Racial Disparity in Stroke Awareness in the US: An Analysis of the 2014 National Health Interview Survey

Physiotherapy Efficiency in Post-stroke Upper Extremity Spasticity: TENS vs. Ultrasound vs. Paraffin

BACKGROUND/AIM

Post-stroke spasticity is a significant debilitating condition with negative consequences on individual functional independence and quality of life. This study aimed to identify the differences between transcutaneous electrical stimulation (TENS), ultrasound therapy and paraffin procedures on post-stroke upper extremity spasticity and dexterity.

PATIENTS AND METHODS

Twenty-six patients were enrolled in the study, divided into three therapy groups: TENS (n=9), paraffin (n=10) and ultrasound therapy (n=7). For 10 days, the patients received specific group therapy and conventional physical therapy exercises for upper extremities. Modified Ashworth Scale, Functional Independence Measure, Functional Coefficient, Stroke Specific Quality of Life Scale, Activities of Daily Living score and ABILHAND questionnaire were used to assess the participants before and after therapy.

RESULTS

The results of the group comparisons by analysis of variance showed no significant difference between outcomes by the applied treatments. In contrast, one-way analysis of variance suggested significant improvements in patients in all three groups after therapy. Step-wise regression results on functional independence measure and quality-of-life scales suggested that functional range of motion values for elbow and wrist influence individual independence and quality of life.

CONCLUSION

TENS, ultrasound, and paraffin therapy bring equal benefits in the management of post-stroke spasticity.

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

BACKGROUND

Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care.

OBJECTIVE

We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group.

METHODS

We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach.

RESULTS

One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting.

CONCLUSIONS

Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Educational Intervention in the Emergency Department to Address Disparities in Stroke Knowledge

OBJECTIVES

In the United States, Black individuals have higher stroke incidence and mortality when compared to white individuals and are also at risk of having lower stroke knowledge and awareness. With the need to implement focused interventions to decrease stroke disparities, the objective of this study is to evaluate the feasibility and efficacy of an emergency department-based educational intervention aimed at increasing stroke awareness and preparedness among a disproportionately high-risk group.

MATERIALS AND METHODS

Over a three-month timeframe, an emergency department-based, prospective educational intervention was implemented for Black patients in an urban, academic emergency department. All participants received stroke education in the forms of a video, written brochure and verbal counseling.  Stroke knowledge was assessed pre-intervention, immediately post-intervention, and at one-month post-intervention.

RESULTS

One hundred eighty-five patients were approached for enrollment, of whom 100 participants completed the educational intervention as well as the pre- and immediate post- intervention knowledge assessments. Participants demonstrated increased stroke knowledge from baseline knowledge assessment (5.35 ± 1.97) at both immediate post-intervention (7.66 ± 2.42, p < .0001) and one-month post-intervention assessment (7.21 ± 2.21, p < .0001).

CONCLUSIONS

Emergency department-based stroke education can result in improved knowledge among this focused demographic. The emergency department represents a potential site for educational interventions to address disparities in stroke knowledge.

A cross-sectional analysis of 2017 stroke symptoms recognition at the US regional level

OBJECTIVES

Stroke symptom recognition is critical in reducing time to treatment, but it is not known whether the increased support for stroke education programs during the last several years has led to an improvement in regional stroke symptom recognition levels since they were last assessed in the mid-2010s.

METHODS

We used the most current estimates of recognition from the 2017 National Health Interview Survey to examine regional recognition levels for individual stroke symptoms and correct identification of all five stroke symptoms.

RESULTS

Recognition of individual stroke symptoms was ≥76% in all regions, but correct identification of all stroke symptoms was lower ranging from 68.8 to 70.2%. Recognition of sudden numbness or weakness of face, arm, or leg, especially on one side (Northeast: 94.9%, Midwest: 95.8%, South: 93.8%, West: 94.5%) was the highest and recognition of sudden headache with no known cause (Northeast: 77.6%, Midwest: 76.4%, South: 77.7%, West: 76.5%) was the lowest for all regions.

DISCUSSION

We observed similar stroke symptom recognition levels in each US region with little improvement since the mid-2010s. Additional effort should be made to increase recognition of sudden headache with no known cause in US regions with current high prevalence of stroke risk factors.

Mechanical Thrombectomy Access for All? Challenges in Increasing Endovascular Treatment for Acute Ischemic Stroke in the United States

Mechanical thrombectomy (MT) is the most effective treatment for selected patients with an acute ischemic stroke due to emergent large vessel occlusions (LVOs). There is an urgent need to identify and address challenges in access to MT to maximize the numbers of patients who can benefit from this treatment. Barriers in access to MT include delays in evaluation and accurate diagnosis of LVO leading to inappropriate triage, logistical delays related to availability of facilities and trained interventionalists, and financial hurdles that affect treatment reimbursement. Collection of regional data related to these barriers is critical to better understand current access gaps and a measurable access score to thrombectomy could be useful to plan local public health intervention.

Leveraging Multimedia Patient Engagement to Address Minority Cerebrovascular Health Needs: Prospective Observational Study

BACKGROUND

Social inequities affecting minority populations after Hurricane Katrina led to an expansion of environmental justice literature. In August 2017, Hurricane Harvey rainfall was estimated as a 3000- to 20,000-year flood event, further affecting minority populations with disproportionate stroke prevalence. The Stomp Out Stroke initiative leveraged multimedia engagement, creating a patient-centered cerebrovascular health intervention.

OBJECTIVE

This study aims to address social inequities in cerebrovascular health through the identification of race- or ethnicity-specific health needs and the provision of in-person stroke prevention screening during two community events (May 2018 and May 2019).

METHODS

Stomp Out Stroke recruitment took place through internet-based channels (websites and social networking). Exclusively through web registration, Stomp Out Stroke participants (aged >18 years) detailed sociodemographic characteristics, family history of stroke, and stroke survivorship. Participant health interests were compared by race or ethnicity using Kruskal-Wallis or chi-square test at an α=.05. A Bonferroni-corrected P value of .0083 was used for multiple comparisons.

RESULTS

Stomp Out Stroke registrants (N=1401) were 70% (973/1390) female (median age 45 years) and largely self-identified as members of minority groups: 32.05% (449/1401) Hispanic, 25.62% (359/1401) African American, 13.63% (191/1401) Asian compared with 23.63% (331/1401) non-Hispanic White. Stroke survivors comprised 11.55% (155/1401) of our population. A total of 124 stroke caregivers participated. Approximately 36.81% (493/1339) of participants had a family history of stroke. African American participants were most likely to have Medicare or Medicaid insurance (84/341, 24.6%), whereas Hispanic participants were most likely to be uninsured (127/435, 29.2%). Hispanic participants were more likely than non-Hispanic White participants to obtain health screenings (282/449, 62.8% vs 175/331, 52.9%; P=.03). Asian (105/191, 54.9%) and African American (201/359, 55.9%) participants were more likely to request stroke education than non-Hispanic White (138/331, 41.6%) or Hispanic participants (193/449, 42.9%). African American participants were more likely to seek overall health education than non-Hispanic White participants (166/359, 46.2% vs 108/331, 32.6%; P=.002). Non-Hispanic White participants (48/331, 14.5%) were less likely to speak to health care providers than African American (91/359, 25.3%) or Asian participants (54/191, 28.3%). During the 2018 and 2019 events, 2774 health screenings were completed across 12 hours, averaging four health screenings per minute. These included blood pressure (1031/2774, 37.16%), stroke risk assessment (496/2774, 17.88%), bone density (426/2774, 15.35%), carotid ultrasound (380/2774, 13.69%), BMI (182/2774, 6.56%), serum lipids (157/2774, 5.65%), and hemoglobin A_1c (102/2774, 3.67%). Twenty multimedia placements using the Stomp Out Stroke webpage, social media, #stompoutstroke, television, iQ radio, and web-based news reached approximately 849,731 people in the Houston area.

CONCLUSIONS

Using a combination of internet-based recruitment, registration, and in-person assessments, Stomp Out Stroke identified race- or ethnicity-specific health care needs and provided appropriate screenings to minority populations at increased risk of urban flooding and stroke. This protocol can be replicated in Southern US Stroke Belt cities with similar flood risks.

Knowledge, Prevention Practice and Associated Factors of Stroke Among Hypertensive and Diabetic Patients - A Systematic Review

INTRODUCTION

Because of the inadequate level of public awareness of the disease, the incidence of stroke has been sharply rising. Eventually, due to the prehospital delay, many stroke cases could not be eligible for thrombolysis thereby poor rehabilitative outcome has been tremendously increased. Thus, this study aimed to review the level of knowledge, prevention practice, and associated factors of stroke among hypertensive and diabetic patients.

METHODS

A systematic review of primarily published articles (2010-2020) related to knowledge and prevention practices of stroke was performed by searching online electronic databases like PubMed, Google Scholar, Refseek, Science direct, ResearchGate, and manual Google search by using the keywords and MeSH terms. Studies conducted on knowledge and prevention practices amongst hypertensive and/or diabetic patients were included.

RESULTS

Out of 531 searched studies, 42 articles were identified to be reviewed. The reported overall knowledge of stroke was ranging from 4.4% to 79%. Knowledge to the signs/symptoms of stroke was 23.6% to 87%. However, 15% to 77% of subjects were also reported that they did not know any sign of stroke. The range of risk factor knowledge was 10.5% to 86.6%. The reported level of stroke prevention practice was 2.4% to 72% but physical activity and weight reduction practice were relatively low. Inadequate level of knowledge and prevention practice of stroke was related to elderly, female gender, uneducated, unmarried, rural residents, economically low, comorbidity and unemployed individuals.

CONCLUSION

The current finding revealed that the level of knowledge and prevention practice of stroke was inadequate. Hence, the finding highlights health educational programs should be planned as an important avenue to enhance stroke awareness among the high-risk populations.

Association Between Sociodemographic Determinants and Disparities in Stroke Symptom Awareness Among US Young Adults

BACKGROUND AND PURPOSE

Despite declining stroke rates in the general population, stroke incidence and hospitalizations are rising among younger individuals. Awareness of and prompt response to stroke symptoms are crucial components of a timely diagnosis and disease management. We assessed awareness of stroke symptoms and response to a perceived stroke among young adults in the United States.

METHODS

Using data from the 2017 National Health Interview Survey, we assessed awareness of 5 common stroke symptoms and the knowledge of planned response (ie, calling emergency medical services) among young adults (<45 years) across diverse sociodemographic groups. Common stroke symptoms included: (1) numbness of face/arm/leg, (2) confusion/trouble speaking, (3) difficulty walking/dizziness/loss of balance, (4) trouble seeing in one/both eyes, and (5) severe headache.

RESULTS

Our study population included 24 769 adults, of which 9844 (39.7%) were young adults who were included in our primary analysis, and represented 107.2 million US young adults (mean age 31.3 [±7.5] years, 50.6% women, and 62.2% non-Hispanic White). Overall, 2718 young adults (28.9%) were not aware of all 5 stroke symptoms, whereas 242 individuals (2.7%; representing 2.9 million young adults in the United States) were not aware of a single symptom. After adjusting for confounders, Hispanic ethnicity (odds ratio, 1.96 [95% CI, 1.17-3.28]), non-US born immigration status (odds ratio, 2.02 [95% CI, 1.31-3.11]), and lower education level (odds ratio, 2.77 [95% CI, 1.76-4.35]), were significantly associated with lack of symptom awareness. Individuals with 5 high-risk characteristics (non-White, non-US born, low income, uninsured, and high school educated or lower) had nearly a 4-fold higher odds of not being aware of all symptoms (odds ratio, 3.70 [95% CI, 2.43-5.62]).

CONCLUSIONS

Based on data from the National Health Interview Survey, a large proportion of young adults may not be aware of stroke symptoms. Certain sociodemographic subgroups with decreased awareness may benefit from focused public health interventions.

Effect of multi-level stroke education on treatment and prognosis of acute ischemic stroke

This observational study aimed at the significance of multi-level education in the treatment and prognosis of acute ischemic stroke. Multi-level stroke education was carried out among residents and medical staff for one year in Guancheng district. After 1 year, 519 patients with acute ischemic stroke admitted to The First People's Hospital of Zhengzhou were invited to the study, 272 patients from the Guancheng district were divided into the experimental group, and 247 patients who were not from the Guancheng district but in the neighborhood of The First People's Hospital of Zhengzhou were divided into the control group. Statistical methods were applied to analyze the degree of awareness of stroke, the time from onset to hospital, the route to hospital, the number of patients coming to the hospital within 4.5 h, the number of intravenous thrombolysis, door-to-needle time (DNT), modified Rankin scale (MRS) score, and the number of hemorrhagic transformation cases. After one year of multi-level systematic stroke education, there were significant differences in stroke awareness between the experimental group and the control group in terms of limb weakness (87.87 vs. 62.75%), speech inarticulation (78.3 vs. 55.06%), facial paralysis (69.12 vs. 38.06%), limb numbness (57.35 vs. 29.15%), consciousness disorder (62.50 vs. 42.11%), walking instability with severe dizziness (39.97 vs. 15.79%) (P<0.05). There was no statistical significant difference in unclear vision or blind eyes or severe headache (P>0.05). There were statistical differences between the two groups in the time from the onset to the hospital (14.82±17.67 vs. 25.92±25.23), emergency medical services (EMS) (36.02 vs. 16.19%), number of patients coming to the hospital within 4.5 h (67 vs. 32), venous thrombolysis cases (55 vs. 17), DNT time (42.43±17.30 vs. 63.35±26.53), hemorrhagic transformation cases (11 vs. 21), and MRS score grade ≥2 (230 vs. 169) (P<0.05). Multi-level education can effectively improve the patient's awareness of stroke, encourage more patients to use EMS system to the hospital. More patients were aware that they should reach the hospital within 4.5 h. It helps shorten DNT time and give more patients the opportunity to receive intravenous thrombolysis or intravascular thrombectomy, which may improve the prognosis and reduce hemorrhagic transformation without reducing mortality.

Aspirin Use and Awareness for Cardiovascular Disease Prevention Among Hispanics: Prevalence and Associations with Health Behavior Beliefs

Cardiovascular disease (CVD) persists as the leading cause of death and disability in many Americans including Hispanics. Primary prevention for CVD may be achieved through regular aspirin use in high risk individuals. This study examined regular aspirin use and specific attitudes and social norms toward CVD and aspirin use within an urban Hispanic population in Minnesota. A sample of primary prevention Hispanics aged 45-79 years were surveyed about CVD history and risk factors, aspirin use, demographic characteristics, and health beliefs and social norms in relation to CVD and aspirin. Relative risk estimation using Poisson regression with robust error variance was used to examine associations with aspirin use. In this sample of 152 Hispanics (55% women), the mean age was 53 years, 70% had a regular healthcare provider, and 22% used aspirin. Aspirin discussions with a regular healthcare provider were strongly associated with aspirin use (adjusted risk ratio 3.02, 95% CI 1.20-7.60). There was a positive association between health beliefs and social norms that affirm preventive behaviors and aspirin use (adjusted linear risk ratio 1.23, 95% CI 1.04-1.45) while uncertainty about the role of aspirin for individual use and in the community was negatively associated with aspirin use (adjusted linear risk ratio 0.85, 95% CI 0.70-1.03). This growing population may benefit from health education about CVD risk and the role of aspirin in prevention.

"Worth the Walk": Culturally Tailored Stroke Risk Factor Reduction Intervention in Community Senior Centers

Background Racial/ethnic minority older adults have worse stroke burden than non-Hispanic white and younger counterparts. Our academic-community partner team tested a culturally tailored 1-month (8-session) intervention to increase walking and stroke knowledge among Latino, Korean, Chinese, and black seniors. Methods and Results We conducted a randomized wait-list controlled trial of 233 adults aged 60 years and older, with a history of hypertension, recruited from senior centers. Outcomes were measured at baseline (T0), immediately after the 1-month intervention (T1), and 2 months later (T2). The primary outcome was pedometer-measured change in steps. Secondary outcomes included stroke knowledge (eg, intention to call 911 for stroke symptoms) and other self-reported and clinical measures of health. Mean age of participants was 74 years; 90% completed T2. Intervention participants had better daily walking change scores than control participants at T1 (489 versus -398 steps; mean difference in change=887; 97.5% CI, 137-1636), but not T2 after adjusting for multiple comparisons (233 versus -714; mean difference in change=947; 97.5% CI, -108 to 2002). The intervention increased the percent of stroke symptoms for which participants would call 911 (from 49% to 68%); the control group did not change (mean difference in change T0-T1=22%; 99.9% CI, 9-34%). This effect persisted at T2. The intervention did not affect measures of health (eg, blood pressure). Conclusions This community-partnered intervention did not succeed in increasing and sustaining meaningful improvements in walking levels among minority seniors, but it caused large, sustained improvements in stroke preparedness. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02181062.

Sexual Identity and Racial/Ethnic Differences in Awareness of Heart Attack and Stroke Symptoms: Findings From the National Health Interview Survey

PURPOSE

Investigate sexual identity and racial/ethnic differences in awareness of heart attack and stroke symptoms.

DESIGN

Cross-sectional.

SETTING

2014 and 2017 National Health Interview Survey.

SAMPLE

54 326 participants.

MEASURES

Exposure measures were sexual identity (heterosexual, gay/lesbian, bisexual, "something else") and race/ethnicity. Awareness of heart attack and stroke symptoms was assessed.

ANALYSIS

Sex-stratified logistic regression analyses to examine sexual identity and racial/ethnic differences in awareness of heart attack and stroke symptoms.

RESULTS

Gay men were more likely than heterosexual men to identify calling 911 as the correct action if someone is having a heart attack (adjusted odds ratio [AOR] = 2.16, 95% CI: 1.18-3.96). The majority of racial/ethnic minority heterosexuals reported lower rates of awareness of heart attack and stroke symptoms than White heterosexuals. Hispanic sexual minority women had lower awareness of heart attack symptoms than White heterosexual women (AOR = 0.43, 95% CI: 0.25-0.74), whereas Asian sexual minority women reported lower awareness of stroke symptoms (AOR = 0.25, 95% CI: 0.08-0.80). Hispanic (AOR = 0.52, 95% CI: 0.33-0.84) and Asian (AOR = 0.35, 95% CI: 0.14-0.84) sexual minority men reported lower awareness of stroke symptoms than White heterosexual men.

CONCLUSION

Hispanic and Asian sexual minorities had lower rates of awareness of heart attack and stroke symptoms. Health information technology may be a platform for delivering health education and targeted health promotion for sexual minorities of color.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Impact of prehospital stroke code in a public center in Paraguay: A pilot study

Prehospital stroke code activation results in reduced pre- and in-hospital delays and triage and transport of stroke patients to the right centers. In Paraguay, data about acute reper fusion treatment are not available. Recently, a pilot prehospital stroke code program was implemented in the country in November 2016. In an observational, single-center cohort study with a before–after design, from April 2015 to July 2018, we found that 193/832 (23.1%) of stroke patients were stroke code activated, and from these, 54 (6.5%) were brought to hospital under the prehospital stroke code protocol. Fifty-eight patients (58 alteplase and 2 additional endovascular treatment) received reperfusion therapy. Prehospital stroke code patients had a lower mean door-to-CT time (24 vs. 33 min, p = 0.021) and lower mean door-to-needle time (35.3 vs.76.3 min, p < 0.001) compared to in-hospital stroke code patients. Prehospital stroke code is feasible in Paraguay and has a positive impact on in-hospital acute stroke management, reducing delays and increasing the rates of reperfusion treatments.

Hospital distance, socioeconomic status, and timely treatment of ischemic stroke

OBJECTIVE

To determine whether lower socioeconomic status (SES) and longer home to hospital driving time are associated with reductions in tissue plasminogen activator (tPA) administration and timeliness of the treatment.

METHODS

We conducted a retrospective observational study using data from the Get With The Guidelines-Stroke Registry (GWTG-Stroke) between January 2015 and March 2017. The study included 118,683 ischemic stroke patients age ≥18 who were transported by emergency medical services to one of 1,489 US hospitals. We defined each patient's SES based on zip code median household income. We calculated the driving time between each patient's home zip code and the hospital where he or she was treated using the Google Maps Directions Application Programing Interface. The primary outcomes were tPA administration and onset-to-arrival time (OTA). Outcomes were analyzed using hierarchical multivariable logistic regression models.

RESULTS

SES was not associated with OTA (p = 0.31) or tPA administration (p = 0.47), but was associated with the secondary outcomes of onset-to-treatment time (OTT) (p = 0.0160) and in-hospital mortality (p = 0.0037), with higher SES associated with shorter OTT and lower in-hospital mortality. Driving time was associated with tPA administration (p < 0.001) and OTA (p < 0.0001), with lower odds of tPA (0.83, 0.79-0.88) and longer OTA (1.30, 1.24-1.35) in patients with the longest vs shortest driving time quartiles. Lower SES quintiles were associated with slightly longer driving time quartiles (p = 0.0029), but there was no interaction between the SES and driving time for either OTA (p = 0.1145) or tPA (p = 0.6103).

CONCLUSIONS

Longer driving times were associated with lower odds of tPA administration and longer OTA; however, SES did not modify these associations.

Awareness of Stroke Signs and Symptoms and Calling 9-1-1 Among US Adults: National Health Interview Survey, 2009 and 2014

INTRODUCTION

Early recognition of stroke symptoms and recognizing the importance of calling 9-1-1 improves the timeliness of appropriate emergency care, resulting in improved health outcomes. The objective of this study was to assess changes in awareness of stroke symptoms and calling 9-1-1 from 2009 to 2014.

METHODS

We analyzed data among 27,211 adults from 2009 and 35,862 adults from 2014 using the National Health Interview Survey (NHIS). The NHIS included 5 questions in both 2009 and 2014 about stroke signs and symptoms and one about the first action to take when someone is having a stroke. We estimated the prevalence of awareness of each symptom, all 5 symptoms, the importance of calling 9-1-1, and knowledge of all 5 symptoms plus the importance of calling 9-1-1 (indicating recommended stroke knowledge). We assessed changes from 2009 to 2014 in the prevalence of awareness. Data analyses were conducted in 2016.

RESULTS

In 2014, awareness of stroke symptoms ranged from 76.1% (sudden severe headache) to 93.7% (numbness of face, arm, leg, side); 68.3% of respondents recognized all 5 symptoms, and 66.2% were aware of all recommended stroke knowledge. After adjusting for sex, age, educational attainment, and race/ethnicity, logistic regression results showed a significant absolute increase of 14.7 percentage points in recommended stroke knowledge from 2009 (51.5%) to 2014 (66.2%). Among US adults, recommended stroke knowledge increased from 2009 to 2014.

CONCLUSION

Stroke awareness among US adults has improved but remains suboptimal.

Differences in the awareness of stroke symptoms and emergency response by occupation in the Korean general population

We evaluated the difference in awareness of stroke warning signs (SWS) and emergency response among occupational groups in the community-dwelling population. From the 2016 Korea Community Health Survey, a total of 10,445 individuals without stroke were included in the analysis. Multiple logistic regression analysis was used to explore the association of occupation with awareness of SWS and correct emergency response. SWS included the following: sudden numbness or weakness, sudden difficulty speaking or understanding speech, sudden dizziness, sudden visual impairment, and sudden severe headache. Respondents’ occupation was classified into six groups: managers and professionals (MP); clerks; service and sales workers (SSW); agricultural, forestry, and fishery workers (AFFW); mechanical and manual laborers (MML); or housewives and unemployed people (HUP). Awareness of each SWS was the same with the highest for MP and lowest for AFFW. After adjusting for socio-demographic factors, compared to MP (reference), AFFW (odds ratio 0.49; 95% confidence interval 0.36–0.67), HUP (0.55; 0.40–0.75), MML (0.57; 0.42–0.79), and SSW (0.62; 0.45–0.86) had significantly lower ORs for knowing at least one of the SWS. Additionally, AFFW (0.79; 0.66–0.96) and MML (0.76; 0.63–0.91) had significantly lower ORs for knowing all five SWS compared to MP. However, there was no significant occupational difference in correct emergency response when a stroke occurred. To improve stroke literacy and to reduce the disparity of awareness of SWS in community settings, public health efforts with an emphasis on AFFW and MML are needed.

Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update

In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.

Need to Prioritize Education of the Public Regarding Stroke Symptoms and Faster Activation of the 9-1-1 System: Findings from the Florida-Puerto Rico CReSD Stroke Registry

Objective: Demographic differences (race/ethnicity/sex) in 9-1-1 emergency medical services (EMS) access and utilization have been reported for various time-dependent critical illnesses along with associated outcome disparities. However, data are lacking with respect to measuring the various components of time taken to reach definitive care facilities following the onset of acute stroke symptoms (i.e., stroke onset to 9-1-1 call, EMS response, time on-scene, transport interval) and particularly with respect to any differences across ethnicities and sex. Therefore, the specific aim of this study was to measure the various time intervals elapsing following the first symptom onset (FSO) from an acute stroke until stroke hospital arrival (SHA) and to delineate any race/ethnic/sex-related differences among any of those measurements. Methods: The Florida-Puerto Rico Stroke Registry (FLPRSR) is an on-going, voluntary stroke registry of hospitals participating in the Get with the Guidelines-Stroke initiative. The study population included patients treated at Florida hospitals participating in the FLPRSR between 2010 and 2014 who had called 9-1-1 and were managed and transported by EMS. In total, 10,481 patients (16% black, 8% Hispanic, 74% white) had complete data-sets that included birthdate/year, sex, ethnic background, date/hour/minute of FSO and date/hour/minute of EMS response, scene arrival, and SHA. Results: Median time from FSO to SHA was 339 minutes (interquartile range [IQR] of 284-442), 301 of which constituted the time elapsed from FSO to the 9-1-1 call (IQR =249-392) versus only 10 from 9-1-1 call to EMS arrival (IQR =7-14), 14 on-scene (IQR =11-18) and 12 for transport to SHA (IQR =8-19). The FSO to 9-1-1 call interval, being by far the longest interval, was longest among whites and blacks (302 minutes for both) versus 291 for Hispanics (p = 0.01). However, this 11-minute difference was not deemed clinically-significant. There were neither significant sex-related differences nor any racial/ethnic/sex differences in the relatively short EMS-related intervals. Conclusions: Following acute stroke onset, time elapsed for EMS response and transport is relatively short compared to the lengthy intervals elapsing between symptom onset and 9-1-1 system activation, regardless of demographics. Exploration of innovative strategies to improve public education regarding stroke symptoms and immediate 9-1-1 system activation are strongly recommended.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format.

RESULTS

These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings.

CONCLUSIONS

These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Moderate and Severe Blood Pressure Elevation Associated with Stroke in the Mexican Hispanic Population

BACKGROUND

Stroke is the fourth leading cause of death in US. Amongst other factors such as age, sex, race, genetics, obesity, diabetes etc., hypertension continues to be the leading contributing factor towards stroke. Studies regarding stroke in Hispanics are sparse and inconclusive.

OBJECTIVES

The objective of the present study is to investigate the potential association between blood pressure elevation and risk of ischemic stroke among the Mexican Hispanic population.

METHODS

A retrospective data analysis was carried out for a planned case-control study with case-control ratios of 1:2. Mexican Hispanic cases were from the ElPasoStroke database with diagnosed hypertension that had sustained an ischemic stroke (n = 505) and Mexican Hispanics diagnosed with hypertension who were stroke-free as controls from the 2005-2010 NHANES databases (n = 1010). In this analysis, we included subjects who had data on systolic, diastolic or mean arterial blood pressures for cases (327) and controls (772). In cases, blood pressure was determined by the initial admission measurement, and in controls, the first measured blood pressure was used. The unadjusted and adjusted effects of continuous measurements of systolic, diastolic and mean arterial blood pressure on stroke were determined using logistic regression analyses. Subjects were further classified into groups based on prehypertension and hypertension ranges, as established by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). Unadjusted and adjusted logistic regression models were also used to determine the effect of categorized blood pressures.

RESULTS

Our data indicate that per unit increase in systolic, diastolic or mean arterial blood pressure elevates the odds of stroke among the Mexican Hispanic population. Adjusted analysis of categorized blood pressures showed that mild or moderate/severe high blood pressure significantly associated with odds of stroke. Maintaining and controlling blood pressure at more stringent and lower levels, specifically lowering mean arterial pressure may effectively reduce the odds of ischemic stroke among the Mexican Hispanic population.

CONCLUSION

Elevation of blood pressure increases the odds of stroke among the Mexican Hispanic population. Our results provide new strategies to manage the stroke prevention and health disparity issues among the Mexican Hispanic population.