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Nuñez M, Allende MI, González F, Cavada G, Anderson CS, Muñoz Venturelli P. Sex Differences in Profile and In-Hospital Death for Acute Stroke in Chile: Data From a Nationwide Hospital Registry. J Am Heart Assoc 2024; 13:e035152. [PMID: 39023058 DOI: 10.1161/jaha.123.035152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/20/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Knowledge of local contextual sex differences in the profile and outcome for stroke can improve service delivery. We aimed to determine sex differences in the profile of patients with acute stroke and their associations with in-hospital death in the national hospital database of Chile. METHODS AND RESULTS We present a retrospective cohort based on the analysis of the 2019 Chilean database of Diagnosis-Related Groups, which represents 70% of the operational expenditure of the public health system. Random-effects multiple logistic regression models were used to determine independent associations of acute stroke (defined by main diagnosis International Classification of Diseases, Tenth Revision [ICD-10] codes) and in-hospital death, and reported with odds ratios (ORs) and 95% CIs. Of 1 048 575 hospital discharges, 15 535 were for patients with acute stroke (7074 [45.5%] in women), and 2438 (15.6%) of them died during hospitalization. Differences by sex in sociodemographic and clinical characteristics were identified for stroke and main subtypes. After fully adjusted model, women with ischemic stroke had lower in-hospital death (OR, 0.79 [95% CI, 0.69-0.91]) compared with men; other independent predictors included age per year increase (OR, 1.03 [95% CI, 1.03-1.04]), chronic kidney disease (OR, 1.47 [95% CI, 1.20-1.80]), atrial fibrillation (OR, 1.50 [95% CI, 1.26-1.80]), and other risk factors. Conversely, for intracerebral hemorrhage, women had a higher in-hospital mortality rate than men (OR, 1.19 [95% CI, 1.02-1.40]); other independent predictors included age per year increase (OR, 1.009 [95% CI, 1.003-1.01]), chronic kidney disease (OR, 1.55 [95% CI, 1.23-1.97]), oral anticoagulant use (OR, 1.88 [95% CI, 1.37-2.58]), and other risk factors. CONCLUSIONS Sex differences in characteristics and in-hospital death of hospitalized patients exist for acute stroke in Chile. In-hospital death is higher for acute ischemic stroke in men and higher for intracerebral hemorrhage in women. Future research is needed to better identify contributing factors.
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Affiliation(s)
- Marilaura Nuñez
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Ma Ignacia Allende
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Francisca González
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- Facultad de Ciencias de la Salud Blanquerna Universitat Ramon Llull Barcelona Spain
| | - Gabriel Cavada
- Escuela de Salud Pública Facultad de Medicina Universidad de Chile Santiago Chile
- Facultad de Medicina Universidad Finis Terrae Santiago Chile
- Unidad de Investigación Clínica Clínica Alemana de Santiago Santiago Chile
| | - Craig S Anderson
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- The George Institute for Global Health Faculty of Medicine, University of New South Wales Sydney NSW Australia
| | - Paula Muñoz Venturelli
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- The George Institute for Global Health Faculty of Medicine, University of New South Wales Sydney NSW Australia
- Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
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Sterenstein A, Garg R. The impact of sex on epidemiology, management, and outcome of spontaneous intracerebral hemorrhage (sICH). J Stroke Cerebrovasc Dis 2024; 33:107755. [PMID: 38705497 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/07/2024] Open
Abstract
OBJECTIVE Data on sex differences in spontaneous intracerebral hemorrhages are limited. METHODS An automated comprehensive scoping literature review was performed using PubMed and Scopus. Articles written in English about spontaneous intracerebral hemorrhage and sex were reviewed. RESULTS Males experience spontaneous intracerebral hemorrhage more frequently than females, at younger ages, and have a higher prevalence of deep bleeds compared to females. Risk factors between sexes vary and may contribute to differing incidences and locations of spontaneous intracranial hemorrhage. Globally, females receive less aggressive care than males, likely impacting survival. CONCLUSIONS Epidemiology, risk factors, and treatment of spontaneous intracranial hemorrhage vary by sex, with limited and oftentimes conflicting data available. Further research into the sex-based differences of spontaneous intracranial hemorrhage is necessary for clinicians to better understand how to evaluate and guide treatment in the future.
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Affiliation(s)
- Andrea Sterenstein
- Rush University Medical Center, Division of Critical Care Neurology, Department of Neurological Sciences.
| | - Rajeev Garg
- Rush University Medical Center, Division of Critical Care Neurology, Department of Neurological Sciences
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Kalasapudi L, Williamson S, Shipper AG, Motta M, Esenwa C, Otite FO, Chaturvedi S, Morris NA. Scoping Review of Racial, Ethnic, and Sex Disparities in the Diagnosis and Management of Hemorrhagic Stroke. Neurology 2023; 101:e267-e276. [PMID: 37202159 PMCID: PMC10382273 DOI: 10.1212/wnl.0000000000207406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/28/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the United States, Black, Hispanic, and Asian Americans experience excessively high incidence rates of hemorrhagic stroke compared with White Americans. Women experience higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity. METHODS We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients aged 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke. RESULTS After reviewing 6,161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control after intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care. DISCUSSION Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke.
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Affiliation(s)
- Lakshman Kalasapudi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Stacey Williamson
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Andrea G Shipper
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Melissa Motta
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Charles Esenwa
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Fadar Oliver Otite
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Seemant Chaturvedi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Nicholas A Morris
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse.
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Abstract
Differences exist between genders in intracerebral hemorrhage cause, epidemiology, and outcomes. These gender differences are in part attributable to physiologic differences; however, demographic, social/behavioral risk factors, along with health care system variation and potential family and/or clinician bias play a role as well. These factors vary from region to region and interact, making comprehensive and definitive conclusions regarding sex differences a challenging task. Differences between the genders in intracerebral hemorrhage epidemiology and extensive differences in underlying pathophysiology, intervention, risk factors, and outcome are all discussed.
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Affiliation(s)
- Nicholas Dykman Osteraas
- Department of Neurological Sciences, Division of Cerebrovascular Diseases, Rush University Medical Center, 1725 West Harrison Street Suite 118, Chicago, IL 60612, USA.
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5
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Zeidan AJ, Smith M, Leff R, Cordone A, Moran TP, Brackett A, Agrawal P. Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research. J Immigr Minor Health 2023; 25:181-189. [PMID: 35652977 DOI: 10.1007/s10903-022-01368-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/08/2022] [Accepted: 05/04/2022] [Indexed: 01/07/2023]
Abstract
AIMS Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S. METHODS A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language. RESULTS A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable. CONCLUSIONS As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.
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Affiliation(s)
- Amy J Zeidan
- Department of Emergency Medicine, Emory University School of Medicine, 80 Jesse Hill Junior Drive S#, 30303, Atlanta, GA, USA.
| | | | - Rebecca Leff
- Department of Emergency Medicine, Mayo Clinic, New York, USA
| | - Alexis Cordone
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, 80 Jesse Hill Junior Drive S#, 30303, Atlanta, GA, USA
| | | | - Pooja Agrawal
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
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6
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Lu P, Cao Z, Gu H, Li Z, Wang Y, Cui L, Wang Y, Zhao X. Association of sex and age with in-hospital mortality and complications of patients with intracerebral hemorrhage: A study from the Chinese Stroke Center Alliance. Brain Behav 2023; 13:e2846. [PMID: 36495127 PMCID: PMC9847591 DOI: 10.1002/brb3.2846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/06/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE The impact of sex and age on prognosis in patients with intracerebral hemorrhage (ICH) in the Chinese population remains unclear. Our study aimed to investigate the relationship between sex and age of Chinese ICH patients and adverse prognosis. METHODS We used the Chinese Stroke Center Alliance database with in-hospital mortality as the primary outcome and hospital complications as the secondary outcome. Patients were divided into four groups by sex and age. Logistic regression analyses were performed to assess the association between sex and age and the prognosis of ICH patients. RESULTS We enrolled 60,911 ICH patients, including 22,284 young and middle-aged males, 15,651 older males, 11,948 young and middle-aged females, and 11,028 older females. After adjusting for variables, older male patients had a higher mortality rate (OR = 1.21, 95% CI 1.01-1.45), combined with more frequent hematoma expansion (OR = 1.14, 95% CI 1.03-1.26), pneumonia (OR = 1.91, 95% CI 1.81-2.03), and hydrocephalus (OR = 1.28, 95% CI 1.04-1.59). Young and middle-aged female patients had a lower mortality rate (OR = 0.74, 95% CI 0.58-0.95) and less frequent combined pneumonia (OR = 0.81, 95% CI 0.75-0.87). In-hospital mortality was not significantly different in older females compared with young and middle-aged males, but the odds of deep vein thrombosis, swallowing disorders, urinary tract infections, and gastrointestinal bleeding were significantly higher. CONCLUSION Among young and middle-aged patients, females are related to a lower in-hospital mortality rate from ICH. Older patients are at an increased risk of ICH complications, with higher in-hospital mortality in older men.
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Affiliation(s)
- Ping Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhentang Cao
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Yu Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lingyun Cui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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7
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Sandset EC, Wang X, Carcel C, Sato S, Delcourt C, Arima H, Stapf C, Robinson T, Lavados P, Chalmers J, Woodward M, Anderson CS. Sex differences in treatment, radiological features and outcome after intracerebral haemorrhage: Pooled analysis of Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2. Eur Stroke J 2020; 5:345-350. [PMID: 33598552 DOI: 10.1177/2396987320957513] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/14/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction Reports vary on how sex influences the management and outcome from acute intracerebral haemorrhage. We aimed to quantify sex disparities in clinical characteristics, management, including response to blood pressure lowering treatment, and outcomes in patients with acute intracerebral haemorrhage, through interrogation of two large clinical trial databases. Patients and Methods Post-hoc pooled analysis of the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2, where patients with a hypertensive response (systolic, 150-220 mmHg) after spontaneous intracerebral haemorrhage (<6 h) were randomised to intensive (target <140 mmHg <1 h) or guideline-recommended (<180 mmHg) blood pressure lowering treatment. The interaction of sex on early haematoma growth (24 h), death or major disability (modified Rankin scale scores 3-6 at 90 days), and effect of randomised treatment were determined in multivariable logistic regression models adjusted for baseline confounding variables. Results In 3233 participants, 1191 (37%) were women who were significantly older, had higher baseline National Institutes of Health Stroke Scale scores and smaller haematoma volumes compared to men. Men had higher three-month mortality (odds ratio 1.48, 95% confidence interval 1.10-2.00); however, there was no difference between women and men in the combined endpoint of death or major disability. There were no significant sex differences on mean haematoma growth or effect of randomised blood pressure lowering treatment. Discussion Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had more comorbidities, larger baseline haematoma volumes and higher mortality after adjustment for age, as compared with women. Conclusion Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had a greater odds of dying after intracerebral haemorrhage than women, which could not be readily explained by differing casemix or patterns of blood pressure management. Clinical trial registration The Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials studies are registered with ClinicalTrials.gov (NCT00226096 and NCT00716079).
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Affiliation(s)
| | - Xia Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Shoichiro Sato
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Hisatomi Arima
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Christian Stapf
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Département de Neurosciences, Université de Montréal, Montréal, Canada
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Pablo Lavados
- Unidad de Neurología vascular, Servicio de Neurología, Departamento de Medicina, Clínica Alemana; Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,The George Institute for Global Health, Imperial College London, UK.,Department of Epidemiology, Johns Hopkins University, Baltimore, USA
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia.,The George Institute China at Peking University Health Science Center, Beijing, China
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8
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Linzey JR, Burke JF, Nadel JL, Williamson CA, Savastano LE, Wilkinson DA, Pandey AS. Incidence of the initiation of comfort care immediately following emergent neurosurgical and endovascular procedures. J Neurosurg 2019; 131:1725-1733. [PMID: 30554183 DOI: 10.3171/2018.7.jns181226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/31/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery. METHODS This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively. RESULTS Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70-79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00. CONCLUSIONS Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.
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Affiliation(s)
| | | | | | - Craig A Williamson
- Departments of2Neurology and
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Luis E Savastano
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - D Andrew Wilkinson
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Aditya S Pandey
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
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9
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McNicholas BA, Madotto F, Pham T, Rezoagli E, Masterson CH, Horie S, Bellani G, Brochard L, Laffey JG. Demographics, management and outcome of females and males with acute respiratory distress syndrome in the LUNG SAFE prospective cohort study. Eur Respir J 2019; 54:13993003.00609-2019. [DOI: 10.1183/13993003.00609-2019] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/04/2019] [Indexed: 02/06/2023]
Abstract
RationaleWe wished to determine the influence of sex on the management and outcomes in acute respiratory distress syndrome (ARDS) patients in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE).MethodsWe assessed the effect of sex on mortality, intensive care unit and hospital length of stay, and duration of invasive mechanical ventilation (IMV) in patients with ARDS who underwent IMV, adjusting for plausible clinical and geographic confounders.FindingsOf 2377 patients with ARDS, 905 (38%) were female and 1472 (62%) were male. There were no sex differences in clinician recognition of ARDS or critical illness severity profile. Females received higher tidal volumes (8.2±2.1 versus 7.2±1.6 mL·kg−1; p<0.0001) and higher plateau and driving pressures compared with males. Lower tidal volume ventilation was received by 50% of females compared with 74% of males (p<0.0001). In shorter patients (height ≤1.69 m), females were significantly less likely to receive lower tidal volumes. Surviving females had a shorter duration of IMV and reduced length of stay compared with males. Overall hospital mortality was similar in females (40.2%) versus males (40.2%). However, female sex was associated with higher mortality in patients with severe confirmed ARDS (OR for sex (male versus female) 0.35, 95% CI 0.14–0.83).ConclusionsShorter females with ARDS are less likely to receive lower tidal volume ventilation, while females with severe confirmed ARDS have a higher mortality risk. These data highlight the need for better ventilatory management in females to improve their outcomes from ARDS.
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10
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Faigle R, Gottesman RF. Variability in Palliative Care Use after Intracerebral Hemorrhage at US Hospitals: A Multilevel Analysis. Neuroepidemiology 2019; 53:84-92. [PMID: 31238305 DOI: 10.1159/000500276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/09/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Palliative care (PC) is an essential component of comprehensive care of patients with intracerebral hemorrhage (ICH). In the present study, we sought to characterize the variability of PC use after ICH among US hospitals. METHODS ICH admissions from hospitals with at least 12 annual ICH cases were identified in the Nationwide Inpatient Sample between 2008 and 2011. We used multilevel logistic regression modeling to estimate between-hospital variance in PC use. We calculated the intraclass correlation coefficient (ICC), proportional variance change, and median OR after accounting for individual-level and hospital-level covariates. RESULTS Among 26,791 ICH admissions, 12.5% received PC (95% CI 11.5-13.5). Among the 629 included hospitals, the median rate of PC use was 9.1 (interquartile range 1.5-19.3) per 100 ICH admissions, and 150 (23.9%) hospitals had no recorded PC use. The ICC of the random intercept (null) model was 0.274, suggesting that 27.4% of the overall variability in PC use was due to between-hospital variability. Adding hospital-level covariates to the model accounted for 25.8% of the between-hospital variance observed in the null model, with 74.2% of between-hospital variance remaining unexplained. The median OR of the fully adjusted model was 2.62 (95% CI 2.41-2.89), indicating that a patient moving from 1 hospital to another with a higher intrinsic propensity of PC use had a 2.63-fold median increase in the odds of receiving PC, independent of patient and hospital factors. CONCLUSIONS Substantial variation in PC use after ICH exists among US hospitals. A substantial proportion of this between-hospital variability remains unexplained even after accounting for patient and hospital characteristics.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Sex-Specific Differences in Clinical Characteristics and Outcomes Among Patients with Vascular Abnormality-Related Intracerebral Hemorrhage. World Neurosurg 2019; 129:e669-e676. [PMID: 31181362 DOI: 10.1016/j.wneu.2019.05.243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Results are conflicting as to whether sex has an impact on the outcome of intracerebral hemorrhage (ICH), especially when etiologies differ. In this study, we investigated whether sex differences exist in patients with vascular abnormality-related ICH. METHODS Patients (age ≥18 years) diagnosed with ICH within 7 days of symptom onset were admitted consecutively between January 2012 and February 2014 from 50 hospitals across mainland China. Vascular abnormality related to ICH included aneurysm, arteriovenous malformation, moyamoya disease, and cavernous malformation. The outcomes were death and death/disability at 3 months. Disability was defined as modified Rankin Scale score >2. Multivariable logistic regression was used to estimate the association between sex and outcome. RESULTS Women accounted for 41.9% (170) of the 406 patients, and they tended to be older than the men (women: 43.5 ± 19.3 years; men: 40.0 ± 17.7 years; P = 0.056). The proportions of ICH-related vascular abnormalities were as follows: aneurysm, 32% (130/406); arteriovenous malformation, 50.3% (204/406); moyamoya disease, 11.3% (46/406); and cavernous malformation, 6.4% (26/406). After we adjusted for age, National Institute of Health Stroke Scale, Glasgow Coma Scale score, location of hemorrhage, and surgery, female sex remained an independent predictor of death/disability at 3 months (odd ratio 2.49, 95% confidence interval 1.31-4.75), but not for death alone (odd ratio 1.45, 95% confidence interval 0.58-3.61). CONCLUSIONS In our study, female sex was an independent risk factor for poor outcomes in patients with vascular abnormality-related ICH. The factors contributing to this sex difference should be investigated in the future.
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Abstract
OBJECTIVES Evidence about sex differences in blood pressure (BP) at the time of acute stroke presentation is scarce. We aimed to summarize available data on sex differences in BP at the time of acute stroke presentation, including stratification by prior history of hypertension and stroke subtype. METHODS We performed a systematic literature search across MEDLINE and Embase, from inception to 21 December 2018, to identify all population-based observational studies that reported BP at the time of acute stroke presentation. We extracted data on patient demographics, stroke-type (ischaemic or haemorrhagic), stroke severity, vascular risk factors, and SBP and DBP at the time of stroke presentation. Wherever possible, data were pooled for meta-analysis with weighted mean difference (WMD) and corresponding 95% confidence intervals (CI) using random effects meta-analysis. RESULTS We included 128 138 stroke patients from 43 studies. Women had higher SBP at presentation than men (WMD, 1.46; 95% CI, 0.65-2.26); this difference was significant in ischaemic stroke (1.49; 0.25-2.72 mmHg), but not in intracerebral haemorrhage (0.19; -4.21 to 4.59 mmHg). Meta regression show that sex differences in SBP were consistent with increasing age, stroke severity, other comorbidities and medication history. CONCLUSION This systematic review and meta-analysis indicates that women have higher SBP at the time of presentation with acute stroke. These differences are consistent with sex differences in hypertension patterns in older age, and may be explained by the fact that women are more likely to have a premorbid hypertension. This highlights the need for effective sex-specific blood pressure control in patients at high risk for stroke.
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Brodtmann A. Comment: Does patient sex affect decision-making after hemorrhagic stroke? Neurology 2017; 89:353. [DOI: 10.1212/wnl.0000000000004162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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