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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [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: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Meng G, McAiney C, McKillop I, Perlman CM, Tsao SF, Chen H. Factors That Influence Patient Satisfaction With the Service Quality of Home-Based Teleconsultation During the COVID-19 Pandemic: Cross-Sectional Survey Study. JMIR Cardio 2024; 8:e51439. [PMID: 38363590 PMCID: PMC10907934 DOI: 10.2196/51439] [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: 08/04/2023] [Revised: 12/21/2023] [Accepted: 01/03/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Ontario stroke prevention clinics primarily held in-person visits before the COVID-19 pandemic and then had to shift to a home-based teleconsultation delivery model using telephone or video to provide services during the pandemic. This change may have affected service quality and patient experiences. OBJECTIVE This study seeks to understand patient satisfaction with Ontario stroke prevention clinics' rapid shift to a home-based teleconsultation delivery model used during the COVID-19 pandemic. The research question explores explanatory factors affecting patient satisfaction. METHODS Using a cross-sectional service performance model, we surveyed patients who received telephone or video consultations at 2 Ontario stroke prevention clinics in 2021. This survey included closed- and open-ended questions. We used logistic regression and qualitative content analysis to understand factors affecting patient satisfaction with the quality of home-based teleconsultation services. RESULTS The overall response rate to the web survey was 37.2% (128/344). The quantitative analysis was based on 110 responses, whereas the qualitative analysis included 97 responses. Logistic regression results revealed that responsiveness (adjusted odds ratio [AOR] 0.034, 95% CI 0.006-0.188; P<.001) and empathy (AOR 0.116, 95% CI 0.017-0.800; P=.03) were significant factors negatively associated with low satisfaction (scores of 1, 2, or 3 out of 5). The only characteristic positively associated with low satisfaction was when survey consent was provided by the substitute decision maker (AOR 6.592, 95% CI 1.452-29.927; P=.02). In the qualitative content analysis, patients with both low and high global satisfaction scores shared the same factors of service dissatisfaction (assurance, reliability, and empathy). The main subcategories associated with dissatisfaction were missing clinical activities, inadequate communication, administrative process issues, and absence of personal connection. Conversely, the high-satisfaction group offered more positive feedback on assurance, reliability, and empathy, as well as on having a competent clinician, appropriate patient selection, and excellent communication and empathy skills. CONCLUSIONS The insights gained from this study can be considered when designing home-based teleconsultation services to enhance patient experiences in stroke prevention care.
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Affiliation(s)
- Guangxia Meng
- School of Public Health Sciences, University of Walterloo, Waterloo, ON, Canada
| | - Carrie McAiney
- School of Public Health Sciences, University of Walterloo, Waterloo, ON, Canada
| | - Ian McKillop
- School of Public Health Sciences, University of Walterloo, Waterloo, ON, Canada
| | | | - Shu-Feng Tsao
- School of Public Health Sciences, University of Walterloo, Waterloo, ON, Canada
| | - Helen Chen
- School of Public Health Sciences, University of Walterloo, Waterloo, ON, Canada
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Hachinski V. The comprehensive, customized, cost-effective approach (CCCAP) to prevention of dementia. Alzheimers Dement 2022; 18:1565-1568. [PMID: 35103397 DOI: 10.1002/alz.12586] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 12/26/2022]
Abstract
The Food and Drug Administration's controversial approval of aducanumab has sounded a wake-up call. Is the search of a silver bullet to stop Alzheimer's disease the only way to prevent dementia? The controversies and costs have opened minds to alternative approaches, the most promising being that we are already preventing some dementias in some high-income countries but do not know yet how. This article proposes one way. It requires that the approach be (1) comprehensive, taking into account all relevant environmental, socioeconomic, and individual risk and protective factors; (2) customized, because contributing factors vary by region and among individuals; and (3) cost effective, implemented in actionable units. Savings of scale could occur by preventing stroke, heart disease, and dementia together. They share the same risk factors and pose risks for each other. Brain health could be the unifying, motivating, and actionable key to health, productivity, and well-being.
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Affiliation(s)
- Vladimir Hachinski
- Department of Clinical Neurological Sciences, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
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Harris JL, DelVecchio D, Seabury RW, Miller CD, Phillips E. Pharmacists Act on Care Transitions in Stroke (PACT-Stroke): A Systems Approach. Clin Ther 2022; 44:466-472. [DOI: 10.1016/j.clinthera.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
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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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Ganesh A, Ospel JM, Marko M, van Zwam WH, Roos YBWEM, Majoie CBLM, Goyal M. From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke. Front Neurol 2021; 12:713738. [PMID: 34381418 PMCID: PMC8350336 DOI: 10.3389/fneur.2021.713738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond. Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT. Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability. Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.
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Affiliation(s)
- Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | | | - Martha Marko
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | | | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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7
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1144] [Impact Index Per Article: 381.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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8
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Morovatdar N, Avan A, Azarpazhooh MR, Di Napoli M, Stranges S, Kapral MK, Rezayat AA, Shariatzadeh A, Abootalebi S, Mokhber N, Spence JD, Hachinski V. Secular trends of ischaemic heart disease, stroke, and dementia in high-income countries from 1990 to 2017: the Global Burden of Disease Study 2017. Neurol Sci 2021; 43:255-264. [PMID: 33934273 DOI: 10.1007/s10072-021-05259-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/12/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND We assessed secular trends in the burden of ischaemic heart disease (IHD), stroke, and dementia in the Organization for Economic Co-operation and Development (OECD) countries. METHODS Using the Global Burden of Disease (GBD) Study 2017, we compared sex-specific and age-standardized rates of disability-adjusted life years (DALY); mortality, incidence, and prevalence of IHD and stroke; and dementia per 100,000 people, in the world, OECD countries, and Canada. RESULTS From 1990 to 2017, the crude incidence number of IHD, stroke, and dementia increased 52%, 76%, and 113%, respectively. Likewise, the prevalence of IHD (75%), stroke (95%), and dementia (119%) increased worldwide. In addition during the study period, the crude global number of deaths of IHD increased 52%, stroke by 41%, and dementia by 146% (9, 6, and 3 million deaths in 2017, respectively). Despite an increase in the crude number of these diseases, the global age-standardized incidence rate of IHD, stroke, and dementia decreased by -27%, - 11%, and - 5%, respectively. Moreover, there was a decline in their age-standardized DALY rates (- 1.17%, - 1.32%, and - 0.23% per year, respectively) and death rates (- 1.29%, - 1.46%, and - 0.17% per year, respectively), with sharper downward trends in Canada and OECD countries. Almost all trends flattened during the last decade. CONCLUSIONS From 1990 to 2017, the age-standardized burden of IHD, stroke, and dementia decreased, more prominently in OECD countries than the world. However, their rising crude numbers mainly due to population growth and ageing require urgent identification of reversible risk and protective factors.
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Affiliation(s)
- Negar Morovatdar
- Clinical Research Development Unit, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abolfazl Avan
- Department of Public Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - M Reza Azarpazhooh
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, Siebens-Drake Building, 1400 Western Rd, London, ON, N6G 2V4, Canada. .,Department of Clinical Neurological Sciences, Western University, London, ON, Canada. .,Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
| | - Mario Di Napoli
- Department of Neurology and Stroke Unit, San Camillo de' Lellis General District Hospital, Rieti, Italy.,Neurological Section, Neuro-epidemiology Unit, SMDN-Centre for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Sulmona, L'Aquila, Italy
| | - Saverio Stranges
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Moira K Kapral
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Arash Akhavan Rezayat
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Aidin Shariatzadeh
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, Siebens-Drake Building, 1400 Western Rd, London, ON, N6G 2V4, Canada
| | - Shahram Abootalebi
- Dr. Everett Chalmers Regional Hospital, Dalhousie University, New Brunswick, Canada
| | - Naghmeh Mokhber
- Department of Psychiatry and Behavioural Neurosciences, Western University, London, Ontario, Canada.,Department of Psychiatry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, Siebens-Drake Building, 1400 Western Rd, London, ON, N6G 2V4, Canada.,Department of Clinical Neurological Sciences, Western University, London, ON, Canada.,Division of Clinical Pharmacology, Western University, London, Ontario, Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Boursin P, Coutier S, Chrétien S, Yordanov Y, Maïer B. [Perspectives offered by advanced nursing practice with stroke victims in France in 2021]. SOINS; LA REVUE DE RÉFÉRENCE INFIRMIÈRE 2021; 66:10-17. [PMID: 33750550 DOI: 10.1016/s0038-0814(21)00015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
30% more strokes are expected by 2030. To face this incoming huge public health challenge, large-scale projects for primary, secondary and tertiary prevention of neurovascular risk have to be developed. French new advanced nursing practices will be most promising if they are based on the timeliness of pathology follow-up but also on leadership in training, research and innovation in the care pathway for stroke victims.
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Affiliation(s)
- Perrine Boursin
- Hôpital Fondation de Rothschild, neuroradiologie interventionnelle et neurologie vasculaire, 29 rue Manin, 75019 Paris, France.
| | - Séverine Coutier
- Hôpital Bichat, AP-HP, service de neurologie vasculaire, 46 rue Henri-Huchard, 75018 Paris, France
| | - Sophie Chrétien
- Hôpital Bichat, AP-HP, équipe mobile d'accompagnement et de soins palliatifs, 46 rue Henri-Huchard, 75018 Paris, France
| | - Youri Yordanov
- Hôpital Saint-Antoine, AP-HP, service d'accueil des urgences, 34 rue Crozatier, 75012 Paris, France; Sorbonne-Université, institut Pierre-Louis d'épidémiologie et de santé publique, UMR-S 1136, Inserm, 27 rue Chaligny, 75012 Paris, France
| | - Benjamin Maïer
- Hôpital Fondation de Rothschild, neuroradiologie interventionnelle et neurologie vasculaire, 29 rue Manin, 75019 Paris, France; Université de Paris, Laboratory for vascular translational science, UMR-S 1148, Inserm, 46 rue Henri-Huchard, 75018 Paris, France
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10
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Zhao J, Wang Y, Fisher M, Liu R. Slower recovery of outpatient clinics than inpatient services for stroke and other neurological diseases after COVID-19 Pandemic. CNS Neurosci Ther 2020; 26:1322-1326. [PMID: 33058536 PMCID: PMC7675482 DOI: 10.1111/cns.13459] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/14/2022] Open
Abstract
Background In this brief report, we investigated the impact of COVID‐19 on outpatient stroke clinics and inpatient services and their recovery process. Methods We sent a survey to physicians worldwide through the network of the World Stroke Organization to investigate the impact of COVID‐19 on stroke clinics. To farther along in recovering from the outbreak, we reviewed stroke and other neurology outpatient clinic visits (approximately 50% were stroke related) and the number of inpatient services from December 2019 to July 2020 in a large neurology department in Shanghai, China, where there was no official city lockdown. Results We received 112 valid survey responses from 46 countries, representing all continents except for Antarctica. Only seven of the survey responders (7/112, 6.3%) reported that they have kept their outpatient clinics open as usual, but they did exercise increased precautions for COVID‐19 by following recent guidelines regarding use of personal protective equipment and isolation techniques. The remainder of the respondents have either reduced outpatient clinic services or suspended outpatient clinics completely. Telephone consultation or telemedicine with video capability was used for new patients or follow‐ups, with limited in‐person evaluations when necessary. Outpatient clinic visits and inpatient services from a large tertiary hospital in China decreased dramatically during the peak period of the outbreak, but then rebounded back quickly following the partial or full recovery from the outbreak. Compared with the recovery process of inpatient services, outpatient clinic visits decreased faster and recovered much slower. This is consistent with our global survey data which indicates that some outpatient clinics have rescheduled their outpatient visits for 3 to 6 months. Conclusions The COVID‐19 pandemic caused a significant drop of in‐person outpatient visits and inpatient services. Clinic visits recovered slower than inpatient services in stroke and other neurological diseases after the pandemic.
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Affiliation(s)
- Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
| | - Yong Wang
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Renyu Liu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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11
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Reduction in Stroke After Transient Ischemic Attack in a Province-Wide Cohort Between 2003 and 2015. Can J Neurol Sci 2020; 48:335-343. [PMID: 32959741 DOI: 10.1017/cjn.2020.205] [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: 11/07/2022]
Abstract
BACKGROUND Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province. METHODS Using administrative data from the Canadian Institute for Health Information's (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015. RESULTS From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001). INTERPRETATION At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.
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12
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Botly LC, Lindsay MP, Mulvagh SL, Hill MD, Goia C, Martin-Rhee M, Casaubon LK, Yip CY. Recent Trends in Hospitalizations for Cardiovascular Disease, Stroke, and Vascular Cognitive Impairment in Canada. Can J Cardiol 2020; 36:1081-1090. [DOI: 10.1016/j.cjca.2020.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 10/23/2022] Open
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13
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Affiliation(s)
- Shadi Yaghi
- From the Department of Neurology, New York University, Brooklyn (S.Y.).,Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y.)
| | | | - Pooja Khatri
- Department of Neurology, University of Cincinnati, OH (P.K.)
| | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California at Los Angeles (D.S.L.)
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Kao A, Lanford J, Wong LK, Ranta A. Do clinical nurse specialist led stroke follow-up clinics reduce post-stroke hospital readmissions and recurrent vascular events? Intern Med J 2019; 50:1202-1207. [PMID: 31762157 DOI: 10.1111/imj.14707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Post-discharge stroke follow-up clinics intend to improve care and may reduce readmission. Pre-2013, there was no consistent post-stroke specialist follow up offered at Wellington Hospital. We tested whether the establishment of a clinical nurse specialist follow-up clinic reduced the 12-month readmission rate. METHODS This is a sequential comparison of stroke patients admitted 1 year prior and 1 year after clinic establishment in 2013. The primary outcome was 12-month hospital readmission rate; main secondary outcomes were guideline adherence and recurrent vascular events. Patients were identified from hospital discharge records and underwent chart review. We adjusted results for differences in baseline characteristics. RESULTS We identified 603 eligible patients; 288 pre- and 315 post-nurse clinic implementations. There was no difference based on study cohort in the 1-year readmission rate (adjusted odds ratio (aOR) = 1.14; 95% CI, 0.7-1.89; P = 0.583), or recurrent composite vascular events at 1 year (aOR = 1.56; 95% CI, 0.89-2.9; P = 0.159). When looking at clinic attendance as the main variable of interest, a pre-specified sub-group analysis, there was a significant difference in implementation of best medical therapy (aOR 2.66 (1.19-5.94); P = 0.017), and a trend towards reduction of vascular events and/or death at 1 year post discharge (aOR 0.53 (0.28-1.02); P = 0.056). CONCLUSIONS There was no reduction in the 1-year hospital readmission or vascular event recurrence rate for patients admitted with stroke following the establishment of a specialist nurse-led stroke follow-up clinic. Actual clinic attendance, however, did appear to confer some benefit. This study suggests that more consistent and potentially earlier timed follow up is probably desirable.
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Affiliation(s)
- Alex Kao
- Department of Neurology, Wellington Regional Hospital, Wellington, New Zealand
| | - Jeremy Lanford
- Department of Neurology, Wellington Regional Hospital, Wellington, New Zealand
| | - Lai-Kin Wong
- Department of Neurology, Wellington Regional Hospital, Wellington, New Zealand
| | - Annemarei Ranta
- Department of Neurology, Wellington Regional Hospital, Wellington, New Zealand.,Department of Medicine, University of Otago, Wellington, New Zealand
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Hachinski V. The convergence of stroke and dementia. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 76:849-852. [PMID: 30698209 DOI: 10.1590/0004-282x20180148] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 11/09/2018] [Indexed: 12/28/2022]
Abstract
Neurological disorders account for the most Disability Adjusted Life Years (DALY's) -of the Global Burden of Disease (10%). More than half of neurological DALY's result from the combination of stroke (42%) and dementia (10%). The two pose risk for each other and share the same predisposing factors. A stroke doubles the risk of dementia. The close interactions call for convergent approaches. Stroke and dementia also converge at the microscopic level. The neurovascular unit has emerged as a key organizational structure of the brain. Involvement of any of its elements affects all the others. Thus, neurodegeneration impairs the microcirculation and disturbances of the microcirculation accelerate neurodegeneration. Evolving technologies allow "in vivo" imaging of the usual mixture of vascular and neurodegenerative pathology of the elderly that makes them prone to stroke and dementia. Since they occur together, they should be prevented together with a multimodal approach of lifestyle changes and mechanistic therapeutic targets. The two fields are also converging at the policy level. The World Stroke Organization has updated its Proclamation to include potentially preventable dementias that has been endorsed by Alzheimer Disease International, The World Federation of Neurology, the American Academy of Neurology and 20 international, regional and national organizations. Those interested in stroke and those dealing with dementia should work together where they can, differ where they must, with the common aim of preventing jointly, both stroke and dementia.
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Affiliation(s)
- Vladimir Hachinski
- Western University, Department of Clinical Neurological Sciences, London, Ontario, Canada
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The Advanced Practice Nurse Will See You Now: Impact of a Transitional Care Clinic on Hospital Readmissions in Stroke Survivors. J Nurs Care Qual 2019; 35:147-152. [PMID: 31136530 DOI: 10.1097/ncq.0000000000000414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a paucity of evidence-based, posthospital stroke care in the United States proven to reduce preventable hospital readmissions. LOCAL PROBLEM Follow-up with a provider after hospitalization for stroke or transient ischemic attack had low compliance rates. This may contribute to preventable readmissions. METHODS A retrospective, descriptive chart review to determine whether an advanced practice registered nurse (APRN)-led transitional care clinic for stroke survivors impacted 30- and 90-day hospital readmissions. Readmissions between clinic patients and nonclinic patients were compared. INTERVENTIONS The site implemented an APRN-led transitional care stroke clinic to improve patient transitions from hospital to home. RESULTS The 30-day readmission proportion was significantly higher in nonclinic patients (n = 335) than in clinic patients (n = 68) (13.4% vs 1.5%, respectively; P = .003). The 90-day readmission proportion was numerically higher in nonclinic patients (12.8% vs 4.4%, respectively; P = .058). CONCLUSIONS The results suggest the APRN-led clinic may impact 30-day hospital readmissions in stroke/transient ischemic attack survivors.
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Abstract
AbstractBackgroundIn 2010, we published our stroke prevention clinic’s performance as compared to Canadian stroke prevention guidelines. We now compare our clinic’s adherence with guidelines to our previous results, following the implementation of an electronic documentation form.MethodsAll new patients referred to our clinic (McGill University Health Center) for recent transient ischemic attack (TIA) or ischemic stroke between 2014 and 2017 were included. We compared adherence to guidelines to our previous report (N=408 patients for period 2008–2010) regarding vascular risk management and treatment.ResultsThree hundred and ninety-two patients were included, of which 36% had a TIA and 64% had an ischemic stroke, with a mean age of 70 years and 43% female. Although the more recent cohort has shown a higher proportion of cardioembolic stroke compared to previous (19.1% vs. 14.7%) following new guidelines regarding prolonged cardiac monitoring, increased popularity in CT angiography has not translated into greater proportion of large-artery stroke subtype (26.3% vs. 26.2%). Blood pressure (BP) targets were achieved in 83% compared with 70% in our previous report (p<0.01). Attainment of low-density lipoprotein cholesterol target was also improved in our recent study (66% vs. 46%, p<0.01). No significant difference was found in the consistency of antithrombotic use (97.7% vs. 99.8%, p=0.08). However, there was a decline in smoking cessation (35% vs. 73%, p=0.02). Overall, optimal therapy status was better attained in the present cohort compared to the previous one (52% vs. 22%, p<0.01). The male sex was associated with better attainment of optimal therapy status (odds ratio, 1.61; 95% confidence interval, 1.04–2.51). The number of follow-up visits and the length of follow-up were not associated with attainment of stroke prevention targets.ConclusionsOur study shows improvement in attainment of therapeutic goals as recommended by Canadian stroke prevention guidelines, possibly attributed in part to the implementation of electronic medical recording in our clinic. Areas for improvement include smoking cessation counseling and diabetes screening.
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Hachinski V. Dementia: new vistas and opportunities. Neurol Sci 2019; 40:763-767. [PMID: 30666474 DOI: 10.1007/s10072-019-3714-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022]
Abstract
Over the past four decades, Alzheimer disease has become near synonymous with dementia and the amyloid/tau hypothesis as its dominant explanation. However, this monorail approach to etiology has failed to yield a single disease-modifying drug. Part of the explanation stems from the fact that most dementias in the elderly result from interactive Alzheimer and cerebrovascular pathologies. Stroke and dementia share the same risk factors and their control is associated with a decrease in stroke and some dementias. Additionally, intensive control of risk factors and enhancement of protective factors improve cognition. Moreover, anticoagulation of atrial fibrillation patients decreases their chance of developing dementia by 48%. Preliminary data suggest that treating blood pressure to a target of 120 mmHg systolic compared to a target of 140 mmHg decreases the chances of mild cognitive impairment by 19%. The Berlin Manifesto establishes the scientific bases of "preventing dementia by preventing stroke." Enlarging our vista of dementia to include cerebrovascular disease offers the opportunity of preventing not only stroke, but some dementias, beginning now.
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Affiliation(s)
- Vladimir Hachinski
- Department of Clinical Neurological Sciences, Western University, 339 Windermere Road, London, Ontario, N6A 5A5, Canada.
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Jewett L, Harroud A, Hill MD, Côté R, Wein T, Smith EE, Gubitz G, Demchuk AM, Sahlas DJ, Gladstone DJ, Lindsay MP. Secondary stroke prevention services in Canada: a cross-sectional survey and geospatial analysis of resources, capacity and geographic access. CMAJ Open 2018; 6:E95-E102. [PMID: 29472251 PMCID: PMC5878947 DOI: 10.9778/cmajo.20170130] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Rapid assessment and management of transient ischemic attacks and nondisabling strokes by specialized stroke prevention services reduces the risk of recurrent stroke and improves outcomes. In Canada, with its vast geography and with 16.8% of the population living in rural areas, access to these services is challenging, and considerable variation in access to care exists. The purpose of this multiphase study was to identify sites across Canada providing stroke prevention services, evaluate resource capacity and determine geographic access for Canadians. METHODS We developed a Stroke Prevention Services Resource Inventory that contained 22 questions on the organization and delivery of stroke prevention services and quality monitoring. The inventory ran from November 2015 to January 2016 and was administered online. We conducted a geospatial analysis to estimate access by drive times. Considerations were made for hours of operation and access within and across provincial borders. RESULTS A total of 123 stroke prevention sites were identified, of which 119 (96.7%) completed the inventory. Most (95) are designated stroke prevention or rapid assessment clinics. Of the 119 sites, 68 operate full time, and 39 operate less than 2.5 days per week. A total of 87.3% of the Canadian population has access to a stroke prevention service within a 1-hour drive; however, only 69.2% has access to a service that operates 5-7 days a week. Allowing provincial border crossing improves access (< 6-h drive) for those who are beyond a 6-hour drive within their home province (3.4%). INTERPRETATION Most Canadians have reasonable geographic access to stroke prevention services. Allowing patients to cross borders improves the existing access for many, particularly some remote communities along the Ontario-Quebec and British Columbia-Alberta borders.
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Affiliation(s)
- Lauren Jewett
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - Adil Harroud
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - Michael D Hill
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - Robert Côté
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - Theodore Wein
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - Eric E Smith
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - Gord Gubitz
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - Andrew M Demchuk
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - Demetrios J Sahlas
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - David J Gladstone
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
| | - M Patrice Lindsay
- Affiliations: Department of Geography and Planning (Jewett), University of Toronto, Toronto, Ont.; Department of Neurology and Neurosurgery (Harroud, Côté, Wein) and Department of Medicine (Harroud, Cote, Wein), McGill University, Montréal, Que.; Calgary Stroke Program (Hill, Smith, Demchuk), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta; Queen Elizabeth II Health Sciences Centre (Gubitz), Dalhousie University, Halifax, NS; Division of Neurology (Sahlas), Department of Medicine, McMaster University, Hamilton, Ont.; Sunnybrook Health Sciences Centre (Gladstone) and Hurvitz Brain Sciences Research Program (Gladstone), Sunnybrook Research Institute, Department of Medicine, University of Toronto; Heart and Stroke Foundation of Canada (Lindsay), Toronto, Ont
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Nucera A, Hachinski V. Cerebrovascular and Alzheimer disease: fellow travelers or partners in crime? J Neurochem 2018; 144:513-516. [PMID: 29266273 DOI: 10.1111/jnc.14283] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/30/2017] [Accepted: 12/06/2017] [Indexed: 12/22/2022]
Abstract
In this review, we will discuss the progressive decline in cognitive and intellectual performance in late life that has led to great challenges for medical and community services. The term 'vascular cognitive impairment' is defined as any cognitive impairment that is caused by or associated with vascular factors. It can occur alone or in association with Alzheimer disease. The good news is that because vascular risk factors are treatable, it should be possible to prevent or delay some dementias. Since vascular cognitive impairment may often go unrecognized, many experts recommend screening with brief tests to assess memory, thinking, and reasoning for everyone considered to be at high risk for this disorder. Up to 64% of persons 65 years or older who have experienced a stroke have some degree of cognitive impairment with up to one third developing dementia. Postmortem studies indicate that up to 34% of dementia cases show significant vascular pathology. It suggests that ischemic stroke triggers additional pathophysiological process that may lead to a secondary degenerative process that may interact with Alzheimer disease pathology thus accelerating the ongoing primary neurodegeneration. Mechanisms could include hypoperfusion, hypoxia, and neuroinflammation, one of the links between the two pathologies. Stroke and dementia share the same risk and protective factors. Since stroke interact with dementia of all types it may already be possible to reduce or delay some dementias by a number of interventions known to prevent stroke. This article is part of the Special Issue "Vascular Dementia".
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Affiliation(s)
- Antonia Nucera
- Department of Clinical Neurological Science, University Hospital, the University of Western Ontario, London, Ontario, Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Science, University Hospital, the University of Western Ontario, London, Ontario, Canada.,Department of Epidemiology and Biostatics, the University of Western Ontario, London, Ontario, Canada
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Cerasuolo JO, Cipriano LE, Sposato LA, Kapral MK, Fang J, Gill SS, Hackam DG, Hachinski V. Population‐based stroke and dementia incidence trends: Age and sex variations. Alzheimers Dement 2017; 13:1081-1088. [DOI: 10.1016/j.jalz.2017.02.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Joshua O. Cerasuolo
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry Western University London Ontario Canada
| | - Lauren E. Cipriano
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry Western University London Ontario Canada
- Ivey Business School Western University London Ontario Canada
| | - Luciano A. Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre Western University London Ontario Canada
| | - Moira K. Kapral
- Department of Medicine University of Toronto Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences Toronto Ontario Canada
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences Toronto Ontario Canada
| | - Sudeep S. Gill
- Institute for Clinical Evaluative Sciences Queen's University Kingston Ontario Canada
- Division of Geriatric Medicine Queen's University Kingston Ontario Canada
- Division of Geriatric Medicine St. Mary's of the Lake Hospital Kingston Ontario Canada
| | - Daniel G. Hackam
- Division of Clinical Pharmacology, Department of Medicine Western University London Ontario Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, London Health Sciences Centre Western University London Ontario Canada
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Long B, Koyfman A. Best Clinical Practice: Controversies in Transient Ischemic Attack Evaluation and Disposition in the Emergency Department. J Emerg Med 2017; 52:299-310. [DOI: 10.1016/j.jemermed.2016.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 02/07/2023]
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Abstract
BACKGROUND Few studies have assessed the performance of stroke prevention clinics. In particular, limited information exists on patient compliance, achievement of therapeutic targets, and related occurrence of vascular events. METHODS We compared our clinical practice to recommendations from published guidelines in newly referred patients for transient ischemic attack (TIA) or ischemic stroke between 2008 and 2010. We monitored our cohort for at least 1 year and assessed for adequacy of vascular risk factor management, drug adherence, and occurrence of nonlethal vascular outcomes. RESULTS Of 408 patients, 57.8% had a stroke and 42.2% a TIA. The mean age was 68±13 years, and 52% male. Average follow-up was 15.8 months. During follow-up, 253 patients (70.3%) completely achieved their blood pressure target, 151 (45.5%) achieved their low-density lipoprotein (LDL) cholesterol target, and 407 (99.8%) were on antithrombotics. Eighty-nine patients (21.8%) attained optimal therapy status, defined as reaching targets for LDL cholesterol, blood pressure, and antithrombotic use. Adherence to drug therapy was associated with attainment of optimal therapy status (p=0.01). Diabetes was associated with lower probability of attaining optimal therapy status (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.20-0.66) and blood pressure targets (OR, 0.09; 95% CI, 0.05-0.17). During follow-up, 52 (12.7%) patients had a nonlethal vascular event. CONCLUSION Our study shows good attainment of therapeutic goals associated with adherence to drug therapy. However, optimal therapy status and blood pressure targets were more difficult to attain in patients with diabetes; therefore, more intensive preventive efforts may be required for these individuals.
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Tuppin P, Samson S, Fagot-Campagna A, Woimant F. Care pathways and healthcare use of stroke survivors six months after admission to an acute-care hospital in France in 2012. Rev Neurol (Paris) 2016; 172:295-306. [PMID: 27038535 DOI: 10.1016/j.neurol.2016.01.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/25/2015] [Accepted: 01/08/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Care pathways and healthcare management are not well described for patients hospitalized for stroke. METHODS Among the 51 million beneficiaries of the French national health insurance general scheme (77% of the French population), patients hospitalized for a first stroke in 2012 and still alive six months after discharge were included using data from the national health insurance information system (Sniiram). Patient characteristics were described by discharge destination-home or rehabilitation center (for < 3 months)-and were followed during their first three months back home. RESULTS A total of 61,055 patients had a first admission to a public or private hospital for stroke (mean age; 72 years, 52% female), 13% died during their stay and 37% were admitted to a stroke management unit. Overall, 40,981 patients were still alive at six months: 33% of them were admitted to a rehabilitation center (mean age: 73 years) and 54% were discharged directly to their home (mean age 67 years). For each group, 45 and 62% had been previously admitted to a stroke unit. Patients discharged to rehabilitation centers had more often comorbidities, 39% were highly physically dependent and 44% were managed in specialized neurology centers. For patients with a cerebral infarction who were directly discharged to their home 76% received at least one antihypertensive drug, 96% an antithrombotic drug and 76% a lipid-lowering drug during the following month. For those with a cerebral hemorrhage, these frequencies were respectively 46, 33 and 28%. For those admitted to a rehabilitation center, more than half had at least one visit with a physiotherapist or a nurse, 15% a speech therapist, 10% a neurologist or a cardiologist and 15% a psychiatrist during the following three months back home (average numbers of visits for those with at least one visit: 23 for physiotherapists and 100 for nurses). Patients who returned directly back home had fewer physiotherapist (30%) or nurse (47%) visits but more medical consultations. The 3-month re-hospitalization rate for patients who were discharged directly to their home was 23% for those who had been admitted to a stroke unit and 25% for the others. In rehabilitation centers, this rate was 10% for patients who stayed < 3 months. CONCLUSIONS These results illustrate the value of administrative databases to study stroke management, care pathways and ambulatory care. These data should be used to improve care pathways, organization, discharge planning and treatments.
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Affiliation(s)
- P Tuppin
- CNAMTS, Direction de la stratégie des études et des statistiques, 26-50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France.
| | - S Samson
- CNAMTS, Direction de la stratégie des études et des statistiques, 26-50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France
| | - A Fagot-Campagna
- CNAMTS, Direction de la stratégie des études et des statistiques, 26-50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France
| | - F Woimant
- Département de neurologie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
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Kapral MK, Hall R, Fang J, Austin PC, Silver FL, Gladstone DJ, Casaubon LK, Stamplecoski M, Tu JV. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology 2016; 86:1582-9. [PMID: 27016521 DOI: 10.1212/wnl.0000000000002614] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 12/04/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the care and outcomes of patients with TIA or minor stroke admitted to the hospital vs discharged from the emergency department (ED). METHODS We used the Ontario Stroke Registry to create a cohort of patients with minor ischemic stroke/TIA who presented to the hospital April 1, 2008, to March 31, 2009, or April 1, 2010, to March 31, 2011, in the province of Ontario, Canada. We compared processes of care and outcomes (death or recurrent stroke/TIA) in patients admitted to the hospital and discharged with and without stroke prevention clinic follow-up. RESULTS In our sample of 8,540 patients, the use of recommended interventions was highest in admitted patients, followed by discharged patients referred to prevention clinics, followed by those discharged without clinic referral. Eight percent of nonadmitted patients returned to the hospital with recurrent stroke/TIA within 1 week of the index event. One-year stroke case-fatality was similar in admitted and discharged patients (adjusted hazard ratio 1.11; 95% confidence interval 0.92-1.34). Among patients discharged from EDs, referral to a stroke prevention clinic was associated with a markedly lower risk of mortality (adjusted hazard ratio 0.49; 95% confidence interval 0.38-0.64). CONCLUSIONS Patients with minor ischemic stroke or TIA discharged from the ED are less likely than admitted patients to receive timely stroke care interventions. Among discharged patients, referral to a stroke prevention clinic is associated with improved processes of care and lower mortality. Additional strategies are needed to improve access to high-quality outpatient TIA care.
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Affiliation(s)
- Moira K Kapral
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Ruth Hall
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jiming Fang
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Peter C Austin
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Frank L Silver
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - David J Gladstone
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Leanne K Casaubon
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Melissa Stamplecoski
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jack V Tu
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
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Ganesh A, Lindsay P, Fang J, Kapral MK, Côté R, Joiner I, Hakim AM, Hill MD. Integrated systems of stroke care and reduction in 30-day mortality: A retrospective analysis. Neurology 2016; 86:898-904. [PMID: 26850979 PMCID: PMC4782112 DOI: 10.1212/wnl.0000000000002443] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 10/07/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the association between the presence of integrated systems of stroke care and stroke case-fatality across Canada. METHODS We used the Canadian Institute of Health Information's Discharge Abstract Database to retrospectively identify a cohort of stroke/TIA patients admitted to all acute care hospitals, excluding the province of Quebec, in 11 fiscal years from 2003/2004 to 2013/2014. We used a modified Poisson regression model to compute the adjusted incidence rate ratio (aIRR) of 30-day in-hospital mortality across time for provinces with stroke systems compared to those without, controlling for age, sex, stroke type, comorbidities, and discharge year. We conducted surveys of stroke care resources in Canadian hospitals in 2009 and 2013, and compared resources in provinces with integrated systems to those without. RESULTS A total of 319,972 patients were hospitalized for stroke/TIA. The crude 30-day mortality rate decreased from 15.8% in 2003/2004 to 12.7% in 2012/2013 in provinces with stroke systems, while remaining 14.5% in provinces without such systems. Starting with the fiscal year 2009/2010, there was a clear reduction in relative mortality in provinces with stroke systems vs those without, sustained at aIRR of 0.85 (95% confidence interval 0.79-0.92) in the 2011/2012, 2012/2013, and 2013/2014 fiscal years. The surveys indicated that facilities in provinces with such systems were more likely to care for patients on a stroke unit, and have timely access to a stroke prevention clinic and telestroke services. CONCLUSION In this retrospective study, the implementation of integrated systems of stroke care was associated with a population-wide reduction in mortality after stroke.
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Affiliation(s)
- Aravind Ganesh
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Patrice Lindsay
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Jiming Fang
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Moira K Kapral
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Robert Côté
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Ian Joiner
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Antoine M Hakim
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Michael D Hill
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada.
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Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic. CAN J EMERG MED 2016; 18:331-9. [PMID: 26879765 DOI: 10.1017/cem.2016.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES 1) To evaluate whether transient ischemic attack (TIA) management in emergency departments (EDs) of the Nova Scotia Capital District Health Authority followed Canadian Best Practice Recommendations, and 2) to assess the impact of being followed up in a dedicated outpatient neurovascular clinic. METHODS Retrospective chart review of all patients discharged from EDs in our district from January 1, 2011 to December 31, 2012 with a diagnosis of TIA. Cox proportional hazards models, Kaplan-Meier survival curve, and propensity matched analyses were used to evaluate 90-day mortality and readmission. RESULTS Of the 686 patients seen in the ED for TIA, 88.3% received computed tomography (CT) scanning, 86.3% received an electrocardiogram (ECG), 35% received vascular imaging within 24 hours of triage, 36% were seen in a neurovascular clinic, and 4.2% experienced stroke, myocardial infarction, or vascular death within 90 days. Rates of antithrombotic use were increased in patients seen in a neurovascular clinic compared to those who were not (94% v. 86.3%, p<0.0001). After adjustment for age, sex, vascular disease risk factors, and stroke symptoms, the risk of readmission for stroke, myocardial infarction, or vascular death was lower for those seen in a neurovascular clinic compared to those who were not (adjusted hazard ratio 0.28; 95% confidence interval 0.08-0.99, p=0.048). CONCLUSION The majority of patients in our study were treated with antithrombotic agents in the ED and investigated with CT and ECG within 24 hours; however, vascular imaging and neurovascular clinic follow-up were underutilized. For those with neurovascular clinic follow-up, there was an association with reduced risk of subsequent stroke, myocardial infarction, or vascular death.
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Ben-Yakov M, Kapral MK, Fang J, Li S, Vermeulen MJ, Schull MJ. The Association Between Emergency Department Crowding and the Disposition of Patients With Transient Ischemic Attack or Minor Stroke. Acad Emerg Med 2015; 22:1145-54. [PMID: 26398233 DOI: 10.1111/acem.12766] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 02/13/2015] [Accepted: 05/25/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission. OBJECTIVES The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA. METHODS This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables. RESULTS The study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size. CONCLUSIONS These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.
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Affiliation(s)
- Maxim Ben-Yakov
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Department of Emergency Medicine Sick Kids Hospital; Toronto Ontario Canada
| | - Moira K. Kapral
- Division of General Internal Medicine; University Health Network; Institute for Clinical Evaluative Sciences; Institute for Health Policy, Management and Evaluation; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Canadian Stroke Network; Ottawa Ontario Canada
| | - Jiming Fang
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Shudong Li
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Marian J. Vermeulen
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Clinical Epidemiology Unit; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Michael J. Schull
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Clinical Epidemiology Unit; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
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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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Richards CL, Malouin F, Nadeau S. Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge. PROGRESS IN BRAIN RESEARCH 2015; 218:253-80. [PMID: 25890142 DOI: 10.1016/bs.pbr.2015.01.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This chapter reviews the evolution of stroke rehabilitation in the last 20 years. It begins by describing the different types of stroke that can occur in adults, their potential consequences on a person's capacity to function in daily life and statistics on the number of strokes and their burden on families and the economy. The assessment of stroke severity, recovery of function over time, and the impact of initial stroke severity and age on potential recovery are then addressed as well as the concept of rehabilitation to enhance recovery. Fueled by the synthesis of an ever-increasing research knowledge base and the creation of stroke rehabilitation recommendations for optimal delivery of rehabilitation services and of therapeutic interventions, stroke rehabilitation has changed dramatically. Examples of improvements in stroke rehabilitation in Canada are given with emphasis on the "best practices" inspired stroke rehabilitation continuum recently recommended for the Province of Quebec. The need for an improved community-based rehabilitation approach that includes regular follow-ups and community-based programs promoting reintegration is emphasized. The importance of knowledge translation strategies to promote the uptake of best-practice recommendations is illustrated by describing the activities of the Sensorimotor Rehabilitation Research Team. Over the past 3 years, the researchers of this team and clinicians in three rehabilitation centers, two in Montreal and one in Quebec City, have collaborated to adopt standardized assessment tools, create a common stroke registry, a best-practice recommended approach to interventions and the participation of clinicians in the research process.
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Affiliation(s)
- Carol L Richards
- Faculty of Medicine, Department of Rehabilitation, Université Laval, Quebec City, Quebec, Canada; Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Institut de réadaptation en déficience physique de Québec (IRDPQ), Quebec City, Quebec, Canada; SensoriMotor Rehabilitation Research Team of the Canadian Institute of Health Research, Quebec, Canada.
| | - Francine Malouin
- Faculty of Medicine, Department of Rehabilitation, Université Laval, Quebec City, Quebec, Canada; Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Institut de réadaptation en déficience physique de Québec (IRDPQ), Quebec City, Quebec, Canada; SensoriMotor Rehabilitation Research Team of the Canadian Institute of Health Research, Quebec, Canada
| | - Sylvie Nadeau
- SensoriMotor Rehabilitation Research Team of the Canadian Institute of Health Research, Quebec, Canada; École de réadaptation, Université de Montréal, Montreal, Quebec, Canada; Centre de recherche interdisciplinaire en réadaptation de Montréal métropolitain (CRIR), Institut de réadaptation Gingras-Lindsay-de-Montréal (IRGLM), Montreal, Quebec, Canada
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Checkley W, Ghannem H, Irazola V, Kimaiyo S, Levitt NS, Miranda JJ, Niessen L, Prabhakaran D, Rabadán-Diehl C, Ramirez-Zea M, Rubinstein A, Sigamani A, Smith R, Tandon N, Wu Y, Xavier D, Yan LL. Management of NCD in low- and middle-income countries. Glob Heart 2014; 9:431-43. [PMID: 25592798 PMCID: PMC4299752 DOI: 10.1016/j.gheart.2014.11.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 10/31/2014] [Accepted: 11/14/2014] [Indexed: 12/23/2022] Open
Abstract
Noncommunicable disease (NCD), comprising cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing in incidence rapidly in low- and middle-income countries (LMICs). Some patients have access to the same treatments available in high-income countries, but most do not, and different strategies are needed. Most research on noncommunicable diseases has been conducted in high-income countries, but the need for research in LMICs has been recognized. LMICs can learn from high-income countries, but they need to devise their own systems that emphasize primary care, the use of community health workers, and sometimes the use of mobile technology. The World Health Organization has identified "best buys" it advocates as interventions in LMICs. Non-laboratory-based risk scores can be used to identify those at high risk. Targeting interventions to those at high risk for developing diabetes has been shown to work in LMICs. Indoor cooking with biomass fuels is an important cause of chronic obstructive pulmonary disease in LMICs, and improved cookstoves with chimneys may be effective in the prevention of chronic diseases.
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Program in Global Disease Epidemiology and Control, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hassen Ghannem
- Department of Epidemiology, Chronic Disease Prevention Research Centre, University Hospital Farhat Hached, Sousse, Tunisia
| | - Vilma Irazola
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur (CESCAS), Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Sylvester Kimaiyo
- AMPATH, Moi University School of Medicine, Eldoret, Kenya; Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Naomi S Levitt
- Chronic Disease Initiative for Africa (CDIA), Cape Town, South Africa; Division of Diabetic Medicine and Endocrinology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - J Jaime Miranda
- CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Louis Niessen
- Centre for Control of Chronic Diseases (CCCD), International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India; Centre of Excellence in Cardio-Metabolic Risk Reduction in South Asia, Public Health Foundation of India, New Delhi, India
| | - Cristina Rabadán-Diehl
- Office of Global Health, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Office of Global Affairs, U.S. Department of Health and Human Services, Washington, DC, USA
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Adolfo Rubinstein
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur (CESCAS), Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Alben Sigamani
- St. John's Medical College and Research Institute, Bangalore, India
| | - Richard Smith
- Chronic Disease Initiative, UnitedHealth Group, London, United Kingdom.
| | - Nikhil Tandon
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China; Peking University School of Public Health and Clinical Research Institute, Beijing, China
| | - Denis Xavier
- St. John's Medical College and Research Institute, Bangalore, India
| | - Lijing L Yan
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China; Duke Global Health Institute and Global Heath Research Center, Duke Kunshan University, Kunshan, China
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Goldstein LB. Lipids in High-Risk Patients Presenting With Ischemic Stroke or Transient Ischemic Attack. Stroke 2014; 45:3180-1. [DOI: 10.1161/strokeaha.114.007436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Larry B. Goldstein
- From the Duke Stroke Center, Duke University, and Durham VA Medical Center, Durham, NC
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Tsai JP, Rochon PA, Raptis S, Bronskill SE, Bell CM, Saposnik G. A Prescription at Discharge Improves Long-term Adherence for Secondary Stroke Prevention. J Stroke Cerebrovasc Dis 2014; 23:2308-15. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.04.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 04/13/2014] [Indexed: 10/24/2022] Open
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Bogiatzi C, Hackam DG, McLeod AI, Spence JD. Secular trends in ischemic stroke subtypes and stroke risk factors. Stroke 2014; 45:3208-13. [PMID: 25213343 DOI: 10.1161/strokeaha.114.006536] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Early diagnosis and treatment of a stroke improves patient outcomes, and knowledge of the cause of the initial event is crucial to identification of the appropriate therapy to maximally reduce risk of recurrence. Assumptions based on historical frequency of ischemic subtypes may need revision if stroke subtypes are changing as a result of recent changes in therapy, such as increased use of statins. METHODS We analyzed secular trends in stroke risk factors and ischemic stroke subtypes among patients with transient ischemic attack or minor or moderate stroke referred to an urgent transient ischemic attack clinic from 2002 to 2012. RESULTS There was a significant decline in low-density lipoprotein cholesterol and blood pressure, associated with a significant decline in large artery stroke and small vessel stroke. The proportion of cardioembolic stroke increased from 26% in 2002 to 56% in 2012 (P<0.05 for trend). Trends remained significant after adjusting for population change. CONCLUSIONS With more intensive medical management in the community, a significant decrease in atherosclerotic risk factors was observed, with a significant decline in stroke/transient ischemic attack caused by large artery atherosclerosis and small vessel disease. As a result, cardioembolic stroke/transient ischemic attack has increased significantly. Our findings suggest that more intensive investigation for cardiac sources of embolism and greater use of anticoagulation may be warranted.
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Affiliation(s)
- Chrysi Bogiatzi
- From the Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute (C.B., D.G.H., J.D.S.), Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry (D.G.H.), Department of Medicine, Division of Clinical Pharmacology (D.G.H., J.D.S.), Department of Clinical Neurological Sciences, Division of Neurology (D.G.H., J.D.S.), and Department of Statistical and Actuarial Sciences (A.I.M.), Western University, London, Ontario, Canada
| | - Daniel G Hackam
- From the Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute (C.B., D.G.H., J.D.S.), Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry (D.G.H.), Department of Medicine, Division of Clinical Pharmacology (D.G.H., J.D.S.), Department of Clinical Neurological Sciences, Division of Neurology (D.G.H., J.D.S.), and Department of Statistical and Actuarial Sciences (A.I.M.), Western University, London, Ontario, Canada
| | - A Ian McLeod
- From the Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute (C.B., D.G.H., J.D.S.), Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry (D.G.H.), Department of Medicine, Division of Clinical Pharmacology (D.G.H., J.D.S.), Department of Clinical Neurological Sciences, Division of Neurology (D.G.H., J.D.S.), and Department of Statistical and Actuarial Sciences (A.I.M.), Western University, London, Ontario, Canada
| | - J David Spence
- From the Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute (C.B., D.G.H., J.D.S.), Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry (D.G.H.), Department of Medicine, Division of Clinical Pharmacology (D.G.H., J.D.S.), Department of Clinical Neurological Sciences, Division of Neurology (D.G.H., J.D.S.), and Department of Statistical and Actuarial Sciences (A.I.M.), Western University, London, Ontario, Canada.
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McAlister FA, Majumdar SR, Padwal RS, Fradette M, Thompson A, Buck B, Dean N, Bakal JA, Tsuyuki R, Grover S, Shuaib A. Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial. CMAJ 2014; 186:577-84. [PMID: 24733770 DOI: 10.1503/cmaj.140053] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Optimization of systolic blood pressure and lipid levels are essential for secondary prevention after ischemic stroke, but there are substantial gaps in care, which could be addressed by nurse- or pharmacist-led care. We compared 2 types of case management (active prescribing by pharmacists or nurse-led screening and feedback to primary care physicians) in addition to usual care. METHODS We performed a prospective randomized controlled trial involving adults with recent minor ischemic stroke or transient ischemic attack whose systolic blood pressure or lipid levels were above guideline targets. Participants in both groups had a monthly visit for 6 months with either a nurse or pharmacist. Nurses measured cardiovascular risk factors, counselled patients and faxed results to primary care physicians (active control). Pharmacists did all of the above as well as prescribed according to treatment algorithms (intervention). RESULTS Most of the 279 study participants (mean age 67.6 yr, mean systolic blood pressure 134 mm Hg, mean low-density lipoprotein [LDL] cholesterol 3.23 mmol/L) were already receiving treatment at baseline (antihypertensives: 78.1%; statins: 84.6%), but none met guideline targets (systolic blood pressure ≤ 140 mm Hg, fasting LDL cholesterol ≤ 2.0 mmol/L). Substantial improvements were observed in both groups after 6 months: 43.4% of participants in the pharmacist case manager group met both systolic blood pressure and LDL guideline targets compared with 30.9% in the nurse-led group (12.5% absolute difference; number needed to treat = 8, p = 0.03). INTERPRETATION Compared with nurse-led case management (risk factor evaluation, counselling and feedback to primary care providers), active case management by pharmacists substantially improved risk factor control at 6 months among patients who had experienced a stroke. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT00931788.
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Howard G. Ancel Keys Lecture: Adventures (and misadventures) in understanding (and reducing) disparities in stroke mortality. Stroke 2013; 44:3254-9. [PMID: 24029634 DOI: 10.1161/strokeaha.113.002113] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- George Howard
- From the Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
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Grill JD, Zhou Y, Karlawish J, Elashoff D. Does study partner type impact the rate of Alzheimer's disease progression? J Alzheimers Dis 2013; 38:507-14. [PMID: 23985417 DOI: 10.3233/jad-131052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Most patients with Alzheimer's disease (AD) do not have a spouse. Despite this, the majority of AD research participants enroll with a spouse study partner. It remains unclear if differences between AD patients who do and do not have a spouse may bias study results. In this study, we examined whether AD patients with different study partner types (spouse versus adult child) demonstrate different rates of disease progression over two years on three outcome measures commonly used in AD research, including clinical trials. We used data from the National Alzheimer's Coordinating Center Uniform Data Set to examine disease progression in participants age 55-90 with probable AD dementia. We examined disease progression as measured by the Clinical Dementia Rating Scale-Sum of the Boxes score, the Mini Mental Status Examination, and the Functional Assessment Questionnaire. Analyses were performed on data for all available eligible participants from the NACC UDS and after performing a propensity-matching model to better account for inherent differences between the populations of interest. Propensity matching was successful only when models did not include age and gender. For both propensity-matched analyses and those of all available data, we did not observe any differences between the study partner populations for any outcome measure. These results suggest that if investigators can improve in recruiting AD patients with adult child caregivers to research, the implications to study results may be minimal.
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Affiliation(s)
- Joshua D Grill
- Mary S. Easton Center for Alzheimer's Disease Research, Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Fisher A, Martin J, Srikusalanukul W, Davis M. Trends in stroke survival incidence rates in older Australians in the new millennium and forecasts into the future. J Stroke Cerebrovasc Dis 2013; 23:759-70. [PMID: 23928347 DOI: 10.1016/j.jstrokecerebrovasdis.2013.06.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 06/04/2013] [Accepted: 06/29/2013] [Indexed: 10/26/2022] Open
Abstract
AIMS The objective of this study is (i) to evaluate trends in the incidence rates of stroke survivors aged 60 years and older over a 11-year period in the Australian Capital Territory (ACT) and (ii) to forecast future trends in Australia until 2051. METHODS Analysis of age- and sex-specific standardized incidence rates of older first-ever stroke survivors in ACT from 1999-2000 to 2009-2010 and projections of number of stroke survivors (NSS) in 2021 and 2051 using 2 models based only on (i) demographic changes and (ii) assuming changing of both incidence rates and demography. RESULTS In the ACT in the first decade of the 21st century, the absolute numbers and age-adjusted standardized incidence rates of stroke survivors (measured as a function of age and period) increased among both men and women aged 60 years or older. The trend toward increased survival rates in both sexes was driven mainly by population aging, whereas the effect of stroke year was more pronounced in men compared with women. The absolute NSS (and the financial burden to the society) in Australia is predicted to increase by 35.5%-59.3% in 2021 compared with 2011 and by 1.6- to 4.6-fold in 2051 if current only demographic (first number) or both demographic and incidence trends (second number) continue. CONCLUSIONS Our study demonstrates favorable trends in stroke survivor rates in Australia in the first decade of the new millennium and projects in the foreseeable future significant increases in the absolute numbers of older stroke survivors, especially among those aged 70 years or older and men.
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Affiliation(s)
- Alexander Fisher
- Department of Geriatric Medicine, The Canberra Hospital, Canberra, Australia; Australian National University Medical School, Canberra, Australia.
| | - Jodie Martin
- Australian National University Medical School, Canberra, Australia
| | | | - Michael Davis
- Department of Geriatric Medicine, The Canberra Hospital, Canberra, Australia; Australian National University Medical School, Canberra, Australia
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Abstract
Background and Purpose—
Socioeconomic status is inversely associated with mortality after stroke; however, the reasons behind this finding are not well-understood. We undertook a study to determine whether posthospitalization care and medication adherence vary with neighborhood income.
Methods—
We conducted a cohort study of 11 050 patients with ischemic stroke or transient ischemic attack admitted to any of 11 specialized stroke centers in Ontario, Canada, between July 1, 2003 and March 31, 2008. Socioeconomic status measured as neighborhood income quintiles was imputed from the 2006 Canadian Census. We used linkages to administrative databases to evaluate processes of stroke care and medication adherence within 1 year of discharge. We used multivariable analyses to assess whether differences in stroke care and medication adherence existed across income groups after adjustment for age, sex, stroke severity, and comorbid conditions.
Results—
Higher income was associated with higher rates of stroke unit admission, neurology consultations, referrals to secondary prevention clinics, and physician visits after hospital discharge; however, the absolute differences in rates were small. There was no difference across income quintiles in the use of postdischarge homecare services or in adherence to antihypertensive, antithrombotic, or lipid-lowering medications.
Conclusions—
Higher income is associated with improvements in some aspects of stroke care delivery. However, the magnitude of the care gap across income quintiles is small and is unlikely to account for the previously observed association between socioeconomic status and survival after stroke.
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Affiliation(s)
- Kun Huang
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Nadia Khan
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Allison Kwan
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Jiming Fang
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Lingsong Yun
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Moira K. Kapral
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
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Booth GL, Bishara P, Lipscombe LL, Shah BR, Feig DS, Bhattacharyya O, Bierman AS. Universal drug coverage and socioeconomic disparities in major diabetes outcomes. Diabetes Care 2012; 35:2257-64. [PMID: 22891257 PMCID: PMC3476904 DOI: 10.2337/dc12-0364] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/28/2012] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Due in large part to effective pharmacotherapy, mortality rates have fallen substantially among those with diabetes; however, trends have been less favorable among those of lower socioeconomic status (SES), leading to a widening gap in mortality between rich and poor. We examined whether income disparities in diabetes-related morbidity or mortality decline after age 65 in a setting where much of health care is publicly funded yet universal drug coverage starts only at age 65. RESEARCH DESIGN AND METHODS We conducted a population-based retrospective cohort study using administrative health claims from Ontario, Canada. Adults with diabetes (N = 606,051) were followed from 1 April 2002 to 31 March 2008 for a composite outcome of death, nonfatal acute myocardial infarction (AMI), and nonfatal stroke. SES was based on neighborhood median household income levels from the 2001 Canadian Census. RESULTS SES was a strong predictor of death, nonfatal AMI, or nonfatal stroke among those <65 years of age (adjusted hazard ratio [HR] 1.51 [95% CI 1.45-1.56]) and exerted a lesser effect among those ≥65 years of age (1.12 [1.09-1.14]; P < 0.0001 for interaction), after adjusting for age, sex, baseline cardiovascular disease (CVD), diabetes duration, comorbidity, and health care utilization. SES gradients were consistent for all groups <65 years of age. Similar findings were noted for 1-year post-AMI mortality (<65 years of age, 1.33 [1.09-1.63]; ≥65 years of age, 1.09 [1.01-1.18]). CONCLUSIONS Observed SES differences in CVD burden diminish substantially after age 65 in our population with diabetes, which may be related to universal access to prescription drugs among seniors.
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Affiliation(s)
- Gillian L Booth
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
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