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Cox CS, Notrica DM, Juranek J, Miller JH, Triolo F, Kosmach S, Savitz SI, Adelson PD, Pedroza C, Olson SD, Scott MC, Kumar A, Aertker BM, Caplan HW, Jackson ML, Gill BS, Hetz RA, Lavoie MS, Ewing-Cobbs L. Autologous bone marrow mononuclear cells to treat severe traumatic brain injury in children. Brain 2024; 147:1914-1925. [PMID: 38181433 PMCID: PMC11068104 DOI: 10.1093/brain/awae005] [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: 08/01/2023] [Revised: 11/29/2023] [Accepted: 12/30/2023] [Indexed: 01/07/2024] Open
Abstract
Autologous bone marrow mononuclear cells (BMMNCs) infused after severe traumatic brain injury have shown promise for treating the injury. We evaluated their impact in children, particularly their hypothesized ability to preserve the blood-brain barrier and diminish neuroinflammation, leading to structural CNS preservation with improved outcomes. We performed a randomized, double-blind, placebo-sham-controlled Bayesian dose-escalation clinical trial at two children's hospitals in Houston, TX and Phoenix, AZ, USA (NCT01851083). Patients 5-17 years of age with severe traumatic brain injury (Glasgow Coma Scale score ≤ 8) were randomized to BMMNC or placebo (3:2). Bone marrow harvest, cell isolation and infusion were completed by 48 h post-injury. A Bayesian continuous reassessment method was used with cohorts of size 3 in the BMMNC group to choose the safest between two doses. Primary end points were quantitative brain volumes using MRI and microstructural integrity of the corpus callosum (diffusivity and oedema measurements) at 6 months and 12 months. Long-term functional outcomes and ventilator days, intracranial pressure monitoring days, intensive care unit days and therapeutic intensity measures were compared between groups. Forty-seven patients were randomized, with 37 completing 1-year follow-up (23 BMMNC, 14 placebo). BMMNC treatment was associated with an almost 3-day (23%) reduction in ventilator days, 1-day (16%) reduction in intracranial pressure monitoring days and 3-day (14%) reduction in intensive care unit (ICU) days. White matter volume at 1 year in the BMMNC group was significantly preserved compared to placebo [decrease of 19 891 versus 40 491, respectively; mean difference of -20 600, 95% confidence interval (CI): -35 868 to -5332; P = 0.01], and the number of corpus callosum streamlines was reduced more in placebo than BMMNC, supporting evidence of preserved corpus callosum connectivity in the treated groups (-431 streamlines placebo versus -37 streamlines BMMNC; mean difference of -394, 95% CI: -803 to 15; P = 0.055), but this did not reach statistical significance due to high variability. We conclude that autologous BMMNC infusion in children within 48 h after severe traumatic brain injury is safe and feasible. Our data show that BMMNC infusion led to: (i) shorter intensive care duration and decreased ICU intensity; (ii) white matter structural preservation; and (iii) enhanced corpus callosum connectivity and improved microstructural metrics.
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Affiliation(s)
- Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - David M Notrica
- Department of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA
| | - Jenifer Juranek
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Jeffrey H Miller
- Department of Radiology, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA
| | - Fabio Triolo
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Steven Kosmach
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - P David Adelson
- Department of Pediatric Neurosurgery, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Scott D Olson
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Michael C Scott
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Akshita Kumar
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Benjamin M Aertker
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Henry W Caplan
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Margaret L Jackson
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Brijesh S Gill
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Robert A Hetz
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
| | - Michael S Lavoie
- Department of Psychology, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA
| | - Linda Ewing-Cobbs
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA
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Ling Y, Tariq MB, Tang K, Aronowski J, Fann Y, Savitz SI, Jiang X, Kim Y. An interpretable framework to identify responsive subgroups from clinical trials regarding treatment effects: Application to treatment of intracerebral hemorrhage. PLOS Digit Health 2024; 3:e0000493. [PMID: 38713647 DOI: 10.1371/journal.pdig.0000493] [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] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
Randomized Clinical trials (RCT) suffer from a high failure rate which could be caused by heterogeneous responses to treatment. Despite many models being developed to estimate heterogeneous treatment effects (HTE), there remains a lack of interpretable methods to identify responsive subgroups. This work aims to develop a framework to identify subgroups based on treatment effects that prioritize model interpretability. The proposed framework leverages an ensemble uplift tree method to generate descriptive decision rules that separate samples given estimated responses to the treatment. Subsequently, we select a complementary set of these decision rules and rank them using a sparse linear model. To address the trial's limited sample size problem, we proposed a data augmentation strategy by borrowing control patients from external studies and generating synthetic data. We apply the proposed framework to a failed randomized clinical trial for investigating an intracerebral hemorrhage therapy plan. The Qini-scores show that the proposed data augmentation strategy plan can boost the model's performance and the framework achieves greater interpretability by selecting complementary descriptive rules without compromising estimation quality. Our model derives clinically meaningful subgroups. Specifically, we find those patients with Diastolic Blood Pressure≥70 mm hg and Systolic Blood Pressure<215 mm hg benefit more from intensive blood pressure reduction therapy. The proposed interpretable HTE analysis framework offers a promising potential for extracting meaningful insight from RCTs with neutral treatment effects. By identifying responsive subgroups, our framework can contribute to developing personalized treatment strategies for patients more efficiently.
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Affiliation(s)
- Yaobin Ling
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Muhammad Bilal Tariq
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Kaichen Tang
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Jaroslaw Aronowski
- Institute for Stroke and Cerebrovascular Disease, UTHealth at Houston, Houston, Texas, United States of America
| | - Yang Fann
- Intramural Research Program, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, UTHealth at Houston, Houston, Texas, United States of America
| | - Xiaoqian Jiang
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Yejin Kim
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
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Smith FS, Lai H, Tamí-Maury I, Cornejo Gonzalez A, Stuart S, Denny MC, Ancer Leal A, Sharrief A, Maroufy V, Savitz SI, Beauchamp JES. A Cross-sectional Survey of Comprehension and Satisfaction of Spanish-Reading Adults Regarding RÁPIDO as a Stroke Awareness Acronym. J Neurosci Nurs 2024; 56:69-74. [PMID: 38598848 DOI: 10.1097/jnn.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
ABSTRACT BACKGROUND: Delay time to hospital arrival may be influenced by lack of recognition of stroke signs and the necessity to seek emergency medical, which in turn is influenced by language barriers to, a modifiable risk factor, stroke awareness education. The objective was to determine the comprehension and satisfaction of a Spanish stroke awareness acronym, RÁPIDO, among community-living, Hispanic and Latino, Spanish-reading adults. METHODS: A 33-item survey was completed by 166 adults. Data on sociodemographics, language preferences, stroke education, and comprehension and satisfaction with RÁPIDO were collected. Descriptive characteristics were calculated. Fisher exact tests were performed to determine whether reading language (group 1, only or predominantly reads in Spanish; group 2, reads in Spanish and English equally or reads predominately in English) influenced survey responses. Responses to open-ended questions were categorized. RESULTS: Sixty-nine percent of the participants were born outside of the United States, 82% currently resided in the United States, 34% read only or predominately in Spanish, and 7% had a stroke. Most participants thought RÁPIDO was informative, eye-catching, and easily remembered. Significant differences were found between reading language preference groups for correctly identifying RÁPIDO images for facial drooping (group 1, 80%; group 2, 95%; P ≤ .001) and dizziness/loss of balance (group 1, 54%; group 2, 73%; P = .027). Eighty percent or more of all participants were able to correctly interpret RÁPIDO images for facial drooping, blurry vision, impaired speech, and call emergency services. Adding "911" to the RÁPIDO image of the clock was a common suggestion. CONCLUSIONS: RÁPIDO was well received among the participants. Modifications to RÁPIDO images representing dizziness/loss of balance and arm weakness, and the addition of "911" may improve its usefulness. Obtaining more extensive feedback across the United States and testing the effect of RÁPIDO on increasing knowledge of stroke signs and retention of that knowledge are necessary next steps.
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Prasad S, Jones EM, Gebreyohanns M, Kwon Y, Olson DM, Anderson JA, Savitz SI, Cruz-Flores S, Warach SJ, Rhodes CE, Goldberg MP, Ifejika NL. Multicenter exploration of tenecteplase transition factors: A quantitative analysis. J Stroke Cerebrovasc Dis 2024; 33:107592. [PMID: 38266690 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107592] [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: 09/25/2023] [Revised: 01/02/2024] [Accepted: 01/20/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Tenecteplase (TNK) is gaining recognition as a novel therapy for acute ischemic stroke (AIS). Despite TNK offering a longer half-life, time and cost saving benefits and comparable treatment and safety profiles to Alteplase (ALT), the adoption of TNK as a treatment for AIS presents challenges for hospital systems. OBJECTIVE Identify barriers and facilitators of TNK implementation at acute care hospitals in Texas. METHODS This prospective survey used open-ended questions and Likert statements generated from content experts and informed by qualitative research. Stroke clinicians and nurses working at 40 different hospitals in Texas were surveyed using a virtual platform. RESULTS The 40 hospitals had a median of 34 (IQR 24.5-49) emergency department beds and 42.5 (IQR 23.5-64.5) inpatient stroke beds with 506.5 (IQR 350-797.5) annual stroke admissions. Fifty percent of the hospitals were Comprehensive Stroke Centers, and 18 (45 %) were solely using ALT for treatment of eligible AIS patients. Primary facilitators to TNK transition were team buy-in and a willingness of stroke physicians, nurses, and pharmacists to adopt TNK. Leading barriers were lack of clinical evidence supporting TNK safety profile inadequate evidence supporting TNK use and a lack of American Heart Association guidelines support for TNK administration in all AIS cases. CONCLUSION Understanding common barriers and facilitators to TNK adoption can assist acute care hospitals deciding to implement TNK as a treatment for AIS. These findings will be used to design a TNK adoption Toolkit, utilizing implementation science techniques, to address identified obstacles and to leverage facilitators.
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Affiliation(s)
- Sidarrth Prasad
- University of Texas Southwestern Medical Center, United States
| | - Erica M Jones
- University of Texas Southwestern Medical Center, United States
| | | | - Yoon Kwon
- University of Texas Southwestern Medical Center, United States
| | - DaiWai M Olson
- University of Texas Southwestern Medical Center, United States
| | | | - Sean I Savitz
- University of Texas Health Science Center at Houston, United States
| | | | - Steven J Warach
- Dell Medical School, The University of Texas at Austin, United States
| | - Charlotte E Rhodes
- The University of Texas Health Science Center at San Antonio, United States
| | - Mark P Goldberg
- The University of Texas Health Science Center at San Antonio, United States
| | - Nneka L Ifejika
- University of Texas Southwestern Medical Center, United States.
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Haque ME, Boren SB, Mills J, Schneider KG, Parekh M, Fraser SM, Bach I, Hariharan P, Zelnick PJ, Guerra Castanon FS, Naveed A, Tariq M, Arevalo OD, Hasan KM, Escobar M, Zhao X, Sitton C, Narayana PA, Grotta JC, Aronowski J, Savitz SI. Dynamic Imaging of Blood Coagulation Within the Hematoma of Patients With Acute Hemorrhagic Stroke. Stroke 2024; 55:1015-1024. [PMID: 38275117 PMCID: PMC10962442 DOI: 10.1161/strokeaha.123.044343] [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: 06/27/2023] [Revised: 12/12/2023] [Accepted: 01/03/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND The dynamics of blood clot (combination of Hb [hemoglobin], fibrin, and a higher concentration of aggregated red blood cells) formation within the hematoma of an intracerebral hemorrhage is not well understood. A quantitative neuroimaging method of localized coagulated blood volume/distribution within the hematoma might improve clinical decision-making. METHODS The deoxyhemoglobin of aggregated red blood cells within extravasated blood exhibits a higher magnetic susceptibility due to unpaired heme iron electrons. We propose that coagulated blood, with higher aggregated red blood cell content, will exhibit (1) a higher positive susceptibility than noncoagulated blood and (2) increase in fibrin polymerization-restricted localized diffusion, which can be measured noninvasively using quantitative susceptibility mapping and diffusion tensor imaging. In this serial magnetic resonance imaging study, we enrolled 24 patients with acute intracerebral hemorrhage between October 2021 to May 2022 at a stroke center. Patients were 30 to 70 years of age and had a hematoma volume >15 cm3 and National Institutes of Health Stroke Scale score >1. The patients underwent imaging 3×: within 12 to 24 (T1), 36 to 48 (T2), and 60 to 72 (T3) hours of last seen well on a 3T magnetic resonance imaging system. Three-dimensional anatomic, multigradient echo and 2-dimensional diffusion tensor images were obtained. Hematoma and edema volumes were calculated, and the distribution of coagulation was measured by dynamic changes in the susceptibilities and fractional anisotropy within the hematoma. RESULTS Using a coagulated blood phantom, we demonstrated a linear relationship between the percentage coagulation and susceptibility (R2=0.91) with a positive red blood cell stain of the clot. The quantitative susceptibility maps showed a significant increase in hematoma susceptibility (T1, 0.29±0.04 parts per millions; T2, 0.36±0.04 parts per millions; T3, 0.45±0.04 parts per millions; P<0.0001). A concomitant increase in fractional anisotropy was also observed with time (T1, 0.40±0.02; T2, 0.45±0.02; T3, 0.47±0.02; P<0.05). CONCLUSIONS This quantitative neuroimaging study of coagulation within the hematoma has the potential to improve patient management, such as safe resumption of anticoagulants, the need for reversal agents, the administration of alteplase to resolve the clot, and the need for surgery.
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Affiliation(s)
- Muhammad E. Haque
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Seth B. Boren
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - James Mills
- Department of Psychiatry, University of Iowa, Iowa City (J.M.)
| | - Kerry G. Schneider
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Maria Parekh
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Stuart M. Fraser
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Ivo Bach
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Praveen Hariharan
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Pamela J. Zelnick
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Felix S. Guerra Castanon
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Asim Naveed
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Muhammad Tariq
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Octavio D. Arevalo
- Department of Radiology, Louisiana State University, Shreveport (O.D.A.)
| | - Khader M. Hasan
- Department of Interventional Diagnostic Radiology (K.M.H., P.A.N., C.S.)
| | - Miguel Escobar
- McGovern Medical School, The University of Texas Health Science Center at Houston (M.E.)
| | - Xiurong Zhao
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Clark Sitton
- Department of Interventional Diagnostic Radiology (K.M.H., P.A.N., C.S.)
| | | | - James C. Grotta
- Stroke Research and Mobile Stroke Unit, Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Jaroslaw Aronowski
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
| | - Sean I. Savitz
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology (M.E.H, S.B.B., K.G.S., M.P., S.M.F, I.B., P.H., P.J.Z., F.S.G.C., A.N., M.T., X.Z., J.A., S.I.S.)
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Kolls BJ, Muir KW, Savitz SI, Wechsler LR, Pilitsis JG, Rahimi S, Beckman RL, Holmes V, Chen PR, Albers DS, Laskowitz DT. Experience with a hybrid recruitment approach of patient-facing web portal screening and subsequent phone and medical record review for a neurosurgical intervention trial for chronic ischemic stroke disability (PISCES III). Trials 2024; 25:150. [PMID: 38419030 PMCID: PMC10900735 DOI: 10.1186/s13063-024-07988-z] [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: 08/09/2023] [Accepted: 02/05/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Recruitment of participants is the greatest risk to completion of most clinical trials, with 20-40% of trials failing to reach the targeted enrollment. This is particularly true of trials of central nervous system (CNS) therapies such as intervention for chronic stroke. The PISCES III trial was an invasive trial of stereotactically guided intracerebral injection of CTX0E03, a fetal derived neural stem cell line, in patients with chronic disability due to ischemic stroke. We report on the experience using a novel hybrid recruitment approach of a patient-facing portal to self-identify and perform an initial screen for general trial eligibility (tier 1), followed by phone screening and medical records review (tier 2) prior to a final in-person visit to confirm eligibility and consent. METHODS Two tiers of screening were established: an initial screen of general eligibility using a patient-facing web portal (tier 1), followed by a more detailed screen that included phone survey and medical record review (tier 2). If potential participants passed the tier 2 screen, they were referred directly to visit 1 at a study site, where final in-person screening and consent were performed. Rates of screening were tracked during the period of trial recruitment and sources of referrals were noted. RESULTS The approach to screening and recruitment resulted in 6125 tier 1 screens, leading to 1121 referrals to tier 2. The tier 2 screening resulted in 224 medical record requests and identification of 86 qualifying participants for referral to sites. The study attained a viable recruitment rate of 6 enrolled per month prior to being disrupted by COVID 19. CONCLUSIONS A tiered approach to eligibility screening using a hybrid of web-based portals to self-identify and screen for general eligibility followed by a more detailed phone and medical record review allowed the study to use fewer sites and reduce cost. Despite the difficult and narrow population of patients suffering moderate chronic disability from stroke, this strategy produced a viable recruitment rate for this invasive study of intracranially injected neural stem cells. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03629275.
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Affiliation(s)
- Brad J Kolls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Neurology, Duke University School of Medicine, Duke Box 2900 Bryan Research Building, 311 Research Drive, Durham, NC, 27710, USA.
| | - Keith W Muir
- School of Psychology & Neuroscience, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston, TX, USA
| | - Lawrence R Wechsler
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Scott Rahimi
- Department of Neurosurgery, Medical College of Georgia, Augusta, GA, USA
| | | | | | - Peng R Chen
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | | | - Daniel T Laskowitz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Duke Box 2900 Bryan Research Building, 311 Research Drive, Durham, NC, 27710, USA
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Krenek B, Tundealao S, Beauchamp JES, Savitz SI, Tamí-Maury I. Comparing Stroke Risk Factors Among Sexual Minority Groups in Texas. Int J Behav Med 2024:10.1007/s12529-024-10267-5. [PMID: 38396275 DOI: 10.1007/s12529-024-10267-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Knowledge gaps remain on stroke risk and disparities between sexual minority (SM) subgroups. In this study, stroke risk between SM subgroups, specifically gay/bisexual men and lesbian/bisexual women (G/BM and L/BW), was assessed. METHOD Data were collected in June 2022 using a bilingual (English and Spanish) cross-sectional paper-and-pen survey distributed among 183 SM individuals attending the 2022 Houston Pride Parade and Festival, as well as across Texas via phone call or online format. Relevant sociodemographic and stroke risk factors were compared between G/BM and L/BW using chi-square (or Fisher's exact, when appropriate) and two-sample t-tests. Sexual orientation was used to predict stroke risk using multiple binomial logistic regression, adjusting for other sociodemographic determinants. RESULTS While comparing the stroke risk factors between G/BW and L/BW, statistically significant differences were found in hypertension (p = 0.047), age (p < 0.001), smoking status (p = 0.043), cholesterol level (p < 0.001), and HIV (p = 0.038). G/BM were 2.79 times more likely to have a higher stroke risk compared to L/BW (aOR = 2.79; CI, 1.11-6.05, p = 0.032), after adjusting for other sociodemographic factors. CONCLUSION This pilot study, conducted in Texas, adds to the existing scientific literature on stroke risk among the SM population and revealed that G/BM might have a higher stroke risk compared to L/BW. These findings can inform future research and intervention designs tailored to G/BM and L/BW communities and improve their overall health.
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Affiliation(s)
- Brittany Krenek
- Department of Epidemiology, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Samuel Tundealao
- Department of Epidemiology, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jennifer E S Beauchamp
- Department of Research, Cizik School of Nursing, University of Texas Health Science Center at Houston, Houston, TX, USA
- Institute for Stroke and Cerebrovascular Diseases, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Institute for Stroke and Cerebrovascular Diseases, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Irene Tamí-Maury
- Department of Epidemiology, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Institute for Stroke and Cerebrovascular Diseases, University of Texas Health Science Center at Houston, Houston, TX, USA.
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8
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Li W, Rahbar MH, Savitz SI, Zhang J, Lundin SK, Tahanan A, Ning J. Regression analysis of multivariate recurrent event data allowing time-varying dependence with application to stroke registry data. Stat Methods Med Res 2024; 33:309-320. [PMID: 38263734 PMCID: PMC11080814 DOI: 10.1177/09622802231226330] [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: 01/25/2024]
Abstract
In multivariate recurrent event data, each patient may repeatedly experience more than one type of event. Analysis of such data gets further complicated by the time-varying dependence structure among different types of recurrent events. The available literature regarding the joint modeling of multivariate recurrent events assumes a constant dependency over time, which is strict and often violated in practice. To close the knowledge gap, we propose a class of flexible shared random effects models for multivariate recurrent event data that allow for time-varying dependence to adequately capture complex correlation structures among different types of recurrent events. We developed an expectation-maximization algorithm for stable and efficient model fitting. Extensive simulation studies demonstrated that the estimators of the proposed approach have satisfactory finite sample performance. We applied the proposed model and the estimating method to data from a cohort of stroke patients identified in the University of Texas Houston Stroke Registry and evaluated the effects of risk factors and the dependence structure of different types of post-stroke readmission events.
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Affiliation(s)
- Wen Li
- Division of Clinical and Translational Sciences, Department of Internal Medicine the University of Texas McGovern Medical School at Houston, Houston, TX 77030, USA
- Biostatistics/Epidemiology/Research Design (BERD) Component, Center for Clinical and Translational Sciences (CCTS), University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Mohammad H. Rahbar
- Division of Clinical and Translational Sciences, Department of Internal Medicine the University of Texas McGovern Medical School at Houston, Houston, TX 77030, USA
- Biostatistics/Epidemiology/Research Design (BERD) Component, Center for Clinical and Translational Sciences (CCTS), University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- Division of Epidemiology, Human Genetics, and Environmental Sciences (EHGES), University of Texas School of Public Health at Houston, Houston, TX 77030, USA
| | - Sean I. Savitz
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX 77030, USA
| | - Jing Zhang
- Biostatistics/Epidemiology/Research Design (BERD) Component, Center for Clinical and Translational Sciences (CCTS), University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- Department of Biostatistics & Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Sori Kim Lundin
- Biostatistics/Epidemiology/Research Design (BERD) Component, Center for Clinical and Translational Sciences (CCTS), University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- Center for Biomedical Semantics and Data Intelligence, Houston, TX 77030, USA
| | - Amirali Tahanan
- Biostatistics/Epidemiology/Research Design (BERD) Component, Center for Clinical and Translational Sciences (CCTS), University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Jing Ning
- Department of Biostatistics, University of Texas MD Anderson Cancer Center at Houston, TX 77030, USA
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9
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Houkin K, Osanai T, Uchiyama S, Minematsu K, Taguchi A, Maruichi K, Niiya Y, Asaoka K, Kuga Y, Takizawa K, Haraguchi K, Yoshimura S, Kimura K, Tokunaga K, Aoyama A, Ikawa F, Inenaga C, Abe T, Tominaga A, Takahashi S, Kudo K, Fujimura M, Sugiyama T, Ito M, Kawabori M, Hess DC, Savitz SI, Hirano T. Allogeneic Stem Cell Therapy for Acute Ischemic Stroke: The Phase 2/3 TREASURE Randomized Clinical Trial. JAMA Neurol 2024; 81:154-162. [PMID: 38227308 PMCID: PMC10792497 DOI: 10.1001/jamaneurol.2023.5200] [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: 08/25/2023] [Accepted: 11/15/2023] [Indexed: 01/17/2024]
Abstract
Importance Cell therapy is a promising treatment approach for stroke and other diseases. However, it is unknown whether MultiStem (HLCM051), a bone marrow-derived, allogeneic, multipotent adult progenitor cell product, has the potential to treat ischemic stroke. Objective To assess the efficacy and safety of MultiStem when administered within 18 to 36 hours of ischemic stroke onset. Design, Setting, and Participants The Treatment Evaluation of Acute Stroke Using Regenerative Cells (TREASURE) multicenter, double-blind, parallel-group, placebo-controlled phase 2/3 randomized clinical trial was conducted at 44 academic and clinical centers in Japan between November 15, 2017, and March 29, 2022. Inclusion criteria were age 20 years or older, presence of acute ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score of 8-20 at baseline), confirmed acute infarction involving the cerebral cortex and measuring more than 2 cm on the major axis (determined with diffusion-weighted magnetic resonance imaging), and a modified Rankin Scale (mRS) score of 0 or 1 before stroke onset. Data analysis was performed between May 9 and August 15, 2022. Exposure Patients were randomly assigned to either intravenous MultiStem in 1 single unit of 1.2 billion cells or intravenous placebo within 18 to 36 hours of ischemic stroke onset. Main Outcomes and Measures The primary end points were safety and excellent outcome at day 90, measured as a composite of a modified Rankin Scale (mRS) score of 1 or less, a NIHSS score of 1 or less, and a Barthel index score of 95 or greater. The secondary end points were excellent outcome at day 365, mRS score distribution at days 90 and 365, and mRS score of 0 to 1 and 0 to 2 at day 90. Statistical analysis of efficacy was performed using the Cochran-Mantel-Haenszel test. Results This study included 206 patients (104 received MultiStem and 102 received placebo). Their mean age was 76.5 (range, 35-95) years, and more than half of patients were men (112 [54.4%]). There were no between-group differences in primary and secondary end points. The proportion of excellent outcomes at day 90 did not differ significantly between the MultiStem and placebo groups (12 [11.5%] vs 10 [9.8%], P = .90; adjusted risk difference, 0.5% [95% CI, -7.3% to 8.3%]). The frequency of adverse events was similar between treatment groups. Conclusions and Relevance In this randomized clinical trial, intravenous administration of allogeneic cell therapy within 18 to 36 hours of ischemic stroke onset was safe but did not improve short-term outcomes. Further research is needed to determine whether MultiStem therapy for ischemic stroke has a beneficial effect in patients who meet specific criteria, as indicated by the exploratory analyses in this study. Trial Registration ClinicalTrials.gov Identifier: NCT02961504.
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Affiliation(s)
| | - Toshiya Osanai
- Department of Neurosurgery, Hokkaido University, Sapporo, Japan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Tokyo, Japan
- Center for Brain and Cerebral Vessels, Sanno Medical Center, Tokyo, Japan
| | | | - Akihiko Taguchi
- Department of Regenerative Medicine Research, Foundation for Biomedical Research and Innovation at Kobe, Kobe, Japan
| | - Katsuhiko Maruichi
- Department of Neurosurgery, Kashiwaba Neurosurgical Hospital, Sapporo, Japan
| | - Yoshimasa Niiya
- Department of Neurosurgery, Otaru General Hospital, Otaru, Japan
| | - Katsuyuki Asaoka
- Department of Neurosurgery, Teine Keijinkai Medical Center, Sapporo, Japan
| | - Yoshihiro Kuga
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan
| | - Katsumi Takizawa
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, Japan
| | - Koichi Haraguchi
- Department of Neurosurgery, Hakodate Shintoshi Hospital, Hakodate, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School Hospital, Tokyo, Japan
| | - Koji Tokunaga
- Department of Neurosurgery, Okayama City Hospital, Okayama City, Japan
| | - Atsuo Aoyama
- Department of Neurology, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Chikanori Inenaga
- Department of Neurosurgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Tatsuya Abe
- Department of Neurosurgery, Saga University, Nabeshima, Japan
| | - Atsushi Tominaga
- Department of Neurosurgery and Neuroendovascular Therapy, Hiroshima Prefectural Hospital, Hiroshima City, Japan
| | - Shinichi Takahashi
- Department of Neurology and Stroke, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Hokkaido University, Sapporo, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University, Sapporo, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University, Sapporo, Japan
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University, Sapporo, Japan
| | | | - David C. Hess
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta
| | - Sean I. Savitz
- Department of Neurology Institute for Stroke and Cerebrovascular Disease, UTHealth, Houston, Texas
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
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10
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Beauchamp JES, Wang M, Leon Novelo LG, Cox C, Meyer T, Fagundes C, Savitz SI, Sharrief A, Dishman D, Johnson C. Feasibility and user-experience of a virtual environment for social connection and education after stroke: A pilot study. J Stroke Cerebrovasc Dis 2024; 33:107515. [PMID: 38064972 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107515] [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: 07/04/2023] [Revised: 10/25/2023] [Accepted: 11/26/2023] [Indexed: 01/23/2024] Open
Abstract
OBJECTIVES To evaluate the feasibility and usability of stroke survivor participation in an 8-week virtual environment intervention that provides opportunities for social support exchanges, social network interactions, and recovery education. MATERIALS AND METHODS A single-group, pre- and post-test measure design was used. Descriptive statistics were used to examine enrollment and retention rates, proportion of questionnaires completed, and virtual environment process data (e.g., number of log-ins) and usability scores. Changes in pre- and post-intervention questionnaire (e.g., usability, social support, depression, anxiety, loneliness, and self-efficacy) scores were explored using Wilcoxon signed-rank tests and paired t-test. RESULTS Fifteen (65 %) of the eligible stroke survivors enrolled (60 % white, 27 % black), 12 (80 %) had an ischemic stroke, ages ranged from 33 to 74 years (mean 44 years), and mean months since stroke was 33 ± 23. Retention and questionnaire completion rates were both 93 % (n = 14). Survivors logged into the virtual environment a total of 122 times, logged an average of 49 min/log-in, and 12 (80 %) attended support groups and social activities. Median usability score indicated lower than average usability. Improvement trends in social support, loneliness, and depressive symptoms were found, but significant changes in mean questionnaire scores were not found. CONCLUSIONS Overall, the results suggest that using a virtual environment to foster social support exchanges, social network interactions, and recovery education after stroke is feasible. Similar to other chronic disease populations, stroke survivor adoption of a virtual environment likely requires ongoing technical assistance, repetition of instructions, and opportunities for practice to reinforce engagement. TRIAL REGISTRATION NCT05487144.
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Affiliation(s)
- Jennifer E S Beauchamp
- Cizik School of Nursing, The University of Texas Health Science Center at Houston and the Institute for Stroke and Cerebrovascular Disease, 6901 Bertner Avenue, Houston, TX 77030, United States.
| | - Mengxi Wang
- School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX 77030, United States
| | - Luis G Leon Novelo
- School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX 77030, United States
| | - Caroline Cox
- Cizik School of Nursing, The University of Texas Health Science Center at Houston and the Institute for Stroke and Cerebrovascular Disease, 6901 Bertner Avenue, Houston, TX 77030, United States
| | - Thomas Meyer
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, 1941 East Road, Houston, TX 77030, United States
| | - Christopher Fagundes
- Department of Psychological Sciences, Rice University, 6100 Main Street, Houston, TX 77005, United States
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston and the Institute for Stroke and Cerebrovascular Disease, 6431 Fannin, Houston, TX 77030, United States
| | - Anjail Sharrief
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston and the Institute for Stroke and Cerebrovascular Disease, 6431 Fannin, Houston, TX 77030, United States
| | - Deniz Dishman
- Cizik School of Nursing, The University of Texas Health Science Center at Houston and the Institute for Stroke and Cerebrovascular Disease, 6901 Bertner Avenue, Houston, TX 77030, United States
| | - Constance Johnson
- Cizik School of Nursing, The University of Texas Health Science Center at Houston and the Institute for Stroke and Cerebrovascular Disease, 6901 Bertner Avenue, Houston, TX 77030, United States
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11
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Becerril-Gaitan A, Ding D, Ironside N, Southerland AM, Worrall BB, Testai FD, Flaherty ML, Elkind MS, Koch S, Sung G, Kittner SJ, Mayson DJ, Gonzales N, McCauley JL, Malkoff M, Hall CE, Frankel MR, James ML, Anderson CD, Aronowski J, Savitz SI, Woo D, Chen CJ. Association Between Body Mass Index and Functional Outcomes in Patients With Intracerebral Hemorrhage. Neurology 2024; 102:e208014. [PMID: 38165334 PMCID: PMC10870743 DOI: 10.1212/wnl.0000000000208014] [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: 06/12/2023] [Accepted: 10/13/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Evidence of the so-called "obesity paradox," which refers to the protective effect and survival benefit of obesity in patients with spontaneous intracerebral hemorrhage (ICH), remains controversial. This study aims to determine the association between body mass index (BMI) and functional outcomes in patients with ICH and whether it is modified by race/ethnicity. METHODS Included individuals were derived from the Ethnic/Racial Variations of Intracerebral Hemorrhage study, which prospectively recruited 1,000 non-Hispanic White, 1,000 non-Hispanic Black, and 1,000 Hispanic patients with spontaneous ICH. Only patients with available BMI were included. The primary outcome was 90-day mortality. Secondary outcomes were mortality at discharge, modified Rankin Scale (mRS), Barthel Index, and self-reported health status measures at 90 days. Associations between BMI and ICH outcomes were assessed using univariable and multivariable logistic, ordinal, and linear regression models, as appropriate. Sensitivity analyses after excluding frail patients and by patient race/ethnicity were performed. RESULTS A total of 2,841 patients with ICH were included. The median age was 60 years (interquartile range 51-73). Most patients were overweight (n = 943; 33.2%) or obese (n = 1,032; 36.3%). After adjusting for covariates, 90-day mortality was significantly lower among overweight and obese patients than their normal weight counterparts (adjusted odds ratio [aOR] = 0.71 [0.52-0.98] and aOR = 0.70 [0.50-0.97], respectively). Compared with patients with BMI <25 kg/m2, those with BMI ≥25 kg/m2 had better 90-day mRS (aOR = 0.80 [CI 0.67-0.95]), EuroQoL Group 5-Dimension (EQ-5D) (aβ = 0.05 [0.01-0.08]), and EQ-5D VAS (aβ = 3.80 [0.80-6.98]) scores. These differences persisted after excluding withdrawal of care patients. There was an inverse relationship between BMI and 90-day mortality (aOR = 0.97 [0.96-0.99]). Although non-Hispanic White patients had significantly higher 90-day mortality than non-Hispanic Black and Hispanic (26.6% vs 19.5% vs 18.0%, respectively; p < 0.001), no significant interactions were found between BMI and race/ethnicity. No significant interactions between BMI and age or sex for 90-day mortality were found, whereas for 90-day mRS, there was a significant interaction with age (pinteraction = 0.004). CONCLUSION We demonstrated that a higher BMI is associated with decreased mortality, improved functional outcomes, and better self-reported health status at 90 days, thus supporting the paradoxical role of obesity in patients with ICH. The beneficial effect of high BMI does not seem to be modified by race/ethnicity or sex, whereas age may play a significant role in patient functional outcomes.
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Affiliation(s)
- Andrea Becerril-Gaitan
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Dale Ding
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Natasha Ironside
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Andrew M Southerland
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Bradford B Worrall
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Fernando D Testai
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Matthew L Flaherty
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Mitchell S Elkind
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Sebastian Koch
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Gene Sung
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Steven J Kittner
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Douglas J Mayson
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Nicole Gonzales
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Jacob L McCauley
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Marc Malkoff
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Christiana E Hall
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Michael R Frankel
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Michael L James
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Christopher D Anderson
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Jaroslaw Aronowski
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Sean I Savitz
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Daniel Woo
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
| | - Ching-Jen Chen
- From the Departments of Neurosurgery (A.B.-G., C.-J.C.) and Neurology (J.A., S.I.S.), The University of Texas Health Science Center at Houston; Department of Neurosurgery (D.D.), University of Louisville, KY; Department of Neurosurgery (N.I.); Departments of Neurology and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology and Rehabilitation (F.D.T.), University of Illinois College of Medicine, Chicago; Department of Neurology (M.L.F., D.W.), University of Cincinnati, OH; Department of Neurology (M.S.E.), Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York; Department of Neurology (S.K.) and John P. Hussman Institute for Human Genomics (J.L.M.), University of Miami Miller School of Medicine, FL; Department of Neurology and Neurocritical Care and Stroke (G.S.), Keck School of Medicine, University of Southern California, Los Angeles; Department of Neurology (S.J.K.), University of Maryland School of Medicine, Baltimore; Department of Neurology (D.J.M.), MedStar Georgetown University Hospital, Washington, DC; Department of Neurology (N.G.), University of Colorado School of Medicine, Aurora; Departments of Neurology and Neurosurgery (M.M.), University of Tennessee Health Sciences, Memphis; Department of Neurology (C.E.H.), University of Texas Southwestern, Dallas; Department of Neurology (M.R.F.), Emory University, Grady Memorial Hospital, Atlanta, GA; Departments of Anesthesiology and Neurology (M.L.J.), Duke Clinical Research Institute, Duke University, Durham, NC; and Henry and Allison McCane Center for Brain Health and Center for Genomic Medicine (C.D.A.), Massachusetts General Hospital, Massachusetts, Boston
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Yaghi S, Albin C, Chaturvedi S, Savitz SI. Roundtable of Academia and Industry for Stroke Prevention: Prevention and Treatment of Large-Vessel Disease. Stroke 2024; 55:226-235. [PMID: 38134259 DOI: 10.1161/strokeaha.123.043910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Affiliation(s)
- Shadi Yaghi
- Alpert Medical School at Brown University, Providence, RI (S.Y.)
| | | | | | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston (S.I.S.)
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Prasad S, Jones EM, Gebreyohanns M, Aguilera V, Olson DM, Anderson JA, Savitz SI, Flores SC, Warach SJ, Rhodes CE, Goldberg MP, Ifejika NL. A qualitative study of barriers and facilitators to using tenecteplase to treat acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107458. [PMID: 37956644 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107458] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/18/2023] [Revised: 10/03/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Tenecteplase (TNK) is emerging as an alternative to alteplase (ALT) for thrombolytic treatment of acute ischemic stroke (AIS). Compared to ALT, TNK has a longer half-life, shorter administration time, lower cost, and similarly high efficacy in treating large vessel occlusion. Nevertheless, there are barriers to adopting TNK as a treatment for AIS. This study aimed to identify thematic barriers and facilitators to adopting TNK as an alternative to ALT as a thrombolytic for eligible AIS patients. METHODS Qualitative research methodology using hermeneutic cycling and purposive sampling was used to interview four stroke clinicians in Texas. Interviews were recorded and transcribed verbatim. Enrollment was complete when saturation was reached. All members of the research team participated in content analysis during each cycle and in thematic analysis after saturation. RESULTS Interviews were conducted between November 2022 and February 2023 with stroke center representatives from centers that either had successfully adopted TNK, or had not yet adopted TNK. Three themes and eight sub-themes were identified. The theme "Evidence" had three sub-themes: Pro-Con Balance, Fundamental Knowledge, and Pharmacotherapeutics. The theme "Process Flow" had four subthemes: Proactive, Reflective self-doubt, Change Process Barriers, and Parameter Barriers. The theme "Consensus" had one sub-theme: Getting Buy-In. CONCLUSION Clinicians experience remarkably similar barriers and facilitators to adopting TNK. The results lead to a hypothesis that providing evidence to support a practice change, and identifying key change processes, will help clinicians achieve consensus across teams that need to 'buy in' to adopting TNK for AIS treatment.
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Affiliation(s)
- Sidarrth Prasad
- University of Texas Southwestern Medical Center, United States
| | - Erica M Jones
- University of Texas Southwestern Medical Center, United States
| | | | | | - DaiWai M Olson
- University of Texas Southwestern Medical Center, United States
| | | | - Sean I Savitz
- University of Texas Health Science Center at Houston, United States
| | | | - Steven J Warach
- Dell Medical School, The University of Texas at Austin, United States
| | - Charlotte E Rhodes
- The University of Texas Health Science Center at San Antonio, United States
| | - Mark P Goldberg
- The University of Texas Health Science Center at San Antonio, United States
| | - Nneka L Ifejika
- University of Texas Southwestern Medical Center, United States.
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14
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Dishman D, Lal T, Silos C, Chen L, Jiang X, Beauchamp J, Aggarwal S, Green C, Savitz SI. A retrospective examination of pain in acute stroke at hospital discharge. J Stroke Cerebrovasc Dis 2023; 32:107370. [PMID: 37832269 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107370] [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: 06/16/2023] [Revised: 09/10/2023] [Accepted: 09/12/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVES Pain is an overlooked sequela of stroke. Persistent pain after stroke is an underrecognized experience and significantly impacts survivors' function, ability to participate in rehabilitation, and quality of life. The aim of this retrospective, observational study is to examine the incidence of pain at the acute hospitalization period immediately after stroke, to identify the characteristics of those reporting pain at discharge, and to compare pain reporting between stroke and non-stroke hospital controls. MATERIALS AND METHODS Using discharge diagnosis, this retrospective review examined self- reports of pain during acute hospitalization for stroke compared to those with COPD (control group) admitted during the same time in the same facilities. Variables of interest included age, gender, body mass index (BMI), length of stay, pain assessment score (numeric rating scale [NRS], behavior pain scale [BPS], and medication administration record pain score total [MAR]), smoking history, prevalence of hypertension and race. 821 subjects were included from a total of three campuses from one large hospital system. 772 subjects were included in the comparative analysis with COPD patients from the same facilities during the same time. RESULTS 43% of patients diagnosed with stroke reported pain at discharge. For stroke survivors reporting pain at discharge, the average BMI was higher (p=0.009), average arrival NIHSS was higher (p=0.044), and mean hospital length of stay was longer (p<0.001). CONCLUSIONS The evidence demonstrated in this study highlights the critical need for the implementation of targeted objective pain assessment and effective pain interventions for stroke survivors beginning at initial hospitalization.
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Affiliation(s)
- Deniz Dishman
- Institute for Stroke and Cerebrovascular Disease and Cizik School of Nursing, University of Texas Health Science Center at Houston, United States; Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States.
| | - Tia Lal
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States
| | - Christin Silos
- Baylor College of Medicine, Houston, Texas, United States
| | - Luyao Chen
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, United States
| | - Xiaoqian Jiang
- Institute for Stroke and Cerebrovascular Disease and School of Biomedical Informatics, University of Texas Health Science Center at Houston, United States
| | - Jennifer Beauchamp
- Institute for Stroke and Cerebrovascular Disease and Cizik School of Nursing, University of Texas Health Science Center at Houston, United States
| | - Seema Aggarwal
- Institute for Stroke and Cerebrovascular Disease and Cizik School of Nursing, University of Texas Health Science Center at Houston, United States
| | - Charles Green
- Institute for Stroke and Cerebrovascular Disease and McGovern Medical School, University of Texas Health Science Center at Houston, United States
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States
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15
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Boren SB, Savitz SI, Ellmore TM, Arevalo OD, Aronowski J, Silos C, George S, Haque ME. Longitudinal Resting-State Functional Magnetic Resonance Imaging Study: A Seed-Based Connectivity Biomarker in Patients with Ischemic and Intracerebral Hemorrhage Stroke. Brain Connect 2023; 13:498-507. [PMID: 36097789 DOI: 10.1089/brain.2022.0017] [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] [Indexed: 11/13/2022] Open
Abstract
Objective: The primary aim of the research was to compare the impact of postischemic and hemorrhagic stroke on brain connectivity and recovery using resting-state functional magnetic resonance imaging. Methods and Procedures: We serially imaged 20 stroke patients, 10 with ischemic stroke (IS) and 10 with intracerebral hemorrhage (ICH), at 1, 3, and 12 months (1M, 3M, and 12M) after ictus. Data from 10 healthy volunteers were obtained from a publically available imaging data set. All functional and structural images underwent standard processing for brain extraction, realignment, serial registration, unwrapping, and denoising using SPM12. A seed-based group analysis using CONN software was used to evaluate the default mode network and the sensorimotor network connections by applying bivariate correlation and hemodynamic response function weighting. Results: In comparison with healthy controls, both IS and ICH exhibited disrupted interactions (decreased connectivity) between these two networks at 1M. Interactions then increased by 12M in each group. Temporally, each group exhibited a minimal increase in connectivity at 3M compared with 12M. Overall, the ICH patients exhibited a greater magnitude of connectivity disruption compared with IS patients, despite a significant intrasubject reduction in hematoma volume. We did not observe any significant correlation between change in connectivity and recovery as measured on the National Institutes of Health Stroke Scale (NIHSS) at any time point. Conclusions: These findings demonstrate that the largest changes in functional connectivity occur earlier (3M) rather than later (12M) and show subtle differences between IS and ICH during recovery and should be explored further in larger samples.
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Affiliation(s)
- Seth B Boren
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Timothy M Ellmore
- Department of Psychology, The City College of New York, New York, New York, USA
| | - Octavio D Arevalo
- Department of Radiology, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Jaroslaw Aronowski
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christin Silos
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sarah George
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Muhammad E Haque
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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16
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Zoellner ER, Patterson MA, Sharrief AZ, Savitz SI, Tucker WJ, Miketinas DC. Dietary Intake and Quality among Stroke Survivors: NHANES 1999-2018. J Nutr 2023; 153:3032-3040. [PMID: 37598751 DOI: 10.1016/j.tjnut.2023.08.015] [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: 04/17/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Nutrition is an important modifiable risk factor for prevention and treatment of stroke. However, examination of nutrient intake and diet quality in stroke survivors is limited. OBJECTIVES The aim of the study was to estimate usual nutrient intake and diet quality in US adults with and without a history of self-reported stroke. METHODS Using US National Health and Nutrition Examination Survey (NHANES) 1999-2018, we analyzed demographics, health history, and dietary intake data in 1626 individuals with a history of stroke matched for age, gender, and survey cycle to respective controls (n=1621) with no history of stroke. A minimum of one 24-h dietary recall was used to assess dietary intake. Diet quality was determined using Healthy Eating Index 2015 (HEI-2015) scores. Adult food security was assessed based on responses to the US Department of Agriculture Household Food Security Survey Module. Physical and mental limitations were assessed from responses to the NHANES Physical Functioning Questionnaire. Estimates were reported as mean (standard error). RESULTS In comparison to controls, stroke survivors were more likely to be food insecure, experience poverty, and report physical and mental limitations (P < .001, all comparisons). Stroke survivors were more likely to report excessive (% > acceptable macronutrient distribution range) intake for total fat (50.9 [2.7]% vs. 40.4 [2.2]%, P < .001) and inadequate intake (% < estimated average requirement) for calcium (54.6 [1.8]% vs. 43.5 [2.4]%, P = .001) and magnesium (66 [1.8] vs. 53.6 [1.8]%, P < .001). In addition, stroke survivors reported lower HEI-2015 total scores than controls (49.8 vs. 51.9, P < .001). Finally, HEI-2015 total scores were lower in stroke survivors who were food insecure and those with a lower income-to-poverty ratio (< 185%) (P = .001). CONCLUSIONS Dietary intake in stroke survivors was nutritionally poor, with suboptimal nutrient intake and lower overall diet quality compared with age- and gender-matched controls. Furthermore, poverty and food insecurity were more prevalent in stroke survivors and associated with worse diet quality.
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Affiliation(s)
- Erika R Zoellner
- Department of Nutrition & Food Sciences, Texas Woman's University, Houston, TX, United States
| | - Mindy A Patterson
- Department of Nutrition & Food Sciences, Texas Woman's University, Houston, TX, United States; Institute for Women's Health, College of Health Sciences, Houston, TX, United States
| | - Anjail Z Sharrief
- UTHealth Department of Neurology, McGovern Medical School and Institute for Stroke and Cerebrovascular Disease, Houston, TX, United States
| | - Sean I Savitz
- UTHealth Department of Neurology, McGovern Medical School and Institute for Stroke and Cerebrovascular Disease, Houston, TX, United States
| | - Wesley J Tucker
- Department of Nutrition & Food Sciences, Texas Woman's University, Houston, TX, United States; Institute for Women's Health, College of Health Sciences, Houston, TX, United States
| | - Derek C Miketinas
- Department of Nutrition & Food Sciences, Texas Woman's University, Houston, TX, United States.
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17
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Pon G, Pelsue B, Reddy ST, Parsha K, Zhang X, Gulbis B, Barreto A, Savitz SI, Escobar M, Allison TA. Hemostatic efficacy of four factor prothrombin complex concentrate in intracerebral hemorrhage patients receiving warfarin vs. factor Xa inhibitors. Thromb Res 2023; 229:46-52. [PMID: 37406569 DOI: 10.1016/j.thromres.2023.06.021] [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: 04/21/2023] [Revised: 06/04/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION 4-F PCC is administered for reversal of factor Xa inhibitor-associated coagulopathy despite a lack of quality evidence demonstrating hemostatic efficacy. The aim of this study was to evaluate the hemostatic efficacy of 4-F PCC in intracerebral hemorrhage patients who received factor Xa inhibitors versus warfarin. MATERIALS AND METHODS This was a multi-center, retrospective, observational cohort study at a large healthcare system. Patients taking warfarin received 4-F PCC 25-50 units/kg based on the presenting INR, while patients taking a factor Xa inhibitor received 35 units/kg. The primary outcome was the percentage of patients with good or excellent hemostatic efficacy as assessed by modified Sarode scale, with neurologic outcomes assessed as a secondary endpoint. Patients were included in the primary outcome population if they had a repeat CT scan within 24 h. RESULTS One hundred fifty-seven patients were included in the primary outcome population; [warfarin (n = 76), factor Xa inhibitors (n = 81)]. Hemostatic efficacy was 83 % in the warfarin group versus 75 % in the factor Xa inhibitor group (p = 0.24). The hemostatic efficacy risk difference between the groups was 7.6 % (95 % CI 5.1 %, 20.2 %). Good neurologic outcome (mRS 0-2) at discharge was 17 % in warfarin patients versus 12 % in the factor Xa inhibitor patients (p = 0.40). CONCLUSIONS There was no significant difference in hemostatic efficacy or clinical outcomes between patients taking warfarin or a factor Xa inhibitor following reversal with 4-F PCC. This study provides further support that 4-F PCC can be used for the reversal of factor Xa inhibitor-associated coagulopathy.
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Affiliation(s)
- Gregory Pon
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Brittany Pelsue
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Sujan Teegala Reddy
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America; Mercy Hospital, Fort Smith, AR 72913, United States of America
| | - Kaushik Parsha
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America; Division of Neurology, Baptist Memorial Hospital, Memphis TN 38120, United States of America
| | - Xu Zhang
- Center for Clinical and Translational Sciences, McGovern Medical School at The University of Texas Health Science Center of Houston, 7000 Fannin St, Houston, TX 77030, United States of America; Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, MSB 1.150, Houston, TX 77030, United States of America
| | - Brian Gulbis
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Andrew Barreto
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America
| | - Miguel Escobar
- Department of Hematology, McGovern Medical School at The University of Texas Health, Science Center of Houston, 6410 Fannin St, STE 830, Houston, TX 77030, United States of America
| | - Teresa A Allison
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America.
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18
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Peng T, Booher K, Moody MR, Yin X, Aronowski J, McPherson DD, Savitz SI, Kim H, Huang SL. Enhanced Cerebroprotection of Xenon-Loaded Liposomes in Combination with rtPA Thrombolysis for Embolic Ischemic Stroke. Biomolecules 2023; 13:1256. [PMID: 37627321 PMCID: PMC10452377 DOI: 10.3390/biom13081256] [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: 07/21/2023] [Revised: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Xenon (Xe) has shown great potential as a stroke treatment due to its exceptional ability to protect brain tissue without inducing side effects. We have previously developed Xe-loaded liposomes for the ultrasound-activated delivery of Xe into the cerebral region and demonstrated their therapeutic efficacy. At present, the sole FDA-approved thrombolytic agent for stroke treatment is recombinant tissue plasminogen activator (rtPA). In this study, we aimed to investigate the potential of combining Xe-liposomes with an intravenous rtPA treatment in a clinically relevant embolic rat stroke model. We evaluated the combinational effect using an in vitro clot lysis model and an in vivo embolic middle cerebral artery occlusion (eMCAO) rat model. The treatment groups received intravenous administration of Xe-liposomes (20 mg/kg) at 2 h post-stroke onset, followed by the administration of rtPA (10 mg/kg) at either 2 or 4 h after the onset. Three days after the stroke, behavioral tests were conducted, and brain sections were collected for triphenyltetrazolium chloride (TTC) and TUNEL staining. Infarct size was determined as normalized infarct volume (%). Both in vitro and in vivo clot lysis experiments demonstrated that Xe-liposomes in combination with rtPA resulted in effective clot lysis comparable to the treatment with free rtPA alone. Animals treated with Xe-liposomes in combination with rtPA showed reduced TUNEL-positive cells and demonstrated improved neurological recovery. Importantly, Xe-liposomes in combination with late rtPA treatment reduced rtPA-induced hemorrhage, attributing to the reduction of MMP9 immunoreactivity. This study demonstrates that the combined therapy of Xe-liposomes and rtPA provides enhanced therapeutic efficacy, leading to decreased neuronal cell death and a potential to mitigate hemorrhagic side effects associated with late rtPA treatment.
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Affiliation(s)
- Tao Peng
- Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (T.P.); (M.R.M.); (X.Y.); (D.D.M.)
| | - Keith Booher
- Zymo Research Corporation, Irvine, CA 92614, USA;
| | - Melanie R. Moody
- Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (T.P.); (M.R.M.); (X.Y.); (D.D.M.)
| | - Xing Yin
- Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (T.P.); (M.R.M.); (X.Y.); (D.D.M.)
| | - Jaroslaw Aronowski
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (J.A.); (S.I.S.)
- Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - David D. McPherson
- Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (T.P.); (M.R.M.); (X.Y.); (D.D.M.)
| | - Sean I. Savitz
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (J.A.); (S.I.S.)
- Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Hyunggun Kim
- Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (T.P.); (M.R.M.); (X.Y.); (D.D.M.)
- Department of Biomechatronic Engineering, Sungkyunkwan University, Suwon 16419, Republic of Korea
| | - Shao-Ling Huang
- Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (T.P.); (M.R.M.); (X.Y.); (D.D.M.)
- Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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19
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Chu Y, Tang K, Hsu YC, Huang T, Wang D, Li W, Savitz SI, Jiang X, Shams S. Non-invasive arterial blood pressure measurement and SpO 2 estimation using PPG signal: a deep learning framework. BMC Med Inform Decis Mak 2023; 23:131. [PMID: 37480040 PMCID: PMC10362790 DOI: 10.1186/s12911-023-02215-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 11/28/2022] [Accepted: 06/22/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Monitoring blood pressure and peripheral capillary oxygen saturation plays a crucial role in healthcare management for patients with chronic diseases, especially hypertension and vascular disease. However, current blood pressure measurement methods have intrinsic limitations; for instance, arterial blood pressure is measured by inserting a catheter in the artery causing discomfort and infection. METHOD Photoplethysmogram (PPG) signals can be collected via non-invasive devices, and therefore have stimulated researchers' interest in exploring blood pressure estimation using machine learning and PPG signals as a non-invasive alternative. In this paper, we propose a Transformer-based deep learning architecture that utilizes PPG signals to conduct a personalized estimation of arterial systolic blood pressure, arterial diastolic blood pressure, and oxygen saturation. RESULTS The proposed method was evaluated with a subset of 1,732 subjects from the publicly available ICU dataset MIMIC III. The mean absolute error is 2.52 ± 2.43 mmHg for systolic blood pressure, 1.37 ± 1.89 mmHg for diastolic blood pressure, and 0.58 ± 0.79% for oxygen saturation, which satisfies the requirements of the Association of Advancement of Medical Instrumentation standard and achieve grades A for the British Hypertension Society standard. CONCLUSIONS The results indicate that our model meets clinical standards and could potentially boost the accuracy of blood pressure and oxygen saturation measurement to deliver high-quality healthcare.
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Affiliation(s)
- Yan Chu
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kaichen Tang
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yu-Chun Hsu
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tongtong Huang
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Dulin Wang
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Wentao Li
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Xiaoqian Jiang
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shayan Shams
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Department of Applied Data Science, San Jose State University, One Washington Sq, San Jose, CA, 95192, USA.
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Boren SB, Savitz SI, Gonzales N, Hasan K, Becerril-Gaitan A, Maroufy V, Li Y, Grotta J, Steven EA, Chen CJ, Sitton CW, Aronowski J, Haque ME. Longitudinal Morphometric Changes in the Corticospinal Tract Shape After Hemorrhagic Stroke. Transl Stroke Res 2023:10.1007/s12975-023-01168-y. [PMID: 37308620 DOI: 10.1007/s12975-023-01168-y] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/14/2023]
Abstract
Deep intracerebral hemorrhage (ICH) exerts a direct force on corticospinal tracts (CST) causing shape deformation. Using serial MRI, Generalized Procrustes Analysis (GPA), and Principal Components Analysis (PCA), we temporally evaluated the change in CST shape. Thirty-five deep ICH patients with ipsilesional-CST deformation were serially imaged on a 3T-MRI with a median imaging time of day-2 and 84 of onset. Anatomical and diffusion tensor images (DTI) were acquired. Using DTI color-coded maps, 15 landmarks were drawn on each CST and the centroids were computed in 3 dimensions. The contralesional-CST landmarks were used as a reference. The GPA outlined the shape coordinates and we superimposed the ipsilesional-CST shape at the two-time points. A multivariate PCA was applied to identify eigenvectors associated with the highest percentile of change. The first three principal components representing CST deformation along the left-right (PC1), anterior-posterior (PC2), and superior-inferior (PC3) respectively were responsible for 57.9% of shape variance. The PC1 (36.1%, p < 0.0001) and PC3 (9.58%, p < 0.01) showed a significant deformation between the two-time points. Compared to the contralesional-CST, the ipsilesional PC scores were significantly (p < 0.0001) different only at the first-timepoint. A significant positive association between the ipsilesional-CST deformation and hematoma volume was observed. We present a novel method to quantify CST deformation caused by ICH. Deformation most often occurs in left-right axis (PC1) and superior-inferior (PC3) directions. As compared to the reference, the significant temporal difference at the first time point suggests CST restoration over time.
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Affiliation(s)
- Seth B Boren
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Nicole Gonzales
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center, 6431 Fannin Street, Houston, TX, 77030, USA
- Department of Neurology, Neurohospitalist and Stroke Section, University of Colorado School of Medicine, Aurora, USA
| | - Khader Hasan
- Department of Interventional Diagnostic Radiology, McGovern Medical School, The University of Texas Health Science Center, Houston, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center, Houston, USA
| | - Vahed Maroufy
- Department of Biostatistics and Data Science, School of Public Health, McGovern Medical School, The University of Texas Health Science Center, Houston, USA
| | - Yuan Li
- Department of Biostatistics and Data Science, School of Public Health, McGovern Medical School, The University of Texas Health Science Center, Houston, USA
| | - James Grotta
- Stroke Research and Mobile Stroke Unit, Department of Neurology, Memorial Hermann Hospital, Houston, USA
| | - Emily A Steven
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center, Houston, USA
| | - Clark W Sitton
- Department of Interventional Diagnostic Radiology, McGovern Medical School, The University of Texas Health Science Center, Houston, USA
| | - Jaroslaw Aronowski
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Muhammad E Haque
- Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, McGovern Medical School, The University of Texas Health Science Center, 6431 Fannin Street, Houston, TX, 77030, USA.
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21
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Naqvi IA, Cohen AS, Kim Y, Harris J, Denny MC, Strobino K, Bicher N, Leite RA, Sadowsky D, Adegboye C, Okpala N, Okpala M, Savitz SI, Marshall RS, Sharrief A. Inequities in Telemedicine Use Among Patients With Stroke and Cerebrovascular Diseases. Neurol Clin Pract 2023; 13:e200148. [PMID: 37064589 PMCID: PMC10101710 DOI: 10.1212/cpj.0000000000200148] [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] [Received: 03/14/2022] [Accepted: 01/26/2023] [Indexed: 03/18/2023]
Abstract
Background and ObjectivesIn response to the COVID-19 pandemic, outpatient stroke care delivery was rapidly transformed to outpatient evaluation through video (VTM) and telephone (TPH) telemedicine (TM) visits around the world. We sought to evaluate the sociodemographic differences in outpatient TM use among stroke patients.MethodsWe conducted a retrospective chart review of outpatients evaluated at 3 tertiary stroke centers in the early period of the pandemic, 3/16/2020 through 7/31/2020. We compared the use of TM by patient characteristics including age, sex, race/ethnicity, insurance status, stroke type, patient type, and site. The association between TM use and patient characteristics was measured using the relative risk (RR) from a modified Poisson regression, and site-specific effects were controlled using a multilevel analysis.ResultsA total of 2,024 visits were included from UTHealth (n = 878), MedStar Health (n = 269), and Columbia (n = 877). The median age was 64 [IQR 52–74] years, and 53% were female. Approximately half of the patients had private insurance, 36% had Medicare, and 15% had Medicaid. Two-thirds of the visits were established patients. TM accounted for 90% of total visits, and the use of TM over office visits was primarily associated with site, not patient characteristics. TM utilization was associated with Asian and other/unknown race. Among TM users, older age, Black race, Hispanic ethnicity, and Medicaid insurance were associated with lower VTM use. Black (aRR 0.88, 95% CI 0.86–0.91,p< 0.001) and Hispanic patients (aRR 0.92, 95% CI 0.87–0.98,p= 0.005) had approximately 10% lower VTM use, while Asian patients (aRR 0.98, 95% CI 0.89–1.07,p= 0.59) had similar VTM use compared with White patients. Patients with Medicaid were less likely to use VTM compared with those with private insurance (aRR 0.86, 95% CI 0.81–0.91,p< 0.001).DiscussionIn our diverse cohort across 3 centers, we found differences in TM visit type by race and insurance early during the COVID-19 pandemic. These findings suggest disparities in VTM access across different stroke populations. As VTM remains an integral part of outpatient neurology practice, steps to ensure equitable access are essential.
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Affiliation(s)
- Imama A Naqvi
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Audrey S Cohen
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Youngran Kim
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Jennifer Harris
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Mary Carter Denny
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Kevin Strobino
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Nathan Bicher
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Ryan A Leite
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Dylan Sadowsky
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Comfort Adegboye
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Nnedinma Okpala
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Munachi Okpala
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Sean I Savitz
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Randolph S Marshall
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Anjail Sharrief
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
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22
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Fraser S, Levy SM, Talebi Y, Savitz SI, Zha A, Zhu G, Wu H. A National, Electronic Health Record-Based Study of Perinatal Hemorrhagic and Ischemic Stroke. J Child Neurol 2023; 38:206-215. [PMID: 37122177 PMCID: PMC10213126 DOI: 10.1177/08830738231170739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 03/21/2023] [Accepted: 04/01/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Perinatal stroke occurs in approximately 1 in 1100 live births. Large electronic health record (EHR) data can provide information on exposures associated with perinatal stroke in a larger number of patients than is achievable through traditional clinical studies. The objective of this study is to assess prevalence and odds ratios of known and theorized comorbidities with perinatal ischemic and hemorrhagic stroke. METHODS The data for patients aged 0-28 days with a diagnosis of either ischemic or hemorrhagic stroke were extracted from the Cerner Health Facts Electronic Medical Record (EMR) database. Incidence of birth demographics and perinatal complications were recorded. Odds ratios were calculated against a control group. RESULTS A total of 535 (63%) neonates were identified with ischemic stroke and 312 (37%) with hemorrhagic stroke. The most common exposures for ischemic stroke were sepsis (n = 82, 15.33%), hypoxic injury (n = 61, 11.4%), and prematurity (n = 49, 9.16%). The most common comorbidities for hemorrhagic stroke were prematurity (n = 81, 26%) and sepsis (n = 63, 20%). No perinatal ischemic stroke patients had diagnosis codes for cytomegalovirus disease. Procedure and diagnosis codes related to critical illness, including intubation and resuscitation, were prominent in both hemorrhagic (n = 46, 15%) and ischemic stroke (n = 45, 8%). CONCLUSION This electronic health record-based study of perinatal stroke, the largest of its kind, demonstrated a wide variety of comorbid conditions with ischemic and hemorrhagic stroke. Sepsis, prematurity, and hypoxic injury are associated with perinatal hemorrhagic and ischemic stroke, though prevalence varies between types. Much of our data were similar to prior studies, which lends validity to the electronic health record database in studying perinatal stroke.
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Affiliation(s)
- Stuart Fraser
- Division of Vascular Neurology,
Department of Neurology, McGovern Medical School, University of
Texas Health Science Center at Houston, Houston, TX, USA
- Institute for Stroke and
Cerebrovascular Disease, University of Texas Health Science Center at Houston,
Houston, TX, USA
| | - Samantha M. Levy
- Department of Biostatistics and Data
Science, School of Public Health, University of
Texas Health Science Center at Houston, Houston, TX, USA
| | - Yashar Talebi
- Department of Biostatistics and Data
Science, School of Public Health, University of
Texas Health Science Center at Houston, Houston, TX, USA
| | - Sean I. Savitz
- Division of Vascular Neurology,
Department of Neurology, McGovern Medical School, University of
Texas Health Science Center at Houston, Houston, TX, USA
- Institute for Stroke and
Cerebrovascular Disease, University of Texas Health Science Center at Houston,
Houston, TX, USA
| | - Alicia Zha
- Institute for Stroke and
Cerebrovascular Disease, University of Texas Health Science Center at Houston,
Houston, TX, USA
- Division of Vascular Neurology,
Department of Neurology, Ohio State University School of Medicine, Columbus, OH,
USA
| | - Gen Zhu
- Department of Biostatistics and Data
Science, School of Public Health, University of
Texas Health Science Center at Houston, Houston, TX, USA
| | - Hulin Wu
- Institute for Stroke and
Cerebrovascular Disease, University of Texas Health Science Center at Houston,
Houston, TX, USA
- Department of Biostatistics and Data
Science, School of Public Health, University of
Texas Health Science Center at Houston, Houston, TX, USA
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23
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Dishman D, Lal T, Silos C, Green C, Aggarwal S, Chen L, Jiang X, Savitz SI. Abstract WMP36: Pain In Stroke Patients At Hospital Discharge. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp36] [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:
Persistent pain after stroke significantly impacts patients’ function, ability to participate in rehabilitation, and quality of life. We examined characteristics of stroke survivors discharged with pain.
Methods:
The sample consisted of 824 stroke patients admitted to a large, urban university based acute care facility in Texas with a completed pain assessment (numeric rating scale or Behavior Pain Scale) at discharge. Descriptive analysis of means and frequency distributions was conducted using a two-sided t-test for continuous variables and a Chi-squared test for categorical variables. Univariable and multivariable logistic regression models were used to determine the association between pain at discharge and type of stroke, adjusting for age, sex, race, smoking status, prevalent hypertension, BMI, and length of stay (LOS). We also tested for statistical interactions between stroke type and age, sex, and race.
Results:
The mean age was 64 years, with 56% (n=462) being males. Of the 824 stroke patients, 584 (71%) had ischemic stroke while 237 (29%) had hemorrhagic (ICH) stroke. At discharge, 43% (n=358) reported pain. In unadjusted analyses, those reporting pain were younger (p<0.001), had a higher BMI (p=0.009), had longer LOS (p<0.001), and were less likely to have ischemic stroke (p<0.001). Only sex modified the association between stroke type and pain at discharge (p=0.002; AUC=0.716). In sex-stratified analysis females with ischemic stroke had lowered odds of reporting pain at discharge by 75% compared to those having ICH (OR=0.25; 95% CI: 0.15-0.41).
Conclusions:
Our study finds that 43% of stroke survivors reported pain at discharge. Younger females with an increased BMI and an increased LOS were more likely to report pain. Our model AUC suggests that post stroke pain may be a complicated phenomenon that requires more complex models.
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Affiliation(s)
| | - Tia Lal
- UT Health Science Houston, Houston, TX
| | | | | | | | | | | | - Sean I Savitz
- STROKE INSTITUTE, UTHEALTH Science Houston, Houston, TX
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24
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Haque ME, Boren S, Schneider K, Mills JA, Fraser SM, Bach I, Hariharan P, Zelnick P, Guerra Castanon F, Naveed A, Tariq MB, Arevalo OD, Parekh M, Zhao X, Sitton C, Aronowski JA, Grotta JC, Savitz SI. Abstract WMP23: Dynamic Imaging Of Blood Coagulation Within The Hematoma Of Patients With Acute Intracerebral Hemorrhage. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp23] [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
Objective:
To serially quantify the blood coagulation within hematoma of patients with hyper-acute intracerebral hemorrhagic (ICH) stroke using non-invasive quantitative susceptibility mapping (QSM) MRI.
Introduction:
A blood clot is a combination of aggregated red blood cells, fibrin, platelets, hemosiderin, and other cell debris. An accurate evaluation of clot formation within hematoma could advance the clinical management of hematoma expansion, blood pressure management, and reversal of anticoagulants. Post-ICH hemolysis changes the heme iron oxidation state from oxy to deoxyhemoglobin (deoxy-Hb) resulting in unpaired iron electrons on aggregated RBC’s deoxy-Hb inducing magnetic susceptibility (χ). Therefore, a region with a higher number of aggregated RBC deoxy-Hb molecules, the dominant component of clots, will exhibit a higher positive χ susceptibility. We hypothesized that coagulated blood within hematoma will exhibit a higher positive χ in comparison to the non-clotted which can be quantified using quantitative susceptibility mapping (QSM), which is an advanced MRI image-processing algorithm.
Methods:
For proof of concept, we measured susceptibilities of 5 human blood phantoms with various percentages of the clot. Twenty-four patients with acute spontaneous ICH were enrolled and serially imaged 3 times within 12-24 (T1), 36-48 (T2), and 60-72(T3) hours of last known well (LNW). A 3D anatomical and multi-echo gradient echo images were obtained using a 3T MRI system. Hematoma and edema volumes were segmented and used as a region of interest (ROI). The rate of coagulation was assessed by measuring the change in susceptibilities within the hematoma.
Results:
The blood phantom exhibited a linear relationship between the percent coagulation and χ (R
2
=0.91). The QSM maps showed a significant increased in hematoma susceptibility over time (T1=0.29 ± 0.04, T2=0.36 ± 0.04, T3= 0.45 ± 0.04 ppm, p<0.0001). The overall average rate of coagulation was 0.00290 ± 0.0029 ppm per hour. No significant change in hematoma volume (18.9 ±3.1 cc) over time. A significant edema growth over time (T1=25.3 ± 3.6, T2= 28.1 ± 3, T3= 32.37 cc, p<0.05).
Conclusion:
In conclusion, we present novel surrogate imaging markers of coagulation within the hematoma of ICH.
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Affiliation(s)
| | | | | | | | | | - Ivo Bach
- STROKE INSTITUTE, UTHEALTH, Houston, TX
| | | | | | | | | | | | | | | | | | - Clark Sitton
- UTHealth Science and Rsch Cntr of Houston, Houston, TX
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25
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Rajan SS, Grotta JC, Yamal JM, Parker S, Jacob A, Savitz SI. Abstract WP54: Factors Associated With First Year Inpatient And Outpatient Rehabilitation Use Among Acute Ischemic Stroke Patients. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp54] [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:
Stroke is a leading cause of long-term disability in the U.S., and 90% of stroke survivors have residual movement impairment. Inpatient and outpatient rehabilitation is critical for restoring functionality and quality of life among survivors. However, there are few studies evaluating the patterns and predictors of rehabilitation use among stroke survivors.
Methods:
This study used 947 tPA-eligibe patients from an observational, prospective, multicenter, clinical trial in the U.S., who had complete 1 year follow-up utilization data, collected quarterly as self-reported surveys. We determined the occurrence and length of stay for inpatient rehabilitation, and occurrence and number of visits for outpatient rehabilitation. Logistic and linear regressions were used to examine predictors associated with these occurrences and intensities.
Results:
The majority of rehabilitation use occurred during the first quarter with 19% and 33% of patients using inpatient and outpatient rehabilitation respectively, and rehabilitation use fell considerably over the rest of the year (Table 1). Higher disability at baseline (mRS≥2 and not living at home) reduced rehabilitation use, and higher disability at discharge increased rehabilitation use. Being uninsured reduced rehabilitation use. Other socio-demographic characteristics (such as age, gender and race-ethnicity), baseline comorbidities, and type and timeliness of therapies after stroke did not have an effect on rehabilitation use.
Conclusion:
Rehabilitation use is highest during the first 3 months after discharge. Patients with higher discharge disability are more in need of rehabilitation, hence receive it. Patients already disabled at baseline are often excluded, probably due to a combination of rehabilitation entry requirements and perceived lack of potential benefits. Access barriers, such as lack of insurance reduced rehabilitation use suggesting an unmet need among stroke survivors.
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Davis C, Goh A, Flores SA, Wewior N, Aronowski JA, Savitz SI, Satani N. Abstract TMP118: Brain Derived Neurotrophic Factor Secretion From Lungs Mediate The Post-stroke Functional Recovery After Systemic Administration Of MSCs. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tmp118] [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:
Bone marrow derived mesenchymal stromal cells (MSCs) have been actively tested in clinical trials. After intravenous (IV) administration, vast majority of them are trapped in lung vasculature, with only few reaching brain. Even though MSCs are short-lived in the lungs, their beneficial effects on post-stroke recovery extends for weeks, suggesting a paracrine mechanism of action. Integrins expression on MSCs is known to mediate the lung entrapment by binding to ICAM1-expressing endothelial cells (ECs). Furthermore, ECs can perform paracrine functions by releasing neurotrophins, such as brain derived neurotrophic factor (BDNF). We explored EC-MSC interaction in lungs, and its effect on BDNF release from lung ECs, in an experimental stroke model.
Methods:
Human lung ECs (Cell Biologics) were cultured at P3. Human MSCs were isolated from bone marrow of healthy donor and P3 MSCs were used for experiments. Serum from stroke patients with NIH Stroke Scale (NIHSS) severity ranging from 0 to 10 was collected at 24 hours after stroke. Co-culture experiments were done in trans-well plates. BDNF mRNA was isolated using Qiagen RNeasy kit. Middle Cerebral Artery Occlusion model (filament model) was used in C57BL/6 mice. Modified Neurological Severity Score (mNSS) was used for functional assessment in mice stroke model.
Results:
Human primary lung ECs exposed to plasma from stroke patients as well as recombinant TNF-α showed robust increase in BDNF secretion, with MSCs enhancing the secretion furthermore. BDNF mRNA was robustly increased in whole mouse lungs as well as lung ECs. IV MSC administration robustly increased plasma BDNF and BDNF mRNA expression in mouse lung ECs. Furthermore, IV MSCs provided better functional recovery as compared to IV BDNF.
Conclusion:
BDNF is already known to be neuroprotective. Our results show that BDNF secretions increase from lung ECs after IV MSC administration, which could mediate functional recovery in mice after stroke.
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Affiliation(s)
| | - Andrew Goh
- Neurology, McGovern Med Sch at UTHealth, Houston, TX
| | | | | | | | | | - Nikunj Satani
- Neurology, McGovern Med Sch at UTHealth, Houston, TX
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27
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Solberg S, Boren S, Gonzales NR, Savitz SI, Aronowski JA, Haque ME, Green C. Abstract TP123: Natural Rate Of Hematoma And Edema Resolution In Patients With Intracerebral Hemorrhage Using Serial Magnetic Resonance Imaging. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp123] [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
Objective:
Serially measure the rate of hematoma volume (HV) and edema volume (EV) resolution in patients with acute-to-early chronic ICH
Background:
After ICH, the primary cause of brain injury is the mechanical force from the compression of the brain tissue. The secondary damage involves (bio)chemical injury produced by the toxicity of components of extravasated blood, which directly compromises surrounding tissue by oxidative stress, cell death, neuroinflammation, and brain edema. There is very little known about the rate of HV and EV resolution within one month of ictus.
Methods:
Twelves patients, a placebo sub-cohort of a previous clinical trial, were serially imaged on day-1, 14, and 28 of initial ictus. Anatomical (FLAIR, T1W, and T2W) images were obtained on a 3T MRI system. HV and EV were segmented using semiautomated seed growing algorithm. The prediction of HV and EV resolution rate was calculated using the Bayesian model and compared across the different time points.
Results:
There were 7M/5F with the average age of 57 ± 9y. The baseline average HV/NIHSS 22,998 mm
3
/11. All patients with deep ICH and 6 extended to IVH. The multilevel Bayesian analysis showed the rate of HV resolution -327.90 mm
3
(95% CrI = -475.37- -181.86; Posterior Probability b < 0 ≥ 0.99) with 14 days acceleration of -17.67 mm
3
(95% CrI = -35.89- 1.21; Posterior Probability b < 0 = 0.97). The rate of EV resolution -341.44 mm
3
(95% CrI = -736.32- 60.98; Posterior Probability b < 0 = 0.96) with 14 days acceleration -34.63 mm
3
(95% CrI = -85.47- 16.61; Posterior Probability b < 0 = 0.91). Overall the decrease in HV over time was an offsetting deceleration which increases over time. The overall trend of HV resolution is shown in Fig-1
Conclusion:
There was a high variance in the rate of HV and EV resolution, but overall all the patients exhibited a similar trend. The rates of HV and EV resolution can help us provide optimal patient care.
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Huang S, Guo W, Claypool J, Chen J, Kim H, Yancey R, Yin X, Moody MR, Aronowski JA, Savitz SI, booher K. Abstract WP60: Greater Enrichment Of Neuronal Function Can Be Reflected In
Blood Plasma
Samples Following The Stroke. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp60] [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
Acute ischemic stroke induces widespread cellular necrosis and apoptosis and activation of inflammation. These mediate release of cell-free DNA (cfDNA) into the circulation. Although increased cfDNA concentrations have been associated with clinical outcome in stroke, data concerning neuronal cfDNA is rare. In this study, we assessed the association of cfDNA with neuron biomarkers in patients with acute ischemic stroke.
Methods:
Thirteen patients without stroke and four patients with middle cerebral artery occlusion were recruited at UT Memorial Hermann Hospital. Blood plasma samples were collected and cfDNA samples were prepared for whole-genome bisulfite sequencing (WGBS) in order to generate quantitative DNA methylation datasets. The resulting WGBS data were analyzed for epigenetic biomarker identification using bioinformatic statistical approaches. CelFiE was used for cell deconvolution, designed to accurately estimate the relative abundances of cell types and tissues present in plasma cfDNA from methylation sequencing, a technique frequently referred to as cell deconvolution.
Results:
Differential methylation statistical analysis comparing the stroke against the non-stroke group of samples found 3493 DNA methylation differences. Pathway Analysis discovered greater enrichment for neuronal function with the top hit being “Neuronal System” followed by activity surrounding synapses, demonstrating that a clear enrichment of methylation change in neuronal pathways can be reflected from
blood plasma
samples following the stroke. Cell deconvolution showed trends of increased megakaryocyte and neutrophils which are involved in the post-stroke immune response. It may be that the secreted neutrophil nuclear DNA in blood plasma drives the increase in the observed proportion of neutrophil cell type in the stroke group samples. Principal Component Analysis demonstrated good separation between the stroke and normal groups.
Conclusion:
Blood sample can be used for circulating cfDNA analysis and neuron biomarker discovery for acute ischemic stroke prediction/recovery.
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29
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Contreras GM, Silos C, Aggarwal S, Hernandez A, Savitz SI. Abstract WMP33: Cognitive Outcomes In Patients With A Prior History Of Stroke Participating In Inpatient Rehabilitation. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp33] [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:
We sought to investigate the impact of prior stroke on cognitive improvement in stroke patients participating in inpatient rehabilitation.
Methods:
This was a retrospective review of clinical data from inpatient stroke rehabilitation (ISR) units collected from 09/2017- 08/2019. Age at onset, stroke type (ischemic or intracerebral hemorrhage (ICH)), therapy days, sex, and past medical history of stroke, diabetes, hypertension (HTN) were extracted as predictors of outcome in ISR. The baseline level of disability upon admission to acute stroke care was accounted for with pre-morbid modified Rankin scale (mRS) score and initial NIH Stroke Scale (NIHSS). The outcome variable of interest was total discharge cognitive functional independence measure (TDC-FIM) from ISR. FIM admission to ISR was controlled for in the model.
Results:
The data of 681 patients were used in a Lasso regression analysis (Figure 1), and of these patients there were 202 patients with a history of prior stroke. Univariate analysis showed a significant difference between prior stroke and first-time stroke groups with respect to pre-morbid mRS (p<0.001), initial NIHSS (p = 0.003), HTN (p=0.004), and stroke type (p=0.023). Lasso regression indicated that patients with diabetes had a 0.58 point decrease in TDC-FIM while those with HTN had a 0.38 point decrease as compared to patients who did not have these vascular risk factors. Patients with ischemic stroke type had a 0.73 point decrease in the TDC-FIM as compared to those who had an ICH. Prior stroke and the patient’s sex had no effect on TDC-FIM. The R-squared of the model was 0.74.
Conclusion:
By controlling for vascular risk factors, our findings show no difference in TDC-FIM with respect to prior stroke. This is different from prior studies that found prior stroke was associated with worse cognitive outcomes at discharge from ISR. Our results indicate that managing HTN and diabetes is imperative for post-stroke cognitive rehabilitation
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Tariq MB, Ling Y, Savitz SI, Fann YC, Jiang X, Kim Y. Abstract WP123: Machine Learning To Predict High Risk Adverse Events In Treatment Trials For Intracerebral Hemorrhage. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp123] [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:
ICH clinical trials have shown that aggressive blood pressure (BP) lowering can lead to adverse events (AEs) such as renal failure (RF) or new stroke. These studies focused on whether the study intervention causes AEs on average. By combining trials, we estimate each individual’s risk of developing AEs with BP lowering.
Methods:
We augmented data from ATACH2 by adding patients from the observational ERICH study and performed
propensity score matching
with a radius (radius=0.4, ratio=1). We estimated the individualized counterfactual outcome of renal AEs using augmented ATACH2. ERICH had 127 patients (out of 1,706) with new onset of RF during hospital stay. ATACH2 had 68 patients (out of 1000) with renal AEs (recorded by MedDRA) within 7d. We built the counterfactual prediction model using a neural network model (FlexTENet). We extracted feature importance score using Shap Deep Explainer.
Results:
We borrowed 1,706 patients to augment ATACH2. The augmented cohort had 2706 patients in total. FlexTENet captured the heterogeneity fairly. For factual outcome prediction accuracy, the FlexTENet achieved the best area under precision-recall curve (0.203) and the area under receiver operating curve (0.703). High diastolic BP at admission and low platelets increased the counterfactual effect of BP reduction on occurrence of renal AEs. In addition, high systolic BP and high glucose decreased the counterfactual effect on the occurrence of renal AEs.
Conclusions:
Identifying treatment-related AEs at an individual level has rarely been studied. Our counterfactual machine learning shows potential to predict individual patient’s risk of treatment-related adverse events.
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Affiliation(s)
| | - Yaobin Ling
- Univ of Texas health science center at Houston, Houston, TX
| | | | | | - Xiaoqian Jiang
- Univ of Texas health science center at Houston, Houston, TX
| | - Yejin Kim
- Univ of Texas health science center at Houston, Houston, TX
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31
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Vyas V, Boren S, Suchting R, Solberg S, Gonzales NR, Savitz SI, Aronowski JA, Haque ME. Abstract TMP82: Changes In DTI Metrics In The Lateral Ventricle Of Patients With Intraventricular Hemorrhage (IVH). Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tmp82] [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
Objective:
To evaluate a non-invasive surrogate imaging marker for blood evacuation in patients with IVH.
Clinical Relevance:
Extension of intracerebral hemorrhage (ICH) to the ventricles increases the 48 hours mortality by 43%, requiring external ventricular drains (EVD) to mitigate hydrocephalus and monitor intracranial pressures. Blood increases CSF viscosity, altering the diffusion coefficient. We hypothesize change in lateral ventricle (LV) DTI metrics, fractional anisotropy (FA) and mean diffusivity (MD), can be used as a marker for blood removal after IVH.
Methods:
A sub-cohort of 20 patients in SHRINC trial with ICH and IVH were serially imaged at day 1 (T1=20), 14 (T1=20), 28 (T3=16), and 42 (T4=13) on a 3T MRI system. The serial T1w, segmented LV (JHU WM atlas) volumes, FA, and MD maps were registered. The FA and MD of ipsi and contralesional LV were recorded. Clinical assessment (NIHSS) was associated with the change in FA and MD of LV. A mixed model statistical analysis was performed.
Results:
We serially imaged 11M/9F with average age 55.4±8.7 years. The baseline hematoma volume and NIHSS were 22.1±18.5 cc and 16.1±8.7 respectively. The patients had basal ganglia (n=12) and thalamic (n=8) ICH extended into LV. The ipsilesional FA was significantly (T1=0.24, T4=0.15, p<0.001) decreased (1.17% /day), and MD was significantly (T1 = 1.49*10
-3
mm
2
/sec, T4 = 2.37 *10
-3
mm
2
/sec, p<0.001) increased (2.4 x 10
-5
mm
2
/sec/day). At T4, there was no relationship (p=0.919) between ipsilesional and contra-MD of LV (Fig-1). Patients with higher baseline NIHSS had a significant temporal decline in FA than those with lower NIHSS (p<0.05). Temporally, ipsilesional MD was negatively associated with the baseline NIHSS (p=0.039).
Conclusion:
The data suggest that DTI metrics of FA and MD are associated with blood clearance from the ipsilesional ventricle.
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Affiliation(s)
- Vedang Vyas
- The Institute for Stroke and Cerebrovascular Diseases (Neurology), Univ of Texas Health Sciences Cntr at Houston, Houston, TX
| | - Seth Boren
- The Institute for Stroke and Cerebrovascular Diseases (Neurology), Univ of Texas Health Sciences Cntr at Houston, Houston, TX
| | - Robert Suchting
- Psychiatry, Univ of Texas Health Sciences Cntr at Houston, Houston, TX
| | - Spencer Solberg
- The Institute for Stroke and Cerebrovascular Diseases (Neurology), Univ of Texas Health Sciences Cntr at Houston, Houston, TX
| | | | | | - Jaroslaw A Aronowski
- The Institute for Stroke and Cerebrovascular Diseases (Neurology), Univ of Texas Health Sciences Cntr at Houston, Houston, TX
| | - Muhammad E Haque
- The Institute for Stroke and Cerebrovascular Diseases (Neurology), Univ of Texas Health Sciences Cntr at Houston, Houston, TX
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32
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Zoellner ER, Patterson MA, Sharrief AZ, Savitz SI, Tucker WJ, Miketinas DC. Abstract 145: Dietary Intake And Quality Among Stroke Survivors Compared To Matched Controls Who Participated In The National Health And Nutrition Examination Survey: 1999 - 2018. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.145] [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:
Nutrition is an important modifiable risk factor for the prevention and treatment of stroke. However, the examination of nutrient intake and diet quality in stroke survivors is limited. The purpose of this study was to estimate usual nutrient intake and diet quality in a nationally representative sample of US adults who have a history of stroke and compare to controls.
Methods:
National Health and Nutrition Examination Survey 1999-2018 data were used to examine 1,626 stroke survivors matched for age, gender, and survey cycle to their respective controls (n=1,621), with no history of stroke. Data were collected on demographics and dietary intake and quality (assessed by Healthy Eating Index [HEI] 2015) from at least one reliable 24-h dietary recall. Estimates were reported as mean[SE]. Differences in continuous and categorical variables were assessed using independent-samples t-tests and Rao-Scott Chi-Squared tests, respectively.
Results:
In comparison to controls, stroke survivors were more likely to report excessive (% > Acceptable Macronutrient Distribution Range) intake for total fat (50.9%[2.7] vs. 40.4%[2.2], p<.001), and inadequate intake (% < Estimated Average Requirement) for calcium (54.6%[1.8] vs. 43.5%[2.4], p=.001) and magnesium (66%[1.8] vs. 53.6%[1.8], p<.001). In addition, stroke survivors were less likely to report adequate intakes (% > Adequate Intake) for fiber (6.8%[0.9] vs. 11.9%[1.3]) and potassium (0.8%[0.3] vs. 1.0%[0.4]) (p<.001, all comparisons). Finally, stroke survivors reported lower HEI scores than controls (49.8 vs. 51.9, p<.001) which indicates lower diet quality, and were more likely to be food insecure, and report physical and mental limitations including difficulty preparing and eating meals compared to controls (p<.001, all comparisons).
Conclusions:
Stroke survivors had lower overall diet quality and greater prevalence of inadequate nutrient intake profiles typically associated with increased risk of cardiovascular diseases including higher total fat intake and lower intake of key micronutrients and fiber compared to matched controls. Stroke survivors were also more likely to experience food insecurity and have physical and mental limitations that may directly impact dietary intake.
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Affiliation(s)
| | | | - Anjail Z Sharrief
- Neurology, UTHealth Dept of Neurology and Institute for Stroke and Cerebrovascular Disease, Houston, TX
| | - Sean I Savitz
- UTHealth Dept of Neurology and Institute for Stroke and Cerebrovascular Disease, Houston, TX
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33
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Savitz SI. Intra-arterial bone marrow mononuclear cells for stroke. Lancet Neurol 2023; 22:105-106. [PMID: 36681437 DOI: 10.1016/s1474-4422(23)00005-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023]
Affiliation(s)
- Sean I Savitz
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston 77042, TX, USA.
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34
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Beauchamp JES, Sharrief A, Chaoul A, Casameni Montiel T, Love MF, Cron S, Prossin A, Selvaraj S, Dishman D, Savitz SI. Feasibility of a meditation intervention for stroke survivors and informal caregivers: a randomized controlled trial. BMC Psychol 2023; 11:9. [PMID: 36635775 PMCID: PMC9838004 DOI: 10.1186/s40359-022-01031-z] [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: 07/20/2022] [Accepted: 12/23/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Depressive symptoms are a significant psychological complication of stroke, impacting both survivors and informal caregivers of survivors. Randomized controlled trials are needed to determine optimal non-pharmacological strategies to prevent or ameliorate depressive symptoms in stroke survivors and their informal caregivers. METHODS A prospective, randomized, parallel-group, single-center, feasibility study. Participants were assigned to a 4-week meditation intervention or expressive writing control group. The intervention comprised four facilitator-led group meditation sessions, one session per week and building upon prior session(s). Descriptive statistics were used to examine the proportion of eligible individuals who enrolled, retention and adherence rates, and the proportion of questionnaires completed. Data were collected at baseline, immediately after the 4-week intervention period, and 4 and 8 weeks after the intervention period. Secondary analysis tested for changes in symptoms of depression (Center for Epidemiologic Studies-Depression [CES-D]), anxiety [State-Trait Anxiety Inventory for Adults (STAI)], and pain (Brief Pain Inventory-Short Form) in the intervention group via paired t tests. Linear mixed models were used to compare longitudinal changes in the measures between the groups. Intervention and trial design acceptability were preliminary explored. RESULTS Seventy-one (77%) individuals enrolled and 26 (37%) completed the study (baseline and 8-week post-intervention visits completed). Forty-two (66%) participants completed baseline and immediate post-intervention visits. Mean questionnaire completion rate was 95%. The median meditation group session attendance rate for the intervention group was 75.0%, and the mean attendance rate was 55%. Non-significant reductions in CES-D scores were found. Paired t tests for stroke survivors indicated a significant reduction from baseline through week 8 in BPI-sf severity scores (p = 0.0270). Repeated measures analysis with linear mixed models for informal caregivers indicated a significant reduction in in STAI-Trait scores (F [3,16.2] = 3.28, p = 0.0479) and paired t test showed a significant reduction from baseline to week 4 in STAI-Trait scores (mean = - 9.1250, 95% CI [- 16.8060 to 1.4440], p = 0.0262). No between-group differences were found. CONCLUSIONS Future trials will require strategies to optimize retention and adherence before definitive efficacy testing of the meditation intervention. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03239132. Registration date: 03/08/2017.
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Affiliation(s)
- Jennifer E. S. Beauchamp
- grid.267308.80000 0000 9206 2401Cizik School of Nursing Department of Research and the Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, 6901 Bertner Avenue, Suite 580D, Houston, TX 77030 USA
| | - Anjail Sharrief
- grid.267308.80000 0000 9206 2401McGovern Medical School Department of Neurology and the Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center at Houston, 6410 Fannin St, Suite 1014, Houston, TX 77030 USA
| | - Alejandro Chaoul
- Mind Body Spirit Institute, The Jung Center of Houston, 5200 Montrose Ave., Houston, TX 77006 USA
| | - Tahani Casameni Montiel
- grid.267308.80000 0000 9206 2401Cizik School of Nursing Department of Research, The University of Texas Health Science Center at Houston, 6901 Bertner Avenue, Suite 582, Houston, TX 77030 USA
| | - Mary F. Love
- grid.266436.30000 0004 1569 9707College of Nursing, University of Houston, 14000 University Boulevard, #367G, Sugar Land, Houston, TX 77479 USA
| | - Stanley Cron
- grid.267308.80000 0000 9206 2401Cizik School of Nursing, University of Texas Health Science Center at Houston, 6901 Bertner Avenue, Suite SON 561, Houston, TX 77030 USA
| | - Alan Prossin
- grid.267308.80000 0000 9206 2401McGovern Medical School Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston, 1941 East Road, Suite BBS 2310, Houston, TX 77054 USA
| | - Sudhakar Selvaraj
- grid.267308.80000 0000 9206 2401Louis Faillace Department of Psychiatry and Behavioral Science, McGovern Medical School, The University of Texas Health Science Center at Houston, 1941 East Road, Suite BBS 3152, Houston, TX 77054 USA
| | - Deniz Dishman
- grid.267308.80000 0000 9206 2401Cizik School of Nursing Department of Research, The University of Texas Health Science Center at Houston, 6901 Bertner Avenue, Suite SON580C, Houston, TX 77030 USA
| | - Sean I. Savitz
- grid.267308.80000 0000 9206 2401McGovern Medical School Department of Neurology and the Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center at Houston, 6431 Fannin, Suite MSB-7.128, Houston, TX 77030-1503 USA
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Mavragani A, Ancer Leal A, Montiel TC, Wynne KJ, Edquilang G, Vu KYT, Vahidy F, Savitz SI, Beauchamp JE, Sharrief A. An Intervention Mapping Approach to Developing a Stroke Literacy Video for Recent Stroke Survivors: Development and Usability Study. JMIR Form Res 2023; 7:e31903. [PMID: 35972729 PMCID: PMC9850284 DOI: 10.2196/31903] [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: 12/28/2021] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Most vascular events after stroke may be prevented by modifying vascular risk factors through medical and behavioral interventions. Stroke literacy-an understanding of stroke symptoms, risk factors, and treatment-likely contributes to vascular risk factor control and in turn stroke recurrence risk. Stroke literacy is the lowest among adults belonging to racial and ethnic minority populations in the United States. Video-based interventions targeting stroke literacy may help acute stroke survivors understand stroke and subsequently reduce the risk of stroke recurrence. However, the failure of prior stroke literacy interventions may be due in part to the fact that the interventions were not theory-driven. Intervention mapping (IM) provides a framework for use in the development, implementation, and evaluation of evidence-informed, health-related interventions. OBJECTIVE We aimed to develop a video-based educational intervention to improve stroke literacy in hospitalized patients with acute stroke. METHODS The 6-step iterative process of IM was used to develop a video-based educational intervention and related implementation and evaluation plans. The six steps included a needs assessment, the identification of outcomes and change objectives, the selection of theory- and video-based intervention methods and practical applications, the development of a video-based stroke educational intervention, plans for implementation, and evaluation strategies. RESULTS A 5-minute video-based educational intervention was developed. The IM approach led to successful intervention development by emphasizing stakeholder involvement, generation and adoption, and information retainment in the planning phase of the intervention. A planned approach to video adoption, implementation, and evaluation was also developed. CONCLUSIONS An IM approach guided the development of a 5-minute video-based educational intervention to promote stroke literacy among acute stroke survivors. Future studies are needed to assess the use of technology and digital media to support widespread access and participation in video-based health literacy interventions for populations with acute and chronic stroke. Studies are needed to assess the impact of video-based educational interventions that are paired with stroke systems of care optimization to reduce the risk of stroke recurrence. Furthermore, studies on culturally and linguistically sensitive video-based stroke literacy interventions are needed to address known racial and ethnic disparities in stroke literacy. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1371/journal.pone.0171952.
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Affiliation(s)
| | - Andrea Ancer Leal
- Department of Research, Cizik School of Nursing at UTHealth, Houston, TX, United States
| | | | - Keona J Wynne
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | | | - Kim Yen Thi Vu
- Memorial Hermann - Texas Medical Center, Houston, TX, United States
| | - Farhaan Vahidy
- Center for Outcomes Research, Houston Methodist, Houston, TX, United States.,Department of Population Health Sciences, Weill Cornell Medical School, New York, NY, United States.,Houston Methodist Neurological Institute, Houston Methodist, Houston, TX, United States
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School, UTHealth, Houston, TX, United States.,UTHealth Institute for Stroke and Cerebrovascular Disease, Houston, TX, United States
| | - Jennifer Es Beauchamp
- Department of Research, Cizik School of Nursing at UTHealth, Houston, TX, United States.,UTHealth Institute for Stroke and Cerebrovascular Disease, Houston, TX, United States
| | - Anjail Sharrief
- Department of Neurology, McGovern Medical School, UTHealth, Houston, TX, United States.,UTHealth Institute for Stroke and Cerebrovascular Disease, Houston, TX, United States
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36
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Abstract
Cell-based therapies are an emerging biopharmaceutical paradigm under investigation for the treatment of a range of neurological disorders. Accumulating evidence is demonstrating that cell-based therapies might be effective, but the mechanism of action remains unclear. In this Review, we synthesize results from over 20 years of animal studies that illustrate how transdifferentiation, cell replacement and restoration of damaged tissues in the CNS are highly unlikely mechanisms. We consider the evidence for an alternative model that we refer to as the bioreactor hypothesis, in which exogenous cells migrate to peripheral organs and modulate and reprogramme host immune cells to generate an anti-inflammatory, regenerative environment. The results of clinical trials clearly demonstrate a role for immunomodulation in the effects of cell-based therapies. Greater understanding of these mechanisms could facilitate the optimization of cell-based therapies for a variety of neurological disorders.
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Affiliation(s)
- Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston, TX, USA. .,Department of Neurology, University of Texas Health Science Center, Houston, TX, USA.
| | - Charles S Cox
- Department of Pediatric Surgery, University of Texas Health Science Center, Houston, TX, USA
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37
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Savitz SI, Newport EL, Edwards D. In Memoriam: Alexander W. Dromerick Jr, MD, July 1, 1958-August 21, 2021. Stroke 2022; 53:3525-3528. [PMID: 36441835 DOI: 10.1161/strokeaha.122.039909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sean I Savitz
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, UTHealth-Houston, TX (S.I.S.)
| | - Elissa L Newport
- Center for Brain Plasticity and Recovery, Georgetown University Medical Center, Washington DC (E.L.N.)
| | - Dorothy Edwards
- Collaborative Center for Health Equity, University of Wisconsin, Madison (D.E.)
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38
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Selvaraj S, Aggarwal S, de Dios C, De Figueiredo JM, Sharrief AZ, Beauchamp J, Savitz SI. Predictors of suicidal ideation among acute stroke survivors. Journal of Affective Disorders Reports 2022. [DOI: 10.1016/j.jadr.2022.100410] [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: 12/01/2022] Open
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39
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Zha AM, Trevino AD, Ankrom CM, Chu KM, Joseph MM, Patni T, Cossey TD, Savitz SI, Wu TC, Jagolino-Cole A. Inpatient Teleneurology Follow-up Has Comparable Outcomes to In-Person Neurology Follow-up. Neurol Clin Pract 2022; 12:e181-e188. [DOI: 10.1212/cpj.0000000000200096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 09/15/2022] [Indexed: 11/15/2022]
Abstract
AbstractObjective:Community emergency departments often transfer patients for lack of neurology coverage, potentially burdening patients and accepting facilities. Telestroke improves access to acute stroke care, but there is a lack of data on inpatient teleneurology and telestroke care.Methods:From our prospective telestroke registry, we retrospectively reviewed 3702 consecutive patients who were seen via telestroke between 9/2015 and 12/2018. Patients who required transfer after initial telestroke evaluation or who were kept at hospitals without consistent neurology coverage were excluded from analysis. We compared baseline demographics, clinical characteristics, and hospital outcomes in patients who were subsequently followed remotely by a teleneurology neurohospitalst and those followed in-person by a neurohospitalist.Results:There were 447 (23%) patients followed by a teleneurology neurohospitalist and 1459 (77%) patients followed in-person by a neurohospitalist. Both groups presented with similar stroke severity. In multivariate analysis, there were no significant differences in discharge disposition, stroke readmission rates, or 90-day mRS. Length of stay was shorter with teleneurology follow-up. In the subgroup of patients who received tPA, patients showed no differences in outcomes and had similar complication rates. Teleneurology follow-up resulted in a 3% transfer rate for higher level of care after admission. There remained no difference in outcomes in a sub-analysis without Comprehensive Stroke Centers. A higher proportion of non-Hispanic Black patients and lower proportion of Hispanic patients in the teleneurology follow-up group were possibly due to spoke location demographics.Conclusion:Teleneurology follow-up resulted in comparable outcomes to in-person neurology follow-up, with few transfers after admission. For select neurology and ischemic stroke patients, teleneurology follow-up provides an alternative to transfer for hospitals lacking neurology coverage.
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40
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Satani N, Parsha K, Davis C, Gee A, Olson SD, Aronowski J, Savitz SI. Peripheral blood monocytes as a therapeutic target for marrow stromal cells in stroke patients. Front Neurol 2022; 13:958579. [PMID: 36277912 PMCID: PMC9580494 DOI: 10.3389/fneur.2022.958579] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 05/31/2022] [Accepted: 09/05/2022] [Indexed: 11/22/2022] Open
Abstract
Background Systemic administration of marrow stromal cells (MSCs) leads to the release of a broad range of factors mediating recovery in rodent stroke models. The release of these factors could depend on the various cell types within the peripheral blood as they contact systemically administered MSCs. In this study, we assessed the immunomodulatory interactions of MSCs with peripheral blood derived monocytes (Mϕ) collected from acute stroke patients. Methods Peripheral blood from stroke patients was collected at 5–7 days (N = 5) after symptom onset and from age-matched healthy controls (N = 5) using mononuclear cell preparation (CPT) tubes. After processing, plasma and other cellular fractions were removed, and Mϕ were isolated from the mononuclear fraction using CD14 microbeads. Mϕ were then either cultured alone or co-cultured with MSCs in a trans-well cell-culture system. Secretomes were analyzed after 24 h of co-cultures using a MAGPIX reader. Results Our results show that there is a higher release of IFN-γ and IL-10 from monocytes isolated from peripheral blood at day 5–7 after stroke compared with monocytes from healthy controls. In trans-well co-cultures of MSCs and monocytes isolated from stroke patients, we found statistically significant increased levels of IL-4 and MCP-1, and decreased levels of IL-6, IL-1β, and TNF-α. Addition of MSCs to monocytes increased the secretions of Fractalkine, IL-6, and MCP-1, while the secretions of TNF-α decreased, as compared to the secretions from monocytes alone. When MSCs were added to monocytes from stroke patients, they decreased the levels of IL-1β, and increased the levels of IL-10 significantly more as compared to when they were added to monocytes from control patients. Conclusion The systemic circulation of stroke patients may differentially interact with MSCs to release soluble factors integral to their paracrine mechanisms of benefit. Our study finds that the effect of MSCs on Mϕ is different on those derived from stroke patients blood as compared to healthy controls. These findings suggest immunomodulation of peripheral immune cells as a therapeutic target for MSCs in patients with acute stroke.
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Affiliation(s)
- Nikunj Satani
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Diseases, The University of Texas Health Science Center at Houston, Houston, TX, United States
- *Correspondence: Nikunj Satani
| | - Kaushik Parsha
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Diseases, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Courtney Davis
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Diseases, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Adrian Gee
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Scott D. Olson
- Department of Pediatric Surgery, McGovern Medical School at UTHealth, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jaroslaw Aronowski
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Diseases, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sean I. Savitz
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Diseases, The University of Texas Health Science Center at Houston, Houston, TX, United States
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41
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Fang F, Godlewska B, Cho RY, Savitz SI, Selvaraj S, Zhang Y. Effects of escitalopram therapy on functional brain controllability in major depressive disorder. J Affect Disord 2022; 310:68-74. [PMID: 35500684 DOI: 10.1016/j.jad.2022.04.123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
Abstract
Antidepressant drugs are the mainstay of treatment for patients with major depressive disorders (MDD). Given the critical role of the underlying neural control mechanism in the physiopathology of depression, this study aims to investigate the effects of escitalopram, a type of antidepressant drug, on the changes of functional brain controllability throughout the escitalopram treatment for MDD. We collected resting-state functional magnetic resonance imaging data from 20 unmedicated major depressive patients at baseline (visit 1, pre-treatment), one week (visit 2, 1-week after the onset of the treatment) and six weeks (visit 3, after the 6-week escitalopram treatment). Our results revealed that the global average and modal controllability of MDD patients were significantly larger and smaller, respectively, compared to healthy subjects (P < 0.01). Furthermore, the modal controllability rank of the frontoparietal network in depression patients was also significantly smaller than the healthy subjects (P < 0.01). However, throughout the escitalopram treatment, the global average and modal controllability, and the controllability of the default mode network and frontoparietal network of MDD patients were consistently changed to the healthy subjects' level. Our results also showed that the changes of global average and modal controllability measures can predict the improvements of clinical scores of the MDD patients as the escitalopram treatment advanced (P < 0.05). In conclusion, this study reveals promising brain controllability-based biomarkers to mechanistically understand and predict the effects of the escitalopram treatment for depression and maybe extended to predict and understand the effects of other interventions for other neurological and psychiatric diseases.
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Affiliation(s)
- Feng Fang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Beata Godlewska
- Department of Psychiatry, Medical Sciences Division, University of Oxford, United Kingdom; Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Raymond Y Cho
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine and Menninger Clinic, Houston, TX, USA
| | - Sean I Savitz
- Department of Neurology, The McGovern Medical School of UT Health Houston, Houston, TX, USA
| | - Sudhakar Selvaraj
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, The McGovern Medical School of UT Health Houston, Houston, TX, USA
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA.
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42
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Ma X, Ferguson EC, Jiang X, Savitz SI, Shams S. A multitask deep learning approach for pulmonary embolism detection and identification. Sci Rep 2022; 12:13087. [PMID: 35906477 PMCID: PMC9338063 DOI: 10.1038/s41598-022-16976-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 03/16/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022] Open
Abstract
Pulmonary embolism (PE) is a blood clot traveling to the lungs and is associated with substantial morbidity and mortality. Therefore, rapid diagnoses and treatments are essential. Chest computed tomographic pulmonary angiogram (CTPA) is the gold standard for PE diagnoses. Deep learning can enhance the radiologists’workflow by identifying PE using CTPA, which helps to prioritize important cases and hasten the diagnoses for at-risk patients. In this study, we propose a two-phase multitask learning method that can recognize the presence of PE and its properties such as the position, whether acute or chronic, and the corresponding right-to-left ventricle diameter (RV/LV) ratio, thereby reducing false-negative diagnoses. Trained on the RSNA-STR Pulmonary Embolism CT Dataset, our model demonstrates promising PE detection performances on the hold-out test set with the window-level AUROC achieving 0.93 and the sensitivity being 0.86 with a specificity of 0.85, which is competitive with the radiologists’sensitivities ranging from 0.67 to 0.87 with specificities of 0.89–0.99. In addition, our model provides interpretability through attention weight heatmaps and gradient-weighted class activation mapping (Grad-CAM). Our proposed deep learning model could predict PE existence and other properties of existing cases, which could be applied to practical assistance for PE diagnosis.
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Affiliation(s)
- Xiaotian Ma
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Emma C Ferguson
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, Houston, TX, USA
| | - Xiaoqian Jiang
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School, Houston, TX, USA
| | - Shayan Shams
- Department of Applied Data Science, San José State University, San José, CA, USA.
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43
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Fang F, Godlewska B, Cho RY, Savitz SI, Selvaraj S, Zhang Y. Personalizing repetitive transcranial magnetic stimulation for precision depression treatment based on functional brain network controllability and optimal control analysis. Neuroimage 2022; 260:119465. [PMID: 35835338 DOI: 10.1016/j.neuroimage.2022.119465] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 06/05/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
Brain neuromodulation effectively treats neurological diseases and psychiatric disorders such as Depression. However, due to patient heterogeneity, neuromodulation treatment outcomes are often highly variable, requiring patient-specific stimulation protocols throughout the recovery stages to optimize treatment outcomes. Therefore, it is critical to personalize neuromodulation protocol to optimize the patient-specific stimulation targets and parameters by accommodating inherent interpatient variability and intersession alteration during treatments. The study aims to develop a personalized repetitive transcranial magnetic stimulation (rTMS) protocol and evaluate its feasibility in optimizing the treatment efficiency using an existing dataset from an antidepressant experimental imaging study in depression. The personalization of the rTMS treatment protocol was achieved by personalizing both stimulation targets and parameters via a novel approach integrating the functional brain network controllability analysis and optimal control analysis. First, the functional brain network controllability analysis was performed to identify the optimal rTMS stimulation target from the effective connectivity network constructed from patient-specific resting-state functional magnetic resonance imaging data. The optimal control algorithm was then applied to optimize the rTMS stimulation parameters based on the optimized target. The performance of the proposed personalized rTMS technique was evaluated using datasets collected from a longitudinal antidepressant experimental imaging study in depression (n = 20). Simulation models demonstrated that the proposed personalized rTMS protocol outperformed the standard rTMS treatment by efficiently steering a depressive resting brain state to a healthy resting brain state, indicated by the significantly less control energy needed and higher model fitting accuracy achieved. The node with the maximum average controllability of each patient was designated as the optimal target region for the personalized rTMS protocol. Our results also demonstrated the theoretical feasibility of achieving comparable neuromodulation efficacy by stimulating a single node compared to stimulating multiple driver nodes. The findings support the feasibility of developing personalized neuromodulation protocols to more efficiently treat depression and other neurological diseases.
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Affiliation(s)
- Feng Fang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Beata Godlewska
- Department of Psychiatry, Medical Sciences Division, University of Oxford, United Kingdom; Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Raymond Y Cho
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, and Menninger Clinic, Houston, TX, United States
| | - Sean I Savitz
- Department of Neurology, The McGovern Medical School of UT Health Houston, Houston, TX, United States
| | - Sudhakar Selvaraj
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, The McGovern Medical School of UT Health Houston, Houston, TX, United States
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA.
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44
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Fonseca AC, Savitz SI. Organizational Update: World Stroke Conference 2021. Stroke 2022; 53:e264-e266. [PMID: 35759543 DOI: 10.1161/strokeaha.122.038782] [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)
- Ana Catarina Fonseca
- Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal (A.C.F.).,JMFerro Lab, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal (A.C.F.)
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston (S.I.S.)
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45
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Cox CS, Juranek J, Kosmach S, Pedroza C, Thakur N, Dempsey A, Rennie K, Scott MC, Jackson M, Kumar A, Aertker B, Caplan H, Triolo F, Savitz SI. Autologous cellular therapy for cerebral palsy: a randomized, crossover trial. Brain Commun 2022; 4:fcac131. [PMID: 35702731 PMCID: PMC9188321 DOI: 10.1093/braincomms/fcac131] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/24/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
We examined an autologous mononuclear-cell-therapy-based approach to treat cerebral palsy using autologous umbilical cord blood or bone-marrow-derived mononuclear cells. The primary objective was to determine if autologous cells are safe to administer in children with cerebral palsy. The secondary objectives were to determine if there was improvement in motor function of patients 12 months after infusion using the Gross Motor Function Measure and to evaluate impact of treatment on corticospinal tract microstructure as determined by radial diffusivity measurement. This Phase 1/2a trial was a randomized, blinded, placebo-controlled, crossover study in children aged 2-10 years of age with cerebral palsy enrolled between November 2013 and November 2016. Participants were randomized to 2:1 treatment:placebo. Treatment was either autologous bone-marrow-derived mononuclear cells or autologous umbilical cord blood. All participants who enrolled and completed their baseline visit planned to return for follow-up visits at 6 months, 12 months and 24 months after the baseline visit. At the 12-month post-treatment visit, participants who originally received the placebo received either bone-marrow-derived mononuclear cell or umbilical cord blood treatment. Twenty participants were included; 7 initially randomized to placebo, and 13 randomized to treatment. Five participants randomized to placebo received bone-marrow-derived mononuclear cells, and 2 received umbilical cord blood at the 12-month visit. None of the participants experienced adverse events related to the stem cell infusion. Cell infusion at the doses used in our study did not dramatically alter motor function. We observed concordant bilateral changes in radial diffusivity in 10 of 15 cases where each corticospinal tract could be reconstructed in each hemisphere. In 60% of these cases (6/10), concordant decreases in bilateral corticospinal tract radial diffusivity occurred post-treatment. In addition, 100% of unilateral corticospinal tract cases (3/3) exhibited decreased corticospinal tract radial diffusivity post-treatment. In our discordant cases (n = 5), directionality of changes in corticospinal tract radial diffusivity appeared to coincide with handedness. There was a significant improvement in corticospinal tract radial diffusivity that appears related to handedness. Connectivity strength increased in either or both pathways (corticio-striatal and thalamo-cortical) in each participant at 12 months post-treatment. These data suggest that both stem cell infusions are safe. There may be an improvement in myelination in some groups of patients that correlate with small improvements in the Gross Motor Function Measure scales. A larger autologous cord blood trial is impractical at current rates of blood banking. Either increased private banking or matched units would be required to perform a larger-scale trial.
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Affiliation(s)
- Charles S. Cox
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Jenifer Juranek
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Steven Kosmach
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Nivedita Thakur
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Allison Dempsey
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Kimberly Rennie
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
- Department of Neuropsychology, NeuroBehavioral Health, Milwaukee, WI, USA
| | - Michael C. Scott
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Margaret Jackson
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Akshita Kumar
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Benjamin Aertker
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Henry Caplan
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Fabio Triolo
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Sean I. Savitz
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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46
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Savitz SI. Is There a Time-Sensitive Window in Patients With Stroke to Enhance Arm Recovery With Higher Intensity Motor Therapy? Stroke 2022; 53:1823-1825. [PMID: 35467996 DOI: 10.1161/strokeaha.121.037402] [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]
Affiliation(s)
- Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston
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47
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Varughese T, Casameni Montiel T, Engebretson J, Savitz SI, Sharrief A, Beauchamp JES. A Person-Centered Approach Understanding Stroke Survivor and Family Caregiver Emotional Health. J Neurosci Nurs 2022; 54:68-73. [PMID: 35153291 DOI: 10.1097/jnn.0000000000000640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT BACKGROUND: The purpose of this study was to incorporate a person-centered approach to understand the emotional health needs and perspectives of stroke survivors (SSs) and their caregivers. METHODS: In collaboration with 4 SSs and caregivers as research partners, quantitative data were collected to assess poststroke emotional health needs, and qualitative data were collected to gain insight into SS and caregiver emotional health perspectives after stroke. RESULTS: Forty surveys (n = 26 SSs, n = 14 caregivers) were collected. The predominate emotional health needs were frustration (65%), anxiety (54%), and stress (50%) for SSs and stress (71%), worry (57%), and frustration (57%) for caregivers. Two group interviews (n = 7 SSs, n = 3 caregivers) were completed. Four emerging themes were identified: receiving support from those in similar situations, poststroke emotional responses, situations experienced in healthcare settings, and a hypervigilance for sudden and unexpected events. CONCLUSION: Emotional healthcare services for SSs and their caregivers may consider providing reoccurring mental health education and multifaceted treatment approaches, including provision of peer support, and addressing the unique emotional stressors SSs and caregivers may be experiencing. The small sample size precludes generalizing the results into the broader stroke population. However, by leveraging the lived experience of SSs and their caregivers, the results may help find ways to support SSs' and caregivers' emotional health.
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48
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Kim Y, Zhang K, Savitz SI, Chen L, Schulz PE, Jiang X. Counterfactual analysis of differential comorbidity risk factors in Alzheimer's disease and related dementias. PLOS Digit Health 2022; 1:e0000018. [PMID: 36812506 PMCID: PMC9931358 DOI: 10.1371/journal.pdig.0000018] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/21/2022] [Indexed: 11/19/2022]
Abstract
Alzheimer's disease and related dementias (ADRD) is a multifactorial disease that involves several different etiologic mechanisms with various comorbidities. There is also significant heterogeneity in the prevalence of ADRD across diverse demographics groups. Association studies on such heterogeneous comorbidity risk factors are limited in their ability to determine causation. We aim to compare counterfactual treatment effects of various comorbidity in ADRD in different racial groups (African Americans and Caucasians). We used 138,026 ADRD and 1:1 matched older adults without ADRD from nationwide electronic health records, which extensively cover a large population's long medical history in breadth. We matched African Americans and Caucasians based on age, sex, and high-risk comorbidities (hypertension, diabetes, obesity, vascular disease, heart disease, and head injury) to build two comparable cohorts. We derived a Bayesian network of 100 comorbidities and selected comorbidities with potential causal effect to ADRD. We estimated the average treatment effect (ATE) of the selected comorbidities on ADRD using inverse probability of treatment weighting. Late effects of cerebrovascular disease significantly predisposed older African Americans (ATE = 0.2715) to ADRD, but not in the Caucasian counterparts; depression significantly predisposed older Caucasian counterparts (ATE = 0.1560) to ADRD, but not in the African Americans. Our extensive counterfactual analysis using a nationwide EHR discovered different comorbidities that predispose older African Americans to ADRD compared to Caucasian counterparts. Despite the noisy and incomplete nature of the real-world data, the counterfactual analysis on the comorbidity risk factors can be a valuable tool to support the risk factor exposure studies.
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Affiliation(s)
- Yejin Kim
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Kai Zhang
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Sean I. Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Luyao Chen
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Paul E. Schulz
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Xiaoqian Jiang
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
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49
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Rahbar MH, Medrano M, Diaz-Garelli F, Gonzalez Villaman C, Saroukhani S, Kim S, Tahanan A, Franco Y, Castro-Tejada G, Diaz SA, Hessabi M, Savitz SI. Younger age of stroke in low-middle income countries is related to healthcare access and quality. Ann Clin Transl Neurol 2022; 9:415-427. [PMID: 35142101 PMCID: PMC8935275 DOI: 10.1002/acn3.51507] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 11/19/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/25/2022] Open
Abstract
Stroke is the second leading cause of mortality globally with higher burden and younger age in low‐middle income countries (LMICs) than high‐income countries (HICs). However, it is unclear to what extent differences in healthcare access and quality (HAQ) and prevalence of risk factors between LMICs and HICs contribute to younger age of stroke in LMICs. In this systematic review, we conducted meta‐analysis of 67 articles and compared the mean age of stroke between LMICs and HICs, before and after adjusting for HAQ index. We also compared the prevalence of main stroke risk factors between HICs and LMICs. The unadjusted mean age of stroke in LMICs was significantly lower than HICs (63.1 vs. 68.6), regardless of gender (63.9 vs. 66.6 among men, and 65.6 vs. 70.7 among women) and whether data were collected in population‐ (64.7 vs. 69.5) or hospital‐based (62.6 vs. 65.9) studies (all p < 0.01). However, after adjusting for HAQ index, the difference in the mean age of stroke between LMICs and HICs was not significant (p ≥ 0.10), except among women (p = 0.048). In addition, while the median prevalence of hypertension in LMICs was 23.4% higher than HICs, the prevalence of all other risk factors was lower in LMICs than HICs. Our findings suggest a much larger contribution of HAQ to the younger mean age of stroke in LMICs, as compared with other potential factors. Additional studies on stroke care quality and accessibility are needed in LMICs.
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Affiliation(s)
- Mohammad H Rahbar
- Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,Biostatistics/Epidemiology/Research Design (BERD) Core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, Houston, Texas, USA.,Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Martin Medrano
- Department of Medicine, School of Medicine, Pontificia Universidad Catalica Madre and Maestra (PUCMM), Santiago, Dominican Republic
| | - Franck Diaz-Garelli
- Department of Public Health Sciences, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | | | - Sepideh Saroukhani
- Biostatistics/Epidemiology/Research Design (BERD) Core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, Houston, Texas, USA.,Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sori Kim
- Biostatistics/Epidemiology/Research Design (BERD) Core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, Houston, Texas, USA.,Department of Biostatistics & Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Amirali Tahanan
- Biostatistics/Epidemiology/Research Design (BERD) Core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Yahaira Franco
- Department of Neurology, Clínica Corominas, Santiago, Dominican Republic
| | - Gelanys Castro-Tejada
- Department of Medicine, School of Medicine, Pontificia Universidad Catalica Madre and Maestra (PUCMM), Santiago, Dominican Republic
| | - Sarah A Diaz
- Department of Medicine, School of Medicine, Pontificia Universidad Catalica Madre and Maestra (PUCMM), Santiago, Dominican Republic
| | - Manouchehr Hessabi
- Biostatistics/Epidemiology/Research Design (BERD) Core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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50
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Olmsted ZT, Petersen EA, Pilitsis JG, Rahimi SY, Chen PR, Savitz SI, Laskowitz DT, Kolls BJ, Staudt MD. Toward Generalizable Trajectory Planning for Human Intracerebral Trials and Therapy. Stereotact Funct Neurosurg 2022; 100:214-223. [DOI: 10.1159/000521916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/07/2022] [Indexed: 11/19/2022]
Abstract
<b><i>Introduction:</i></b> Stereotactic neurosurgical techniques are increasingly used to deliver biologics, such as cells and viruses, although standardized procedures are necessary to ensure consistency and reproducibility. <b><i>Objective:</i></b> We provide an instructional guide to help plan for complex image-guided trajectories; this may be of particular benefit to surgeons new to biologic trials and companies planning such trials. <b><i>Methods:</i></b> We show how nuclei can be segmented and multiple trajectories with multiple injection points can be created through a single or multiple burr hole(s) based on preoperative images. Screenshots similar to those shown in this article can be used for planning purposes and for quality control in clinical trials. <b><i>Results:</i></b> This method enables the precise definition of 3-D target structures, such as the putamen, and efficient planning trajectories for biologic injections. The technique is generalizable and largely independent of procedural format, and thus can be integrated with frame-based or frameless platforms to streamline reproducible therapeutic delivery. <b><i>Conclusions:</i></b> We describe an easy-to-use and generalizable protocol for intracerebral trajectory planning for stereotactic delivery of biologics. Although we highlight intracerebral stem cell delivery to the putamen using a frame-based stereotactic delivery system, similar strategies may be employed for different brain nuclei using different platforms. We anticipate this will inform future advanced and fully automated neurosurgical procedures to help unify the field and decrease inherent variability seen with manual trajectory planning.
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