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Shahjouei S, Li J, Koza E, Abedi V, Sadr AV, Chen Q, Mowla A, Griffin P, Ranta A, Zand R. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2136644. [PMID: 34985520 PMCID: PMC8733831 DOI: 10.1001/jamanetworkopen.2021.36644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome. OBJECTIVE To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting. DATA SOURCES MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020. STUDY SELECTION Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer. DATA EXTRACTION AND SYNTHESIS The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models. MAIN OUTCOMES AND MEASURES Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days). RESULTS The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.
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Affiliation(s)
- Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
- Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Alireza Vafaei Sadr
- Department de Physique Theorique and Center for Astroparticle Physics, University Geneva, Geneva, Switzerland
| | - Qiushi Chen
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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Shahjouei S, Sadighi A, Chaudhary D, Li J, Abedi V, Holland N, Phipps M, Zand R. A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 78:77-87. [PMID: 33044505 DOI: 10.1001/jamaneurol.2020.3627] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Management of transient ischemic attack (TIA) has gained significant attention during the past 25 years after several landmark studies indicated the high incidence of a subsequent stroke. Objective To calculate the pooled event rate of subsequent ischemic stroke within 2, 7, 30, and 90 days of a TIA and compare this incidence among the population with TIA recruited before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C). Data Sources All published studies of TIA outcomes were obtained by searching PubMed from 1996, to the last update on January 31, 2020, irrespective of the study design, document type, or language. Study Selection Of 11 516 identified citations, 175 articles were relevant to this review. Both the classic time-based definition of TIA and the new tissue-based definition were accepted. Studies with a combined record of patients with TIA and ischemic stroke, without clinical evaluation for the index TIA, with diagnosis of index TIA event after ischemic stroke occurrence, with low suspicion for TIA, or duplicate reports of the same database were excluded. Data Extraction and Synthesis The study was conducted and reported according to the PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality assessment used the Quality in Prognosis Studies tool. Publication bias was visualized by funnel plots and measured by the Begg-Mazumdar rank correlation Kendall τ2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models. Main Outcomes and Measures The proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size. Results Systematic review yielded 68 unique studies with 223 866 unique patients from 1971 to 2019. The meta-analysis included 206 455 patients (58% women) during a span of 4 decades. The overall subsequent ischemic stroke incidence rates were estimated as 2.4% (95% CI, 1.8%-3.2%) within 2 days, 3.8% (95% CI, 2.5%-5.4%) within 7 days, 4.1% (95% CI, 2.4%-6.3%) within 30 days, and 4.7% (95% CI, 3.3%-6.4%) within 90 days. There was a recurrence risk of 3.4% among group A in comparison with 2.1% in group B or 2.1% in group C within 2 days; 5.5% in group A vs 2.9% in group B or 3.2% in group C within 7 days; 6.3% in group A vs 2.9% in group B or 3.4% in group C within 30 days, and 7.4% in group A vs 3.9% in group B or 3.9% in group C within 90 days. Conclusions and Relevance These findings suggest that TIA continues to be associated with a high risk of early stroke; however, the rate of post-TIA stroke might have decreased slightly during the past 2 decades.
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Affiliation(s)
- Shima Shahjouei
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Alireza Sadighi
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Durgesh Chaudhary
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania.,Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Neil Holland
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Michael Phipps
- Department of Neurology, University of Maryland, Baltimore
| | - Ramin Zand
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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Association between primary caregiver type and mortality among Chinese older adults with disability: a prospective cohort study. BMC Geriatr 2021; 21:268. [PMID: 33882871 PMCID: PMC8061058 DOI: 10.1186/s12877-021-02219-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/15/2021] [Indexed: 11/30/2022] Open
Abstract
Background Socio-demographic transitions have dramatically changed the traditional family care settings in China, caused unmet care needs among older adults. However, whether different primary caregiver types have different influences on disabled older adults’ health outcomes remain poorly understood. We aimed to examine the association between the type of primary caregiver (e.g., spouse and children) and death among community-dwelling Chinese older adults disabled in activities of daily living. Methods We used data from Chinese Longitudinal Healthy Longevity Survey. The analytic sample comprised 4278 eligible adults aged ≥ 80 years. We classified primary caregiver type into five categories: spouse, son/daughter-in-law, daughter/son-in-law, grandchildren, and domestic helper. We used Cox regression model to examine the association between primary caregiver type and all-cause mortality. Covariates included age, sex, residence, years of education, co-residence status, financial independence, whether living with children, number of ADL disability, number of chronic conditions, and self-reported health, cognitive impairment, and caregiving quality. Results Married older adults whose primary caregivers were son/daughter-in-law had a 38% higher hazard of death than those who had spouse as the primary caregiver. Married men who received care primarily from son/daughter-in-law or daughter/son-in-law had a 64 and 68% higher hazard of death, respectively, than those whose primary caregiver was spouse. The association between primary caregiver type and mortality among widowed older adults differed between urban and rural areas. Urban residents who had domestic helpers as the primary caregiver had an 16% lower hazard of death, while those living in rural areas had a 50% higher hazard of death, than those having son/daughter-in-law as the primary caregiver. Conclusions The quality of care of the primary caregiver may be a risk factor for mortality of disabled older adults in China. Interventions are necessary for reducing unmet needs and managing care burden.
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Garg A, Limaye K, Shaban A, Leira EC, Adams HP. Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States. Neuroepidemiology 2020; 55:40-46. [PMID: 33260176 DOI: 10.1159/000511829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/26/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION A diagnosis of transient ischemic attack (TIA) must be followed by prompt investigation and rapid initiation of measures to prevent stroke. Prior studies evaluating the risk of stroke after TIA were conducted in the emergency room or clinic settings. Experience of patients admitted to the hospital after a TIA is not well known. We sought to assess the early risk of ischemic stroke after inpatient hospitalization for TIA. METHODS We used the 2010-2015 Nationwide Readmissions Database to identify all hospitalizations with the primary discharge diagnosis of TIA and investigated the incidence of ischemic stroke readmissions within 90 days of discharge from the index hospitalization. RESULTS Of 639,569 index TIA admissions discharged alive (mean ± SD age 70.4 ± 14.4 years, 58.7% female), 9,131 (1.4%) were readmitted due to ischemic stroke within 90 days. Male sex, head/neck vessel atherosclerosis, hypertension, diabetes, atrial flutter/fibrillation, previous history of TIA/stroke, illicit drug use, and higher Charlson Comorbidity Index score were independently associated with readmissions due to ischemic stroke. Ischemic stroke readmissions were associated with excess mortality, discharge disposition other than to home, and elevated cost. CONCLUSIONS Patients hospitalized for TIA have a lower risk of ischemic stroke compared to that reported in the studies based on the emergency room and/or outpatient clinic evaluation. Among these patients, those with cardiovascular comorbidities remain at a higher risk of readmission due to ischemic stroke despite undergoing an inpatient evaluation and should therefore be the target for future preventive strategies.
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Affiliation(s)
- Aayushi Garg
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA,
| | - Kaustubh Limaye
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Amir Shaban
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Enrique C Leira
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA.,Departments of Neurosurgery, University of Iowa, Iowa City, Iowa, USA.,Departments of Epidemiology, University of Iowa, Iowa City, Iowa, USA
| | - Harold P Adams
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA.,Departments of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
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Li S, Tian Q, Fan J, Shi Z, Guo B, Chen H, Li Y, Shi S. Hospital use in survivors of transient ischaemic attack compared with survivors of stroke in central China: a nested case-control study. BMJ Open 2019; 9:e024052. [PMID: 31292173 PMCID: PMC6624025 DOI: 10.1136/bmjopen-2018-024052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES There is a lack of knowledge regarding post-discharge hospitalisation utilisation after transient ischaemic attack (TIA) in China. The aim of this study is to quantify rehospitalisation use in survivors of TIA compared with their own previous hospital use and matched survivors of stroke. DESIGN Nested case-control study of electronic medical records datasets. SETTING 958 hospitals in Henan, China, from July 2012 to December 2015. PARTICIPANTS In total, 4823 survivors of stroke were matched to the TIA cohort (average age: 64.5 years; proportion of men: 48.4%) at a 1:1 ratio. All subjects with an onset of stroke/TIA were recorded with a 1-year look-back and follow-up. OUTCOME MEASURES Adjusted difference-in-differences (DID) values in 1-year hospital lengths of stay (LOSs) and readmission within 7, 30 and 90 days. RESULTS There was an increase in hospital admissions in survivors of TIA in the year after the index hospitalisation compared with the prior year. Of the 2449 rehospitalisation events that occurred during the first year after TIA, stroke (20.6%) was the most common reason for rehospitalisation. There was no difference in the stroke-specific readmission rates between the TIA and stroke cohorts (p=0.198). The TIA cohort had fewer readmissions within 30 days and 90 days after all-cause discharge compared with the controls. The corresponding covariate-adjusted DID values were -3.5 percentage points (95% CI -5.3 to -1.8) and -4.5 (95% CI -6.5 to -2.4), respectively. A similar trend was observed in the 1-year LOS. In the stratified analysis, the DID reductions were not significant in patients with more comorbidities or in rural patients. CONCLUSIONS Compared with survivors of stroke, survivors of TIA use fewer hospital resources up to 1 year post-discharge. Greater attention to TIAs among patients with more comorbidities and rural patients may provide an opportunity to reduce hospital use.
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Affiliation(s)
- Sangsang Li
- Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
| | - Qingfeng Tian
- Department of Social Medicine, Zhengzhou University, Zhengzhou, China
| | - Junxing Fan
- Statistical Information Center, Health and Family Planning Commission of Henan Province, Zhengzhou, China
| | - Zhan Shi
- Department of Pharmacy, Zhengzhou People’s Hospital, Zhengzhou, UK
| | - Bingxin Guo
- Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
| | - Huanan Chen
- Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
| | - Yapeng Li
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, UK
| | - Songhe Shi
- Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
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Comparing Stroke and Bleeding with Rivaroxaban and Dabigatran in Atrial Fibrillation: Analysis of the US Medicare Part D Data. Am J Cardiovasc Drugs 2017; 17:37-47. [PMID: 27637493 DOI: 10.1007/s40256-016-0189-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND No studies have directly compared the effectiveness and safety of dabigatran and rivaroxaban using US Medicare data. OBJECTIVE Our objective was to compare effectiveness and safety between rivaroxaban 20 mg/dabigatran 150 mg and rivaroxaban 15 mg/dabigatran 75 mg among patients with atrial fibrillation (AF). METHODS Using 2010-2013 US Medicare Part D data, we selected patients with AF initiating dabigatran 150/75 mg or rivaroxaban 20/15 mg between 4 November 2011 (when rivaroxaban was approved) and 31 December 2013. Our sample included 7322 patients receiving dabigatran 150 mg, 5799 patients receiving rivaroxaban 20 mg, 1818 receiving dabigatran 75 mg, and 2568 receiving rivaroxaban 15 mg. We followed them until stroke, other thromboembolic events, bleeding, discontinuation or switch of an anticoagulant, death, or 31 December 2013. We constructed Cox proportional hazard models with propensity score weighting to compare clinical outcomes between groups. RESULTS There was no difference in the risk of stroke between dabigatran 150 mg and rivaroxaban 20 mg (hazard ratio [HR] 1.05; 95 % confidence interval [CI] 0.97-1.13) or between dabigatran 75 mg and rivaroxaban 15 mg (HR 1.05; 95 % CI 0.94-1.18). Compared with dabigatran 150 mg, rivaroxaban 20 mg was associated with a higher risk of other thromboembolic events (HR 1.28; 95 % CI 1.14-1.44), major bleeding (HR 1.32; 95 % CI 1.17-1.50), and death (HR 1.36; 95 % CI 1.19-1.56). The risk of thromboembolic events other than stroke (HR 1.37; 95 % CI 1.15-1.62), major bleeding (HR 1.51; 95 % CI 1.25-1.82), and death (HR 1.21; 95 % CI 1.04-1.41) was also higher for rivaroxaban 15 mg than for dabigatran 75 mg. CONCLUSIONS There was no difference in stroke prevention between rivaroxaban and dabigatran; however, rivaroxaban was associated with a higher risk of thromboembolic events other than stroke, death, and bleeding.
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Hernandez I, Zhang Y, Brooks MM, Chin PKL, Saba S. Anticoagulation Use and Clinical Outcomes After Major Bleeding on Dabigatran or Warfarin in Atrial Fibrillation. Stroke 2016; 48:159-166. [PMID: 27909200 DOI: 10.1161/strokeaha.116.015150] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/05/2016] [Accepted: 10/18/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Little is known about the clinical outcomes associated with posthemorrhage anticoagulation resumption for atrial fibrillation. This study had 2 objectives: first, to evaluate anticoagulation use after a first major bleed on warfarin or dabigatran and, second, to compare effectiveness and safety outcomes between patients discontinuing anticoagulation after a major bleed and patients restarting warfarin or dabigatran. METHODS Using 2010 to 2012 Medicare Part D data, we identified atrial fibrillation patients who experienced a major bleeding event while using warfarin (n=1135) or dabigatran (n=404) and categorized them by their posthemorrhage use of anticoagulation. We followed them until an ischemic stroke, recurrent hemorrhage, or death through December 31, 2012. We constructed logistic regression models to evaluate factors affecting anticoagulation resumption and Cox proportional hazard models to compare the combined risk of ischemic stroke and all-cause mortality and the risk of recurrent bleeding between treatment groups. RESULTS Resumption of anticoagulation with warfarin (hazard ratio [HR] 0.76; 95% confidence interval [CI] 0.59-0.97) or dabigatran (HR 0.66; 95% CI 0.44-0.99) was associated with lower combined risk of ischemic stroke and all-cause mortality than anticoagulation discontinuation. The incidence of recurrent major bleeding was higher for patients prescribed warfarin after the event than for those prescribed dabigatran (HR 2.31; 95% CI 1.19-4.76) or whose anticoagulation ceased (HR 1.56; 95% CI 1.10-2.22), but did not differ between patients restarting dabigatran and those discontinuing anticoagulation (HR 0.65; 95% CI 0.32-1.33). CONCLUSIONS Dabigatran was associated with a superior benefit/risk ratio than warfarin and anticoagulation discontinuation in the treatment of atrial fibrillation patients who have survived a major bleed.
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Affiliation(s)
- Inmaculada Hernandez
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.)
| | - Yuting Zhang
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.).
| | - Maria M Brooks
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.)
| | - Paul K L Chin
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.)
| | - Samir Saba
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.)
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Li OL, Silver FL, Lichtman J, Fang J, Stamplecoski M, Wengle RS, Kapral MK. Sex Differences in the Presentation, Care, and Outcomes of Transient Ischemic Attack: Results From the Ontario Stroke Registry. Stroke 2015; 47:255-7. [PMID: 26556821 DOI: 10.1161/strokeaha.115.010485] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/08/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Little is known about whether sex differences exist in the presentation, management, and outcomes of transient ischemic attack. METHODS We conducted a cohort study of 5991 consecutive patients with transient ischemic attack admitted to 11 stroke centers in Ontario, Canada, between July 1, 2003, and March 31, 2008 and compared presenting symptoms, processes of care, and outcomes in women and men. We used linkages to administrative databases to evaluate mortality and recurrent vascular events within 30 days and 1 year of the initial presentation, with multivariable analyses to assess whether sex differences persisted after adjustment for age and comorbid conditions. RESULTS The most common presenting symptoms for both sexes were weakness, speech impairment, and sensory deficit, with headache being slightly more frequent in women. Women were less likely than men to undergo carotid imaging, carotid endarterectomy, or receive lipid-lowering therapy. One-year mortality was slightly lower in women than in men (adjusted hazard ratio, 0.77; 95% confidence interval, 0.63-0.94). CONCLUSIONS We found only minor sex differences in the presentation and management of transient ischemic attack, suggesting that current public awareness campaigns focusing on classic warning signs are appropriate for both women and men. Future work should focus on evaluating whether lower rates of carotid imaging, endarterectomy, and lipid-lowering therapy in women reflect undertreatment of women or are appropriate based on patient eligibility.
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Affiliation(s)
- Olivia L Li
- From the Department of Medicine, University of Toronto, Ontario, Canada (O.L.L., F.L.S., R.S.W., M.K.K.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.L.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.L.S., J.F., M.S., M.K.K.)
| | - Frank L Silver
- From the Department of Medicine, University of Toronto, Ontario, Canada (O.L.L., F.L.S., R.S.W., M.K.K.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.L.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.L.S., J.F., M.S., M.K.K.)
| | - Judith Lichtman
- From the Department of Medicine, University of Toronto, Ontario, Canada (O.L.L., F.L.S., R.S.W., M.K.K.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.L.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.L.S., J.F., M.S., M.K.K.)
| | - Jiming Fang
- From the Department of Medicine, University of Toronto, Ontario, Canada (O.L.L., F.L.S., R.S.W., M.K.K.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.L.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.L.S., J.F., M.S., M.K.K.)
| | - Melissa Stamplecoski
- From the Department of Medicine, University of Toronto, Ontario, Canada (O.L.L., F.L.S., R.S.W., M.K.K.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.L.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.L.S., J.F., M.S., M.K.K.)
| | - Rebecca S Wengle
- From the Department of Medicine, University of Toronto, Ontario, Canada (O.L.L., F.L.S., R.S.W., M.K.K.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.L.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.L.S., J.F., M.S., M.K.K.)
| | - Moira K Kapral
- From the Department of Medicine, University of Toronto, Ontario, Canada (O.L.L., F.L.S., R.S.W., M.K.K.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.L.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.L.S., J.F., M.S., M.K.K.)
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Kilkenny MF, Dewey HM, Sundararajan V, Andrew NE, Lannin N, Anderson CS, Donnan GA, Cadilhac DA. Readmissions after stroke: linked data from the Australian Stroke Clinical Registry and hospital databases. Med J Aust 2015; 203:102-6. [DOI: 10.5694/mja15.00021] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 05/01/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Monique F Kilkenny
- Monash University, Melbourne, VIC
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC
| | | | | | | | | | - Craig S Anderson
- The George Institute for Global Health, Sydney, NSW
- Royal Prince Alfred Hospital, Sydney, NSW
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC
| | - Dominique A Cadilhac
- Monash University, Melbourne, VIC
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC
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10
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Vilanova MB, Mauri-Capdevila G, Sanahuja J, Quilez A, Piñol-Ripoll G, Begué R, Gil MI, Codina-Barios MC, Benabdelhak I, Purroy F. Prediction of myocardial infarction in patients with transient ischaemic attack. Acta Neurol Scand 2015; 131:111-9. [PMID: 25302931 DOI: 10.1111/ane.12291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Determinants of risk of myocardial infarction (MI) after transient ischaemic attack (TIA) are not well defined. The aim of our study was to determine the risk and risk factors for MI after TIA. METHODS We prospectively recruited patients within 24 h of transient ischaemic cerebrovascular events between October 2006 and January 2013. A total of 628 TIA patients were followed for six months or more. MI and stroke recurrence (SR) were recorded. The duration and typology of clinical symptoms, vascular risk factors and aetiological work-ups were prospectively recorded and established prognostic scores (ABCD2, ABCD2I, ABCD3I, Essen Stroke Risk Score, California Risk Score and Stroke Prognosis Instrument) were calculated. RESULTS Twenty-eight (4.5%) MI and 68 (11.0%) recurrent strokes occurred during a median follow-up period of 31.2 months (16.1-44.9). In Cox proportional hazards multivariate analyses, we identify previous coronary heart disease (CHD) (hazard ratio [HR] 5.65, 95% confidence interval [CI] 2.45-13.04, P < 0.001) and sex male (HR 2.72, 95% CI 1.02-7.30, P = 0.046) as independent predictors of MI. Discrimination for the prognostic scores only ranged from 0.60 to 0.71. The incidence of MI did not vary among the different aetiological subtypes. Positive diffusion weighted imaging (DWI) (7.5% vs 2.5%, P = 0.007), and ECG abnormalities (Q wave or ST-T wave changes) (13.6% vs 3.6%, P = 0.001) were associated to MI. CONCLUSION According to our results, discrimination was poor for all previous risk prediction models evaluated. Variables such as previous CHD, male sex, DWI and ECG abnormalities should be considered in new prediction models.
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Affiliation(s)
- M. B. Vilanova
- Centre d'atenció primària Igualada Nord; Consorci Sanitari de l'Anoia; Igualada Spain
| | - G. Mauri-Capdevila
- Stroke Unit; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
| | - J. Sanahuja
- Stroke Unit; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
| | - A. Quilez
- Stroke Unit; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
| | - G. Piñol-Ripoll
- Stroke Unit; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
| | - R. Begué
- Institut de diagnòstic per la Imatge; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
| | - M. I. Gil
- Institut de diagnòstic per la Imatge; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
| | - M. C. Codina-Barios
- Stroke Unit; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
| | - I. Benabdelhak
- Stroke Unit; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
| | - F. Purroy
- Stroke Unit; Hospital Universitari Arnau de Vilanova; Grup Neurociències Clíniques IRBLleida; Lleida Spain
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11
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Suljic E, Mehicevic A, Gavranovic A. Stroke emergency medical care: initial assessment, risk factors, triage and hospitalization outcome. Mater Sociomed 2013; 25:83-7. [PMID: 24082828 PMCID: PMC3769086 DOI: 10.5455/msm.2013.25.83-87] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 04/05/2013] [Indexed: 11/03/2022] Open
Abstract
CONFLICT OF INTEREST none declared. GOALS THE GOALS OF THIS RESEARCH ARE: a) to determine the number, gender and age representation of patients with a working diagnosis of acute stroke referred by the Institute for Emergency Medical Care (IEMC) in the Clinical Center of Sarajevo University (CCSU); b) determine the incidence of patients that have been or have not been hospitalized and why; c) determine the time and procedure for emergency medical care; d) to determine the characteristics and outcomes of patients hospitalized with ischemic stroke at the Neurology Clinic CCUS. MATERIAL AND METHODS The study was retrospective and included time period from 1st June 2010 to 30th November 2010. The study included patients of both sexes, older than 18 years of age. RESULTS The study included a total of 233 patients. Of these, 65% are female, while 35% of patients were male. Of 82 patients who were admitted to hospital treatment at the Neurology Clinic, 55% of the patients were male and 45% female. The largest number of patients is older than 70 years (71%). Minimum time for emergency medical team arrival was 6 minutes and maximum 70 minutes (mean 35, SD 11.989). Motor weakness was noted in 31% of patients - left sided motor weakness was significantly more represented. In 73% of patients the diagnosis was confirmed. In 5% of patients thrombolytic therapy was administered, while 95% of patients were treated conservatively. Lethal outcome occurred in 30% of hospitalized patients, 37% were discharged as recovered, 30% were discharged as unaltered state, while 3% were discharged with worsening symptoms. Among risk factors, hypertension is the leading one, followed by an earlier stroke, diabetes mellitus, and cardiac arrhythmias. CONCLUSIONS In 91% of patients consciousness was preserved. In 73% of transported patients has been confirmed the diagnosis of ischemic stroke. Of the patients with confirmed diagnosis 59% were hospitalized. A significant number of strokes occur for the first time in relation to relapse. 5% of patients were treated with thrombolysis, while others were treated with conservative therapy. Recurrent stroke and patient confusion have significant impact on the outcome.
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Affiliation(s)
- Enra Suljic
- Neurology Clinic, Clinical Center of Sarajevo University , Bosnia and Herzegovina
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12
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Ghia D, Thomas P, Cordato D, Epstein D, Beran RG, Cappelen-Smith C, Griffith N, Hanna I, McDougall A, Hodgkinson SJ, Worthington JM. Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney transient ischaemic attack study. Intern Med J 2012; 42:913-8. [PMID: 21790923 DOI: 10.1111/j.1445-5994.2011.02564.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The ABCD(2) stroke risk score is recommended in national guidelines for stratifying care in transient ischaemic attack (TIA) patients, based on its prediction of early stroke risk. We had become concerned about the score accuracy and its clinical value in modern TIA cohorts. METHODS We identified emergency department-diagnosed TIA at two hospitals over 3 years (2004-2006). Cases were followed for stroke occurrence and ABCD(2) scores were determined from expert record review. Sensitivity, specificity and positive predictive values (PPV) of moderate-high ABCD(2) scores were determined. RESULTS There were 827 indexed TIA diagnoses and record review was possible in 95.4%. Admitted patients had lower 30-day stroke risk (n = 0) than discharged patients (n = 7; 3.1%) (P < 0.0001). There was no significant difference in proportion of strokes between those with a low or moderate-high ABCD(2) score at 30 (1.2 vs 0.8%), 90 (2.0 vs 1.9%) and 365 days (2.4 vs 2.4%) respectively. At 30 days the sensitivity, specificity and PPV of a moderate-high score were 57% (95% confidence interval (CI) 25.0-84.2), 32.2% (95% CI 29.1-35.6) and 0.75% (95% CI 0.29-1.91) respectively. CONCLUSIONS Early stroke risk was low after an emergency diagnosis of TIA and significantly lower in admitted patients. Moderate-high ABCD(2) scores did not predict early stroke risk. We suggest local validation of ABCD(2) before its clinical use and a review of its place in national guidelines.
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Affiliation(s)
- D Ghia
- Neurology Department, Liverpool Hospital, Sydney, New South Wales, Australia
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13
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Gattellari M, Goumas C, Biost FGM, Worthington JM. Relative Survival After Transient Ischaemic Attack. Stroke 2012; 43:79-85. [DOI: 10.1161/strokeaha.111.636233] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background and Purpose—
There is a lack of modern-day data quantifying the effect of transient ischemic attack (TIA) on survival, and recent data do not take into account expected survival.
Methods—
Data for 22 157 adults hospitalized with a TIA from July 1, 2000, to June 30, 2007, in New South Wales, Australia, were linked with registered deaths to June 30, 2009. We estimated survival relative to the age- and sex-matched general population up to 9-years after hospitalization for TIA comparing relative risk of excess death between selected subgroups.
Results—
At 1 year, 91.5% of hospitalized patients with TIA survived compared with 95.0% expected survival in the general population. After 5 years, observed survival was 13.2% lower than expected in relative terms. By 9 years, observed survival was 20% lower than expected. Females had higher relative survival than males (relative risk, 0.79; 95% CI, 0.69–0.90;
P
<0.001). Increasing age was associated with an increasing risk of excess death compared with the age-matched population. Prior hospitalization for stroke (relative risk, 2.63; 95% CI, 1.98–3.49) but not TIA (relative risk, 1.42; 95% CI, 0.86–2.35) significantly increased the risk of excess death. Of all risk factors assessed, congestive heart failure, atrial fibrillation, and prior hospitalization for stroke most strongly impacted survival.
Conclusions—
This study is the first to quantify the long-term effect of hospitalized TIA on relative survival according to age, sex, and medical history. TIA reduces survival by 4% in the first year and by 20% within 9 years. TIA has a minimal effect on mortality in patients <50 years but heralds significant reduction in life expectancy in those >65 years.
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Affiliation(s)
- Melina Gattellari
- From the School of Public Health and Community Medicine (M.G., C.G., F.G.), The University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute (M.G., J.M.W.), Liverpool, New South Wales, Australia; South Western Sydney Clinical School (J.M.W.), The University of New South Wales, Sydney, New South Wales, Australia; the Department of Neurophysiology (J.M.W.), Liverpool Health Service, Liverpool, New South Wales, Australia; Northern Beaches Stroke Service (J.M.W.), Manly and Mona
| | - Chris Goumas
- From the School of Public Health and Community Medicine (M.G., C.G., F.G.), The University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute (M.G., J.M.W.), Liverpool, New South Wales, Australia; South Western Sydney Clinical School (J.M.W.), The University of New South Wales, Sydney, New South Wales, Australia; the Department of Neurophysiology (J.M.W.), Liverpool Health Service, Liverpool, New South Wales, Australia; Northern Beaches Stroke Service (J.M.W.), Manly and Mona
| | - Frances Garden M. Biost
- From the School of Public Health and Community Medicine (M.G., C.G., F.G.), The University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute (M.G., J.M.W.), Liverpool, New South Wales, Australia; South Western Sydney Clinical School (J.M.W.), The University of New South Wales, Sydney, New South Wales, Australia; the Department of Neurophysiology (J.M.W.), Liverpool Health Service, Liverpool, New South Wales, Australia; Northern Beaches Stroke Service (J.M.W.), Manly and Mona
| | - John M. Worthington
- From the School of Public Health and Community Medicine (M.G., C.G., F.G.), The University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute (M.G., J.M.W.), Liverpool, New South Wales, Australia; South Western Sydney Clinical School (J.M.W.), The University of New South Wales, Sydney, New South Wales, Australia; the Department of Neurophysiology (J.M.W.), Liverpool Health Service, Liverpool, New South Wales, Australia; Northern Beaches Stroke Service (J.M.W.), Manly and Mona
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14
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A Multidimensional Prognostic Index (MPI) based on a comprehensive geriatric assessment predicts short- and long-term all-cause mortality in older hospitalized patients with transient ischemic attack. J Neurol 2011; 259:670-8. [PMID: 21947223 DOI: 10.1007/s00415-011-6241-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 08/31/2011] [Indexed: 10/17/2022]
Abstract
A multidimensional impairment may influence the clinical outcome of acute diseases in older patients. The aim of the current study was to evaluate whether a Multidimensional Prognostic Index (MPI) based on a comprehensive geriatric assessment (CGA) predicts short- and long-term all-cause mortality in older patients hospitalized for transient ischemic attack (TIA). In this prospective study with 1-year follow-up, 654 patients aged 65 and older with a diagnosis of TIA according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM 435.x) were enrolled. A standardized CGA that included information on functional (activities of daily living, ADL, and Instrumental ADL), cognitive status (Short Portable Mental Status Questionnaire), nutrition (Mini Nutritional Assessment), risk of pressure sores (Exton-Smith Scale), comorbidities (Cumulative Illness Rating Scale), medications and co-habitation status was used to calculate the MPI for mortality using a previously validated algorithm. Higher MPI values were significantly associated with higher 1-month all-cause mortality (incidence rates: MPI-1 low risk = 0.32%, MPI-2 moderate risk = 5.36%, MPI-3 high risk = 10.42%; p < 0.001), 6-month all-cause mortality (MPI-1 = 1.95%, MPI-2 = 9.77%, MPI-3 = 27.22%; p < 0.001) and 12-month all-cause mortality (MPI-1 = 5.19%, MPI-2 = 16.47%, MPI-3 = 44.32%; p < 0.001). Age- and gender-adjusted Cox regression analyses demonstrated that MPI was a significant predictor of all-cause mortality. MPI showed a significant high discriminatory power with an area under the receiver operating characteristics (ROC) curve of 0.819, 95% CI = 0.749-0.888 for 1-month mortality, 0.799, 95% CI = 0.738-0.861 for 6-month mortality and 0.770, 95% CI = 0.716-0.824 for 12-month mortality. The MPI, calculated from information collected in a standardized CGA, appeared to be effective in estimating short- and long-term all-cause mortality in older patients hospitalized for TIA.
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15
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Raffe F, Jacquin A, Milleret O, Durier J, Sauze D, Peyron C, Osseby GV, Menassa M, Hervieu M, Pelissier F, Routhier P, Beis JN, Giroud M, Béjot Y. Evaluation of the possible impact of a care network for stroke and transient ischemic attack on rates of recurrence. Eur Neurol 2011; 65:239-44. [PMID: 21474937 DOI: 10.1159/000326298] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 02/21/2011] [Indexed: 11/19/2022]
Abstract
We aimed to demonstrate that a stroke network is able to reduce the proportion of recurrent cerebrovascular events. In 2003, we set up a care network with the aim to reduce the proportion of stroke recurrence. For the statistical analysis, recurrent cerebrovascular events observed from 1985 to 2002 within the population of Dijon made it possible to model trends using Poisson logistic regression. From 1985 to 2002, we recorded 172 recurrent cerebrovascular events which were used to model trends before the creation of the care network. Within the period 2003-2007, we observed 162 recurrent cerebrovascular events compared with 196.7 expected cerebrovascular events with a significant standardized incidence rate of 0.82 (0.70-0.96; p = 0.01). After eliminating the role of some environmental factors, the possible hypothesis for the fall in recurrent stokes is probably the positive effect of the stroke care network.
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Affiliation(s)
- Florie Raffe
- Faculty of Health Economics, University of Burgundy, Dijon, France
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