Heart Association/ASA guidelines. Multivariable regression analyses were used to determine the association between sex and EVT utilization, and outcomes (including mortality, discharge home, functional status) after EVT. Separate analyses were conducted for the 2 time periods: 2012 to 2014, and 2015 to 2019. RESULTS Of 302 965 patients potentially eligible for EVT, 42 422 (14%) received EVT. Before 2015, EVT treatment rates were 5.3% in women and 6.6% in men. From 2015 to 2019, treatment rates increased in both sexes to 16.7% in women and 18.5% in men. The adjusted odds ratio for EVT in women compared with men was 0.93 (95% CI, 0.87-0.99) before 2015, and 0.98 (95% CI, 0.96-1.01) after 2015. There were no significant sex differences in outcomes except that after 2015, women were less able to ambulate at discharge (adjusted odds ratio, 0.95 [95% CI, 0.95-0.99]) and had lower in-hospital mortality (adjusted odds ratio, 0.93 [95% CI, 0.88-0.99]). CONCLUSIONS EVT utilization has increased dramatically in both women and men since EVT approval in 2015. Following statistical adjustment, women were less likely to receive EVT initially, but after 2015, women were as likely as men to receive EVT. After EVT, women were more likely to be disabled at discharge but less likely to experience in-hospital death compared with men.
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Affiliation(s)
- Stacie L Demel
- Department of Neurology, University of Cincinnati, OH (S.L.D.)
| | - Mathew Reeves
- Dsepartment of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (H.X.)
| | - Ying Xian
- UT Southwestern Medical Center, Department of Neurology, Dallas, TX (Y.X.)
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC. (B.M.G.)
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Roland Matsouaka
- Department of Medicine, Duke University School of Medicine, Durham, NC. (R.M.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Jeff Saver
- Department of Neurology, David Geffen School of Medicine, UCLA, Los Angeles, CA (J.S.)
| | - Lee Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.S.)
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Kumar A, McCullough L. Cerebrovascular disease in women. Ther Adv Neurol Disord 2021; 14:1756286420985237. [PMID: 33552237 PMCID: PMC7844450 DOI: 10.1177/1756286420985237] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/16/2020] [Indexed: 12/20/2022] Open
Abstract
Cerebrovascular disease is a major cause of morbidity, mortality, and disability in women. The spectrum of disease differs between men and women, with women being particularly vulnerable to certain conditions, especially during specific periods of life such as pregnancy. There are several unique risk factors for cerebrovascular disease in women, and the influence of some traditional risk factors for stroke is stronger in women. Moreover, disparities persist in representation of women in clinical trials, acute intervention, and stroke outcomes. In this review, we aimed to explore the epidemiology, etiologies, and management of cerebrovascular disease in women, highlighting some of these differences and the growing need for sex-specific management guidelines and health policies.
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Affiliation(s)
- Aditya Kumar
- Department of Neurology, 6431 Fannin Street, Houston, TX 77030, USA
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Ciardi C, Cirio JJ, Scrivano EV, Bleise CD, Lylyk I, Lylyk P. Sex-Related Differences after Endovascular Treatment of Acute Ischemic Stroke in the 'Real World'. J Stroke Cerebrovasc Dis 2020; 29:105240. [PMID: 33066881 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Gender differences are often reported in the field of ischemic stroke, although most of such discrepancies were observed in randomized trials involving highly selected populations. We therefore explored gender differences regarding 90-day outcomes in large vessel occlusion (LVO) strokes receiving endovascular treatment in a real world setting. METHODS This prospective registry included anterior and/or posterior circulation LVO strokes admitted between January 2014 and December 2019 who received mechanical thrombectomy up to 24 hours from symptoms onset or last known to be well. We explored sex-related differences in rates of functional independence (modified Rankin Scale, mRS, ≤2) at 90 days. Secondary outcomes included "National Institutes of Health Stroke Scale" (NIHSS) at 24 hours, successful reperfusion defined as modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, death, and symptomatic intracranial hemorrhage (sICH). RESULTS A total of 288 LVO stroke patients comprised the study population, involving 148 (51.4%) women. Females were older (71.4±15.7 vs. 66.1±14.0 years, p=0.003) and had lower rates of coronary artery disease (15% vs. 24%, p=0.05). The median time from symptoms onset to hospital arrival was 315 min (IQR 139.5-495.0) in females and 255.0 (IQR 117.0-405.0) in males (p=0.052). Rates of mRS ≤2 at 90 days were comparable (females 46% vs. males 49%, p=0.50). Successful reperfusion was achieved in 82% of females and 89% of males (p=0.10). Rates of sICH (females 10% vs. males 13%, p=0.47) and death (females 18% vs. males 21%, p=0.50) at 90 days were similar. NIHSS at 24 hours was the strongest predictor of functional independence at 90 days (area under ROC curve 0.92 (95%CI 0.87; 0.95)]. CONCLUSIONS Our prospective registry involving a real world setting suggests that females are equally likely to achieve good outcomes after endovascular treatment despite being older and having delayed hospital arrival compared to males. In addition, we found that NIHSS at 24 hours was the strongest predictor of functional independence at 90 days, sICH, and death.
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Affiliation(s)
- Celina Ciardi
- Department of Vascular Neurology, Stroke Unit. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina.
| | - Juan J Cirio
- Department of Vascular Neurology, Stroke Unit. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Esteban V Scrivano
- Department of Interventional Neuroradiology. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Carlos D Bleise
- Department of Interventional Neuroradiology. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Ivan Lylyk
- Department of Interventional Neuroradiology. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Neuroradiology. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
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10
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Jiang M, Ma C, Li H, Shen H, Li X, Sun Q, Chen G. Sex Dimorphisms in Ischemic Stroke: From Experimental Studies to Clinic. Front Neurol 2020; 11:504. [PMID: 32636794 PMCID: PMC7318992 DOI: 10.3389/fneur.2020.00504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/07/2020] [Indexed: 11/17/2022] Open
Abstract
Sex dimorphisms are important factors that influence the outcomes after ischemic stroke, which include basic health status, cerebrovascular anatomy, hormone levels, and unique factors such as pregnancy and menopause. It is widely recognized that male and female respond differently to stroke. Women aged 45–74 years old showed a lower risk of stroke incidence compared to age-matched man. This kind of protection is lost with aging. Hence, there is increasing requirement to get a more comprehensive understanding of sex-based factors to stroke on stroke incidence, symptoms, and treatments. This review focuses on sex-specific mechanisms in response to stroke based on experimental studies and highlights recent findings in clinical studies including sex-differential evaluation and outcomes of stroke. Sex-based personalized medicine should be promising in stroke therapies.
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Affiliation(s)
- Ming Jiang
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Cheng Ma
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haiying Li
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haitao Shen
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiang Li
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qing Sun
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Gang Chen
- Brain and Nerve Research Laboratory, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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11
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Strong B, Lisabeth LD, Reeves M. Sex differences in IV thrombolysis treatment for acute ischemic stroke. Neurology 2020; 95:e11-e22. [DOI: 10.1212/wnl.0000000000009733] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 12/05/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveA prior meta-analysis of reports published between 2000 and 2008 found that women were 30% less likely to receive IV recombinant tissue plasminogen activator (rtPA) treatment for stroke than men; we updated this meta-analysis to determine if this sex difference persisted.MethodsWe identified studies that reported sex-specific IV rtPA treatment rates for acute ischemic stroke published between 2008 and 2018. Eligible studies included representative populations of patients with ischemic stroke from hospital-based, registry-based, or administrative data. Random effects odds ratios (ORs) were generated to quantify sex differences.ResultsTwenty-four eligible studies were identified during this 10-year period. The summary unadjusted OR based on 17 studies with data on all ischemic stroke patients was 0.87 (95% confidence interval [CI], 0.82–0.93), indicating that women had 13% lower odds of receiving IV rtPA treatment than men. However, substantial between-study variability existed. Lower treatment odds in women were also observed in 7 studies that provided data on the subgroup of patients eligible for IV rtPA treatment, although the summary OR of 0.95 (95% CI, 0.88–1.02) was not statistically significant. Examination of time trends across 33 studies published between 2000 and 2018 found evidence that the sex difference had narrowed in more recent years.ConclusionsAlthough there is considerable variability in the findings of individual studies, pooled data from recent studies show that women with acute stroke are less likely to be treated with IV thrombolysis compared with men. However, the size of this difference has narrowed compared to studies published before 2008.
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12
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Sharma S, Briley PM, Wright HH, Perry JL, Fang X, Ellis C. Gender differences in aphasia outcomes: evidence from the AphasiaBank. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2019; 54:806-813. [PMID: 31257676 DOI: 10.1111/1460-6984.12486] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Stroke is one of the leading causes of death in the United States. Aphasia is a language impairment which results as a consequence of stroke. Gender differences are reported in underlying mechanisms of stroke, however, gender differences in aphasia type and severity remain unclear. AIMS To examine gender differences in aphasia impairment based on data from AphasiaBank, a research repository of data obtained from studies of aphasia. METHODS & PROCEDURES The data were collected from AphasiaBank for 294 persons with aphasia (PWA) (172 men, 122 women). Baseline comparisons by gender groups were completed using independent samples t-tests and Pearson Chi square statistics. Univariate comparisons of the total Western Aphasia Battery-Revised (WAB-R) -AQ and -R subtests' scores were compared between the two groups using independent samples t-tests. Multivariate comparisons were completed by using multivariate analysis of variance (MANOVA). OUTCOMES & RESULTS Gender differences were observed in the severity of aphasia with men exhibiting more severe aphasia than women. Analyses of WAB-R indicated greater impairment among men based on AQ and greater impairment was observed in individual subtest performance. Men exhibited statistically significantly lower WAB-R AQs than women (67.4 versus 75.6). Lower WAB-R AQs were derived from lower scores among men on individual subtests; information content, fluency, repetition, sentence completion, responsive speech and tests of comprehension (yes/no, auditory word recognition and sequential commands). CONCLUSIONS & IMPLICATIONS This study offers evidence of gender differences in aphasia severity, global communication impairment and lower scores on individual subtests used to derive the WAB-R AQ. The limitations of the study with suggestions for future directions are presented.
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Affiliation(s)
- Saryu Sharma
- Aging and Adult Language Disorders Laboratory, Department of Communication Sciences & Disorders, College of Allied Health Sciences, East Carolina University, Greenville, NC, USA
| | - Patrick M Briley
- Communication Equity and Outcomes Laboratory, Department of Communication Sciences & Disorders, College of Allied Health Sciences, East Carolina University, Greenville, NC, USA
| | - Heather Harris Wright
- Aging and Adult Language Disorders Laboratory, Department of Communication Sciences & Disorders, College of Allied Health Sciences, East Carolina University, Greenville, NC, USA
| | - Jamie L Perry
- Speech Imaging and Visualization Laboratory, Department of Communication Sciences & Disorders, College of Allied Health Sciences, East Carolina University, Greenville, NC, USA
| | - Xiangming Fang
- Department of Biostatistics, East Carolina University, Greenville, NC, USA
| | - Charles Ellis
- Communication Equity and Outcomes Laboratory, Department of Communication Sciences & Disorders, College of Allied Health Sciences, East Carolina University, Greenville, NC, USA
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13
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Chalos V, de Ridder IR, Lingsma HF, Brown S, van Oostenbrugge RJ, Goyal M, Campbell BCV, Muir KW, Guillemin F, Bracard S, White P, Dávalos A, Jovin TG, Hill MD, Mitchell PJ, Demchuk AM, Saver JL, van Zwam WH, Dippel DWJ. Does Sex Modify the Effect of Endovascular Treatment for Ischemic Stroke? Stroke 2019; 50:2413-2419. [PMID: 31412753 PMCID: PMC6727933 DOI: 10.1161/strokeaha.118.023743] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supplemental Digital Content is available in the text. Previous studies have reported less favorable outcome and less effect of endovascular treatment (EVT) after ischemic stroke in women than in men. Our aim was to study the influence of sex on outcome and on the effect of EVT for ischemic stroke in recent randomized trials on EVT.
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Affiliation(s)
- Vicky Chalos
- From the Department of Neurology, Erasmus MC University Medical Center the Netherlands (V.C., D.W.J.D.).,Department of Public Health, Erasmus MC University Medical Center the Netherlands (V.C., H.F.L.).,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center the Netherlands (V.C.)
| | - Inger R de Ridder
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (I.R.d.R., R.J.v.O.)
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center the Netherlands (V.C., H.F.L.)
| | - Scott Brown
- Altair Biostatistics, St. Louis Park, MN (S.B.).,Department of Diagnostic and Interventional Neuroradiology (S.B.)
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (I.R.d.R., R.J.v.O.)
| | - Mayank Goyal
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Canada (M.G., M.D.H., A.M.D.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Australia (B.C.V.C.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Francis Guillemin
- Department of Clinical Epidemiology, Inserm, University of Lorraine and University Hospital of Nancy, France (F.G.)
| | - Serge Bracard
- Altair Biostatistics, St. Louis Park, MN (S.B.).,Department of Diagnostic and Interventional Neuroradiology (S.B.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias y Pujol, Barcelona, Spain (A.D.)
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center Stroke Institute, Presbyterian University Hospital, PA (T.G.J.)
| | - Michael D Hill
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Canada (M.G., M.D.H., A.M.D.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia (P.J.M.)
| | - Andrew M Demchuk
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Canada (M.G., M.D.H., A.M.D.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of Los Angeles, CA (J.L.S.)
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (W.H.v.Z.)
| | - Diederik W J Dippel
- From the Department of Neurology, Erasmus MC University Medical Center the Netherlands (V.C., D.W.J.D.)
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14
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Bongiorno DM, Daumit GL, Gottesman RF, Faigle R. Patients with stroke and psychiatric comorbidities have lower carotid revascularization rates. Neurology 2019; 92:e2514-e2521. [PMID: 31053663 DOI: 10.1212/wnl.0000000000007565] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/25/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE We investigated whether mental illness is associated with lower rates of carotid endarterectomy (CEA)/carotid artery stenting (CAS) after stroke due to carotid stenosis. METHODS In this retrospective cross-sectional study, ischemic stroke cases due to carotid stenosis were identified in the 2007-2014 Nationwide (National) Inpatient Sample. Psychiatric conditions were identified by secondary ICD-9-CM diagnosis codes for schizophrenia/psychoses, bipolar disorder, depression, anxiety, or substance use disorders. Using logistic regression, we tested the association between psychiatric conditions and CEA/CAS, controlling for demographic, clinical, and hospital factors. RESULTS Among 37,474 included stroke cases, 6,922 (18.5%) had a psychiatric comorbidity. The presence of any psychiatric condition was associated with lower odds of CEA/CAS (adjusted odds ratio [OR] 0.84, 95% confidence interval [CI] 0.78-0.90). Schizophrenia/psychoses (OR 0.72, 95% CI 0.55-0.93), depression (OR 0.83, 95% CI 0.75-0.91), and substance use disorders (OR 0.73, 95% CI 0.65-0.83) were each associated with lower odds of CEA/CAS. The association of mental illness and CEA/CAS was dose-dependent: compared to patients without mental illness, patients with multiple psychiatric comorbidities (OR 0.74, 95% CI 0.62-0.87) had lower odds of CEA/CAS than those with only one psychiatric comorbidity (OR 0.86, 95% CI 0.79-0.92; p value for trend <0.001). CONCLUSION The odds of carotid revascularization after stroke is lower in patients with mental illness, particularly those with schizophrenia/psychoses, depression, substance use disorders, and multiple psychiatric diagnoses.
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Affiliation(s)
- Diana M Bongiorno
- From the Johns Hopkins University School of Medicine (D.M.B.); and Division of General Internal Medicine (G.L.D.) and Department of Neurology (R.F.G., R.F.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gail L Daumit
- From the Johns Hopkins University School of Medicine (D.M.B.); and Division of General Internal Medicine (G.L.D.) and Department of Neurology (R.F.G., R.F.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca F Gottesman
- From the Johns Hopkins University School of Medicine (D.M.B.); and Division of General Internal Medicine (G.L.D.) and Department of Neurology (R.F.G., R.F.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roland Faigle
- From the Johns Hopkins University School of Medicine (D.M.B.); and Division of General Internal Medicine (G.L.D.) and Department of Neurology (R.F.G., R.F.), Johns Hopkins University School of Medicine, Baltimore, MD.
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15
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Bushnell C, Howard VJ, Lisabeth L, Caso V, Gall S, Kleindorfer D, Chaturvedi S, Madsen TE, Demel SL, Lee SJ, Reeves M. Sex differences in the evaluation and treatment of acute ischaemic stroke. Lancet Neurol 2019; 17:641-650. [PMID: 29914709 DOI: 10.1016/s1474-4422(18)30201-1] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 05/02/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
Abstract
With the greater availability of treatments for acute ischaemic stroke, including advances in endovascular therapy, personalised assessment of patients before treatment is more important than ever. Women have a higher lifetime risk of stroke; therefore, reducing potential sex differences in the acute stroke setting is crucial for the provision of equitable and fast treatment. Evidence indicates sex differences in prevalence and types of non-traditional stroke symptoms or signs, prevalence of stroke mimics, and door-to-imaging times, but no substantial differences in use of emergency medical services, stroke knowledge, eligibility for or access to thrombolysis or thrombectomy, or outcomes after either therapy. Women presenting with stroke mimics or non-traditional stroke symptoms can be misdiagnosed, which can lead to inappropriate triage, and acute treatment delays. It is essential for health-care providers to recognise possible sex differences in stroke symptoms, signs, and mimics. Future studies focused on confounders that affect treatment and outcomes, such as age and pre-stroke function, are also needed.
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Affiliation(s)
- Cheryl Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA.
| | - Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lynda Lisabeth
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Valeria Caso
- Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stacie L Demel
- Department of Neurology & Ophthalmology and Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA
| | - Seung-Jae Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Mathew Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI, USA
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16
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Tanabe Y, Yamamoto T, Murata T, Mabuchi K, Hara N, Mizuno A, Nozato T, Hisatake S, Obayashi T, Takayama M, Nagao K. Gender Differences Among Patients With Acute Pulmonary Embolism. Am J Cardiol 2018; 122:1079-1084. [PMID: 30072127 DOI: 10.1016/j.amjcard.2018.05.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 05/13/2018] [Accepted: 05/21/2018] [Indexed: 10/28/2022]
Abstract
Gender differences in patients with acute pulmonary embolism (APE) remain unclear and controversial. We aimed to understand the gender differences in patients with APE treated in the cardiovascular care units. The registry database of 1,428 patients with APE treated at the Tokyo cardiovascular care unit Network institutions from 2010 to 2014 was retrieved for analysis. In all, 795 women (55.7%) and 633 men (44.3%) were included in this study. The women were older than men (68.0 ± 16.1 vs 60.9 ± 15.6 years, p < 0.0001). Compared with men, women had more complaints of dyspnea and disturbed consciousness, lesser complaints of leg symptoms, and chest pain. Pulmonary arterial systolic pressure (51.5 ± 22.2 mm Hg vs 47.4 ± 22.4 mm Hg, p = 0.012) and the serum B-type natriuretic peptide level (180.4 [50.7 to 526.1] pg/ml vs 107.0 [25.0 to 306.8] pg/ml, p < 0.0001) on admission, was higher in women than in men. Severe cases with massive embolism were seen more in women compared with men (14.6% vs 9.2%, p = 0.0002). The use of inferior vena cava filters were lower in women than in men (31.9% vs 37.3%, p = 0.029). Furthermore, 30-day PE-related mortality was higher in women than in men significantly (5.0% vs 2.8%, p = 0.043). In conclusion, women APE patients were older with higher severity than men APE patients, resulting in poor prognosis.
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17
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Choleris E, Galea LAM, Sohrabji F, Frick KM. Sex differences in the brain: Implications for behavioral and biomedical research. Neurosci Biobehav Rev 2018; 85:126-145. [PMID: 29287628 PMCID: PMC5751942 DOI: 10.1016/j.neubiorev.2017.07.005] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 07/16/2017] [Indexed: 01/11/2023]
Abstract
Biological differences between males and females are found at multiple levels. However, females have too often been under-represented in behavioral neuroscience research, which has stymied the study of potential sex differences in neurobiology and behavior. This review focuses on the study of sex differences in the neurobiology of social behavior, memory, emotions, and recovery from brain injury, with particular emphasis on the role of estrogens in regulating forebrain function. This work, presented by the authors at the 2016 meeting of the International Behavioral Neuroscience Society, emphasizes varying approaches from several mammalian species in which sex differences have not only been documented, but also become the focus of efforts to understand the mechanistic basis underlying them. This information may provide readers with useful experimental tools to successfully address recently introduced regulations by granting agencies that either require (e.g. the National Institutes of Health in the United States and the Canadian Institutes of Health Research in Canada) or recommend (e.g. Horizon 2020 in Europe) the inclusion of both sexes in biomedical research.
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Affiliation(s)
- Elena Choleris
- Department of Psychology and Neuroscience Program, University of Guelph, MacKinnon Bldg. Room 4020, Guelph, ON N1G 2W1, Canada.
| | - Liisa A M Galea
- Department of Psychology, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC V6T1Z3, Canada
| | - Farida Sohrabji
- Women's Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M HSC College of Medicine, Bryan, TX 77807, United States
| | - Karyn M Frick
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI 53211, United States
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18
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Faigle R, Carrese JA, Cooper LA, Urrutia VC, Gottesman RF. Minority race and male sex as risk factors for non-beneficial gastrostomy tube placements after stroke. PLoS One 2018; 13:e0191293. [PMID: 29351343 PMCID: PMC5774766 DOI: 10.1371/journal.pone.0191293] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/02/2018] [Indexed: 01/27/2023] Open
Abstract
Background Percutaneous endoscopic gastrostomy (PEG) tubes are widely used for enteral feeding after stroke; however, PEG tubes placed in patients in whom death is imminent are considered non-beneficial. Aim We sought to determine whether placement of non-beneficial PEG tubes differs by race and sex. Design and setting/participants In this retrospective cohort study, inpatient admissions for stroke patients who underwent palliative/withdrawal of care, were discharged to hospice, or died during the hospitalization, were identified from the Nationwide Inpatient Sample between 2007 and 2011. Logistic regression was used to evaluate the association between race and sex with PEG placement. Results Of 36,109 stroke admissions who underwent palliative/withdrawal of care, were discharge to hospice, or experienced in-hospital death, a PEG was placed in 2,258 (6.3%). Among PEG recipients 41.1% were of a race other than white, while only 22.0% of patients without PEG were of a minority race (p<0.001). The proportion of men was higher among those with compared to without a PEG tube (50.0% vs. 39.2%, p<0.001). Minority race was associated with PEG placement compared to whites (OR 1.75, 95% CI 1.57–1.96), and men had 1.27 times higher odds of PEG compared to women (95% CI 1.16–1.40). Racial differences were most pronounced among women: ethnic/racial minority women had over 2-fold higher odds of a PEG compared to their white counterparts (OR 2.09, 95% CI 1.81–2.41), while male ethnic/racial minority patients had 1.44 increased odds of a PEG when compared to white men (95% CI 1.24–1.67, p-value for interaction <0.001). Conclusion Minority race and male sex are risk factors for non-beneficial PEG tube placements after stroke.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- * E-mail:
| | - Joseph A. Carrese
- Department of Medicine, Johns Hopkins University School of Medicine and the Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, United States of America
| | - Lisa A. Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Victor C. Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Rebecca F. Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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19
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Chang BP, Wira C, Miller J, Akhter M, Barth BE, Willey J, Nentwich L, Madsen T. Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department. Acad Emerg Med 2018; 25:54-64. [PMID: 28646558 PMCID: PMC6415947 DOI: 10.1111/acem.13243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting. METHODS A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors. RESULTS Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals. CONCLUSION Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.
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Affiliation(s)
- Bernard P. Chang
- Department of Emergency Medicine, Columbia University Medical Center
| | - Charles Wira
- Department of Emergency Medicine, Yale-New Haven Medical Center
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Medical Center
| | - Murtaza Akhter
- Department of Emergency Medicine, University of Arizona College of Medicine–Phoenix, Maricopa Integrated Health System, Phoenix, AZ
| | - Bradley E. Barth
- Department of Emergency Medicine, University of Kansas Medical Center
| | - Joshua Willey
- Department of Neurology, Stroke Service, Columbia University Medical Center
| | | | - Tracy Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
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20
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McGregor AJ, Beauchamp GA, Wira CR, Perman SM, Safdar B. Sex as a Biological Variable in Emergency Medicine Research and Clinical Practice: A Brief Narrative Review. West J Emerg Med 2017; 18:1079-1090. [PMID: 29085541 PMCID: PMC5654878 DOI: 10.5811/westjem.2017.8.34997] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 12/16/2022] Open
Abstract
The National Institutes of Health recently highlighted the significant role of sex as a biological variable (SABV) in research design, outcome and reproducibility, mandating that this variable be accounted for in all its funded research studies. This move has resulted in a rapidly increasing body of literature on SABV with important implications for changing the clinical practice of emergency medicine (EM). Translation of this new knowledge to the bedside requires an understanding of how sex-based research will ultimately impact patient care. We use three case-based scenarios in acute myocardial infarction, acute ischemic stroke and important considerations in pharmacologic therapy administration to highlight available data on SABV in evidence-based research to provide the EM community with an important foundation for future integration of patient sex in the delivery of emergency care as gaps in research are filled.
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Affiliation(s)
- Alyson J McGregor
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Division of Sex and Gender in Emergency Medicine, Providence, Rhode Island
| | - Gillian A Beauchamp
- Oregon Health & Science University, Department of Emergency Medicine, Portland, Oregon
| | - Charles R Wira
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Sarah M Perman
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Basmah Safdar
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
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Miller JB, Merck LH, Wira CR, Meurer WJ, Schrock JW, Nomura JT, Siket MS, Madsen TE, Wright DW, Panagos PD, Lewandowski C. The Advanced Reperfusion Era: Implications for Emergency Systems of Ischemic Stroke Care. Ann Emerg Med 2017; 69:192-201. [DOI: 10.1016/j.annemergmed.2016.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/16/2016] [Accepted: 06/24/2016] [Indexed: 11/30/2022]
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Sohrabji F, Park MJ, Mahnke AH. Sex differences in stroke therapies. J Neurosci Res 2017; 95:681-691. [PMID: 27870437 PMCID: PMC5125551 DOI: 10.1002/jnr.23855] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/20/2016] [Accepted: 07/06/2016] [Indexed: 02/03/2023]
Abstract
Stroke is the fifth leading cause of death and acquired disability in aged populations. Women are disproportionally affected by stroke, having a higher incidence and worse outcomes than men. Numerous preclinical studies have discovered novel therapies for the treatment of stroke, but almost all of these have been shown to be unsuccessful in clinical trials. Despite known sex differences in occurrence and severity of stroke, few preclinical or clinical therapeutics take into account possible sex differences in treatment. Reanalysis of data from studies of tissue plasminogen activator (tPA), the only currently FDA-approved stroke therapy, has shown that tPA improves stroke outcomes for both sexes and also shows sexual dimorphism by more robust improvement in stroke outcome in females. Experimental evidence supports the inclusion of sex as a variable in the study of a number of novel stroke drugs and therapies, including preclinical studies of anti-inflammatory drugs (minocycline), stimulators of cell survival (insulin-like growth factor-1), and inhibitors of cell death pathways (pharmacological inhibition of poly[ADP-ribose] polymerase-1, nitric oxide production, and caspase activation) as well as in current clinical trials of stem cell therapy and cortical stimulation. Overall, study design and analysis in clinical trials as well as in preclinical studies must include both sexes equally, consider possible sex differences in the analyses, and report the differences/similarities in more systematic/structured ways to allow promising therapies for both sexes and increase stroke recovery. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Farida Sohrabji
- Women’s Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center, Bryan, TX 77807, USA
| | - Min Jung Park
- Women’s Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center, Bryan, TX 77807, USA
| | - Amanda H Mahnke
- Women’s Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center, Bryan, TX 77807, USA
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Fredwall M, Sternberg S, Blackhurst D, Lee A, Leacock R, Nathaniel TI. Gender Differences in Exclusion Criteria for Recombinant Tissue-Type Plasminogen Activator. J Stroke Cerebrovasc Dis 2016; 25:2569-2574. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 04/06/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022] Open
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Messé SR, Khatri P, Reeves MJ, Smith EE, Saver JL, Bhatt DL, Grau-Sepulveda MV, Cox M, Peterson ED, Fonarow GC, Schwamm LH. Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry. Neurology 2016; 87:1565-1574. [PMID: 27629092 DOI: 10.1212/wnl.0000000000003198] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 06/29/2016] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To determine patient and hospital characteristics associated with not providing IV tissue plasminogen activator (tPA) to eligible patients with acute ischemic stroke (AIS) in clinical practice. METHODS We performed a retrospective cohort study of patients with AIS arriving within 2 hours of onset to hospitals participating in Get With The Guidelines-Stroke without documented contraindications to IV tPA from April 2003 through December 2011, comparing those who received tPA to those who did not. Multivariable generalized estimating equation logistic regression modeling identified factors associated with not receiving tPA. RESULTS Of 61,698 eligible patients with AIS presenting within 2 hours of onset (median age 73 years, 51% female, 74% non-Hispanic white, median NIH Stroke Scale score 11, interquartile range 6-18), 15,282 (25%) were not treated with tPA within 3 hours. Failure to give tPA decreased over time from 55% in 2003 to 2005 to 18% in 2010 to 2011 (p < 0.0001). After adjustment for all covariates, including stroke severity, factors associated with failure to treat included older age, female sex, nonwhite race, diabetes mellitus, prior stroke, atrial fibrillation, prosthetic heart valve, NIH Stroke Scale score <5, arrival off-hours and not via emergency medical services, longer onset-to-arrival and door-to-CT times, earlier calendar year, and arrival at rural, nonteaching, non-stroke center hospitals located in the South or Midwest. CONCLUSIONS Overall, about one-quarter of eligible patients with AIS presenting within 2 hours of stroke onset failed to receive tPA treatment. Thrombolysis has improved dramatically over time and is strongly associated with stroke center certification. Additionally, some groups, including older patients, milder strokes, women, and minorities, may be undertreated.
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Affiliation(s)
- Steven R Messé
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA.
| | - Pooja Khatri
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Mathew J Reeves
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Eric E Smith
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Jeffrey L Saver
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Deepak L Bhatt
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Maria V Grau-Sepulveda
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Margueritte Cox
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Eric D Peterson
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Gregg C Fonarow
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
| | - Lee H Schwamm
- From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA
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Asdaghi N, Romano JG, Wang K, Ciliberti-Vargas MA, Koch S, Gardener H, Dong C, Rose DZ, Waddy SP, Robichaux M, Garcia EJ, Gonzalez-Sanchez JA, Burgin WS, Sacco RL, Rundek T. Sex Disparities in Ischemic Stroke Care: FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). Stroke 2016; 47:2618-26. [PMID: 27553032 DOI: 10.1161/strokeaha.116.013059] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines-Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment. METHODS Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines-Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity. RESULTS As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93-1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86-0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71-0.97; P=0.02) as compared with men. CONCLUSIONS Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.
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Affiliation(s)
- Negar Asdaghi
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan.
| | - Jose G Romano
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Kefeng Wang
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Maria A Ciliberti-Vargas
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Sebastian Koch
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Hannah Gardener
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Chuanhui Dong
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - David Z Rose
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Salina P Waddy
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Mary Robichaux
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Enid J Garcia
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Juan A Gonzalez-Sanchez
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - W Scott Burgin
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Ralph L Sacco
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
| | - Tatjana Rundek
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., J.G.R., K.W., M.A.C-.V., S.K., H.G., C.D., R.L.S., T.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (M.R.); and Endowed Health Services Research Center (E.J.G.) and Department of Emergency Medicine (J.A.G-.S.), University of Puerto Rico School of Medicine, San Juan
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Paulus JK, Lai LYH, Lundquist C, Daneshmand A, Buettner H, Lutz JS, Raman G, Wessler BS, Kent DM. Field Synopsis of the Role of Sex in Stroke Prediction Models. J Am Heart Assoc 2016; 5:JAHA.115.002809. [PMID: 27151514 PMCID: PMC4889171 DOI: 10.1161/jaha.115.002809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Guidelines for stroke prevention recommend development of sex‐specific stroke risk scores. Incorporating sex in Clinical Prediction Models (CPMs) may support sex‐specific clinical decision making. To better understand their potential to guide sex‐specific care, we conducted a field synopsis of the role of sex in stroke‐related CPMs. Methods and Results We identified stroke‐related CPMs in the Tufts Predictive Analytics and Comparative Effectiveness CPM Database, a systematic summary of cardiovascular CPMs published from January 1990 to May 2012. We report the proportion of models including the effect of sex on stroke incidence or prognosis, summarize the directionality of the predictive effects of sex, and explore factors influencing the inclusion of sex. Of 92 stroke‐related CPMs, 30 (33%) contained a coefficient for sex or presented sex‐stratified models. Only 12/58 (21%) CPMs predicting outcomes in patients included sex, compared to 18/30 (60%) models predicting first stroke (P<0.0001). Sex was most commonly included in models predicting stroke among a general population (69%). Female sex was consistently associated with reduced mortality after ischemic stroke (n=4) and higher risk of stroke from arrhythmias or coronary revascularization (n=5). Models predicting first stroke versus outcomes among patients with stroke (odds ratio=5.75, 95% CI 2.18–15.14, P<0.001) and those developed from larger versus smaller sample sizes (odds ratio=4.58, 95% CI 1.73–12.13, P=0.002) were significantly more likely to include sex. Conclusions Sex is included in a minority of published CPMs, but more frequently in models predicting incidence of first stroke. The importance of sex‐specific care may be especially well established for primary prevention.
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Affiliation(s)
- Jessica K Paulus
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Lana Y H Lai
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Christine Lundquist
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Ali Daneshmand
- Department of Neurology, Tufts Medical Center, Boston, MA
| | | | - Jennifer S Lutz
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Gowri Raman
- Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Benjamin S Wessler
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA Division of Cardiology, Tufts Medical Center, Boston, MA
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA
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Faigle R, Marsh EB, Llinas RH, Urrutia VC, Gottesman RF. ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:26. [PMID: 26818069 PMCID: PMC4730614 DOI: 10.1186/s13054-016-1195-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/15/2016] [Indexed: 12/20/2022]
Abstract
Background Patients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications, commonly necessitating admission to an intensive care unit (ICU). At present, most IVT is administered in the Emergency Department or in dedicated stroke units, but no evidence-based criteria exist that allow for early identification of patients at increased risk of developing ICU needs. The present study describes a novel prediction score aiming to identify a subpopulation of post-IVT patients at high risk for critical care interventions. Methods We retrospectively analyzed data from 301 patients undergoing IVT at our institutions during a 5-year period. Two hundred and ninety patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association. Results Seventy-two patients (24.8 %) required critical care interventions. Black race (odds ratio [OR] 3.81, p =0.006), male sex (OR 3.79, p =0.008), systolic blood pressure (SBP; OR 1.45 per 10 mm Hg increase in SBP, p <0.001), and NIH stroke scale (NIHSS; OR 1.09 per 1 point increase in NIHSS, p =0.071) were independent predictors of critical care needs. The optimal model for score development, predicting critical care needs, achieved an AUC of 0.782 in the validation group. The score was named the ICAT (Intensive Care After Thrombolysis) score, assigning the following points: black race (1 point), male sex (1 point), SBP (2 points if 160–200 mm Hg; 4 points if >200 mm Hg), and NIHSS (1 point if 7–12; 2 points if >12). Each 1-point increase in the score was associated with 2.22-fold increased odds for critical care needs (95 % CI 1.78–2.76, p <0.001). A score ≥2 was associated with over 13 times higher odds of critical care needs compared to a score <2 (OR 13.60, 95 % CI 3.23–57.19), predicting critical care with 97.2 % sensitivity and 28.0 % specificity. Conclusion The ICAT score, combining information about race, sex, SBP, and NIHSS, predicts critical care needs in post-IVT patients and may be helpful when triaging post-IVT patients to the appropriate monitoring environment. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1195-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA.
| | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Rafael H Llinas
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
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Harvey RE, Coffman KE, Miller VM. Women-specific factors to consider in risk, diagnosis and treatment of cardiovascular disease. ACTA ACUST UNITED AC 2015; 11:239-257. [PMID: 25776297 DOI: 10.2217/whe.14.64] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the era of individualized medicine, gaps in knowledge remain about sex-specific risk factors, diagnostic and treatment options that might reduce mortality from cardiovascular disease (CVD) and improve outcomes for both women and men. In this review, contributions of biological mechanisms involving the sex chromosomes and the sex hormones on the cardiovascular system will be discussed in relationship to the female-specific risk factors for CVD: hypertensive disorders of pregnancy, menopause and use of hormonal therapies for contraception and menopausal symptoms. Additionally, sex-specific factors to consider in the differential diagnosis and treatment of four prevalent CVDs (hypertension, stroke, coronary artery disease and congestive heart failure) will be reviewed with emphasis on areas where additional research is needed.
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Affiliation(s)
- Ronée E Harvey
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Kirsten E Coffman
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Virginia M Miller
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.,Department of Surgery, Medical Sciences, 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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Agarwal S, Clark D, Sud K, Jaber WA, Cho L, Menon V. Gender Disparities in Outcomes and Resource Utilization for Acute Pulmonary Embolism Hospitalizations in the United States. Am J Cardiol 2015; 116:1270-6. [PMID: 26341183 DOI: 10.1016/j.amjcard.2015.07.048] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 11/12/2022]
Abstract
Current data regarding gender disparities in outcomes after acute pulmonary embolism (PE) are limited and controversial. We sought to assess the gender-specific rates and trends in treatment, outcomes, and complications after acute PE. We used the 2003 to 2011 Nationwide Inpatient Sample database for this analysis. All hospital admissions with a principal diagnosis of acute PE were identified using the International Classification of Diseases, Ninth Edition, codes. Inhospital mortality and discharge to nursing facility were co-primary outcomes of our study. Secondary outcomes included shock, transfusion of blood products, utilization of thrombolysis, inferior vena cava filter placement, and cost of hospitalization. Over a 9-year period, a total of 276,484 discharges with acute PE were identified. Compared with men, there was significantly higher inhospital mortality in women admitted with acute PE (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03 to 1.15). In addition, there was a significantly higher need for discharge to nursing facility among women compared with men (OR 1.30, 95% CI 1.27 to 1.34). Besides this, women experienced a higher need for transfusion (OR 1.38, 95% CI 1.33 to 1.44) and occurrence of shock (OR 1.10, 95% CI 1.01 to 1.18) during hospitalization. Furthermore, there was a significantly lower utilization of vena cava filters (OR 0.86, 95% CI 0.84 to 0.89) in women compared with men. Among patients in shock who were eligible for thrombolysis (age <75 years, no previous stroke, no bleeding on presentation, and not pregnant), the utilization of thrombolysis was similar between men and women (OR 1.19, 95% CI 0.93 to 1.53). Lastly, the cost of hospitalization after acute PE was significantly higher in men than women (adjusted mean difference $425, 95% CI $304 to $546). In conclusion, among patients admitted with acute PE, women tend to have more adverse outcomes and higher incidence of complications compared with men.
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Affiliation(s)
- Shikhar Agarwal
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Donald Clark
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Karan Sud
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Wael A Jaber
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Leslie Cho
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Madsen TE, Seigel TA, Mackenzie RS, Marcolini EG, Wira CR, Healy ME, Wright DW, Gentile NT. Gender differences in neurologic emergencies part I: a consensus summary and research agenda on cerebrovascular disease. Acad Emerg Med 2014; 21:1403-13. [PMID: 25422086 DOI: 10.1111/acem.12528] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/19/2014] [Accepted: 09/09/2014] [Indexed: 12/12/2022]
Abstract
Cerebrovascular neurologic emergencies including ischemic and hemorrhagic stroke, subarachnoid hemorrhage (SAH), and migraine are leading causes of death and disability that are frequently diagnosed and treated in the emergency department (ED). Although sex and gender differences in neurologic emergencies are beginning to become clearer, there are many unanswered questions about how emergency physicians should incorporate sex and gender into their research initiatives, patient evaluations, and overall management plans for these conditions. After evaluating the existing gaps in the literature, a core group of ED researchers developed a draft of future research priorities. Participants in the 2014 Academic Emergency Medicine consensus conference neurologic emergencies working group then discussed and approved the recommended research agenda using a standardized nominal group technique. Recommendations for future research on the role of sex and gender in the diagnosis, treatment, and outcomes pertinent to ED providers are described for each of three diagnoses: stroke, SAH, and migraine. Recommended future research also includes investigation of the biologic and pathophysiologic differences between men and women with neurologic emergencies as they pertain to ED diagnoses and treatments.
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Affiliation(s)
- Tracy E. Madsen
- Department of Emergency Medicine; The Alpert Medical School of Brown University Rhode Island Hospital; Providence RI
| | - Todd A. Seigel
- Department of Medicine; UCSF School of Medicine; San Francisco CA
| | | | | | - Charles R. Wira
- Department of Emergency Medicine; Yale University; New Haven CT
| | - Megan E. Healy
- Department of Emergency Medicine; Temple University School of Medicine; Philadelphia PA
| | - David W. Wright
- Department of Emergency Medicine; Emory University School of Medicine; Atlanta GA
| | - Nina T. Gentile
- Department of Emergency Medicine; Temple University School of Medicine; Philadelphia PA
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Madsen TE, Choo EK, Seigel TA, Palms D, Silver B. Lack of gender disparities in emergency department triage of acute stroke patients. West J Emerg Med 2014; 16:203-9. [PMID: 25671042 PMCID: PMC4307718 DOI: 10.5811/westjem.2014.11.23063] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 10/14/2014] [Accepted: 11/04/2014] [Indexed: 11/22/2022] Open
Abstract
Introduction Previous literature has shown gender disparities in the care of acute ischemic stroke. Compared to men, women wait longer for brain imaging and are less likely to receive intravenous (IV) tissue plasminogen activator (tPA). Emergency department (ED) triage is an important step in the rapid assessment of stroke patients and is a possible contributor to disparities. It is unknown whether gender differences exist in ED triage of acute stroke patients. Our primary objective was to determine whether gender disparities exist in the triage of acute stroke patients as defined by Emergency Severity Index (ESI) levels and use of ED critical care beds. Methods This was a retrospective, observational study of both ischemic and hemorrhagic stroke patients age ≥18 years presenting to a large, urban, academic ED within six hours of symptom onset between January 2010, and December 2012. Primary outcomes were triage to a non-critical ED bed and Emergency Severity Index (ESI) level. Primary outcome data were extracted from electronic medical records by a blinded data manager; secondary outcome data and covariates were abstracted by trained research assistants. We performed bivariate and multivariate analyses. Logistic regression was performed using age, race, insurance status, mode of and time to arrival, National Institutes of Health Stroke Scale, and presence of atypical symptoms as covariates. Results There were 537 patients included in this study. Women were older (75.6 vs. 69.5, p<0.001), and more women had a history of atrial fibrillation (39.8% vs. 25.3%, p<0.001). Compared to 9.5% of men, 10.3% of women were triaged to a non-critical care ED bed (p=0.77); 92.1% of women were triaged as ESI 1 or 2 vs. 93.6% of men (p=0.53). After adjustment, gender was not associated with triage location or ESI level, though atypical symptoms were associated with higher odds of being triaged to a non-critical care bed (aOR 1.98, 95%CI [1.03 – 3.81]) and 3.04 times higher odds of being triaged as ESI 3 vs. ESI 1 or 2 (95% CI [1.36 – 6.82]). Conclusion In a large, urban, academic ED at a primary stroke center, there were no gender differences in triage to critical care beds or ESI levels among acute stroke patients arriving within six hours of symptom onset. These findings suggest that ED triage protocols for stroke patients may be effective in minimizing gender disparities in care.
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Affiliation(s)
- Tracy E Madsen
- Alpert Medical School of Brown University/Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island
| | - Esther K Choo
- Alpert Medical School of Brown University/Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island
| | - Todd A Seigel
- Kaiser Permanente East Bay, Department of Criticial Care Medicine, Department of Emergency Medicine, Oakland, California
| | - Danielle Palms
- Emory University, Department of Epidemiology, Rollins School of Public Health Atlanta, Georgia
| | - Brian Silver
- Alpert Medical School of Brown University/Rhode Island Hospital, Department of Neurology, Providence, Rhode Island
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Murphy SJ, Lusardi TA, Phillips JI, Saugstad JA. Sex differences in microRNA expression during development in rat cortex. Neurochem Int 2014; 77:24-32. [PMID: 24969725 PMCID: PMC4177314 DOI: 10.1016/j.neuint.2014.06.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 06/09/2014] [Accepted: 06/16/2014] [Indexed: 11/15/2022]
Abstract
There are important sex differences in the risk and outcome of conditions and diseases between males and females. For example, stroke occurs with greater frequency in men than in women across diverse ethnic backgrounds and nationalities. Work from our lab and others have revealed a sex-specific sensitivity to cerebral ischemia whereby males exhibit a larger extent of brain damage following an ischemic event compared to females. Studies suggest that the difference in male and female susceptibility to ischemia may be triggered by innate variations in gene regulation and protein expression between the sexes that are independent of post-natal exposure to sex hormones. We have shown that there are differences in microRNA (miRNA) expression in adult male and female brain following focal cerebral ischemia in mouse cortex. Herein we examine a role for differential expression of miRNAs during development in male and female rat cortex as potential effectors of the phenotype that leads to sex differences to ischemia. Expression studies in male and female cortices isolated from postnatal day 0 (P0), postnatal day 7 (P7), and adult rats using TaqMan Low Density miRNA arrays and NanoString nCounter analysis revealed differential miRNA levels between males and females at each developmental stage. We focused on the miR-200 family of miRNAs that showed higher levels in females at P0, but higher levels in males at P7 that persisted into adulthood, and validated the expression of miR-200a, miR-200b, and miR-429 by individual qRT-PCR as these are clustered on chromosome 5 and may be transcriptionally co-regulated. Prediction analysis of the miR-200 miRNAs revealed that genes within the Gonadotropin releasing hormone receptor pathway are the most heavily targeted. These studies support that developmental changes in miRNA expression may influence phenotypes in adult brain that underlie sexually dimorphic responses to disease, including ischemia.
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Affiliation(s)
- Stephanie J Murphy
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Theresa A Lusardi
- Dow Neurobiology Laboratories, Legacy Research Institute, Portland, OR, USA
| | - Jay I Phillips
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Julie A Saugstad
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA.
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Lusardi TA, Murphy SJ, Phillips JI, Chen Y, Davis CM, Young JM, Thompson SJ, Saugstad JA. MicroRNA responses to focal cerebral ischemia in male and female mouse brain. Front Mol Neurosci 2014; 7:11. [PMID: 24574964 PMCID: PMC3920114 DOI: 10.3389/fnmol.2014.00011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 01/23/2014] [Indexed: 12/31/2022] Open
Abstract
Stroke occurs with greater frequency in men than in women across diverse ethnic backgrounds and nationalities. Work from our lab and others have revealed a sex-specific sensitivity to cerebral ischemia whereby males exhibit a larger extent of brain damage resulting from an ischemic event compared to females. Previous studies revealed that microRNA (miRNA) expression is regulated by cerebral ischemia in males; however, no studies to date have examined the effect of ischemia on miRNA responses in females. Thus, we examined miRNA responses in male and female brain in response to cerebral ischemia using miRNA arrays. These studies revealed that in male and female brains, ischemia leads to both a universal miRNA response as well as a sexually distinct response to challenge. Target prediction analysis of the miRNAs increased in male or female ischemic brain reveal sex-specific differences in gene targets and protein pathways. These data support that the mechanisms underlying sexually dimorphic responses to cerebral ischemia includes distinct changes in miRNAs in male and female brain, in addition to a miRNA signature response to ischemia that is common to both.
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Affiliation(s)
- Theresa A Lusardi
- Dow Neurobiology Laboratories, Legacy Research Institute Portland, OR, USA
| | - Stephanie J Murphy
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University Portland, OR, USA
| | - Jay I Phillips
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University Portland, OR, USA
| | - Yingxin Chen
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University Portland, OR, USA
| | - Catherine M Davis
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University Portland, OR, USA
| | - Jennifer M Young
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University Portland, OR, USA
| | - Simon J Thompson
- Dow Neurobiology Laboratories, Legacy Research Institute Portland, OR, USA
| | - Julie A Saugstad
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University Portland, OR, USA
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