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Chirap-Mitulschi IA, Antoniu S, Schreiner TG. The impact of palliative care on the frailty-stroke continuum: from theoretical concepts to practical aspects. Postgrad Med 2024:1-9. [PMID: 38954726 DOI: 10.1080/00325481.2024.2374701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024]
Abstract
With a constant increase in prevalence and incidence worldwide, stroke remains a public health issue in the 21st century. Additionally, population aging inevitably leads to increased vulnerability in the general population, a clinical state known as frailty. While there are adequate guidelines on the treatment of stroke in the acute setting, there are a lot of gaps regarding the chronic management of stroke patients, particularly the frail ones. From the therapeutic point of view, palliative care could be the key to offering complex and individualized treatment to these frail chronic stroke patients. In the context of the heterogeneous data and incomplete therapeutic guidelines, this article provides a new and original perspective on the topic, aiming to increase awareness and understanding and improve palliative care management in stroke patients. Based on current knowledge, the authors describe a new concept called the frailty-stroke continuum and offer a detailed explanation of the intricate stroke-frailty connection in the first part. After understanding the role of palliative care in managing this kind of patients, the authors discuss the most relevant practical aspects aiming to offer an individualized framework for daily clinical practice. The novel approach consists of developing a four-step scale for characterizing frail stroke patients, with the final aim of providing personalized treatment and correctly evaluating prognosis. By pointing out the limitations of current guidelines and the challenges of new research directions, this article opens the pathway for the better evaluation of frail stroke patients, offering a better perception of patients' prognosis.
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Affiliation(s)
- Ioan-Alexandru Chirap-Mitulschi
- Department of Medicine II/Nursing-Palliative Care, Faculty of Medicine, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Romania
- Neurology Clinic, Clinical Rehabilitation Hospital, Iasi, Romania
| | - Sabina Antoniu
- Department of Medicine II/Nursing-Palliative Care, Faculty of Medicine, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Romania
| | - Thomas Gabriel Schreiner
- Department of Electrical Measurements and Materials, Faculty of Electrical Engineering and Information Technology, Gheorghe Asachi Technical University of Iasi, Iasi, Romania
- Department of Medicine III/Neurology, Faculty of Medicine, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Romania
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Delgardo M, Rabin G, Tudor T, Tang AJ, Reeves G, Connolly ES. Monitoring risk and preventing ischemic stroke in the very old. Expert Rev Neurother 2023; 23:791-801. [PMID: 37540092 DOI: 10.1080/14737175.2023.2244674] [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: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Stroke is a significant cause of death, and the leading cause of severe long-term disability for individuals over 80 (the very old), yet few studies of such risk factors for ischemic stroke, or the known mitigation techniques, in this population, and the evidence base regarding risk modification strategies in this susceptible population can be inconsistent and incomplete. This article examines current guidelines and evidence regarding medical management, lifestyle changes, and psychosocial interactions that can contribute to the primary and secondary prevention of ischemic stroke in the very old. AREAS COVERED The authors conducted a literature search for ischemic stroke prevention and risk assessment in the elderly via PubMed. Furthermore, they describe current strategies for monitoring risk and preventing ischemic stroke in the elderly population. EXPERT OPINION Ischemic stroke poses a significant health risk to the elderly, with prevention relying on managing modifiable risk factors such as hypertension, atrial fibrillation, diabetes, and high cholesterol, as well as promoting healthy lifestyle choices like quitting smoking, regular physical activity and a heart-healthy diet. Healthcare providers must adopt a multifaceted approach, addressing individual and population-level factors while remaining vigilant in monitoring and managing risk factors to reduce the incidence and impact of stroke in older adults.
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Affiliation(s)
- Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Grant Rabin
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Thilan Tudor
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Anthony J Tang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Geoffrey Reeves
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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3
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Vazquez S, Stadlan Z, Lapow JM, Feldstein E, Shah S, Das A, Naftchi AF, Spirollari E, Thaker A, Kazim SF, Dominguez JF, Patel N, Kurian C, Chong J, Mayer SA, Kaur G, Gandhi CD, Bowers CA, Al-Mufti F. Frailty and outcomes in lacunar stroke. J Stroke Cerebrovasc Dis 2023; 32:106942. [PMID: 36525849 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lacunar strokes (LS) are ischemic strokes of the small perforating arteries of deep gray and white matter of the brain. Frailty has been associated with greater mortality and attenuated response to treatment after stroke. However, the effect of frailty on patients with LS has not been previously described. OBJECTIVE To analyze the association between frailty and outcomes in LS. METHODS Patients with LS were selected from the National Inpatient Sample (NIS) 2016-2019 using the International Classification of Disease, 10th edition (ICD-10) diagnosis codes. The 11-point modified frailty scale (mFI-11) was used to group patients into severely frail and non-severely frail cohorts. Demographics, clinical characteristics, and complications were defined. Health care resource utilization (HRU) was evaluated by comparing total hospital charges and length of stay (LOS). Other outcomes studied were discharge disposition and inpatient death. RESULTS Of 48,980 patients with LS, 10,830 (22.1%) were severely frail. Severely frail patients were more likely to be older, have comorbidities, and pertain to lower socioeconomic status categories. Severely frail patients with LS had worse clinical stroke severity and increased rates of complications such as urinary tract infection (UTI) and pneumonia (PNA). Additionally, severe frailty was associated with unfavorable outcomes and increased HRU. CONCLUSION Severe frailty in LS patients is associated with higher rates of complications and increased HRU. Risk stratification based on frailty may allow for individualized treatments to help mitigate adverse outcomes in the setting of LS.
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Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Zehavya Stadlan
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Justin M Lapow
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Smit Shah
- Department of Neurology, University of South Carolina/PRISMA Health Richland, Columbia, SC, United States
| | - Ankita Das
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | | | - Eris Spirollari
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Akash Thaker
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, United States
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Neisha Patel
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Christeena Kurian
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Stephan A Mayer
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Chirag D Gandhi
- School of Medicine, New York Medical College, Valhalla, NY, United States; Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, United States
| | - Fawaz Al-Mufti
- School of Medicine, New York Medical College, Valhalla, NY, United States; Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
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Huang YN, Yan FH, Wang XY, Chen XL, Chong HY, Su WL, Chen YR, Han L, Ma YX. Prevalence and Risk Factors of Frailty in Stroke Patients: A Meta-Analysis and Systematic Review. J Nutr Health Aging 2023; 27:96-102. [PMID: 36806864 DOI: 10.1007/s12603-023-1879-z] [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: 01/18/2023]
Abstract
OBJECTIVES Summarize the existing evidence regarding the prevalence and risk factors of frailty in stroke patients. DESIGN A meta-analysis and systematic review. PARTICIPANTS Stroke patients in hospitals or communities. METHODS We undertook a systematic review and meta-analysis using articles available in 8 databases, including PubMed, The Cochrane Library, Web of Science, Embase, Chinese Biomedical Database (CBM), China National Knowledge Infrastructure Database (CNKI), Wanfang Database, and Weipu Database (VIP) from January 1990 to April 2022. Studies were quality rated using the Newcastle-Ottawa Scale and Agency for Healthcare Research and Quality tool. RESULTS A total of 24 studies involving 30,423 participants were identified. The prevalence of frailty and pre-frailty in stroke patients was 27% (95%CI: 0.23-0.31) and 47.9% (95%CI: 0.43-0.53). Female gender (OR = 1.76, 95%CI: 1.63-1.91), advanced age (MD = 6.73, 95%CI: 3.55-9.91), diabetes (OR = 1.34, 95%CI: 1.06-1.69), hyperlipidemia (OR = 1.46, 95%CI: 1.04-2.04), atrial fibrillation (OR = 1.36, 95%CI: 1.01-1.82), National Institutes of Stroke Scale (NIHSS) admission scores (MD = 2.27, 95%CI: 1.72-2.81) were risk factors of frailty in stroke patients. CONCLUSIONS Frailty was more prevalent in stroke patients. Female gender, advanced age, diabetes, hyperlipidemia, atrial fibrillation, and National Institutes of Stroke Scale (NIHSS) admission scores were identified as risk factors for frailty in stroke patients. In the future, medical staff should pay attention to the early screening of frailty in high-risk groups and provide information on its prevention.
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Affiliation(s)
- Y N Huang
- Yuxia Ma, Lin Han, Lanzhou University, China ,
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Asik Z, Özen M. Evaluation of frailty and neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios relationship in elderly people. NAGOYA JOURNAL OF MEDICAL SCIENCE 2022; 84:101-110. [PMID: 35392007 PMCID: PMC8971038 DOI: 10.18999/nagjms.84.1.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/25/2021] [Indexed: 11/13/2022]
Abstract
It was aimed to evaluate the relationship between frailty and inflammation in people receiving home health care. It was a cross-sectional study. Edmonton Frail Scale was used to determine the level of frailty and, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were used to determine inflammation. Of 332 people included in the study, 54.82% were females and 45.18% were males. Participants' ages were between 65 and 106. When we examined the frailty of the participants according to the Edmonton Frail Scale, the mean score was 9.403 ± 2.032. The mean neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio of the participants were 4,397±5,038 and 169,363±101,461 respectively. Accordingly, neutrophil-to-lymphocyte ratio was high in men, frail elderly, 75-84 age range, hypertension patients, malnutrition patients; and neutrophil-to-lymphocyte ratio was low in diabetes mellitus, dementia, cerebrovascular accident and hemiplegia. Platelet-to-lymphocyte ratio, another inflammatory marker, was high in men, non-frail elderly, 75-84 age range, hypertension patients and cerebrovascular accident patients; it was low in hemiplegia, malnutrition, dementia, diabetes mellitus. In the study, no statistically significant difference was found between Edmonton Frail Scale and inflammatory markers. More studies are needed on this subject. In addition, we think that examining NLR and PLR values will be useful for monitoring inflammation in frail elderly.
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Affiliation(s)
- Zeynep Asik
- The Clinic of Family Medicine, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
| | - Mehmet Özen
- The Clinic of Family Medicine, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
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Yogendrakumar V, Churilov L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu TY, Shah DG, Ng FC, Dewey HM, Wijeratne T, Yan B, Desmond PM, Parsons MW, Donnan GA, Davis SM, Campbell BCV. Safety and Efficacy of Tenecteplase in Older Patients With Large Vessel Occlusion: A Pooled Analysis of the EXTEND-IA TNK Trials. Neurology 2022; 98:e1292-e1301. [PMID: 35017305 DOI: 10.1212/wnl.0000000000013302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Detailed study of tenecteplase (TNK) in patients greater than 80 years of age is limited. The objective of our study was to assess the safety and efficacy of TNK at 0.25 and 0.40 mg/kg doses in patients greater than 80 years with large vessel occlusion. METHODS A pooled analysis of the EXTEND-IA TNK randomized controlled trials (n=502). Patients were adults presenting with ischemic stroke due to occlusion of the intracranial internal carotid, middle cerebral, or basilar artery presenting within 4.5 hours of symptom onset. We compared the treatment effect of TNK 0.25mg/kg, TNK 0.40mg/kg, and alteplase 0.90mg/kg, stratifying for patient age (>80 years). Outcomes evaluated include 90-day modified Rankin scale (mRS), all-cause mortality, and symptomatic ICH. Treatment effect was adjusted for baseline NIHSS, age, and time from symptom onset to puncture via mixed effects proportional odds and logistic regression models. RESULTS In patients >80 years (n=137), TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs. 4, adjusted common OR=2.70, 95% CI: 1.23-5.94) and reduced mortality (aOR=0.34, 95% CI: 0.13-0.91) versus 0.40 mg/kg. TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs. 4, acOR=2.28, 95% CI: 1.03-5.05) versus alteplase. No difference in 90-day mRS or mortality was detected between alteplase and TNK 0.40 mg/kg. Symptomatic ICH was observed in 4 patients treated with TNK 0.40 mg/kg, one patient treated with alteplase and zero patients treated with TNK 0.25 mg/kg. In patients ≤ 80 years, no differences in 90-day mRS, mortality, or symptomatic ICH was observed between TNK 0.25 mg/kg, alteplase, and TNK 0.40 mg/kg. CONCLUSIONS TNK 0.25 mg/kg was associated with improved 90-day mRS and lower mortality in patients greater than 80 years of age. No differences between the doses were observed in younger patients. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tenecteplase 0.25 mg/kg given before endovascular therapy in patients >80 years old with large vessel occlusion stroke is associated with better functional outcomes at 90 days and reduced mortality when compared to tenecteplase 0.40 mg/kg or alteplase 0.90 mg/kg. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT02388061, NCT03340493 https://www.clinicaltrials.gov/ct2/show/NCT02388061 https://www.clinicaltrials.gov/ct2/show/NCT03340493.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Vincent Thijs
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Melbourne Medical School, Department of Medicine and Neurology, The University of Melbourne and Western Health, Sunshine Hospital, St Albans Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Geoffrey Alan Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
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Al-Mufti F, Schirmer CM, Starke RM, Chaudhary N, De Leacy R, Tjoumakaris SI, Haranhalli N, Abecassis IJ, Amuluru K, Bulsara KR, Hetts SW. Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2021; 14:1033-1041. [PMID: 34244337 DOI: 10.1136/neurintsurg-2021-017888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 06/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis. METHODS We performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged <18 years and >80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence. RESULTS MT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurosurgery & Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Neil Haranhalli
- Department of Neurosurgery, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Krishna Amuluru
- Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, Indiana, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Department of Radiology, UCSF, San Francisco, California, USA
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Kilkenny MF, Phan HT, Lindley RI, Kim J, Lopez D, Dalli LL, Grimley R, Sundararajan V, Thrift AG, Andrew NE, Donnan GA, Cadilhac DA. Utility of the Hospital Frailty Risk Score Derived From Administrative Data and the Association With Stroke Outcomes. Stroke 2021; 52:2874-2881. [PMID: 34134509 DOI: 10.1161/strokeaha.120.033648] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (M.F.K., H.T.P., J.K., L.L.D., R.G., A.G.T., N.E.A., D.A.C.).,The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (M.F.K., J.K., D.A.C.)
| | - Hoang T Phan
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (M.F.K., H.T.P., J.K., L.L.D., R.G., A.G.T., N.E.A., D.A.C.).,Menzies Institute for Medical Research, University of Tasmania, Australia (H.T.P.)
| | - Richard I Lindley
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia (R.I.L.).,George Institute for Global Health, Sydney, New South Wales, Australia (R.I.L.)
| | - Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (M.F.K., H.T.P., J.K., L.L.D., R.G., A.G.T., N.E.A., D.A.C.).,The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (M.F.K., J.K., D.A.C.)
| | - Derrick Lopez
- School of Population and Global Health, The University of Western Australia, Perth, Australia (D.L.)
| | - Lachlan L Dalli
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (M.F.K., H.T.P., J.K., L.L.D., R.G., A.G.T., N.E.A., D.A.C.)
| | - Rohan Grimley
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (M.F.K., H.T.P., J.K., L.L.D., R.G., A.G.T., N.E.A., D.A.C.).,Sunshine Coast Clinical School, Griffith University, Birtinya, Queensland, Australia (R.G.)
| | - Vijaya Sundararajan
- Department of Public Health, La Trobe University, Bundoora, Victoria, Australia (V.S.)
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (M.F.K., H.T.P., J.K., L.L.D., R.G., A.G.T., N.E.A., D.A.C.)
| | - Nadine E Andrew
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (M.F.K., H.T.P., J.K., L.L.D., R.G., A.G.T., N.E.A., D.A.C.).,Department of Medicine, Peninsula Clinical School, Monash University, Victoria, Australia (N.E.A.)
| | - Geoffrey A Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (G.A.D.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (M.F.K., H.T.P., J.K., L.L.D., R.G., A.G.T., N.E.A., D.A.C.).,The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (M.F.K., J.K., D.A.C.)
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9
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Ricci L, Mangiardi M, Lanzone J, De Liso A, Fallacara A, Bravi MC, Pezzella FR, Anticoli S. Ischemic Stroke in the Very Elderly: Experience from an Italian Stroke Unit Hub Over a Period of 8 Years in the Era of Thrombectomy. J Stroke Cerebrovasc Dis 2021; 30:105754. [PMID: 33784523 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/03/2021] [Accepted: 03/10/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The goal of this study is to understand how very elderly patients (VEP) after ischemic stroke are currently treated in a Stroke Unit (SU) Hub in Italy. We designed a retrospective monocentric study on patients admitted in the SU of "AO San Camillo Forlanini" over an 8-year period. MATERIAL AND METHODS Data were collected among patients with acute ischemic stroke admitted to SU between January 2012 and December 2019. Patients were divided into three sub-groups: Adults (18-65 years); Elderly (66-85 years); and VEP (>85 years). Vascular risk factors and clinical variables as predictors of short-term clinical outcome were compared among age groups. RESULTS A total of 1979 patients were enrolled, 254 were VEP (12.8%). The proportion of VEP showed no significant modifications during the 8-year period (11.9% in 2012-2015 and 13.7% in 2016-2019; p=0.93). The proportion of women, hypertension and atrial fibrillation was significantly higher in VEP compared to other age groups (p<0.001). The rate of VEP being treated with rt-PA increased from 2012-2015 to 2016-2019 (from 12.8% to 25.5%, p<0.001). Endovascular thrombectomy was rarely performed in VEP (1.5% of VEP). Rt-PA treatment was associated with favorable outcome for all three age groups (p<0.05). CONCLUSIONS We showed that VEP present different vascular risk factor profiles, clinical features, and prognostic elements for short-term stroke outcome. Future studies will reveal whether we will observe an increasing trend in the use of rt-PA and endovascular thrombectomy and whether it will result in improved functional outcome for VEP.
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Affiliation(s)
- Lorenzo Ricci
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, Rome 00128, Italy.
| | - Marilena Mangiardi
- Stroke Unit, Departement of Neuroscience, AO S. Camillo Forlanini, Roma, Italy
| | - Jacopo Lanzone
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, Rome 00128, Italy
| | - Alfredo De Liso
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, Rome 00128, Italy.
| | - Adriana Fallacara
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, Rome 00128, Italy.
| | | | | | - Sabrina Anticoli
- Stroke Unit, Departement of Neuroscience, AO S. Camillo Forlanini, Roma, Italy.
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10
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Hawe RL, Cluff T, Dowlatshahi D, Hill MD, Dukelow SP. Assessment of Sex Differences in Recovery of Motor and Sensory Impairments Poststroke. Neurorehabil Neural Repair 2020; 34:746-757. [PMID: 32672513 DOI: 10.1177/1545968320935811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Understanding potential sex differences in stroke recovery is important for prognosis, ensuring appropriate allocation of health care resources, and for stratification in research studies. Previously, functional measures have shown poorer outcomes for females, however, little is known about sex differences that may exist in specific motor and sensory impairments. Objective. The aim of this study was to utilize robotic assessments of motor and sensory impairments to determine if there are sex differences at the impairment level in stroke recovery over the first 6 months poststroke. Methods. We used robotic and clinical assessments of motor and sensory impairments at 1, 6, 12, and 26 weeks poststroke in 108 males and 52 females. Linear mixed models were used to examine the effect of sex on recovery poststroke, controlling for age and lesion volume. Results. In general, we did not find significant sex differences across a range of assessments. The exception to this was a sex × age interaction for the Purdue Pegboard Assessment, where we found that females had better performance than males at younger ages (<62 years), but males had better performance at older ages. Conclusions. While recruitment biases need to be acknowledged when generalizing our results to stroke recovery at-large, our results suggest that sex differences do not exist at the impairment level poststroke.
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Affiliation(s)
- Rachel L Hawe
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Tyler Cluff
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sean P Dukelow
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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11
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Higano CS, Armstrong AJ, Sartor AO, Vogelzang NJ, Kantoff PW, McLeod DG, Pieczonka CM, Penson DF, Shore ND, Vacirca J, Concepcion RS, Tutrone RF, Nordquist LT, Quinn DI, Kassabian V, Scholz MC, Harmon M, Tyler RC, Chang NN, Tang H, Cooperberg MR. Real-world outcomes of sipuleucel-T treatment in PROCEED, a prospective registry of men with metastatic castration-resistant prostate cancer. Cancer 2019; 125:4172-4180. [PMID: 31483485 PMCID: PMC6856402 DOI: 10.1002/cncr.32445] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND The large registry, PROVENGE Registry for the Observation, Collection, and Evaluation of Experience Data (PROCEED)(NCT01306890), evaluated sipuleucel-T immunotherapy for asymptomatic/minimally symptomatic metastatic castration-resistant prostate cancer (mCRPC). METHODS PROCEED enrolled patients with mCRPC receiving 3 biweekly sipuleucel-T infusions. Assessments included overall survival (OS), serious adverse events (SAEs), cerebrovascular events (CVEs), and anticancer interventions (ACIs). Follow-up was for ≥3 years or until death or study withdrawal. RESULTS In 2011-2017, 1976 patients were followed for 46.6 months (median). The median age was 72 years, and the baseline median prostate-specific antigen level was 15.0 ng/mL; 86.7% were white, and 11.6% were African American. Among the patients, 1902 had 1 or more sipuleucel-T infusions. The median OS was 30.7 months (95% confidence interval [CI], 28.6-32.2 months). Known prognostic factors were independently associated with OS in a multivariable analysis. Among the 1255 patients who died, 964 (76.8%) died of prostate cancer (PC) progression. The median time from the first infusion to PC death was 42.7 months (95% CI, 39.4-46.2 months). The incidence of sipuleucel-T-related SAEs was 3.9%. The incidence of CVEs was 2.8%, and the rate per 100 person-years was 1.2 (95% CI, 0.9-1.6). The CVE incidence among 11,972 patients with mCRPC from the Surveillance, Epidemiology, and End Results-Medicare database was 2.8%; the rate per 100 person-years was 1.5 (95% CI, 1.4-1.7). One or more ACIs (abiraterone, enzalutamide, docetaxel, cabazitaxel, or radium 223) were received by 77.1% of the patients after sipuleucel-T; 32.5% and 17.4% of the patients experienced 1- and 2-year treatment-free intervals, respectively. CONCLUSIONS PROCEED provides contemporary survival data for sipuleucel-T-treated men in a real-world setting of new life-prolonging agents, which will be useful in discussing treatment options with patients and in powering future trials with sipuleucel-T. The safety and tolerability of sipuleucel-T in PROCEED were consistent with previous findings.
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Affiliation(s)
- Celestia S Higano
- Division of Medical Oncology, Departments of Medicine and Urology, University of Washington and Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Andrew J Armstrong
- Division of Medical Oncology, Duke University Medical Center, Duke Cancer Institute, Duke University, Durham, North Carolina.,Division of Urology, Duke University Medical Center, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - A Oliver Sartor
- Section of Hematology and Medical Oncology, Department of Medicine, Tulane Cancer Center and Tulane University School of Medicine, New Orleans, Louisiana
| | - Nicholas J Vogelzang
- Division of Hematology/Oncology, Comprehensive Cancer Centers of Nevada, Las Vegas, Nevada
| | - Philip W Kantoff
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York
| | - David G McLeod
- Department of Surgery, Center for Prostate Disease Research at the Uniformed Services of Health Sciences, Bethesda, Maryland
| | | | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neal D Shore
- Department of Urology, Carolina Urologic Research Center, Myrtle Beach, South Carolina
| | | | | | | | - Luke T Nordquist
- Department of Medical Oncology, GU Research Network, Omaha, Nebraska
| | - David I Quinn
- Division of Medical Oncology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | | | - Mark C Scholz
- Prostate Cancer Research Institute, Marina del Rey, California
| | - Matt Harmon
- Department of Biometrics, Dendreon Pharmaceuticals LLC, Seattle, Washington
| | - Robert C Tyler
- Department of Medical Affairs, Dendreon Pharmaceuticals LLC, Seattle, Washington
| | - Nancy N Chang
- Department of Medical Affairs, Dendreon Pharmaceuticals LLC, Seattle, Washington
| | - Hong Tang
- Department of Medical Affairs, Dendreon Pharmaceuticals LLC, Seattle, Washington
| | - Matthew R Cooperberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
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12
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Klochihina OA, Stakhovskaya LV, Polunina EA, Strakhov OA, Klochihina MM. Epidemiology and prognosis of the level of morbidity and mortality from stroke in different age groups according to the territorial-population register. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:5-12. [DOI: 10.17116/jnevro20191190825] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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13
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Wen SW, Wong CHY. Aging- and vascular-related pathologies. Microcirculation 2018; 26:e12463. [PMID: 29846990 DOI: 10.1111/micc.12463] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/27/2018] [Indexed: 12/13/2022]
Abstract
Our aging population is set to grow considerably in the coming decades. In fact, the number of individuals older than 65 years will double by 2050. This projected increase in people living with extended life expectancy represents an inevitable upsurge in the presentation of age-related pathologies. However, our current understanding of the impact of aging on a number of biological processes is unfortunately inadequate. Cardiovascular, cerebrovascular, and neurodegenerative diseases are particularly prevalent in the elderly population. Intriguingly, these pathologies are all associated with vascular dysfunction, suggesting that the process of aging can induce structural and functional impairments in vascular networks. Together with elevated cell senescence, pre-existing comorbidities, and the emerging concept of age-associated inflammatory imbalance, impaired vascular functions can significantly increase one's risk in acquiring age-related diseases. In this short review, we highlight some current clinical and experimental evidence of how biological aging contributes to three vascular-associated pathologies: atherosclerosis, stroke, and Alzheimer's disease.
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Affiliation(s)
- Shu Wen Wen
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Vic., Australia
| | - Connie H Y Wong
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Vic., Australia
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14
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Kwong PWH, Ng GYF, Chung RCK, Ng SSM. Bilateral Transcutaneous Electrical Nerve Stimulation Improves Lower-Limb Motor Function in Subjects With Chronic Stroke: A Randomized Controlled Trial. J Am Heart Assoc 2018; 7:e007341. [PMID: 29437598 PMCID: PMC5850185 DOI: 10.1161/jaha.117.007341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 01/10/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Transcutaneous electrical nerve stimulation (TENS) has been used to augment the efficacy of task-oriented training (TOT) after stroke. Bilateral intervention approaches have also been shown to be effective in augmenting motor function after stroke. The purpose of this study was to compare the efficacy of bilateral TENS combined with TOT versus unilateral TENS combined with TOT in improving lower-limb motor function in subjects with chronic stroke. METHODS AND RESULTS Eighty subjects were randomly assigned to bilateral TENS+TOT or to unilateral TENS+TOT and underwent 20 sessions of training over a 10-week period. The outcome measures included the maximal strength of the lower-limb muscles and the results of the Lower Extremity Motor Coordination Test, Berg Balance Scale, Step Test, and Timed Up and Go test. Each participant was assessed at baseline, after 10 and 20 sessions of training and 3 months after the cessation of training. The subjects in the bilateral TENS+TOT group showed greater improvement in paretic ankle dorsiflexion strength (β=1.32; P=0.032) and in the completion time for the Timed Up and Go test (β=-1.54; P=0.004) than those in the unilateral TENS+TOT group. However, there were no significant between-group differences for other outcome measures. CONCLUSIONS The application of bilateral TENS over the common peroneal nerve combined with TOT was superior to the application of unilateral TENS combined with TOT in improving paretic ankle dorsiflexion strength after 10 sessions of training and in improving the completion time for the Timed Up and Go test after 20 sessions of training. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02152813.
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Affiliation(s)
- Patrick W H Kwong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Gabriel Y F Ng
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Raymond C K Chung
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Shamay S M Ng
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
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