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Li S, Gu HQ, Li H, Wang X, Jin A, Guo S, Lu G, Che F, Wang W, Wei Y, Wang Y, Li Z, Meng X, Zhao X, Liu L, Wang Y. Reteplase versus Alteplase for Acute Ischemic Stroke. N Engl J Med 2024; 390:2264-2273. [PMID: 38884332 DOI: 10.1056/nejmoa2400314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
BACKGROUND Alteplase is the standard agent used in early reperfusion therapy, but alternative thrombolytic agents are needed. The efficacy and safety of reteplase as compared with alteplase in patients with acute ischemic stroke are unclear. METHODS We randomly assigned patients with ischemic stroke within 4.5 hours after symptom onset in a 1:1 ratio to receive intravenous reteplase (a bolus of 18 mg followed 30 minutes later by a second bolus of 18 mg) or intravenous alteplase (0.9 mg per kilogram of body weight; maximum dose, 90 mg). The primary efficacy outcome was an excellent functional outcome, defined as a score of 0 or 1 on the modified Rankin scale (range, 0 [no neurologic deficit, no symptoms, or completely recovered] to 6 [death]) at 90 days. The primary safety outcome was symptomatic intracranial hemorrhage within 36 hours after symptom onset. RESULTS A total of 707 patients were assigned to receive reteplase, and 705 were assigned to receive alteplase. An excellent functional outcome occurred in 79.5% of the patients in the reteplase group and in 70.4% of those in the alteplase group (risk ratio, 1.13; 95% confidence interval [CI], 1.05 to 1.21; P<0.001 for noninferiority and P = 0.002 for superiority). Symptomatic intracranial hemorrhage within 36 hours after disease onset was observed in 17 of 700 patients (2.4%) in the reteplase group and in 14 of 699 (2.0%) of those in the alteplase group (risk ratio, 1.21; 95% CI, 0.54 to 2.75). The incidence of any intracranial hemorrhage at 90 days was higher with reteplase than with alteplase (7.7% vs. 4.9%; risk ratio, 1.59; 95% CI, 1.00 to 2.51), as was the incidence of adverse events (91.6% vs. 82.4%; risk ratio, 1.11; 95% CI, 1.03 to 1.20). CONCLUSIONS Among patients with ischemic stroke within 4.5 hours after symptom onset, reteplase was more likely to result in an excellent functional outcome than alteplase. (Funded by China Resources Angde Biotech Pharma and others; RAISE ClinicalTrials.gov number, NCT05295173.).
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Affiliation(s)
- Shuya Li
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Hong-Qiu Gu
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Hao Li
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Xuechun Wang
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Aoming Jin
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Shuming Guo
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Guozhi Lu
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Fengyuan Che
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Weiwei Wang
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Yan Wei
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Yilong Wang
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Zixiao Li
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Xia Meng
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Xingquan Zhao
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Liping Liu
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
| | - Yongjun Wang
- From the Departments of Neurology (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang) and Clinical Trial Center (S.L., H.L., X.W., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), and the China National Clinical Research Center for Neurologic Diseases (S.L., H.-Q.G., H.L., X.W., A.J., Yilong Wang, Z.L., X.M., X.Z., L.L., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, the Emergency Department, Linfen Central Hospital, Linfen (S.G.), the Department of Neurology, Ke shi ke teng Banner Traditional Chinese Medicine and Mongolian Medical Hospital, Chifeng (G.L.), the Department of Neurology, Linyi People's Hospital, Linyi (F.C.), the Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang (W.W.), and the Department of Neurology, Halison International Peace Hospital, Hengshui (Y. Wei) - all in China
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Yamanie N, Felistia Y, Susanto NH, Lamuri A, Sjaaf AC, Miftahussurur M, Santoso A. Prognostic model of in-hospital ischemic stroke mortality based on an electronic health record cohort in Indonesia. PLoS One 2024; 19:e0305100. [PMID: 38865423 PMCID: PMC11168658 DOI: 10.1371/journal.pone.0305100] [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: 02/22/2023] [Accepted: 05/23/2024] [Indexed: 06/14/2024] Open
Abstract
Stroke patients rarely have satisfactory survival, which worsens further if comorbidities develop in such patients. Limited data availability from Southeast Asian countries, especially Indonesia, has impeded the disentanglement of post-stroke mortality determinants. This study aimed to investigate predictors of in-hospital mortality in patients with ischemic stroke (IS). This retrospective observational study used IS medical records from the National Brain Centre Hospital, Jakarta, Indonesia. A theoretically driven Cox's regression and Fine-Gray models were established by controlling for age and sex to calculate the hazard ratio of each plausible risk factor for predicting in-hospital stroke mortality and addressing competing risks if they existed. This study finally included 3,278 patients with IS, 917 (28%) of whom had cardiovascular disease and 376 (11.5%) suffered renal disease. Bivariate exploratory analysis revealed lower blood levels of triglycerides, low density lipoprotein, and total cholesterol associated with in-hospital-stroke mortality. The average age of patients with post-stroke mortality was 64.06 ± 11.32 years, with a mean body mass index (BMI) of 23.77 kg/m2 and a median Glasgow Coma Scale (GCS) score of 12 and an IQR of 5. Cardiovascular disease was significantly associated with IS mortality risk. NIHSS score at admission (hazard ratio [HR] = 1.04; 95% confidence interval [CI]: 1.00-1.07), male sex (HR = 1.51[1.01-2.26] and uric acid level (HR = 1.02 [1.00-1.03]) predicted survivability. Comorbidities, such as cardiovascular disease (HR = 2.16 [1.37-3.40], pneumonia (HR = 2.43 [1.42-4.15] and sepsis (HR = 2.07 [1.09-3.94, had higher hazards for post-stroke mortality. Contrarily, the factors contributing to a lower hazard of mortality were BMI (HR = 0.94 [0.89-0.99]) and GCS (HReye = 0.66 [0.48-0.89]. In summary, our study reported that male sex, NIHSS, uric acid level, cardiovascular diseases, pneumonia, sepsis. BMI, and GCS on admission were strong determinants of in-hospital mortality in patients with IS.
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Affiliation(s)
- Nizar Yamanie
- Doctoral Program of Medical Science, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- National Brain Centre Hospital, Jakarta, Indonesia
| | | | - Nugroho Harry Susanto
- Indonesia Research Partnership on Infectious Diseases (INA-RESPOND), Jakarta, Indonesia
| | - Aly Lamuri
- National Brain Centre Hospital, Jakarta, Indonesia
| | - Amal Chalik Sjaaf
- Department of Public Health, University of Indonesia, Jakarta, Indonesia
| | - Muhammad Miftahussurur
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine-Dr. Soetomo Teaching Hospital, Airlangga University, Surabaya, Indonesia
| | - Anwar Santoso
- Department of Cardiology–Vascular Medicine, National Cardiovascular Centre–Harapan Kita Hospital, Universitas Indonesia, Jakarta, Indonesia
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Reeves MJ, Fonarow GC, Smith EE, Sheth KN, Messe SR, Schwamm LH. Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges. Stroke 2024; 55:1689-1698. [PMID: 38738376 PMCID: PMC11208062 DOI: 10.1161/strokeaha.124.046527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.
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Affiliation(s)
- Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine, University of California Los Angeles (G.C.F.)
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Kevin N. Sheth
- Center for Brain & Mind Health, Departments of Neurology & Neurosurgery (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Steven R. Messe
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (S.R.M.)
| | - Lee H. Schwamm
- Department of Neurology and Bioinformatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
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Chongolo AM, Alphonce B, Mbelele PM, Meda J, Nyundo A. Predictors of 30-day mortality following the first episode of stroke among patients admitted at referral hospitals in Dodoma, central Tanzania: A prospective longitudinal observational study. Health Sci Rep 2024; 7:e2198. [PMID: 38933419 PMCID: PMC11199172 DOI: 10.1002/hsr2.2198] [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: 09/05/2023] [Revised: 05/12/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024] Open
Abstract
Background and Aims Stroke is the leading cause of disability and the second most common cause of death after ischemic heart disease worldwide. Understanding predictors of early poststroke mortality provides opportunities for interventions and favorable outcomes. This study aimed to determine the incidence and predictors of 30-day mortality among patients admitted with the first stroke at referral hospitals in Dodoma. Methods A prospective longitudinal observational design enrolled patients with acute stroke confirmed by CT scan or MRI admitted at referral hospitals in Dodoma. The National Institute of Health Stroke Scale was used to assess stroke severity at baseline. A comparison of risk factors, clinical profiles, and mortality was done using the Chi-square test. A logistic regression model was used to determine the predictors of 30-day mortality in patients with the stroke while the 30-day probability of survival was estimated using Kaplan-Meier analysis. Results Out of 226 patients with first-ever stroke, 121(54%) were males, and the population mean age was 63(15) years. The 140(62%) had Ischemic stroke, and 154(68%) survived at the 30th day. Patients with a history of smoking 2.4 [95% confidence interval (CI) (1.0-5.6), p = 0.048], loss of consciousness 2.7 [95% CI (1.2-6.4; p = 0.019] and unequal pupil size 13.7 [95% CI (4.1-58.1, p < 0.001 were significantly more associated with mortality within 30 days. The median survival was 7 (3-9) days, whereas alcohol drinkers and those aged above 60 years had a shorter time to mortality compared to non-alcohol drinkers and those aged <60 years. Conclusion The study showed a high incidence of mortality within 30 days after the first stroke episode, with the highest proportion dying within 7 days of being hospitalized. Advanced age of ≥60 years, smoking, alcohol use, and severe stroke at admission warrant special attention.
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Affiliation(s)
- Anna M. Chongolo
- Kibong'oto Infectious Diseases HospitalSihaTanzania
- Department of Internal Medicine, School of Medicine and DentistryThe University DodomaDodomaTanzania
| | - Baraka Alphonce
- Department of Internal Medicine, School of Medicine and DentistryThe University DodomaDodomaTanzania
| | | | - John Meda
- Department of Internal Medicine, School of Medicine and DentistryThe University DodomaDodomaTanzania
- Department of CardiologyThe Benjamin Mkapa HospitalDodomaTanzania
- Department of Internal MedicineThe Benjamin Mkapa HospitalDodomaTanzania
| | - Azan Nyundo
- Department of Internal Medicine, School of Medicine and DentistryThe University DodomaDodomaTanzania
- Department of Internal MedicineThe Benjamin Mkapa HospitalDodomaTanzania
- Department of Psychiatry and Mental Health, School of Medicine and DentistryThe University of DodomaDodomaTanzania
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Irie F, Matsuo R, Mezuki S, Wakisaka Y, Kamouchi M, Kitazono T, Ago T. Effect of smoking status on clinical outcomes after reperfusion therapy for acute ischemic stroke. Sci Rep 2024; 14:9290. [PMID: 38654009 PMCID: PMC11039615 DOI: 10.1038/s41598-024-59508-3] [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: 05/23/2023] [Accepted: 04/11/2024] [Indexed: 04/25/2024] Open
Abstract
Smoking has detrimental effects on the cardiovascular system; however, some studies have reported better clinical outcomes after thrombolysis for ischemic stroke in smokers than in nonsmokers, a phenomenon known as the smoking paradox. Therefore, this study aimed to examine the smoking paradox in patients with ischemic stroke receiving reperfusion therapy. Data were collected from a multicenter hospital-based acute stroke registry in Fukuoka, Japan. The 1148 study patients were categorized into current and noncurrent smokers. The association between smoking and clinical outcomes, including neurological improvement (≥ 4-point decrease in the National Institutes of Health Stroke Scale during hospitalization or 0 points at discharge) and good functional outcomes (modified Rankin Scale score of 0-2) at 3 months, was evaluated using logistic regression analysis and propensity score-matched analysis. Among the participants, 231 (20.1%) were current smokers. The odds ratios (ORs) of favorable outcomes after adjusting for potential confounders were not significantly increased in current smokers (OR 0.85, 95% confidence interval [CI] 0.60-1.22 for neurological improvement; OR 0.95, 95% CI 0.65-1.38 for good functional outcome). No significant association was found in the propensity score-matched cohorts. Smoking cessation is strongly recommended since current smoking was not associated with better outcomes after reperfusion therapy.
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Affiliation(s)
- Fumi Irie
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
| | - Ryu Matsuo
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan.
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan.
| | - Satomi Mezuki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
- Emergency and Clinical Care Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoshinobu Wakisaka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
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6
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Abujaber AA, Albalkhi I, Imam Y, Nashwan A, Akhtar N, Alkhawaldeh IM. Machine learning-based prognostication of mortality in stroke patients. Heliyon 2024; 10:e28869. [PMID: 38601648 PMCID: PMC11004568 DOI: 10.1016/j.heliyon.2024.e28869] [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: 09/11/2023] [Revised: 02/22/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
Objectives Predicting stroke mortality is crucial for personalized care. This study aims to design and evaluate a machine learning model to predict one-year mortality after a stroke. Materials and methods Data from the National Multiethnic Stroke Registry was utilized. Eight machine learning (ML) models were trained and evaluated using various metrics. SHapley Additive exPlanations (SHAP) analysis was used to identify the influential predictors. Results The final analysis included 9840 patients diagnosed with stroke were included in the study. The XGBoost algorithm exhibited optimal performance with high accuracy (94.5%) and AUC (87.3%). Core predictors encompassed National Institutes of Health Stroke Scale (NIHSS) at admission, age, hospital length of stay, mode of arrival, heart rate, and blood pressure. Increased NIHSS, age, and longer stay correlated with higher mortality. Ambulance arrival and lower diastolic blood pressure and lower body mass index predicted poorer outcomes. Conclusions This model's predictive capacity emphasizes the significance of NIHSS, age, hospital stay, arrival mode, heart rate, blood pressure, and BMI in stroke mortality prediction. Specific findings suggest avenues for data quality enhancement, registry expansion, and real-world validation. The study underscores machine learning's potential for early mortality prediction, improving risk assessment, and personalized care. The potential transformation of care delivery through robust ML predictive tools for Stroke outcomes could revolutionize patient care, allowing for personalized plans and improved preventive strategies for stroke patients. However, it is imperative to conduct prospective validation to evaluate its practical clinical effectiveness and ensure its successful adoption across various healthcare environments.
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Affiliation(s)
| | - Ibrahem Albalkhi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, United Kingdom
| | - Yahia Imam
- Neurology Section, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | | | - Naveed Akhtar
- Neurology Section, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
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7
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Yu AYX, Austin PC, Park AL, Fang J, Hill MD, Kamal N, Field TS, Joundi RA, Peterson S, Zhao Y, Kapral MK. Validation of the Passive Surveillance Stroke Severity Score in Three Canadian Provinces. Can J Neurol Sci 2024:1-6. [PMID: 38443764 DOI: 10.1017/cjn.2024.36] [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: 03/07/2024]
Abstract
BACKGROUND Stroke outcomes research requires risk-adjustment for stroke severity, but this measure is often unavailable. The Passive Surveillance Stroke SeVerity (PaSSV) score is an administrative data-based stroke severity measure that was developed in Ontario, Canada. We assessed the geographical and temporal external validity of PaSSV in British Columbia (BC), Nova Scotia (NS) and Ontario, Canada. METHODS We used linked administrative data in each province to identify adult patients with ischemic stroke or intracerebral hemorrhage between 2014-2019 and calculated their PaSSV score. We used Cox proportional hazards models to evaluate the association between the PaSSV score and the hazard of death over 30 days and the cause-specific hazard of admission to long-term care over 365 days. We assessed the models' discriminative values using Uno's c-statistic, comparing models with versus without PaSSV. RESULTS We included 86,142 patients (n = 18,387 in BC, n = 65,082 in Ontario, n = 2,673 in NS). The mean and median PaSSV were similar across provinces. A higher PaSSV score, representing lower stroke severity, was associated with a lower hazard of death (hazard ratio and 95% confidence intervals 0.70 [0.68, 0.71] in BC, 0.69 [0.68, 0.69] in Ontario, 0.72 [0.68, 0.75] in NS) and admission to long-term care (0.77 [0.76, 0.79] in BC, 0.84 [0.83, 0.85] in Ontario, 0.86 [0.79, 0.93] in NS). Including PaSSV in the multivariable models increased the c-statistics compared to models without this variable. CONCLUSION PaSSV has geographical and temporal validity, making it useful for risk-adjustment in stroke outcomes research, including in multi-jurisdiction analyses.
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Affiliation(s)
- Amy Y X Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | | | | | | | - Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - Thalia S Field
- Department of Medicine (Neurology), Vancouver Stroke Program, University of British Columbia, Vancouver, BC, Canada
| | - Raed A Joundi
- Department of Medicine, Hamilton Health Sciences Centre, McMaster University, Hamilton, ON, Canada
| | - Sandra Peterson
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada
| | - Yinshan Zhao
- Population Data BC, University of British Columbia, Vancouver, BC, Canada
| | - Moira K Kapral
- ICES, Toronto, ON, Canada
- Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, Toronto, ON, Canada
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8
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Sheth KN, Solomon N, Alhanti B, Messe SR, Xian Y, Bhatt DL, Hemphill JC, Frontera JA, Chang RC, Danelich IM, Huang J, Schwamm L, Smith EE, Goldstein JN, Mac Grory B, Fonarow GC, Saver JL. Time to Anticoagulation Reversal and Outcomes After Intracerebral Hemorrhage. JAMA Neurol 2024; 81:2815044. [PMID: 38335064 PMCID: PMC11002694 DOI: 10.1001/jamaneurol.2024.0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/19/2024] [Indexed: 02/12/2024]
Abstract
Importance Intracerebral hemorrhage (ICH) is the deadliest stroke subtype, and mortality rates are especially high in anticoagulation-associated ICH. Recently, specific anticoagulation reversal strategies have been developed, but it is not clear whether there is a time-dependent treatment effect for door-to-treatment (DTT) times in clinical practice. Objective To evaluate whether DTT time is associated with outcome among patients with anticoagulation-associated ICH treated with reversal interventions. Design, Setting, and Participants This cohort study used data from the American Heart Association Get With The Guidelines-Stroke quality improvement registry. Patients with ICH who presented within 24 hours of symptom onset across 465 US hospitals from 2015 to 2021 were included. Data were analyzed from January to September 2023. Exposures Anticoagulation-associated ICH. Main Outcomes and Measures DTT times and outcomes were analyzed using logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site. The primary outcome of interest was the composite inpatient mortality and discharge to hospice. Additional prespecified secondary outcomes, including functional outcome (discharge modified Rankin Scale score, ambulatory status, and discharge venue), were also examined. Results Of 9492 patients with anticoagulation-associated ICH and documented reversal intervention status, 4232 (44.6%) were female, and the median (IQR) age was 77 (68-84) years. A total of 7469 (78.7%) received reversal therapy, including 4616 of 5429 (85.0%) taking warfarin and 2856 of 4069 (70.2%) taking a non-vitamin K antagonist oral anticoagulant. For the 5224 patients taking a reversal intervention with documented workflow times, the median (IQR) onset-to-treatment time was 232 (142-482) minutes and the median (IQR) DTT time was 82 (58-117) minutes, with a DTT time of 60 minutes or less in 1449 (27.7%). A DTT time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82; 95% CI, 0.69-0.99) but no difference in functional outcome (ie, a modified Rankin Scale score of 0 to 3; adjusted odds ratio, 0.91; 95% CI, 0.67-1.24). Factors associated with a DTT time of 60 minutes or less included White race, higher systolic blood pressure, and lower stroke severity. Conclusions and Relevance In US hospitals participating in Get With The Guidelines-Stroke, earlier anticoagulation reversal was associated with improved survival for patients with ICH. These findings support intensive efforts to accelerate evaluation and treatment for patients with this devastating form of stroke.
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Affiliation(s)
- Kevin N. Sheth
- Yale Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole Solomon
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Steven R. Messe
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
| | - Ying Xian
- Department of Neurology, University of Texas at Southwestern, Dallas
| | - Deepak L. Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | | | - Lee Schwamm
- Department of Biomedical Informatics and Data Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Eric E. Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C. Fonarow
- Division of Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jeffrey L. Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, California
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Man S, Solomon N, Mac Grory B, Alhanti B, Saver JL, Smith EE, Xian Y, Bhatt DL, Schwamm LH, Uchino K, Fonarow GC. Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021. JAMA Netw Open 2024; 7:e2352927. [PMID: 38324315 PMCID: PMC10851100 DOI: 10.1001/jamanetworkopen.2023.52927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/04/2023] [Indexed: 02/08/2024] Open
Abstract
Importance Understanding is needed of racial and ethnic-specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke. Objective To examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups. Design, Setting, and Participants This retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines-Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023. Exposures TS phases I (2010-2013), II (2014-2018), and III (2019-2021). Main Outcomes and Measures The primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes. Results Analyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours. Conclusions and Relevance In this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.
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Affiliation(s)
- Shumei Man
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole Solomon
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Eric E. Smith
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deepak L. Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ken Uchino
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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10
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Smith EE, Yaghi S, Sposato LA, Fisher M. Atrial Fibrillation Detection and Load: Knowledge Gaps Related to Stroke Prevention. Stroke 2024; 55:205-213. [PMID: 38134250 DOI: 10.1161/strokeaha.123.043665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Atrial fibrillation is a major cause of ischemic stroke. Technological advances now support prolonged cardiac rhythm monitoring using either surface electrodes or insertable cardiac monitors. Four major randomized controlled trials show that prolonged cardiac monitoring detects subclinical paroxysmal atrial fibrillation in 9% to 16% of patients with ischemic stroke, including in patients with potential alternative causes such as large artery disease or small vessel occlusion; however, the optimal monitoring strategy, including the target patient population and the monitoring device (whether to use an event monitor, insertable cardiac monitor, or stepped approach) has not been well defined. Furthermore, the clinical significance of very short duration paroxysmal atrial fibrillation remains controversial. The relevance of the duration of monitoring, burden of device-detected atrial fibrillation, and its proximity to the acute ischemic stroke will require more research to define the most effective methods for stroke prevention in this patient population.
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Affiliation(s)
| | | | | | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
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11
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García-Torrecillas JM, Lea-Pereira MC, Amaya-Pascasio L, Rosa-Garrido C, Quesada-López M, Reche-Lorite F, Iglesias-Espinosa M, Aparicio-Mota A, Galván-Espinosa J, Martínez-Sánchez P, Rodríguez-Barranco M. External Validation and Recalibration of a Mortality Prediction Model for Patients with Ischaemic Stroke. J Clin Med 2023; 12:7168. [PMID: 38002780 PMCID: PMC10672719 DOI: 10.3390/jcm12227168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Stroke is a highly prevalent disease that can provoke severe disability. We evaluate a predictive model based on the Minimum Basic Data Set (MBDS) compiled by the Spain Health Ministry, obtained for the period 2008-2012 for patients with ischaemic stroke in Spain, to establish the model's validity and to optimise its calibration. The MBDS is the main clinical-administrative database for hospitalisations recorded in Spain, and to our knowledge, no predictive models for stroke mortality have previously been developed using this resource. The main study aim is to perform an external validation and recalibration of the coefficients of this predictive model with respect to a chronologically later cohort. MATERIAL AND METHODS External validation (testing the model on a different cohort to assess its performance) and recalibration (validation with optimisation of model coefficients) were performed using the MBDS for patients admitted for ischaemic stroke in the period 2016-2018. A cohort study was designed, in which a recalibrated model was obtained by applying the variables of the original model without their coefficients. The variables from the original model were then applied to the subsequent cohort, together with the coefficients from the initial model. The areas under the curve (AUC) of the recalibration and the external validation procedure were compared. RESULTS The recalibrated model produced an AUC of 0.743 and was composed of the following variables: age (odds ratio, OR:1.073), female sex (OR:1.143), ischaemic heart disease (OR:1.192), hypertension (OR:0.719), atrial fibrillation (OR:1.414), hyperlipidaemia (OR:0.652), heart failure (OR:2.133) and posterior circulation stroke (OR: 0.755). External validation produced an AUC of 0.726. CONCLUSIONS The recalibrated clinical model thus obtained presented moderate-high discriminant ability and was generalisable to predict death for patients with ischaemic stroke. Rigorous external validation slightly decreased the AUC but confirmed the validity of the baseline model for the chronologically later cohort.
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Affiliation(s)
- Juan Manuel García-Torrecillas
- Emergency and Research Unit, Torrecárdenas University Hospital, 04009 Almería, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain;
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
| | | | - Laura Amaya-Pascasio
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain; (L.A.-P.); (M.Q.-L.); (P.M.-S.)
| | - Carmen Rosa-Garrido
- FIBAO, Hospital Universitario de Jaén, Servicio Andaluz de Salud, 23007 Jaén, Spain;
| | - Miguel Quesada-López
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain; (L.A.-P.); (M.Q.-L.); (P.M.-S.)
| | | | - Mar Iglesias-Espinosa
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain; (L.A.-P.); (M.Q.-L.); (P.M.-S.)
| | - Adrián Aparicio-Mota
- Unidad de Investigación Biomédica, Hospital Universitario Torrecárdenas, 04009 Almería, Spain;
| | - José Galván-Espinosa
- FIBAO, Hospital Universitario Torrecárdenas, Servicio Andaluz de Salud, 04009 Almería, Spain;
| | - Patricia Martínez-Sánchez
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain; (L.A.-P.); (M.Q.-L.); (P.M.-S.)
- Faculty of Health Sciences, Health Research Center (CEINSA), University of Almeria, Carretera de Sacramento s/n, 04120 Almeria, Spain
| | - Miguel Rodríguez-Barranco
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain;
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
- Escuela Andaluza de Salud Pública (EASP), 18011 Granada, Spain
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12
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Yu AYX, Kapral MK, Park AL, Fang J, Hill MD, Kamal N, Field TS, Joundi RA, Peterson S, Zhao Y, Austin PC. Change in Hospital Risk-standardized Stroke Mortality Performance With and Without the Passive Surveillance Stroke Severity Score. Med Care 2023:00005650-990000000-00180. [PMID: 37962442 DOI: 10.1097/mlr.0000000000001944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Adjustment for baseline stroke severity is necessary for accurate assessment of hospital performance. We evaluated whether adjusting for the Passive Surveillance Stroke SeVerity (PaSSV) score, a measure of stroke severity derived using administrative data, changed hospital-specific estimated 30-day risk-standardized mortality rate (RSMR) after stroke. METHODS We used linked administrative data to identify adults who were hospitalized with ischemic stroke or intracerebral hemorrhage across 157 hospitals in Ontario, Canada between 2014 and 2019. We fitted a random effects logistic regression model using Markov Chain Monte Carlo methods to estimate hospital-specific 30-day RSMR and 95% credible intervals with adjustment for age, sex, Charlson comorbidity index, and stroke type. In a separate model, we additionally adjusted for stroke severity using PaSSV. Hospitals were defined as low-performing, average-performing, or high-performing depending on whether the RSMR and 95% credible interval were above, overlapping, or below the cohort's crude mortality rate. RESULTS We identified 65,082 patients [48.0% were female, the median age (25th,75th percentiles) was 76 years (65,84), and 86.4% had an ischemic stroke]. The crude 30-day all-cause mortality rate was 14.1%. The inclusion of PaSSV in the model reclassified 18.5% (n=29) of the hospitals. Of the 143 hospitals initially classified as average-performing, after adjustment for PaSSV, 20 were reclassified as high-performing and 8 were reclassified as low-performing. Of the 4 hospitals initially classified as low-performing, 1 was reclassified as high-performing. All 10 hospitals initially classified as high-performing remained unchanged. CONCLUSION PaSSV may be useful for risk-adjusting mortality when comparing hospital performance. External validation of our findings in other jurisdictions is needed.
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Affiliation(s)
- Amy Y X Yu
- Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto
- ICES
| | - Moira K Kapral
- ICES
- Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, Toronto, ON
| | | | | | - Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, AB
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, NS
| | - Thalia S Field
- Department of Medicine (Neurology), Vancouver Stroke Program, University of British Columbia, Vancouver, BC
| | - Raed A Joundi
- Department of Medicine, Hamilton Health Sciences Centre, McMaster University, Hamilton, ON
| | - Sandra Peterson
- Centre for Health Services and Policy Research, University of British Columbia
| | - Yinshan Zhao
- Population Data BC, University of British Columbia, Vancouver, BC, Canada
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13
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Jeon ET, Jung SJ, Yeo TY, Seo WK, Jung JM. Predicting short-term outcomes in atrial-fibrillation-related stroke using machine learning. Front Neurol 2023; 14:1243700. [PMID: 38020627 PMCID: PMC10663332 DOI: 10.3389/fneur.2023.1243700] [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: 06/21/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Prognostic prediction and the identification of prognostic factors are critical during the early period of atrial-fibrillation (AF)-related strokes as AF is associated with poor outcomes in stroke patients. Methods Two independent datasets, namely, the Korean Atrial Fibrillation Evaluation Registry in Ischemic Stroke Patients (K-ATTENTION) and the Korea University Stroke Registry (KUSR), were used for internal and external validation, respectively. These datasets include common variables such as demographic, laboratory, and imaging findings during early hospitalization. Outcomes were unfavorable functional status with modified Rankin scores of 3 or higher and mortality at 3 months. We developed two machine learning models, namely, a tree-based model and a multi-layer perceptron (MLP), along with a baseline logistic regression model. The area under the receiver operating characteristic curve (AUROC) was used as the outcome metric. The Shapley additive explanation (SHAP) method was used to evaluate the contributions of variables. Results Machine learning models outperformed logistic regression in predicting both outcomes. For 3-month unfavorable outcomes, MLP exhibited significantly higher AUROC values of 0.890 and 0.859 in internal and external validation sets, respectively, than those of logistic regression. For 3-month mortality, both machine learning models exhibited significantly higher AUROC values than the logistic regression for internal validation but not for external validation. The most significant predictor for both outcomes was the initial National Institute of Health and Stroke Scale. Conclusion The explainable machine learning model can reliably predict short-term outcomes and identify high-risk patients with AF-related strokes.
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Affiliation(s)
- Eun-Tae Jeon
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Seung Jin Jung
- Department of Family Medicine, Gimpo Woori Hospital, Gimpo, Republic of Korea
| | - Tae Young Yeo
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
- Korea University Zebrafish Translational Medical Research Center, Ansan, Republic of Korea
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Marcucci M, Chan MTV, Smith EE, Absalom AR, Devereaux PJ. Prevention of perioperative stroke in patients undergoing non-cardiac surgery. Lancet Neurol 2023; 22:946-958. [PMID: 37739575 DOI: 10.1016/s1474-4422(23)00209-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/17/2023] [Accepted: 05/26/2023] [Indexed: 09/24/2023]
Abstract
About 300 million adults undergo non-cardiac surgery annually. Although, in this setting, the incidence of perioperative stroke is low, the absolute number of patients experiencing a stroke is substantial. Furthermore, most patients with this complication will die or end up with severe disability. Covert brain infarctions are more frequent than overt strokes and are associated with postoperative delirium, cognitive decline, and cerebrovascular events at 1 year after surgery. Evidence shows that traditional stroke risk factors including older age, hypertension, and atrial fibrillation are also associated with perioperative stroke; previous stroke is the strongest risk factor for perioperative stroke. Increasing evidence also suggests the pathogenic role of perioperative events, such as hypotension, new atrial fibrillation, paradoxical embolism, and bleeding. Clinicians involved in perioperative care should be aware of this evidence on prevention strategies to improve patient outcomes after non-cardiac surgery.
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Affiliation(s)
- Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.
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15
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Liu Z, Gu H, Wei M, Feng X, Yu F, Feng J, Li Z, Xia J, Yang X. Comparison between healthcare quality in primary stroke centers and comprehensive stroke centers for acute stroke patients: evidence from the Chinese Stroke Center Alliance. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 38:100863. [PMID: 37577368 PMCID: PMC10416019 DOI: 10.1016/j.lanwpc.2023.100863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 08/15/2023]
Abstract
Background To improve stroke care quality, the guidelines for stroke center construction in China recommended establishing primary stroke centers (PSCs) and comprehensive stroke centers (CSCs). We aimed to compare stroke care quality between the two types of centers. Methods Data were collected from acute stroke patients admitted to PSCs or CSCs in the China Stroke Center Alliance program. Twenty-one individual guideline-recommended performance measures and two summary measures were compared between the two groups. Multivariable logistic regression models were used to examine the association between stroke center status (CSC vs. PSC) and healthcare quality. Findings Data from 750,594 stroke patients from 1474 stroke centers (252 CSCs and 1222 PSCs) were analyzed. For many components of healthcare performance in stroke patients, comparable levels of performance were observed between CSCs and PCSs. Nonetheless, CSCs outperformed PSCs in the areas of administering intravenous recombinant tissue plasminogen activator within 4.5 h (aOR = 1.31 [95% CI: 1.07-1.60]), rehabilitation for acute ischaemic stroke (AIS) (aOR = 1.19 [95% CI: 1.01-1.40]), and the provision of hypoglycemic medication and statin therapy upon discharge for AIS (aOR = 1.26 [95% CI: 1.00-1.59] and aOR = 1.28 [95% CI: 1.04-1.59], respectively). More patients with intracerebral haemorrhage and subarachnoid haemorrhage received neurosurgery in CSCs (14.4% vs. 10.6% and 51.0% vs. 33.9%, respectively). Additionally, CSCs had higher in-hospital mortality than PSCs (aOR = 1.33 [95% CI: 1.01-1.73]). Interpretation Overall PSCs provided equivalent care for many quality measures to CSCs in China with the exception of thrombolysis, rehabilitation access, and medication at discharge for AIS, whereby improvements should be directed. Nevertheless, PSCs have demonstrated lower risk-adjusted in-hospital mortality rates. Funding The National Key Research and Development Projects of China.
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Affiliation(s)
- Zeyu Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minping Wei
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xianjing Feng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fang Yu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jie Feng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Xia
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Widmer RE, Bink A, Hamann J, Herzog L, El Amki M, Sarikaya H, Kulcsar Z, Luft AR, Wegener S. Resolving the Smoking Paradox: No Evidence for Smoking-Induced Preconditioning in Large Vessel Occlusion Stroke. Eur Neurol 2023; 86:325-333. [PMID: 37562368 DOI: 10.1159/000533436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/21/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Smoking is an established risk factor for stroke. However, several studies have reported a better outcome after stroke for patients who smoke. According to this "smoking paradox" hypothesis, smoking might promote less severe strokes, higher collateral scores, and smaller infarct cores. METHODS In this retrospective study, we screened data of 2,980 acute ischemic stroke patients with MCA-M1 occlusion treated with mechanical thrombectomy. Patients were categorized according to smoking status (current, former, or never). We assessed univariate associations between clinical characteristics and smoking status. Subsequently, we used adjusted regression analysis to evaluate associations of smoking with stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]; primary endpoint), infarct core volume, and collateral status (secondary endpoints). RESULTS Out of 320 patients, 19.7% (n = 63) were current smokers and 18.8% (n = 60) were former smokers. Admission NIHSS, reperfusion success, and modified Rankin Scale (mRS) after 3-6 months were similar in all groups. Current smokers were younger, more often male and less likely to have atrial fibrillation compared to former and never smokers. In regression analyses, smoking status was neither associated with admission NIHSS (estimate 0.54, 95% confidence interval [CI]: -1.27-2.35, p = 0.557) nor with collateral status (estimate 0.79, 95% CI: 0.44-1.44, p = 0.447) or infarct core volume (estimate -0.69, 95% CI: -15.15-13.77, p = 0.925 for current vs. never smokers). CONCLUSION We could not confirm the smoking paradox. Our results support the fact that smoking causes stroke at a younger age, highlighting the role of smoking as a modifiable vascular risk factor.
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Affiliation(s)
- Roni E Widmer
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland,
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland,
| | - Andrea Bink
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Janne Hamann
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lisa Herzog
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- Institute of Data Analysis and Process Design, ZHAW Winterthur, Winterthur, Switzerland
| | - Mohamad El Amki
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, InselSpital Bern, Bern, Switzerland
| | - Zsolt Kulcsar
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Andreas R Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Iluţ S, Vesa ŞC, Văcăraș V, Mureșanu DF. Predictors of Short-Term Mortality in Patients with Ischemic Stroke. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1142. [PMID: 37374346 DOI: 10.3390/medicina59061142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: The purpose of this study is to investigate the predictive factors for intrahospital mortality in ischemic stroke patients. We will examine the association between a range of clinical and demographic factors and intrahospital mortality, including age, sex, comorbidities, laboratory values, and medication use. Materials and Methods: This retrospective, longitudinal, analytic, observational cohort study included 243 patients over 18 years old with a new ischemic stroke diagnosis who were hospitalized in Cluj-Napoca Emergency County Hospital. Data collected included the patient demographics, baseline characteristics at hospital admission, medication use, carotid artery Doppler ultrasound, as well as cardiology exam, and intrahospital death. Results: Multivariate logistic regression was used to determine which variables were independently associated with intrahospital death. An NIHSS score > 9 (OR-17.4; p < 0.001) and a lesion volume > 22.3 mL (OR-5.8; p = 0.003) were found to be associated with the highest risk of death. In contrast antiplatelet treatment (OR-0.349; p = 0.04) was associated with lower mortality rates. Conclusions: Our study identified a high NIHSS score and large lesion volume as independent risk factors for intrahospital mortality in ischemic stroke patients. Antiplatelet therapy was associated with lower mortality rates. Further studies are needed to explore the potential mechanisms underlying these associations and to develop targeted interventions to improve patient outcomes.
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Affiliation(s)
- Silvina Iluţ
- Department of Neurosciences, "Iuliu Haţieganu" University of Medicine and Pharmacy, 8 Victor Babeş Street, 400012 Cluj-Napoca, Romania
| | - Ştefan Cristian Vesa
- Department of Pharmacology, Toxicology and Clinical Pharmacology, "Iuliu Haţieganu" University of Medicine and Pharmacy, 23 Gheorghe Marinescu Street, 400337 Cluj-Napoca, Romania
| | - Vitalie Văcăraș
- Department of Neurosciences, "Iuliu Haţieganu" University of Medicine and Pharmacy, 8 Victor Babeş Street, 400012 Cluj-Napoca, Romania
| | - Dafin-Fior Mureșanu
- Department of Neurosciences, "Iuliu Haţieganu" University of Medicine and Pharmacy, 8 Victor Babeş Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
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Demir Unal E. Clinico-topographic evaluation of anterior versus posterior acute ischemic stroke and correlation with early mortality-based scale prediction. eNeurologicalSci 2023; 31:100458. [PMID: 37095895 PMCID: PMC10121384 DOI: 10.1016/j.ensci.2023.100458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/07/2023] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
Objective Posterior circulation ischaemic strokes (PCIs) are a clinical syndrome associated with ischemia related to stenosis, in situ thrombosis, or embolic occlusion of the posterior circulation and differ from anterior circulation ischaemic strokes (ACIs) in many aspects. In this study, ACIs and PCIs were evaluated in terms of clinico-radiological and demographic aspects, and the relevance of objective scales to early disability and mortality was investigated. Methods The definition of ACIS or PCIS was classified according to the Oxfordshire Community Stroke Project (OCSP). There are mainly two groups divided into ACIs and PCIs. ACIs were included as total anterior circulation syndrome (TACS), partial anterior circulation syndrome (PACS) (right and left), and lacunar syndrome (LACS) (right and left), and PCIs were posterior circulation syndrome (POCS) (right and left). Arrival NIH Stroke Scale/Score (NIHSS) and Glasgow Coma Scale (GCS) scores were evaluated in clinical assessment and modified SOAR Score for Stroke (mSOAR) was for early mortality-based scale prediction. All data were compared, and mean, IQR (if applicable) values and ROC curve analysis were determined. Results A total of 100 AIS patients, 50 of whom were ACIs and 50 were PCIs, were included in the study and were evaluated within the first 24 h. Hypertension was the most common disease for both groups. The second most common was hyperlipidemia (82%) in the ACIs and diabetes mellitus (40%) in the PCIs. The frequency of right hemisphere ischemia was higher in ACIs (63.6%) and PCIs (48%). The mean NIHSS and GCS score (also median IQR) was higher in the right ACIs and the highest NIHSS mean was in the right partial anterior circulation syndrome (PACS) (respectively median (IQR): 9.5 (13) and median (IQR):14.5 (3)). The mean NIHSS and GCS score of bilateral posterior circulation syndrome (POCS) were the highest in PCIs (median (IQR):3 (17), (IQR):15 (4) respectively). The mSOAR mean was the highest in the right PACS in ACIs (median (IQR):2.5 (2)) and in bilateral POCs among PCIs (median(IQR):2(2)). Conclusion The association of PCIs with hyperlipidemia and the male gender was interpreted, and anterior infarcts were found to cause higher early clinical disability scores. The NIHSS scale was effective and reliable, especially in anterior acute strokes, but also emphasized the necessity of using the GCS assessment together in the first 24 h in the assessment of PCIs. mSOAR scale is a helpful predictor in estimating early mortality not only in ACIs but also in PCIs, similar to GCS.
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Affiliation(s)
- Esra Demir Unal
- Corresponding author at: Nevşehir State Hospital Neurology Clinic, Nevşehir 5004, Turkey.
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19
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Huang J, Jin W, Duan X, Liu X, Shu T, Fu L, Deng J, Chen H, Liu G, Jiang Y, Liu Z. Twenty-eight-day in-hospital mortality prediction for elderly patients with ischemic stroke in the intensive care unit: Interpretable machine learning models. Front Public Health 2023; 10:1086339. [PMID: 36711330 PMCID: PMC9878123 DOI: 10.3389/fpubh.2022.1086339] [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: 11/01/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
Background Risk stratification of elderly patients with ischemic stroke (IS) who are admitted to the intensive care unit (ICU) remains a challenging task. This study aims to establish and validate predictive models that are based on novel machine learning (ML) algorithms for 28-day in-hospital mortality in elderly patients with IS who were admitted to the ICU. Methods Data of elderly patients with IS were extracted from the electronic intensive care unit (eICU) Collaborative Research Database (eICU-CRD) records of those elderly patients admitted between 2014 and 2015. All selected participants were randomly divided into two sets: a training set and a validation set in the ratio of 8:2. ML algorithms, such as Naïve Bayes (NB), eXtreme Gradient Boosting (xgboost), and logistic regression (LR), were applied for model construction utilizing 10-fold cross-validation. The performance of models was measured by the area under the receiver operating characteristic curve (AUC) analysis and accuracy. The present study uses interpretable ML methods to provide insight into the model's prediction and outcome using the SHapley Additive exPlanations (SHAP) method. Results As regards the population demographics and clinical characteristics, the analysis in the present study included 1,236 elderly patients with IS in the ICU, of whom 164 (13.3%) died during hospitalization. As regards feature selection, a total of eight features were selected for model construction. In the training set, both the xgboost and NB models showed specificity values of 0.989 and 0.767, respectively. In the internal validation set, the xgboost model identified patients who died with an AUC value of 0.733 better than the LR model which identified patients who died with an AUC value of 0.627 or the NB model 0.672. Conclusion The xgboost model shows the best predictive performance that predicts mortality in elderly patients with IS in the ICU. By making the ML model explainable, physicians would be able to understand better the reasoning behind the outcome.
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Affiliation(s)
- Jian Huang
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China,Guangxi University of Chinese Medical, Nanning, China
| | - Wanlin Jin
- Health Management Center, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiangjie Duan
- Department of Infectious Diseases, The First People's Hospital of Changde City, Changde, China
| | - Xiaozhu Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China,Key Laboratory of Neurological Diseases, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Tingting Shu
- Army Medical University (The Third Military Medical University), Chongqing, China
| | - Li Fu
- Key Laboratory of Novel Materials for Sensor of Zhejiang Province, College of Materials and Environmental Engineering, Hangzhou Dianzi University, Hangzhou, China
| | - Jiewen Deng
- Department of Neurosurgery, Xiu Shan People's Hospital, Chongqing, China
| | - Huaqiao Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guojing Liu
- Department of Neurosurgery, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Jiang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ziru Liu
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China,*Correspondence: Ziru Liu ✉
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Farghaly WM, Ahmed MA, El-Bassiouny A, Hamed AA, Shehata GA. Predictors of three months mortality after endovascular mechanical thrombectomy for acute ischemic stroke. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00533-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
This study aims to determine predictive factors of mortality within 3 months after mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS).
Methods
This prospective cohort study was carried out at Assiut University stroke center in collaboration with Ain Shams University Egypt. Forty-four patients with anterior circulation AIS underwent MT between the first of January 2020 to the end of December 2020. They were evaluated for detection of death rates and identification of risks of 3-month mortality after MT.
Results
This study comprised 44 patients (52.3% male) with a mean age of 64.3 years. The mean time from onset to femoral arterial puncture was 304.1 min. The mean Alberta Stroke Program Early CT Score (ASPECTS) and National Institutes of Health Stroke Scale (NIHSS) score were 9.3 and 19.2, respectively. The 3-month mortality rate was 13.6%. Univariate analyses found that higher baseline NIHSS score (mean 22.2 vs. 18.7, p = 0.021), absence of good collateral (16.7% vs. 68.4%, p = 0.02), longer duration of procedure ≥ 60 min (66.7% vs. 23.7%, p = 0.032), lower rates of successful recanalization (83.3% vs. 28.9%, p = 0.01) and developing symptomatic intracerebral hemorrhage (33.3% vs. 5.3%, p = 0.026) were associated with 3-month mortality. Multivariate analyses found that low rates of successful recanalization (OR 0.081; 95% CI 0.009–0.780, p = 0.030) remained significant independent predictive factor of 3-month mortality.
Conclusion
Successful recanalization was an independent predictor of 3-month mortality after MT.
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Hu J, Fang Z, Lu X, Wang F, Zhang N, Pan W, Fu X, Huang G, Tan X, Chen W. Influence Factors and Predictive Models for the Outcome of Patients with Ischemic Stroke after Intravenous Thrombolysis: A Multicenter Retrospective Cohort Study. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3363735. [PMID: 36035225 PMCID: PMC9402302 DOI: 10.1155/2022/3363735] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/24/2022] [Accepted: 07/28/2022] [Indexed: 12/26/2022]
Abstract
Objective Intravenous thrombolysis (IVT) is currently the main effective treatment for patients with ischemic stroke. This study aimed to analyze the factors affecting the early neurological recovery and prognosis of thrombolytic therapy after surgery and to construct predictive models. Materials and Methods A total of 849 patients with ischemic stroke who received IVT treatment at six centers from June 2017 to March 2021 were included. Patients were divided into the training cohort and the validation cohort. Based on the independent factors that influence the early recovery of neurological function and the prognosis, the respective predictive nomograms were established. The predictive accuracy and discrimination ability of the nomograms were evaluated by ROC and calibration curve, while the decision curve and clinical impact curve were adopted to evaluate the clinical applicability of the nomograms. Results The nomogram constructed based on the factors affecting the prognosis in 3 months had ideal accuracy as the AUC (95% CI) was 0.901 (0.874~0.927) in the training cohort and 0.877 (0.826~0.929) in the validation cohort. The accuracy of the nomogram is required to be improved, since the AUC (95% CI) of the training cohort and the validation cohort was 0.641 (0.597~0.685) and 0.627 (0.559~0.696), respectively. Conclusions Based on this ideal and practical prediction model, we can early identify and actively intervene in patients with ischemic stroke after IVT to improve their prognosis. Nevertheless, the accuracy of predicting nomograms for the recovery of early neurological function after IVT still needs improvement.
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Affiliation(s)
- Jin Hu
- Department of Neurology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Zhixian Fang
- Department of Respiration, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Xia Lu
- Department of Neurology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Fei Wang
- Department of Neurology, The First People's Hospital of Jiashan County, Jiaxing, China
| | - Ningyuan Zhang
- Department of Neurology, The First People's Hospital of Tongxiang, Jiaxing, China
| | - Wenliang Pan
- Department of Neurology, The People's Hospital of Haiyan, Jiaxing, China
| | - Xinzheng Fu
- Department of Neurology, The People's Hospital of Haining, Jiaxing, China
| | - Gongchun Huang
- Department of Neurology, The First People's Hospital of Pinghu, Jiaxing, China
| | - Xiaoli Tan
- Department of Respiration, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Wenyu Chen
- Department of Respiration, The Affiliated Hospital of Jiaxing University, Jiaxing, China
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22
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Yu AY, Bravata DM, Norrving B, Reeves MJ, Liu L, Kilkenny MF. Measuring Stroke Quality: Methodological Considerations in Selecting, Defining, and Analyzing Quality Measures. Stroke 2022; 53:3214-3221. [DOI: 10.1161/strokeaha.122.036485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Knowledge about stroke and its management is growing rapidly and stroke systems of care must adapt to deliver evidence-based care. Quality improvement initiatives are essential for translating knowledge from clinical trials and recommendations in guidelines into routine clinical practice. This review focuses on issues central to the measurement of the quality of stroke care, including selection and definition of quality measures, identification of the eligible patient cohorts, optimization of data quality, and considerations for data analysis and interpretation.
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Affiliation(s)
- Amy Y.X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (A.Y.X.Y.)
| | - Dawn M. Bravata
- VA HSR&D Center for Health Information and Communication (CHIC)‚ Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B.)
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis (D.M.B.)
- Regenstrief Institute, Indianapolis, IN (D.M.B.)
| | - Bo Norrving
- Department of Clinical Sciences (Neurology), Lund, Lund University, and Neurology, Skåne University Hospital Lund/Malmö, Sweden (B.N.)
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (L.L.)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (L.L.)
| | - Monique F. Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (M.F.K.)
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (M.F.K.)
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Cabral Frade H, Wilson SE, Beckwith A, Powers WJ. Comparison of Outcomes of Ischemic Stroke Initially Imaged With Cranial Computed Tomography Alone vs Computed Tomography Plus Magnetic Resonance Imaging. JAMA Netw Open 2022; 5:e2219416. [PMID: 35862046 PMCID: PMC9305377 DOI: 10.1001/jamanetworkopen.2022.19416] [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: 02/01/2023] Open
Abstract
IMPORTANCE Patients with acute ischemic stroke often undergo magnetic resonance imaging (MRI) in addition to computed tomography (CT), but its association with clinical outcomes is uncertain. OBJECTIVE To assess whether clinical outcomes of patients with acute ischemic stroke with initial CT alone were noninferior to those with additional MRI. DESIGN, SETTING, AND PARTICIPANTS A retrospective observational propensity score-matched cohort study of clinical outcomes at discharge and 1 year for patients hospitalized with acute ischemic stroke was conducted at an academic medical center between January 2015 and December 2017. Data collection from an electronic medical record system performed from May 2020 through January 2022 was not completely blinded. Noninferiority margins were based on the designs of previous randomized clinical trials of ischemic stroke treatments. Statistical analysis was performed in January 2022. Participants were adults hospitalized with acute ischemic stroke with admission diagnosis based on CT. Exclusion criteria were primarily missing data. From 508 eligible patients, all 123 cases with additional MRI were propensity-score matched to 123 controls without. EXPOSURE MRI after initial diagnosis. MAIN OUTCOMES AND MEASURES Death or dependence at hospital discharge (modified Rankin Scale score of 3-6) and stroke or death occurring in survivors within 1 year after discharge. RESULTS Among 246 participants, the median age was 68 years (IQR, 58-78.8 years) and 131 (53.0%) were men. Death or dependence at discharge occurred more often in patients with additional MRI (59 of 123 [48.0%]) than in those with CT alone (52 of 123 [42.3%]; absolute difference, 5.7%; 95% CI, -6.7% to 18.1%), meeting the -7.50% criterion for noninferiority. Stroke or death within 1 year after discharge determined for 225 of 235 (96%) survivors occurred more often in patients with additional MRI (22 of 113 [19.5%]) than in those with CT alone (14 of 112 [12.5%]; relative risk, 1.14; 95% CI, 0.86-1.50), meeting the 0.725 relative risk criterion for noninferiority. CONCLUSIONS AND RELEVANCE This propensity score-matched cohort study of patients hospitalized with acute ischemic stroke found that a diagnostic imaging strategy of initial CT alone was noninferior to initial CT plus additional MRI with regard to clinical outcomes at discharge and at 1 year. Further research is needed to determine which patients hospitalized with acute ischemic stroke benefit from MRI.
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Affiliation(s)
- Heitor Cabral Frade
- Department of Neurology, the University of Texas Medical Branch at Galveston
| | - Susan E. Wilson
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill
| | - Anne Beckwith
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill
| | - William J. Powers
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill
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Favilla CG, Ford AF, Khazaal O, Cristancho D, Grodinsky E, Dawod J, Kasner SE. Reliability of Past Medical History in a Single Hospital Participating in Get With The Guidelines-Stroke Registry. J Am Heart Assoc 2022; 11:e025308. [PMID: 35730609 PMCID: PMC9333368 DOI: 10.1161/jaha.122.025308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The GWTG (Get With The Guidelines)‐Stroke registry supports clinical research and quality improvement projects that often rely on past medical history elements, the reliability of which remains largely unknown. Here, we evaluated the reliability of specific past medical history elements in a local GWTG–Stroke data set, with particular attention to calculating the CHA2DS2‐VASc score. Methods and Results A single‐center cohort was identified by querying the Hospital of the University of Pennsylvania’s GWTG IQVIA Registry Platform for patients admitted with acute ischemic stroke between January 2017 and December 2020, with a previously known history of atrial fibrillation. Demographics and previously known medical history elements were retrieved from the registry to calculate the CHA2DS2‐VASc score. Five neurologists abstracted the same medical history elements from the health records. The κ statistics quantified the reliability of medical history elements and CHA2DS2‐VASc score. Four hundred fifty‐three patients with acute ischemic stroke and previously known atrial fibrillation were included in the cohort. In comparison with manual reabstraction, registry‐based medical history elements were only moderately reliable: congestive heart failure (κ=0.53), hypertension (κ=0.42), diabetes (κ=0.80), prior stroke (κ=0.45), and vascular disease (κ=0.48). However, leveraging these variables to calculate the CHA2DS2‐VASc score was more reliable (κ=0.73). Conclusions Previously known medical history elements in the GWTG‐Stroke registry were only modestly reliable in this single‐center study, suggesting caution should be exercised when relying on any individual history elements in registry‐based research. Combining these variables to calculate the CHA2DS2‐VASc score was somewhat more reliable. Multicenter data are needed before assuming generalizability.
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Affiliation(s)
| | - Alice F Ford
- Department of Neurology University of Pennsylvania Philadelphia PA
| | - Ossama Khazaal
- Department of Neurology University of Pennsylvania Philadelphia PA
| | | | - Emily Grodinsky
- Department of Neurology University of Pennsylvania Philadelphia PA
| | - Judy Dawod
- Department of Neurology University of Pennsylvania Philadelphia PA
| | - Scott E Kasner
- Department of Neurology University of Pennsylvania Philadelphia PA
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Kim JT, Kim NR, Choi SH, Oh S, Park MS, Lee SH, Kim BC, Choi J, Kim MS. Neural network-based clustering model of ischemic stroke patients with a maximally distinct distribution of 1-year vascular outcomes. Sci Rep 2022; 12:9420. [PMID: 35676413 PMCID: PMC9177616 DOI: 10.1038/s41598-022-13636-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 05/17/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractClustering stroke patients with similar characteristics to predict subsequent vascular outcome events is critical. This study aimed to compare several clustering methods, particularly a deep neural network-based model, and identify the best clustering method with a maximally distinct 1-year outcome in patients with ischemic stroke. Prospective stroke registry data from a comprehensive stroke center from January 2011 to July 2018 were retrospectively analyzed. Patients with acute ischemic stroke within 7 days of onset were included. The primary outcomes were the composite of all strokes (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality within one year. Neural network-based clustering models (deep lifetime clustering) were compared with other clustering models (k-prototype and semi-supervised clustering, SSC) and a conventional risk score (Stroke Prognostic Instrument-II, SPI-II) to obtain a distinct distribution of 1-year vascular events. Ultimately, 7,650 patients were included, and the 1-year primary outcome event occurred in 13.1%. The DLC-Kuiper UB model had a significantly higher C-index (0.674), log-rank score (153.1), and Brier score (0.08) than the other cluster models (SSC and DLC-MMD) and the SPI-II score. There were significant differences in primary outcome events among the 3 clusters (41.7%, 13.4%, and 6.5% in clusters 0, 1, and 2, respectively) when the DLC-Kuiper UB model was used. A neural network-based clustering model, the DLC-Kuiper UB model, can improve the clustering of stroke patients with a maximally distinct distribution of 1-year vascular outcomes among each cluster. Further studies are warranted to validate this deep neural network-based clustering model in ischemic stroke.
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Nielsen VM, Song G, DeJoie-Stanton C, Zachrison KS. Emergency Medical Services Prenotification is Associated with Reduced Odds of In-Hospital Mortality in Stroke Patients. PREHOSP EMERG CARE 2022:1-7. [PMID: 35583481 DOI: 10.1080/10903127.2022.2079784] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: Arrival by emergency medical services (EMS) and prenotification among ischemic stroke patients is well-established to improve the timeliness and quality of stroke care, yet the association of prenotification with in-hospital mortality has not been previously described. Our cross-sectional study aimed to assess the association between EMS prenotification and in-hospital mortality for patients with acute ischemic stroke or transient ischemic attack.Methods: We analyzed data from the Massachusetts Paul Coverdell National Acute Stroke Program registry. Our study population included adult patients presenting by EMS with transient ischemic attack or acute ischemic stroke from non-health care settings between 2016 and 2020. We excluded patients who were comfort measures only on arrival or day after arrival. We used generalized estimating equations to assess the association between prenotification and in-hospital stroke mortality.Results: In the adjusted model, prenotification was associated with lower odds of in-hospital mortality (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.76-0.98). Other variables associated with in-hospital mortality were longer door-to-imaging interval (OR 1.03, 95% CI 1.03-1.04) and year of presentation (OR 0.91 for each year, 95% CI 0.88-0.93). Odds of in-hospital mortality also varied by insurance, race, and ethnicity.Conclusions: Prenotification by EMS was associated with reduced in-hospital mortality for patients with ischemic stroke and transient ischemic attack. These findings add to the large body of literature demonstrating the key role of EMS in the stroke systems of care. Our study underscores the importance of standardizing prehospital screening and triage, increasing rates of prenotification via feedback and education, and encouraging active collaborations between prehospital personnel and stroke-capable hospitals to increase in-hospital survival among patients with stroke and transient ischemic attack.
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Affiliation(s)
- Victoria M Nielsen
- Massachusetts Department of Public Health, 250 Washington Street, Boston MA 02108, United States
| | - Glory Song
- Massachusetts Department of Public Health, 250 Washington Street, Boston MA 02108, United States
| | - Claudine DeJoie-Stanton
- Massachusetts Department of Public Health, 250 Washington Street, Boston MA 02108, United States
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, United States
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27
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External validation of the Passive Surveillance Stroke Severity Indicator. Neurol Sci 2022; 50:399-404. [PMID: 35478064 DOI: 10.1017/cjn.2022.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Passive Surveillance Stroke Severity (PaSSV) Indicator was derived to estimate stroke severity from variables in administrative datasets but has not been externally validated. METHODS We used linked administrative datasets to identify patients with first hospitalization for acute stroke between 2007-2018 in Alberta, Canada. We used the PaSSV indicator to estimate stroke severity. We used Cox proportional hazard models and evaluated the change in hazard ratios and model discrimination for 30-day and 1-year case fatality with and without PaSSV. Similar comparisons were made for 90-day home time thresholds using logistic regression. We also linked with a clinical registry to obtain National Institutes of Health Stroke Scale (NIHSS) and compared estimates from models without stroke severity, with PaSSV, and with NIHSS. RESULTS There were 28,672 patients with acute stroke in the full sample. In comparison to no stroke severity, addition of PaSSV to the 30-day case fatality models resulted in improvement in model discrimination (C-statistic 0.72 [95%CI 0.71-0.73] to 0.80 [0.79-0.80]). After adjustment for PaSSV, admission to a comprehensive stroke center was associated with lower 30-day case fatality (adjusted hazard ratio changed from 1.03 [0.96-1.10] to 0.72 [0.67-0.77]). In the registry sample (N = 1328), model discrimination for 30-day case fatality improved with the inclusion of stroke severity. Results were similar for 1-year case fatality and home time outcomes. CONCLUSION Addition of PaSSV improved model discrimination for case fatality and home time outcomes. The validity of PASSV in two Canadian provinces suggests that it is a useful tool for baseline risk adjustment in acute stroke.
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Bonkhoff AK, Rübsamen N, Grefkes C, Rost NS, Berger K, Karch A. Development and Validation of Prediction Models for Severe Complications After Acute Ischemic Stroke: A Study Based on the Stroke Registry of Northwestern Germany. J Am Heart Assoc 2022; 11:e023175. [PMID: 35253466 PMCID: PMC9075320 DOI: 10.1161/jaha.121.023175] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background The treatment of stroke has been undergoing rapid changes. As treatment options progress, prediction of those under risk for complications becomes more important. Available models have, however, frequently been built based on data no longer representative of today’s care, in particular with respect to acute stroke management. Our aim was to build and validate prediction models for 4 clinically important, severe outcomes after stroke. Methods and Results We used German registry data from 152 710 patients with acute ischemic stroke obtained in 2016 (development) and 2017 (validation). We took into account potential predictors that were available at admission and focused on in‐hospital mortality, intracranial mass effect, secondary intracerebral hemorrhage, and deep vein thrombosis as outcomes. Validation cohort prediction and calibration performances were assessed using the following 4 statistical approaches: logistic regression with backward selection, l1‐regularized logistic regression, k‐nearest neighbor, and gradient boosting classifier. In‐hospital mortality and intracranial mass effects could be predicted with high accuracy (both areas under the curve, 0.90 [95% CI, 0.90–0.90]), whereas the areas under the curve for intracerebral hemorrhage (0.80 [95% CI, 0.80–0.80]) and deep vein thrombosis (0.73 [95% CI, 0.73–0.73]) were considerably lower. Stroke severity was the overall most important predictor. Models based on gradient boosting achieved better performances than those based on logistic regression for all outcomes. However, area under the curve estimates differed by a maximum of 0.02. Conclusions We validated prediction models for 4 severe outcomes after acute ischemic stroke based on routinely collected, recent clinical data. Model performance was superior to previously proposed approaches. These predictions may help to identify patients at risk early after stroke and thus facilitate an individualized level of care.
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Affiliation(s)
- Anna K. Bonkhoff
- J. Philip Kistler Stroke Research Center Massachusetts General HospitalHarvard Medical School Boston MA
- Institute of Epidemiology and Social Medicine University of MuensterAlbert‐Schweitzer‐Campus 1 Muenster Germany
| | - Nicole Rübsamen
- Institute of Epidemiology and Social Medicine University of MuensterAlbert‐Schweitzer‐Campus 1 Muenster Germany
| | - Christian Grefkes
- Cognitive Neuroscience Institute of Neuroscience and Medicine Research Centre Juelich Juelich Germany
- Department of Neurology Department of Neurology University Hospital Cologne and Medical FacultyUniversity of Cologne Germany
| | - Natalia S. Rost
- J. Philip Kistler Stroke Research Center Massachusetts General HospitalHarvard Medical School Boston MA
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine University of MuensterAlbert‐Schweitzer‐Campus 1 Muenster Germany
| | - André Karch
- Institute of Epidemiology and Social Medicine University of MuensterAlbert‐Schweitzer‐Campus 1 Muenster Germany
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29
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Aparicio HJ, Tarko LM, Gagnon D, Costa L, Galloway A, Demissie S, Djousse L, Seshadri S, Cho K, Wilson PW. Low Blood Pressure, Comorbidities, and Ischemic Stroke Mortality in US Veterans. Stroke 2022; 53:886-894. [PMID: 34727740 PMCID: PMC8885902 DOI: 10.1161/strokeaha.120.033195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Low blood pressure (BP) is associated with higher stroke mortality, although the factors underlying this association have not been fully explored. We investigated prestroke BP and long-term mortality after ischemic stroke in a national sample of US veterans. METHODS Using a retrospective cohort study design of veterans hospitalized between 2002 and 2007 with a first ischemic stroke and with ≥1 outpatient BP measurements 1 to 18 months before admission, we defined 6 categories each of average prestroke systolic BP (SBP) and diastolic BP, and 7 categories of pulse pressure. Patients were followed-up to 12 years for primary outcomes of all-cause and cardiovascular mortality. We used Cox models to relate prestroke BP indices to mortality and stratified analyses by the presence of preexisting comorbidities (smoking, myocardial infarction, heart failure, atrial fibrillation/flutter, cancer, and dementia), race and ethnicity. RESULTS Of 29 690 eligible veterans with stroke (mean±SD age 67±12 years, 98% men, 67% White), 2989 (10%) had average prestroke SBP<120 mm Hg. During a follow-up of 4.1±3.3 years, patients with SBP<120 mm Hg experienced 61% all-cause and 27% cardiovascular mortality. In multivariable analyses, patients with the lowest SBP, lowest diastolic BP, and highest pulse pressure had the highest mortality risk: SBP<120 versus 130 to 139 mm Hg (hazard ratio=1.26 [95% CI, 1.19-1.34]); diastolic BP <60 versus 70 to 79 mm Hg (hazard ratio=1.35 [95% CI, 1.23-1.49]); and pulse pressure ≥90 versus 60 to 69 mm Hg (hazard ratio=1.24 [95% CI, 1.15-1.35]). Patients with average SBP<120 mm Hg and at least one comorbidity (smoking, heart disease, cancer, or dementia) had the highest mortality risk (hazard ratio=1.45 [95% CI, 1.37-1.53]). CONCLUSIONS Compared with normotension, low prestroke BP was associated with mortality after stroke, particularly among patients with at least one comorbidity.
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Affiliation(s)
- Hugo J. Aparicio
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, Department of Neurology, Boston University School of Medicine, Boston, MA, Boston Medical Center, Boston, MA
| | - Laura M. Tarko
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA
| | - David Gagnon
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Lauren Costa
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA
| | - Ashley Galloway
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA
| | - Serkalem Demissie
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Luc Djousse
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Sudha Seshadri
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, Department of Neurology, Boston University School of Medicine, Boston, MA, Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases, University of Texas Health Sciences Center, San Antonio, TX
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Peter W.F. Wilson
- Atlanta VA Medical Center, Atlanta, GA, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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30
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Kam W, Holmes DN, Hernandez AF, Saver JL, Fonarow GC, Smith EE, Bhatt DL, Schwamm LH, Reeves MJ, Matsouaka RA, Khan YM, Unverdorben M, Birmingham MC, Lyden PD, Asimos AW, Altschul D, Schoonover TL, Jumaa MA, Nomura JT, Suri MFK, Moore SA, Lafranchise EF, Olson D, Peterson ED, Xian Y. Association of Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants With Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA 2022; 327:760-771. [PMID: 35143601 PMCID: PMC8832308 DOI: 10.1001/jama.2022.0948] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Current guidelines recommend against use of intravenous alteplase in patients with acute ischemic stroke who are taking non-vitamin K antagonist oral anticoagulants (NOACs). OBJECTIVE To evaluate the safety and functional outcomes of intravenous alteplase among patients who were taking NOACs prior to stroke and compare outcomes with patients who were not taking long-term anticoagulants. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of 163 038 patients with acute ischemic stroke either taking NOACs or not taking anticoagulants prior to stroke and treated with intravenous alteplase within 4.5 hours of symptom onset at 1752 US hospitals participating in the Get With The Guidelines-Stroke program between April 2015 and March 2020, with complementary data from the Addressing Real-world Anticoagulant Management Issues in Stroke registry. EXPOSURES Prestroke treatment with NOACs within 7 days prior to alteplase treatment. MAIN OUTCOMES AND MEASURES The primary outcome was symptomatic intracranial hemorrhage occurring within 36 hours after intravenous alteplase administration. There were 4 secondary safety outcomes, including inpatient mortality, and 7 secondary functional outcomes assessed at hospital discharge, including the proportion of patients discharged home. RESULTS Of 163 038 patients treated with intravenous alteplase (median age, 70 [IQR, 59 to 81] years; 49.1% women), 2207 (1.4%) were taking NOACs and 160 831 (98.6%) were not taking anticoagulants prior to their stroke. Patients taking NOACs were older (median age, 75 [IQR, 64 to 82] years vs 70 [IQR, 58 to 81] years for those not taking anticoagulants), had a higher prevalence of cardiovascular comorbidities, and experienced more severe strokes (median National Institutes of Health Stroke Scale score, 10 [IQR, 5 to 17] vs 7 [IQR, 4 to 14]) (all standardized differences >10). The unadjusted rate of symptomatic intracranial hemorrhage was 3.7% (95% CI, 2.9% to 4.5%) for patients taking NOACs vs 3.2% (95% CI, 3.1% to 3.3%) for patients not taking anticoagulants. After adjusting for baseline clinical factors, the risk of symptomatic intracranial hemorrhage was not significantly different between groups (adjusted odds ratio [OR], 0.88 [95% CI, 0.70 to 1.10]; adjusted risk difference [RD], -0.51% [95% CI, -1.36% to 0.34%]). There were no significant differences in the secondary safety outcomes, including inpatient mortality (6.3% for patients taking NOACs vs 4.9% for patients not taking anticoagulants; adjusted OR, 0.84 [95% CI, 0.69 to 1.01]; adjusted RD, -1.20% [95% CI, -2.39% to -0%]). Of the secondary functional outcomes, 4 of 7 showed significant differences in favor of the NOAC group after adjustment, including the proportion of patients discharged home (45.9% vs 53.6% for patients not taking anticoagulants; adjusted OR, 1.17 [95% CI, 1.06 to 1.29]; adjusted RD, 3.84% [95% CI, 1.46% to 6.22%]). CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke treated with intravenous alteplase, use of NOACs within the preceding 7 days, compared with no use of anticoagulants, was not associated with a significantly increased risk of intracranial hemorrhage.
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Affiliation(s)
- Wayneho Kam
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | | | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | | | - Eric E. Smith
- Department of Clinical Neurosciences and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
| | - Roland A. Matsouaka
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Yosef M. Khan
- Health Informatics and Analytics, Center for Health Metrics and Evaluation, American Heart Association, Dallas, Texas
| | | | | | - Patrick D. Lyden
- Zilkha Neurogenetic Institute of the Keck School of Medicine, University of Southern California, Los Angeles
| | - Andrew W. Asimos
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | | | | | - Mouhammad A. Jumaa
- Department of Neurology, ProMedica Toledo Hospital, University of Toledo, Toledo, Ohio
| | - Jason T. Nomura
- Department of Emergency Medicine, ChristianaCare, Newark, Delaware
| | | | | | | | - DaiWai Olson
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
| | - Eric D. Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
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Vinding NE, Kristensen SL, Rørth R, Butt JH, Østergaard L, Olesen JB, Torp‐Pedersen C, Gislason GH, Køber L, Kruuse C, Johnsen SP, Fosbøl EL. Ischemic Stroke Severity and Mortality in Patients With and Without Atrial Fibrillation. J Am Heart Assoc 2022; 11:e022638. [PMID: 35156393 PMCID: PMC9245802 DOI: 10.1161/jaha.121.022638] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Our objective was to investigate stroke severity and subsequent rate of mortality among patients with and without atrial fibrillation (AF). Contemporary data on stroke severity and prognosis in patients with AF are lacking. Methods and Results First‐time ischemic stroke patients from the Danish Stroke Registry (January 2005–December 2016) were included in an observational study. Patients with AF were matched 1:1 by sex, age, calendar year, and CHA2DS2‐VASc score with patients without AF. Stroke severity was determined by the Scandinavian Stroke Scale (0–58 points). The rate of death was estimated by Kaplan‐Meier plots and multivariable Cox regression. Among 86 458 identified patients with stroke, 17 205 had AF. After matching, 14 662 patients with AF and 14 662 patients without AF were included (51.8% women; median age, 79.6 years [25th–75th percentile, 71.8–86.0]). More patients with AF had very severe stroke (0–14 points) than patients without AF (13.7% versus 7.9%, P<0.01). The absolute rates of 30‐day and 1‐year mortality were significantly higher for patients with AF (12.1% and 28.4%, respectively) versus patients without AF (8.7% and 21.8%, respectively). This held true in adjusted models for 30‐day mortality (hazard ratio [HR], 1.40 [95% CI, 1.30–1.51]). However, this association became nonsignificant when additionally adjusting for stroke severity (HR, 1.10 [95% CI, 1.00–1.23]). AF was associated with a higher rate of 1‐year mortality (HR, 1.39 [95% CI, 1.32–1.46]), although it was mediated by stroke severity (HR, 1.15 [95% CI, 1.09–1.23], model including stroke severity). Conclusions In a contemporary nationwide cohort of patients with ischemic stroke, patients with AF had more severe strokes and higher mortality than patients without AF. The difference in mortality was mainly driven by stroke severity.
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Affiliation(s)
- Naja E. Vinding
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Gentofte Denmark
| | - Søren L. Kristensen
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Gentofte Denmark
| | - Rasmus Rørth
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Gentofte Denmark
| | - Jawad H. Butt
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Gentofte Denmark
| | - Lauge Østergaard
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Gentofte Denmark
| | - Jonas B. Olesen
- Department of Cardiology, Herlev and Gentofte Hospital Copenhagen University Hospital Gentofte Denmark
| | - Christian Torp‐Pedersen
- Department of Cardiology and Clinical Investigation Nordsjaellands Hospital Hilerød Denmark
- Department of Cardiology Aalborg University Hospital Aalborg Denmark
| | - Gunnar H. Gislason
- Department of Cardiology, Herlev and Gentofte Hospital Copenhagen University Hospital Gentofte Denmark
- The Danish Heart Foundation Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Gentofte Denmark
| | - Christina Kruuse
- Department of Neurology Herlev and Gentofte HospitalCopenhagen University Hospital Gentofte Denmark
- Department of Neurology Herlev and Gentofte HospitalCopenhagen University Hospital Herlev Denmark
| | - Søren P. Johnsen
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus N Denmark
| | - Emil L. Fosbøl
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Gentofte Denmark
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Del Brutto VJ, Rundek T, Sacco RL. Prognosis After Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Schilter M, Epstein A, Vynckier J, Mujanovic A, Belachew NF, Beyeler M, Siepen B, Goeldlin M, Scutelnic A, Seiffge DJ, Jung S, Gralla J, Dobrocky T, Arnold M, Kaesmacher J, Fischer U, Meinel TR. Chronic cerebral infarctions and white matter lesions link to long-term survival after a first ischemic event: A cohort study. J Neuroimaging 2022; 32:1134-1141. [PMID: 35922890 PMCID: PMC9804158 DOI: 10.1111/jon.13033] [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: 05/23/2022] [Revised: 07/15/2022] [Accepted: 07/23/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE To investigate the association of different phenotypes, count, and locations of chronic covert brain infarctions (CBI) with long-term mortality in patients with first-ever manifest acute ischemic stroke (AIS) or transient ischemic attack (TIA). Additionally, to analyze their potential interaction with white matter hyperintensities (WMH) and predictive value in addition to established mortality scores. METHODS Single-center cohort study including consecutive patients with first-ever AIS or TIA with available MRI imaging from January 2015 to December 2017. Blinded raters adjudicated CBI phenotypes and WMH (age-related white matter changes score) according to established definitions. We compared Cox regression models including prespecified established predictors of mortality using Harrell's C and likelihood ratio tests. RESULTS A total of 2236 patients (median [interquartile range] age: 71 [59-80] years, 43% female, National Institutes of Health Stroke Scale: 2 [1-6], median follow-up: 1436 days, 21% death during follow-up) were included. Increasing WMH (per point adjusted Hazard Ratio [aHR] = 1.29 [1.14-1.45]), but not CBI (aHR = 1.21 [0.99-1.49]), were independently associated with mortality. Neither CBI phenotype, count, nor location was associated with mortality and there was no multiplicative interaction between CBI and WMH (p > .1). As compared to patients without CBI or WMH, patients with moderate or severe WMH and additional CBI had the highest hazards of death (aHR = 1.62 [1.23-2.13]). The Cox regression model including CBI and WMH had a small but significant increment in Harrell's C when compared to the model including 14 clinical variables (0.831 vs. 0.827, p < .001). DISCUSSION WMH represent a strong surrogate biomarker of long-term mortality in first-ever manifest AIS or TIA patients. CBI phenotypes, count, and location seem less relevant. Incorporation of CBI and WMH slightly improves predictive capacity of established risk scores.
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Affiliation(s)
- Marina Schilter
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Alessandra Epstein
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Jan Vynckier
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Nebiyat Filate Belachew
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Bernhard Siepen
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - David Julian Seiffge
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Urs Fischer
- Department of NeurologyBasel University Hospital, University of BaselBernSwitzerland
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
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You S, Xu J, Ou Z, Zhong C, Han Q, Chen J, Cao Y, Liu CF. Prognostic significance of urinary protein and urinary ketone bodies in acute ischemic stroke. Nutr Metab Cardiovasc Dis 2021; 31:3152-3160. [PMID: 34518087 DOI: 10.1016/j.numecd.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/27/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Prior studies have shown an association between positive urinary protein and an elevated risk of long-term mortality in patients with acute ischemic stroke (AIS); however, data on the short-term prognostic significance of urinary protein and urinary ketone bodies in patients with AIS is sparse. METHODS AND RESULTS A total of 2842 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included. Patients were divided into urinary protein positive and negative, urinary ketone bodies positive and negative by urine dipstick. Cox and logistic regression models were used to estimate the effect of urinary protein and urinary ketone bodies on all cause in-hospital mortality and poor outcome upon discharge (modified Rankin Scale score ≥3) in AIS patients. Patients with positive urinary protein was associated with a 2.74-fold and 1.62-fold increase in the risk of in-hospital mortality (adjusted HR 2.74; 95% CI, 1.54-4.89; P-value = 0.001) and poor outcome upon discharge (aOR, 1.62; 95% CI 1.26-2.08; P-value <0.001) in comparison to negative urinary protein after adjusting for potential covariates. Moreover, Patients with positive urinary ketone bodies was associated with 2.11-fold in the risk of poor outcome upon discharge (aOR 2.11; 95% CI 1.52-2.94; P-value <0.001) but not in-hospital mortality (P-value = 0.066) after adjusting for potential covariates. CONCLUSIONS Urinary protein at admission was independently associated with in-hospital mortality and poor functional outcome at hospital discharge in acute stroke patients and urinary ketone bodies also associated with poor functional outcome at hospital discharge.
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Affiliation(s)
- Shoujiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Jiaping Xu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Zhijie Ou
- Department of Neurology, Changshu TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215000, China
| | - Chongke Zhong
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, 215123, China
| | - Qiao Han
- Department of Neurology, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, China
| | - Juping Chen
- Department of Neurology, Changshu TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215000, China.
| | - Yongjun Cao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China; Institutes of Neuroscience, Soochow University, Suzhou, 215123, China.
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China; Institutes of Neuroscience, Soochow University, Suzhou, 215123, China
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Man S, Bruckman D, Tang AS, Uchino K, Schold JD. The Association of Socioeconomic Status and Discharge Destination with 30-Day Readmission after Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:106146. [PMID: 34644664 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/04/2021] [Accepted: 09/26/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES This study aimed to explore the association of socioeconomic status and discharge destination with 30-day readmission after ischemic stroke. MATERIALS AND METHODS We examined 30-day all-cause readmission among patients hospitalized for ischemic stroke in states of Arkansas, Iowa, and Wisconsin in 2016 and 2017 and New York in 2016 using Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. RESULTS Among the 52301 patients included, 51.1% were female. The 30-day readmission rates were 10.2%, 8.2%, 9.3%, 10.4%, 11.6%, and 11.2% for age group 18-34, 35-44, 45-54, 55-64, 65-74, and ≥75 years, respectively (p<0.001). In Generalized Estimating Equation analysis, patients with Medicare and Medicaid insurance were more likely to be readmitted, compared with private insurance, (adjusted Odds Ratio [aOR] 1.37, 95% CI 1.23-1.53; and aOR 1.26, 95% CI 1.09-1.45, respectively). Patients in the bottom quartile of zip code level median household income had higher 30-day readmission rate (12.4%) than those in the 2nd, 3rd and 4th quartile (10.3%, 10.1%, and 10.7%, respectively, p<0.001). Compared with those discharged home with self-care which had the lowest readmission rate (8.4%), patients who left against medical advice had the highest readmission rate (18.6%; aOR 2.23, 95% CI 1.75-2.83), followed by rehabilitation and skilled nursing facilities (13.2%; aOR 1.33, 95% CI 1.22-1.46), and home with home health care (11.3%, aOR 1.18, 95% CI 1.08-1.28). CONCLUSIONS Socioeconomic status and discharged destination affect readmission after stroke. These results provide evidence to inform vulnerable patient population as targets for readmission prevention.
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Affiliation(s)
- Shumei Man
- Department of Neurology, Neurological Institute, Cleveland Clinic, United States; Cerebrovascular Center, Neurological Institute, Cleveland Clinic, United States.
| | - David Bruckman
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Anne S Tang
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, United States
| | - Jesse D Schold
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
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Seo KD, Kang MJ, Lee JK, Suh SH, Lee KY. Mechanical thrombectomy reduces the gap in treatment outcomes of ischemic stroke between hospital levels of care: analysis of a Korean nationwide data. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1227. [PMID: 34532364 PMCID: PMC8421926 DOI: 10.21037/atm-21-2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/25/2021] [Indexed: 11/06/2022]
Abstract
Background Mechanical thrombectomy (MT) of ischemic stroke was demonstrated to be effective in clinical trials and was reported to have favorable outcomes in real clinical settings since 2015. We aimed to determine the national trends of MT and compare the outcomes between the different levels of treating hospital. Methods We obtained data from the nationwide database from 2008 to 2017. Patients with ischemic stroke who received MT were identified using the International Classification of Disease Codes. Good outcome was defined as discharge to home, and a poor outcome was defined as cerebral hemorrhage, physical disability, or death. The study period was divided into three (off-label MT, transitional, MT period). Hospital groups where MT was performed were divided into tertiary and non-tertiary hospitals. Results In MT period, 47.0% of the MT procedures were performed in non-tertiary hospitals compared with 36.1% in off-label MT period. Comparison of the 3-month mortality between patients who were treated in tertiary vs. non-tertiary hospitals revealed significant lower mortality in tertiary hospital through all period. The incidence of cerebral hemorrhage and physical disability did not differ between hospital groups. However, the percentage of patients discharged home was 41.4% for tertiary hospitals and 42.4% for non-tertiary hospitals, which was not statistically different in MT period (P=0.4671). Conclusions Analysis of the nationwide data confirmed that the extent of increase in MT was higher in non-tertiary hospitals than tertiary hospitals. In addition, no significant difference was revealed in the number of favorable clinical outcome between the hospital groups during MT period.
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Affiliation(s)
- Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Min Jin Kang
- Institute of Health Insurance and Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Kwang Lee
- Institute of Health Insurance and Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Simmonds KP, Burke J, Kozlowski AJ, Andary M, Luo Z, Reeves MJ. Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities. Arch Phys Med Rehabil 2021; 103:1213-1221. [PMID: 34480886 DOI: 10.1016/j.apmr.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/02/2021] [Accepted: 08/06/2021] [Indexed: 11/26/2022]
Abstract
In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.
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Affiliation(s)
- Kent P Simmonds
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - James Burke
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Allan J Kozlowski
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI; John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI
| | - Michael Andary
- Department of Physical Medicine & Rehabilitation, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI.
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Laible M, Jenetzky E, Möhlenbruch MA, Bendszus M, Ringleb PA, Rizos T. The Impact of Post-contrast Acute Kidney Injury on In-hospital Mortality After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke. Front Neurol 2021; 12:665614. [PMID: 34163423 PMCID: PMC8215575 DOI: 10.3389/fneur.2021.665614] [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: 02/08/2021] [Accepted: 04/20/2021] [Indexed: 01/22/2023] Open
Abstract
Background and Purpose: Clinical outcome and mortality after endovascular thrombectomy (EVT) in patients with ischemic stroke are commonly assessed after 3 months. In patients with acute kidney injury (AKI), unfavorable results for 3-month mortality have been reported. However, data on the in-hospital mortality after EVT in this population are sparse. In the present study, we assessed whether AKI impacts in-hospital and 3-month mortality in patients undergoing EVT. Materials and Methods: From a prospectively recruiting database, consecutive acute ischemic stroke patients receiving EVT between 2010 and 2018 due to acute large vessel occlusion were included. Post-contrast AKI (PC-AKI) was defined as an increase of baseline creatinine of ≥0.5 mg/dL or >25% within 48 h after the first measurement at admission. Adjusting for potential confounders, associations between PC-AKI and mortality after stroke were tested in univariate and multivariate logistic regression models. Results: One thousand one hundred sixty-nine patients were included; 166 of them (14.2%) died during the acute hospital stay. Criteria for PC-AKI were met by 29 patients (2.5%). Presence of PC-AKI was associated with a significantly higher risk of in-hospital mortality in multivariate analysis [odds ratio (OR) = 2.87, 95% confidence interval (CI) = 1.16–7.13, p = 0.023]. Furthermore, factors associated with in-hospital mortality encompassed higher age (OR = 1.03, 95% CI = 1.01–1.04, p = 0.002), stroke severity (OR = 1.05, 95% CI = 1.03–1.08, p < 0.001), symptomatic intracerebral hemorrhage (OR = 3.20, 95% CI = 1.69–6.04, p < 0.001), posterior circulation stroke (OR = 2.85, 95% CI = 1.72–4.71, p < 0.001), and failed recanalization (OR = 2.00, 95% CI = 1.35–3.00, p = 0.001). Conclusion: PC-AKI is rare after EVT but represents an important risk factor for in-hospital mortality and for mortality within 3 months after hospital discharge. Preventing PC-AKI after EVT may represent an important and potentially lifesaving effort in future daily clinical practice.
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Affiliation(s)
- Mona Laible
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, University of Ulm, Ulm, Germany
| | - Ekkehart Jenetzky
- Faculty of Health/School of Medicine, Witten/Herdecke University, Witten, Germany.,Department for Child and Adolescent Psychiatry, Johannes Gutenberg-University, Mainz, Germany
| | | | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Karamchandani RR, Rhoten JB, Strong D, Chang B, Asimos AW. Mortality after large artery occlusion acute ischemic stroke. Sci Rep 2021; 11:10033. [PMID: 33976365 PMCID: PMC8113323 DOI: 10.1038/s41598-021-89638-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 04/29/2021] [Indexed: 12/23/2022] Open
Abstract
Despite randomized trials showing a functional outcome benefit in favor of endovascular therapy (EVT), large artery occlusion acute ischemic stroke is associated with high mortality. We performed a retrospective analysis from a prospectively collected code stroke registry and included patients presenting between November 2016 and April 2019 with internal carotid artery and/or proximal middle cerebral artery occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality. Among 764 patients, mortality rate was 26%. Increasing age (per 10 years, OR 1.48, 95% CI 1.25–1.76; p < 0.0001), higher presenting NIHSS (per 1 point, OR 1.05, 95% CI 1.01–1.09, p = 0.01), and higher discharge modified Rankin Score (per 1 point, OR 4.27, 95% CI 3.25–5.59, p < 0.0001) were independently associated with higher odds of mortality. Good revascularization therapy, compared to no EVT, was independently associated with a survival benefit (OR 0.61, 95% CI 0.35–1.00, p = 0.048). We identified factors independently associated with mortality in a highly lethal form of stroke which can be used in clinical decision-making, prognostication, and in planning future studies.
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Affiliation(s)
- Rahul R Karamchandani
- Department of Neurology, Neurosciences Institute, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
| | - Jeremy B Rhoten
- Department of Neurology, Neurosciences Institute, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Dale Strong
- Information and Analytics Services, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Brenda Chang
- Information and Analytics Services, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Andrew W Asimos
- Department of Emergency Medicine, Neurosciences Institute, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
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Gadisa DA, Busawa GB, Gebremariam ET, Tefera GM, Belete KT, Taye GM, Meskele LB, Gudeta BM, Gelaw BK. Clinical Characteristics, Treatment Outcomes, and its Predictors Among Hospitalized Stroke Patients in Ambo University Referral Hospital, West Ethiopia: A Retrospective Hospital-Based Study. Vasc Health Risk Manag 2021; 16:591-604. [PMID: 33447039 PMCID: PMC7802015 DOI: 10.2147/vhrm.s287465] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/09/2020] [Indexed: 12/02/2022] Open
Abstract
Background Stroke is becoming a leading cause of death and adult disability in the developing world. Objective The objective of the study was to assess the clinical characteristics, treatment outcomes, and its predictors among stroke patients admitted to Ambo University Referral Hospital (AURH), West Ethiopia. Methods All 111 stroke patients hospitalized from April 2016 to May 2019 were included using a hospital-based retrospective study. Socio-demographic profile, past medication history, clinical presentation, drugs prescribed for comorbid condition and stroke treatment, and outcomes data were collected using data abstraction formats and results were summarized using both descriptive and inferential statistics. Key Findings According to WHO clinical criteria, 89 (80.2%) were diagnosed with ischemic stroke, and 20 (18.0%) were diagnosed with hemorrhagic stroke. The majority of the patients 94 (84.7%) had at least one antecedent risk factor in which hypertension accounted for 44.1%. More than half, 69 (62.2%), of hospitalized stroke patients had good treatment outcomes while 42 (37.8%) had a poor outcome. The overall case-fatality rate was 18 (16.2%), 12 (13.5%) from ischemic stroke, and 6 (30.0%) from hemorrhagic stroke. Acetyl salicylic acid (ASA) with atorvastatin/simvastatin, 67 (73.5%) in ischemic stroke and 12 (60.0%) in hemorrhagic stroke, was the most frequent medications prescribed for stroke during admission while it was frequently prescribed for 48 (53.6%) of ischemic stroke and 10 (50.0%) of the hemorrhagic stroke on discharge. Overall, ceftriaxone + metronidazole 32 (28.8%) was frequently prescribed concomitant medications during admission. The major predictors identified for poor stroke outcomes were substance abuse (AOR=2.839, P=0.024) and have had not received any medication for stroke treatment during admission (AOR=12.503, P≤0.001). Conclusion A significant number of the admitted stroke patients had poor treatment outcome in which the case-fatality rate was relatively high. Substance abuse and having not received medication for stroke were the significant predictors for poor treatment outcome. Hence, a well-established stroke unit setup at AURH is required for accurate diagnosis and management of stroke to overcome stroke-related mortality and/or poor treatment outcome.
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Affiliation(s)
- Diriba Alemayehu Gadisa
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Guye Betero Busawa
- Department of Pharmacy, College of Medicine and Health Sciences, Bule Hora University, Bule Hora, Ethiopia
| | | | - Gosaye Mekonen Tefera
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Kefyalew Taye Belete
- Department of Public Health, College of Medicine and Health Science, Ambo University, Ambo, Ethiopia
| | - Getu Melesie Taye
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Lemma Bose Meskele
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Biruk Mosisa Gudeta
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Belayneh Kefale Gelaw
- Department of Pharmacy, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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Huang ZX, Gu HQ, Yang X, Wang CJ, Wang YJ, Li ZX. Risk factors for in-hospital mortality among acute ischemic stroke patients in China: a nationwide prospective study. Neurol Res 2020; 43:387-395. [PMID: 33357098 DOI: 10.1080/01616412.2020.1866356] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: We aimed to investigate factors related to in-hospital mortality (IHM) in acute ischemic stroke (AIS) patients.Methods: We prospectively investigated 827,314 patients who were admitted within 7 days of AIS between August 2015 and July 2019. Demographic characteristics, risk factors, and clinical and laboratory characteristics of patients were assessed. Univariate and multivariate logistic regression analyses were performed to identify predictors associated with IHM.Results: The IHM rate in this study was 0.5% in women and 0.3% in men. Factors associated with IHM in AIS included diabetes (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.03-1.43), female (OR 0.84, 95%CI 0.74-0.96), hypertension (OR 1.16, 95%CI 1.01-1.34), atrial fib/flutter (OR 1.51, 95%CI 1.29-1.77), other heart disease (OR1.43, 95%CI 1.23-1.67), prior myocardial infarction (OR 2.00, 95%CI 1.54-2.60), antiplatelet therapies (OR 0.71, 95%CI 0.60-0.84), gastrointestinal bleeding (OR 3.54, 95%CI 2.83-4.44), pulmonary embolism (OR 2.53, 95%CI1.41-4.53), dysphagia(OR7.32, 95%CI6.23-8.61), glycosylated hemoglobin (OR1.05, 95%CI 1.02-1.09), serum creatinine (OR 1.001, 95%CI 1.001-1.002), urea nitrogen (OR 1.10, 95%CI 1.08-1.12), National Institutes of Health Stroke Scale (NIHSS) score (4-5 vs. 0-4: OR 3.58; ≥15 vs. 0-4: OR 8.78), stroke rehabilitation (OR 0.27, 95%CI 0.23-0.30), age (third IQR vs. first IQR: OR 1.57; fourth IQR vs. first IQR: OR 2.23), and in-hospital stroke/TIArecurrence (OR 2.38, 95%CI 2.03-2.78).Conclusions: The findings from this study may help clinicians control the risk of IHM better for patients with AIS.
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Affiliation(s)
- Zhi-Xin Huang
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China.,Department of Neurology, The Second Clinical Medical College of Southern Medical University, Guangzhou, Guangdong, China
| | - Hong-Qiu Gu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xin Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chun-Juan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zi-Xiao Li
- 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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Man S, Xian Y, Holmes DN, Matsouaka RA, Saver JL, Smith EE, Bhatt DL, Schwamm LH, Fonarow GC. Target: Stroke Was Associated With Faster Intravenous Thrombolysis and Improved One-Year Outcomes for Acute Ischemic Stroke in Medicare Beneficiaries. Circ Cardiovasc Qual Outcomes 2020; 13:e007150. [PMID: 33302714 DOI: 10.1161/circoutcomes.120.007150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The benefit of intravenous thrombolytic therapy for acute ischemic stroke is time dependent. To assist hospitals in providing faster thrombolytic treatment, the American Heart Association launched target: stroke quality initiative in January 2010 which disseminated feasible strategies to shorten door-to-needle times for thrombolytic therapy. This study aimed to examine whether target: stroke was associated with improved door-to-needle times and 1-year outcomes. METHODS We analyzed Medicare beneficiaries aged ≥65 years receiving intravenous thrombolytic treatment for acute ischemic stroke at 1490 Get With The Guidelines-Stroke hospitals during January 2006 and December 2009 (preintervention, n=10 804) and January 2010 and December 2014 (postintervention, n=31 249). The median age was 80 years and 42.7% were male. RESULTS The median door-to-needle times decreased from 80 minutes for the preintervention to 68 minutes for the postintervention (P<0.001). The proportion of patients receiving intravenous thrombolysis with door-to-needle times 45 minutes and 60 minutes increased from 9.6% and 24.8% for preintervention to 17.1% and 40.6% for postintervention, respectively (P<0.001). The annual rate of increase in the door-to-needle times of 60 minutes or less accelerated from 0.20% (95% CI, -0.43% to 0.83%) per each 4 quarters for preintervention to 5.68% (95% CI, 5.23%-6.13%) for postintervention (P<0.001) which was further confirmed in piecewise multivariable generalized estimating analysis (adjusted odds ratio, 1.27 [95% CI, 1.19-1.35]). Cox proportional hazards analysis, after adjusting for patient and hospital characteristics and within-hospital clustering, showed that target: stroke was associated with lower all-cause readmission (40.4% versus 44.1%; hazard ratio, 0.91 [95% CI, 0.88-0.95]), cardiovascular readmission (19.7% versus 22.9%; hazard ratio, 0.85 [95% CI, 0.80-0.89]), and composite of all-cause mortality or readmission (56.0% versus 58.4%; hazard ratio, 0.96 [95% CI, 0.93-1.00]). The risk decline in all-cause mortality dissipated after risk adjustment (adjusted hazard ratio, 0.98 [95% CI, 0.94-1.02]). CONCLUSIONS Target: stroke quality initiative was associated with faster thrombolytic treatment times for acute ischemic stroke and modestly lower 1-year all-cause and cardiovascular readmissions.
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Affiliation(s)
- Shumei Man
- Department of Neurology & Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH (S.M.)
| | - Ying Xian
- Duke Clinical Research Institute (Y.X., D.N.H., R.A.M.), Duke University, Durham, NC
| | - DaJuanicia N Holmes
- Duke Clinical Research Institute (Y.X., D.N.H., R.A.M.), Duke University, Durham, NC
| | - Roland A Matsouaka
- Duke Clinical Research Institute (Y.X., D.N.H., R.A.M.), Duke University, Durham, NC.,Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC
| | - Jeffrey L Saver
- Department of Neurology (J.L.S.), University of California, Los Angeles, CA
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Lee H Schwamm
- Department of Neurology, Comprehensive Stroke Center, Massachusetts General Hospital, Boston, MA (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology (G.C.F.), University of California, Los Angeles, CA
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Braun RG, Kittner SJ, Ryan KA, Cole JW. Effects of the BDNF Val66Met polymorphism on functional status and disability in young stroke patients. PLoS One 2020; 15:e0237033. [PMID: 33306691 PMCID: PMC7732081 DOI: 10.1371/journal.pone.0237033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/17/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE The preponderance of evidence from recent studies in human subjects supports a negative effect of the BDNF Val66Met polymorphism on motor outcomes and motor recovery. However prior studies have generally reported the effect of the Met allele in older stroke patients, while potential effects in younger stroke patients have remained essentially unexamined. The lack of research in younger patients is significant since aging effects on CNS repair and functional recovery after stroke are known to interact with the effects of genetic polymorphisms. Here we present a study of first-ever ischemic stroke patients aged 15-49 years that examines the effect of Met carrier status on functional disability. METHODS 829 patients with a first ischemic stroke (Average age = 41.4 years, SD = 6.9) were recruited from the Baltimore-Washington region. Genotyping was performed at the Johns Hopkins University Center for Inherited Disease Research (CIDR). Data cleaning and harmonization were done at the GEI-funded GENEVA Coordinating Center at the University of Washington. Our sample contained 165 Met carriers and 664 non-Met carriers. Modified Rankin scores as recorded at discharge were obtained from the hospital records by study personnel blinded to genotype, and binarized into "Good" versus "Poor" outcomes (mRS 0-2 vs. 3+), with mRS scores 3+ reflecting a degree of disability that causes loss of independence. RESULTS Our analysis showed that the Met allele conveyed a proportionally greater risk for poor outcomes and disability-related loss of independence with mRS scores 3+ (adjusted OR 1.73, 95% CI 1.13-2.64, p = 0.01). CONCLUSIONS The BDNF Val66Met polymorphism was negatively associated with functional outcomes at discharge in our sample of 829 young stroke patients. This finding stands in contrast to what would be predicted under the tenets of the resource modulation hypothesis (i.e. that younger patients would be spared from the negative effect of the Met allele on recovery since it is posited to arise as a manifestation of age-related decline in physiologic resources).
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Affiliation(s)
- Robynne G. Braun
- University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Steven J. Kittner
- University of Maryland School of Medicine, Baltimore, MD, United States of America
- Veterans Affairs Maryland Health Care System, Baltimore, MD, United States of America
| | - Kathleen A. Ryan
- Veterans Affairs Maryland Health Care System, Baltimore, MD, United States of America
| | - John W. Cole
- University of Maryland School of Medicine, Baltimore, MD, United States of America
- Veterans Affairs Maryland Health Care System, Baltimore, MD, United States of America
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Man S, Tang AS, Schold JD, Kolikonda MK, Uchino K. The Patterns and Outcomes of Inter-Hospital Transfer Among Medicare Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:105331. [PMID: 32992204 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/03/2020] [Accepted: 09/12/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND PURPOSE Inter-hospital transfer for ischemic stroke is an essential part of stroke system of care. This study aimed to understand the national patterns and outcomes of ischemic stroke transfer. METHODS AND RESULTS This retrospective study examined Medicare beneficiaries aged ≥65 years undergoing inter-hospital transfer for ischemic stroke in 2012. Cox proportional hazards model was used to compare 30-day and one-year mortality between transferred patients and direct admissions from the emergency department (ED admissions). Among 312,367 ischemic stroke admissions, 5.7% underwent inter-hospital transfer. Using this value as cut-off, the hospitals were classified into receiving (n = 411), sending (n = 559), and low-transfer (n = 1863) hospitals. Receiving hospitals were larger than low-transfer and sending hospitals as demonstrated by the median bed number (371, 189, and 88, respectively, p < 0.001); more frequently to be certified stroke centers (75%, 47%, and 16%, respectively, p < 0.001); and less commonly located in the rural area (2%, 7%, and 24%, respectively, p < 0.001). For receiving hospitals, transfer-in patients and ED admissions had comparable mortality at 30 days (10% vs 10%; adjusted HR [aHR]=1.07; 95% CI, 0.99-1.14) and 1 year (23% vs 24%; aHR=1.03; 95% CI, 0.99-1.08). For sending hospitals, transfer-out patients, compared to ED admissions, had higher mortality at 30 days (14% vs 11%; aHR=1.63; 95% CI, 1.39-1.91) and 1 year (30% vs 27%; aHR=1.33; 95% CI, 1.20-1.48). For low-transfer hospitals, overall transfer-in and transfer-out patients, compared to ED admissions, had higher mortality at 30 days (13% vs 10%; aHR=1.46; 95% CI, 1.33-1.60) and 1 year (28% vs 25%; aHR=1.27; 95% CI, 1.19-1.36). CONCLUSIONS Hospitals in the US, based on their transfer patterns, could be classified into 3 groups that shared distinct characteristics including hospital size, rural vs urban location, and stroke certification. Transferred patients at sending and low-transfer hospitals had worse outcomes than their ED admission counterpart.
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Affiliation(s)
- Shumei Man
- Department of Neurology & Cerebrovascular Center, Neurological Institute, Cleveland Clinic, United States
| | - Anne S Tang
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Jesse D Schold
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Murali K Kolikonda
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue/S80, Cleveland, OH, United States
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue/S80, Cleveland, OH, United States.
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Farooque U, Lohano AK, Kumar A, Karimi S, Yasmin F, Bollampally VC, Ranpariya MR. Validity of National Institutes of Health Stroke Scale for Severity of Stroke to Predict Mortality Among Patients Presenting With Symptoms of Stroke. Cureus 2020; 12:e10255. [PMID: 33042693 PMCID: PMC7536102 DOI: 10.7759/cureus.10255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Cerebrovascular accident (CVA), also termed as stroke, is the third leading cause of mortality and the most common cause of disability globally. The National Institutes of Health Stroke Scale (NIHSS) is a valid assessment tool utilized to determine the severity of the stroke and can be used to prioritize patients to design treatment plans, rehabilitation, and better clinical outcomes. The primary objective of this study was to determine the validity of the NIHSS to predict mortality among patients presenting with symptoms of a stroke. Material and methods This was a descriptive case-series conducted over a period of six months between September 2019 and February 2020 at a tertiary care hospital in Nawabshah, Pakistan. The sample population included 141 patients admitted within 24 hours of the onset of symptoms of a stroke. A neurological examination of the patients was performed. On admission, stroke severity was evaluated with the NIHSS. After an initial clinical evaluation, patients underwent a non-enhanced computed tomography (CT) scan of the brain. The score of NIHSS and mortality at 72 hours were recorded on the pre-defined proforma by the investigators. All statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0 (Armonk, NY: IBM Corp). Results The mean age of the participants was 52.37±8.61 years. 68.1% of patients were hypertensive, 29.1% were diabetic, and 36.9% of patients were found with hyperlipidemia. The mortality rate was 41.1%. The mean NIHSS score was 16.68±6.72 points. The findings of this study demonstrated that the score of 14.9% cases was good (0-6 points), the score of 29.1% cases was moderate (7-15 points), and the score of 56% cases was poor (≥16 points). There was a significant association of NIHSS score with mortality (p<0.001). Conclusions Baseline NIHSS score has a profound association with mortality after acute stroke. It can help clinicians decide whether to provide thrombolytic treatment, rehabilitation or a combination of both in these patients and decrease the mortality rate. However, more studies are needed to potentiate these conclusions.
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Affiliation(s)
- Umar Farooque
- Neurology, Dow University of Health Sciences, Karachi, PAK
| | - Ashok Kumar Lohano
- Medicine, Peoples University of Medical and Health Sciences for Women, Nawabshah, PAK
| | - Ashok Kumar
- Internal Medicine, Peoples University of Medical and Health Sciences for Women, Nawabshah, PAK
| | - Sundas Karimi
- General Surgery, Combined Military Hospital, Karachi, PAK
| | - Farah Yasmin
- Cardiology, Dow University of Health Sciences, Karachi, PAK
| | | | - Margil R Ranpariya
- Internal Medicine, Surat Municipal Institute of Medical Education and Research, Surat, IND
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Melnick KF, Winton J, Corliss BM, Fox WC, Hoh BL, Polifka AJ. Off-Label Utilization of Syphontrak Catheter for Mechanical Thrombectomy in Acute Stroke. World Neurosurg 2020; 143:e106-e111. [PMID: 32653512 DOI: 10.1016/j.wneu.2020.06.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is not known whether aspiration-specific catheters are necessary for successful mechanical thrombectomy, but if not, off-label use of more versatile catheters could offer significant cost savings over specialized aspiration catheters. The Syphontrak (Depuy Synthes, Raynham, MA, USA) support catheter is designed for introduction of devices into distal neurovasculature but is not specifically indicated for use in mechanical thrombectomy. We sought to compare our experience using this catheter to historical controls to show the non-inferiority of aspiration achieved. METHODS Data were collected retrospectively on patients who underwent mechanical thrombectomy using the Syphontrak catheter for aspiration at our institution. Patient demographics, procedure characteristics, and outcome information was recorded. Results were compared to five landmark studies on mechanical thrombectomy: MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA. RESULTS There were 63 patients who underwent mechanical thrombectomy for anterior circulation ischemic stroke. Despite significantly older patients and greater time from symptom onset to groin puncture, Thrombolysis in Cerebral Infarction grade 2B or 3 reperfusion was achieved in significantly more patients than in MR CLEAN, ESCAPE, and REVASCAT. Development of symptomatic intracranial hemorrhage occurred in 6.4% of patients, which was not significantly different from MR CLEAN, ESCAPE, REVASCAT, and EXTEND-IA. Mortality was 19.1%, which was not significantly different from any of the trials. CONCLUSIONS These data support the off-label use of distal intracranial support catheters for this mechanical thrombectomy, which may result in significant cost savings over aspiration-specific catheters, especially in low-volume centers.
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Affiliation(s)
- Kaitlyn F Melnick
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA.
| | - Jesse Winton
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - Brian M Corliss
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - W Christopher Fox
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - Brian L Hoh
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - Adam J Polifka
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
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Xu J, Yalkun G, Wang M, Wang A, Wangqin R, Zhang X, Chen Z, Mo J, Meng X, Li H, Li Z, Wang Y. Impact of Infection on the Risk of Recurrent Stroke Among Patients With Acute Ischemic Stroke. Stroke 2020; 51:2395-2403. [PMID: 32586226 DOI: 10.1161/strokeaha.120.029898] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Infection occurs commonly in patients with acute ischemic stroke. We aimed to investigate the association of infection with short- and long-term risk of recurrent stroke in patients with ischemic stroke. METHODS Data were derived from ischemic stroke patients in 2 stroke registries: the CSCA (Chinese Stroke Center Alliance) program recorded medical data during hospitalization, and the CNSR-III (Third China National Stroke Registry) recorded the medical data during hospitalization and finished 1-year follow-up. Associations of infection (pneumonia or urinary tract infection) during hospitalization with recurrent stroke in short (during hospitalization) and long term (since 30 days to 1 year after stroke onset) were analyzed. Short-term outcomes were analyzed with logistic models and long-term outcomes with Cox models. RESULTS In the CSCA (n=789 596), the incidence of infection during hospitalization reached 9.6%. Patients with infection had a higher risk of stroke recurrence during hospitalization compared with patients without infection (10.4% versus 5.2%; adjusted odds ratio, 1.70 [95% CI, 1.65-1.75]; P<0.0001). In the CNSR-III (n=13 549), the incidence of infection during hospitalization was 6.5%. Infection during hospitalization was significantly associated with short-term risk of recurrent stroke (7.4% versus 3.9%; adjusted odds ratio, 1.40 [95% CI, 1.05-1.86]; P=0.02) but not with long-term risk of recurrent stroke (7.2% versus 5.2%; adjusted hazard ratio, 1.16 [95% CI, 0.88-1.52]; P=0.30). CONCLUSIONS Infection was an independent risk factor for high risk of early stroke recurrence during hospitalization, but we have not found its sustained effect on long-term recurrent risk in patients with acute ischemic stroke.
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Affiliation(s)
- Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Gulbahram Yalkun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Meng Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Runqi Wangqin
- Department of Neurology, Duke University Medical Center, Durham, NC (R.W.)
| | - Xiaoli Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Zimo Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Jinglin Mo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing (J.X., G.Y., M.W., A.W., X.Z., Z.C., J.M., X.M., H.L., Z.L., Y.W.)
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Dabilgou AA, Dravé A, Kyelem JMA, Ouedraogo S, Napon C, Kaboré J. Frequency and Mortality Risk Factors of Acute Ischemic Stroke in Emergency Department in Burkina Faso. Stroke Res Treat 2020; 2020:9745206. [PMID: 32577197 PMCID: PMC7305528 DOI: 10.1155/2020/9745206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/26/2020] [Accepted: 05/20/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To determine the prevalence of ischemic stroke deaths and their predictive factors in the Emergency Department at Yalgado Ouedraogo University Teaching Hospital (YOUTH). Methodology. This was a retrospective study with an analytical and descriptive focus over a period of three years from January 1, 2015, to December 31, 2017. RESULTS During the study period, 302 acute ischemic stroke patients with a mean age of 62.2 ± 14.26 years were included. Atrial hypertension was the most common vascular risk factor in 52.5%. On admission, 34.8% of patients had loss of consciousness. The mean time to perform brain CT was 1.5 days. The average length of stay was 4 days. Electrocardiogram, echocardiography, and cervical Doppler were not performed during hospitalization in ED. The mortality rate was 39%, respectively, 37.6% in male and 41.6% in female. The mean age of patients who died in ED was 63.6 ± 13.52 years. Hypertension was the most common vascular risk factors in 54.2% of death. After logistic regression, the predictors of death were past history of heart disease, consciousness disorders, hyperthermia, hyperglycemia on admission, poststroke pneumonia, and urinary tract infection. CONCLUSIONS Acute ischemic stroke was frequent in Emergency Department with high mortality rate. The mortality risk factors were the same than those found in literature. This higher mortality can be avoided by early diagnosis and an adequate management.
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Affiliation(s)
| | - Alassane Dravé
- Department of Neurology, Regional University Hospital of Ouahigouya, Burkina Faso
| | | | - Saïdou Ouedraogo
- Department of Neurology, University Hospital Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Christian Napon
- Department of Neurology, University Hospital of Bogodogo, Ouagadougou, Burkina Faso
| | - Jean Kaboré
- Department of Neurology, University Hospital Yalgado Ouedraogo, Ouagadougou, Burkina Faso
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Man S, Xian Y, Holmes DN, Matsouaka RA, Saver JL, Smith EE, Bhatt DL, Schwamm LH, Fonarow GC. Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke. JAMA 2020; 323:2170-2184. [PMID: 32484532 PMCID: PMC7267850 DOI: 10.1001/jama.2020.5697] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Earlier administration of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is associated with reduced mortality by the time of hospital discharge and better functional outcomes at 3 months. However, it remains unclear whether shorter door-to-needle times translate into better long-term outcomes. OBJECTIVE To examine whether shorter door-to-needle times with intravenous tPA for acute ischemic stroke are associated with improved long-term outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included Medicare beneficiaries aged 65 years or older who were treated for acute ischemic stroke with intravenous tPA within 4.5 hours from the time they were last known to be well at Get With The Guidelines-Stroke participating hospitals between January 1, 2006, and December 31, 2016, with 1-year follow-up through December 31, 2017. EXPOSURES Door-to-needle times for intravenous tPA. MAIN OUTCOMES AND MEASURES The primary outcomes were 1-year all-cause mortality, all-cause readmission, and the composite of all-cause mortality or readmission. RESULTS Among the 61 426 patients treated with tPA within 4.5 hours, the median age was 80 years and 43.5% were male. The median door-to-needle time was 65 minutes (interquartile range, 49-88 minutes). The 48 666 patients (79.2%) who were treated with tPA and had door-to-needle times of longer than 45 minutes, compared with those treated within 45 minutes, had significantly higher all-cause mortality (35.0% vs 30.8%, respectively; adjusted HR, 1.13 [95% CI, 1.09-1.18]), higher all-cause readmission (40.8% vs 38.4%; adjusted HR, 1.08 [95% CI, 1.05-1.12]), and higher all-cause mortality or readmission (56.0% vs 52.1%; adjusted HR, 1.09 [95% CI, 1.06-1.12]). The 34 367 patients (55.9%) who were treated with tPA and had door-to-needle times of longer than 60 minutes, compared with those treated within 60 minutes, had significantly higher all-cause mortality (35.8% vs 32.1%, respectively; adjusted hazard ratio [HR], 1.11 [95% CI, 1.07-1.14]), higher all-cause readmission (41.3% vs 39.1%; adjusted HR, 1.07 [95% CI, 1.04-1.10]), and higher all-cause mortality or readmission (56.8% vs 53.1%; adjusted HR, 1.08 [95% CI, 1.05-1.10]). Every 15-minute increase in door-to-needle times was significantly associated with higher all-cause mortality (adjusted HR, 1.04 [95% CI, 1.02-1.05]) within 90 minutes after hospital arrival, but not after 90 minutes (adjusted HR, 1.01 [95% CI, 0.99-1.03]), higher all-cause readmission (adjusted HR, 1.02; 95% CI, 1.01-1.03), and higher all-cause mortality or readmission (adjusted HR, 1.02 [95% CI, 1.01-1.03]). CONCLUSIONS AND RELEVANCE Among patients aged 65 years or older with acute ischemic stroke who were treated with tissue plasminogen activator, shorter door-to-needle times were associated with lower all-cause mortality and lower all-cause readmission at 1 year. These findings support efforts to shorten time to thrombolytic therapy.
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Affiliation(s)
- Shumei Man
- Department of Neurology and Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ying Xian
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Roland A. Matsouaka
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Eric E. Smith
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Comprehensive Stroke Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Joundi RA, Saposnik G, Martino R, Fang J, Kapral MK. Development and Validation of a Prognostic Tool for Direct Enteral Tube Insertion After Acute Stroke. Stroke 2020; 51:1720-1726. [PMID: 32397928 DOI: 10.1161/strokeaha.120.028949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods- We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from July 1, 2003 to June 30, 2010 (derivation cohort) and July 1, 2010 to March 31, 2013 (validation cohort). We used multivariable regression to assign scores to predictor variables for 3 outcomes after tube placement: favorable outcome (discharge modified Rankin Scale score 0-3 and alive at 90 days), poor outcome (discharge modified Rankin Scale score 5 or death at 90 days), and 30-day mortality. Results- Variables associated with a favorable outcome were younger age, preadmission independence, ischemic stroke rather than intracerebral hemorrhage, lower stroke severity, and a shorter time between stroke and tube placement. Variables associated with a poor outcome were older age, preadmission dependence, atrial fibrillation, greater stroke severity, and tracheostomy. Age, preadmission dependence, atrial fibrillation, cancer, chronic obstructive pulmonary disease, and shorter time to tube placement were associated with increased 30-day mortality. Using these variables, we created an online calculator to facilitate estimation of individual patient risk of favorable and poor outcomes. C-statistic in the validation cohort was 0.82 for favorable outcome, 0.65 for poor outcome, and 0.62 for 30-day mortality, and calibration was adequate. Conclusions- We developed risk scores to estimate outcomes after direct enteral tube insertion for acute dysphagic stroke. This information may be useful in discussions with patients and families when there is prognostic uncertainty surrounding outcomes with direct enteral tube placement after stroke.
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Affiliation(s)
- Raed A Joundi
- From the Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary (R.A.J.).,ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Gustavo Saposnik
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), University of Toronto, Canada.,Institute of Health Policy, Management and Evaluation (G.S.), University of Toronto, Canada
| | - Rosemary Martino
- Department of Speech-Language Pathology (R.M.), University of Toronto, Canada.,Graduate Department of Rehabilitation Science (R.M.), University of Toronto, Canada.,Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Canada (R.M.)
| | - Jiming Fang
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Moira K Kapral
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Division of General Internal Medicine, Department of Medicine (M.K.), University of Toronto, Canada.,Institute of Health Policy, Management, and Evaluation (M.K.), University of Toronto, Canada
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