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Dymm B, Goldstein LB, Unnithan S, Al-Khalidi HR, Koltai D, Bushnell C, Husseini NE. Depression following small vessel stroke is common and more prevalent in women. J Stroke Cerebrovasc Dis 2024; 33:107646. [PMID: 38395097 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES We sought to examine the frequency of depression after small vessel-type stroke (SVS) and associated risk factors. MATERIALS AND METHODS We conducted a retrospective analysis of a prospective cohort of patients enrolled in the American Stroke Association-Bugher SVS Study, which included 200 participants within 2-years of SVS and 79 controls without a history of stroke from 2007 to 2012 at four sites. The primary outcome was PHQ-8, with scores ≥10 consistent with post-stroke depression (PSD). A logistic regression adjusted for age, race, sex, history of diabetes and Short-Form Montreal Cognitive Assessment score (SF-MoCA) was used to compare the risk of having depression after SVS compared to controls. Another logistic regression, adjusted for age, sex, race, level of education, SF-MoCA, white matter disease (WMD) burden, stroke severity (NIHSS), time between stroke and depression screen, history of diabetes, and history of hypertension was used to identify factors independently associated with depression in participants with SVS. RESULTS The cohort included 161 participants with SVS (39 excluded due to missing data) and 79 controls. The mean interval between stroke and depression screening was 74 days. Among participants with SVS, 31.7% (n = 51) had PSD compared to 6.3% (n = 5) of controls (RR = 5.44, 95% CI = 2.21-13.38, p = 0.0002). The only two variables independently associated with PSD in participants with SVS were female sex (RR = 1.84, 95% CI = 1.09-3.09, p = 0.020) and diabetes (RR 1.69, 95% CI 1.03-2.79). CONCLUSIONS After adjusting for several demographic and clinical variables, having a SVS was associated with an approximate 5-fold increased risk of depression and was more frequent in women and in those with diabetes. The extent of WMD was not independently associated with PSD, suggesting that small vessel disease in the setting of an overt SVS may not account for the increased prevalence of depression.
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Affiliation(s)
- Braydon Dymm
- Duke University Hospital, Department of Neurology, 2301 Erwin Rd, Durham, NC 27705, United States.
| | | | - Shakthi Unnithan
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, United States
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, United States
| | - Deborah Koltai
- Duke University Hospital, Department of Neurology, 2301 Erwin Rd, Durham, NC 27705, United States
| | - Cheryl Bushnell
- Wake Forest Atrium Health, Department of Neurology, United States
| | - Nada El Husseini
- Duke University Hospital, Department of Neurology, 2301 Erwin Rd, Durham, NC 27705, United States
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Hogge C, Goldstein LB, Aroor SR. Mnemonic utilization in stroke education: FAST and BEFAST adoption by certified comprehensive stroke centers. Front Neurol 2024; 15:1359131. [PMID: 38533413 PMCID: PMC10963602 DOI: 10.3389/fneur.2024.1359131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/19/2024] [Indexed: 03/28/2024] Open
Abstract
Introduction Symptom recognition and timely access to treatment are critical components of acute stroke care systems. Two mnemonics widely used in public educational campaigns for recognizing stroke symptoms include FAST (Face-Arm-Speech-Time) and BEFAST (Balance-Eyes-Face-Arm Speech-Time). The FAST mnemonic can miss up to 14% of strokes. BEFAST includes common posterior circulation stroke symptoms and has been implemented by several Comprehensive Stroke Centers (CSCs). Methods We sought to analyze the pattern of public educational materials available on the websites of US CSCs. The Joint Commission (JC) quality check website compiles a list containing the names and locations of the country's 217 JC-certified CSCs, which was downloaded in August, 2022. Each CSC's website was searched for educational material containing FAST and BEFAST mnemonics for stroke symptom recognition. Results The FAST mnemonic was listed by 35% of CSCs, the BEFAST by 58%, with 7% listing no specific mnemonic. The highest portion of CSCs using BEFAST was in western (65%) and southeastern (63%) states. The highest percentage of CSCs with no listed mnemonic were in the northeastern (14%) and southeastern (13%) states. Conclusion Consistency is critical in shaping public health education related to stroke symptoms recognition. Our study suggests further effort is needed to unify the public messaging on stroke recognition.
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Affiliation(s)
- Christopher Hogge
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Larry B. Goldstein
- Department of Neurology, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Sushanth R. Aroor
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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Gaist D, García Rodríguez LA, Hallas J, Hald SM, Möller S, Høyer BB, Selim M, Goldstein LB. Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage. Neurology 2023; 101:e1793-e1806. [PMID: 37648526 PMCID: PMC10634647 DOI: 10.1212/wnl.0000000000207792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/12/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Survivors of spontaneous intracerebral hemorrhage (ICH) may have indications for statin therapy. The effect of statins on the risk of subsequent hemorrhagic and ischemic stroke (IS) in this setting is uncertain. We sought to determine the risk of any stroke (ischemic stroke, IS or recurrent ICH), IS, and recurrent ICH associated with statin use among ICH survivors. METHODS Using the Danish Stroke Registry, we identified all patients admitted to a hospital in Denmark (population 5.8 million) with a first-ever ICH between January 2003 and December 2021 who were aged 50 years or older and survived >30 days. Patients were followed up until August 2022. Within this cohort, we conducted 3 nested case-control analyses for any stroke, IS, and recurrent ICH. We matched controls for age, sex, time since first-ever ICH, and history of prior IS. The primary exposure was statin use before or on the date of subsequent stroke or the equivalent date in matched controls. Using conditional logistic regression, we calculated adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) for any stroke, IS, and recurrent ICH associated with statin exposure. RESULTS We identified 1,959 patients with any stroke (women 45.3%; mean [SD] age, 72.6 [9.7] years) who were matched to 7,400 controls; 1,073 patients with IS (women 42.0%; mean [SD] age, 72.4 [10.0] years) who were matched to 4,035 controls and 984 patients with recurrent ICH (women 48.7%; mean [SD] age, 72.7 [9.2] years) who were matched to 3,755 controls. Statin exposure was associated with a lower risk of both any stroke (cases 38.6%, controls 41.1%; aOR 0.88; 95% CI 0.78-0.99) and IS (cases 39.8%, controls 41.8%, aOR 0.79; 95% CI 0.67-0.92), but was not associated with recurrent ICH risk (cases 39.1%, controls 40.8%, aOR 1.05; 95% CI 0.88-1.24). DISCUSSION Exposure to statins was not associated with an increased risk of recurrent ICH but was associated with a lower risk of any stroke, largely due to a lower risk of IS. Confirmation of these findings in randomized trials is needed. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that statin use in patients with ICH is associated with a lower risk of any stroke and IS and not with increased risk of recurrent ICH.
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Affiliation(s)
- David Gaist
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington.
| | - Luis Alberto García Rodríguez
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Birgit Bjerre Høyer
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Magdy Selim
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
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Leifheit EC, Wang Y, Goldstein LB, Lichtman JH. Outcomes after ischemic stroke for dual-eligible Medicare-Medicaid beneficiaries in the United States. PLoS One 2023; 18:e0292546. [PMID: 37797070 PMCID: PMC10553827 DOI: 10.1371/journal.pone.0292546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 09/24/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Medicaid serves as a safety net for low-income US Medicare beneficiaries with limited assets. Approximately 7.7 million Americans aged ≥65 years rely on a combination of Medicare and Medicaid to obtain critical medical services, yet little is known about whether these patients have worse outcomes after stroke than patients with Medicare alone. We compared geographic patterns in dual Medicare-Medicaid eligibility and ischemic stroke hospitalizations and examined whether these dual-eligible beneficiaries had worse post-stroke outcomes than those with Medicare alone. METHODS We identified fee-for-service Medicare beneficiaries aged ≥65 years who were discharged from US acute-care hospitals with a principal diagnosis of ischemic stroke in 2014. Medicare beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We mapped risk-standardized stroke hospitalization rates and percentages of beneficiaries with dual eligibility. Mixed models and Cox regression were used to evaluate relationships between dual-eligible status and outcomes up to 1 year after stroke, adjusting for demographic and clinical factors. RESULTS At the national level, 12.5% of beneficiaries were dual eligible. Dual-eligible rates were highest in Maine, Alaska, and the southern half of the United States, whereas stroke hospitalization rates were highest in the South and parts of the Midwest (Pearson's r = 0.469, p<0.001). Among 254,902 patients hospitalized for stroke, 17.4% were dual eligible. In adjusted analyses, dual-eligible patients had greater risk of all-cause readmission within 30 days (hazard ratio 1.06, 95% confidence interval [CI] 1.03-1.09) and 1 year (hazard ratio 1.03, 95% CI 1.02-1.05) and had greater odds of death within 1 year (odds ratio 1.20, 95% CI 1.17-1.23) when compared with Medicare-only patients; there was no difference in in-hospital or 30-day mortality. CONCLUSION Dual-eligible stroke patients had higher readmissions and long-term mortality than other patients, even after comorbidity adjustment. A better understanding of the factors contributing to these poorer outcomes is needed.
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Affiliation(s)
- Erica C. Leifheit
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Yun Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Larry B. Goldstein
- University of Kentucky College of Medicine and Kentucky Neuroscience Institute, Lexington, Kentucky, United States of America
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, United States of America
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Goldstein LB, Toth PP, Dearborn-Tomazos JL, Giugliano RP, Hirsh BJ, Peña JM, Selim MH, Woo D. Aggressive LDL-C Lowering and the Brain: Impact on Risk for Dementia and Hemorrhagic Stroke: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol 2023; 43:e404-e442. [PMID: 37706297 DOI: 10.1161/atv.0000000000000164] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
The objective of this scientific statement is to evaluate contemporary evidence that either supports or refutes the conclusion that aggressive low-density lipoprotein cholesterol lowering or lipid lowering exerts toxic effects on the brain, leading to cognitive impairment or dementia or hemorrhagic stroke. The writing group used literature reviews, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion to summarize existing evidence and to identify gaps in current knowledge. Although some retrospective, case control, and prospective longitudinal studies suggest that statins and low-density lipoprotein cholesterol lowering are associated with cognitive impairment or dementia, the preponderance of observational studies and data from randomized trials do not support this conclusion. The risk of a hemorrhagic stroke associated with statin therapy in patients without a history of cerebrovascular disease is nonsignificant, and achieving very low levels of low-density lipoprotein cholesterol does not increase that risk. Data reflecting the risk of hemorrhagic stroke with lipid-lowering treatment among patients with a history of hemorrhagic stroke are not robust and require additional focused study.
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Das S, Verma N, Goldstein LB, Despa F. Skin capillary amylin deposition resembles brain amylin vasculopathy in rats. J Stroke Cerebrovasc Dis 2023; 32:107300. [PMID: 37572602 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Human amylin is a 37 amino-acid pancreatic peptide that forms neuro-toxic aggregates that deposit in the endothelium of brain capillaries of patients with diabetes, potentially contributing to cerebral small vessel ischemic injury. Pathogenic amylin also deposits in the capillary endothelium in other organs, including the skin. The aim of this study was to test the hypothesis that skin capillary amylin deposition correlates with cerebral small vessel amylin deposition, potentially providing a clinically useful marker of cerebral amylin deposition. METHODS Immunohistochemistry (IHC) was performed for human amylin and collagen IV in brain and skin sections of rats (age 15-16 months) with pancreatic overexpression of amyloidogenic human amylin polypeptide (HIP rats), and control rats (Wild type; WT; rats that express non-amyloidogenic rat amylin) using antibodies binding amylin (n = 5 male and 5 female rats for each group) and antibodies binding Hypoxia inducing factor (HIF)-1α and HIF-2α (n = 3 for each group). The reactive amylin-aldehyde 4-hydroxynonenal (4-HNE) adduct was measured in skin homogenates. (n = 4 for each group) RESULTS: Brain capillaries isolated from HIP rats had higher amylin content compared to WT rats using Western blot with anti-amylin antibody (p = 0.0010). The HIF-1α and HIF-2α immunoreactivity signals in skin from HIP and WT rats were similar (p = 0.2 for HIF-1 α, and p = 0.75 for HIF-2α). Amylin-4HNE adduct formation was higher in HIP rats compared to WT rats (p = 0.0014). There was phenotypic similarity between brain and skin capillary amylin based on co-staining for human amylin and collagen IV in both HIP and WT rats. CONCLUSION Skin and brain capillary amylin deposition are similar providing evidence that a skin biopsy might be providing a potential biomarker for diabetes-associated intracranial vasculopathy.
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Affiliation(s)
- Saurav Das
- Department of Neurology, University of Kentucky, United States.
| | - Nirmal Verma
- Pharmacology and Nutritional Sciences, University of Kentucky, United States
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky, United States. https://twitter.com/https://twitter.com/LBGoldsteinMD
| | - Florin Despa
- Pharmacology and Nutritional Sciences, University of Kentucky, United States. https://twitter.com/https://twitter.com/UKyNeuroscience
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Wang Y, Leifheit EC, Goldstein LB, Lichtman JH. Association of short-term hospital-level outcome metrics with 1-year mortality and recurrence for US Medicare beneficiaries with ischemic stroke. PLoS One 2023; 18:e0289790. [PMID: 37561680 PMCID: PMC10414659 DOI: 10.1371/journal.pone.0289790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 07/26/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Whether stroke patients treated at hospitals with better short-term outcome metrics have better long-term outcomes is unknown. We investigated whether treatment at US hospitals with better 30-day hospital-level stroke outcome metrics was associated with better 1-year outcomes, including reduced mortality and recurrent stroke, for patients after ischemic stroke. METHODS This cohort study included Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke from 07/01/2015 to 12/31/2018. We categorized patients by the treating hospital's performance on the CMS hospital-specific 30-day risk-standardized all-cause mortality and readmission measures for ischemic stroke from 07/01/2012 to 06/30/2015: Low-Low (both CMS mortality and readmission rates for the hospital were <25th percentile of national rates), High-High (both >75th percentile), and Intermediate (all other hospitals). We balanced characteristics between hospital performance categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical factors. We fit Cox models assessing patient risks of 1-year all-cause mortality and ischemic stroke recurrence across hospital performance categories, weighted by the IPW and accounting for competing risks. RESULTS There were 595,929 stroke patients (mean age 78.9±8.8 years, 54.4% women) discharged from 2,563 hospitals (134 Low-Low, 2288 Intermediate, 141 High-High). For Low-Low, Intermediate, and High-High hospitals, respectively, 1-year mortality rates were 23.8% (95% confidence interval [CI] 23.3%-24.3%), 25.2% (25.1%-25.3%), and 26.5% (26.1%-26.9%), and recurrence rates were 8.0% (7.6%-8.3%), 7.9% (7.8%-8.0%), and 8.0% (7.7%-8.3%). Compared with patients treated at High-High hospitals, those treated at Low-Low and Intermediate hospitals, respectively, had 15% (hazard ratio 0.85; 95% CI 0.82-0.87) and 9% (0.91; 0.89-0.93) lower risks of 1-year mortality but no difference in recurrence. CONCLUSIONS Ischemic stroke patients treated at hospitals with better CMS short-term outcome metrics had lower risks of post-discharge 1-year mortality, but similar recurrent stroke rates, compared with patients treated at other hospitals.
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Affiliation(s)
- Yun Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Erica C. Leifheit
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Larry B. Goldstein
- University of Kentucky College of Medicine and Kentucky Neuroscience Institute, Lexington, Kentucky, United States of America
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, United States of America
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Kotiya D, Leibold N, Verma N, Jicha GA, Goldstein LB, Despa F. Rapid, scalable assay of amylin-β amyloid co-aggregation in brain tissue and blood. J Biol Chem 2023; 299:104682. [PMID: 37030503 PMCID: PMC10192925 DOI: 10.1016/j.jbc.2023.104682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/30/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023] Open
Abstract
Islet amyloid polypeptide (amylin) secreted from the pancreas crosses from the blood to the brain parenchyma and forms cerebral mixed amylin-β amyloid (Aβ) plaques in persons with Alzheimer's disease (AD). Cerebral amylin-Aβ plaques are found in both sporadic and early-onset familial AD; however, the role of amylin-Aβ co-aggregation in potential mechanisms underlying this association remains unknown, in part due to lack of assays for detection of these complexes. Here, we report the development of an ELISA to detect amylin-Aβ hetero-oligomers in brain tissue and blood. The amylin-Aβ ELISA relies on a monoclonal anti-Aβ mid-domain antibody (detection) and a polyclonal anti-amylin antibody (capture) designed to recognize an epitope that is distinct from the high affinity amylin-Aβ binding sites. The utility of this assay is supported by the analysis of molecular amylin-Aβ codeposition in postmortem brain tissue obtained from persons with and without AD pathology. By using transgenic AD-model rats, we show that this new assay can detect circulating amylin-Aβ hetero-oligomers in the blood and is sensitive to their dissociation to monomers. This is important because therapeutic strategies to block amylin-Aβ co-aggregation could reduce or delay the development and progression of AD.
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Affiliation(s)
- Deepak Kotiya
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA; The Research Center for Healthy Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Noah Leibold
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA; The Research Center for Healthy Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Nirmal Verma
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA; The Research Center for Healthy Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Gregory A Jicha
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA; Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
| | - Florin Despa
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA; The Research Center for Healthy Metabolism, University of Kentucky, Lexington, Kentucky, USA; Department of Neurology, University of Kentucky, Lexington, Kentucky, USA.
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Kaddumukasa MN, Kaddumukasa M, Katabira E, Sewankambo N, Namujju LD, Goldstein LB. Prevalence and predictors of post-stroke cognitive impairment among stroke survivors in Uganda. BMC Neurol 2023; 23:166. [PMID: 37098461 PMCID: PMC10127321 DOI: 10.1186/s12883-023-03212-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/15/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Little is known about the characteristics and determinants of post-stroke cognitive impairment in residents of low- and middle-income countries. The objective of this study was to determine the frequencies, patterns, and risk factors for cognitive impairment in a cross-sectional study of consecutive stroke patients cared for at Uganda's Mulago Hospital, located in sub-Saharan Africa. METHODS 131 patients were enrolled a minimum of 3-months after hospital admission for stroke. A questionnaire, clinical examination findings, and laboratory test results were used to collect demographic information and data on vascular risk factors and clinical characteristics. Independent predictor variables associated with cognitive impairment were ascertained. Stroke impairments, disability, and handicap were assessed using the National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), and modified Rankin scale (mRS), respectively. The Montreal Cognitive Assessment (MoCA) was used to assess participants' cognitive function. Stepwise multiple logistic regression was used to identify variables independently associated with cognitive impairment. RESULTS The overall mean MoCA score was 11.7-points (range 0.0-28.0-points) for 128 patients with available data of whom 66.4% were categorized as cognitively impaired (MoCA < 19-points). Increasing age (OR 1.04, 95% CI 1.00-1.07; p = 0.026), low level of education (OR 3.23, 95% CI 1.25-8.33; p = 0.016), functional handicap (mRS 3-5; OR 1.84, 95% CI 1.28-2.63; p < 0.001) and high LDL cholesterol (OR 2.74, 95% CI 1.14-6.56; p = 0.024) were independently associated with cognitive impairment. CONCLUSIONS Our findings highlight the high burden and need for awareness of cognitive impairment in post stroke populations in the sub-Saharan region and serve to emphasize the importance of detailed cognitive assessment as part of routine clinical evaluation of patients who have had a stroke.
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Affiliation(s)
- Martin N Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nelson Sewankambo
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lillian D Namujju
- Department of Electrical and Computer Engineering, College of Engineering, Design, Art and Technology, Makerere University, Kampala, Uganda
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10
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Chyou JY, Barkoudah E, Dukes JW, Goldstein LB, Joglar JA, Lee AM, Lubitz SA, Marill KA, Sneed KB, Streur MM, Wong GC, Gopinathannair R. Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e676-e698. [PMID: 36912134 DOI: 10.1161/cir.0000000000001133] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.
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11
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Boe NJ, Hald SM, Jensen MM, Kristensen LMB, Bojsen JA, Elhakim MT, Clausen A, Möller S, Hallas J, García Rodríguez LA, Selim M, Goldstein LB, Al-Shahi Salman R, Gaist D. Major Cardiovascular Events After Spontaneous Intracerebral Hemorrhage by Hematoma Location. JAMA Netw Open 2023; 6:e235882. [PMID: 37017964 PMCID: PMC10077102 DOI: 10.1001/jamanetworkopen.2023.5882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/23/2023] [Indexed: 04/06/2023] Open
Abstract
Importance Survivors of spontaneous (ie, nontraumatic and with no known structural cause) intracerebral hemorrhage (ICH) have an increased risk of major cardiovascular events (MACEs), including recurrent ICH, ischemic stroke (IS), and myocardial infarction (MI). Only limited data are available from large, unselected population studies assessing the risk of MACEs according to index hematoma location. Objective To examine the risk of MACEs (ie, the composite of ICH, IS, spontaneous intracranial extra-axial hemorrhage, MI, systemic embolism, or vascular death) after ICH based on ICH location (lobar vs nonlobar). Design, Setting, and Participants This cohort study identified 2819 patients in southern Denmark (population of 1.2 million) 50 years or older hospitalized with first-ever spontaneous ICH from January 1, 2009, to December 31, 2018. Intracerebral hemorrhage was categorized as lobar or nonlobar, and the cohorts were linked to registry data until the end of 2018 to identify the occurrence of MACEs and separately recurrent ICH, IS, and MI. Outcome events were validated using medical records. Associations were adjusted for potential confounders using inverse probability weighting. Exposure Location of ICH (lobar vs nonlobar). Main Outcomes and Measures The main outcomes were MACEs and separately recurrent ICH, IS, and MI. Crude absolute event rates per 100 person-years and adjusted hazard ratios (aHRs) with 95% CIs were calculated. Data were analyzed from February to September 2022. Results Compared with patients with nonlobar ICH (n = 1255; 680 [54.2%] men and 575 [45.8%] women; mean [SD] age, 73.5 [11.4] years), those with lobar ICH (n = 1034; 495 [47.9%] men and 539 [52.1%] women, mean [SD] age, 75.2 [10.7] years) had higher rates of MACEs per 100 person-years (10.84 [95% CI, 9.51-12.37] vs 7.91 [95% CI, 6.93-9.03]; aHR, 1.26; 95% CI, 1.10-1.44) and recurrent ICH (3.74 [95% CI, 3.01-4.66] vs 1.24 [95% CI, 0.89-1.73]; aHR, 2.63; 95% CI, 1.97-3.49) but not IS (1.45 [95% CI, 1.02-2.06] vs 1.77 [95% CI, 1.34-2.34]; aHR, 0.81; 95% CI, 0.60-1.10) or MI (0.42 [95% CI, 0.22-0.81] vs 0.64 [95% CI, 0.40-1.01]; aHR, 0.64; 95% CI, 0.38-1.09). Conclusions and Relevance In this cohort study, spontaneous lobar ICH was associated with a higher rate of subsequent MACEs than nonlobar ICH, primarily due to a higher rate of recurrent ICH. This study highlights the importance of secondary ICH prevention strategies in patients with lobar ICH.
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Affiliation(s)
- Nils Jensen Boe
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Stine Munk Hald
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Mie Micheelsen Jensen
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Line Marie Buch Kristensen
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Jonas Asgaard Bojsen
- Department of Radiology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Mohammad Talal Elhakim
- Department of Radiology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Anne Clausen
- Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Sören Möller
- Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Department of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Magdy Selim
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Larry B. Goldstein
- Department of Neurology and Kentucky Neuroscience Institute, University of Kentucky, Lexington
| | | | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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12
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Tran PM, Warren JL, Leifheit EC, Goldstein LB, Lichtman JH. Associations Between Long-Term Air Pollutant Exposure and 30-Day All-Cause Hospital Readmissions in US Patients With Stroke. Stroke 2023; 54:e126-e129. [PMID: 36729388 DOI: 10.1161/strokeaha.122.042265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/01/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Long-term exposure to air pollutants is associated with increased stroke incidence, morbidity, and mortality; however, research on the association of pollutant exposure with poststroke hospital readmissions is lacking. METHODS We assessed associations between average annual carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), particulate matter 2.5, and sulfur dioxide (SO2) exposure and 30-day all-cause hospital readmission in US fee-for-service Medicare beneficiaries age ≥65 years hospitalized for ischemic stroke in 2014 to 2015. We fit Cox models to assess 30-day readmissions as a function of these pollutants, adjusted for patient and hospital characteristics and ambient temperature. Analyses were then stratified by treating hospital performance on the Centers for Medicare and Medicaid Services risk-standardized 30-day poststroke all-cause readmission measure to determine if the results were independent of performance: low (Centers for Medicare and Medicaid Services rate for hospital <25th percentile of national rate), high (>75th percentile), and intermediate (all others). RESULTS Of 448 148 patients with stroke, 12.5% were readmitted within 30 days. Except for tropospheric NO2 (no national standard), average 2-year CO, O3, particulate matter 2.5, and SO2 values were below national limits. Each one SD increase in average annual CO, NO2, particulate matter 2.5, and SO2 exposure was associated with an adjusted 1.1% (95% CI, 0.4-1.9%), 3.6% (95% CI, 2.9%-4.4%), 1.2% (95% CI, 0.2%-2.3%), and 2.0% (95% CI, 1.1%-3.0%) increased risk of 30-day readmission, respectively, and O3 with a 0.7% (95% CI, 0.0%-1.5%) decrease. Associations between long-term air pollutant exposure and increased readmissions persisted across hospital performance categories. CONCLUSIONS Long-term air pollutant exposure below national limits was associated with increased 30-day readmissions after stroke, regardless of hospital performance category. Whether air quality improvements lead to reductions in poststroke readmissions requires further research.
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Affiliation(s)
- Phoebe M Tran
- Department of Public Health, University of Tennessee, Knoxville (P.M.T.)
| | - Joshua L Warren
- Departments of Biostatistics (J.L.W.), Yale School of Public Health, New Haven, CT
| | - Erica C Leifheit
- Chronic Disease Epidemiology (E.C.L., J.H.L.), Yale School of Public Health, New Haven, CT
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky College of Medicine, Lexington (L.B.G.)
| | - Judith H Lichtman
- Chronic Disease Epidemiology (E.C.L., J.H.L.), Yale School of Public Health, New Haven, CT
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13
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Boe NJ, Hald SM, Jensen MM, Bojsen JA, Elhakim MT, Florisson S, Saleh A, Clausen A, Möller S, Harbo FSG, Graumann O, Hallas J, García Rodríguez LA, Al-Shahi Salman R, Goldstein LB, Gaist D. Association Between Statin Use and Intracerebral Hemorrhage Location: A Nested Case-Control Registry Study. Neurology 2023; 100:e1048-e1061. [PMID: 36878720 PMCID: PMC9990851 DOI: 10.1212/wnl.0000000000201664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A causal relationship between statin use and intracerebral hemorrhage (ICH) is uncertain. We hypothesized that an association between long-term statin exposure and ICH risk might vary for different ICH locations. METHODS We conducted this analysis using linked Danish nationwide registries. Within the Southern Denmark Region (population 1.2 million), we identified all first-ever cases of ICH between 2009 and 2018 in persons aged ≥55 years. Patients with medical record-verified diagnoses were classified as having a lobar or nonlobar ICH and matched for age, sex, and calendar year to general population controls. We used a nationwide prescription registry to ascertain prior statin and other medication use that we classified for recency, duration, and intensity. Using conditional logistic regression adjusted for potential confounders, we calculated adjusted ORs (aORs) and corresponding 95% CIs for the risk of lobar and nonlobar ICH. RESULTS We identified 989 patients with lobar ICH (52.2% women, mean age 76.3 years) who we matched to 39,500 controls and 1,175 patients with nonlobar ICH (46.5% women, mean age 75.1 years) who we matched to 46,755 controls. Current statin use was associated with a lower risk of lobar (aOR 0.83; 95% CI, 0.70-0.98) and nonlobar ICH (aOR 0.84; 95% CI, 0.72-0.98). Longer duration of statin use was also associated with a lower risk of lobar (<1 year: aOR 0.89; 95% CI, 0.69-1.14; ≥1 year to <5 years aOR 0.89; 95% CI 0.73-1.09; ≥5 years aOR 0.67; 95% CI, 0.51-0.87; p for trend 0.040) and nonlobar ICH (<1 year: aOR 1.00; 95% CI, 0.80-1.25; ≥1 year to <5 years aOR 0.88; 95% CI 0.73-1.06; ≥5 years aOR 0.62; 95% CI, 0.48-0.80; p for trend <0.001). Estimates stratified by statin intensity were similar to the main estimates for low-medium intensity therapy (lobar aOR 0.82; nonlobar aOR 0.84); the association with high-intensity therapy was neutral. DISCUSSION We found that statin use was associated with a lower risk of ICH, particularly with longer treatment duration. This association did not vary by hematoma location.
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Affiliation(s)
- Nils Jensen Boe
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Mie Micheelsen Jensen
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jonas Asgaard Bojsen
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Mohammad Talal Elhakim
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sandra Florisson
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Alisa Saleh
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Anne Clausen
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Frederik Severin Gråe Harbo
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Ole Graumann
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Luis Alberto García Rodríguez
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Rustam Al-Shahi Salman
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - David Gaist
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington.
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14
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Charlotte Sandset E, Goldstein LB. Advances in Stroke: Treatments-Preventive. Stroke 2023; 54:868-869. [PMID: 36756888 DOI: 10.1161/strokeaha.123.042097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.).,The Norwegian Air Ambulance, Oslo, Norway (E.C.S.)
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15
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Leifheit EC, Wang Y, Goldstein LB, Lichtman JH. Abstract 157: Association Of Hospital Performance With 1-Year Mortality And Recurrence After Ischemic Stroke Among US Medicare Beneficiaries. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Whether stroke patients treated at hospitals with better short-term quality performance metrics have better long-term outcomes is unknown. We determined if ischemic stroke patients treated at US hospitals with better past performance on the Centers for Medicare & Medicaid Services (CMS) 30-day mortality and readmission outcome measures for stroke had better 1-year outcomes compared to those treated at other hospitals.
Methods:
We included all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke from 07/01/2015 to 12/31/2018. We categorized patients by the treating hospital’s performance on the CMS hospital-specific 30-day risk-standardized all-cause mortality and readmission rate measures for stroke from 07/01/2012 to 06/30/2015: Low-Low (both CMS mortality and readmission rates for the hospital were <25
th
percentile of national rates), High-High (both >75
th
percentile), and Intermediate (all others). We balanced characteristics between hospital performance categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical factors. We fit Cox models to assess patient risks of 1-year mortality and recurrent stroke across hospital performance categories, weighted by the IPW and accounting for competing risks.
Results:
There were 595,929 stroke patients (mean age 78.9y, 54.4% women, 82.2% White) discharged from 134 Low-Low, 2288 Intermediate, and 141 High-High hospitals. For patients treated at Low-Low, Intermediate, and High-High hospitals, respectively, 1-year mortality rates were 23.8% (95% CI 23.3-24.3%), 25.2% (25.1-25.3%), and 26.5% (26.1-26.9%), and recurrence rates were 8.0% (7.6-8.3%), 7.9% (7.8-8.0%), and 8.0% (7.7-8.3%). Compared with patients at High-High hospitals, those at Low-Low and Intermediate hospitals, respectively, had 15% (hazard ratio 0.85; 95% CI 0.82-0.87) and 9% (0.91; 0.89-0.93) lower risks of 1-year mortality but no difference in 1-year recurrence.
Conclusions:
Ischemic stroke patients treated at better-performing hospitals had lower risks of post-discharge 1-year mortality but similar risks of recurrent stroke compared with patients treated at other hospitals.
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Affiliation(s)
| | - Yun Wang
- Yale Sch of Medicine, New Haven, CT
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16
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Dymm B, Goldstein LB, El Husseini NK, Bushnell CD, Koltai D. Abstract 139: Depression Following Small Vessel Stroke Is Common And More Prevalent In Women. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Post-stroke depression (PSD) affects about one third of stroke survivors and is associated with poorer quality of life. Little is known about the prevalence and independent risk factors for depression associated with small vessel stroke (SVS).
Methods:
We conducted a retrospective analysis of a prospective cohort of patients enrolled in the American Stroke Association-Bugher SVS Study, which enrolled 200 patients within 2 years of SVS and 79 controls without stroke history from 2007 to 2012 at four clinical sites. The primary outcome was PHQ-8 dichotomized at (≥10 and <10) with higher scores consistent with PSD. Chi-square test was used to compare the rates of depression between the two groups. Logistic regression was used to evaluate factors associated with depression in patients with SVS adjusted for age, sex, race/ethnicity, NIH Stroke Scale, white matter disease (WMD) burden, Montreal Cognitive Assessment short-form score, and history of diabetes.
Results:
The cohort included 161 participants with SVS (excluding 39 due to missing key variables) and 79 controls. Participant characteristics are described in Table 1. The mean time between stroke and depression screening was 74 days. Among participants with SVS, 31.7% (n=51) screened positive for PSD, compared to 6.3% (n=5) of controls, OR= 6.9 (95%CI 2.6-18.0%; p<0.0001). PSD was prevalent in 35.9% of participants with SVS who had good functional outcome (modified Rankin score ≤2). Female sex was the only variable associated with PSD in those with SVS (OR 2.3, 95%CI 1.0-5.2, p=0.041).
Conclusion:
In this well-characterized cohort of SVS with mostly mild stroke severity, depression within 3 months of the incident stroke was about 7 times more likely than those without a history of stroke. The extent of WMD was not associated with PSD, suggesting that small vessel disease other than the incident SVS does not account for the increased rates of PSD. Depression following SVS was more prevalent in women.
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Leibold N, Kotiya D, Sheikhi L, Dornbos DL, Pahwa SS, Trout AL, Frank JA, Pennypacker KR, Goldstein LB, Despa F, Fraser JF. Abstract WP247: Amylin, A Diabetes-associated Amyloid-forming Peptide, Accumulates In Thrombi And On Red Blood Cells - A New Biomarker For Stroke? Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Emergent large vessel occlusions result in severe ischemic stroke without appropriate treatment with thrombolysis and/or mechanical thrombectomy. Type-2 diabetes mellitus (T2DM) is a major risk factor in stroke, with 25% of ischemic attacks occurring in individuals with T2DM. T2DM diagnosis is also associated with poorer functional outcomes, prolonged hospitalizations, and increased risk of recurrent stroke. Amylin, a peptide co-secreted with insulin in pancreatic β-cells, is hypersecreted in T2DM and readily forms neurotoxic oligomers which deposit in brain parenchyma. Due to amylin’s role in T2DM and T2DM’s relationship to stroke, we anticipated an increased level of amylin would be deposited on red blood cells (RBCs) of stroke patients when compared to non-stroke patients. Additionally, we anticipated an increased level of amylin immunoreactivity (AIR) in clot lysates when compared to RBC lysates and plasma. Blood samples and thrombi (
n
=47) were collected from patients undergoing mechanical thrombectomies for stroke while blood samples (
n
=21) were collected from patients with non-stroke neurological conditions. Samples were lysed and assayed for total protein concentration and intensity of AIR. Amylin uptake coefficients (AUCs) demonstrating the proportionality of amylin deposited on RBCs compared to total circulating amylin were calculated. After normalizing to total protein concentration, analysis revealed a significantly increased level of AIR in stroke clots when compared to stroke and non-stroke plasma and RBC lysates (p<0.001 for each). Additionally, a significant increase (p<0.0073) in AUC was found in stroke versus non-stroke. In summary, amylin accumulates in thrombi and deposits on RBCs of stroke patients. Further research into amylin’s potential role in thrombus formation is justified. Future studies are also needed to determine if stroke severity is associated with amylin level in thrombi and if T2DM exacerbates amylin-stroke pathology.
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Affiliation(s)
- Noah Leibold
- Pharmacology & Nutritional Sciences, Univ of Kentucky, Lexington, KY
| | - Deepak Kotiya
- Pharmacology & Nutritional Sciences, Univ of Kentucky, Lexington, KY
| | | | | | | | | | | | | | | | - Florin Despa
- Pharmacology & Nutritional Sciences, Univ of Kentucky, Lexington, KY
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18
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Hogge C, Goldstein LB, Aroor S. Abstract TP56: Us Comprehensive Stroke Center Utilization Of FAST And BEFAST Mnemonics For Public Education. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Symptom recognition and timely access to treatment are critical components of acute stroke care systems. Two mnemonics widely used in public educational campaigns for recognizing stroke symptoms include FAST (Face-Arm-Speech-Time) and BEFAST (Balance-Eyes-Face-Arm Speech-Time). The FAST mnemonic, endorsed by the AHA/ASA can miss up to 14% of strokes. BEFAST includes common posterior circulation stroke symptoms and has been implemented by several Comprehensive Stroke Centers (CSCs).
Methods:
We sought to analyze the pattern of public educational materials available on the websites of US CSCs. The Joint Commission (JC) quality check website compiles a list containing the names and locations of the country’s 217 JC-certified CSCs, which was downloaded in August, 2022. Each CSC’s website was searched for educational material containing FAST and BEFAST mnemonics for stroke symptom recognition.
Results:
The FAST mnemonic was listed by 35% of CSCs, the BEFAST by 58%, with 7% listing no specific mnemonic. The highest portion of CSCs using BEFAST was in western (65%) and southeastern (63%) states. The highest percentage of CSCs with no listed mnemonic were in the northeastern (14%) and southeastern (13%) states.
Conclusions:
Consistency is critical in shaping public health education related to stroke symptoms recognition. Our study suggests further effort is needed to unify the public messaging on stroke recognition.
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19
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Leifheit EC, Wang Y, Goldstein LB, Lichtman JH. Abstract WMP104: Mortality And Recurrence Within 1 Year After Ischemic Stroke For Urban Vs Rural US Medicare Beneficiaries. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Approximately 14% of the US population resides in rural areas, which have higher rates of chronic disease and are often medically underserved. We compared 1-year outcomes after ischemic stroke for Medicare beneficiaries living in urban vs rural areas.
Methods:
We identified all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US acute-care hospitals with ischemic stroke in 2015 to 2017. Patients were followed up to 1 year through 2018 for death or ischemic stroke recurrence and categorized according to geographic remoteness of their residence using the Rural-Urban Community Area codes. We balanced patient characteristics between the rural/urban categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical characteristics. We created adjusted Kaplan-Meier curves based on the IPW and fit Cox models to assess differences in 1-year all-cause mortality and recurrent stroke weighted by the IPW and accounting for competing risks.
Results:
There were 536,930 stroke patients (32,635 isolated rural, 40,240 small rural, 66,320 large rural, 397,735 urban; mean age 79.0 years, 54.7% women, 82.5% White). For isolated rural, small rural, large rural, and urban residents, 1-year adjusted mortality rates were 24.1%, 24.6%, 24.7%, and 22.9%, and 1-year stroke recurrence rates were 8.0%, 7.8%, 7.9%, and 8.1%, respectively. Compared with urban residents, isolated rural (HR 1.07, 95% CI 1.04-1.09), small rural (1.09, 1.07-1.12), and large rural (1.10, 1.08-1.12) residents had greater risk of death within 1 year after stroke, but there was little difference in recurrence (Fig. A). Urban residents had the lowest mortality across regions, but there was variation among the rural subcategories and for recurrence in region-stratified analyses (Fig. B).
Conclusions:
Ischemic stroke patients living in urban areas had a lower risk of mortality within 1 year compared with those living in more rural areas.
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Affiliation(s)
| | - Yun Wang
- Yale Sch of Medicine, New Haven, CT
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20
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Verma N, Velmurugan GV, Winford E, Coburn H, Kotiya D, Leibold N, Radulescu L, Despa S, Chen KC, Van Eldik LJ, Nelson PT, Wilcock DM, Jicha GA, Stowe AM, Goldstein LB, Powel DK, Walton JH, Navedo MF, Nystoriak MA, Murray AJ, Biessels GJ, Troakes C, Zetterberg H, Hardy J, Lashley T, Despa F. Aβ efflux impairment and inflammation linked to cerebrovascular accumulation of amyloid-forming amylin secreted from pancreas. Commun Biol 2023; 6:2. [PMID: 36596993 PMCID: PMC9810597 DOI: 10.1038/s42003-022-04398-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 12/21/2022] [Indexed: 01/04/2023] Open
Abstract
Impairment of vascular pathways of cerebral β-amyloid (Aβ) elimination contributes to Alzheimer disease (AD). Vascular damage is commonly associated with diabetes. Here we show in human tissues and AD-model rats that bloodborne islet amyloid polypeptide (amylin) secreted from the pancreas perturbs cerebral Aβ clearance. Blood amylin concentrations are higher in AD than in cognitively unaffected persons. Amyloid-forming amylin accumulates in circulating monocytes and co-deposits with Aβ within the brain microvasculature, possibly involving inflammation. In rats, pancreatic expression of amyloid-forming human amylin indeed induces cerebrovascular inflammation and amylin-Aβ co-deposits. LRP1-mediated Aβ transport across the blood-brain barrier and Aβ clearance through interstitial fluid drainage along vascular walls are impaired, as indicated by Aβ deposition in perivascular spaces. At the molecular level, cerebrovascular amylin deposits alter immune and hypoxia-related brain gene expression. These converging data from humans and laboratory animals suggest that altering bloodborne amylin could potentially reduce cerebrovascular amylin deposits and Aβ pathology.
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Affiliation(s)
- Nirmal Verma
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
- The Research Center for Healthy Metabolism, University of Kentucky, Lexington, KY, USA
| | | | - Edric Winford
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
- Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | - Han Coburn
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Deepak Kotiya
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
- The Research Center for Healthy Metabolism, University of Kentucky, Lexington, KY, USA
| | - Noah Leibold
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
- The Research Center for Healthy Metabolism, University of Kentucky, Lexington, KY, USA
| | - Laura Radulescu
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
- The Research Center for Healthy Metabolism, University of Kentucky, Lexington, KY, USA
| | - Sanda Despa
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
- The Research Center for Healthy Metabolism, University of Kentucky, Lexington, KY, USA
| | - Kuey C Chen
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
- UKHC Genomics Laboratory, University of Kentucky, Lexington, KY, USA
| | - Linda J Van Eldik
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
| | - Peter T Nelson
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
| | - Donna M Wilcock
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
- Department of Physiology, University of Kentucky, Lexington, KY, USA
| | - Gregory A Jicha
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Ann M Stowe
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | | | - David K Powel
- Magnetic Resonance Imaging and Spectroscopy Center, University of Kentucky, Lexington, KY, USA
| | | | - Manuel F Navedo
- Department of Pharmacology, University of California, Davis, CA, USA
| | | | - Andrew J Murray
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, CB2 3EG, UK
| | - Geert Jan Biessels
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Claire Troakes
- Basic and Clinical Neuroscience Department, King's College London, London, UK
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL and Department of Neurodegenerative Disease, UCL Institute of Neurology, University College London, London, UK
| | - John Hardy
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL and Department of Neurodegenerative Disease, UCL Institute of Neurology, University College London, London, UK
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, 1 Wakefield Street, London, WC1N 1PJ, UK
- UCL Movement Disorders Centre, University College London, London, UK
- Institute for Advanced Study, The Hong Kong University of Science and Technology, Hong Kong SAR, China
| | - Tammaryn Lashley
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
- Queen Square Brain Bank for Neurological Disorders, Department of Clinical and Movement Neuroscience, UCL Queen Square Institute of Neurology, London, UK
| | - Florin Despa
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA.
- The Research Center for Healthy Metabolism, University of Kentucky, Lexington, KY, USA.
- Department of Neuroscience, University of Kentucky, Lexington, KY, USA.
- Department of Neurology, University of Kentucky, Lexington, KY, USA.
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21
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Bahrani AA, Abner EL, DeCarli CS, Barber JM, Sutton AC, Maillard P, Sandoval F, Arfanakis K, Yang YC, Evia AM, Schneider JA, Habes M, Franklin CG, Seshadri S, Satizabal CL, Caprihan A, Thompson JF, Rosenberg GA, Wang DJJ, Jann K, Zhao C, Lu H, Rosenberg PB, Albert MS, Ali DG, Singh H, Schwab K, Greenberg SM, Helmer KG, Powel DK, Gold BT, Goldstein LB, Wilcock DM, Jicha GA. Multi-Site Cross-Site Inter-Rater and Test-Retest Reliability and Construct Validity of the MarkVCID White Matter Hyperintensity Growth and Regression Protocol. J Alzheimers Dis 2023; 96:683-693. [PMID: 37840499 PMCID: PMC11009792 DOI: 10.3233/jad-230629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND White matter hyperintensities (WMH) that occur in the setting of vascular cognitive impairment and dementia (VCID) may be dynamic increasing or decreasing volumes or stable over time. Quantifying such changes may prove useful as a biomarker for clinical trials designed to address vascular cognitive-impairment and dementia and Alzheimer's Disease. OBJECTIVE Conducting multi-site cross-site inter-rater and test-retest reliability of the MarkVCID white matter hyperintensity growth and regression protocol. METHODS The NINDS-supported MarkVCID Consortium evaluated a neuroimaging biomarker developed to track WMH change. Test-retest and cross-site inter-rater reliability of the protocol were assessed. Cognitive test scores were analyzed in relation to WMH changes to explore its construct validity. RESULTS ICC values for test-retest reliability of WMH growth and regression were 0.969 and 0.937 respectively, while for cross-site inter-rater ICC values for WMH growth and regression were 0.995 and 0.990 respectively. Word list long-delay free-recall was negatively associated with WMH growth (p < 0.028) but was not associated with WMH regression. CONCLUSIONS The present data demonstrate robust ICC validity of a WMH growth/regression protocol over a one-year period as measured by cross-site inter-rater and test-retest reliability. These data suggest that this approach may serve an important role in clinical trials of disease-modifying agents for VCID that may preferentially affect WMH growth, stability, or regression.
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Affiliation(s)
- Ahmed A Bahrani
- Department of Neurology, University of Kentucky, College of Medicine, Lexington, KY, USA
- Sanders-Brown Center on Aging, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Erin L Abner
- Sanders-Brown Center on Aging, University of Kentucky, College of Medicine, Lexington, KY, USA
- Department of Epidemiology & Environmental Health, University of Kentucky, College of Public Health, Lexington, KY, USA
| | | | - Justin M Barber
- Sanders-Brown Center on Aging, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Abigail C Sutton
- Sanders-Brown Center on Aging, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Pauline Maillard
- Department of Neurology, University of California, Davis, CA, USA
| | | | - Konstantinos Arfanakis
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, USA
| | - Yung-Chuan Yang
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Arnold M Evia
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Julie A Schneider
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Mohamad Habes
- Research Imaging Institute, University of Texas Health San Antonio, San Antonio, TX, USA
- Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Crystal G Franklin
- Research Imaging Institute, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Claudia L Satizabal
- Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases, University of Texas Health San Antonio, San Antonio, TX, USA
| | | | | | - Gary A Rosenberg
- Center for Memory and Aging, University of New Mexico, Health Sciences Center, Albuquerque, NM, USA
| | - Danny J J Wang
- Departments of Neurology and Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kay Jann
- Departments of Neurology and Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Chenyang Zhao
- Departments of Neurology and Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hanzhang Lu
- Department of Radiology and Radiological Science, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Paul B Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Marilyn S Albert
- Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Doaa G Ali
- Sanders-Brown Center on Aging, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Herpreet Singh
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kristin Schwab
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Karl G Helmer
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David K Powel
- Department of Neuroscience, University of Kentucky, College of Medicine, Lexington, KY, USA
- Magnetic Resonance Imaging and Spectroscopy Center, University of Kentucky, Lexington, KY, USA
| | - Brian T Gold
- Sanders-Brown Center on Aging, University of Kentucky, College of Medicine, Lexington, KY, USA
- Department of Neuroscience, University of Kentucky, College of Medicine, Lexington, KY, USA
- Magnetic Resonance Imaging and Spectroscopy Center, University of Kentucky, Lexington, KY, USA
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Donna M Wilcock
- Sanders-Brown Center on Aging, University of Kentucky, College of Medicine, Lexington, KY, USA
- Department of Physiology, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Gregory A Jicha
- Department of Neurology, University of Kentucky, College of Medicine, Lexington, KY, USA
- Sanders-Brown Center on Aging, University of Kentucky, College of Medicine, Lexington, KY, USA
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22
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Leibold NS, Kotiya D, Despa F, Sheikhi L, III DLD, Pahwa SS, Trout A, Frank JA, Pennypacker KR, Goldstein LB, Fraser JF. Amyloidogenic amylin deposits on red blood cells of stroke patients. Alzheimers Dement 2022. [DOI: 10.1002/alz.069419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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23
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Bahrani AA, Barber JM, Gold BT, Ali D, Powell DK, Van Eldik LJ, Goldstein LB, Wilcock DM, Jicha GA. Discrete white matter hyperintensity (WMH) growth quantification is superior to measurements of total longitudinal WMH volume change: implications for clinical trials in VCID. Alzheimers Dement 2022. [DOI: 10.1002/alz.064505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Ahmed Ali Bahrani
- Sanders‐Brown Center on Aging Lexington KY USA
- University of Kentucky College of Medicine Lexington KY USA
| | - Justin M Barber
- Sanders‐Brown Center on Aging Lexington KY USA
- University of Kentucky College of Medicine Lexington KY USA
| | - Brian T. Gold
- Sanders‐Brown Center on Aging Lexington KY USA
- University of Kentucky College of Medicine Lexington KY USA
| | - Doaa Ali
- Sanders‐Brown Center on Aging Lexington KY USA
- University of Kentucky College of Medicine Lexington KY USA
| | - David K Powell
- University of Kentucky College of Medicine Lexington KY USA
| | - Linda J Van Eldik
- Sanders‐Brown Center on Aging Lexington KY USA
- University of Kentucky College of Medicine Lexington KY USA
| | | | - Donna M Wilcock
- University of Kentucky College of Medicine Lexington KY USA
- University of Kentucky / Sanders‐Brown Center on Aging Lexington KY USA
| | - Gregory A Jicha
- Sanders‐Brown Center on Aging Lexington KY USA
- University of Kentucky College of Medicine Lexington KY USA
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24
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Jicha GA, Goldstein LB, Wilcock DM, Despa F. Baseline blood amylin levels predict longitudinal cognitive decline in participants at risk for or with mild cognitive impairment and dementia. Alzheimers Dement 2022. [DOI: 10.1002/alz.066330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Donna M Wilcock
- University of Kentucky / Sanders‐Brown Center on Aging Lexington KY USA
- University of Kentucky College of Medicine Lexington KY USA
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25
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Abstract
BACKGROUND There have been important advances in secondary stroke prevention and a focus on healthcare delivery over the past decades. Yet, data on US trends in recurrent stroke are limited. We examined national and regional patterns in 1-year recurrence among Medicare beneficiaries hospitalized for ischemic stroke from 2001 to 2017. METHODS This cohort study included all fee-for-service Medicare beneficiaries aged ≥65 years who were discharged alive with a principal diagnosis of ischemic stroke from 2001 to 2017. Follow-up was up to 1 year through 2018. Cox models were used to assess temporal trends in 1-year recurrent ischemic stroke, adjusting for demographic and clinical characteristics. We mapped recurrence rates and identified persistently high-recurrence counties as those with rates in the highest sextile for stroke recurrence in ≥5 of the following periods: 2001-2003, 2004-2006, 2007-2009, 2010-2012, 2013-2015, and 2016-2017. RESULTS There were 3 638 346 unique beneficiaries discharged with stroke (mean age 79.0±8.1 years, 55.2% women, 85.3% White). The national 1-year recurrent stroke rate decreased from 11.3% in 2001-2003 to 7.6% in 2016-2017 (relative reduction, 33.5% [95% CI, 32.5%-34.5%]). There was a 2.3% (95% CI, 2.2%-2.4%) adjusted annual decrease in recurrence from 2001 to 2017 that included reductions in all age, sex, and race subgroups. County-level recurrence rates ranged from 5.5% to 14.0% in 2001-2003 and from 0.2% to 8.9% in 2016-2017. There were 76 counties, concentrated in the South-Central United States, that had the highest recurrence throughout the study. These counties had populations with a higher proportion of Black residents and uninsured adults, greater wealth inequity, poorer general health, and reduced preventive testing rates as compared with other counties. CONCLUSIONS Recurrent ischemic strokes decreased over time overall and across demographic subgroups; however, there were geographic areas with persistently higher recurrence rates. These findings can inform secondary prevention intervention opportunities for high-risk populations and communities.
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Affiliation(s)
- Erica C Leifheit
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.C.L., J.H.L.)
| | - Yun Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W.)
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.W.)
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky College of Medicine and Kentucky Neuroscience Institute, Lexington (L.B.G.)
| | - Judith H Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.C.L., J.H.L.)
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Rudolph DA, Hald SM, García Rodríguez LA, Möller S, Hallas J, Goldstein LB, Gaist D. Association of Long-term Statin Use With the Risk of Intracerebral Hemorrhage: A Danish Nationwide Case-Control Study. Neurology 2022; 99:e711-e719. [PMID: 35577575 DOI: 10.1212/wnl.0000000000200713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/24/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A causal relationship between long-term statin use and the risk of intracerebral hemorrhage (ICH) remains uncertain. We investigated the association with statin use before hospital admission for ICH in a Danish population-based, nationwide case-control study. METHODS We used the Danish Stroke Registry to identify all patients aged 45 years or older with a first-ever ICH between 2005 and 2018. Patients with ICH were matched for age, sex, and calendar year to controls selected from the general population. A medication registry with information on all dispensed prescriptions at community pharmacies in Denmark since 1995 was used to ascertain previous statin exposure that was classified for recency, duration, and intensity. Using conditional regression and adjusting for potential confounders, we calculated adjusted odds ratios (aORs) and corresponding 95% CIs for the risk of ICH. RESULTS The study population consisted of 16,235 patients with ICH and 640,943 controls. Current statin use (cases 25.9% vs controls 24.5%; aOR 0.74, 95% CI, 0.71-0.78) and a longer duration of current statin use (<1 year: aOR 0.86; 95% CI, 0.81-0.92; ≥1 to <5 years: aOR 0.72; 95% CI, 0.68-0.76; ≥5 to <10 years: aOR 0.65; 95% CI, 0.60-0.71; ≥10 years of use, 0.53; 95% CI 0.45-0.62; p for trend <0.001) were associated with a lower risk of ICH. Similar treatment duration relationships were found in analyses stratified by statin use intensity (high-intensity therapy: <1 year of use: aOR 0.78; 95% CI, 0.66-0.93; ≥10 years of use: aOR 0.46; 95% CI 0.33-0.65; p for trend 0.001). DISCUSSION We found that a longer duration of statin use was associated with a lower risk of ICH. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that current statin use and a longer duration of statin use are each associated with a lower risk of ICH.
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Affiliation(s)
- Daniel Albjerg Rudolph
- From the Research Unit for Neurology (D.A.R., S.M.H., D.G.), Odense University Hospital; University of Southern Denmark (D.A.R., S.M.H., S.M.H.), Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Department of Clinical Research (S.M.), University of Southern Denmark, Odense; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Research Unit for Neurology (D.A.R., S.M.H., D.G.), Odense University Hospital; University of Southern Denmark (D.A.R., S.M.H., S.M.H.), Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Department of Clinical Research (S.M.), University of Southern Denmark, Odense; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Luis Alberto García Rodríguez
- From the Research Unit for Neurology (D.A.R., S.M.H., D.G.), Odense University Hospital; University of Southern Denmark (D.A.R., S.M.H., S.M.H.), Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Department of Clinical Research (S.M.), University of Southern Denmark, Odense; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Research Unit for Neurology (D.A.R., S.M.H., D.G.), Odense University Hospital; University of Southern Denmark (D.A.R., S.M.H., S.M.H.), Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Department of Clinical Research (S.M.), University of Southern Denmark, Odense; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Research Unit for Neurology (D.A.R., S.M.H., D.G.), Odense University Hospital; University of Southern Denmark (D.A.R., S.M.H., S.M.H.), Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Department of Clinical Research (S.M.), University of Southern Denmark, Odense; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Research Unit for Neurology (D.A.R., S.M.H., D.G.), Odense University Hospital; University of Southern Denmark (D.A.R., S.M.H., S.M.H.), Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Department of Clinical Research (S.M.), University of Southern Denmark, Odense; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - David Gaist
- From the Research Unit for Neurology (D.A.R., S.M.H., D.G.), Odense University Hospital; University of Southern Denmark (D.A.R., S.M.H., S.M.H.), Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Department of Clinical Research (S.M.), University of Southern Denmark, Odense; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington.
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Tran PM, Tran LT, Zhu C, Chang T, Powers IP, Goldstein LB, Lichtman JH. Rural Residence and Antihypertensive Medication Use in US Stroke Survivors. J Am Heart Assoc 2022; 11:e026678. [PMID: 35862140 PMCID: PMC9375512 DOI: 10.1161/jaha.122.026678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022]
Abstract
Background Relatively greater increases in hypertension prevalence among US rural residents may contribute to geographic disparities in recurrent stroke. There is limited US information on poststroke antihypertensive medication use by rural/urban residence. We assessed antihypertensive use and lifestyle characteristics for US rural compared with urban stroke survivors and residence-based trends in use between 2005 and 2019. Methods and Results US stroke survivors with hypertension were identified in the 2005 to 2019 national Behavioral Risk Factor Surveillance System surveys. We ascertained the survey-weighted prevalence of reported antihypertensive use and lifestyle characteristics (ie, physical activity, diabetes, cholesterol, body mass index, and smoking) among respondents with hypertension in odd years over this period by rural/urban residence. Separate trend analyses were used to detect changes in use over time. Survey-weighted logistic regression was used to calculate unadjusted and adjusted (sociodemographic and lifestyle factors) odds ratios for antihypertensive use by year. Our study included 82 175 individuals (36.4% rural residents). Lifestyle characteristics were similar between rural and urban residents except for higher smoking prevalence among rural residents. Antihypertensive use was similar between rural and urban stroke survivors in unadjusted and adjusted analyses (>90% in both populations). Trend analyses showed a small but significant increase in antihypertensive use over time among urban (P=0.033) but not rural stroke survivors (P=0.587). Conclusions Our findings indicate that poststroke antihypertensive use is comparable in rural and urban residents with a reported history of hypertension, but additional work is merited to identify reasons for a trend for increased use of these drugs among urban residents.
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Affiliation(s)
- Phoebe M. Tran
- Department of Public HealthUniversity of TennesseeKnoxvilleTN
| | - Lam T. Tran
- Department of BiostatisticsUniversity of MichiganAnn ArborMI
| | - Cenjing Zhu
- Department of Chronic Disease EpidemiologyYale UniversityNew HavenCT
| | - Tiffany Chang
- Department of Chronic Disease EpidemiologyYale UniversityNew HavenCT
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Goldstein LB. Individual and Joint Effects of Influenza-Like Illness and Vaccinations on Stroke in the Young: A Case-Control Study: Can You Catch a Stroke? Stroke 2022; 53:2594-2596. [DOI: 10.1161/strokeaha.122.039968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Jicha GA, Abner EL, Arnold SE, Carrillo MC, Dodge HH, Edland SD, Fargo KN, Feldman HH, Goldstein LB, Hendrix J, Peters R, Robillard JM, Schneider LS, Titiner JR, Weber CJ. Committee on High-quality Alzheimer's Disease Studies (CHADS) consensus report. Alzheimers Dement 2022; 18:1109-1118. [PMID: 34590417 PMCID: PMC8960469 DOI: 10.1002/alz.12461] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/14/2021] [Accepted: 07/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Consensus guidance for the development and identification of high-quality Alzheimer's disease clinical trials is needed for protocol development and conduct of clinical trials. METHODS An ad hoc consensus committee was convened in conjunction with the Alzheimer's Association to develop consensus recommendations. RESULTS Consensus was readily reached for the need to provide scientific justification, registration of trials, institutional review board oversight, conflict of interest disclosure, funding source disclosure, defined trial population, recruitment resources, definition of the intervention, specification of trial duration, appropriate payment for participant engagement, risk-benefit disclosure as part of the consent process, and the requirement to disseminate and/or publish trial results even if the study is negative. CONCLUSIONS This consensus guidance should prove useful for the protocol development and conduct of clinical trials, and may further provide a platform for the development of education materials that may help guide appropriate clinical trial participation decisions for potential trial participants and the general public.
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Affiliation(s)
- Greg A. Jicha
- Department of Neurology & the Sanders‐Brown Center on AgingUniversity of KentuckyLexingtonKentuckyUSA
| | - Erin L. Abner
- Department of Epidemiology & the Sanders‐Brown Center on AgingUniversity of KentuckyLexingtonKentuckyUSA
| | - Steven E. Arnold
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Hiroko H. Dodge
- Department of Neurology & Layton Aging and Alzheimer's Disease CenterOregon Health & Science UniversityPortlandOregonUSA
| | - Steven D. Edland
- Division of BiostatisticsSchool of Public Health and Human Longevity ScienceUniversity of California, San DiegoSan DiegoCaliforniaUSA
| | - Keith N. Fargo
- Alzheimer's Association, Chicago, Illinois, USA (affiliation at time of publication is CMT Research Foundation, Atlanta, Georgia, USA)
| | - Howard H. Feldman
- Department of NeuroscienceUniversity of CaliforniaSan DiegoCaliforniaUSA
| | | | - James Hendrix
- Alzheimer's Association, Chicago, Illinois, USA (affiliation at time of publication is LuMind IDSC Foundation, Burlington, Massachusetts, USA)
| | - Ruth Peters
- Department of PsychologyUniversity of New South WalesSydneyNew South WalesAustralia,Neuroscience Research AustraliaSydneyNew South WalesAustralia,School of Public HealthImperial CollegeLondonUK
| | - Julie M. Robillard
- Division of Neurology, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Lon S. Schneider
- Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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Turan TN, Zaidat OO, Gronseth GS, Chimowitz MI, Culebras A, Furlan AJ, Goldstein LB, Gonzalez NR, Latorre JG, Messé SR, Nguyen TN, Sangha RS, Schneck MJ, Singhal AB, Wechsler LR, Rabinstein AA, Dolan O'Brien M, Silsbee H, Fletcher JJ. Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee. Neurology 2022; 98:486-498. [PMID: 35314513 DOI: 10.1212/wnl.0000000000200030] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To review treatments for reducing the risk of recurrent stroke or death in patients with symptomatic intracranial atherosclerotic arterial stenosis (sICAS). METHODS The development of this practice advisory followed the process outlined in the American Academy of Neurology Clinical Practice Guideline Process Manual, 2011 Edition, as amended. The systematic review included studies through November 2020. Recommendations were based on evidence, related evidence, principles of care, and inferences. MAJOR RECOMMENDATIONS Clinicians should recommend aspirin 325 mg/d for long-term prevention of stroke and death and should recommend adding clopidogrel 75 mg/d to aspirin for up to 90 days to further reduce stroke risk in patients with severe (70%-99%) sICAS who have low risk of hemorrhagic transformation. Clinicians should recommend high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol level <70 mg/dL, a long-term blood pressure target of <140/90 mm Hg, at least moderate physical activity, and treatment of other modifiable vascular risk factors for patients with sICAS. Clinicians should not recommend percutaneous transluminal angioplasty and stenting for stroke prevention in patients with moderate (50%-69%) sICAS or as the initial treatment for stroke prevention in patients with severe sICAS. Clinicians should not routinely recommend angioplasty alone or indirect bypass for stroke prevention in patients with sICAS outside clinical trials. Clinicians should not recommend direct bypass for stroke prevention in patients with sICAS. Clinicians should counsel patients about the risks of percutaneous transluminal angioplasty and stenting and alternative treatments if one of these procedures is being contemplated.
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Affiliation(s)
- Tanya N Turan
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Osama O Zaidat
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Gary S Gronseth
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Marc I Chimowitz
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Antonio Culebras
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Anthony J Furlan
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Larry B Goldstein
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Nestor R Gonzalez
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Julius G Latorre
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Steven R Messé
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Thanh N Nguyen
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Rajbeer S Sangha
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Michael J Schneck
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Aneesh B Singhal
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Lawrence R Wechsler
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Alejandro A Rabinstein
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Mary Dolan O'Brien
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
| | - Heather Silsbee
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids.
| | - Jeffrey J Fletcher
- From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids
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Chang TE, Goldstein LB, Leifheit EC, Howard VJ, Lichtman JH. Cardiovascular Risk Factor Profiles, Emergency Department Visits, and Hospitalizations for Women and Men with a History of Stroke or Transient Ischemic Attack: A Cross-Sectional Study. J Womens Health (Larchmt) 2022; 31:834-841. [PMID: 35148481 DOI: 10.1089/jwh.2021.0471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: The relationship between cardiovascular disease risk factors (CVD-RFs) and health care utilization may differ by sex. We determined whether having more CVD-RFs was associated with all-cause emergency department (ED) visits and all-cause hospitalizations for women and men with prior stroke/transient ischemic attack (TIA). Materials and Methods: In this cross-sectional study, we used nationally representative Medical Expenditure Panel Survey (2012-2015) data for persons aged ≥18 years with a prior stroke/TIA. CVD-RF summary scores include six self-reported factors (hypertension, diabetes, high cholesterol, physical inactivity, smoking, and obesity). Sex-specific covariate-adjusted logistic regression models assessed associations between CVD-RF scores and having one or more all-cause ED visits and one or more all-cause hospitalizations. Results: The weighted sample represents 9.1 million individuals (mean age 66.6 years; 54.3% women). Prevalence of low (0-1 risk factors), intermediate (2-3), and high (4-6) CVD-RF scores was 19.4%, 60.5%, and 20.1% for women and 14.6%, 60.2%, and 25.2% for men, respectively. Women having intermediate and high scores had a 1.58-fold (95% confidence interval [CI], 1.14-2.18) and 2.21-fold (95% CI, 1.50-3.25) increased odds of ED visits compared with women with low scores. Women with high CVD-RF scores had a 2.18-fold (95% CI, 1.42-3.34) increased odds of hospitalizations, but there was no association for women with intermediate CVD-RF profiles. There was no association between CVD-RF scores and either outcome for men. Conclusions: Women, but not men, with high and intermediate CVD-RF profiles had increased odds of all-cause ED visits; women with high CVD-RF profiles had increased odds of all-cause hospitalizations. The burden of CVD-RFs may be a sex-specific predictor of higher health care utilization in women with a history of stroke/TIA.
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Affiliation(s)
- Tiffany E Chang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Larry B Goldstein
- Department of Neurology, KY Neuroscience Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Erica C Leifheit
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Judith H Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
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Zhu C, Tran PM, Dreyer RP, Goldstein LB, Lichtman JH. Disparities in Internet Use Among US Stroke Survivors: Implications for Telerehabilitation During COVID-19 and Beyond. Stroke 2022; 53:e90-e91. [PMID: 35109676 PMCID: PMC10155674 DOI: 10.1161/strokeaha.121.037175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite evidence-based guidelines,1 stroke rehabilitation remains underutilized, particularly among women and minorities.2 Telerehabilitation is a promising alternative to traditional in-person rehabilitation and offers a novel strategy to overcome access barriers,3 which intensified during the COVID-19 pandemic.4 A broadband connection is a prerequisite for its wide adoption but its availability varies across the United States (https://broadbandnow.com/national-broadband-map). Little is known about demographic and geographic variation in internet use among stroke survivors. In this study, we sought to compare internet use in a nationally representative sample of individuals with and without stroke.
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Affiliation(s)
- Cenjing Zhu
- Department of Chronic Disease Epidemiology, Yale University, New Haven, CT. (C.Z., P.M.T., J.H.L.)
| | - Phoebe M Tran
- Department of Chronic Disease Epidemiology, Yale University, New Haven, CT. (C.Z., P.M.T., J.H.L.)
| | - Rachel P Dreyer
- Department of Emergency Medicine, Yale University, New Haven, CT. (R.P.D.)
| | | | - Judith H Lichtman
- Department of Chronic Disease Epidemiology, Yale University, New Haven, CT. (C.Z., P.M.T., J.H.L.)
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Ionel DL, Odago FO, Ene AN, Lee JD, O'Connor WN, Goldstein LB, Pettigrew LC. Paradoxical Cerebral Air Embolism after Cardiac Ablation in Williams-Beuren Syndrome: A Clinico-Pathological Correlation. J Stroke Cerebrovasc Dis 2022; 31:106317. [PMID: 35123277 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 11/28/2022] Open
Abstract
Non-traumatic neurological deterioration is a medical emergency that may arise from diverse causes, to include cerebral infarction or intracranial hemorrhage, meningoencephalitis, seizure, hypoxic-ischemic or toxic/metabolic encephalopathy, poisoning, or drug intoxication. We describe the abrupt onset of neurological deterioration in a 53-year-old man with Williams-Beuren syndrome, a sporadically occurring genetic disorder caused by chromosomal microdeletion at 7q11.23. The clinical phenotype of Williams-Beuren syndrome is suggested by distinctive elfin facies, limited intellect, unique personality features, growth abnormalities, and endocrinopathies. The causative microdeletion of chromosomal material will frequently involve loss of the elastin gene, ELN, with resulting arteriopathy, supravalvular aortic stenosis, non-ischemic cardiopathy, and atrial fibrillation. Our patient sustained acute neurological decline within one month after undergoing a cardiac ablative procedure to convert atrial fibrillation to sinus rhythm. We present our findings in the setting of a clinico-pathological correlation, in which we reveal the cause of the abrupt neurological deterioration and discuss how our patient was affected by an uncommon stroke disorder.
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Affiliation(s)
- Dana L Ionel
- Department of Neurology, Kentucky Neuroscience Institute
| | - Fred O Odago
- Department of Neurology, Kentucky Neuroscience Institute
| | - Andre N Ene
- Department of Pathology & Laboratory Medicine, University of Kentucky Chandler Medical Center, Lexington, Kentucky, USA
| | - Jessica D Lee
- Department of Neurology, Kentucky Neuroscience Institute
| | - William N O'Connor
- Department of Pathology & Laboratory Medicine, University of Kentucky Chandler Medical Center, Lexington, Kentucky, USA
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El Husseini NK, Jiang R, Bennett E, Goldstein LB. Abstract TP179: Candidate Genes For Small Vessel Ischemic Stroke: A Gwas Pilot Study. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tp179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The genetic basis of small vessel stroke (SVS) is poorly understood. Few genetic loci have been identified that may provide insights into SVS pathogenesis. We sought to identify genetic associations with incident SVS.
Methods:
A GWAS analysis was performed on a prospective cohort of patients enrolled in the American Stroke Association- Bugher Small Vessel Intracranial Disease Whole Genome Association Study which included patients from 4 hospitals in North Carolina recruited between December 2007-August 2012. Patients with SVS in the prior 2 years confirmed clinically and on neuroimaging were compared to a control group who had no previous history of stroke. A logistic regression model with SVS as the outcome and single nucleotide polymorphisms (SNPs) as the main predictor was performed and adjusted for baseline demographics and clinical characteristics, including age, race/ethnicity, sex, tobacco use, history of hypertension, diabetes, hyperlipidemia, atrial fibrillation, history of stroke/TIA, and principal components. Because of the relatively small sample size, SNPs with p-values <1E-4 were considered significant.
Results:
The cohort included 139 patients who had SVS and 64 controls. Among this cohort, 50% were men and 38% African-American. The mean age of the study group was 63-years. Sixteen SNPs in 9 genes met the statistical cutoff for association with SVS. These were involved in extracellular matrix integrity (CHD23, CLDN14, SPTBN1), neuronal differentiation (DSCAML1), cholesterol transport (GRAMD1B), transcriptional regulation (JARID2, LINC02111, LINC01993) and voltage-gated potassium channel (KCND2).
Conclusion:
In this pilot GWAS study, several loci variations were associated with SVS. Although this study is hypothesis generating, previous studies have also shown an association of SVS with genes involved in extracellular matrix integrity. In addition, we found it interesting that SNPs in both CLDN14 and CDH23 genes, which have been linked to non-syndromic sensorineural deafness, are also more common in SVS. Some forms of sensorineural deafness have been associated with cognitive impairment and stroke, and if a genetic association is confirmed, it would suggest a common pathophysiology may link the two conditions.
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Lichtman JH, Leifheit EC, Wang Y, Goldstein LB. Abstract 31: One-year Mortality And Stroke Readmissions After Ischemic Stroke In Critical Access Hospitals. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Critical access hospitals (CAHs) provide emergency and inpatient care in rural communities. CAHs have higher 30-day mortality after stroke, but little is known about long-term outcomes. We compared 1-year outcomes after ischemic stroke for patients treated at CAHs versus other hospitals.
Methods:
We identified all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke in 2015. Patients were followed 1 year for death or stroke recurrence, accounting for competing risks. We balanced characteristics between CAH and non-CAH patients using stabilized inverse probability weights (IPW) based on patient demographic and clinical characteristics. We created adjusted Kaplan-Meier curves based on the IPW and fit Cox models to assess differences in 1-year mortality and recurrent stroke weighted by the IPW.
Results:
There were 4,487 patients discharged with stroke from CAHs and 202,502 from non-CAHs. CAH vs non-CAH patients were older (mean age 82.8y vs 78.6y) and more often women (61.8% vs 53.9%), white (94.3% vs 83.7%), and dual Medicare-Medicaid eligible (21.6% vs 17.1%). Discharge to home (29.6% vs 36.8%) and inpatient rehabilitation (4.2% vs 18.9%) was less common for CAH patients, whereas discharge to an intermediate care/skilled nursing facility was more common (26.7% vs 23.9%). For CAHs and non-CAHs, respectively, 1-year mortality rates were 27.8% (95% CI 26.5-29.0) and 22.2% (22.0-22.4), and 1-year recurrence rates were 4.3% (3.6-4.9) and 4.6% (4.5-4.7) (Figure). In IPW-adjusted analyses, stroke patients treated at CAHs vs non-CAHs had higher risk of 1-year mortality (HR 1.29, 95% CI 1.22-1.37) but not recurrent stroke (0.91, 0.78-1.06).
Conclusions:
Stroke patients discharged from CAHs vs non-CAHs had greater risk of 1-year mortality but not recurrence. Further work is needed to understand the observed disparity, potentially with a focus on post-acute care services.
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Affiliation(s)
| | | | - Yun Wang
- Beth Israel Deaconess Med Cntr, Boston, MA
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Aroor SR, Asif KS, Potter-Vig J, Sharma A, Menon BK, Inoa V, Zevallos CB, Romano JG, Ortega-Gutierrez S, Goldstein LB, Yavagal DR. Mechanical Thrombectomy Access for All? Challenges in Increasing Endovascular Treatment for Acute Ischemic Stroke in the United States. J Stroke 2022; 24:41-48. [PMID: 35135058 PMCID: PMC8829477 DOI: 10.5853/jos.2021.03909] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/11/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Sushanth Rao Aroor
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Kaiz S. Asif
- Department of Neurosurgery, University of Illinois and AMITA Health, Chicago, IL, USA
| | | | - Arun Sharma
- University of Miami, Herbert Business School, Miami, FL, USA
| | - Bijoy K. Menon
- Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Violiza Inoa
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cynthia B. Zevallos
- Department of Neurology, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Jose G. Romano
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Larry B. Goldstein
- Department of Neurology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Correspondence: Dileep R. Yavagal Departments of Neurology and Neurosurgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave 1140, Miami, FL 33136, USA Tel: +1-305-355-1103 E-mail:
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Sandset EC, Goldstein LB. Advances in Stroke: Treatments-Preventive. Stroke 2022; 53:608-610. [PMID: 34983247 DOI: 10.1161/strokeaha.121.036977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.).,The Norwegian Air Ambulance, Oslo, Norway (E.C.S.)
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Goldstein LB, Seshadri S, Sacco RL. Risk Factors and Prevention. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00016-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Adams HP, Adeoye O, Albers GW, Alexandrov AV, Amin-Hanjani S, An H, Anderson CS, Anrather J, Aparicio HJ, Arai K, Aronowski J, Atchaneeyasakul K, Audebert H, Auer RN, Awad IA, Ay H, Baltan S, Balu R, Behbahani M, Benavente OR, Bershad EM, Berthaud JV, Blackburn SL, Bonati LH, Bösel J, Bousser MG, Broderick JP, Brown MM, Brown W, Brust JC, Bushnell C, Canhão P, Caplan LR, Carrión-Penagos J, Castellanos M, Caunca MR, Chabriat H, Chamorro A, Chen J, Chen J, Chopp M, Christorforids G, Connolly ES, Cramer SC, Cucchiara BL, Czap AL, Dannenbaum MJ, Davis PH, Dawson TM, Dawson VL, Day AL, De Silva TM, de Sousa DA, Del Brutto VJ, del Zoppo GJ, Derdeyn CP, Di Tullio MR, Diener HC, Diringer MN, Dobkin BH, Dzialowski I, Elkind MS, Elm J, Feigin VL, Ferro JM, Field TS, Fischer M, Fornage M, Furie KL, Garcia-Bonilla L, Giannotta SL, Gobin YP, Goldberg MP, Goldstein LB, Gonzales NR, Greer DM, Grotta JC, Guo R, Gutierrez J, Harmel P, Howard G, Howard VJ, Hwang JY, Iadecola C, Jahan R, Jickling GC, Joutel A, Kasner SE, Katan M, Kellner CP, Khan M, Kidwell CS, Kim H, Kim JS, Kircher CE, Krings T, Krishnamurthi RV, Kurth T, Lansberg MG, Levy EI, Liebeskind DS, Liew SL, Lin DJ, Lisle B, Lo EH, Lyden PD, Maki T, Maragkos GA, Marosfoi M, McCullough LD, Meckler JM, Meschia JF, Messé SR, Mocco J, Mokin M, Mooney MA, Morgenstern LB, Moskowitz MA, Mullen MT, Nägel S, Nedergaard M, Neira JA, Newman S, Nicholson PJ, Norrving B, O’Donnell M, Ofengeim D, Ogata J, Ogilvy CS, Orrù E, Ortega-Gutiérrez S, Padrick MM, Parsha K, Parsons M, Patel NV, Patel VI, Pawlikowska L, Pérez A, Perez-Pinzon MA, Picard JM, Polster SP, Powers WJ, Puetz V, Putaala J, Rabinovich M, Ransom BR, Roa JA, Rosenberg GA, Rossitto CP, Rundek T, Russin JJ, Sacco RL, Safouris A, Samaniego EA, Sansing LH, Satani N, Sattenberg RJ, Saver JL, Savitz SI, Schmidt C, Seshadri S, Sharma VK, Sharp FR, Sheth KN, Siddiqi OK, Singhal AB, Sobey CG, Sommer CJ, Spetzler RF, Stapleton CJ, Strickland BA, Su H, Suarez JI, Takayama H, Tarsia J, Tatlisumak T, Thomas AJ, Thompson JW, Tsivgoulis G, Tournier-Lasserve E, Vidal G, Wakhloo AK, Weksler BB, Willey JZ, Wintermark M, Wong LK, Xi G, Xu J, Yaghi S, Yamaguchi T, Yang T, Yasaka M, Zahuranec DB, Zhang F, Zhang JH, Zheng Z, Zukin RS, Zweifler RM. Contributors. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.01002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gelb DJ, Kraakevik J, Safdieh JE, Agarwal S, Odia Y, Govindarajan R, Quick A, Soni M, Bickel J, Gamaldo C, Hannon P, Hatch HAM, Hernandez C, Merlin LR, Noble JM, Reyes-Iglesias Y, Salas RME, Sandness DJ, Treat L, Benameur K, Brown RD, DeLuca GC, Garg N, Goldstein LB, Gutmann L, Henchcliffe C, Hessler A, Jordan JT, Kilgore SM, Khan J, Levin KH, Mohile NA, Nevel KS, Roberts K, Said RR, Simpson EP, Sirven JI, Smith AG, Southerland AM, Wilson RB. Contemporary Neuroscience Core Curriculum for Medical Schools. Neurology 2021; 97:675-684. [PMID: 34400582 PMCID: PMC8520386 DOI: 10.1212/wnl.0000000000012664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/04/2021] [Indexed: 11/15/2022] Open
Abstract
Medical students need to understand core neuroscience principles as a foundation for their required clinical experiences in neurology. In fact, they need a solid neuroscience foundation for their clinical experiences in all other medical disciplines also because the nervous system plays such a critical role in the function of every organ system. Because of the rapid pace of neuroscience discoveries, it is unrealistic to expect students to master the entire field. It is also unnecessary, as students can expect to have ready access to electronic reference sources no matter where they practice. In the preclerkship phase of medical school, the focus should be on providing students with the foundational knowledge to use those resources effectively and interpret them correctly. This article describes an organizational framework for teaching the essential neuroscience background needed by all physicians. This is particularly germane at a time when many medical schools are reassessing traditional practices and instituting curricular changes such as competency-based approaches, earlier clinical immersion, and increased emphasis on active learning. This article reviews factors that should be considered when developing the preclerkship neuroscience curriculum, including goals and objectives for the curriculum, the general topics to include, teaching and assessment methodology, who should direct the course, and the areas of expertise of faculty who might be enlisted as teachers or content experts. These guidelines were developed by a work group of experienced educators appointed by the Undergraduate Education Subcommittee (UES) of the American Academy of Neurology (AAN). They were then successively reviewed, edited, and approved by the entire UES, the AAN Education Committee, and the AAN Board of Directors.
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Affiliation(s)
- Douglas J Gelb
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles.
| | - Jeff Kraakevik
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Joseph E Safdieh
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Sachin Agarwal
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Yazmin Odia
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Raghav Govindarajan
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Adam Quick
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Madhu Soni
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Jennifer Bickel
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Charlene Gamaldo
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Peter Hannon
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Hayden A M Hatch
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Christian Hernandez
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Lisa R Merlin
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - James M Noble
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Yolanda Reyes-Iglesias
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Rachel Marie E Salas
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - David James Sandness
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Lauren Treat
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Karima Benameur
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Robert D Brown
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Gabriele C DeLuca
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Neeta Garg
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Larry B Goldstein
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Laurie Gutmann
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Claire Henchcliffe
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Amy Hessler
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Justin T Jordan
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Shannon M Kilgore
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Jaffar Khan
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Kerry H Levin
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Nimish A Mohile
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Kathryn S Nevel
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Kirk Roberts
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Rana R Said
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Ericka P Simpson
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Joseph I Sirven
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - A Gordon Smith
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Andrew Mebane Southerland
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
| | - Rujuta B Wilson
- From the University of Michigan (D.J.G.), Ann Arbor; Oregon Health &Science University (J. Kraakevik), Portland; Weill Cornell Medicine/New York Presbyterian Hospital (J.E.S., C. Henchcliffe); Columbia University (S.A., J.M.N., K.R.), New York; Miami Cancer Institute (Y.O.), FL; University of Missouri (R.G., J.B.), Columbia; Ohio State University (A.Q.), Columbus; Rush University Medical Center (M.S.), Chicago, IL; Johns Hopkins University (C.G., R.M.E.S.), Baltimore, MD; University of Utah (P.H.), Salt Lake City; Albert Einstein College of Medicine (H.A.M.H.), Bronx, NY; Duke University (C. Hernandez), Raleigh, NC; State University of New York Downstate (L.R.M.), Brooklyn; University of Miami (Y.R.-I., N.G.), FL; University of Rochester Medical Center (D.J.S., N.A.M.), NY; Children's Hospital Colorado (L.T.), Denver; Emory University (K.B., J. Khan), Atlanta, GA; Mayo Clinic (R.D.B.), Rochester, MN; Mayo Clinic (J.I.S.), Jacksonville, FL; Oxford University (G.C.D.), UK; University of Kentucky (L.B.G., A.H.), Lexington; Indiana University (L.G., K.S.N.), Indianapolis; Massachusetts General Hospital (J.T.J.), Boston; Veterans Affairs Health Care System (S.M.K.), Palo Alto, CA; Cleveland Clinic (K.H.L.), OH; University of Texas Southwestern (R.R.S.), Dallas; Houston Methodist (E.P.S.), TX; Virginia Commonwealth University (A.G.S.), Richmond; University of Virginia (A.M.S.), Charlottesville; and University of California (R.B.W.), Los Angeles
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41
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Abstract
Recent histological analyses of human brains show that small vessel-type injuries in the setting of type-2 diabetes colocalize with deposits of amylin, an amyloid-forming hormone secreted by the pancreas. Amylin inclusions are also identified in circulating red blood cells in people with type-2 diabetes and stroke or cardiovascular disease. In laboratory models of type-2 diabetes, accumulation of aggregated amylin in blood and the cerebral microvasculature induces brain microhemorrhages and reduces cerebral blood flow leading to white matter ischemia and neurological deficits. At the cellular level, aggregated amylin causes cell membrane lipid peroxidation injury, downregulation of tight junction proteins, and activation of proinflammatory signaling pathways which, in turn, induces macrophage activation and macrophage infiltration in vascular areas positive for amylin deposition. We review each step of this cascade based on experimental and clinical evidence and propose the hypothesis that systemic amylin dyshomeostasis may underlie the disparity between glycemic control and stroke risk and may be a therapeutic target to reduce the risk of small vessel ischemic stroke in patients with type-2 diabetes.
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Affiliation(s)
- Florin Despa
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA,Department of Neurology, University of Kentucky, Lexington, KY, USA
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42
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Venketasubramanian N, Anderson C, Ay H, Aybek S, Brinjikji W, de Freitas GR, Del Brutto OH, Fassbender K, Fujimura M, Goldstein LB, Haberl RL, Hankey GJ, Heiss WD, Lestro Henriques I, Kase CS, Kim JS, Koga M, Kokubo Y, Kuroda S, Lee K, Lee TH, Liebeskind DS, Lip GYH, Meairs S, Medvedev R, Mehndiratta MM, Mohr JP, Nagayama M, Pantoni L, Papanagiotou P, Parrilla G, Pastori D, Pendlebury ST, Pettigrew LC, Renjen PN, Rundek T, Schminke U, Shinohara Y, Tang WK, Toyoda K, Wartenberg KE, Wasay M, Hennerici MG. Stroke Care during the COVID-19 Pandemic: International Expert Panel Review. Cerebrovasc Dis 2021; 50:245-261. [PMID: 33756459 PMCID: PMC8089455 DOI: 10.1159/000514155] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/16/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions. SUMMARY The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.
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Affiliation(s)
| | - Craig Anderson
- The George Institute for Global Health, Camperdown, Washington, Australia
| | - Hakan Ay
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard School of Medicine, Boston, Massachusetts, USA
- Takeda Pharmaceutical Co. Limited, Cambridge, Massachusetts, USA
| | - Selma Aybek
- Department of Neurology, University Hospital Inselspital, Bern University, Bern, Switzerland
| | - Waleed Brinjikji
- Department of Radiology, Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabriel R de Freitas
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
- Department of Neurology, Universidade Federal Fluminense (UFF), Niterói, Brazil
| | - Oscar H Del Brutto
- School of Medicine, Universidad Espiritu Santo-Ecuador, Samborondón, Ecuador
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
- Division of Advanced Cerebrovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
| | - Roman L Haberl
- Department of Neurology and Neurological Intensive Medicine, Munich Clinic gGmbH, Academic Teaching Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, Washington, Australia
| | | | - Isabel Lestro Henriques
- Department of Neurosciences, Neurology Service, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Carlos S Kase
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jong S Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Kiwon Lee
- Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Stephen Meairs
- Department of Neurology, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Roman Medvedev
- Research Center of Neurology, Moscow, Russian Federation
| | | | - Jay P Mohr
- Tananbaum Stroke Center, New York, New York, USA
| | - Masao Nagayama
- Department of Neurology, International University of Health and Welfare(IUHW), Graduate School of Medicine, Tokyo, Japan
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte, Germany
- Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Guillermo Parrilla
- Department of Neurology, Interventional Neuroradiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Sarah T Pendlebury
- Departments of Internal Medicine and Geratology, John Radcliffe Hospital, Oxford, United Kingdom
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | | | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Ulf Schminke
- Department of Neurology, University Medicine, Greifswald, Germany
| | | | - Wai Kwong Tang
- Department of Psychiatry, Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Mohammad Wasay
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Michael G Hennerici
- Department of Neurology, Medical Faculty, Mannheim University of Heidelberg, Mannheim, Germany
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43
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Tran P, Leifheit EC, Wang Y, Goldstein LB, Lichtman JH. Abstract P644: Average Daily Temperature Fluctuation and Hospitalizations and 30-Day Mortality for Stroke and AMI. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Daily average temperature is associated with increased hospitalizations and mortality for vascular conditions, but it is unclear if daily temperature variation is also associated with these outcomes. We assessed the relationship of daily temperature fluctuations with stroke and AMI hospitalizations and mortality in the elderly.
Methods:
We identified fee-for-service Medicare beneficiaries aged ≥65 y with a primary discharge diagnosis of ischemic stroke or AMI in 2014-2015. Daily temperature data from the National Centers for Environmental Information were linked with Medicare beneficiary data by county and admission date. We fit a Poisson model for the relationship between daily temperature range (county daily maximum minus minimum) and 30-day hospitalizations, adjusted for season and patient demographics. Logistic regression assessed 30-day mortality, adjusted for season, patient demographics, and clinical characteristics. Overall and NOAA climate region-stratified relationships were assessed.
Results:
There were 311,213 unique stroke hospitalizations (mean age 78.8 y, 53% women, 84% White) and 274,703 for AMI (mean age 77.6 y, 45.4% women, 86% White). The national hospitalization rate per 100,000 beneficiary-years was 735 for stroke and 639 for AMI. Thirty-day mortality was 12.0% for stroke and 12.8% for AMI. Each 1
o
F increase in daily temperature range was associated with a 1.26 percentage point (95% CI 1.09-1.44) increase in stroke and a 1.48 percentage point (95% CI 1.43-1.53%) increase in AMI hospitalizations and varied by climate region (figure). Daily temperature range had little influence on stroke or AMI mortality (both OR 1.00, 95% CI 1.00-1.00).
Conclusions:
Daily temperature fluctuations were associated with increased hospitalizations for stroke and AMI. Additional research is needed to understand meteorological effects on vascular events to inform prevention efforts for vulnerable populations.
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Affiliation(s)
| | | | - Yun Wang
- Beth Israel Deaconess Med Cntr, Boston, MA
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44
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Kam W, Goldstein LB, McConnell A, Al-Khalidi H, Bennett E, Colton C, Bushnell CD, Koltai D, El Husseini NK. Abstract P67: Role of Genetic Variants in Predicting Cognitive Outcomes Following Small Vessel Ischemic Stroke. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
About 20% of patients with small vessel ischemic stroke (SVS) have cognitive impairment; however, the role of genetic factors in predicting cognitive outcomes following SVS has not been fully explored. APOE and ABCC9 have been associated with Alzheimer’s disease and hippocampal sclerosis respectively and play an important role in the neurovascular unit. We evaluated whether allelic variants in these genes influence cognitive outcomes following SVS.
Methods:
We conducted a retrospective analysis of a prospective cohort of patients enrolled in the ASA-Bugher Small Vessel Intracranial Disease Whole Genome Association Studies. Patients with SVS were categorized by APOE (presence or absence of ε4 allele) and ABCC9 SNP rs704180 (presence or absence of A allele) status. The primary outcomes were total score on the short form of the MoCA, which assesses global cognition, and time to complete Trails B, which is a measure of executive function that can be affected by stroke. Linear regression analyses were performed using the genetic exposures of interest, adjusting for age, education, sex, race/ethnicity, NIHSS score, burden of white matter disease (WMD; using the CHS validated score 0-9), and time between stroke and the cognitive assessment.
Results:
The sample included 145 patients who had SVS and available APOE and ABCC9 data. Among this cohort, 51.4% were men and 27.6% African American. The median age of the study participants was 63.4 years, the median years of education was 12, the median NIHSS was 2, and the median WMD burden score was 2. The mean time between stroke and the cognitive assessment was 75 days. The APOE ε4 allele was present in 35.0% and ABCC9 A allele in 74.8%. The presence of APOE ε4 allele was not associated with post-stroke MoCA scores (p=0.31) or Trails B (p=0.86). ABCC9 A allele was also not associated with post-stroke MoCA scores (p=0.34) or Trails B (p=0.31). Older age, higher NIHSS score, and greater burden of WMD were independently associated with longer times to complete Trails B (p<0.0001), but not with the MoCA score.
Conclusion:
Following SVS, several patient characteristics, including age, stroke severity, and WMD burden, rather than their APOE and ABCC9 allelic statuses, were associated with post-stroke measures of executive function.
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45
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Chang TE, Goldstein LB, Leifheit EC, Lichtman JH. Abstract P245: Sex Differences in the Association Between Cardiovascular Risk Profiles and Hospitalizations/ED Visits Among Patients With a History of Stroke/TIA. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Secondary prevention addressing cardiovascular risk factors is a key care component for reducing the risk of vascular events among those who had a stroke/TIA. We assessed cardiovascular risk factor (CVD-RF) profiles and their impact on hospitalizations and Emergency Department (ED) visits and whether the association differs for men and women with prior stroke/TIA.
Methods:
We used data from the nationally representative Medical Expenditure Panel Survey (2012-2015) for persons aged
≥
18 years with a prior stroke/TIA. CVD-RF score included 6 self-reported factors (hypertension, diabetes, high cholesterol, lack of exercise, smoking, obesity), categorized as low (0-1 factors), intermediate (2-3), or high (4-6). Outcomes included
≥
1 hospitalization discharges or ED visits during the participant’s survey year. Multivariable logistic regression models assessed the association between CVD-RF scores and outcomes, stratified by sex. We tested for interaction by sex in a combined model with men and women.
Results:
The weighted sample represents 9.9 million individuals (mean age 65.1 years; 54.3% women). Overall, 16.7%, 59.3%, and 24.1% of men had low, intermediate, and high CVD-RF scores compared to 21.6%, 59.5%, and 18.9% of women. Among men, there was no significant association between CVD-RF score and the two outcomes (
Table
). Among women, even after adjustment for covariates, those with high scores had 1.89 and 2.06-fold increases in the odds of hospitalizations and ED visits, compared to those with low CVD-RF scores (
P
<0.05). Furthermore, women with intermediate CVD-RF scores had a 1.68-fold increase in the odds of ED visits compared to those with low scores (
P
<0.05). The combined model showed a significant interaction by sex.
Conclusion:
Women with increased CVD-RF scores had increased odds of ED visits and hospitalizations, which could be due to less effective secondary prevention. Further research is needed to explore reasons for this sex disparity.
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Affiliation(s)
- Tiffany E Chang
- Dept of Chronic Disease Epidemiology, Yale Sch of Public Health, New Haven, CT
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Lichtman JH, Leifheit EC, Wang Y, Arakaki A, Goldstein LB. Abstract P655: Race Differences in 10-Year Mortality After Ischemic Stroke. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Few studies report 10-year mortality outcomes after stroke in the US by race. We assessed long-term survivorship by race among elderly ischemic stroke patients.
Methods:
We identified fee-for-service Medicare beneficiaries aged ≥65 years discharged alive from US acute-care hospitals with a principal diagnosis of ischemic stroke from 2005 to 2007. Patients were followed through 2016 to calculate 10-year all-cause mortality, censoring for change in Medicare enrollment. Inverse probability weighting (IPW) was used to assess race differences in mortality. We used logistic regression to calculate the probability of a patient being Black as a function of age, Medicaid eligibility, comorbidities, in-hospital complications, discharge disposition, length of stay, and Medicare payment. We then fit a Cox regression model for the relationship between race and 10-year mortality that adjusted for sex and the inverse probability of being Black.
Results:
There were 744,044 patients discharged alive with stroke (mean age 78.7y, 54.7% women, 85.6% White, 9.9% Black, and 4.5% other race). Black patients tended to be younger and were more often women. There were race differences in comorbidities, with renal failure, dementia, and diabetes more common in Blacks; atherosclerosis and COPD were more common in Whites. The 10-year mortality rate was 75.3% (95% CI 75.2–75.4%) for the overall population, with Blacks having the highest mortality (76.4%, 76.1–76.7%), followed by Whites (75.4%, 75.3–75.5%) and those of other race (70.3%, 69.8–70.8%; Figure). In the IPW analysis, the risk of death within 10 years of stroke was higher for Blacks (RR 1.04, 95% CI 1.03–1.04) but lower for other races (RR 0.92, 95% CI 0.90–0.93) when compared with Whites.
Conclusions:
More than 75% of stroke patients died within 10 years. The 10-year stroke mortality risk was higher for Black stroke patients even after accounting for sociodemographic and index hospitalization factors.
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Affiliation(s)
| | | | - Yun Wang
- Beth Israel Deaconess Med Cntr, Boston, MA
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Lichtman JH, Leifheit EC, Wang Y, Goldstein LB. Abstract 60: National Temporal Patterns in Recurrent Stroke by Demographic Characteristics and Geographic Regions: 2001-2016. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
There have been important advances in secondary stroke prevention and a focus on healthcare delivery in the US over the past two decades. Yet, little is known about temporal patterns of recurrent stroke in the US. We examined temporal trends in recurrent stroke by sociodemographic characteristics and geographic areas using national Medicare data.
Methods:
We included fee-for-service Medicare beneficiaries aged ≥65y with a primary discharge diagnosis of ischemic stroke from 2001 to 2016. We fit a Cox proportional hazards model that censored for change in Medicare enrollment and accounted for death to evaluate the temporal trend in 1-year recurrent stroke, adjusting for demographic and clinical factors. Models were repeated for subgroups defined by age, sex, race, and state. We mapped smoothed rates of 1-year recurrent stroke by county to assess geographic variation over time.
Results:
There were 3,485,618 unique beneficiaries discharged with stroke during the study period. Demographic and clinical characteristics remained relatively stable over time, but the proportions discharged with home health services and inpatient rehabilitation increased. The observed 1-year recurrent stroke rate decreased from 11.2% in 2001-2004 to 9.3% in 2013-2016, with an adjusted annual reduction in recurrence from 2001-2016 of 1.49% (95% CI 1.40%-1.58%). There were significant reductions for all age, sex, and race groups (A). Geographic areas with persistently high rates were identified over time (B). In state-stratified analysis, the annual percentage reduction in recurrence ranged from -1.2% to 2.5% and was significant for all but 12 states.
Conclusions:
Recurrent strokes decreased over time overall and by sociodemographic subgroups; however, we identified geographic areas with persistently high recurrence rates. Such findings can target secondary prevention intervention opportunities for high-risk populations and communities.
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Affiliation(s)
| | | | - Yun Wang
- Beth Israel Deaconess Med Cntr, Boston, MA
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Leifheit EC, Wang Y, Goldstein LB, Lichtman JH. Abstract 61: Community Factors Associated With Persistently High 1-Year Recurrent Stroke Rates in the United States. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
There is known geographic variation in recurrent stroke rates in the US; however, the contributions of socioeconomic status (SES), healthcare access/utilization, and community resources to these disparities are uncertain. We assessed community characteristics in counties having persistently higher recurrent stroke rates over a 16-year period.
Methods:
We included 3,485,618 fee-for-service Medicare beneficiaries aged ≥65y discharged with ischemic stroke from 2001-2016, grouped into four 4-year periods. We categorized 3221 US counties or equivalents into 6 groups based on the % of stroke patients with a recurrent stroke within 1 year. Persistently high-recurrence counties were those in the highest sextile for each 4-year period. We integrated county-specific demographic, geographic, SES, general health, care availability, health behavior, and environmental data from the US Census Bureau, USDA Economic Research Service, and Dartmouth Atlas. We calculated mean standardized differences in county characteristics between high-recurrence and other counties and used logistic regression to model high-recurrence counties as a function of 12 potentially modifiable county characteristics.
Results:
There were 133 persistently high-recurrence counties that were concentrated in the South Central US and included 140,144 stroke patients during the study (A; mean age 78.3y, 57% women, 82% White, 11.5% stroke recurrence vs 79.0 y, 55% women, 86% White, 10.5% stroke recurrence in other counties). Compared with the rest of the US, these counties had populations with lower SES, poorer health, more limited access to care providers and recreation/fitness, and reduced rates of preventive testing (B). The model including 12 potentially actionable characteristics had a c statistic of 0.84.
Conclusions:
Our findings highlight the value of identifying potentially modifiable community characteristics that, if improved, might reduce recurrent stroke rates.
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Affiliation(s)
| | - Yun Wang
- Beth Israel Deaconess Med Cntr, Boston, MA
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Goldstein SA, Goldstein LB. Neurologic complications of congenital heart disease in adults. Handb Clin Neurol 2021; 177:15-22. [PMID: 33632433 DOI: 10.1016/b978-0-12-819814-8.00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Congenital heart disease (CHD) is a heterogeneous group of structural abnormalities of the cardiovascular system that are present at birth. Advances in childhood medical and surgical treatment have led to increasing numbers of adults with CHD. Neurological complications of CHD in adults are varied and can include an increased risk of stroke not only related to the underlying congenital defect and its surgical management but also due to atherosclerotic disease associated with advancing age. In addition to cerebrovascular events, CHD in adults is also associated with an increased risk of neurodevelopmental disorders, cognitive impairment, psychiatric disease, and epilepsy. Collaborative multidisciplinary care with contributions from neurologists and cardiologists with expertise in adult CHD is necessary to provide optimal long-term care for this complex and rapidly evolving population.
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Affiliation(s)
- Sarah A Goldstein
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, United States
| | - Larry B Goldstein
- Department of Neurology, Kentucky Neuroscience Institute, University of Kentucky, Lexington, KY, United States.
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50
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Sandset EC, Goldstein LB. Treatments-Preventive. Stroke 2021; 52:1118-1120. [PMID: 33563014 DOI: 10.1161/strokeaha.120.033236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.).,Norwegian Air Ambulance, Oslo, Norway (E.C.S.)
| | - Larry B Goldstein
- Department of Neurology, Kentucky Neuroscience Institute, University of Kentucky, Lexington (L.B.G.)
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