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Reeves MJ, Fonarow GC, Smith EE, Sheth KN, Messe SR, Schwamm LH. Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges. Stroke 2024; 55:1689-1698. [PMID: 38738376 PMCID: PMC11208062 DOI: 10.1161/strokeaha.124.046527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.
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Affiliation(s)
- Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine, University of California Los Angeles (G.C.F.)
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Kevin N. Sheth
- Center for Brain & Mind Health, Departments of Neurology & Neurosurgery (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Steven R. Messe
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (S.R.M.)
| | - Lee H. Schwamm
- Department of Neurology and Bioinformatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
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2
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Li Y, Ou Q, Lu Y, Shen Z, Li J, Zhang Z, Tai L, Li G, Chen H, Zhang G, Zhang L, Sun X, Qiu J, Wei Y, Zhu S, Wang Z, Sun W, Huang Y. Geographic differences in pharmacotherapy patterns and outcomes of acute ischemic stroke in China. BMC Neurol 2024; 24:64. [PMID: 38360588 PMCID: PMC10868026 DOI: 10.1186/s12883-024-03564-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/06/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Vast economic and healthcare status discrepancies exist among regions in China, contributing to different treatment patterns. This study was aimed to investigate the current status of pharmacotherapy for acute ischemic stroke (AIS) and outcomes in China and explore the geographic variation in stroke care. METHODS This study was a multicenter prospective registry study, which collected the data of patients with AIS from 80 hospitals in 46 cities in 2015-2017 across China. Poor functional outcome defined as a modified Rankin Scale score of 3-6 was assessed at 3 and 12 months. Multivariate logistic regression was used. RESULTS Among 9973 eligible patients, the number of receiving intravenous thrombolysis (IVT), antiplatelet agents, anticoagulants, statin and human urinary kallidinogenase was 429 (4.3%), 9363 (93.9%), 1063 (10.7%), 6828 (74.7%) and 5112 (51.2%), respectively. Multivariable analysis showed IVT use in northeastern was significantly more frequent than in eastern region (OR = 3.17, 95% CI, 2.53-3.99), while the antiplatelets agents use were less frequent (OR = 0.46, 95%CI: 0.38-0.57). The proportions of poor outcomes at 3 and 12 months were 20.7% and 15.8%, respectively. Multivariate analysis showed AIS patients from northeastern and central region had significantly lower risk of poor outcome at month 3 and 12 than those from eastern region (all P < 0.05). CONCLUSIONS There was a low IVT use and a high antiplatelet agent and statin use for AIS in China. The pharmacotherapy and prognosis of AIS had variation by geographic region. TRIAL REGISTRATION This study was registered with ClinicalTrials.gov (NCT02470624).
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Affiliation(s)
- Ying Li
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Qianhua Ou
- Department of medical affairs, Techpool Bio-Pharma Co., LTD, Guangzhou, China
| | - Yuxuan Lu
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Zhiyuan Shen
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Jieyu Li
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Zhuangzhuang Zhang
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Liwen Tai
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guozhong Li
- Department of Neurology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Shenyang Military Command, Shenyang, China
| | - Guiru Zhang
- Department of Neurology, Penglai People's Hospital, Penglai, China
| | - Lei Zhang
- Department of Neurology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xuwen Sun
- Department of Neurology, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Jinhua Qiu
- Department of Neurology, Huizhou First Hospital, Huizhou, China
| | - Yan Wei
- Department of Neurology, Harrison International Peace Hospital, Hengshui, China
| | - Sainan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Weiping Sun
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China.
| | - Yining Huang
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China.
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Janssen PM, van Overhagen K, Vinklárek J, Roozenbeek B, van der Worp HB, Majoie CB, Bar M, Černík D, Herzig R, Jurák L, Ostrý S, Mikulik R, Lingsma HF, Dippel DW. Between-Center Variation in Outcome After Endovascular Treatment of Acute Stroke: Analysis of Two Nationwide Registries. Circ Cardiovasc Qual Outcomes 2022; 15:e008180. [PMID: 35094522 PMCID: PMC8920023 DOI: 10.1161/circoutcomes.121.008180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 12/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Insight in differences in patient outcomes between endovascular thrombectomy (EVT) centers can help to improve stroke care. We assessed between-center variation in functional outcome of patients with acute ischemic stroke who were treated with EVT. We analyzed to what extent this variation may be explained by modifiable center characteristics. METHODS We used nationwide registry data of patients with stroke treated with EVT in the Netherlands and in the Czech Republic. Primary outcome was modified Rankin Scale score at 90 days as an indicator of disability. We used multilevel ordinal logistic regression to quantify the between-center variation in outcomes and the impact of patient and center characteristics. Between-center variation was expressed as the relative difference in odds of a more favorable modified Rankin Scale score between a relatively better performing center (75th percentile) and a relatively worse performing center (25th percentile). RESULTS We included a total of 4518 patients treated in 33 centers. Adjusted for patient characteristics, the odds of a more favorable outcome in a center at the 75th percentile of the outcome distribution were 1.46 times higher (95% CI, 1.31-1.70) than the odds in a center at the 25th percentile. Adjustment for center characteristics, including the median time between stroke onset and reperfusion per center, decreased this relative difference in odds to 1.30 (95% CI, 1.18-1.50, P=0.01). This translates into an absolute difference in likelihood of good functional outcome of 8% after adjustment for patient characteristics and to 5% after further adjustment for modifiable center characteristics. CONCLUSIONS The considerable between-center variation in patient outcomes after EVT for acute ischemic stroke could be largely explained by center-specific characteristics, such as time to reperfusion. Improvement of these parameters may likely result in a decrease in center-specific differences, and an overall improvement in outcome of patients with acute ischemic stroke.
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Affiliation(s)
- Paula M. Janssen
- Department of Neurology (P.M.J, K.v.O., B.R., D.W.J.D.), Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Katrine van Overhagen
- Department of Neurology (P.M.J, K.v.O., B.R., D.W.J.D.), Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Jan Vinklárek
- International Clinical Research Center, Department of Neurology, St Anne’s University Hospital, Brno, Czech Republic (J.V., R.M.)
- Faculty of Medicine at Masaryk University, Brno, Czech Republic (J.V., R.M.)
| | - Bob Roozenbeek
- Department of Neurology (P.M.J, K.v.O., B.R., D.W.J.D.), Erasmus MC University Medical Center Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (B.R.), Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - H. Bart van der Worp
- Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, the Netherlands (H.B.v.d.W.)
| | - Charles B. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, the Netherlands (C.B.M.)
| | - Michal Bar
- Department of Neurology, University Hospital Ostrava, Czech Republic (M.B.)
- Faculty of Medicine at University Ostrava, Czech Republic (M.B.)
| | - David Černík
- Masaryk Hospital Ústí nad Labem - KZ a.s., Comprehensive Stroke Center, Department of Neurology, Ústí nad Labem, Czech Republic (D.C.)
| | - Roman Herzig
- Comprehensive Stroke Center, University Hospital Hradec Králové, Czech Republic (R.H.)
- Charles University Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic (R.H.)
| | - Lubomir Jurák
- Regional Hospital Liberec, Neurocenter, Liberec, Czech Republic (L.J.)
| | - Svatopluk Ostrý
- Comprehensive Stroke Center, Department of Neurology, Hospital České Budějovice, a.s., České Budějovice, Czech Republic (S.O.)
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague (S.O.)
| | - Robert Mikulik
- International Clinical Research Center, Department of Neurology, St Anne’s University Hospital, Brno, Czech Republic (J.V., R.M.)
- Faculty of Medicine at Masaryk University, Brno, Czech Republic (J.V., R.M.)
| | - Hester F. Lingsma
- Department of Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Diederik W.J. Dippel
- Department of Neurology (P.M.J, K.v.O., B.R., D.W.J.D.), Erasmus MC University Medical Center Rotterdam, the Netherlands
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4
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Bosch PR, Karmarkar AM, Roy I, Fehnel CR, Burke RE, Kumar A. Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity. JAMA Netw Open 2022; 5:e224596. [PMID: 35357456 PMCID: PMC8972034 DOI: 10.1001/jamanetworkopen.2022.4596] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/03/2022] [Indexed: 12/13/2022] Open
Abstract
Importance Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. Objective To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. Design, Setting, and Participants This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. Exposures Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. Main Outcomes and Measures Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. Results Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. Conclusions and Relevance In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.
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Affiliation(s)
- Pamela R. Bosch
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
| | - Amol M. Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond
- Sheltering Arms Institute, Richmond, Virginia
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff
| | - Corey R. Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Marcus Institute for Aging Research, Boston, Massachusetts
| | - Robert E. Burke
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amit Kumar
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
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5
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Therapeutic Nanoparticles for the Different Phases of Ischemic Stroke. Life (Basel) 2021; 11:life11060482. [PMID: 34073229 PMCID: PMC8227304 DOI: 10.3390/life11060482] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 12/27/2022] Open
Abstract
Stroke represents the second leading cause of mortality and morbidity worldwide. Ischemic strokes are the most prevalent type of stroke, and they are characterized by a series of pathological events prompted by an arterial occlusion that leads to a heterogeneous pathophysiological response through different hemodynamic phases, namely the hyperacute, acute, subacute, and chronic phases. Stroke treatment is highly reliant on recanalization therapies, which are limited to only a subset of patients due to their narrow therapeutic window; hence, there is a huge need for new stroke treatments. Nonetheless, the vast majority of promising treatments are not effective in the clinical setting due to their inability to cross the blood-brain barrier and reach the brain. In this context, nanotechnology-based approaches such as nanoparticle drug delivery emerge as the most promising option. In this review, we will discuss the current status of nanotechnology in the setting of stroke, focusing on the diverse available nanoparticle approaches targeted to the different pathological and physiological repair mechanisms involved in each of the stroke phases.
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6
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Feng YW, Wu C, Liang FY, Lin T, Li WQ, Jing YH, Dai P, Yu HX, Lan Y, Pei Z, Xu GQ. hUCMSCs Mitigate LPS-Induced Trained Immunity in Ischemic Stroke. Front Immunol 2020; 11:1746. [PMID: 33013828 PMCID: PMC7516337 DOI: 10.3389/fimmu.2020.01746] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/30/2020] [Indexed: 12/11/2022] Open
Abstract
Innate immune memory is a part of the innate immune system that facilitates the elimination of pathogens. However, it may exacerbate neuropathology. In this study, we found that innate immune memory is detrimental in stroke, because it promotes the acute immune response and exacerbates ischemic infarcts. Mesenchymal stem cell therapy has been widely studied for its therapeutic potential in various diseases including stroke, but whether it diminishes innate immune memory has not been studied. Here, our study demonstrates that, after the activation of innate immune memory by lipopolysaccharide, mesenchymal stem cell therapy can diminish innate immune memory though down-regulation of H3 methylation and subsequently protect against stroke. Our results demonstrate that innate immune memory is detrimental in stroke, and we describe a novel potential therapeutic target involving the use of mesenchymal stem cells to treat stroke patients.
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Affiliation(s)
- Yi-Wei Feng
- Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Cheng Wu
- Department of Rehabilitation Medicine, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China
| | - Feng-Yin Liang
- Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tuo Lin
- Department of Rehabilitation Medicine, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China.,Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou, China
| | - Wan-Qi Li
- Department of Rehabilitation Medicine, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China.,Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou, China
| | - Ying-Hua Jing
- Department of Rehabilitation Medicine, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China
| | - Pei Dai
- Department of Rehabilitation Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hui-Xian Yu
- Department of Rehabilitation Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yue Lan
- Department of Rehabilitation Medicine, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China.,Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou, China
| | - Zhong Pei
- Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guang-Qing Xu
- Department of Rehabilitation Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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7
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Kamdar HA, Senay B, Mainali S, Lee V, Gulati DK, Greene-Chandos D, Hinduja A, Strohm T. Clinician's Perception of Practice Changes for Stroke During the COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2020; 29:105179. [PMID: 32912564 PMCID: PMC7375301 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/15/2020] [Accepted: 07/18/2020] [Indexed: 01/07/2023] Open
Abstract
Background Approach to acute cerebrovascular disease management has evolved in the past few months to accommodate the rising needs of the 2019 novel coronavirus (COVID-19) pandemic. In this study, we investigated the changes in practices and policies related to stroke care through an online survey. Methods A 12 question, cross-sectional survey targeting practitioners involved in acute stroke care in the US was distributed electronically through national society surveys, social media and personal communication. Results Respondants from 39 states completed 206 surveys with the majority (82.5%) from comprehensive stroke centers. Approximately half stated some change in transport practices with 14 (7%) reporting significant reduction in transfers. Common strategies to limit healthcare provider exposure included using personal protective equipment (PPE) for all patients (127; 63.5%) as well as limiting the number of practitioners in the room (129; 64.5%). Most respondents (81%) noted an overall decrease in stroke volume. Many (34%) felt that the outcome or care of acute stroke patients had been impacted by COVID-19. This was associated with a change in hospital transport guidelines (OR 1.325, P = 0.047, 95% CI: 1.004–1.748), change in eligibility criteria for IV-tPA or mechanical thrombectomy (MT) (OR 3.146, P = 0.052, 95% CI: 0.988–10.017), and modified admission practices for post IV-tPA or MT patients (OR 2.141, P = 0.023, 95% CI: 1.110–4.132). Conclusion Our study highlights a change in practices and polices related to acute stroke management in response to COVID-19 which are variable among institutions. There is also a reported reduction in stroke volume across hospitals. Amongst these changes, updates in hospital transport guidelines and practices related to IV-tPA and MT may affect the perceived care and outcome of acute stroke patients.
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Affiliation(s)
- Hera A Kamdar
- Department of Neurology, The Ohio State University, Columbus, Ohio USA
| | - Blake Senay
- Department of Neurology, The Ohio State University, Columbus, Ohio USA
| | - Shraddha Mainali
- Department of Neurology, The Ohio State University, Columbus, Ohio USA
| | - Vivien Lee
- Department of Neurology, The Ohio State University, Columbus, Ohio USA
| | | | | | - Archana Hinduja
- Department of Neurology, The Ohio State University, Columbus, Ohio USA
| | - Tamara Strohm
- Department of Neurology, The Ohio State University, Columbus, Ohio USA.
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8
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Arling G, Sico JJ, Reeves MJ, Myers L, Baye F, Bravata DM. Modelling care quality for patients after a transient ischaemic attack within the US Veterans Health Administration. BMJ Open Qual 2019; 8:e000641. [PMID: 31909209 PMCID: PMC6937041 DOI: 10.1136/bmjoq-2019-000641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 10/22/2019] [Accepted: 11/23/2019] [Indexed: 12/25/2022] Open
Abstract
Objective Timely preventive care can substantially reduce risk of recurrent vascular events or death after a transient ischaemic attack (TIA). Our objective was to understand patient and facility factors influencing preventive care quality for patients with TIA in the US Veterans Health Administration (VHA). Methods We analysed administrative data from a retrospective cohort of 3052 patients with TIA cared for in the emergency department (ED) or inpatient setting in 110 VHA facilities from October 2010 to September 2011. A composite quality indicator (QI score) pass rate was constructed from four process-related quality measures—carotid imaging, brain imaging, high or moderate potency statin and antithrombotic medication, associated with the ED visit or inpatient admission after the TIA. We tested a multilevel structural equation model where facility and patient characteristics, inpatient admission, and neurological consultation were predictors of the resident’s composite QI score. Results Presenting with a speech deficit and higher Charlson Comorbidity Index (CCI) were positively related to inpatient admission. Being admitted increased the likelihood of neurology consultation, whereas history of dementia, weekend arrival and a higher CCI score made neurological consultation less likely. Speech deficit, higher CCI, inpatient admission and neurological consultation had direct positive effects on the composite quality score. Patients in facilities with fewer full-time equivalent neurology staff were less likely to be admitted or to have a neurology consultation. Facilities having greater organisational complexity and with a VHA stroke centre designation were more likely to provide a neurology consultation. Conclusions Better TIA preventive care could be achieved through increased inpatient admissions, or through enhanced neurology and other care resources in the ED and during follow-up care.
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Affiliation(s)
- Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana, USA.,Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Jason J Sico
- Department of Internal Medicine and Neurology, Yale School of Medicine, New Haven, Connecticut, USA.,Clinical Epidemiology Research Center, VA Connecticut Health System West Haven Campus, West Haven, Connecticut, USA
| | - Mathew J Reeves
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Epidemiology, Michigan State University, East Lansing, Michigan, USA
| | - Laura Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Center for Health Information and Communication (CHIC), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana, USA
| | - Fitsum Baye
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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9
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Feng YW, Huang YQ, Yan Y, Li G, He XF, Liang FY, Pei Z, Lan Y, Xu GQ. Phasic GABA signaling mediates the protective effects of cTBS against cerebral ischemia in mice. Neurosci Lett 2019; 715:134611. [PMID: 31698026 DOI: 10.1016/j.neulet.2019.134611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 09/25/2019] [Accepted: 11/03/2019] [Indexed: 01/26/2023]
Abstract
Continuous theta burst stimulation (cTBS) has been widely recognized as a therapeutic treatment for ischemic stroke, but the underlying mechanism is still elusive. Here, we investigated the protective effects of cTBS in the posterior parietal cortex during the chronic phase of stroke in the photothrombotic ischemic model. Infarction volume and neuron excitability in the peri-infarct area were assessed using immunohistochemistry and whole-cell patch-clamp. Spatial cognitive function was measured using the Morris water maze. Gamma-Amino butyric acid (GABA) interneurons were responsive to cTBS, and cTBS induced elevated phasic inhibition rather than tonic inhibition. Given that GABA-A-mediated phasic inhibition was elevated during the chronic phase of ischemic stroke for 30 days and was beneficial for stroke recovery, we investigated the therapeutic potential of cTBS in promoting functional recovery and found that the elevated phasic inhibition by cTBS improved spatial cognitive function in the photothrombotic stroke mouse model with induction in the posterior parietal cortex. Our study indicates the mechanism by which cTBS may modify the excitability of the brain cortex and provides novel insight into the potential of cTBS to protect against neuronal dysfunction in ischemic stroke.
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Affiliation(s)
- Yi-Wei Feng
- Department of Rehabilitation Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi-Qing Huang
- Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Department of Rehabilitation Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Yan
- Research Center of Basic Medical Sciences, School of Basic Medical Sciences, Hubei University of Science and Technology, 88 Xianning Road, Xianning, 437100, Hubei, China
| | - Ge Li
- Guangdong Provincial Key Laboratory of Laboratory Animals, Guangdong Laboratory Animals Monitoring Institute, Guangzhou, China
| | - Xiao-Fei He
- Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Feng-Yin Liang
- Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhong Pei
- Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yue Lan
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou, China; Department of Rehabilitation Medicine, The Second Affiliated Hospital of South China University of Technology, Guangzhou, China.
| | - Guang-Qing Xu
- Department of Rehabilitation Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
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10
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Shen YC, Chen G, Hsia RY. Community and Hospital Factors Associated With Stroke Center Certification in the United States, 2009 to 2017. JAMA Netw Open 2019; 2:e197855. [PMID: 31348507 PMCID: PMC6661722 DOI: 10.1001/jamanetworkopen.2019.7855] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The increased number of stroke centers in the United States may not be equitably distributed across all populations. Anecdotal reports suggest there may be differential proliferation in wealthier and urban communities. OBJECTIVE To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non-stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. MAIN OUTCOMES AND MEASURES Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. RESULTS The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). CONCLUSIONS AND RELEVANCE This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco
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11
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Thompson MP, Zhao X, Bekelis K, Gottlieb DJ, Fonarow GC, Schulte PJ, Xian Y, Lytle BL, Schwamm LH, Smith EE, Reeves MJ. Regional Variation in 30-Day Ischemic Stroke Outcomes for Medicare Beneficiaries Treated in Get With The Guidelines-Stroke Hospitals. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.003604. [PMID: 28798017 DOI: 10.1161/circoutcomes.117.003604] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 07/06/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND We explored regional variation in 30-day ischemic stroke mortality and readmission rates and the extent to which regional differences in patients, hospitals, healthcare resources, and a quality of care composite care measure explain the observed variation. METHODS AND RESULTS This ecological analysis aggregated patient and hospital characteristics from the Get With The Guidelines-Stroke registry (2007-2011), healthcare resource data from the Dartmouth Atlas of Health Care (2006), and Medicare fee-for-service data on 30-day mortality and readmissions (2007-2011) to the hospital referral region (HRR) level. We used linear regression to estimate adjusted HRR-level 30-day outcomes, to identify HRR-level characteristics associated with 30-day outcomes, and to describe which characteristics explained variation in 30-day outcomes. The mean adjusted HRR-level 30-day mortality and readmission rates were 10.3% (SD=1.1%) and 13.1% (SD=1.1%), respectively; a modest, negative correlation (r=-0.17; P=0.003) was found between one another. Demographics explained more variation in readmissions than mortality (25% versus 6%), but after accounting for demographics, comorbidities accounted for more variation in mortality compared with readmission rates (17% versus 7%). The combination of hospital characteristics and healthcare resources explained 11% and 16% of the variance in mortality and readmission rates, beyond patient characteristics. Most of the regional variation in mortality (65%) and readmission (50%) rates remained unexplained. CONCLUSIONS Thirty-day mortality and readmission rates vary substantially across HRRs and exhibit an inverse relationship. While regional variation in 30-day outcomes were explained by patient and hospital factors differently, much of the regional variation in both outcomes remains unexplained.
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Affiliation(s)
- Michael P Thompson
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.).
| | - Xin Zhao
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Kimon Bekelis
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Daniel J Gottlieb
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Gregg C Fonarow
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Phillip J Schulte
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Ying Xian
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Barbara L Lytle
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Lee H Schwamm
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Eric E Smith
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Mathew J Reeves
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
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12
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Bassand JP, Accetta G, Al Mahmeed W, Corbalan R, Eikelboom J, Fitzmaurice DA, Fox KAA, Gao H, Goldhaber SZ, Goto S, Haas S, Kayani G, Pieper K, Turpie AGG, van Eickels M, Verheugt FWA, Kakkar AK. Risk factors for death, stroke, and bleeding in 28,628 patients from the GARFIELD-AF registry: Rationale for comprehensive management of atrial fibrillation. PLoS One 2018; 13:e0191592. [PMID: 29370229 PMCID: PMC5784935 DOI: 10.1371/journal.pone.0191592] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/08/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The factors influencing three major outcomes-death, stroke/systemic embolism (SE), and major bleeding-have not been investigated in a large international cohort of unselected patients with newly diagnosed atrial fibrillation (AF). METHODS AND RESULTS In 28,628 patients prospectively enrolled in the GARFIELD-AF registry with 2-year follow-up, we aimed at analysing: (1) the variables influencing outcomes; (2) the extent of implementation of guideline-recommended therapies in comorbidities that strongly affect outcomes. Median (IQR) age was 71.0 (63.0 to 78.0) years, 44.4% of patients were female, median (IQR) CHA2DS2-VASc score was 3.0 (2.0 to 4.0); 63.3% of patients were on anticoagulants (ACs) with or without antiplatelet (AP) therapy, 24.5% AP monotherapy, and 12.2% no antithrombotic therapy. At 2 years, rates (95% CI) of death, stroke/SE, and major bleeding were 3.84 (3.68; 4.02), 1.27 (1.18; 1.38), and 0.71 (0.64; 0.79) per 100 person-years. Age, history of stroke/SE, vascular disease (VascD), and chronic kidney disease (CKD) were associated with the risks of all three outcomes. Congestive heart failure (CHF) was associated with the risks of death and stroke/SE. Smoking, non-paroxysmal forms of AF, and history of bleeding were associated with the risk of death, female sex and heavy drinking with the risk of stroke/SE. Asian race was associated with lower risks of death and major bleeding versus other races. AC treatment was associated with 30% and 28% lower risks of death and stroke/SE, respectively, compared with no AC treatment. Rates of prescription of guideline-recommended drugs were suboptimal in patients with CHF, VascD, or CKD. CONCLUSIONS Our data show that several variables are associated with the risk of one or more outcomes, in terms of death, stroke/SE, and major bleeding. Comprehensive management of AF should encompass, besides anticoagulation, improved implementation of guideline-recommended therapies for comorbidities strongly associated with outcomes, namely CHF, VascD, and CKD. TRIAL REGISTRATION ClinicalTrials.gov NCT01090362.
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Affiliation(s)
- Jean-Pierre Bassand
- Department of Cardiology–EA 3920, University of Besançon, Besançon, France
- Thrombosis Research Institute, London, United Kingdom
- * E-mail:
| | | | - Wael Al Mahmeed
- Cardiology, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Ramon Corbalan
- Department of Cardiology, Catholic University School of Medicine, Santiago, Chile
| | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Keith A. A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Haiyan Gao
- Thrombosis Research Institute, London, United Kingdom
| | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Karen Pieper
- Thrombosis Research Institute, London, United Kingdom
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | | | | | - Freek W. A. Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Ajay K. Kakkar
- Thrombosis Research Institute, London, United Kingdom
- University College London, London, United Kingdom
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13
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Alves MB, Silva GS, Miranda RCA, Massaud RM, Vaccari AMH, Cendoroglo-Neto M, Diccini S. Patterns of Care and Temporal Trends in Ischemic Stroke Management: A Brazilian Perspective. J Stroke Cerebrovasc Dis 2017. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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14
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Utilization of long-term care after decompressive hemicraniectomy for severe stroke among older patients. Aging Clin Exp Res 2017; 29:631-638. [PMID: 27495258 DOI: 10.1007/s40520-016-0615-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND While clinical trial data support decompressive hemicraniectomy (DHC) as improving survival among patients with severe ischemic stroke, quality of life outcomes among older persons remain controversial. AIMS To aid decision-making and understand practice variation, we measured long-term outcomes and patterns of regional variation for a nationwide cohort of ischemic stroke patients after DHC. METHODS Medicare fee-for-service ischemic stroke cases over age 65 during the year 2008 were used to create a cohort followed for 2 years (2009-2010) after stroke and DHC procedure. Rates of mortality, acute hospital readmission, and long-term care (LTC) utilization were calculated. Multiple logistic regression was used to identify individual predictors of institutional LTC. Regional variation in DHC was calculated through aggregation and merging with the state-level data. RESULTS Among 397,503 acute ischemic stroke patients, 130 (0.03 %) underwent DHC. Mean age was 72 years, and 75 % were between the ages of 65 and 74. Mortality was highest (38 %) within the first 30 days. At 2 years, 59 % of the original cohort had died. The 30-day rate of acute hospital readmission was 25 %. Among survivors, 75 % returned home 1 year after index stroke admission. States with higher per capita health expenditures were associated with wider variation in utilization of DHC. CONCLUSIONS There is a high rate of mortality among older stroke patients undergoing DHC. Although most survivors of DHC are not permanently institutionalized, there is wide variation in utilization of DHC across the USA.
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Learoyd AE, Woodhouse L, Shaw L, Sprigg N, Bereczki D, Berge E, Caso V, Christensen H, Collins R, Czlonkowska A, El Etribi A, Farr TD, Gommans J, Laska AC, Ntaios G, Ozturk S, Pocock SJ, Prasad K, Wardlaw JM, Fone KC, Bath PM, Trueman RC. Infections Up to 76 Days After Stroke Increase Disability and Death. Transl Stroke Res 2017; 8:541-548. [PMID: 28752410 DOI: 10.1007/s12975-017-0553-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/02/2017] [Accepted: 07/03/2017] [Indexed: 01/23/2023]
Abstract
Early infection after stroke is associated with a poor outcome. We aimed to determine whether delayed infections (up to 76 days post-stroke) are associated with poor outcome at 90 days. Data came from the international Efficacy of Nitric Oxide Stroke (ENOS, ISRCTN99414122) trial. Post hoc data on infections were obtained from serious adverse events reports between 1 and 76 days following stroke in this large cohort of patients. Regression models accounting for baseline covariates were used to analyse fatalities and functional outcomes (modified Rankin Scale (mRS), Barthel Index, Euro-Qol-5D) at 90 days, in patients with infection compared to those without infection. Of 4011 patients, 242 (6.0%) developed one or more serious infections. Infections were associated with an increased risk of death (p < 0.001) and an increased likelihood of dependency (measured by mRS) compared to those of all other patients (p < 0.001). This remained when only surviving patients were analysed, indicating that the worsening of functional outcome is not due to mortality (p < 0.001). In addition, the timing of the infection after stroke did not alter its detrimental association with fatality (p = 0.14) or functional outcome (p = 0.47). In conclusion, severe post-stroke infections, whether occurring early or late after stroke, are associated with an increased risk of death and poorer functional outcome, independent of differences in baseline characteristics or treatment. Not only are strategies needed for reducing the risk of infection immediately after stroke, but also during the first 3 months following a stroke. This study is registered: ISRCTN registry, number ISRCTN99414122, ClinicalTrials.gov Identifier, NCT00989716.
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Affiliation(s)
| | - Lisa Woodhouse
- Stroke Trials Unit Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Laurence Shaw
- School of Mathematical Sciences, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Valeria Caso
- Stroke Unit, Santa Maria Hospital, University of Perugia, Perugia, Italy
| | | | - Ronan Collins
- Stroke Service, Adelaide and Meath Hospital, Tallaght, Ireland
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Anwar El Etribi
- Ainshams University, 7 Ahram Street, Heliopolis, Cairo, Egypt
| | - Tracy D Farr
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - John Gommans
- Department of Medicine, Hawke's Bay Hospital, Hastings, New Zealand
| | - Ann-Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Serefnur Ozturk
- Department of Neurology, Selcuk University Medical Faculty, Konya, Turkey
| | - Stuart J Pocock
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Joanna M Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, Western General Hospital, Edinburgh, UK
| | - Kevin C Fone
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
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16
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Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017; 2:94-105. [PMID: 28959497 PMCID: PMC5600018 DOI: 10.1136/svn-2017-000092] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/06/2023] Open
Abstract
The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.
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Affiliation(s)
- Cora H Ormseth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Abstract
Recent advancements in stem cell biology and neuromodulation have ushered in a battery of new neurorestorative therapies for ischemic stroke. While the understanding of stroke pathophysiology has matured, the ability to restore patients' quality of life remains inadequate. New therapeutic approaches, including cell transplantation and neurostimulation, focus on reestablishing the circuits disrupted by ischemia through multidimensional mechanisms to improve neuroplasticity and remodeling. The authors provide a broad overview of stroke pathophysiology and existing therapies to highlight the scientific and clinical implications of neurorestorative therapies for stroke.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Hiu T, Farzampour Z, Paz JT, Wang EHJ, Badgely C, Olson A, Micheva KD, Wang G, Lemmens R, Tran KV, Nishiyama Y, Liang X, Hamilton SA, O'Rourke N, Smith SJ, Huguenard JR, Bliss TM, Steinberg GK. Enhanced phasic GABA inhibition during the repair phase of stroke: a novel therapeutic target. Brain 2015; 139:468-80. [PMID: 26685158 PMCID: PMC4805083 DOI: 10.1093/brain/awv360] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 10/20/2015] [Indexed: 11/13/2022] Open
Abstract
Ischaemic stroke is the leading cause of severe long-term disability yet lacks drug therapies that promote the repair phase of recovery. This repair phase of stroke occurs days to months after stroke onset and involves brain remapping and plasticity within the peri-infarct zone. Elucidating mechanisms that promote this plasticity is critical for the development of new therapeutics with a broad treatment window. Inhibiting tonic (extrasynaptic) GABA signalling during the repair phase was reported to enhance functional recovery in mice suggesting that GABA plays an important function in modulating brain repair. While tonic GABA appears to suppress brain repair after stroke, less is known about the role of phasic (synaptic) GABA during the repair phase. We observed an increase in postsynaptic phasic GABA signalling in mice within the peri-infarct cortex specific to layer 5; we found increased numbers of α1 receptor subunit-containing GABAergic synapses detected using array tomography, and an associated increased efficacy of spontaneous and miniature inhibitory postsynaptic currents in pyramidal neurons. Furthermore, we demonstrate that enhancing phasic GABA signalling using zolpidem, a Food and Drug Administration (FDA)-approved GABA-positive allosteric modulator, during the repair phase improved behavioural recovery. These data identify potentiation of phasic GABA signalling as a novel therapeutic strategy, indicate zolpidem’s potential to improve recovery, and underscore the necessity to distinguish the role of tonic and phasic GABA signalling in stroke recovery.
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Affiliation(s)
- Takeshi Hiu
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA
| | - Zoya Farzampour
- 3 Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Jeanne T Paz
- 3 Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA 4 Gladstone Institute of Neurological Disease and University of California, San Francisco San Francisco, CA USA
| | - Eric Hou Jen Wang
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA
| | - Corrine Badgely
- 3 Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Andrew Olson
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Kristina D Micheva
- 5 Department of Molecular and Cellular Physiology, Stanford University, Stanford, CA, USA
| | - Gordon Wang
- 5 Department of Molecular and Cellular Physiology, Stanford University, Stanford, CA, USA
| | - Robin Lemmens
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA 6 KU Leuven - University of Leuven, Department of Neurosciences, Experimental Neurology; VIB - Vesalius Research Center University Hospitals Leuven, Department of Neurology, B-3000 Leuven, Belgium
| | - Kevin V Tran
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA
| | - Yasuhiro Nishiyama
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA
| | - Xibin Liang
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA
| | - Scott A Hamilton
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA
| | - Nancy O'Rourke
- 5 Department of Molecular and Cellular Physiology, Stanford University, Stanford, CA, USA
| | - Stephen J Smith
- 5 Department of Molecular and Cellular Physiology, Stanford University, Stanford, CA, USA
| | - John R Huguenard
- 3 Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Tonya M Bliss
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA
| | - Gary K Steinberg
- 1 Department of Neurosurgery, Stanford University, Stanford, CA, USA 2 Stanford Stroke Centre, Palo Alto, CA 94304, USA 3 Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
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Uchino K, Man S, Schold JD, Katzan IL. Stroke Legislation Impacts Distribution of Certified Stroke Centers in the United States. Stroke 2015; 46:1903-8. [PMID: 26089328 DOI: 10.1161/strokeaha.114.008007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The number of certified primary stroke centers (PSCs) have increased dramatically during the past decade in the United States We aimed to understand the factors affecting PSC distribution in the United States, including the impact of state stroke legislation. METHODS PSCs certified by national organization or state until December 2013 were searched from available databases. The proportion of PSC among short-term general hospitals in each state was calculated and factors affecting its distribution were analyzed. RESULTS By the end of 2013, the proportion of PSC varied from 4% to 100% among the 50 states and District of Columbia. The 18 states that had legislation in designating stroke centers and regulating stroke triage had higher PSC percentages (median, 43%; range, 13%-100%) than the remaining states (median, 13%; range, 4%-75%; P<0.001). State stroke legislation, urbanization, state economic output, and larger hospital size independently increased the likelihood of a hospital to be stroke certified. From 2009 to 2013, states with stroke legislation had greater increase of PSC percentages when compared with the states without legislation (median increase, 16% versus 6%; P=0.0067). Among the 1505 stroke centers, 74% were certified by the Joint Commission, 20% by state, and 6% by other organizations. Stroke centers certified only by state were smaller in size by hospital bed count compared with those certified by the Joint Commission (P<0.001). CONCLUSIONS State stroke legislation, a generalizable intervention, increased the number of certified stroke centers in the United States, potentially improving accessibility of standardized care for patients with acute ischemic stroke.
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Affiliation(s)
- Ken Uchino
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH.
| | - Shumei Man
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
| | - Jesse D Schold
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
| | - Irene L Katzan
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
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20
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Su EJ, Lawrence DA. α2 Antiplasmin and microvascular thrombosis in ischemic stroke. Arterioscler Thromb Vasc Biol 2015; 34:2522-3. [PMID: 25411105 DOI: 10.1161/atvbaha.114.304616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Enming J Su
- From the Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | - Daniel A Lawrence
- From the Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor.
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21
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Affiliation(s)
- Sandy Middleton
- From the Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, St Vincent’s Hospital, Darlinghurst, NSW, Australia (S.M.); Sunshine Coast Hospital and Health Service/Sunshine Coast Clinical School, The University of Queensland, Nambour, Queensland, Australia (R.G.); Centre for Research, College of Nursing, University of Tennessee Health Science Center-Memphis (A.W.A.); and Australian Catholic University, NSW, Australia (A.W.A.)
| | - Rohan Grimley
- From the Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, St Vincent’s Hospital, Darlinghurst, NSW, Australia (S.M.); Sunshine Coast Hospital and Health Service/Sunshine Coast Clinical School, The University of Queensland, Nambour, Queensland, Australia (R.G.); Centre for Research, College of Nursing, University of Tennessee Health Science Center-Memphis (A.W.A.); and Australian Catholic University, NSW, Australia (A.W.A.)
| | - Anne W. Alexandrov
- From the Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, St Vincent’s Hospital, Darlinghurst, NSW, Australia (S.M.); Sunshine Coast Hospital and Health Service/Sunshine Coast Clinical School, The University of Queensland, Nambour, Queensland, Australia (R.G.); Centre for Research, College of Nursing, University of Tennessee Health Science Center-Memphis (A.W.A.); and Australian Catholic University, NSW, Australia (A.W.A.)
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22
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Abstract
PURPOSE OF REVIEW Medical decision-making in stroke patients can be complex and often involves ethical challenges, from the perspective of healthcare providers as well as patients and their families. Awareness of these challenges and knowledge of current ethical topics in stroke may improve the quality of care provided to stroke patients. RECENT FINDINGS Predictive scores are increasingly available to estimate prognosis following stroke, though their usefulness in decision-making for individual patients remains unclear. Medical decisions requiring a surrogate decision-maker can be challenging; surrogates may also be susceptible to systematic biases in their decision-making. Variations in care are common and possibly related to under-utilization or over-utilization of resources. However, patient preferences may explain some of the variability as well. Early mortality may be related to patient and family preferences regarding life-sustaining measures rather than the provision of care that is not well tolerated or evidence-based. SUMMARY Ethical challenges are common in the care of stroke patients. An effective understanding of these topics is essential for clinicians to deliver patient-centered, preference-sensitive care.
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Wang HE, Donnelly JP, Shapiro NI, Hohmann SF, Levitan EB. Hospital variations in severe sepsis mortality. Am J Med Qual 2014; 30:328-36. [PMID: 24814940 DOI: 10.1177/1062860614534461] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This study sought to characterize variations in severe sepsis mortality between hospitals in the United States. Hospital discharge data (2012) were used from the University HealthSystem Consortium (UHC), a cooperative of US not-for-profit academic medical centers and affiliated hospitals. Discharge diagnosis codes were used to define severe sepsis as the presence of a serious infection with at least 1 organ dysfunction on hospital presentation. Expected mortality was determined from UHC risk adjustment mortality models. Among the 188 hospitals in the analysis, there were 256 509 patients with severe sepsis on admission. The median number of severe sepsis cases per hospital was 1202 (interquartile range [IQR] = 718-1940). Severe sepsis observed mortality (median = 8.6%; IQR = 6.8%-10.3%; range = 0.9%-18.2%) and observed-to-expected (O:E) mortality ratios (median = 0.91; IQR = 0.77-1.05; range = 0.16-1.95) varied across the hospitals. Variations in institutional severe sepsis observed mortality rates and O:E mortality ratios were observed in this national consortium of major medical centers.
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Affiliation(s)
- Henry E Wang
- University of Alabama School of Medicine, Birmingham, AL
| | | | | | - Samuel F Hohmann
- University HealthSystem Consortium, Chicago, IL Rush University, Chicago, IL
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24
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Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SCC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160-236. [PMID: 24788967 DOI: 10.1161/str.0000000000000024] [Citation(s) in RCA: 2863] [Impact Index Per Article: 286.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.
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25
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Treatment with afobazole at delayed time points following ischemic stroke improves long-term functional and histological outcomes. Neurobiol Dis 2014; 62:354-64. [DOI: 10.1016/j.nbd.2013.10.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/09/2013] [Accepted: 10/07/2013] [Indexed: 02/06/2023] Open
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Lahr MMH, Vroomen PCAJ, Luijckx GJ, van der Zee DJ, de Vos R, Buskens E. Prehospital factors determining regional variation in thrombolytic therapy in acute ischemic stroke. Int J Stroke 2013; 9 Suppl A100:31-5. [PMID: 24373584 DOI: 10.1111/ijs.12236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 10/14/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment rates with intravenous tissue plasminogen activator vary by region, which can be partially explained by organizational models of stroke care. A recent study demonstrated that prehospital factors determine a higher thrombolysis rate in a centralized vs. decentralized model in the north of the Netherlands. AIM To investigate prehospital factors that may explain variation in thrombolytic therapy between a centralized and a decentralized model. METHODS A consecutive case observational study was conducted in the north of the Netherlands comparing patients arriving within 4·5 h in a centralized vs. decentralized stroke care model. Factors investigated were transportation mode, prehospital diagnostic accuracy, and preferential referral of thrombolysis candidates. Potential confounders were adjusted using logistic regression analysis. RESULTS A total of 172 and 299 arriving within 4·5 h were enrolled in centralized and decentralized settings, respectively. The rate of transportation by emergency medical services was greater in the centralized model (adjusted odds ratio 3·11; 95% confidence interval, 1·59-6·06). Also, more misdiagnoses of stroke occurred in the central model (P = 0·05). In postal code areas with and without potential preferential referral of thrombolysis candidates due to overlapping catchment areas, the odds of hospital arrival within 4·5 h in the central vs. decentral model were 2·15 (95% confidence interval, 1·39-3·32) and 1·44 (95% confidence interval, 1·04-2·00), respectively. CONCLUSIONS These results suggest that the larger proportion of patients arriving within 4·5 h in the centralized model might be related to a lower threshold to use emergency services to transport stroke patients and partly to preferential referral of thrombolysis candidates.
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Affiliation(s)
- Maarten M H Lahr
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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27
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Masrur S, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Zhao X, Olson D, Pan W, Hernandez AF, Fonarow GC, Schwamm LH. Dysphagia Screening and Hospital-acquired Pneumonia in Patients with Acute Ischemic Stroke: Findings from Get with the Guidelines–Stroke. J Stroke Cerebrovasc Dis 2013; 22:e301-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.11.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 11/15/2012] [Accepted: 11/19/2012] [Indexed: 11/17/2022] Open
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Moradiya Y, Crystal H, Valsamis H, Levine SR. Thrombolytic utilization for ischemic stroke in US hospitals with neurology residency program. Neurology 2013; 81:1986-95. [PMID: 24186911 DOI: 10.1212/01.wnl.0000436946.08647.b5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE We aimed to compare the rates of thrombolysis utilization for acute ischemic stroke in hospitals with neurology residency (NR) to those of other teaching (OT) and nonteaching (NT) hospitals. METHODS A retrospective serial cross-sectional cohort study of a nationally representative sample of stroke patients was conducted. Accreditation Council for Graduate Medical Education-accredited NR program-affiliated hospitals in the United States were cross-matched to the hospitals in the Nationwide Inpatient Sample from 2000 to 2010. ICD-9-CM codes were used for case ascertainment. RESULTS A total of 712,433 adult ischemic stroke patients from 6,839 hospital samples were included, of whom 10.1%, 29.1%, and 60.8% were treated in NR, OT, and NT hospitals, respectively. Stroke patients in NR received thrombolysis more frequently (3.74% ± 0.24% [standard error]) than in OT (2.28% ± 0.11%, p < 0.001) and NT hospitals (1.44% ± 0.06%, p < 0.001). The adjusted odds ratios (ORs) of thrombolysis rates in NR vs OT and NR vs NT increased with each decade increment in age. In multivariate analysis, NR was independently predictive of higher thrombolysis rate (adjusted OR 1.51; 95% confidence interval [CI] 1.44-1.59 [NR vs OT], and adjusted OR 1.82; 95% CI 1.73-1.91 [NR vs NT]). CONCLUSIONS Acute stroke care in NR hospitals is associated with an increased thrombolytic utilization. The disparities between the thrombolysis rate in NR and that in OT and NT hospitals are greater among elderly patients.
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Affiliation(s)
- Yogesh Moradiya
- From the Neurosciences Critical Care Division (Y.M.), Johns Hopkins University, Baltimore, MD; Stroke Center and Departments of Neurology (Y.M., H.C., H.V., and S.R.L.), Pathology (H.C.), and Emergency Medicine (S.R.L.), SUNY Downstate Medical Center, Brooklyn; and Department of Neurology (Y.M., H.V., and S.R.L.), Kings County Hospital Center, Brooklyn, NY
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29
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Silva GS, Schwamm LH. Review of Stroke Center Effectiveness and Other Get with the Guidelines Data. Curr Atheroscler Rep 2013; 15:350. [DOI: 10.1007/s11883-013-0350-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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30
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Affiliation(s)
- Lee H. Schwamm
- From the Department of Neurology, Massachusetts General Hospital, Boston, MA
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31
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Gorelick PB. Primary and comprehensive stroke centers: history, value and certification criteria. J Stroke 2013; 15:78-89. [PMID: 24324943 PMCID: PMC3779669 DOI: 10.5853/jos.2013.15.2.78] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 01/24/2013] [Accepted: 01/24/2013] [Indexed: 01/28/2023] Open
Abstract
In the United States (US) stroke care has undergone a remarkable transformation in the past decades at several levels. At the clinical level, randomized trials have paved the way for many new stroke preventives, and recently, several new mechanical clot retrieval devices for acute stroke treatment have been cleared for use in practice by the US Federal Drug Administration. Furthermore, in the mid 1990s we witnessed regulatory approval of intravenous recombinant tissue plasminogen activator for administration in acute ischemic stroke. In the domain of organization of medical care and delivery of health services, stroke has transitioned from a disease dominated by neurologic consultation services only to one managed by vascular neurologists in geographical stroke units, stroke teams and care pathways, primary stroke center certification according to The Joint Commission, and most recently comprehensive stroke center designation under the aegis of The Joint Commission. Many organizations in the US have been involved to enhance stroke care. To name a few, the American Heart Association/American Stroke Association, Brain Attack Coalition, and National Stroke Association have been on the forefront of this movement. Additionally, governmental initiatives by the US Centers for Disease Control and Prevention and legislative initiatives such as the Paul Coverdell National Acute Stroke Registry program have paved the way to focus on stroke prevention, acute treatment and quality improvement. In this invited review, we discuss a brief history of organized stroke care in the United States, evidence to support the value of primary and comprehensive stroke centers, and the certification criteria and process to become a primary or comprehensive stroke center.
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Affiliation(s)
- Philip B Gorelick
- Translational Science and Molecular Medicine, Michigan State College of Human Medicine, Michigan, USA. ; Hauenstein Neuroscience Center, Saint Mary's Health Care, Michigan, USA
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32
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Nilanont Y, Nidhinandana S, Suwanwela NC, Hanchaiphiboolkul S, Pimpak T, Tatsanavivat P, Saposnik G, Poungvarin N. Quality of acute ischemic stroke care in Thailand: a prospective multicenter countrywide cohort study. J Stroke Cerebrovasc Dis 2013; 23:213-9. [PMID: 23305673 DOI: 10.1016/j.jstrokecerebrovasdis.2012.12.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 12/04/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Data concerning quality of acute stroke care and outcome are scarce in developing countries. OBJECTIVE This study aimed to evaluate quality of acute stroke care and stroke outcomes in Thailand. METHODS We performed a multicenter countrywide prospective cohort study. Consecutive patients with an acute ischemic stroke admitted to the participating institutions between June 2008 and November 2010 were included. Baseline characteristics, process measures including thrombolysis use, acute stroke unit admission, initiation of aspirin within 48 hours, and antithrombotic and/or anticoagulation medication at discharge were recorded. Main outcome measures were death and disability at discharge as well as in-hospital complications. RESULTS A total of 1222 patients were included with a mean (±SD) age of 65.0 ± 13 years, and 55.0% were men. Median National Institutes of Health Stroke Scale score was 6.5. Patients were given aspirin within 48 hours, admitted to acute stroke unit, and given thrombolytic therapy in 71.1%, 24.6%, and 3.8%, respectively. Good recovery at discharge (modified Rankin scale score 0-1) was found in 26.1%, and 3.2% of patients died during hospitalization. The median length of stay was 4 days. Factors predicting poor outcome (modified Rankin scale score 5-6) at discharge included: age (by 10-year increments: adjusted odds ratio [OR] 1.23; 95% confidence interval [CI], 1.06-1.43), female sex (adjusted OR 1.52; 95% CI, 1.05-2.19), initial National Institutes of Health Stroke Scale score (adjusted OR 1.35; 95% CI, 1.27-1.43), and in-hospital complications (adjusted OR 3.16; 95% CI, 1.58-6.35). CONCLUSIONS Limited access to acute ischemic stroke care interventions were observed in many domains especially thrombolysis and stroke unit admission. These findings emphasize an urgent need for strategies to improve standard acute stroke care among developing countries.
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Affiliation(s)
- Yongchai Nilanont
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Samart Nidhinandana
- Division of Neurology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Nijasri C Suwanwela
- Neurological Unit, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Taksin Pimpak
- Data Management Unit, Clinical Research Collaboration Network (CRCN), 4th Fl. Boromarajonani College of Nursing, Bamrasnaradun Building, Nonthaburi, Thailand
| | - Pyatat Tatsanavivat
- Division of Cardiovascular Disease and Internal Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Gustavo Saposnik
- Stroke Outcomes Research Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Niphon Poungvarin
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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