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Amikam U, Badeghiesh A, Baghlaf H, Brown R, Dahan MH. Transient ischemic attack and pregnancy, delivery and neonatal outcomes-An evaluation of a population database. Int J Gynaecol Obstet 2024; 166:412-418. [PMID: 38311958 DOI: 10.1002/ijgo.15387] [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: 12/15/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE Transient ischemic attack (TIA) is rare in women of reproductive age. We aimed to compare perinatal outcomes between women who suffered from a TIA to those who did not. METHODS A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). All women who delivered or had a maternal death in the US (2004-2014) were included in the study. Pregnancy, delivery, and neonatal outcomes were compared between women with an ICD-9 diagnosis of a TIA to those without. RESULTS Overall, 9 096 788 women met the inclusion criteria. Of these, 203 women (2.2/100000) had a TIA (either before or during pregnancy). Women with TIA, compared to those without, were more likely to be older than 35 years of age, white, in the highest income quartile, be insured by private insurance and suffer from obesity and chronic hypertension. Patients in the TIA group, compared to those without, had a higher rate of pregnancy-induced hypertension (aOR 2.5, 95% CI: 1.55-4.05, P < 0.001), pre-eclampsia (aOR 3.77, 95% CI: 2.15-6.62, P < 0.001), eclampsia (aOR 28.05, 95% CI: 6.91-113.95, P < 0.001), preterm delivery (aOR 1.78, 95% CI: 1.03-3.07, P = 0.039), and maternal complications such as deep vein thrombosis (aOR 33.3, 95% CI: 8.07-137.42, P < 0.001). Regarding neonatal outcomes, patients with a TIA, compared to those without, had a higher rate of congenital anomalies (aOR 7.04, 95% CI: 2.86-17.32, P < 0.001). CONCLUSION Women with a TIA diagnosis before or during pregnancy had a higher rate of maternal complications, including hypertensive disorders of pregnancy and venous thromboembolism, as well as an increased risk of congenital anomalies.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Rabigh Branch, Rabigh, Saudi Arabia
| | - Haitham Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
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Chen H, Yang F, Duan Y, Yang L, Li J. A novel higher performance nomogram based on explainable machine learning for predicting mortality risk in stroke patients within 30 days based on clinical features on the first day ICU admission. BMC Med Inform Decis Mak 2024; 24:161. [PMID: 38849903 PMCID: PMC11161998 DOI: 10.1186/s12911-024-02547-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND This study aimed to develop a higher performance nomogram based on explainable machine learning methods, and to predict the risk of death of stroke patients within 30 days based on clinical characteristics on the first day of intensive care units (ICU) admission. METHODS Data relating to stroke patients were extracted from the Medical Information Marketplace of the Intensive Care (MIMIC) IV and III database. The LightGBM machine learning approach together with Shapely additive explanations (termed as explain machine learning, EML) was used to select clinical features and define cut-off points for the selected features. These selected features and cut-off points were then evaluated using the Cox proportional hazards regression model and Kaplan-Meier survival curves. Finally, logistic regression-based nomograms for predicting 30-day mortality of stroke patients were constructed using original variables and variables dichotomized by cut-off points, respectively. The performance of two nomograms were evaluated in overall and individual dimension. RESULTS A total of 2982 stroke patients and 64 clinical features were included, and the 30-day mortality rate was 23.6% in the MIMIC-IV datasets. 10 variables ("sofa (sepsis-related organ failure assessment)", "minimum glucose", "maximum sodium", "age", "mean spo2 (blood oxygen saturation)", "maximum temperature", "maximum heart rate", "minimum bun (blood urea nitrogen)", "minimum wbc (white blood cells)" and "charlson comorbidity index") and respective cut-off points were defined from the EML. In the Cox proportional hazards regression model (Cox regression) and Kaplan-Meier survival curves, after grouping stroke patients according to the cut-off point of each variable, patients belonging to the high-risk subgroup were associated with higher 30-day mortality than those in the low-risk subgroup. The evaluation of nomograms found that the EML-based nomogram not only outperformed the conventional nomogram in NIR (net reclassification index), brier score and clinical net benefits in overall dimension, but also significant improved in individual dimension especially for low "maximum temperature" patients. CONCLUSIONS The 10 selected first-day ICU admission clinical features require greater attention for stroke patients. And the nomogram based on explainable machine learning will have greater clinical application.
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Affiliation(s)
- Haoran Chen
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China.
- Key Laboratory of Medical Information Intelligent Technology, Chinese Academy of Medical Sciences, Beijing, 100020, China.
| | - Fengchun Yang
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China
- Key Laboratory of Medical Information Intelligent Technology, Chinese Academy of Medical Sciences, Beijing, 100020, China
| | - Yifan Duan
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China
| | - Lin Yang
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China
- Key Laboratory of Medical Information Intelligent Technology, Chinese Academy of Medical Sciences, Beijing, 100020, China
| | - Jiao Li
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China.
- Key Laboratory of Medical Information Intelligent Technology, Chinese Academy of Medical Sciences, Beijing, 100020, China.
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Barone V, Foschi M, Pavolucci L, Rondelli F, Rinaldi R, Nicodemo M, D’Angelo R, Favaretto E, Brusi C, Cosmi B, Degli Esposti D, D’Addato S, Bacchelli S, Giostra F, Pomata DP, Spinardi L, Faccioli L, Faggioli G, Donti A, Borghi C, Cortelli P, Guarino M. Enhancing stroke risk prediction in patients with transient ischemic attack: insights from a prospective cohort study implementing fast-track care. Front Neurol 2024; 15:1407598. [PMID: 38859972 PMCID: PMC11163114 DOI: 10.3389/fneur.2024.1407598] [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: 03/26/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024] Open
Abstract
Background and aims Fast-track care have been proved to reduce the short-term risk of stroke after transient ischemic attack (TIA). We aimed to investigate stroke risk and to characterize short- and long-term stroke predictors in a large cohort of TIA patients undergoing fast-track management. Methods Prospective study, enrolling consecutive TIA patients admitted to a Northern Italy emergency department from August 2010 to December 2017. All patients underwent fast-track care within 24 h of admission. The primary outcome was defined as the first stroke recurrence at 90 days, 12 and 60 months after TIA. Stroke incidence with 95% confidence interval (CI) at each timepoint was calculated using Poisson regression. Predictors of stroke recurrence were evaluated with Cox regression analysis. The number needed to treat (NNT) of fast-track care in preventing 90-day stroke recurrence in respect to the estimates based on baseline ABCD2 score was also calculated. Results We enrolled 1,035 patients (54.2% males). Stroke incidence was low throughout the follow-up with rates of 2.2% [95% CI 1.4-3.3%] at 90 days, 2.9% [95% CI 1.9-4.2%] at 12 months and 7.1% [95% CI 5.4-9.0%] at 60 months. Multiple TIA, speech disturbances and presence of ischemic lesion at neuroimaging predicted stroke recurrence at each timepoint. Male sex and increasing age predicted 90-day and 60-month stroke risk, respectively. Hypertension was associated with higher 12-month and 60-month stroke risk. No specific TIA etiology predicted higher stroke risk throughout the follow-up. The NNT for fast-track care in preventing 90-day stroke was 14.5 [95% CI 11.3-20.4] in the overall cohort and 6.8 [95% CI 4.6-13.5] in patients with baseline ABCD2 of 6 to 7. Conclusion Our findings support the effectiveness of fast-track care in preventing both short- and long-term stroke recurrence after TIA. Particular effort should be made to identify and monitor patients with baseline predictors of higher stroke risk, which may vary according to follow-up duration.
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Affiliation(s)
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
- Department of Neuroscience, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Lucia Pavolucci
- Department of Neuroscience, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | | | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | | | | | - Elisabetta Favaretto
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carlotta Brusi
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniela Degli Esposti
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sergio D’Addato
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Bacchelli
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabrizio Giostra
- Emergency Department, Medicina d’Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniela Paola Pomata
- Emergency Department, Medicina d’Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, DIMEC – University of Bologna, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Donti
- Pediatric Cardiology and Adult Congenital Heart Disease Program, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudio Borghi
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
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Cannizzaro F, Izquierdo A, Cocho D. Rate of atrial fibrillation by Holter-Stroke Risk Analysis in undetermined TIA/rapidly improving stroke symptoms patients. Front Neurol 2024; 15:1353812. [PMID: 38742045 PMCID: PMC11089105 DOI: 10.3389/fneur.2024.1353812] [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: 12/11/2023] [Accepted: 04/02/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction Holter-SRA (Stroke Risk Analysis) is an automated analysis of ECG monitoring for Atrial Fibrillation (AF) detection. The aim of this study was to evaluate the rate of AF in undetermined TIA/Rapidly improving stroke symptoms (RISS) patients. Methods Prospective study of undetermined TIA/RISS patients who presented to the emergency department. Early vascular studies (angio CT, transthoracic echocardiography and ECG) were performed in emergency department. The Holter-SRA device was placed for 2 h and the patients were classified into: confirmed AF, high risk of AF or low risk of AF. Prolonged ambulatory monitoring (7 days) was carried out every month for patients with a high-risk pattern. The results were evaluated until definitive detection of AF or low-risk pattern. The endpoints were rate of AF and vascular recurrence at 90 days. Results Over a period of 24 months, 83 undetermined TIA/RISS patients were enrolled. The mean age was 70 ± 10 years and 61% were men. The median ABCD2 score was 4 points (1-7). After 2 h of monitoring in the emergency department, AF was detected in one patient (1.2%), 51 patients with a low-risk pattern and 31 patients (37.3%) showed a high-risk pattern of AF. During the ambulatory monitoring, of the 31 patients high risk pattern patients, AF was diagnosed to 17 cases and of the 51 patients with a low-risk pattern, one case experienced a recurrent vascular due to undetected AF (1.9% false negative). Three patients (3.6%) suffered a vascular recurrence within the first 90 days, before AF diagnosis. Conclusions In our study, AF was detected in 22.9% of the 83 patients with indeterminate TIA/RISS. Holter-SRA has allowed us to increase the detection of AF, especially those patients with a high-risk pattern in the first 3 months.
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Affiliation(s)
- F Cannizzaro
- Family Medicine Department, Hospital General de Granollers, Barcelona, Spain
| | - A Izquierdo
- Neurology Department, Hospital General de Granollers, Barcelona, Spain
| | - D Cocho
- Neurology Department, Hospital General de Granollers, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
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Pitton Rissardo J, Fornari Caprara AL. Limb-Shaking And Transient Ischemic Attack: A Systematic Review. Neurologist 2024; 29:126-132. [PMID: 37839077 DOI: 10.1097/nrl.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND Limb-shaking is one of the transient ischemic attacks (TIA) 'chameleons.' This literature review aims to evaluate the clinical, epidemiological profile, pathologic mechanisms, and management of limb-shaking TIA. REVIEW SUMMARY Relevant reports in Medline's (PubMed) database were identified and assessed by 2 reviewers without language restriction from 1985 to 2022. A total of 82 reports containing 161 cases that developed limb-shaking TIA were reported. The mean and median age were 61.36 (SD: 15.29) and 62 years (range: 4-93 y). Most of the individuals affected were males (64.34%). Limb-shaking was reported as unilateral in 83.33% of the patients. Limb-shaking presented with other neurological deficits in 44.33% of the individuals, in which the most common concurrent neurological deficit was the weakness of at least 1 limb. A recurrence of the "shaking" phenomenon was observed in 83 individuals. A trigger of limb-shaking was reported in 69 cases, and the most common was changing body position. The internal carotid artery was the most frequent vessel involved in limb-shaking. A chronically occluded internal carotid artery was observed in 42 individuals. Hypertension was the most common comorbidity. The management was conservative in 42.30% of the cases. The most frequent misdiagnoses were seizures. A full recovery was achieved in 56.60% of the individuals. CONCLUSIONS Limb-shaking TIA could be defined as involuntary, rhythmic, brief (<5 min), recurrent, jerky movement usually precipitated by activities that may reduce cerebral blood flow. The "shaking" phenomenon was primarily described as a manifestation of symptomatic complete internal carotid artery obstruction.
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Madsen TE, Ding L, Khoury JC, Haverbusch M, Woo D, Ferioli S, De Los Rios La Rosa F, Martini SR, Adeoye O, Khatri P, Flaherty ML, Mackey J, Mistry EA, Demel S, Coleman E, Jasne A, Slavin S, Walsh KB, Star M, Broderick JP, Kissela B, Kleindorfer DO. Trends Over Time in Stroke Incidence by Race in the Greater Cincinnati Northern Kentucky Stroke Study. Neurology 2024; 102:e208077. [PMID: 38546235 PMCID: PMC11097768 DOI: 10.1212/wnl.0000000000208077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/07/2023] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Understanding the current status of and temporal trends of stroke epidemiology by age, race, and stroke subtype is critical to evaluate past prevention efforts and to plan future interventions to eliminate existing inequities. We investigated trends in stroke incidence and case fatality over a 22-year time period. METHODS In this population-based stroke surveillance study, all cases of stroke in acute care hospitals within a 5-county population of southern Ohio/northern Kentucky in adults aged ≥20 years were ascertained during a full year every 5 years from 1993 to 2015. Temporal trends in stroke epidemiology were evaluated by age, race (Black or White), and subtype (ischemic stroke [IS], intracranial hemorrhage [ICH], or subarachnoid hemorrhage [SAH]). Stroke incidence rates per 100,000 individuals from 1993 to 2015 were calculated using US Census data and age-standardized, race-standardized, and sex-standardized as appropriate. Thirty-day case fatality rates were also reported. RESULTS Incidence rates for stroke of any type and IS decreased in the combined population and among White individuals (any type, per 100,000, 215 [95% CI 204-226] in 1993/4 to 170 [95% CI 161-179] in 2015, p = 0.015). Among Black individuals, incidence rates for stroke of any type decreased over the study period (per 100,000, 349 [95% CI 311-386] in 1993/4 to 311 [95% CI 282-340] in 2015, p = 0.015). Incidence of ICH was stable over time in the combined population and in race-specific subgroups, and SAH decreased in the combined groups and in White adults. Incidence rates among Black adults were higher than those of White adults in all time periods, and Black:White risk ratios were highest in adults in young and middle age groups. Case fatality rates were similar by race and by time period with the exception of SAH in which 30-day case fatality rates decreased in the combined population and White adults over time. DISCUSSION Stroke incidence is decreasing over time in both Black and White adults, an encouraging trend in the burden of cerebrovascular disease in the US population. Unfortunately, however, Black:White disparities have not decreased over a 22-year period, especially among younger and middle-aged adults, suggesting the need for more effective interventions to eliminate inequities by race.
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Affiliation(s)
- Tracy E Madsen
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Lili Ding
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Jane C Khoury
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Mary Haverbusch
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Daniel Woo
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Simona Ferioli
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Felipe De Los Rios La Rosa
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Sharyl R Martini
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Opeolu Adeoye
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Pooja Khatri
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Matthew L Flaherty
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Jason Mackey
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Eva A Mistry
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Stacie Demel
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Elisheva Coleman
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Adam Jasne
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Sabreena Slavin
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Kyle B Walsh
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Michael Star
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Joseph P Broderick
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Brett Kissela
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
| | - Dawn O Kleindorfer
- From the Department of Emergency Medicine (T.E.M.), Alpert Medical School of Brown University; Department of Epidemiology (T.E.M.), Brown University School of Public Health, Providence, RI; Division of Biostatistics and Epidemiology (L.D., J.C.K.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Department of Neurology and Rehabilitation Medicine (M.H., D.W., S.F., F.D.L.R.L.R., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), University of Cincinnati College of Medicine; UC Gardner Neuroscience Institute (S.F., P.K., M.L.F., E.A.M., S.D., K.B.W., J.P.B., B.K., D.O.K.), Cincinnati, OH; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, FL; Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale School of Medicine, New Haven, CT; University of Kansas Medical Center (S.S.), Kansas City; Soroka Medical Center (M.S.), Beersheba, Israel; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor
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Wen J, Zhang T, Ye S, Zhang P, Han R, Chen X, Huang R, Chen A, Li Q. Quantitative patient graph analysis for transient ischemic attack risk factor distribution based on electronic medical records. Heliyon 2024; 10:e22766. [PMID: 38163107 PMCID: PMC10755279 DOI: 10.1016/j.heliyon.2023.e22766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/26/2023] [Accepted: 11/19/2023] [Indexed: 01/03/2024] Open
Abstract
A transient ischemic attack (TIA) affects millions of people worldwide. Although TIA risk factors have been identified individually, a systemic quantitative analysis of all health factors relevant to TIA using electronic medical records (EMR) remains lacking. This study employed a data-driven approach, leveraging hospital EMR data to create a TIA patient health factor graph. This graph consisted of 737 TIA and 737 control patient nodes, 740 health factor nodes, and over 33,000 relations between patients and factors. For all health factors in the graph, the connection delta ratios (CDRs) were determined and ranked, generating a quantitative distribution of TIA health factors. A literature review confirmed 56 risk factors in the distribution and unveiled a potential new risk factor "rhinosinusitis" for future validation. Moreover, the patient graph was visualized together with the TIA knowledge graph in the Unified Medical Language System. This integration enables clinicians to access and visualize patient data and international standard knowledge within a unified graph. In conclusion, graph CDR analysis can effectively quantify the distribution of TIA risk factors. The resulting TIA risk factor distribution might be instrumental in developing new risk prediction machine learning models for screening and early detection of TIA.
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Affiliation(s)
- Jian Wen
- Guilin Medical University Affiliated Hospital, Guilin, Guangxi, China
| | - Tianmei Zhang
- Guilin Medical University Affiliated Hospital, Guilin, Guangxi, China
| | - Shangrong Ye
- Guilin Medical University Affiliated Hospital, Guilin, Guangxi, China
| | - Peng Zhang
- Guilin Medical University Affiliated Hospital, Guilin, Guangxi, China
| | - Ruobing Han
- Guilin Medical University Affiliated Hospital, Guilin, Guangxi, China
| | - Xiaowang Chen
- Guilin Medical University Affiliated Hospital, Guilin, Guangxi, China
| | - Ran Huang
- West China Hospital, Chengdu, Sichuan, China
| | - Anjun Chen
- Learning Health Community, Palo Alto, CA, USA
| | - Qinghua Li
- Guilin Medical University Affiliated Hospital, Guilin, Guangxi, China
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8
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Roy A, Sreekrishnan A, Camargo Faye E, Silverman S, Zachrison KS, Harriott AM, Matiello M, Manzano GS, Prasanna M, Nedelcu S, Singhal AB. Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke. Neurol Clin Pract 2023; 13:e200209. [PMID: 37829551 PMCID: PMC10567120 DOI: 10.1212/cpj.0000000000200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 08/28/2023] [Indexed: 10/14/2023]
Abstract
Background and Objectives Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging. Methods As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months. Results We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge. Discussion Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.
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Affiliation(s)
- Alexis Roy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anirudh Sreekrishnan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Erica Camargo Faye
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Scott Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kori S Zachrison
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea M Harriott
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marcelo Matiello
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giovanna S Manzano
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mrinalini Prasanna
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Simona Nedelcu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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9
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Chu T, Lee S, Jung IY, Song Y, Kim HA, Shin JW, Tak S. Task-residual effective connectivity of motor network in transient ischemic attack. Commun Biol 2023; 6:843. [PMID: 37580508 PMCID: PMC10425379 DOI: 10.1038/s42003-023-05212-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/03/2023] [Indexed: 08/16/2023] Open
Abstract
Transient ischemic attack (TIA) is a temporary episode of neurological dysfunction that results from focal brain ischemia. Although TIA symptoms are quickly resolved, patients with TIA have a high risk of stroke and persistent impairments in multiple domains of cognitive and motor functions. In this study, using spectral dynamic causal modeling, we investigate the changes in task-residual effective connectivity of patients with TIA during fist-closing movements. 28 healthy participants and 15 age-matched patients with TIA undergo functional magnetic resonance imaging at 7T. Here we show that during visually cued motor movement, patients with TIA have significantly higher effective connectivity toward the ipsilateral primary motor cortex and lower connectivity to the supplementary motor area than healthy controls. Our results imply that TIA patients have aberrant connections among motor regions, and these changes may reflect the decreased efficiency of primary motor function and disrupted control of voluntary movement in patients with TIA.
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Affiliation(s)
- Truc Chu
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju, 28119, Republic of Korea
- Graduate School of Analytical Science and Technology, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Seonjin Lee
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju, 28119, Republic of Korea
- Graduate School of Analytical Science and Technology, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Il-Young Jung
- Department of Rehabilitation Medicine, Chungnam National University Sejong Hospital, Sejong, 30099, Republic of Korea
| | - Youngkyu Song
- Bio-Chemical Analysis Team, Korea Basic Science Institute, Cheongju, 28119, Republic of Korea
| | - Hyun-Ah Kim
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
| | - Jong Wook Shin
- Department of Neurology, Chungnam National University Sejong Hospital, Sejong, 30099, Republic of Korea.
| | - Sungho Tak
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju, 28119, Republic of Korea.
- Graduate School of Analytical Science and Technology, Chungnam National University, Daejeon, 34134, Republic of Korea.
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10
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Jeerakathil TJ, Yu AYX, Choi PMC, Fang S, Shuaib A, Majumdar SR, Demchuk AM, Butcher K, Watson TJ, Dean N, Gordon D, Hill MD, Edmond C, Coutts SB. Effects of a Province-wide Triaging System for TIA: The ASPIRE Intervention. Neurology 2023; 100:e2093-e2102. [PMID: 36977597 PMCID: PMC10186240 DOI: 10.1212/wnl.0000000000207201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 02/03/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Urgent transient ischemic attack (TIA) management to reduce stroke recurrence is challenging, particularly in rural and remote areas. In Alberta, Canada, despite an organized stroke system, data from 1999 to 2000 suggested that stroke recurrence after TIA was as high as 9.5% at 90 days. Our objective was to determine whether a multifaceted population-based intervention resulted in a reduction in recurrent stroke after TIA. METHODS In this quasi-experimental health services research intervention study, we implemented a TIA management algorithm across the entire province, centered around a 24-hour physician's TIA hotline and public and health provider education on TIA. From administrative databases, we linked emergency department discharge abstracts to hospital discharge abstracts to identify incident TIAs and recurrent strokes at 90 days across a single payer system with validation of recurrent stroke events. The primary outcome was recurrent stroke; with a secondary composite outcome of recurrent stroke, acute coronary syndrome, and all-cause death. We used an interrupted time series regression analysis of age-adjusted and sex-adjusted stroke recurrence rates after TIA, incorporating a 2-year preimplementation period (2007-2009), a 15-month implementation period, and a 2-year postimplementation period (2010-2012). Logistic regression was used to examine outcomes that did not fit the time series model. RESULTS We assessed 6,715 patients preimplementation and 6,956 patients postimplementation. The 90-day stroke recurrence rate in the pre-Alberta Stroke Prevention in TIA and mild Strokes (ASPIRE) period was 4.5% compared with 5.3% during the post-ASPIRE period. There was neither a step change (estimate 0.38; p = 0.65) nor slope change (parameter estimate 0.30; p = 0.12) in recurrent stroke rates associated with the ASPIRE intervention implementation period. Adjusted all-cause mortality (odds ratio 0.71, 95% CI 0.56-0.89) was significantly lower after the ASPIRE intervention. DISCUSSION The ASPIRE TIA triaging and management interventions did not further reduce stroke recurrence in the context of an organized stroke system. The apparent lower mortality postintervention may be related to improved surveillance after events identified as TIAs, but secular trends cannot be excluded. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that a standardized population-wide algorithmic triage system for patients with TIA did not reduce recurrent stroke rate.
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Affiliation(s)
- Thomas J Jeerakathil
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
| | - Amy Ying Xin Yu
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Philip M C Choi
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Shoufan Fang
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Ashfaq Shuaib
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Sumit R Majumdar
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Andrew M Demchuk
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Kenneth Butcher
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Tim J Watson
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Naeem Dean
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Deb Gordon
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Michael D Hill
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Cathy Edmond
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Shelagh B Coutts
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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11
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Amin HP, Madsen TE, Bravata DM, Wira CR, Johnston SC, Ashcraft S, Burrus TM, Panagos PD, Wintermark M, Esenwa C. Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association. Stroke 2023; 54:e109-e121. [PMID: 36655570 DOI: 10.1161/str.0000000000000418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
At least 240 000 individuals experience a transient ischemic attack each year in the United States. Transient ischemic attack is a strong predictor of subsequent stroke. The 90-day stroke risk after transient ischemic attack can be as high as 17.8%, with almost half occurring within 2 days of the index event. Diagnosing transient ischemic attack can also be challenging given the transitory nature of symptoms, often reassuring neurological examination at the time of evaluation, and lack of confirmatory testing. Limited resources, such as imaging availability and access to specialists, can further exacerbate this challenge. This scientific statement focuses on the correct clinical diagnosis, risk assessment, and management decisions of patients with suspected transient ischemic attack. Identification of high-risk patients can be achieved through use of comprehensive protocols incorporating acute phase imaging of both the brain and cerebral vasculature, thoughtful use of risk stratification scales, and ancillary testing with the ultimate goal of determining who can be safely discharged home from the emergency department versus admitted to the hospital. We discuss various methods for rapid yet comprehensive evaluations, keeping resource-limited sites in mind. In addition, we discuss strategies for secondary prevention of future cerebrovascular events using maximal medical therapy and patient education.
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12
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Yurtsever G, Karaali R, Bora ES. Evaluation of ABCD2 score during the development of stroke in COVID-19 patients diagnosed with transient ischemic attack in the emergency department. J Stroke Cerebrovasc Dis 2023; 32:106918. [PMID: 36621122 PMCID: PMC9715486 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106918] [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: 06/23/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The aim of the present study is to reveal the association between the risk of stroke using ABCD2 score and COVID-19 in patients who presented to our emergency department during the pandemic and were diagnosed with TIA. METHODS According to the recommendations of the European Stroke Association, patients with an ABCD2 score of <4 were classified as low-risk, and patients with an ABCD2 score of ≥4 were classified as high-risk. Within 90 days of the patient's admission to the emergency room, the development of stroke was tracked and recorded on the system. RESULTS Stroke occurred in 35.78% of the patients. Regarding COVID-19, 75.34% of stroke patients were positive for COVID-19 and 65.75% had COVID-19 compatible pneumonia on 'thoracic CT'. Regarding mortality, 16.4% of the patients who were positive for COVID-19 and developed a stroke died. The presence of COVID-19 compatible pneumonia on thorax CT, PCR test result and ABCD2 score were determined as independent risk factors for the development of stroke. According to the PCR test results, the probability of having a stroke decreases 0.283 times in patients who are negative for COVID-19. According to the PCR test results, the probability of having a stroke increased 2.7 times in COVID-19 positive patients. CONCLUSIONS Adding the presence of COVID-19 and the presence of COVID-19 pneumonia to the ABCD2 score, based on the information about the increased risk of stroke in TIA patients, improves the predictive power of the score. More studies are needed in this regard.
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Affiliation(s)
- Güner Yurtsever
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey.
| | - Rezan Karaali
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey
| | - Ejder Saylav Bora
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey
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13
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Predictive Role of hsCRP in Recurrent Stroke Differed According to Severity of Cerebrovascular Disease: Analysis from a Prospective Cohort Study. J Clin Med 2023; 12:jcm12041676. [PMID: 36836211 PMCID: PMC9967664 DOI: 10.3390/jcm12041676] [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: 12/27/2022] [Revised: 01/26/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Elevated levels of high-sensitivity C-reactive protein (hsCRP) were associated with an increased risk of recurrent stroke. However, it is still unknown whether the predictive value of hsCRP differed according to the severity of cerebrovascular disease. We used the cohort of the prospective multicenter cohort study of the Third China National Stroke Registry (CNSR-III), in which 10,765 consecutive patients with acute ischemic stroke or transient ischemic attack (TIA) had hsCRP levels measured. Patients were classified into minor stroke, or TIA, and non-minor stroke. The primary outcome was a new stroke within 1 year. Cox proportional hazards models were used to assess the association of hsCRP and its outcome. Elevated levels of hsCRP were associated with an increased risk of recurrent stroke in minor stroke or TIA patients, irrespective of using a National Institutes of Health Stroke Scale (NIHSS) score of ≤3 (the highest quartile vs. the lowest quartile: adjusted hazard ratio, 1.48; 95% CI, 1.12-1.97; p = 0.007) or ≤5 (the highest quartile vs. the lowest quartile: adjusted hazard ratio, 1.45; 95% CI, 1.15-1.84; p = 0.002) to define minor stroke. Such association was more apparent in the large-artery atherosclerosis subtype. However, for the patients with non-minor stroke, the association of hsCRP with recurrent stroke disappeared.
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14
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Marriott DJ, Kuo S, Ye W, Levine DA, Herman WH. Cost-effectiveness of carotid artery stenting vs endarterectomy: A simulation. J Stroke Cerebrovasc Dis 2023; 32:106908. [PMID: 36462450 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/20/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Clinical trials conducted before the introduction of modern medical management to prevent stroke demonstrated that carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke following transient ischemic attack (TIA). We compared the cost-effectiveness of CEA, CAS, and modern medical management in two secular settings of medical management in individuals with incident TIA and type 2 diabetes. METHODS Using simulation modeling, our base-case analyses were performed from the healthcare sector perspective over a 20-year time horizon with an annual 3% discount rate applied to both costs and quality-adjusted life years (QALYs). Outcomes depended on age, sex, biomarkers associated with cardiovascular risk, and treatment effects based on a validated model of type 2 diabetes. Our simulation population was drawn from the National Health and Nutrition Examination Survey (NHANES) 2014 cohort. Costs for modern medical management were based on average wholesale prices, and revascularization costs were derived from published literature. One-way and probabilistic sensitivity analyses were conducted. RESULTS Compared to all other strategies, historical medical management plus CEA was either cost-saving or cost-effective at a threshold of $100,000 per QALY gained. Modern medical management was cost-effective compared to historical medical management without revascularization at a $100,000 acceptability threshold. However, both revascularization approaches (plus medical management) were cost-saving compared to modern medical management alone. CONCLUSION Among individuals requiring carotid revascularization, carotid endarterectomy is the cost-effective strategy to treat individuals with type 2 diabetes following a TIA. For individuals for whom revascularization is contraindicated, modern medical therapy is cost-effective.
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Affiliation(s)
| | - Shihchen Kuo
- Medicine, University of Michigan, Ann Arbor, Michigan
| | - Wen Ye
- Public Health, University of Michigan, Ann Arbor, Michigan
| | | | - William H Herman
- Medicine, University of Michigan, Ann Arbor, Michigan; Public Health, University of Michigan, Ann Arbor, Michigan
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15
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Lang AE, de Havenon A, Mac Grory B, Henninger N, Shu L, Furie KL, Easton JD, Kim A, Johnston SC, Yaghi S. Subsequent ischemic stroke and tobacco smoking: A secondary analysis of the POINT trial. Eur Stroke J 2022; 8:328-333. [PMID: 37021190 PMCID: PMC10069178 DOI: 10.1177/23969873221148224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/12/2022] [Indexed: 12/30/2022] Open
Abstract
Background: The aim of this study was to determine the effect of smoking status on subsequent stroke risk in patients with minor ischemic stroke or TIA and to determine whether smoking modifies the effect of clopidogrel-based DAPT on subsequent stroke risk. Methods: This was a post-hoc analysis of the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial, which had a 90-day follow-up period. We used multivariable Cox regression and subgroup interaction analysis to determine the effect of smoking on the risk of subsequent ischemic stroke and major hemorrhage, respectively. Results: Data from 4877 participants enrolled in the POINT trial were analyzed. Among these, 1004 were current smokers and 3873 were non-smokers at the time of index event. Smoking was associated with a non-significant trend toward an increased risk of subsequent ischemic stroke during follow up (adjusted HR, 1.31 (95% CI, 0.97–1.78), p = 0.076). The effect of clopidogrel on ischemic stroke did not differ between non-smokers (HR, 0.74 (95% CI, 0.56–0.98), p = 0.03) and smokers (HR, 0.63 (95% CI, 0.37–1.05), p = 0.078), p for interaction = 0.572. Similarly, the effect of clopidogrel on major hemorrhage did not differ between non-smokers (hazard ratio, 1.67 (95% CI, 0.40–7.00), p = 0.481) and smokers (HR, 2.59 (95% CI, 1.08–6.21), p = 0.032), p for interaction = 0.613. Conclusions: In this post-hoc analysis of the POINT trial we found that the effect of clopidogrel on reducing subsequent ischemic stroke as well as risk of major hemorrhage did not depend on smoking status, indicating that smokers benefit to a similar degree from DAPT as non-smokers.
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Affiliation(s)
- Adam Edward Lang
- Department of Primary Care, McDonald Army Health Center, Fort Eustis, VA, USA
- Department of Family Medicine and Population Health, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Liqi Shu
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Karen L. Furie
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, Sandler Neurosciences Center, San Francisco, CA, USA
| | - Anthony Kim
- Department of Neurology, University of California, San Francisco, Sandler Neurosciences Center, San Francisco, CA, USA
| | | | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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16
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Lip GYH, Genaidy A, Estes C, McKay D, Falks T. Transient ischemic attack events and incident cardiovascular and non-cardiovascular complications: Observations from a large diversified multimorbid cohort. Eur Stroke J 2022; 8:334-343. [PMID: 37021195 PMCID: PMC10069223 DOI: 10.1177/23969873221146044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Transient ischemic attack (TIA) is a strong signal prompting the incidence of future cardiovascular and non-cardiovascular complications, in light of recent debate on the so-called “stroke-heart syndrome.” We aimed to investigate the relation of TIAs to incident clinical events. Methods: Patients were drawn from three health plans with a wide spectrum of age groups and a wide mix of socio-economic/disability status. Two TIA cohorts in a retrospective design were used to achieve the study specific aims: (i) to investigate the incidence of TIA and associated cardiovascular and non-cardiovascular complications within 30 and 90 days from the onset of incident TIA events; and (ii) to examine the potential risk factors for developing incident TIA events in the general population with/without a history of prior stroke. Results: The incident TIA cohort consisted of 53,716 patients with an average age of 64.2 years (SD 15.2) and 46.1% male. Following TIA, the incidence proportions of ischemic stroke within 30 and 90 days were 2.7% and 3.8%, respectively, and for incident acute coronary syndrome being 0.94 and 1.84, respectively. Ventricular arrhythmia had proportions of 1.2 and 2.14, respectively within 30 and 90 days, with acute heart failure having values of 0.49 and 0.923. About 45% or more of the cardiovascular and non-cardiovascular complications occurred in the first 30 days following the incident TIA cases. About one-third of the recurrent TIA cases followed the incident TIA cases within a span of 30 days. Amongst comorbidities with stroke in the comorbid history, prior stroke provided the strongest risk factor in terms of odds ratio (OR = 8.34, 95% CI 7.21–9.66) for incident TIA events. Age was strongly associated with incident TIA events. Without a prior history of stroke (ischemic stroke/transient ischemic attack/thrombo-embolic events), valvular disease was the strongest risk factor from among the comorbidities (OR-1.87, 95% CI 1.51–2.32). Age also provided strong associations with incident TIA events. Conclusions: Following a TIA, there was a high risk of stroke, acute coronary syndrome, ventricular arrhythmia, acute heart failure, and non-cardiovascular complications.
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Affiliation(s)
- Gregory YH Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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Spampinato MD, Covino M, Passaro A, Guarino M, Marziani B, Ghirardi C, Ricciardelli A, Fabbri IS, Strada A, Gasbarrini A, Franceschi F, De Giorgio R. ABCD 2, ABCD 2-I, and OTTAWA scores for stroke risk assessment: a direct retrospective comparison. Intern Emerg Med 2022; 17:2391-2401. [PMID: 35986834 PMCID: PMC9652278 DOI: 10.1007/s11739-022-03074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/02/2022] [Indexed: 11/25/2022]
Abstract
Transient ischemic attack (TIA) is a neurologic emergency characterized by cerebral ischemia eliciting a temporary focal neurological deficit. Many clinical prediction scores have been proposed to assess the risk of stroke after TIA; however, studies on their clinical validity and comparisons among them are scarce. The objective is to compare the accuracy of ABCD2, ABCD2-I, and OTTAWA scores in the prediction of a stroke at 7, 90 days, and 1 year in patients presenting with TIA. Single-centre, retrospective study including patients with TIA admitted to the Emergency Department of our third-level, University Hospital, between 2018 and 2019. Five hundred three patients were included. Thirty-nine (7.7%) had a stroke within 1 year from the TIA: 9 (1.7%) and 24 (4.7%) within 7 and 90 days, respectively. ABCD2, ABCD2-I, and OTTAWA scores were significantly higher in patients who developed a stroke. AUROCs ranged from 0.66 to 0.75, without statistically significant differences at each time-point. Considering the best cut-off of each score, only ABCD2 > 3 showed a sensitivity of 100% only in the prediction of stroke within 7 days. Among clinical items of each score, duration of symptoms, previous TIA, hemiparesis, speech disturbance, gait disturbance, previous cerebral ischemic lesions, and known carotid artery disease were independent predictors of stroke. Clinical scores have moderate prognostic accuracy for stroke after TIA. Considering the independent predictors for stroke, our study indicates the need to continue research and prompts the development of new tools on predictive scores for TIA.
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Affiliation(s)
- Michele Domenico Spampinato
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Angelina Passaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Matteo Guarino
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Beatrice Marziani
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Caterina Ghirardi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | | | - Irma Sofia Fabbri
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Andrea Strada
- Emergency Medicine, St. Anna Hospital, Ferrara, Italy
| | - Antonio Gasbarrini
- Internal Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
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Jalilianhasanpour R, Huntley JH, Alvin MD, Hause S, Ali N, Urrutia V, Ghazi Sherbaf F, Johnson PT, Yousem DM, Yedavalli V. Value of acute neurovascular imaging in patients with suspected transient ischemic attack. Eur J Radiol 2022; 154:110427. [DOI: 10.1016/j.ejrad.2022.110427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022]
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19
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Lip GYH, Murphy RR, Sahiar F, Ingall TJ, Dhamane AD, Ferri M, Hlavacek P, Preib MT, Keshishian A, Russ C, Rosenblatt L, Yuce H, Deitelzweig S. Risk Levels and Adverse Clinical Outcomes Among Patients With Nonvalvular Atrial Fibrillation Receiving Oral Anticoagulants. JAMA Netw Open 2022; 5:e2229333. [PMID: 36044214 PMCID: PMC9434362 DOI: 10.1001/jamanetworkopen.2022.29333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The CHA2DS2-VASc score (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or TIA, vascular disease, age 65 to 74 years, and sex category) is the standard for assessing risk of stroke and systemic embolism and includes age and thromboembolic history. To our knowledge, no studies have comprehensively evaluated safety and effectiveness outcomes among patients with nonvalvular atrial fibrillation receiving oral anticoagulants according to independent, categorical risk strata. OBJECTIVE To evaluate the incidence of key adverse outcomes among patients with nonvalvular atrial fibrillation receiving oral anticoagulants by CHA2DS2-VASc risk score range, thromboembolic event history, and age group. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a retrospective claims data analysis using combined data sets from 5 large health claims databases. Eligible participants were adult patients with nonvalvular atrial fibrillation who initiated oral anticoagulants. Data were analyzed between January 2012 and June 2019. EXPOSURE Initiation of oral anticoagulants. MAIN OUTCOMES AND MEASURES We observed clinical outcomes (including stroke or systemic embolism, major bleeding, and a composite outcome) on treatment through study end, censoring for discontinuation of oral anticoagulants, death, and insurance disenrollment. The population was stratified by CHA2DS2-VASc risk score; history of stroke, systemic embolism, or transient ischemic attack; and age groups. We calculated time to event, incidence rates, and cumulative incidence for outcomes. RESULTS We identified 1 141 097 patients with nonvalvular atrial fibrillation; the mean (SD) age was 75.0 (10.5) years, 608 127 patients (53.3%) were men, and over 1 million were placed in the 2 highest risk categories (high risk 1, 327 766 participants; high risk 2, 688 449 participants). Deyo-Charlson Comorbidity Index scores ranged progressively alongside CHA2DS2-VASc risk score strata (mean [SD] scores: low risk, 0.4 [1.0]; high risk 2, 4.1 [2.9]). The crude incidence of stroke and systemic embolism generally progressed alongside risk score strata (low risk, 0.25 events per 100 person-years [95% CI, 0.18-0.34 events]; high risk 2, 3.43 events per 100 person-years [95% CI, 3.06-4.20 events]); patients at the second-highest risk strata with thromboembolic event history had higher stroke incidence vs patients at the highest risk score strata without event history (2.06 events per 100 person-years [95% CI, 2.00-3.12 events] vs 1.18 events per 100 person-years [95% CI, 1.14-1.30 events]). Major bleeding and composite incidence also increased progressively alongside risk score strata (major bleeding: low risk, 0.68 events per 100 person-years [95% CI, 0.56-0.82 events]; high risk 2, 6.29 events per 100 person-years [95% CI, 6.21-6.62 events]; composite incidence: 1.22 events per 100 person-years [95% CI, 1.06-1.41 events]; high risk 2, 10.67 events per 100 person-years [95% CI, 10.26-11.48 events]). The 12-month cumulative incidence proportions for stroke and systemic embolism, major bleeding, and composite outcomes progressed alongside risk score strata (stroke or systemic embolism, 0.30%-1.85%; major bleeding, 0.55%-5.55%; composite, 1.05%-8.23%). Age subgroup analysis followed similar trends. CONCLUSIONS AND RELEVANCE The observed incidence of stroke or systemic embolism and major bleeding events generally conformed to an expected increasing incidence by risk score, adding insight into the importance of specific risk score range, thromboembolic event history, and age group strata. These results can help inform clinical decision-making, research, and policy.
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Affiliation(s)
- Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | | | - Farhad Sahiar
- Federal Aviation Administration, Oklahoma City, Oklahoma
| | | | | | | | | | | | | | | | | | - Huseyin Yuce
- Pfizer, New York, New York
- New York City College of Technology, City University of New York, New York
| | - Steven Deitelzweig
- Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, Louisiana
- Ochsner Clinical School, University of Queensland School of Medicine, Herston, Queensland, Australia
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20
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Zhang X, Jing J, Zhao X, Liu L, Wang A, Pan Y, Wang D, Johnston SC, Wang Y, Wang Y, Meng X. No rebound effect after a course of clopidogrel in patients with acute TIA or minor stroke. Neurol Res 2022; 44:957-963. [PMID: 35695332 DOI: 10.1080/01616412.2022.2075660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies demonstrated that discontinuation of clopidogrel in patients after ACS was associated with a rebound increase in risk of recurrent events. In this study, we aimed to investigate the rebound effect after discontinuation of clopidogrel therapy in patients with TIA or stroke. METHODS All patients with minor stroke or TIA were recruited from the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial. Patients were divided into two groups: patients who discontinued clopidogrel and switched to aspirin therapy (Clopidogrel Discontinuation Group) and patients who continued one mono-antiplatelet therapy (non-Clopidogrel Discontinuation Group) during 90-180 days. The outcomes included risks of recurrent ischemic stroke, recurrent TIA, and composite events during 90-180 days. The prevalence of each outcome was compared between two groups for every 30 days. Further subgroup analysis was conducted in patients with and without CYP2C19 loss-of-function alleles. RESULTS Among the 3456 patients included, a total of 10 patients in the Clopidogrel Discontinuation Group and 11 patients in the non-Clopidogrel Discontinuation Group presented ischemic stroke recurrence during the 90-180-day period. The inter-group comparisons were not significant in each 30 days. Similar results were found for recurrent stroke, recurrent TIA, and composite events in these two groups, which were also found in CYP2C19 subgroup analysis. CONCLUSIONS No rebound increase in the risk of ischemic stroke and composite events was found during the 90 days after discontinuation of clopidogrel therapy in patients with TIA or minor stroke in the CHANCE trial. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00979589.
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Affiliation(s)
- Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Az, USA
| | | | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Raposeiras-Roubín S, Abu-Assi E, Cespón Fernández M, Blanco Prieto S, Barreiro Pardal C, Domínguez-Erquicia P, Melendo Viu M, Bonanad Lozano C, Rosselló X, Ibáñez B, Íñiguez Romo A. Balance entre el efecto de los eventos embólicos frente a los hemorrágicos en la mortalidad de los pacientes ancianos con fibrilación auricular. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Park J, Shim J, Lee JM, Park J, Heo J, Chang Y, Song T, Kim D, Lee HA, Yu HT, Kim T, Uhm J, Kim YD, Nam HS, Joung B, Lee M, Heo JH, Pak H. Risks and Benefits of Early Rhythm Control in Patients With Acute Strokes and Atrial Fibrillation: A Multicenter, Prospective, Randomized Study (the RAFAS Trial). J Am Heart Assoc 2022; 11:e023391. [PMID: 35043663 PMCID: PMC9238486 DOI: 10.1161/jaha.121.023391] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/08/2021] [Indexed: 12/23/2022]
Abstract
Background The purpose of the RAFAS (Risk and Benefits of Urgent Rhythm Control of Atrial Fibrillation in Patients With Acute Stroke) trial was to explore the risks and benefits of early rhythm control in patients with newly documented atrial fibrillation (AF) during an acute ischemic stroke (IS). Method and Results An open-label, randomized, multicenter trial design was used. If AF was diagnosed, the patients in the early rhythm control group started rhythm control within 2 months after the occurrence of an IS, unlikely the usual care. The primary end points were recurrent IS within 3 and 12 months. The secondary end points were a composite of all deaths, unplanned hospitalizations from any cause, and adverse arrhythmia events. Patients (n=300) with AF and an acute IS (63.0% men, aged 69.6±8.5 years; 51.2% with paroxysmal AF) were randomized 2:1 to early rhythm control (n=194) or usual care (n=106). A total of 273 patients excluding those lost to follow-up (n=27) were analyzed. The IS recurrences did not differ between the groups within 3 months of the index stroke (2 [1.1%] versus 4 [4.2%]; hazard ratio [HR], 0.257 [log-rank P=0.091]) but were significantly lower in the early rhythm control group at 12 months (3 [1.7%] versus 6 [6.3%]; HR, 0.251 [log-rank P=0.034]). Although the rates of overall mortality, any cause of hospitalizations (25 [14.0%] versus 16 [16.8%]; HR, 0.808 [log-rank P=0.504]), and arrhythmia-related adverse events (5 [2.8%] versus 1 [1.1%]; HR, 2.565 [log-rank P=0.372]) did not differ, the proportion of sustained AF was lower in the early rhythm control group than the usual care group (60 [34.1%] versus 59 [62.8%], P<0.001) in 12 months. Conclusions The early rhythm control strategy of an acute IS decreased the sustained AF and recurrent IS within 12 months without an increase in the composite adverse outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02285387.
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Affiliation(s)
| | | | | | | | - JoonNyung Heo
- Department of NeurologyYonsei University College of MedicineSeoulSouth Korea
| | | | | | | | - Hye Ah Lee
- Ewha Womans University Medical CenterSeoulKorea
| | - Hee Tae Yu
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Tae‐Hoon Kim
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Jae‐Sun Uhm
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Young Dae Kim
- Department of NeurologyYonsei University College of MedicineSeoulSouth Korea
| | - Hyo Suk Nam
- Department of NeurologyYonsei University College of MedicineSeoulSouth Korea
| | - Boyoung Joung
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Moon‐Hyoung Lee
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Ji Hoe Heo
- Department of NeurologyYonsei University College of MedicineSeoulSouth Korea
| | - Hui‐Nam Pak
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
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23
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2321] [Impact Index Per Article: 1160.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Shahjouei S, Li J, Koza E, Abedi V, Sadr AV, Chen Q, Mowla A, Griffin P, Ranta A, Zand R. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2136644. [PMID: 34985520 PMCID: PMC8733831 DOI: 10.1001/jamanetworkopen.2021.36644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome. OBJECTIVE To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting. DATA SOURCES MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020. STUDY SELECTION Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer. DATA EXTRACTION AND SYNTHESIS The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models. MAIN OUTCOMES AND MEASURES Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days). RESULTS The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.
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Affiliation(s)
- Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
- Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Alireza Vafaei Sadr
- Department de Physique Theorique and Center for Astroparticle Physics, University Geneva, Geneva, Switzerland
| | - Qiushi Chen
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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25
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Kircher CE, Adeoye O. Prehospital and Emergency Department Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Luo Y, Xia LX, Li ZL, Pi DF, Tan XP, Tu Q. Early neutrophil-to-lymphocyte ratio is a prognostic marker in acute minor stroke or transient ischemic attack. Acta Neurol Belg 2021; 121:1415-1421. [PMID: 32036555 DOI: 10.1007/s13760-020-01289-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 01/23/2020] [Indexed: 01/12/2023]
Abstract
Intravenous injection of alteplase is recommended for patients with minor disabling and not non-disabling ischemic stroke symptoms within 4.5 h of ischemic stroke symptom onset. However, it is hard for clinicians to distinguish which type of minor ischemic stroke is disabled at an early stage. In this study, we aimed to demonstrate early neutrophil-to-lymphocyte ratio is a prognostic marker in acute minor stroke or transient ischemic attack. 196 patients diagnosed with acute minor stroke or transient ischemic attack within 24 h of symptom onset were enrolled. Patients were divided into three groups according to the neutrophil-to-lymphocyte ratio value (< 2, 2-3, > 3). Clinical, neuroradiological, laboratory and follow-up data were collected from electronic database. Functional outcome was assessed by modified Rankin Scale. Neutrophil-to-lymphocyte ratio associated with functional outcome of 90 days was evaluated by logistic regression analysis, and we used receiver operating characteristic curve analysis to detect the overall predictive accuracy of this marker. Early neutrophil-to-lymphocyte ratio was associated with an increased risk of short-term functional outcome (OR 4.502, 95% CI 1.533-13.046, P = 0.006). The optimal cutoff value of neutrophil-to-lymphocyte ratio for prediction of short-term unfavorable outcome was 2.94 with a sensitivity of 69.6% and a specificity of 77.1% (area under the curve: 0.767, 95% CI 0.691-0.843). Early neutrophil-to-lymphocyte ratio is associated with short-term unfavorable functional outcome in patients with acute minor stroke or transient ischemic attack. Early neutrophil-to-lymphocyte ratio is beneficial for clinicians to distinguish minor disabling ischemic stroke at an early stage.
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Validation and Extension Study Exploring the Role of RNF213 p.R4810K in 2,877 Chinese Moyamoya Disease Patients. J Stroke Cerebrovasc Dis 2021; 30:106071. [PMID: 34482123 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/12/2021] [Accepted: 08/14/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To validate, update, and extend the role of RNF213 p.R4810K (G>A) for predicting the phenotype of moyamoya disease (MMD) patients and explore the different effects on pediatric and adult groups. METHODS A total of 2,877 patients conducted from 2004 to 2018 were included. Review Manage 5.3 and SPSS 20.0 were applied to complete all statistical analyses. Information on age at onset, sex, initial symptom, family history and complications were obtained via retrospective chart review. Angiographic records were evaluated. RESULTS In China, geographic proximity to Korea or Japan may affect the carrying rate of RNF213 p.R4810K. The proportion of patients with the following characteristics was significantly higher (P <0.017) in the GA than in the GG group: female, age at onset < 18 years, infarct after transient ischemic attack, family history of MMD, and posterior cerebral artery involvement. For pediatric patients, GA showed more cerebral hemorrhage (CH) (odds ratios (ORs) [95% confidence intervals (CIs)] = 3.99 (1.61-9.88), P = 0.003), more patients were in the Suzuki early and intermediate stage (P = 0.001; P = 0.001, respectively), while for the adult group, GA indicated more female (OR [95% CIs] = 1.43 [1.15-1.79], P = 0.001), fewer patients with diabetes (0.58 [0.38-0.86], P = 0.007) and intermediate Suzuki stage (P = 3.70 × 10-4). CONCLUSIONS The incidence and carrying rates of RNF213 p.R4810K in various regions for Chinese MMD patients were obviously different. RNF213 p.R4810K has different predictive effects on phenotypes of pediatric and adult patients.
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Garg A, Maran I, Amin H, Vlieks K, Neuschatz K, Coppola A, Poskus K, Johnson J, Davis M, Minja F, Schindler J, Sansing LH, Malhotra A, Jasne AS, Sharma R. Expedited and Comprehensive Management of Low-Risk TIA Patients in the Emergency Department is Safe and Less Costly. J Stroke Cerebrovasc Dis 2021; 30:106016. [PMID: 34325273 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106016] [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: 06/14/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Transient ischemic attack (TIA) can be a warning sign of an impending stroke. The objective of our study is to assess the feasibility, safety, and cost savings of a comprehensive TIA protocol in the emergency room for low-risk TIA patients. MATERIALS AND METHODS This is a retrospective, single-center cohort study performed at an academic comprehensive stroke center. We implemented an emergency department-based TIA protocol pathway for low-risk TIA patients (defined as ABCD2 score < 4 and without significant vessel stenosis) who were able to undergo vascular imaging and a brain MRI in the emergency room. Patients were set up with rapid outpatient follow-up in our stroke clinic and scheduled for an outpatient echocardiogram, if indicated. We compared this cohort to TIA patients admitted prior to the implementation of the TIA protocol who would have qualified. Outcomes of interest included length of stay, hospital cost, radiographic and echocardiogram findings, recurrent neurovascular events within 30 days, and final diagnosis. RESULTS A total of 138 patients were assessed (65 patients in the pre-pathway cohort, 73 in the expedited, post-TIA pathway implementation cohort). Average time from MRI order to MRI end was 6.4 h compared to 2.3 h in the pre- and post-pathway cohorts, respectively (p < 0.0001). The average length of stay for the pre-pathway group was 28.8 h in the pre-pathway cohort compared to 7.7 h in the post-pathway cohort (p < 0.0001). There were no differences in neuroimaging or echocardiographic findings. There were no differences in the 30 days re-presentation for stroke or TIA or mortality between the two groups. The direct cost per TIA admission was $2,944.50 compared to $1,610.50 for TIA patients triaged through the pathway at our institution. CONCLUSIONS This study demonstrates the feasibility, safety, and cost-savings of a comprehensive, emergency department-based TIA protocol. Further study is needed to confirm overall benefit of an expedited approach to TIA patient management and guide clinical practice recommendations.
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Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Ilavarasy Maran
- Department of Neurology, Trillium Health Partners, Missisauga, Canada
| | - Hardik Amin
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Kelsey Vlieks
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | | | | | | | | | | | - Frank Minja
- Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Lauren H Sansing
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Ajay Malhotra
- Department of Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Adam S Jasne
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA.
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Wang H, Lu H, Zhang XM, Goto KI, Kobayashi E, Yoshida Y, Adachi A, Matsutani T, Iwadate Y, Mine S, Machida T, Sata M, Yamagishi K, Iso H, Sawada N, Tsugane S, Kamitsukasa I, Wada T, Aotsuka A, Sugimoto K, Takizawa H, Kashiwado K, Shin H, Tomiyoshi G, Nakamura R, Shinmen N, Kuroda H, Xu A, Hiwasa T. Association of serum levels of antibodies against ALDOA and FH4 with transient ischemic attack and cerebral infarction. BMC Neurol 2021; 21:274. [PMID: 34243715 PMCID: PMC8268454 DOI: 10.1186/s12883-021-02301-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background Ischemic stroke, including transient ischemic attack (TIA) and acute-phase cerebral infarction (aCI), is a serious health problem in the aging society. Thus, this study aimed to identify TIA and aCI biomarkers. Methods In 19 patients with TIA, candidate antigens recognized by serum IgG autoantibodies were screened using a human aortic endothelial cell cDNA library. Through amplified luminescent proximity homogeneous assay-linked immunosorbent assay (AlphaLISA), serum antibody levels against the candidate antigens were examined in healthy donor (HD), TIA, and aCI cohorts (n = 285, 92, and 529). The plasma antibody levels in the Japan Public Health Center-based Prospective Cohort Study (1991–1993) were also examined. Results The candidate antigens were aldolase A (ALDOA) and fumarate hydratase (FH). In AlphaLISA, patients with TIA or aCI had higher anti-ALDOA antibody (ALDOA-Ab) and anti-FH antibody (FH-Ab) levels than the HDs (P < 0.05). In a multivariate logistic regression analysis, the ALDOA-Ab (odds ratio [OR]: 2.46, P = 0.0050) and FH-Ab (OR: 2.49, P = 0.0037) levels were independent predictors of TIA. According to the case–control study, the ALDOA-Ab (OR: 2.50, P < 0.01) and FH-Ab (OR: 2.60, P < 0.01) levels were associated with aCI risk. In a correlation analysis, both ALDOA-Abs and FH-Abs were well associated with hypertension, coronary heart disease, and habitual smoking. These antibody levels also correlated well with maximum intima–media thickness, which reflects atherosclerotic stenosis. Conclusions ALDOA-Abs and FH-Abs can be novel potential biomarkers for predicting atherosclerotic TIA and aCI.
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Affiliation(s)
- Hao Wang
- Stroke Center, the First Affiliated Hospital, Jinan University, NO. 613, West Huangpu Ave., Tianhe Dist., Guangzhou, 510630, China.,Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan
| | - Hao Lu
- Stroke Center, the First Affiliated Hospital, Jinan University, NO. 613, West Huangpu Ave., Tianhe Dist., Guangzhou, 510630, China
| | - Xiao-Meng Zhang
- Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan
| | - Ken-Ichiro Goto
- Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan
| | - Eiichi Kobayashi
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba, 260-8670, Japan.,Comprehensive Stroke Center, Chiba University Hospital, Chiba, 260-8677, Japan
| | - Yoichi Yoshida
- Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan.,Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba, 260-8670, Japan.,Comprehensive Stroke Center, Chiba University Hospital, Chiba, 260-8677, Japan
| | - Akihiko Adachi
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba, 260-8670, Japan
| | - Tomoo Matsutani
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba, 260-8670, Japan
| | - Yasuo Iwadate
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba, 260-8670, Japan.,Comprehensive Stroke Center, Chiba University Hospital, Chiba, 260-8677, Japan
| | - Seiichiro Mine
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba, 260-8670, Japan.,Department of Neurological Surgery, Chiba Prefectural Sawara Hospital, Chiba, 287-0003, Japan.,Department of Neurological Surgery, Chiba Cerebral and Cardiovascular Center, Chiba, 290-0512, Japan
| | - Toshio Machida
- Department of Neurological Surgery, Chiba Cerebral and Cardiovascular Center, Chiba, 290-0512, Japan.,Department of Neurosurgery, Eastern Chiba Medical Center, Chiba, 283-8686, Japan
| | - Mizuki Sata
- Department of Public Health, Social Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kazumasa Yamagishi
- Department of Public Health Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hiroyasu Iso
- Department of Public Health, Social Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Norie Sawada
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Shoichiro Tsugane
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Ikuo Kamitsukasa
- Department of Neurology, Chiba Rosai Hospital, Chiba, 290-0003, Japan.,Department of Neurology, Chibaken Saiseikai Narashino Hospital, Chiba, 275-8580, Japan
| | - Takeshi Wada
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, 260-0852, Japan
| | - Akiyo Aotsuka
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, 260-0852, Japan
| | - Kazuo Sugimoto
- Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan.,Department of Neurology, Dongzhimen Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Hirotaka Takizawa
- Port Square Kashiwado Clinic, Kashiwado Memorial Foundation, Chiba, 260-0025, Japan
| | - Koichi Kashiwado
- Department of Neurology, Kashiwado Hospital, Chiba, 260-0854, Japan
| | - Hideo Shin
- Department of Neurosurgery, Higashi Funabashi Hospital, Chiba, 274-0065, Japan
| | - Go Tomiyoshi
- Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan.,Medical Project Division, Research Development Center, Fujikura Kasei Co., Saitama, 340-0203, Japan
| | - Rika Nakamura
- Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan.,Medical Project Division, Research Development Center, Fujikura Kasei Co., Saitama, 340-0203, Japan
| | - Natsuko Shinmen
- Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan.,Medical Project Division, Research Development Center, Fujikura Kasei Co., Saitama, 340-0203, Japan
| | - Hideyuki Kuroda
- Medical Project Division, Research Development Center, Fujikura Kasei Co., Saitama, 340-0203, Japan
| | - Anding Xu
- Stroke Center, the First Affiliated Hospital, Jinan University, NO. 613, West Huangpu Ave., Tianhe Dist., Guangzhou, 510630, China.
| | - Takaki Hiwasa
- Department of Biochemistry and Genetics, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan. .,Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba, 260-8670, Japan. .,Comprehensive Stroke Center, Chiba University Hospital, Chiba, 260-8677, Japan.
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1054] [Impact Index Per Article: 351.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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31
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Isaman DJM, Herman WH, Ye W. Prediction of transient ischemic attack and minor stroke in people with type 2 diabetes mellitus. J Diabetes Complications 2021; 35:107911. [PMID: 33902996 PMCID: PMC8169622 DOI: 10.1016/j.jdiacomp.2021.107911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/07/2021] [Accepted: 03/07/2021] [Indexed: 12/14/2022]
Abstract
AIMS People with type 2 diabetes (T2DM) have an increased risk of transient ischemic attack and minor stroke (TIA) which are frequently followed by an ischemic stroke. We aimed to develop a predictive model for incident TIA in people with T2DM. METHODS We pooled data from two longitudinal cohort studies, Atherosclerosis Risk in Communities (ARIC) and the Cardiovascular Health Study (CHS), using a two-stage approach. First, we used a random effects model to interpolate risk factors of individuals between follow-up exams. Second, we used forward selection to develop a proportional hazards model for time to incident TIA. We internally validated our model using 10-fold cross-validation. RESULTS Among 3575 participants with T2DM, mean (SD) age was 60 (10) years and body mass index was 30 (6) kg/m2. Sixty-nine incident TIAs occurred during 38,364 person-years of follow-up. The multivariable model included age at diagnosis of diabetes (hazard ratio 1.13 (95% confidence interval: 1.05,1.21) per year), systolic blood pressure (1.25 (1.04,1.49) per 10 mmHg), a quadratic function of diastolic blood pressure, and history of congestive heart failure (2.08 (1.26, 3.42)). The median cross-validated Harrell's C-index was 0.80. CONCLUSION Blood pressure and heart failure are risk factors for the earliest stages of cerebrovascular disease.
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Affiliation(s)
- Deanna J M Isaman
- School of Nursing, University of Michigan, Ann Arbor, MI, United States of America.
| | - William H Herman
- Schools of Nursing, University of Michigan, Ann Arbor, MI, United States of America; School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Wen Ye
- School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
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Shahjouei S, Sadighi A, Chaudhary D, Li J, Abedi V, Holland N, Phipps M, Zand R. A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 78:77-87. [PMID: 33044505 DOI: 10.1001/jamaneurol.2020.3627] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Management of transient ischemic attack (TIA) has gained significant attention during the past 25 years after several landmark studies indicated the high incidence of a subsequent stroke. Objective To calculate the pooled event rate of subsequent ischemic stroke within 2, 7, 30, and 90 days of a TIA and compare this incidence among the population with TIA recruited before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C). Data Sources All published studies of TIA outcomes were obtained by searching PubMed from 1996, to the last update on January 31, 2020, irrespective of the study design, document type, or language. Study Selection Of 11 516 identified citations, 175 articles were relevant to this review. Both the classic time-based definition of TIA and the new tissue-based definition were accepted. Studies with a combined record of patients with TIA and ischemic stroke, without clinical evaluation for the index TIA, with diagnosis of index TIA event after ischemic stroke occurrence, with low suspicion for TIA, or duplicate reports of the same database were excluded. Data Extraction and Synthesis The study was conducted and reported according to the PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality assessment used the Quality in Prognosis Studies tool. Publication bias was visualized by funnel plots and measured by the Begg-Mazumdar rank correlation Kendall τ2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models. Main Outcomes and Measures The proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size. Results Systematic review yielded 68 unique studies with 223 866 unique patients from 1971 to 2019. The meta-analysis included 206 455 patients (58% women) during a span of 4 decades. The overall subsequent ischemic stroke incidence rates were estimated as 2.4% (95% CI, 1.8%-3.2%) within 2 days, 3.8% (95% CI, 2.5%-5.4%) within 7 days, 4.1% (95% CI, 2.4%-6.3%) within 30 days, and 4.7% (95% CI, 3.3%-6.4%) within 90 days. There was a recurrence risk of 3.4% among group A in comparison with 2.1% in group B or 2.1% in group C within 2 days; 5.5% in group A vs 2.9% in group B or 3.2% in group C within 7 days; 6.3% in group A vs 2.9% in group B or 3.4% in group C within 30 days, and 7.4% in group A vs 3.9% in group B or 3.9% in group C within 90 days. Conclusions and Relevance These findings suggest that TIA continues to be associated with a high risk of early stroke; however, the rate of post-TIA stroke might have decreased slightly during the past 2 decades.
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Affiliation(s)
- Shima Shahjouei
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Alireza Sadighi
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Durgesh Chaudhary
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania.,Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Neil Holland
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Michael Phipps
- Department of Neurology, University of Maryland, Baltimore
| | - Ramin Zand
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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Gong L, Wang H, Dong Q, Zhu X, Zheng X, Gu Y, Cai W, Zhao Y, Liu X. Intracranial Atherosclerotic Stenosis is Related to Post-stroke Cognitive Impairment: A Cross-sectional Study of Minor Stroke. Curr Alzheimer Res 2021; 17:177-184. [PMID: 32124696 DOI: 10.2174/1567205017666200303141920] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 01/30/2020] [Accepted: 03/01/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intracranial Atherosclerotic Stenosis (ICAS) is an important risk factor for cognitive impairment. However, it is unclear whether patients with ICAS are more likely to develop cognitive impairment after an acute, non-disabling ischemic stroke (minor stroke). OBJECTIVE We aimed to investigate the association between ICAS and post-stroke cognitive impairment. METHODS In this cross-sectional study, patients with acute, non-disabling ischemic stroke underwent two cognitive tests and imaging evaluation for ICAS, within two weeks after the stroke. To determine the association between ICAS and post-stroke cognitive impairment, we performed a multivariate logistic regression analysis adjusted for several demographic and vascular risk factors. RESULTS Of the 164 patients with minor stroke in this study, 98 (59.76%) were diagnosed with poststroke cognitive impairment (Montreal Cognitive Assessment score<26). After adjusting for potential confounders, we found that patients with ICAS were more likely to develop cognitive impairment after an acute, non-disabling ischemic stroke, compared to patients without ICAS (Odds Ratio: 2.13; 95% Confidence Interval: 1.07-4.26), and underperformed in the tests of visuospatial and executive function. CONCLUSION In this cross-sectional study of a population that has experienced a minor stroke, our findings demonstrated a positive association between ICAS and post-stroke cognitive impairment.
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Affiliation(s)
- Li Gong
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
| | - Haichao Wang
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
| | - Qiong Dong
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
| | - Xiaoping Zhu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
| | - Xiaoran Zheng
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
| | - Yongzhe Gu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
| | - Wangli Cai
- Department of Radiology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
| | - Yanxin Zhao
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
| | - Xueyuan Liu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, 301# Middle Yanchang Road, Shanghai 200072, China
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Wang W, Sun P, Han F, Qu C. Sex Differences in Risk Factors for Transient Ischemic Attack in a Chinese Population. Front Neurol 2021; 12:615399. [PMID: 34025549 PMCID: PMC8134545 DOI: 10.3389/fneur.2021.615399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: This study aimed to collect and evaluate basic information of a stroke screening population in eastern China and to compare distribution differences in risk factors between males and females in a transient ischemic attack (TIA) population. Methods: A standardization of the risk factors for stroke was performed according to an implementation plan of stroke in a high-risk population screening and intervention project in Shandong Province. Of the 231,289 residents, 8,603 patients with a previous TIA were identified and risk factors in this cohort were analyzed for sex differences. Results: In our initial cohort of 231,289 residents, we found 3,390 men and 5,213 women with TIA, accounting for a prevalence of 3.1 and 4.2%, respectively. Risk factors for TIA were hypertension, atrial fibrillation, diabetes, smoking, lack of exercise, overweight, and family history of stroke. In our TIA cohort, we found that the prevalence of smoking was significantly higher in men (41.3%) compared with that found in women (4.2%). Further, hypertension (58.8 vs. 55.5%) and family history of stroke (22.3 vs. 20.0%) were more prevalent in men compared with women, whereas atrial fibrillation (AF) (14.7 vs. 16.4%), diabetes (11.1 vs. 13.2%), lack of exercise (27.2 vs. 28.0%), and overweight (29.5 vs. 35.7%) were less prevalent. Conclusions: In our TIA cohort from eastern China, we found significant sex differences for the risk factors of hypertension, atrial fibrillation, smoking, diabetes, and overweight.
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Affiliation(s)
- Wendi Wang
- Neurology Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Pei Sun
- Neurology Department, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Fengyue Han
- Neurology Department, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chuanqiang Qu
- Neurology Department, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Raposeiras-Roubín S, Abu-Assi E, Cespón Fernández M, Blanco Prieto S, Barreiro Pardal C, Domínguez-Erquicia P, Melendo Viu M, Bonanad Lozano C, Rosselló X, Ibáñez B, Íñiguez Romo A. Trade-off between the effects of embolic versus bleeding events on mortality in elderly patients with atrial fibrillation. ACTA ACUST UNITED AC 2021; 75:334-342. [PMID: 33839062 DOI: 10.1016/j.rec.2021.02.003] [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: 10/18/2020] [Accepted: 02/15/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES Clinical decision-making on anticoagulation in elderly patients with atrial fibrillation (AF) requires clinicians to consider not only the incidence of embolic and bleeding events, but also the risk of death following these adverse events. We aimed to analyze the trade-off between embolic and bleeding events with respect to mortality in elderly patients with AF. METHODS The study cohort comprised all patients aged ≥ 75 years from a Spanish health area diagnosed with AF between 2014 and 2017 (n=9365). The risk of death was investigated using Cox proportional hazards models, including embolic and bleeding events as time-dependent binary indicators. RESULTS During a median follow-up of 4.0 years, both embolic and bleeding events were associated with a higher risk of death (adjusted HR, 2.39; 95%CI, 2.12-2.69; and adjusted HR, 1.79; 95%CI, 1.64-1.96, respectively). The relative risk of death was 33% higher following an embolism than following a bleeding event (rRR, 1.33; 95%CI, 1.15-1.55), although for transient ischemic attack the risk was lower than for bleeding (rRR, 0.79; 95%CI, 0.63-0.99). The risk of death associated with intracranial hemorrhage was similar to that of major embolisms (RR, 1.00; 95%CI, 0.75-1.29). CONCLUSIONS In elderly AF patients, embolic events appeared to be associated with a higher risk of mortality than extracranial bleeding, except for transient ischemic attacks, which have a better prognosis. For ICH, the mortality risk was similar to that of major embolism.
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Affiliation(s)
- Sergio Raposeiras-Roubín
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain; Instituto de Investigación Sanitaria Galicia Sur, Vigo, Pontevedra, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
| | - Emad Abu-Assi
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain; Instituto de Investigación Sanitaria Galicia Sur, Vigo, Pontevedra, Spain
| | - María Cespón Fernández
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | | | | | | | - María Melendo Viu
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Clara Bonanad Lozano
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Xavier Rosselló
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Borja Ibáñez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Andrés Íñiguez Romo
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain; Instituto de Investigación Sanitaria Galicia Sur, Vigo, Pontevedra, Spain
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Schultz BG, Tilton J, Jun J, Scott-Horton T, Quach D, Touchette DR. Cost-Effectiveness Analysis of a Pharmacist-Led Medication Therapy Management Program: Hypertension Management. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:522-529. [PMID: 33840430 DOI: 10.1016/j.jval.2020.10.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Uncontrolled hypertension is a common cause of cardiovascular disease, which is the deadliest and costliest chronic disease in the United States. Pharmacists are an accessible community healthcare resource and are equipped with clinical skills to improve the management of hypertension through medication therapy management (MTM). Nevertheless, current reimbursement models do not incentivize pharmacists to provide clinical services. We aim to investigate the cost-effectiveness of a pharmacist-led comprehensive MTM clinic compared with no clinic for 10-year primary prevention of stroke and cardiovascular disease events in patients with hypertension. METHODS We built a semi-Markov model to evaluate the clinical and economic consequences of an MTM clinic compared with no MTM clinic, from the payer perspective. The model was populated with data from a recently published controlled observational study investigating the effectiveness of an MTM clinic. Methodology was guided using recommendations from the Second Panel on Cost-Effectiveness in Health and Medicine, including appropriate sensitivity analyses. RESULTS Compared with no MTM clinic, the MTM clinic was cost-effective with an incremental cost-effectiveness ratio of $38 798 per quality-adjusted life year (QALY) gained. The incremental net monetary benefit was $993 294 considering a willingness-to-pay threshold of $100 000 per QALY. Health-benefit benchmarks at $100 000 per QALY and $150 000 per QALY translate to a 95% and 170% increase from current reimbursement rates for MTM services. CONCLUSIONS Our model shows current reimbursement rates for pharmacist-led MTM services may undervalue the benefit realized by US payers. New reimbursement models are needed to allow pharmacists to offer cost-effective clinical services.
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Affiliation(s)
- Bob G Schultz
- Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Jessica Tilton
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Julie Jun
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Tiffany Scott-Horton
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Danny Quach
- Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Daniel R Touchette
- Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA.
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Singh D, Wasan H, Reeta KH. Preclinical Stroke Research and Translational Failure: A Bird's Eye View on Preventable Variables. Cell Mol Neurobiol 2021; 42:2003-2017. [PMID: 33786698 DOI: 10.1007/s10571-021-01083-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
Despite achieving remarkable success in understanding the cellular, molecular and pathophysiological aspects of stroke, translation from preclinical research has always remained an area of debate. Although thousands of experimental compounds have been reported to be neuro-protective, their failures in clinical setting have left the researchers and stakeholders in doldrums. Though the failures described have been excruciating, they also give us a chance to refocus on the shortcomings. For better translational value, evidences from preclinical studies should be robust and reliable. Preclinical study design has a plethora of variables affecting the study outcome. Hence, this review focusses on the factors to be considered for a well-planned preclinical study while adhering to guidelines with emphasis on the study design, commonly used animal models, their limitations with special attention on various preventable attritions including comorbidities, aged animals, time of dosing, outcome measures and physiological variables along with the concept of multicentric preclinical randomized controlled trials. Here, we provide an overview of a panorama of practical aspects, which could be implemented, so that a well-defined preclinical study would result in a neuro-protectant with better translational value.
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Affiliation(s)
- Devendra Singh
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Himika Wasan
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - K H Reeta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Mendelson SJ, Prabhakaran S. Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review. JAMA 2021; 325:1088-1098. [PMID: 33724327 DOI: 10.1001/jama.2020.26867] [Citation(s) in RCA: 262] [Impact Index Per Article: 87.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually. OBSERVATIONS Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic resonance diffusion or computed tomography perfusion imaging (modified Rankin Scale score 0-2: 53% vs 18%; OR, 4.92 [95% CI, 2.87-8.44]). CONCLUSIONS AND RELEVANCE Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.
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Affiliation(s)
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois
- Pritzker School of Medicine, Department of Neurology, University of Chicago, Chicago, Illinois
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 2985] [Impact Index Per Article: 995.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Perry JJ, Sivilotti MLA, Émond M, Stiell IG, Stotts G, Lee J, Worster A, Morris J, Cheung KW, Jin AY, Oczkowski WJ, Sahlas DJ, Murray HE, Mackey A, Verreault S, Camden MC, Yip S, Teal P, Gladstone DJ, Boulos MI, Chagnon N, Shouldice E, Atzema C, Slaoui T, Teitlebaum J, Abdulaziz K, Nemnom MJ, Wells GA, Sharma M. Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study. BMJ 2021; 372:n49. [PMID: 33541890 PMCID: PMC7859838 DOI: 10.1136/bmj.n49] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To validate the previously derived Canadian TIA Score to stratify subsequent stroke risk in a new cohort of emergency department patients with transient ischaemic attack. DESIGN Prospective cohort study. SETTING 13 Canadian emergency departments over five years. PARTICIPANTS 7607 consecutively enrolled adult patients attending the emergency department with transient ischaemic attack or minor stroke. MAIN OUTCOME MEASURES The primary outcome was subsequent stroke or carotid endarterectomy/carotid artery stenting within seven days. The secondary outcome was subsequent stroke within seven days (with or without carotid endarterectomy/carotid artery stenting). Telephone follow-up used the validated Questionnaire for Verifying Stroke Free Status at seven and 90 days. All outcomes were adjudicated by panels of three stroke experts, blinded to the index emergency department visit. RESULTS Of the 7607 patients, 108 (1.4%) had a subsequent stroke within seven days, 83 (1.1%) had carotid endarterectomy/carotid artery stenting within seven days, and nine had both. The Canadian TIA Score stratified the risk of stroke, carotid endarterectomy/carotid artery stenting, or both within seven days as low (risk ≤0.5%; interval likelihood ratio 0.20, 95% confidence interval 0.09 to 0.44), medium (risk 2.3%; interval likelihood ratio 0.94, 0.85 to 1.04), and high (risk 5.9% interval likelihood ratio 2.56, 2.02 to 3.25) more accurately (area under the curve 0.70, 95% confidence interval 0.66 to 0.73) than did the ABCD2 (0.60, 0.55 to 0.64) or ABCD2i (0.64, 0.59 to 0.68). Results were similar for subsequent stroke regardless of carotid endarterectomy/carotid artery stenting within seven days. CONCLUSION The Canadian TIA Score stratifies patients' seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use. Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritisation of specialist referral.
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Affiliation(s)
- Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Marcel Émond
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, QC, Canada
- Division of Emergency Medicine, Université Laval, Québec City, QC, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Grant Stotts
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jacques Lee
- Schwartz\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Judy Morris
- Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Ka Wai Cheung
- University of British Columbia, Vancouver, BC, Canada
| | - Albert Y Jin
- Division of Neurology, Queen's University, Kingston, ON, Canada
| | | | - Demetrios J Sahlas
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Heather E Murray
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, QC, Canada
| | - Ariane Mackey
- Division of Emergency Medicine, Université Laval, Québec City, QC, Canada
- Division of Neurology, Laval University, Quebec City, QC, Canada
| | - Steve Verreault
- Division of Emergency Medicine, Université Laval, Québec City, QC, Canada
- Division of Neurology, Laval University, Quebec City, QC, Canada
| | - Marie-Christine Camden
- Division of Emergency Medicine, Université Laval, Québec City, QC, Canada
- Division of Neurology, Laval University, Quebec City, QC, Canada
| | - Samuel Yip
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Philip Teal
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - David J Gladstone
- Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Mark I Boulos
- Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Nicolas Chagnon
- Department of Emergency Medicine, Montfort Hospital and University of Ottawa, Ottawa, ON, Canada
| | | | | | - Tarik Slaoui
- University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | - Mukul Sharma
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
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Zhang R, Jiang Y, Zhang G, Yu M, Wang Y, Liu G. Association between short-term exposure to ambient air pollution and hospital admissions for transient ischemic attacks in Beijing, China. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2021; 28:6877-6885. [PMID: 33010014 PMCID: PMC7840640 DOI: 10.1007/s11356-020-10963-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/21/2020] [Indexed: 05/02/2023]
Abstract
Numerous studies have examined the associations between air pollution and stroke. However, little is known about the associations between air pollution and transient ischemic attack (TIA). In this study, we aimed to conduct a time-series study to systematically examine the associations between hospital admissions for TIA and air pollutants. Admissions for TIA (ICD-10: G45) from 1 January 2014 to 31 December 2016 were identified based on the primary diagnosis from 134 hospitals in Beijing, China. Hourly measurements of air pollutants were obtained from the National Air Pollution Monitoring System. Generalized additive models with quasi-Poisson regression were used to determine the associations for each pollutant. Additionally, stratified analysis was implemented to examine whether age, gender, temperature, and season were the potential effect modifiers. Restricted cubic spline was applied to investigate the exposure-response curve. In total, 109,975 hospital admissions for TIA were included. The positive associations were detected between PM2.5, PM10, SO2, NO2, and CO and hospital admissions for TIA. The effects of PM2.5 and PM10 in men are stronger than in women. Additionally, the effects of PM2.5, PM10, SO2, and O3 are more pronounced on warm days than cool days. From exposure-response curves, we observe a nearly linear relationship for PM2.5, PM10, CO, and NO2. Further studies are needed to verify the association. This research contributes evidence on the association between air pollution and admissions for TIA in the low- and middle-income countries and may promote related public health policy development.
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Affiliation(s)
- Runhua Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 10070, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 10070, China
| | - Guitao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 10070, China
| | - Miaoxin Yu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 10070, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, 10070, China.
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, 10070, China.
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Lioutas VA, Ivan CS, Himali JJ, Aparicio HJ, Leveille T, Romero JR, Beiser AS, Seshadri S. Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke. JAMA 2021; 325:373-381. [PMID: 33496774 PMCID: PMC7838926 DOI: 10.1001/jama.2020.25071] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 12/03/2020] [Indexed: 12/24/2022]
Abstract
Importance Accurate estimation of the association between transient ischemic attack (TIA) and risk of subsequent stroke can help to improve preventive efforts and limit the burden of stroke in the population. Objective To determine population-based incidence of TIA and the timing and long-term trends of stroke risk after TIA. Design, Setting, and Participants Retrospective cohort study (Framingham Heart Study) of prospectively collected data of 14 059 participants with no history of TIA or stroke at baseline, followed up from 1948-December 31, 2017. A sample of TIA-free participants was matched to participants with first incident TIA on age and sex (ratio, 5:1). Exposures Calendar time (TIA incidence calculation, time-trends analyses), TIA (matched longitudinal cohort). Main Outcomes and Measures The main outcomes were TIA incidence rates; proportion of stroke occurring after TIA in the short term (7, 30, and 90 days) vs the long term (>1-10 years); stroke after TIA vs stroke among matched control participants without TIA; and time trends of stroke risk at 90 days after TIA assessed in 3 epochs: 1954-1985, 1986-1999, and 2000-2017. Results Among 14 059 participants during 66 years of follow-up (366 209 person-years), 435 experienced TIA (229 women; mean age, 73.47 [SD, 11.48] years and 206 men; mean age, 70.10 [SD, 10.64] years) and were matched to 2175 control participants without TIA. The estimated incidence rate of TIA was 1.19/1000 person-years. Over a median of 8.86 years of follow-up after TIA, 130 participants (29.5%) had a stroke; 28 strokes (21.5%) occurred within 7 days, 40 (30.8%) occurred within 30 days, 51 (39.2%) occurred within 90 days, and 63 (48.5%) occurred more than 1 year after the index TIA; median time to stroke was 1.64 (interquartile range, 0.07-6.6) years. The age- and sex-adjusted cumulative 10-year hazard of incident stroke for patients with TIA (130 strokes among 435 cases) was 0.46 (95% CI, 0.39-0.55) and for matched control participants without TIA (165 strokes among 2175) was 0.09 (95% CI, 0.08-0.11); fully adjusted hazard ratio [HR], 4.37 (95% CI, 3.30-5.71; P < .001). Compared with the 90-day stroke risk after TIA in 1948-1985 (16.7%; 26 strokes among 155 patients with TIA), the risk between 1986-1999 was 11.1% (18 strokes among 162 patients) and between 2000-2017 was 5.9% (7 strokes among 118 patients). Compared with the first epoch, the HR for 90-day risk of stroke in the second epoch was 0.60 (95% CI, 0.33-1.12) and in the third epoch was 0.32 (95% CI, 0.14-0.75) (P = .005 for trend). Conclusions and Relevance In this population-based cohort study from 1948-2017, the estimated crude TIA incidence was 1.19/1000 person-years, the risk of stroke was significantly greater after TIA compared with matched control participants who did not have TIA, and the risk of stroke after TIA was significantly lower in the most recent epoch from 2000-2017 compared with an earlier period from 1948-1985.
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Framingham Heart Study, Framingham, Massachusetts
| | - Cristina S. Ivan
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Jayandra J. Himali
- Framingham Heart Study, Framingham, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Glenn Biggs Institute for Alzheimer’s Disease and Neurodegenerative Diseases, University of Texas Health San Antonio
- Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio
| | - Hugo J. Aparicio
- Framingham Heart Study, Framingham, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Jose Rafael Romero
- Framingham Heart Study, Framingham, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Alexa S. Beiser
- Framingham Heart Study, Framingham, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Sudha Seshadri
- Framingham Heart Study, Framingham, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Glenn Biggs Institute for Alzheimer’s Disease and Neurodegenerative Diseases, University of Texas Health San Antonio
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Siket MS, Cadena R. Novel Treatments for Transient Ischemic Attack and Acute Ischemic Stroke. Emerg Med Clin North Am 2020; 39:227-242. [PMID: 33218660 DOI: 10.1016/j.emc.2020.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The treatment of acute ischemic stroke is one of the most rapidly evolving areas in medicine. Like all ischemic vascular emergencies, the priority is reperfusion before irreversible infarction. The central nervous system is sensitive to brief periods of hypoperfusion, making stroke a golden hour diagnosis. Although the phrase "time is brain" is relevant today, emerging treatment strategies use more specific markers for consideration of reperfusion than time alone. Innovations in early stroke detection and individualized patient selection for reperfusion therapies have equipped the emergency medicine clinician with more opportunities to help stroke patients and minimize the impact of this disease.
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Affiliation(s)
- Matthew S Siket
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine at the University of Vermont, 111 Colchester Avenue, EC2-216, Burlington, VT 05401, USA; Department of Neurological Sciences, Larner College of Medicine at the University of Vermont, 111 Colchester Avenue, EC2-216, Burlington, VT 05401, USA.
| | - Rhonda Cadena
- Division of Neurocritical Care, Department of Neurology, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA; Department of Neurosurgery, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA; Department of Emergency Medicine, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA
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Krementz NA, Landman A, Gardener HE, Arauz A, Rodriguez AD, Cannon H, Lau HL, Sur N, Marulanda-Londoño E, Yavagal DR, Yan B, Nagel S, Demchuk AM, Khatri P, Romano JG, Asdaghi N. Endovascular Therapy in Mild Ischemic Strokes Presenting Under 6 hours: An International Survey. J Stroke Cerebrovasc Dis 2020; 29:105234. [PMID: 33066890 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105234] [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: 05/26/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Endovascular therapy (EVT) for patients with mild ischemic stroke (NIHSS ≤5) and visible intracranial occlusion remains controversial, including within 6 hours of symptom onset. We conducted a survey to evaluate global practice patterns of EVT in this population. METHODS Vascular stroke clinicians and neurointerventionalists were invited to participate through professional stroke listservs. The survey consisted of six clinical vignettes of mild stroke patients with intracranial occlusion. Cases varied by NIHSS, neurological symptoms and occlusion site. All had the same risk factors, time from symptom onset (5h) and unremarkable head CT. Advanced imaging data was available upon request. We explored independent case and responder specific factors associated with advanced imaging request and EVT decision. RESULTS A total of 482/492 responders had analyzable data ([median age 44 (IQR 11.25)], 22.7% women, 77% attending, 22% interventionalist). Participants were from USA (45%), Europe (32%), Australia (12%), Canada (6%), and Latin America (5%). EVT was offered in 48% (84% M1, 29% M2 and 19% A2) and decision was made without advanced imaging in 66% of cases. In multivariable analysis, proximal occlusion (M1 vs. M2 or A2, p<0.001), higher NIHSS (p<0.001) and fellow level training (vs. attending; p=0.001) were positive predictors of EVT. Distal occlusions (M2 and A2) and higher age of responders were independently associated with increased advanced imaging requests. Compared to US and Australian responders, Canadians were less likely to offer EVT, while those in Europe and Latin America were more likely (p<0.05). CONCLUSIONS Treatment patterns of EVT in mild stroke vary globally. Our data suggest wide equipoise exists in current treatment of this important subset of mild stroke.
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Affiliation(s)
- Nastajjia A Krementz
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Avi Landman
- Department of Neurology, Osceola Regional Medical Center, Kissimmee, FL, United States
| | - Hannah E Gardener
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Mexico DF, Mexico
| | - Anny D Rodriguez
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Hershel Cannon
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - H Lee Lau
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Nicole Sur
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Erika Marulanda-Londoño
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Dileep R Yavagal
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre, Department of Radiology, University of Melbourne, Melbourne, VIC, Australia
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, United States
| | - Jose G Romano
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Negar Asdaghi
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States.
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45
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Perry SB, Billek-Sawhney B, Schreiber J. Stroke Prevention: Education and Barriers for Physical and Occupational Therapists Caring for Older Adults. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2020. [DOI: 10.1080/02703181.2020.1755410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Susan B. Perry
- Physical Therapy Program, Chatham University, Pittsburgh, Pennsylvania, USA
| | | | - Jodi Schreiber
- Occupational Therapy Program, Chatham University, Pittsburgh, Pennsylvania, USA
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46
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Landry KK, Judd SE, Kleindorfer DO, Howard G, Howard VJ, Zakai NA, Cushman M. N-Terminal pro-B-type natriuretic peptide and stroke risk across a spectrum of cerebrovascular disease: The REasons for Geographic and Racial Differences in Stroke cohort. Res Pract Thromb Haemost 2020; 4:893-901. [PMID: 32685900 PMCID: PMC7354407 DOI: 10.1002/rth2.12365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/08/2020] [Accepted: 04/20/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND N-terminal pro-B-type natriuretic peptide (NT-proBNP), a commonly used clinical marker of cardiac function, is associated with the presence of stroke symptoms and is a strong risk factor for future atrial fibrillation, stroke, and all-cause mortality. Few data are available on the association between NT-proBNP levels and stroke recurrence. OBJECTIVE We studied the relationship between NT-proBNP and risk of future ischemic stroke across the continuum of preexisting cerebrovascular conditions: asymptomatic, prior stroke symptoms, prior transient ischemic attack (TIA), and prior stroke. METHODS The Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort enrolled 30,239 black and white Americans aged 45 years and older from 2003 to 2007. With 5.4 years follow-up, baseline NT-proBNP was measured in 892 participants who developed ischemic stroke and a 4328-person cohort random sample. Hazard ratios of stroke by baseline NT-proBNP were calculated in groups based on the presence of prebaseline cerebrovascular conditions. RESULTS In the fully adjusted model, elevated NT-proBNP was associated with stroke risk in participants without a preexisting cerebrovascular condition (hazard ratio [HR], 2.32; 95% confidence interval [CI], 1.84-2.94) and in participants with a history of stroke symptoms (HR, 1.67; 95% CI, 1.01-2.78) or transient ischemic attack (HR, 2.66; 95% CI, 1.00-7.04) but not among those with prior stroke (HR, 1.26; 95% CI, 0.71-2.21). CONCLUSIONS These findings support the potential for NT-proBNP testing to identify people who are at highest risk for future stroke.
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Affiliation(s)
| | - Suzanne E. Judd
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | | | - George Howard
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Virginia J. Howard
- Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Neil A. Zakai
- Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVermontUSA
- Department of Pathology and Laboratory MedicineLarner College of Medicine at the University of VermontBurlingtonVermontUSA
| | - Mary Cushman
- Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVermontUSA
- Department of Pathology and Laboratory MedicineLarner College of Medicine at the University of VermontBurlingtonVermontUSA
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47
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Teo KC, Leung WCY, Wong YK, Liu RKC, Chan AHY, Choi OMY, Kwok WM, Leung KK, Tse MY, Cheung RTF, Tsang ACO, Lau KK. Delays in Stroke Onset to Hospital Arrival Time During COVID-19. Stroke 2020; 51:2228-2231. [PMID: 32432998 PMCID: PMC7258759 DOI: 10.1161/strokeaha.120.030105] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose: The current coronavirus disease 2019 (COVID-19) pandemic represents a global public health crisis, disrupting emergency healthcare services. We determined whether COVID-19 has resulted in delays in stroke presentation and affected the delivery of acute stroke services in a comprehensive stroke center in Hong Kong. Methods: We retrospectively reviewed all patients with transient ischemic attack and stroke admitted via the acute stroke pathway of Queen Mary Hospital, Hong Kong, during the first 60 days since the first diagnosed COVID-19 case in Hong Kong (COVID-19: January 23, 2020–March 24, 2020). We compared the stroke onset to hospital arrival (onset-to-door) time and timings of inpatient stroke pathways with patients admitted during the same period in 2019 (pre–COVID-19: January 23, 2019–March 24, 2019). Results: Seventy-three patients in COVID-19 were compared with 89 patients in pre–COVID-19. There were no significant differences in age, sex, vascular risk factors, nor stroke severity between the 2 groups (P>0.05). The median stroke onset-to-door time was ≈1-hour longer in COVID-19 compared with pre–COVID-19 (154 versus 95 minutes, P=0.12), and the proportion of individuals with onset-to-door time within 4.5 hours was significantly lower (55% versus 72%, P=0.024). Significantly fewer cases of transient ischemic attack presented to the hospital during COVID-19 (4% versus 16%, P=0.016), despite no increase in referrals to the transient ischemic attack clinic. Inpatient stroke pathways and treatment time metrics nevertheless did not differ between the 2 groups (P>0.05 for all comparisons). Conclusions: During the early containment phase of COVID-19, we noted a prolongation in stroke onset to hospital arrival time and a significant reduction in individuals arriving at the hospital within 4.5 hours and presenting with transient ischemic attack. Public education about stroke should continue to be reinforced during the COVID-19 pandemic.
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Affiliation(s)
- Kay-Cheong Teo
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - William C Y Leung
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Yuen-Kwun Wong
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Roxanna K C Liu
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Anna H Y Chan
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Olivia M Y Choi
- Division of Neurosurgery, Department of Surgery (O.N.Y.C., A.C.-O.T.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Wing-Man Kwok
- Department of Accident and Emergency, Queen Mary Hospital, Hong Kong (W.-M.K.)
| | - Kung-Ki Leung
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Man-Yu Tse
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Raymond T F Cheung
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Anderson Chun-On Tsang
- Division of Neurosurgery, Department of Surgery (O.N.Y.C., A.C.-O.T.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong
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Risk of Acute Ischemic Stroke in Patients With Monocular Vision Loss of Vascular Etiology. J Neuroophthalmol 2020; 38:328-333. [PMID: 29369960 DOI: 10.1097/wno.0000000000000613] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To evaluate the risk of concurrent acute ischemic stroke and monocular vision loss (MVL) of vascular etiology. DESIGN Retrospective, cross-sectional study. SUBJECTS Patients aged 18 or older diagnosed with MVL of suspected or confirmed vascular etiology who had no other neurologic deficits and who received brain MRI within 7 days of onset of visual symptoms were included. METHODS A medical record review was performed from 2013 to 2016 at Yale New Haven Hospital. Patients were included if vision loss was unilateral and due to transient monocular vision loss (TMVL), central retinal artery occlusion (CRAO), or branch retinal artery occlusion (BRAO). Any patients with neurologic deficits other than vision loss were excluded. Other exclusion criteria were positive visual phenomena, nonvascular intraocular pathology, and intracranial pathology other than ischemic stroke. MAIN OUTCOME MEASURES The presence or absence of acute stroke on diffusion-weighted imaging (DWI) on brain MRI. RESULTS A total of 641 records were reviewed, with 293 patients found to have MVL. After excluding those with focal neurologic deficits, there were 41 patients who met the inclusion criteria and received a brain MRI. Eight of the 41 subjects (19.5%) were found to have findings on brain MRI positive for acute cortical strokes. The proportion of lesion positive MRI was 1/23 (4.3%) in TMVL subjects, 4/12 (33.3%) in CRAO subjects, and 2/5 (40%) in BRAO subjects. Brain computed tomography (CT) scans were not able to identify the majority of acute stroke lesions in this study. CONCLUSIONS Patients with MVL of vascular etiology such as TMVL, CRAO, or BRAO may have up to 19.5% risk of concurrent ischemic stroke, even when there are no other neurologic deficits. These strokes were detected acutely with brain MRI using DWI but were missed on CT.
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Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4728] [Impact Index Per Article: 1182.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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50
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Wang Q, Jiang Y, Luo X, Wang C, Wang N, He H, Zhang T, Chen L. Chitooligosaccharides Modulate Glucose-Lipid Metabolism by Suppressing SMYD3 Pathways and Regulating Gut Microflora. Mar Drugs 2020; 18:md18010069. [PMID: 31968646 PMCID: PMC7024377 DOI: 10.3390/md18010069] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 12/21/2022] Open
Abstract
Chitooligosaccharides (COS) have a variety of biological activities due to their positively charged amino groups. Studies have shown that COS have antidiabetic effects, but their molecular mechanism has not been fully elucidated. The present study confirmed that COS can reduce hyperglycemia and hyperlipidemia, prevent obesity, and enhance histological changes in the livers of mice with type 2 diabetes mellitus (T2DM). Additionally, treatment with COS can modulate the composition of the gut microbiota in the colon by altering the abundance of Firmicutes, Bacteroidetes, and Proteobacteria. Furthermore, in T2DM mice, treatment with COS can upregulate the cholesterol-degrading enzymes cholesterol 7-alpha-hydroxylase (CYP7A1) and incretin glucagon-like peptide 1 (GLP-1) while specifically inhibiting the transcription and expression of 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR), the key enzyme in cholesterol synthesis. Furthermore, using an oleic acid-induced hepatocyte steatosis model, we found that HMGCR can be directly transactivated by SET and MYND domain containing 3 (SMYD3), a transcriptional regulator, via 5'-CCCTCC-3' element in the promoter. Overexpression of SMYD3 can suppress the inhibitory effect of COS on HMGCR, and COS might regulate HMGCR by inhibiting SMYD3, thereby exerting hypolipidemic functions. To the best of our knowledge, this study is the first to illustrate that COS mediate glucose and lipid metabolism disorders by regulating gut microbiota and SMYD3-mediated signaling pathways.
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Affiliation(s)
- Qiutong Wang
- Key Lab of Industrial Fermentation Microbiology of the Ministry of Education & Tianjin Key Lab of Industrial Microbiology, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China; (Q.W.); (Y.J.); (C.W.); (N.W.); (H.H.); (T.Z.)
- Tianjin Engineering Research Center of Microbial Metabolism and Fermentation Process Control, Tianjin 300457, China
| | - Yajie Jiang
- Key Lab of Industrial Fermentation Microbiology of the Ministry of Education & Tianjin Key Lab of Industrial Microbiology, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China; (Q.W.); (Y.J.); (C.W.); (N.W.); (H.H.); (T.Z.)
- Tianjin Engineering Research Center of Microbial Metabolism and Fermentation Process Control, Tianjin 300457, China
| | - Xuegang Luo
- Key Lab of Industrial Fermentation Microbiology of the Ministry of Education & Tianjin Key Lab of Industrial Microbiology, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China; (Q.W.); (Y.J.); (C.W.); (N.W.); (H.H.); (T.Z.)
- Tianjin Engineering Research Center of Microbial Metabolism and Fermentation Process Control, Tianjin 300457, China
- Correspondence: (X.L.); (L.C.); Tel.: +86-22-60601104 (X.L.); +86-15382999119 (L.C.)
| | - Chang Wang
- Key Lab of Industrial Fermentation Microbiology of the Ministry of Education & Tianjin Key Lab of Industrial Microbiology, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China; (Q.W.); (Y.J.); (C.W.); (N.W.); (H.H.); (T.Z.)
- Tianjin Engineering Research Center of Microbial Metabolism and Fermentation Process Control, Tianjin 300457, China
| | - Nan Wang
- Key Lab of Industrial Fermentation Microbiology of the Ministry of Education & Tianjin Key Lab of Industrial Microbiology, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China; (Q.W.); (Y.J.); (C.W.); (N.W.); (H.H.); (T.Z.)
- Tianjin Engineering Research Center of Microbial Metabolism and Fermentation Process Control, Tianjin 300457, China
| | - Hongpeng He
- Key Lab of Industrial Fermentation Microbiology of the Ministry of Education & Tianjin Key Lab of Industrial Microbiology, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China; (Q.W.); (Y.J.); (C.W.); (N.W.); (H.H.); (T.Z.)
- Tianjin Engineering Research Center of Microbial Metabolism and Fermentation Process Control, Tianjin 300457, China
| | - Tongcun Zhang
- Key Lab of Industrial Fermentation Microbiology of the Ministry of Education & Tianjin Key Lab of Industrial Microbiology, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China; (Q.W.); (Y.J.); (C.W.); (N.W.); (H.H.); (T.Z.)
- Tianjin Engineering Research Center of Microbial Metabolism and Fermentation Process Control, Tianjin 300457, China
| | - Liehuan Chen
- College of Animal Sciences and Technology, Zhongkai Agricultural Engineering College, Guangzhou 510225, China
- Guangzhou Youlan Marine Biological Technology Co., Ltd., Guangzhou 510530, China
- Correspondence: (X.L.); (L.C.); Tel.: +86-22-60601104 (X.L.); +86-15382999119 (L.C.)
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