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Author Interviews, Neurological Disorders, Stroke / 29.02.2016

MedicalResearch.com Interview with: Georgios Tsivgoulis , M.D., Ph.D., MSc, FESO Assistant Professor of Neurology University of Athens, Athens, Greece Visiting Associate Professor of Neurology Director of Stroke Research Department of Neurology University of Tennessee Health Science Center Medical Research: What is the background for this study? What are the main findings? Dr. Tsivgoulis: Literature data suggest that taking statins before an acute ischemic stroke may improve early outcomes including early neurological deterioration, mortality and disability in patients with acute ischemic stroke. However,the potential beneficial effect of statin pretreatment has never been investigated in acute ischemic stroke due to large artery atherosclerosis. The research question in this specific subgroup of ischemic stroke patients is of great importance, as large-artery atherosclerotic stroke carries the highest risk of early recurrent stroke in comparison to other acute ischemic stroke subtypes. Using prospectively collected data from over 516 consecutive patients with acute large-artery atherosclerotic stroke from seven tertiary-care stroke centers during a three-year period we found that statin pretreatment in patients with acute large-artery atherosclerotic stroke is associated with better early outcomes in terms of neurological improvement, disability, survival and stroke recurrence. (more…)
Author Interviews, Compliance, Neurological Disorders, Stroke / 23.02.2016

MedicalResearch.com Interview with: Dr-William-Patrick-Neil William P. Neil, MD Vascular Neurologist SCPMG Regional Stroke Champion Neurology    Medical Research: What is the background for this study? Dr. Neil: Stroke survivors are less likely to have a recurrent stroke, or other complications if they take their medications as prescribed by their doctor. Mail order pharmacies are increasingly being used to deliver medications for a variety of diseases, and their use is associated with better medication adherence.  We wanted to see whether stroke patients who use mail-order pharmacies were more likely to have good medication adherence than those who used  local pharmacies. Medical Research: What are the main findings? Dr. Neil: We looked through a large electronic medical database in California, and found a total of 48,746 people discharged from the hospital with a stroke, and who also filled either a cholesterol medication or an anticoagulant (blood thinner). Of these, 136,722 refills were from a local pharmacy and 68,363 were by mail. Overall, patients were adherent to the medications 46.5% of the time if they picked up the medication from the pharmacy and 74% of the time if they had prescriptions mailed to them. (more…)
Author Interviews, Heart Disease, Stroke / 22.02.2016

MedicalResearch.com Interview with: Dr. Rolf Wachter Head Senior physician University of Goettingen Göttingen, Germany Medical Research: What is the background for this study? What are the main findings? Dr. Wachter: Atrial Fibrillation is a known risk factor for stroke, and in stroke patients, it is a strong predictor of adverse outcome, if it is not adequately treated (e.g. by anticoagulation). However, in its paroxysmal form, Atrial Fibrillation (AF) may escape routine diagnostics. We aimed to show that we can increase the number of patients with detected AF if we do more monitoring for atrial fibrillation. As a unique feature of our study, we did not focus on a certain stroke subtype (i.e. cryptogenic stroke), but we aimed to consider all patients >= 60 years in whom the detection of  Atrial Fibrillation has a clinical relevance. The main finding of our study was that enhanced and prolonged Holter ECG monitoring (3x10 days of monitoring, analysed in a dedicated core lab) tripled the number of detected AF cases (from 4.5 to 13.5 %). 11 patients had to undergo enhanced and prolonged monitoring to find one additional case of Atrial Fibrillation. (more…)
Author Interviews, Clots - Coagulation, Stroke / 21.02.2016

MedicalResearch.com Interview with: Thorsten Steiner, MD, PhD Klinikum Frankfurt Hoechst and Heidelberg University Hospital Germany Medical Research: What is the background for this study? What are the main findings? Dr. Steiner: Background of the study is intracranial hemorrhage (ICH) related to vitamin-K antagonists. The mortality rate is about 60%. Main reason for the high mortality rate is hematoma expansion which occurs in about 50% during the acute phase right after the start of symptoms. We performed an investigator initiated randomized controlled trial (RCT) and found that a 4-factor prothrombin complex (PCC) is superior to fresh frozen plasma (FFP) in normalizing the international normalized ratio (INR) and prevents hematoma expansion. This let to more deaths within 48 hours in the FFP-group but had no clinical impact at 3 months - but our study was powered to detect INR normalization and not a clinical endpoint. (more…)
Author Interviews, Gender Differences, Race/Ethnic Diversity, Stroke, Wake Forest / 20.02.2016

MedicalResearch.com Interview with: Cheryl Bushnell, MD, MHS Professor of Neurology Director, Wake Forest Baptist Stroke Center Wake Forest Baptist Health Medical Center Boulevard Winston Salem, NC  27157  Medical Research: What is the background for this study? What are the main findings? Dr. Bushnell: The catalyst for the study was to see if comorbidities and the management of them might influence functional status.  But, we pre-specified gender and race because we knew these could be important predictors of outcome.  As it turns out, the results of our analysis did, in fact, show that gender and race were the most significant predictors of poor functional outcome. Medical Research: What should clinicians and patients take away from your report? Dr. Bushnell: The take-home message is that women and minorities have poorer functional outcome after stroke, but the reasons for this outcome need to be further explored.  Our model showed that we only explained 31% of the variance in SIS-16 with gender, race/ethnicity, and stroke severity, so unmeasured factors are extremely important.  We could speculate from this dataset and other published data that women may be more likely to have functional deficits prior to stroke, be unmarried/widowed, live alone, or institutionalized after stroke.  Non-white stroke survivors may have poorer access to care, have multiple strokes, and more comorbidities. (more…)
Author Interviews, Epilepsy, Neurological Disorders, Stroke / 20.02.2016

MedicalResearch.com Interview with: Alexander Merkler, MD Fellow in neuro critical care Weill Cornell Medical College and New York-Presbyterian Hospital, New York Medical Research: What is the background for this study? What are the main findings? Dr. Merkler:  Patients with stroke often ask about what type of problems they may expect in the future. As neurologists, we often warm our patients about the risk for recurrent stroke, infections, clots, eating difficulty, and depression. Although seizures are a well-known complication of stroke, there was little data regarding the long-term rate of seizures in patients who have a stroke. Therefore, we sought to evaluate the long-term risk of seizures following stroke in order to better advise physicians and patients on the likelihood of developing seizures after suffering a stroke. We identified over 600,000 patients with stroke and found that the rate of seizures after stroke is high – 15.3% of all patients with stroke will develop seizures. Patients who have hemorrhagic stroke face an even higher rate of seizures – 24% of patients with hemorrhagic type stroke will develop seizures. The rate of seizures after ischemic stroke was significantly higher than previous literature - 13.5% of patients with an ischemic stroke had a seizure in our study. (more…)
Author Interviews, Mayo Clinic, Stroke / 19.02.2016

MedicalResearch.com Interview with: Thomas G. Brott, M.D. Professor of neurology and director for research and The Eugene and Marcia Applebaum Professor of Neurosciences and James C. and Sarah K. Kennedy Dean for Research. Mayo Clinic in Jacksonville, Fla Medical Research: What is the background for this study? What are the main findings? Dr. Brott: Revascularization for carotid artery stenosis is the accepted treatment for symptomatic patients with >50% stenosis and for asymptomatic patients with >70% stenosis.  The original CREST report in 2010 showed both surgery and stenting were the safe methods to treat severe carotid stenosis.  But the follow-up averaged 2.5 years and Medicare-age patients live for an average of 18-20 years.  These patients and their families needed to know if surgery and stenting are durable in preventing stroke. CREST was designed to answer the questions of clinical and anatomic durability for the long-run. (more…)
Author Interviews, Blood Pressure - Hypertension, OBGYNE, Stroke / 19.02.2016

MedicalResearch.com Interview with: Dr. Adnan Qureshi MD Professor of Neurology, Neurosurgery and Radiology University of Minnesota  Medical Research: What is the background for this study? Dr. Quershi: Women who have the last pregnancy at advanced age (usually defined as pregnancy at age of 40 years or greater) have higher risk of developing hypertension, hypertension related disorders, and diabetes mellitus during pregnancy. There is some evidence that disproportionately higher rates of cardiovascular risk factors continue years after the pregnancy. Perhaps there are unknown medical conditions triggered during pregnancy at advanced age. These changes continue to progress without being clinically evident until years later manifesting as a cardiovascular event. Medical Research: What are the main findings? Dr. Quershi: We analyzed the data for 72,221 women aged 50-79 years who were enrolled in the observational arm of the Women's Health Initiative Study. We determined the effect of pregnancy in advanced age (last pregnancy at age≥40 year) on risk of ischemic stroke, hemorrhagic stroke, myocardial infarction, and cardiovascular death over a mean period  of 12 years. A total of 3306 (4.6%) of the 72,221 participants reported pregnancy in advanced age. Compared with pregnancy in normal age, the rate of ischemic stroke (2.4% versus 3.8%, p<0.0001), hemorrhagic stroke (0.5% versus 1.0%, p<0.0001), myocardial infarction (2.5% versus 3.0%, p<0.0001), and cardiovascular death (2.3% versus 3.9%, p<0.0001) was significantly higher among women with pregnancy in advanced age. In multivariate analysis, women with pregnancy in advanced age were 60% more likely to experience a hemorrhagic stroke even after adjusting for differences in age, race/ethnicity, congestive heart failure, systolic blood pressure, atrial fibrillation, alcohol use and cigarette smoking were adjusted. (more…)
Author Interviews, Stroke / 18.02.2016

MedicalResearch.com Interview with: Michael D Hill, MD MSc FRCPC Calgary Stroke Program Professor, Dept Clinical Neurosciences Hotchkiss Brain Institute Cumming School of Medicine, University of Calgary Calgary, Canada  Medical Research: What is the background for this study? What are the main findings? Dr. Hill: The HERMES collaboration is a pooled analysis of 5 randomized controlled trials of endovascular stroke therapy.  The purpose is of this analysis is to assess the relationship between time from stroke onset and effect size. The main finding is that there is a declining effect size as time elapses from stroke onset.  Shorter onset to reperfusion times are associated with better outcomes.  However, the slope of the decline is shallow compared to past estimates.  We believe this is because imaging selection identifies a group a patients in whom there is slow growth of the core infarct. (more…)
Alzheimer's - Dementia, Author Interviews, Dental Research, Infections, Stroke / 18.02.2016

MedicalResearch.com Interview with: Dr. Robert Friedland MD Mason C. and Mary D. Rudd Endowed Chair In Neurology Professor, Dept. of Neurology University of Louisville Health Care Outpatient Center Louisville, KY 40292 Medical Research: What is the background for this study? What are the main findings? Dr. Robert Friedland: Oral infectious diseases are associated with stroke. Previous research by this group has shown that oral bacteria, cnm-positive Streptococcus mutans, was associated with cerebral microbleeds and intracerebral hemorrhage. We developed this study to investigate the roles of this bacteria in patients entering the hospital for all types of stroke. Among the patients who experienced intracerebral hemorrhage (ICH), 26 percent were found to have a specific bacterium in their saliva, cnm-positive S. mutans. Among patients with other types of stroke, only 6 percent tested positive for the bacterium. We also evaluated MRIs of study subjects for the presence of cerebral microbleeds (CMB), small brain hemorrhages which may cause dementia and also often underlie ICH. We found that the number of CMBs was significantly higher in subjects with cnm-positive S. mutans than in those without. (more…)
Author Interviews, BMJ, Clots - Coagulation, Heart Disease, Stroke / 06.02.2016

MedicalResearch.com Interview with: Dr. Deborah Cohen Associate Editor BMJ BMA House, Tavistock Square London Medical Research: What is the background for this study? What are the main findings? Dr. Cohen: Anyone familiar with warfarin understands the critical role of INR values in determining the proper dose for warfarin patients. The INR value in an individual patient is the most important piece of information a doctor considers when determining the warfarin dose. If the doctor gives too little warfarin then the patient may be at undue risk of stroke; if too much, the patient may be at undue risk of a major bleed. The BMJ investigation revealed that the INR device used to manage the ~7,000 warfarin patients in the ROCKET trial (which served as the basis for approval of the non-valvular atrial fibrillation indication) was defective. As such – doctors were relying upon a defective device in determining the dose of the warfarin patients – which has a direct influence on the stroke and bleeding risk in that patient. Since this was a comparative trial – any deficiency in the performance of the comparator arm (warfarin) would skew the results in favour of the study drug (rivaroxaban). Since INR directly influences strokes and bleeds – the primary efficacy and safety endpoints – it very much questions, if not undermines, the overall results of this trial. (more…)
Author Interviews, JAMA, Stroke / 07.01.2016

MedicalResearch.com Interview with: Michael F. Waters, MD, PhD Department of Neurology Department of Neuroscience McKnight Brain Institute University of Florida College of Medicine Gainesville, Florida Medical Research: What is the background for this study? What are the main findings? Dr. Waters: This study was based on a subgroup of medically managed patients with severe, symptomatic, intracranial, atherosclerotic disease. Historically we know that these patients have a very high rate of additional strokes, and multiple studies have attempted to determine the best management for these patients. In SAMMPRIS, we were able to prove that aggressive medical management was superior to stenting in these patients. However, certain patients in the medically managed group still had a very high rate of repeat strokes, as much as 30% of those with certain risk factors. This study was an attempt to identify those risk factors to determine which patients were at the greatest risk for another stroke. (more…)
Author Interviews, Beth Israel Deaconess, CT Scanning, JAMA, Neurological Disorders, Stroke / 04.01.2016

MedicalResearch.com Interview with: Sandeep Kumar, MD Assistant Professor of Neurology Harvard Medical School Director, Inpatient Stroke Service Department of Neurology, Stroke Division Beth Israel Deaconess Medical Center Boston, MA 02215 Medical Research: What is the background for this study? What are the main findings? Dr. Kumar: Transient deficits that start suddenly and typically last for a few minutes to a few hours are the hallmark of a transient ischemic attack (TIA) or a minor ischemic stroke. In this single-center observational study, we have reported similar clinical presentation in some patients with intracerebral hemorrhage (ICH) that are difficult to distinguish from cerebral ischemia based only on clinical signs and symptoms. (more…)
AHA Journals, Author Interviews, Education, Heart Disease, Stroke / 23.12.2015

MedicalResearch.com Interview with: Carole Decker, RN, PhD, CPHQ, FAHA Director, Cardiovascular Outcomes Research Saint Luke's Mid America Heart Institute Kansas City, MO 64111 Medical Research: What is the background for this study? What are the main findings? Dr. Decker: Stroke is the leading cause of disability and the fifth leading cause of death. The utilization of thrombolytic therapy is the national standard of care for acute ischemic stroke (AIS) treatment resulting in improved outcomes at 90 days and yet only 7% of patients with AIS receive a thrombolytic. The American College of Emergency Physicians emphasizes the importance of using a shared medical decision-making model with AIS patients and their caregivers to discuss benefits and risks of treatment. The recommended door-to-needle (emergency door to thrombolytic administration) is 60 minutes to achieve the optimal patient outcomes which can be problematic in that conversation on benefits and risks occurs in a hurried emergency setting. Multiple risk models to identify individualized benefits and risks of thrombolytic therapy have been developed but few are used prospectively and are not used at the point of care. Our team created ePRISM (Personalized Risk Information Services Manager), a Web-based tool, to generate personalized documents with patient-specific outcomes based on validated risks models. To support knowledge transfer and creation of a shared decision-making tool, our multidisciplinary team conducted qualitative interviews to define the information needs and preferred presentation format for stroke survivors, caregivers, and clinicians considering thrombolytic treatment. (more…)
Author Interviews, JAMA, MRI, Stroke / 22.12.2015

MedicalResearch.com Interview with: Sepideh Amin-Hanjani, MD FAANS FACS FAHA Professor & Program Director Co-Director, Neurovascular Surgery Department of Neurosurgery University of Illinois at Chicago Past Chair, AANS/CNS Cerebrovascular Section  Medical Research: What is the background for this study? What are the main findings? Dr. Amin-Hanjani: Posterior circulation strokes account for up to 30% of all ischemic strokes, and atherosclerotic occlusive disease of the vertebrobasilar (VB) is responsible for approximately one third of these cases. Symptomatic atherosclerotic VB occlusive disease is associated with a high risk of recurrent stroke despite medical therapy, in the range of 10-15% within 2 years. There have been advances in treatment options, particularly endovascular angioplasty and stenting, aimed at reverting the blockage; however these procedures themselves carry risks, and are likely to benefit only selected patients who are at highest risk without intervention. Our study, VERiTAS, aimed to determine if measurement of blood flow in the posterior circulation vessels could identify the high risk patients. Flow measurements were performed using the technique of quantitative magnetic resonance angiography (QMRA) relying on standard MR sequences and  the commercial software NOVA. These flow measurements were used to designate patients presenting with symptomatic vertebrobasilar disease as flow compromised or not, and patients were then followed for a median of 23 months in a blinded fashion to determine the risk of subsequent strokes. We found that among 72 such patients, only one quarter (18 patients) demonstrated flow compromise on QMRA, but that this group had a significantly higher risk of subsequent stroke at one year, 22% vs only 4% in the other group. The hazard ratio for subsequent stroke was markedly elevated at 11.5 even after adjusting for age and other stroke risk factors. (more…)
Author Interviews, Cleveland Clinic, Emergency Care, JAMA, Stroke, Telemedicine / 08.12.2015

MedicalResearch.com Interview with: Ken Uchino, MD FAHA FANA Director, Vascular Neurology Fellowship Research Director, Cerebrovascular Center, Cleveland Clinic Associate Professor of Medicine (Neurology) Cleveland Clinic Lerner College of Medicine of CWRU Cleveland, OH 44195 Medical Research: What is the background for this study? What are the main findings? Dr. Uchino: Treatment for acute ischemic stroke is time dependent. Multiple studies have reported strategies to improve time to treatment after arrival in the hospital. Mimicking pre-hospital thrombolysis of acute myocardial infarction pioneered 30 years ago, two groups in Germany have implemented pre-hospital ischemic stroke thrombolysis using mobile stroke unit (“stroke ambulance”) that includes CT scan and laboratory capabilities. These units have been demonstrated to provide stroke treatment earlier than bringing patients to the emergency departments. Our report extends the concept mobile stroke unit further by using telemedicine for remote physician presence. The other mobile stroke units were designed to have at least one physician on board. This allows potential multiple or geographically distant units to be supported by stroke specialists. The study demonstrates that after patient arrival in the ambulance, the time to evaluation (CT scanning and blood testing) and to thrombolytic treatment is as quick or better as patient arrival in emergency department door. We are reporting the overall time efficiency after emergency medical service notification (911 call) in a separate paper. (more…)
Author Interviews, Gender Differences, Heart Disease, JAMA, Stroke / 23.11.2015

MedicalResearch.com Interview with: Bob Siegerink PhD Frits R. Rosendaal MD, PhD Department of Clinical Epidemiology Leiden University Medical Center Leiden, the Netherlands Medical Research: What is the background for this study? What are the main findings? Response: The rates of death due to arterial thrombosis have been declining in the past years, which means that there are more patients with a high burden of disease. Arterial thrombosis is a uncommon disease in the young, but the burden of the disease might have a profound impact on their lives. We analyzed data form the RATIO study, in which we followed women with a ischemic stroke and myocardial infarction for up to 20 years. During this time, overall mortality was 2-4 times higher compared to the general population. This increase in risk was mainly driven by deaths from acute vascular events and persisted over the whole course of the follow up. (more…)
AHA Journals, Author Interviews, Cognitive Issues, Stroke / 19.11.2015

MedicalResearch.com Interview with: Dr. Thomas Bak Centre for Cognitive Aging and Cognitive Epidemiology and Centre for Clinical Brain Sciences, University of Edinburgh and Dr. Suvarna Alladi Nizam's Institute of Medical Sciences, Hyderabad, India Medical Research: What is the background for this study? What are the main findings? Response: In a previous study published in 2013 (attached) we have reported that bilingual patients develop dementia around 4 years later than monolingual ones - a phenomenon, which we tried to explain in a commentary in 2014 (also attached); the mechanism we have postulated as a possible explanation is so called "cognitive reserve": the ability of the brain, boosted by a range of different mental activities, to cope better with potential damage. One manifestation of it has been now described in several studies: bilingual patients seem to develop dementia later than monolingual ones. But if the cognitive reserve helps in coping with brain damage, it should also help with the recovery after stroke. This was exactly what we set out to examine and exactly what we found. Bilingual patients showed a complete recovery of cognitive functions after stroke over twice as often as monolingual ones (40/5% vs. 19.6%). (more…)
AHA Journals, Author Interviews, McGill, Stroke / 14.11.2015

MedicalResearch.com Interview with: Sophie Vincent, Medical Student McGill University and Kristian Filion, PhD FAHA Assistant Professor of Medicine Division of Clinical Epidemiology Jewish General Hospital/McGill University Medical Research: What is the background for this study? What are the main findings? Response: Patients with carotid atherosclerosis causing vascular stenosis are at increased risk of stroke, which is the third leading cause of death in the United States and in Canada. Carotid artery stenting and carotid endarterectomy are the primary surgical options for the treatment of carotid stenosis. With the assumption that an endovascular approach would offer a more favorable safety profile than open surgical procedure, the use of stenting increased significantly following its entry into the market in the 1990s. However, despite this observed increase in use, the long-term safety and efficacy of stenting relative to endarterectomy remained unclear, which is why we decided to conduct this study. Although carotid artery stenting has more favorable periprocedural outcomes with respect to myocardial infarction, hematoma, and cranial nerve palsy, the observed increased risk of stroke throughout follow-up with stenting suggests that endarterectomy remains the treatment of choice for the management of carotid stenosis. (more…)
Author Interviews, Clots - Coagulation, Heart Disease, Stroke, University of Michigan / 10.11.2015

MedicalResearch.com Interview with: Geoffrey Barnes, MD, MSc Clinical Lecturer Cardiovascular Medicine and Vascular Medicine University of Michigan Health System Medical Research: What is the background for this study? Dr. Barnes: Although warfarin has been the primary anticoagulant used for stroke prevention in atrial fibrillation for over 60 years, four new direct oral anticoagulants (DOACs) have been introduced into the market since 2010. Dabigatran, which directly inhibits thrombin, was found to have better prevention of ischemic stroke and a significant reduction in hemorrhagic stroke (bleeding strokes) for patients with atrial fibrillation at intermediate and high risk of stroke.  Prior cost-effectiveness studies have shown that dabigatran is cost-effective from both the societal and payer (usually Medicare) perspectives.  However, none of those studies looked at the patient’s out-of-pocket costs and the impact of prescription drug coverage Medical Research: What are the main findings? Dr. Barnes: We found that patients with prescription drug coverage (Medicare Part D) had significant cost savings when choosing dabigatran over warfarin.  This is primarily because of the reduction in both types of stroke as well not needing to have frequent blood draws, as are required by warfarin.  However, when patients do not have prescription drug coverage, the costs for dabigatran are quite high.  (more…)
Author Interviews, Duke, JAMA, Pharmacology, Stroke / 10.11.2015

MedicalResearch.com Interview with: Ying Xian, PhD Assistant Professor of Medicine. Member in the Duke Clinical Research Institute Medical Research: What is the background for this study? What are the main findings? Dr. Xian: Intravenous tissue plasminogen activator (tPA) is the only FDA approved medical therapy to reduce disability and improve outcomes for patients with acute ischemic stroke. But treatment with tPA also carries the risk of symptomatic intracranial hemorrhage (sICH), which is often fatal. Nearly half of ischemic stroke patients are taking antiplatelet drugs such as aspirin and/or clopidogrel prior to stroke. We found these patients had higher risk for sICH when treated with tPA. But the risk is relatively small. For every 147 patients on aspirin treated with tPA, only 1 more symptomatic intracranial hemorrhage as compared with those treated with tPA without prior antiplatelet therapy. The risk is slightly higher among those on dual antiplatelet therapy of aspirin and clopidogrel (number needed to harm 60). Despite the higher bleeding risk, patients treated with tPA on prior antiplatelet therapy appeared to have better functional outcomes in terms of ambulatory status and modified Rankin scale than those not on prior antiplatelet therapy. Therefore, overall the benefits of thrombolytic therapy may outweigh the risks. (more…)
AHA Journals, Author Interviews, Duke, Outcomes & Safety, Stroke, Surgical Research / 04.11.2015

MedicalResearch.com Interview with: Soko Setoguchi-Iwata, M.D MPH Adjunct Associate Professor Department of Medicine Duke Clinical Research Institute Medical Research: What is the background for this study? What are the main findings? Dr. Setoguchi: Medicare made a decision to cover Carotid Artery Stenting (CAS) in 2005 after publication of SAPPHIRE, which demonstrated the efficacy of Carotid Artery Stenting vs Carotid Endarterectomy in high risk patients for CEA. Despite the data showing increased carotid artery stenting dissemination following the 2005 National Coverage Determination, peri-procedural and long-term outcomes have not been described among Medicare beneficiaries, who are quite different from trial patients, older and with more comorbidities in general population. Understanding the outcomes in these population is particularly important in the light of more recent study, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which established CAS as a safe and efficacious alternative to CEA among non-high-surgical risk patients that also expanded the clinical indication of carotid artery stenting. Another motivation to study ‘real world outcomes in the general population is expected differences in the proficiency of physicians performing stenting in trial setting vs. real world practice setting. SAPPHIRE and CREST physicians were enrolled only after having demonstrated  Carotid Artery Stenting proficiency with low complication rates whereas hands-on experience and patient outcomes among real-world physicians and hospitals is likely to be more diverse. We found that unadjusted mortality risks over study period of 5 years with an mean of 2 years of follow-up in our population was 32%.  Much higher mortality risks observed among certain subgroups with older age, symptomatic patients and non-elective hospitalizations.   (more…)
Author Interviews, JAMA, Stroke, Surgical Research / 04.11.2015

MedicalResearch.com Interview with: Saleh A Almenawer, MD Neurosurgeon, Hamilton Health Sciences McMaster University Hamilton, ON Canada  Medical Research: What is the background for this study? Dr. Almenawer: The current standard therapy for acute ischemic stroke is intravenous tissue plasminogen activator (tPA), which improves survival and functional outcomes when administered as early as possible after stroke. However, the use of intravenous tPA is limited by the narrow therapeutic time window (< 4.5 hours) and by important contraindications, including coagulopathy, recent surgery, or stroke or head injury within the past 3 months. This leaves as few as 10% of patients presenting with ischemic stroke eligible for treatment with tPA. Moreover, intravenous tPA is associated with long recanalization times and poor revascularization rates in proximal large vessel occlusion, and the prognosis of these patients remains poor. The limitations of intravenous tPA have spurred interest in endovascular thrombectomy for acute ischemic stroke, analogous to thrombolysis versus percutaneous coronary intervention for myocardial infarction. Several randomized clinical trials (RCTs) have compared clinical outcomes of mechanical thrombectomy to standard medical treatment with intravenous tPA. The current study was a meta-analysis of RCTs that aimed to answer the question of whether endovascular thrombectomy is associated with better clinical outcomes than intravenous tPA, and accordingly, whether endovascular thrombectomy should replace intravenous tPA as the new standard of care for ischemic stroke. (more…)
AHA Journals, Author Interviews, Health Care Systems, Outcomes & Safety, Stroke / 29.10.2015

MedicalResearch.com Interview with: Mathew J. Reeves BVSc, PhD, FAHA Professor, Department of Epidemiology and Biostatistics, Michigan State University East Lansing, MI 48824  Medical Research: What is the background for this study? Dr. Reeves: The National Institutes of Health Stroke Scale (NIHSS) is the single most important prognostic factor in predicting outcomes of individual stroke patients. NIHSS data is obviously important at the patient level but also at a hospital level since the case mix of stroke patients are assumed to vary widely across different hospitals and referral centers. Measuring stroke outcomes at a hospital level is becoming increasingly important as work proceeds in the US to develop integrated stroke systems of care. But it is also very relevant to the new payment models being introduced by CMS which are based on hospital rankings that are developed from statistical risk adjustment models. One would expect that NIHSS would be a major contributor to these models but currently a major limitation is that NIHSS is incompletely documented in clinical registries such as GWTG-Stroke, and is completely absent from administrative data. The problem of missing NIHSS data plays havoc with the ability to risk adjust stroke outcomes across hospitals. Missing data results is a smaller number of stroke cases being included in the risk adjusted calculations for a given hospital which results in greater uncertainty over what the actual hospital outcomes are. Further there is concern that NIHSS data is not missing at random, and so the NIHSS data that is documented may represent a biased selection of all the cases that a hospital admits. This too could have important consequences for hospital rankings. To determine the degree of potential bias in the documentation of NIHSS data this study examined trends in and predictors of documentation of NIHSS across 10 years of data (2003-2012) in the GWTG-Stroke program. (more…)
AHA Journals, Author Interviews, Stroke / 26.10.2015

MedicalResearch.com Interview with: Shadi Yaghi, MD Assistant Professor of Neurology The Warren Alpert Medical School of Brown University Rhode Island Hospital Stroke Center, Staff Neurologist Medical Research: What is the background for this study? What are the main findings? Dr. Yaghi: In this study, we pooled data from 10 stroke centers across the country to investigate the treatment and outcome of post thrombolysis hemorrhage in acute ischemic stroke. This study included 128 patients and showed that the treatments used were not effective in improving the mortality related to this condition. (more…)
Author Interviews, Heart Disease, Karolinski Institute, Nutrition, Stroke / 27.09.2015

Susanna C. Larsson | PhD, Associate Professor Associate professor, Nutritional Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm, SwedenMedicalResearch.com Interview with: Susanna C. Larsson  PhD, Associate Professor Associate professor, Nutritional Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm, Sweden Medical Research: What are the main findings? Dr. Larsson: A high dietary cholesterol intake has been postulated to increase the risk of cardiovascular disease. Egg is a rich source of dietary cholesterol and has been positively associated with risk of heart failure in previous prospective studies. High consumption of eggs has also been associated with a higher risk of myocardial infarction in diabetic patients. Medical Research: What is the background for this study? Dr. Larsson:  We investigated the association between egg consumption and risk of cardiovascular diseases in two population-based prospective cohort studies of approximately 38,000 Swedish men and 33,000 Swedish women. Findings from our study indicate that egg consumption does not increase the risk of myocardial infarction, ischemic stroke, or hemorrhagic stroke. High egg consumption (one or more times per day) was associated with an elevated risk of heart failure in men but not in women. Egg consumption was not associated with an increased risk of heart failure, myocardial infarction, or stroke in individuals with diabetes. (more…)
AHA Journals, Author Interviews, Stroke / 20.08.2015

Josefine Persson Doctoral student Institute of Neuroscience and Physiology Sahlgrenska Academy University of GothenburgMedicalResearch.com Interview with: Josefine Persson Doctoral student Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Medical Research: What is the background for this study? Response: Stroke is a major global disease that requires extensive care and support from the society and the family. We know from previous research that a stroke often has a wide-spread impact on the daily life of the family. To provide support to a partner is often perceived as natural and important, but can be demanding and have an impact on the spouses own health. The situation for spouses as caregivers is well studied during the first two years after the stroke, while the long-term effects are less well known. By this, we studied the physical and mental health of 248 spouses of stroke survivors, below age 70 at stroke onset, seven years after the stroke event and compared our result with 245 spouses of non-stroke, age- and sex-matched controls. Medical Research:  What are the main findings? Response: The main finding of our study is that caregiver spouses of stroke survivors are at an increased risk of mental and physical health issues even seven years after stroke onset. This is the first study with this long period of follow up and the results show that the restriction on the spouses own activity and social relationships studied in shorter follow up is also obvious for a large proportion of the spouses in a very long perspective. Spouses’ quality of life was most adversely affected by their partners’ level of disability, cognitive difficulties and depressive symptoms. (more…)
Author Interviews, Lancet, Stroke / 20.08.2015

Professor Mika Kivimäki Chair of Social Epidemiology Epidemiology & Public Health Institute of Epidemiology & Health Faculty of Population Health Sciences University College London London MedicalResearch.com Interview with: Professor Mika Kivimäki Chair of Social Epidemiology Epidemiology & Public Health Institute of Epidemiology & Health Faculty of Population Health Sciences University College London Medical Research: What is the background for this study? What are the main findings? Prof Kivimäki:  Long working hours have been implicated in the cause of cardiovascular disease, but the evidence is limited. We conducted a systematic review of published studies on this topic and located additional individual-level data by searching open-access data archives and by including unpublished data from IPD-Work, a consortium of prospective cohort studies. This resulted in a pooled sample of over 600,000 men and women who were followed for cardiovascular disease 7-8 years after the assessment of working hours. During the follow-up, more than 4700 participants had a coronary event and 1700 had a stroke. Our findings show that individuals who worked 55 hours or more per week had a 1.3-times higher risk of stroke compared to those working standard 35-40 hours. This finding remained unchanged in analyses adjusted for other stroke risk factors, such as age, sex, socioeconomic position and health behaviours. (more…)