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Nuñez M, Allende MI, González F, Cavada G, Anderson CS, Muñoz Venturelli P. Sex Differences in Profile and In-Hospital Death for Acute Stroke in Chile: Data From a Nationwide Hospital Registry. J Am Heart Assoc 2024; 13:e035152. [PMID: 39023058 DOI: 10.1161/jaha.123.035152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/20/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Knowledge of local contextual sex differences in the profile and outcome for stroke can improve service delivery. We aimed to determine sex differences in the profile of patients with acute stroke and their associations with in-hospital death in the national hospital database of Chile. METHODS AND RESULTS We present a retrospective cohort based on the analysis of the 2019 Chilean database of Diagnosis-Related Groups, which represents 70% of the operational expenditure of the public health system. Random-effects multiple logistic regression models were used to determine independent associations of acute stroke (defined by main diagnosis International Classification of Diseases, Tenth Revision [ICD-10] codes) and in-hospital death, and reported with odds ratios (ORs) and 95% CIs. Of 1 048 575 hospital discharges, 15 535 were for patients with acute stroke (7074 [45.5%] in women), and 2438 (15.6%) of them died during hospitalization. Differences by sex in sociodemographic and clinical characteristics were identified for stroke and main subtypes. After fully adjusted model, women with ischemic stroke had lower in-hospital death (OR, 0.79 [95% CI, 0.69-0.91]) compared with men; other independent predictors included age per year increase (OR, 1.03 [95% CI, 1.03-1.04]), chronic kidney disease (OR, 1.47 [95% CI, 1.20-1.80]), atrial fibrillation (OR, 1.50 [95% CI, 1.26-1.80]), and other risk factors. Conversely, for intracerebral hemorrhage, women had a higher in-hospital mortality rate than men (OR, 1.19 [95% CI, 1.02-1.40]); other independent predictors included age per year increase (OR, 1.009 [95% CI, 1.003-1.01]), chronic kidney disease (OR, 1.55 [95% CI, 1.23-1.97]), oral anticoagulant use (OR, 1.88 [95% CI, 1.37-2.58]), and other risk factors. CONCLUSIONS Sex differences in characteristics and in-hospital death of hospitalized patients exist for acute stroke in Chile. In-hospital death is higher for acute ischemic stroke in men and higher for intracerebral hemorrhage in women. Future research is needed to better identify contributing factors.
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Affiliation(s)
- Marilaura Nuñez
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Ma Ignacia Allende
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Francisca González
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- Facultad de Ciencias de la Salud Blanquerna Universitat Ramon Llull Barcelona Spain
| | - Gabriel Cavada
- Escuela de Salud Pública Facultad de Medicina Universidad de Chile Santiago Chile
- Facultad de Medicina Universidad Finis Terrae Santiago Chile
- Unidad de Investigación Clínica Clínica Alemana de Santiago Santiago Chile
| | - Craig S Anderson
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- The George Institute for Global Health Faculty of Medicine, University of New South Wales Sydney NSW Australia
| | - Paula Muñoz Venturelli
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- The George Institute for Global Health Faculty of Medicine, University of New South Wales Sydney NSW Australia
- Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
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Abdel-Fattah AR, Pana TA, Tiamkao S, Sawanyawisuth K, Kasemsap N, Mamas MA, Myint PK. [Sex differences in stroke mortality in Thailand : A National cohort study]. Ann Cardiol Angeiol (Paris) 2023; 72:1-7. [PMID: 36435621 DOI: 10.1016/j.ancard.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Over half of the growing global stroke-mortality burden is accounted for by the East-Asian-subcontinent alone. Sex differences in stroke-mortality in the Asian population is yet to be assessed in the literature. We aimed to assess the sex-differences in mortality following stroke in a large cohort of Thai-patients. METHOD All stroke admissions between 2004-2015 were included from the Thailand public-health-insurance-database. The association between sex and mortality was assessed in-hospital, at 1 month, 1 year and 5 years, using multivariable Cox-regressions, separately for ischaemic-stroke (IS), haemorrhagic-stroke (HS) and stroke-of-undetermined-type(SUT), adjusting for confounders. RESULTS 608,890 patients were included: 370,527 patients with IS(60.9%), 173,236 with HS(28.5%) and 65,127 with SUT(10.6%). Women were older than men in all three groups and had higher prevalence of comorbidities. Adjusted hazard-ratios(HRs) of mortality showed women had higher mortality post-IS compared to men (in-hospital: HR: 1.20; 95% CI: 1.17-1.23; 1 month: HR: 1.17; 95% CI: 1.15-1.20; 1 year: HR: 1.10; 95% CI: 1.09-1.12 and 5 years: HR: 1.02; 95% CI: 1.01-1.03). Women also had higher mortality after HS (in-hospital: HR: 1.02; 95% CI: 1.00-1.04; 1 month: HR: 1.08; 95% CI: 1.06-1.10; 1 year: HR: 1.04; 95% CI: 1.03-1.06 and 5 years: HR: 1.09; 95% CI: 1.08-1.11), and SUT (in-hospital: HR: 1.04; 95% CI: 1.03-1.06; 1 month: HR: 1.20; 95% CI: 1.14-1.27; 1 year: HR: 1.14; 95% CI: 1.09-1.18 and 5 years: HR: 1.06; 95% CI: 1.03-1.10). CONCLUSIONS Compared to men, women were older at time of stroke-diagnosis and had higher burden of stroke risk-factors. Women also had higher mortality after stroke regardless of stroke-type or duration since stroke-onset. Post-IS, excess stroke-mortality in women was greatest during the in-hospital period, whereas excess stroke-mortality increased with time in women who had HS. No clear relationship was found between duration since stroke-onset and mortality in patients who had SUT.
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Affiliation(s)
- Abdel-Rahman Abdel-Fattah
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, Scotland, UK.
| | - Tiberiu A Pana
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, Scotland, UK
| | - Somsak Tiamkao
- Neurology Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; North-Eastern Stroke Research Group, Khon Kaen University, Khon Kaen, Thailand
| | - Kittisak Sawanyawisuth
- Ambulatory Medicine Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Narongrit Kasemsap
- Neurology Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; North-Eastern Stroke Research Group, Khon Kaen University, Khon Kaen, Thailand
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - Phyo K Myint
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, Scotland, UK
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Broberg E, Hjalmarsson C, Setalani M, Milenkoski R, Andersson B. Sex Differences in Treatment and Prognosis of Acute Intracerebral Hemorrhage. J Womens Health (Larchmt) 2023; 32:102-108. [PMID: 35960812 DOI: 10.1089/jwh.2021.0577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Intracerebral hemorrhage (ICH) accounts for 10%-15% of all stroke cases and is associated with a high risk of death and disability. Prior studies in ischemic stroke have demonstrated a less favorable outcome in women compared with men, but there is a paucity of data regarding differences in outcome by sex in ICH. The aim of the present study was to investigate possible sex differences in acute care and the 3-months follow-up of patients with ICH. Methods: Data were collected from the Swedish National Stroke Registry (Riksstroke). Demographic and baseline characteristics were collected, based on in-hospital data and data from 3-months follow-up. Results: Variables of interest were collected from 1,403 patients. Women (45.1%) were significantly older than men, with a mean age ± standard deviation of 77 ± 13years, versus 71 ± 14 years, p < 0.01. On admission, the ICH severity was similar in men and women. There was no significant association between sex and reception of neuroimaging or neurosurgery. Women were less likely to be treated in a stroke unit (80.8% vs. 85.3%, p = 0.03), or discharged to home (51.5% vs. 63.4%, p < 0.01). At 3-months follow-up, there were no sex-related differences regarding dependence, post-ICH self-reported depression, or case fatality. Conclusions: Women were less likely to be treated in a stroke unit, and were less often discharged to home. However, no significant differences in 3-month functional outcome or survival between men and women with ICH were found in this study.
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Affiliation(s)
- Erika Broberg
- Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clara Hjalmarsson
- Department of Cardiology, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mehrnoush Setalani
- Department of Geriatric, Neurology and Rehabilitation, Kungälv Hospital, Kungälv, Sweden
| | | | - Björn Andersson
- Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Lu P, Cao Z, Gu H, Li Z, Wang Y, Cui L, Wang Y, Zhao X. Association of sex and age with in-hospital mortality and complications of patients with intracerebral hemorrhage: A study from the Chinese Stroke Center Alliance. Brain Behav 2023; 13:e2846. [PMID: 36495127 PMCID: PMC9847591 DOI: 10.1002/brb3.2846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/06/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE The impact of sex and age on prognosis in patients with intracerebral hemorrhage (ICH) in the Chinese population remains unclear. Our study aimed to investigate the relationship between sex and age of Chinese ICH patients and adverse prognosis. METHODS We used the Chinese Stroke Center Alliance database with in-hospital mortality as the primary outcome and hospital complications as the secondary outcome. Patients were divided into four groups by sex and age. Logistic regression analyses were performed to assess the association between sex and age and the prognosis of ICH patients. RESULTS We enrolled 60,911 ICH patients, including 22,284 young and middle-aged males, 15,651 older males, 11,948 young and middle-aged females, and 11,028 older females. After adjusting for variables, older male patients had a higher mortality rate (OR = 1.21, 95% CI 1.01-1.45), combined with more frequent hematoma expansion (OR = 1.14, 95% CI 1.03-1.26), pneumonia (OR = 1.91, 95% CI 1.81-2.03), and hydrocephalus (OR = 1.28, 95% CI 1.04-1.59). Young and middle-aged female patients had a lower mortality rate (OR = 0.74, 95% CI 0.58-0.95) and less frequent combined pneumonia (OR = 0.81, 95% CI 0.75-0.87). In-hospital mortality was not significantly different in older females compared with young and middle-aged males, but the odds of deep vein thrombosis, swallowing disorders, urinary tract infections, and gastrointestinal bleeding were significantly higher. CONCLUSION Among young and middle-aged patients, females are related to a lower in-hospital mortality rate from ICH. Older patients are at an increased risk of ICH complications, with higher in-hospital mortality in older men.
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Affiliation(s)
- Ping Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhentang Cao
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Yu Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lingyun Cui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Red Cell Microparticles Suppress Hematoma Growth Following Intracerebral Hemorrhage in Chronic Nicotine-Exposed Rats. Int J Mol Sci 2022; 23:ijms232315167. [PMID: 36499494 PMCID: PMC9736308 DOI: 10.3390/ijms232315167] [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: 10/21/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022] Open
Abstract
Spontaneous intracerebral hemorrhage (sICH) is a disabling stroke sub-type, and tobacco use is a prominent risk factor for sICH. We showed that chronic nicotine exposure enhances bleeding post-sICH. Reduction of hematoma growth is a promising effective therapy for sICH in smoking subjects. Red-blood-cell-derived microparticles (RMPs) are hemostatic agents that limit hematoma expansion following sICH in naïve rats. Considering the importance of testing the efficacy of experimental drugs in animal models with a risk factor for a disease, we tested RMP efficacy and the therapeutic time window in limiting hematoma growth post-sICH in rats exposed to nicotine. Young rats were chronically treated with nicotine using osmotic pumps. sICH was induced in rats using an injection of collagenase in the right striatum. Vehicle/RMPs were administered intravenously. Hematoma volume and neurological impairment were quantified ≈24 h after sICH. Hematoma volumes in male and female nicotine-exposed rats that were treated with RMPs at 2 h post-sICH were significantly lower by 26 and 31% when compared to their respective control groups. RMP therapy was able to limit hematoma volume when administered up to 4.5 h post-sICH in animals of both sexes. Therefore, RMPs may limit hematoma growth in sICH patients exposed to tobacco use.
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Knepp B, Ander BP, Jickling GC, Hull H, Yee AH, Ng K, Rodriguez F, Carmona-Mora P, Amini H, Zhan X, Hakoupian M, Alomar N, Sharp FR, Stamova B. Gene expression changes implicate specific peripheral immune responses to Deep and Lobar Intracerebral Hemorrhages in humans. BRAIN HEMORRHAGES 2022; 3:155-176. [PMID: 36936603 PMCID: PMC10019834 DOI: 10.1016/j.hest.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The peripheral immune system response to Intracerebral Hemorrhage (ICH) may differ with ICH in different brain locations. Thus, we investigated peripheral blood mRNA expression of Deep ICH, Lobar ICH, and vascular risk factor-matched control subjects (n = 59). Deep ICH subjects usually had hypertension. Some Lobar ICH subjects had cerebral amyloid angiopathy (CAA). Genes and gene networks in Deep ICH and Lobar ICH were compared to controls. We found 774 differentially expressed genes (DEGs) and 2 co-expressed gene modules associated with Deep ICH, and 441 DEGs and 5 modules associated with Lobar ICH. Pathway enrichment showed some common immune/inflammatory responses between locations including Autophagy, T Cell Receptor, Inflammasome, and Neuroinflammation Signaling. Th2, Interferon, GP6, and BEX2 Signaling were unique to Deep ICH. Necroptosis Signaling, Protein Ubiquitination, Amyloid Processing, and various RNA Processing terms were unique to Lobar ICH. Finding amyloid processing pathways in blood of Lobar ICH patients suggests peripheral immune cells may participate in processes leading to perivascular/vascular amyloid in CAA vessels and/or are involved in its removal. This study identifies distinct peripheral blood transcriptome architectures in Deep and Lobar ICH, emphasizes the need for considering location in ICH studies/clinical trials, and presents potential location-specific treatment targets.
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Affiliation(s)
- Bodie Knepp
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Bradley P. Ander
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Glen C. Jickling
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada
| | - Heather Hull
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Alan H. Yee
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Kwan Ng
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Fernando Rodriguez
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Paulina Carmona-Mora
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Hajar Amini
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Xinhua Zhan
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Marisa Hakoupian
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Noor Alomar
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Frank R. Sharp
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
| | - Boryana Stamova
- Department of Neurology, School of Medicine, University of California at Davis, Sacramento, CA, USA
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Zhao J, Zhang T, Wan H, Yu Y, Wen J, Wang X. Sex-related differences in spontaneous intracerebral hemorrhage outcomes: A prognostic study based on 111,112 medical records. Front Neurol 2022; 13:957132. [PMID: 36212662 PMCID: PMC9539800 DOI: 10.3389/fneur.2022.957132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/29/2022] [Indexed: 11/20/2022] Open
Abstract
Objective To identify sex-related differences in the outcome of hospitalized patients with spontaneous intracerebral hemorrhage (SICH), and to identify potential causal pathways between sex and SICH outcome. Methods A total of 111,112 medical records of in-hospital patients with SICH were collected. Data- and expert-driven techniques were applied, such as a multivariate logistic regression model and causal mediation analysis. These analyses were used to determine the confounders and mediators, estimate the true effect of sex on the SICH outcome, and estimate the average causal mediation effect for each mediator. Results (1) Failure (disability or death) rates in women with SICH were significantly lower than in men with SICH. On the day of discharge, the odds ratio (OR) of failure between women and men was 0.9137 [95% confidence interval (CI), 0.8879–0.9402], while the odds ratio at 90 days post-discharge was 0.9353 (95% confidence interval, 0.9121–0.9591). (2) The sex-related difference in SICH outcome decreased with increasing age and disappeared after 75 years. (3) Deep coma, brainstem hemorrhage, and an infratentorial hemorrhage volume of >10 ml accounted for 62.76% (p < 0.001), 33.46% (p < 0.001), and 11.56% (p < 0.001) of the overall effect on the day of discharge, and for 52.28% (p < 0.001), 27.65% (p < 0.001), and 10.86% (p < 0.001) of the overall effect at the 90-day post-discharge. Conclusion Men have a higher failure risk than women, which may be partially mediated by a higher risk for deep coma, brainstem hemorrhage, and an infratentorial hemorrhage volume of >10 ml. Future work should explore the biological mechanisms underlying this difference.
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Affiliation(s)
- Jieyi Zhao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Zhang
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Hongli Wan
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Yang Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Wen
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyu Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xiaoyu Wang
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Abdel-Fattah AR, Pana TA, Smith TO, Pasdar Z, Aslam M, Mamas MA, Myint PK. Gender differences in mortality of hospitalised stroke patients. Systematic review and meta-analysis. Clin Neurol Neurosurg 2022; 220:107359. [PMID: 35835023 DOI: 10.1016/j.clineuro.2022.107359] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/22/2022] [Accepted: 07/03/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Gender differences in mortality after stroke remains unclear in the current literature. We therefore aimed to systematically review the gender differences in mortality up to five years after ischaemic (IS) or haemorrhagic stroke (HS) to address this evidence gap. METHODS The literature was systematically searched using Ovid EMBASE, Ovid Medline, and Web of Science databases, from inception-November 2021. The quality of evidence was appraised using the CASP Cohort-study checklist. Unadjusted and adjusted odds and hazard ratios were meta-analysed, separately for IS and HS and a subgroup analysis of age-stratified mortality data was conducted. RESULTS Forty-one studies were included (n = 8,128,700; mean-age 68.5 yrs; 47.1% female). 37 studies were included in meta-analysis (n = 8, 8008, 110). Compared to men, women who had an IS had lower mortality risk in-hospital (0.94; 95%CI 0.91-0.97), at one-month (0.87; 95%CI 0.77-0.98), 12-months (0.94; 95%CI 0.91-0.98) and five-years (0.93 95%CI 0.90-0.96). The subgroup analysis showed that this gender difference in mortality was present in women ≥ 70 years up to one-month post-IS (in-hospital: 0.94; 95%CI 0.91-0.97; one-month: 0.87; 95% CI 0.77-0.98), however, in women < 70 years this difference was no longer present. Nevertheless, analysis of crude data showed women were at higher risk of mortality in-hospital, at 12-months and five-years (in-hospital: 1.05; 95%CI 1.03-1.07, 12-months: 1.10; 95%CI 1.06-1.14, five-years: 1.06; 95%CI 1.02-1.10). After HS, women had higher mortality risk in-hospital (1.03; 95%CI 1.01-1.04) however, no gender differences were found post-discharge. CONCLUSION The gender differences in post-stroke mortality differ by stroke type, age group and follow-up. Crude stroke mortality in women is higher than in men and this appears to be driven by pre-existing comorbidities. In adjusted models, women have a lower mortality risk following IS, independent of duration of follow-up. After HS, women had higher mortality in hospital however, no gender differences after hospital discharge were found.
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Affiliation(s)
- Abdel-Rahman Abdel-Fattah
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK.
| | - Tiberiu A Pana
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
| | - Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Zahra Pasdar
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
| | - Maha Aslam
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - Phyo K Myint
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
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Neuroprotective Pentapeptide, CN-105, Improves Outcomes in Translational Models of Intracerebral Hemorrhage. Neurocrit Care 2021; 35:441-450. [PMID: 33474632 DOI: 10.1007/s12028-020-01184-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/27/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a devastating form of cerebrovascular disease for which there are no approved pharmacological interventions that improve outcomes. Apolipoprotein E (apoE) has emerged as a promising therapeutic target given its isoform-specific neuroprotective properties and ability to modify neuroinflammatory responses. We developed a 5-amino acid peptide, CN-105, that mimics the polar face of the apoE helical domain involved in receptor interactions, readily crosses the blood-brain barrier, and improves outcomes in well-established preclinical ICH models. In the current study, we investigated the therapeutic potential of CN-105 in translational ICH models that account for hypertensive comorbidity, sex, species, and age. METHODS In three separate experiments, we delivered three intravenous doses of CN-105 (up to 0.20 mg/kg) or vehicle to hypertensive male BPH/2 J mice, spontaneously hypertensive female rats, or 11-month-old male mice within 24-h of ICH. Neuropathological and neurobehavioral outcomes were determined over 3, 7, and 9 days, respectively. RESULTS In spontaneously hypertensive male mice, there was a significant dose-dependent effect of CN-105 on vestibulomotor function at 0.05 and 0.20 mg/kg doses (p < 0.05; 95% CI: 0.91-153.70 and p < 0.001; 95% CI: 49.54-205.62), while 0.20 mg/kg also improved neuroseverity scores (p < 0.05; 95% CI: 0.27-11.00) and reduced ipsilateral brain edema (p < 0.05; 95% CI: - 0.037 to - 0.001). In spontaneously hypertensive female rats, CN-105 (0.05 mg/kg) had a significant effect on vestibulomotor function (p < 0.01; η2 = 0.093) and neuroseverity scores (p < 0.05; η2 = 0.083), and reduced contralateral edema expansion (p < 0.01; 95% CI: - 1.41 to - 0.39). In 11-month-old male mice, CN-105 had a significant effect on vestibulomotor function (p < 0.001; η2 = 0.111) but not neuroseverity scores (p > 0.05; η2 = 0.034). CONCLUSIONS Acute treatment with CN-105 improves outcomes in translational ICH models independent of sex, species, age, or hypertensive comorbidity.
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Lopez-de-Andres A, Jimenez-Garcia R, Hernández-Barrera V, Jiménez-Trujillo I, de Miguel-Yanes JM, Carabantes-Alarcon D, de Miguel-Diez J, Lopez-Herranz M. Sex-related disparities in the incidence and outcomes of hemorrhagic stroke among type 2 diabetes patients: a propensity score matching analysis using the Spanish National Hospital Discharge Database for the period 2016-18. Cardiovasc Diabetol 2021; 20:138. [PMID: 34243780 PMCID: PMC8272346 DOI: 10.1186/s12933-021-01334-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/05/2021] [Indexed: 12/29/2022] Open
Abstract
Background To analyze incidence, use of therapeutic procedures, use of oral anticoagulants (OACs) and antiplatelet agents prior to hospitalization, and in-hospital outcomes among patients who were hospitalized with hemorrhagic stroke (HS) according to the presence of type 2 diabetes mellitus (T2DM) in Spain (2016–2018) and to assess the role of sex differences among those with T2DM. Methods Using the Spanish National Hospital Discharge Database we estimated the incidence of HS hospitalizations in men and women aged ≥ 35 years with and without T2DM. Propensity score matching (PSM) was used to compare population subgroups according to sex and the presence of T2DM. Results HS was coded in 31,425 men and 24,975 women, of whom 11,915 (21.12%) had T2DM. The adjusted incidence of HS was significantly higher in patients with T2DM (both sexes) than in non-T2DM individuals (IRR 1.15; 95% CI 1.12–1.17). The incidence of HS was higher in men with T2DM than in T2DM women (adjusted IRR 1.60; 95% CI 1.57–1.63). After PSM, men and women with T2DM have significantly less frequently received decompressive craniectomy than those without T2DM. In-hospital mortality (IHM) was higher among T2DM women than matched non-T2DM women (32.89% vs 30.83%; p = 0.037), with no differences among men. Decompressive craniectomy was significantly more common in men than in matched women with T2DM (5.81% vs. 3.33%; p < 0.001). IHM was higher among T2DM women than T2DM men (32.89% vs. 28.28%; p < 0.001). After adjusting for confounders with multivariable logistic regression, women with T2DM had a 18% higher mortality risk than T2DM men (OR 1.18; 95% CI 1.07–1.29). Use of OACs and antiplatelet agents prior to hospitalization were associated to higher IHM in men and women with and without T2DM. Conclusions T2DM is associated with a higher incidence of HS and with less frequent use of decompressive craniectomy in both sexes, but with higher IHM only among women. Sex differences were detected in T2DM patients who had experienced HS, with higher incidence rates, more frequent decompressive craniectomy, and lower IHM in men than in women. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01334-2.
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Affiliation(s)
- Ana Lopez-de-Andres
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040, Madrid, Spain
| | - Rodrigo Jimenez-Garcia
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040, Madrid, Spain.
| | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - Isabel Jiménez-Trujillo
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - José M de Miguel-Yanes
- Internal Medicine Department. Hospital General, Universitario Gregorio Marañón, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - David Carabantes-Alarcon
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040, Madrid, Spain
| | - Javier de Miguel-Diez
- Respiratory Care Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Marta Lopez-Herranz
- Faculty of Nursing, Physiotherapy and Podology, Universidad Complutense de Madrid, Madrid, Spain
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11
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Sun Q, Xu X, Wang T, Xu Z, Lu X, Li X, Chen G. Neurovascular Units and Neural-Glia Networks in Intracerebral Hemorrhage: from Mechanisms to Translation. Transl Stroke Res 2021; 12:447-460. [PMID: 33629275 DOI: 10.1007/s12975-021-00897-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH), the most lethal type of stroke, often leads to poor outcomes in the clinic. Due to the complex mechanisms and cell-cell crosstalk during ICH, the neurovascular unit (NVU) was proposed to serve as a promising therapeutic target for ICH research. This review aims to summarize the development of pathophysiological shifts in the NVU and neural-glia networks after ICH. In addition, potential targets for ICH therapy are discussed in this review. Beyond cerebral blood flow, the NVU also plays an important role in protecting neurons, maintaining central nervous system (CNS) homeostasis, coordinating neuronal activity among supporting cells, forming and maintaining the blood-brain barrier (BBB), and regulating neuroimmune responses. During ICH, NVU dysfunction is induced, along with neuronal cell death, microglia and astrocyte activation, endothelial cell (EC) and tight junction (TJ) protein damage, and BBB disruption. In addition, it has been shown that certain targets and candidates can improve ICH-induced secondary brain injury based on an NVU and neural-glia framework. Moreover, therapeutic approaches and strategies for ICH are discussed.
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Affiliation(s)
- Qing Sun
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Xiang Xu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Tianyi Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Zhongmou Xu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Xiaocheng Lu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China.
| | - Xiang Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China.
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
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Molecular Correlates of Hemorrhage and Edema Volumes Following Human Intracerebral Hemorrhage Implicate Inflammation, Autophagy, mRNA Splicing, and T Cell Receptor Signaling. Transl Stroke Res 2020; 12:754-777. [PMID: 33206327 PMCID: PMC8421315 DOI: 10.1007/s12975-020-00869-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/02/2020] [Accepted: 10/18/2020] [Indexed: 12/16/2022]
Abstract
Intracerebral hemorrhage (ICH) and perihematomal edema (PHE) volumes are major determinants of ICH outcomes as is the immune system which plays a significant role in damage and repair. Thus, we performed whole-transcriptome analyses of 18 ICH patients to delineate peripheral blood genes and networks associated with ICH volume, absolute perihematomal edema (aPHE) volume, and relative PHE (aPHE/ICH; rPHE). We found 440, 266, and 391 genes correlated with ICH and aPHE volumes and rPHE, respectively (p < 0.005, partial-correlation > |0.6|). These mainly represented inflammatory pathways including NF-κB, TREM1, and Neuroinflammation Signaling-most activated with larger volumes. Weighted Gene Co-Expression Network Analysis identified seven modules significantly correlated with these measures (p < 0.05). Most modules were enriched in neutrophil, monocyte, erythroblast, and/or T cell-specific genes. Autophagy, apoptosis, HIF-1α, inflammatory and neuroinflammatory response (including Toll-like receptors), cell adhesion (including MMP9), platelet activation, T cell receptor signaling, and mRNA splicing were represented in these modules (FDR p < 0.05). Module hub genes, potential master regulators, were enriched in neutrophil-specific genes in three modules. Hub genes included NCF2, NCF4, STX3, and CSF3R, and involved immune response, autophagy, and neutrophil chemotaxis. One module that correlated negatively with ICH volume correlated positively with rPHE. Its genes and hubs were enriched in T cell-specific genes including hubs LCK and ITK, Src family tyrosine kinases whose modulation improved outcomes and reduced BBB dysfunction following experimental ICH. This study uncovers molecular underpinnings associated with ICH and PHE volumes and pathophysiology in human ICH, where knowledge is scarce. The identified pathways and hub genes may represent novel therapeutic targets.
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13
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Howe MD, Furr JW, Zhu L, Edwards NJ, McCullough LD, Gonzales NR. Sex-specific Association of Matrix Metalloproteinases with Secondary Injury and Outcomes after Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:1718-1725. [PMID: 30922669 DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/02/2019] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Intracerebral hemorrhage affects approximately 2 million individuals per year. While the incidence is roughly equal in men and women, few studies have examined the influence of sex on secondary injury and associated long-term functional outcomes. Matrix metalloproteinases (MMPs) promote vessel rupture and worsen outcomes by potentiating blood-brain barrier breakdown after injury. We hypothesized that different MMP isoform levels would be predictive of injury severity, secondary injury, and long-term functional outcomes in males and females, respectively. METHODS We examined the levels of MMP isoforms in serum samples from a prospective patient biobank (n = 55). Baseline clinical, radiographic, and laboratory data were also analyzed. RESULTS We found that MMP-1 (P = .036), MMP-2 (P = .014), MMP-3 (P < .001), and MMP-9 (P = .02) levels gradually increased over time in male patients until 10 DPI. In female patients, we found a different pattern of activation: MMP-8 (P = .02) was the only isoform that significantly changed with time, which reached a peak at 3-5 days postinjury. Several MMP isoforms correlated with markers of secondary injury in female patients (all P < .05). Additionally, serum levels of MMP-3 (P = .011) in males and MMP-10 (P = .044) in females were significantly associated with long-term functional outcomes in a sex-specific manner. CONCLUSIONS This is the first sex-specific study to examine serum MMP levels and their correlation with clinicoradiologic measures after intracerebral hemorrhage, and identifies potential biomarkers of secondary injury and long-term outcomes in both sexes.
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Affiliation(s)
- Matthew D Howe
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas.
| | - J Weldon Furr
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Liang Zhu
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Nancy J Edwards
- Neuroscience, Kaiser Permanente Redwood City Medical Center, Redwood City, California
| | - Louise D McCullough
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Nicole R Gonzales
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas
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Yu HH, Pan C, Tang YX, Liu N, Zhang P, Hu Y, Zhang Y, Wu Q, Deng H, Li GG, Li YY, Nie H, Tang ZP. Effects of Prior Antiplatelet Therapy on the Prognosis of Primary Intracerebral Hemorrhage: A Meta-analysis. Chin Med J (Engl) 2018; 130:2969-2977. [PMID: 29237930 PMCID: PMC5742925 DOI: 10.4103/0366-6999.220302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Antiplatelet therapy (APT) was prevalently being used in the prevention of vascular disease, but the influence of prior APT on the prognosis of patients with intracerebral hemorrhage (ICH) remains controversial. This meta-analysis was to explore the effects of prior APT on the prognosis of patients with primary ICH. METHODS PubMed and Embase were searched to identify the eligible studies. The studies comparing the mortality of ICH patients with or without prior APT were included. The quality of these studies was evaluated by the Newcastle-Ottawa quality assessment scale. The adjusted or unadjusted odds ratio (OR) for mortality between ICH patients with and without prior APT were pooled with 95% confidence interval (95% CI) as the effect of this meta-analysis. RESULTS Twenty-two studies fulfilled the inclusion criteria and exhibited high qualities. The pooled OR was 1.37 (95% CI: 1.13-1.66, P = 0.001) for univariate analysis and 1.41 (95% CI: 1.05-1.90, P = 0.024) for multivariate analysis. The meta-regression indicated that for each 1-day increase in the time of assessment, the adjusted OR for the mortality of APT patients decreased by 0.0049 (95% CI: 0.0006-0.0091, P = 0.026) as compared to non-APT patients. CONCLUSION Prior APT was associated with high mortality in patients with ICH that might be attributed primarily to its strong effect on early time.
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Affiliation(s)
- Hai-Han Yu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Ying-Xin Tang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Na Liu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Ping Zhang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yang Hu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Ye Zhang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Qian Wu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Hong Deng
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Gai-Gai Li
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yan-Yan Li
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Hao Nie
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Zhou-Ping Tang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
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James ML, Christianson T, Woo D, Kon NKK. Gonadal hormone regulation as therapeutic strategy after acute intracerebral hemorrhage. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105817725081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Daniel Woo
- Department of Neurology, University of Cincinnati, USA
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Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017; 2:94-105. [PMID: 28959497 PMCID: PMC5600018 DOI: 10.1136/svn-2017-000092] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/06/2023] Open
Abstract
The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.
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Affiliation(s)
- Cora H Ormseth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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