AHA Journals, Author Interviews, Health Care Systems, Outcomes & Safety, Stroke / 29.10.2015

[caption id="attachment_18912" align="alignleft" width="169"]Mathew J. Reeves BVSc, PhD, FAHA Professor, Department of Epidemiology and Biostatistics, Michigan State University East Lansing, MI 48824 Prof. Reeves[/caption] 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.
AHA Journals, Author Interviews, Stroke / 26.10.2015

[caption id="attachment_18708" align="alignleft" width="125"]Shadi Yaghi, MD Assistant Professor of Neurology The Warren Alpert Medical School of Brown University Rhode Island Hospital Stroke Center, Staff Neurologist Dr. Shadi Yaghi[/caption] 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.
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.
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.
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.
Author Interviews, Columbia, Emergency Care, Race/Ethnic Diversity, Stroke / 14.08.2015

Heidi Mochari-Greenberger Ph.D., M.P.H Associate research scientist Columbia University Medical Center New York, N.YMedicalResearch.com Interview with: Heidi Mochari-Greenberger Ph.D., M.P.H Associate research scientist Columbia University Medical Center New York, N.Y MedicalResearch: What is the background for this study? Dr. Mochari-Greenberger: Differences in activation of emergency medical services (EMS) may contribute to race/ethnic and sex disparities in stroke outcomes. The purpose of this study was to determine whether EMS use varied by race/ethnicity or sex among a contemporary, diverse national sample of hospitalized acute stroke patients. MedicalResearch: What are the main findings? Dr. Mochari-Greenberger: Use of EMS transport among hospitalized stroke patients was less than 60% and varied by race/ethnicity and sex; EMS use was highest among white females and lowest among Hispanic males. Our analyses showed that Hispanic and Asian men and women were significantly less likely than their white counterparts to use EMS; black females were less likely than white females to use EMS, but black men had a similar rate to white men. These observed associations between race/ethnicity and sex with EMS use persisted after adjustment for stroke symptoms and other factors known to be associated with EMS use, indicating they were not driven solely by stroke symptom differences.
Author Interviews, CDC, Heart Disease, Stroke / 23.07.2015

Dr. Jing Fang Ph.D. Epidemiologist Center For Disease ControlMedicalResearch.com Interview with: Dr. Jing Fang Ph.D. Epidemiologist Center For Disease Control MedicalResearch: What is the background for this study? What are the main findings? Dr. Fang: Although the effectiveness of aspirin for secondary prevention (e.g. people who already have coronary heart disease or have had an ischemic stroke) of cardiovascular disease has been determined, its prevalence as a preventive measure has varied widely across settings, data collection methods and U.S. states. As a result, we wanted to more closely examine aspirin use among U.S. adults with a history of coronary heart disease or stroke. To determine these findings, we analyzed data from the 2013 Behavioral Risk Factor Surveillance System. Nearly 18,000 people from 20 states and the District of Columbia with a self-reported history of coronary heart disease or stroke were included in the annual telephone survey. Overall, we found about 70 percent of U.S. adults with heart disease or stroke reported regularly taking aspirin – meaning every day or every other day. Out of that group, nearly 94 percent said they take aspirin for heart attack prevention, about 80 percent linked it to stroke prevention efforts, and approximately 76 percent said they use it for both heart attack and stroke prevention. However, four percent of respondents with pre-existing cardiovascular problems said they take aspirin for pain relief without awareness of its benefits for cardiovascular disease. Aspirin use also differed by state and sociodemographic characteristics including gender, race/ethnicity and age. In general, men, non-Hispanic whites, individuals aged 65 and older, and people with at least two of four risk factors (hypertension, smoking, diabetes and high cholesterol) are more likely to use aspirin than other groups. By state, aspirin use ranged from 44 percent in Missouri to more than 71 percent in Mississippi.
AHA Journals, Author Interviews, Stroke / 13.07.2015

MedicalResearch.com Interview with: Dr. Ángel Chamorro Director, Comprehensive Stroke Center Hospital Clinic Barcelona, Spain Medical Research: What is the background for this study? What are the main findings? Dr. Chamorro: There is a great need of new therapies in patients with acute stroke and our study is based on the clinical observation that patients with acute stroke recover better if at the time of the stroke the levels of uric acid are increased in their blood. That first observation led to a long way of research and administrative challenges but we finally came out with a solution of uric acid (a potent antioxidant) manufactured according to the strict rules which apply to drugs aimed for human use. Thus, we performed a pilot study that showed that uric acid could be safely administered to these patients. We then performed a larger clinical trial in 421 patients which provided very encouraging results overall. Now we are reporting in the Stroke journal appearing on July 9, that women obtained a much greater benefit than men because they had lower levels of uric acid than men because estrogens (female hormones) are efficient excretors of uric acid. In consequence, women were in greater need of uric acid replenishment following the stroke than men.
AHA Journals, Author Interviews, Cleveland Clinic, Stroke / 19.06.2015

Dr. Ken Uchino, MD Cleveland Clinic Main Campus Cleveland, OH 44195MedicalResearch.com Interview with: Dr. Ken Uchino, MD Cleveland Clinic Main Campus Cleveland, OH 44195 Medical Research: What is the background for this study? What are the main findings? Dr. Uchino: Stroke center designation started in 2003 and more hospitals have been certified as primary stroke centers over time. We asked the question how many are certified now? What are the characteristics of the hospitals that are certified? In 2013, nearly a third (23%) of acute short-term adult general hospitals with emergency departments were certified as stroke centers. 74% of the stroke centers were certified by the Joint Commission, a non-profit organization that certifies health care facilities and programs. 20% were certified by state health departments. States varied in percentages of hospitals that were certified, ranging from 4% in Wyoming to 100% in Delaware. Not unexpectedly larger hospitals and hospitals in urban locations were more likely to be certified as stroke centers. But a hospital being located in a state with so-called “stroke legislation” more than tripled the chance of being a certified stroke centers, even accounting for other factors. These states passed legislation to promote stroke centers and mandated stroke patients to be preferentially transported to qualified hospitals.
Author Interviews, BMJ, Geriatrics, Lipids, Statins, Stroke / 19.05.2015

Christophe Tzourio, MD, PhD Professor of Epidemiology University of BordeauxMedicalResearch.com Interview with: Christophe Tzourio, MD, PhD Professor of Epidemiology University of Bordeaux Medical Research: What is the background for this study? What are the main findings? Dr. Tzourio: The efficacy of lipid-lowering drugs (LLD) - which include statins and fibrates - to reduce the risk of coronary events and stroke has already been demonstrated in randomized trials. However, these trials were performed on highly selected patients, usually of middle-age (50-70 yrs) and with a history of cardiovascular disease or a high vascular profile. There is therefore currently no indication on the benefit of these drugs in elderly individuals of the general population without a past-history of cardiovascular disease and guidelines do not recommend the use of lipid-lowering drugs in elderly individuals without clinical atherosclerotic disease. As there are not randomized trials in non-selected individuals in this age category, observational population-based cohorts are therefore the only alternative to study the impact of lipid-lowering drugs on the risk of cardiovascular diseases in the elderly. We analyzed data from the Three-City study, a community-based cohort in 7484 elderly individuals (mean age 74 years), followed-up during 9 years, without known history of vascular disease at baseline. We observed a one third decrease in the risk of stroke in lipid lowering drug users (hazard ratio 0.66, 0.49 to 0.90) compared with non-users. Reduction in stroke risk was similar for the statin and fibrate groups. No protective effect was seen on the risk of coronary heart disease.
Author Interviews, MRI, Neurology, Stroke / 14.05.2015

Amie W. Hsia, MD Medical Director, Comprehensive Stroke Center MedStar Washington Hospital Center NIH Stroke Program at MWHC Associate Professor, Neurology Georgetown University Washington, DC 20010MedicalResearch.com Interview with: Amie W. Hsia, MD Medical Director, Comprehensive Stroke Center MedStar Washington Hospital Center NIH Stroke Program at MWHC Associate Professor, Neurology Georgetown University Washington, DC 20010   Medical Research: What is the background for this study? What are the main findings? Dr. Hsia: Acute stroke is a common presenting problem in the emergency department. We know that “time is brain” and that for patients experiencing an ischemic or “blockage” type of stroke, the most common type, the sooner we can administer tPA, a clot-busting medication and the only FDA-approved medication to treat acute stroke, the better chance for a good outcome. Therefore, there is a goal national benchmark time of administering the drug to appropriate acute stroke patients within 60 minutes of their arrival to the emergency department. There are many steps that are necessary in the evaluation of an acute stroke patient in the emergency department before tPA can be given. This includes a brain scan to make sure a patient is not having the less common bleeding type of stroke. A CT or “CAT” scan is the typical type of brain scan that is performed in emergency departments across the country and the world to screen a patient before giving tPA. The primary purpose of the CT scan is to exclude bleeding; it is difficult to visualize an early stroke on CT. Though an MRI can give more complete information including showing the stroke as it is happening in these first few hours and though most hospitals have an MRI scanner, an MRI takes longer to perform and has not traditionally been used in an emergency setting. At the two hospitals included in this study, MedStar Washington Hospital Center in D.C. and Suburban Hospital in Maryland, we are fortunate to serve as the sites for the NINDS intramural stroke clinical research program and use MRI routinely to screen acute stroke patients to learn more about stroke and develop new treatments for stroke. It is upon this foundation that we performed independent hospital-wide quality improvement initiatives engaging multidisciplinary committees with leadership from all the departments involved in the care of the acute stroke patient in that critical first 60 minutes. Inspired by our colleagues at Washington University in St. Louis led by Dr. Andria Ford who used similar methods in reducing treatment times with CT screening, we used lean manufacturing principles to streamline our processes that include MRI screening and dramatically reduced our treatment times from a baseline of 93 minutes down to 55 minutes while still maintaining safety. Through these efficiency improvements, we were able to achieve a 4-fold increase in the percentage of stroke patients treated with tPA within 60 minutes.
Author Interviews, Brigham & Women's - Harvard, Electronic Records, JACC, Stroke / 11.05.2015

Dr. Karen E. Joynt, MD MPH Cardiovascular Division Brigham and Women's Hospital and VA Boston Healthcare System Department of Health Policy and Management, Harvard School of Public HealthMedicalResearch.com Interview with: Karen E. Joynt, MD MPH Cardiovascular Division, Brigham and Women's Hospital and VA Boston Healthcare System Department of Health Policy and Management Harvard T.H. Chan School of Public Health MedicalResearch: What is the background for this study?  What are the main findings? Dr. Joynt: While there is a great deal of optimism about the potential of Electronic Health Records (EHRs) to improve health care, there is little national data examining whether hospitals that have implemented EHRs have higher-quality care or better patient outcomes.  We used national data on 626,473 patients with ischemic stroke to compare quality and outcomes between hospitals with versus without EHRs.  We found no difference in quality of care, discharge home (a marker of good functional status), or in-hospital mortality between hospital with versus without EHRs.  We did find that the chances of having a long length of stay were slightly lower in hospitals with EHRs than those without them.
AHA Journals, Author Interviews, Outcomes & Safety, Stroke / 08.05.2015

James S McKinney, MD, FAHAAssistant Professor of Neurology Rutgers-Robert Wood Johnson Medical School Medical Director, RWJUH Comprehensive Stroke Center New Brunswick, NJ 08901MedicalResearch.com Interview with: James S McKinney, MD, FAHA Assistant Professor of Neurology Rutgers-Robert Wood Johnson Medical School Medical Director, RWJUH Comprehensive Stroke Center New Brunswick, NJ 08901 Medical Research: What is the background for this study? What are the main findings? Dr. McKinney: The current study evaluated outcomes of patients admitted to New Jersey hospitals with hemorrhagic stroke, including intracerebral hemorrhage (bleeding into the brain) and subarachnoid hemorrhage (bleeding along the surface of the brain) between 1996 and 2012 using the Myocardial Infarction Data Acquisition System (MIDAS) administrative database.  The New Jersey Department of Health and Senior Services designates certain hospitals as comprehensive stroke centers (CSCs).  We found that patients admitted to comprehensive stroke centers with hemorrhagic stroke were less likely to die than those admitted to other hospital types.  This was particularly true for those patients admitted with subarachnoid hemorrhage, which is usually caused by a ruptured aneurysm.
Author Interviews, Heart Disease, JACC, Stroke, University of Pennsylvania / 25.04.2015

Jay Giri, MD MPH Director, Peripheral Intervention Assistant Professor of Clinical Medicine University of PennsylvaniaMedicalResearch.com Interview with Jay Giri, MD MPH Director, Peripheral Intervention Assistant Professor of Clinical Medicine University of Pennsylvania MedicalResearch: What is the background for this study? What are the main findings? Dr. Giri: Carotid artery stents are placed by vascular surgeons or interventional cardiologists to decrease the risk of long-term stroke in patients with severe atherosclerotic disease of the carotid artery.  When these procedures are performed, there is a risk of releasing small amounts of debris into the brain’s circulation, causing a stroke around the time of the procedure (peri-procedural stroke).  In order to mitigate this issue, embolic protection devices (EPD) have been developed to decrease the chances of small debris reaching the brain. Two types of EPD exist.  The first is a small filter meant to catch the debris released by placement of the carotid stent (distal filter EPD). The second is a more complex device type that leads to transient halting of blood flow to the brain in the carotid artery being stented (proximal EPD). Debris-containing blood is removed from the body prior to allowing normal blood flow to proceed back to the brain after stent placement. Our prior research has shown that nearly all (>95%) of domestic carotid stenting procedures are performed with utilization of one of these devices.  We sought to compare important clinical outcomes of stroke and death between these 2 device types within a large national sample of patients undergoing carotid stenting. Some small prior studies have investigated whether the total amount of debris reaching the brain is less with proximal embolic protection devices.  These studies have shown mixed results.  However, no prior study has investigated important clinical outcomes of stroke and death in relation to these devices. We found that overall uptake of proximal embolic protection devices utilization in America has not been robust.  Less than 7% of all domestic CAS procedures are performed with this technology.   Our analysis showed that in-hospital and 30-day stroke/death rates with proximal EPD and distal filter EPD were similar (1.6% vs. 2.0%, p = 0.56 and 2.7% vs. 4.0%, p = 0.22, respectively).
Author Interviews, CDC, Cost of Health Care, Heart Disease, JACC, Stroke / 22.04.2015

Guijing Wang, PhD Senior health economist Division for Heart Disease and Stroke Prevention Centers for Disease Control and PreventionMedicalResearch.com Interview with: Guijing Wang, PhD Senior health economist Division for Heart Disease and Stroke Prevention Centers for Disease Control and Prevention Medical Research: What is the background for this study? What are the main findings? Dr. Wang: Our study is one of the first to analyze the impact of hospital costs related to atrial fibrillation (or AFib) in a younger stroke population. To determine these findings, we examined more than 40,000 hospital admissions information involving adults between the ages of 18 and 64 with a primary diagnosis of ischemic stroke between 2010 and 2012. Although AFib is more common among those ages 65 and older, with strokes among younger adults on the rise in the U.S., we wanted to take a comprehensive look at AFib’s impact on hospital costs for these patients. AFib is associated with a 4- to 5-fold increased risk of ischemic stroke, which is the most common type of stroke. Overall, our research found that AFib substantially increased hospital costs for patients with ischemic stroke – and that was consistent across different age groups and genders of those aged 18-64. Of the 33,500 first-time stroke admissions, more than seven percent had AFib, and these admissions cost nearly $5,000 more than those without the condition. In addition, we found that both the costs of hospitalization, as well as the costs associated with AFib, were higher among younger adults (18-54) than those aged 55 to 64.
Author Interviews, Brigham & Women's - Harvard, Mental Health Research, Stroke, Toxin Research / 22.04.2015

Elissa Hope Wilker, Sc.D. Beth Israel Deaconess Medical Center Cardiovascular Epidemiology Research Harvard Medical SchoolMedicalResearch.com Interview with: Elissa Hope Wilker, Sc.D. Beth Israel Deaconess Medical Center Cardiovascular Epidemiology Research Harvard Medical School Medical Research: What is the background for this study? What are the main findings? Dr. Wilke: Long-term exposure to ambient air pollution is associated with cerebrovascular disease and cognitive impairment, but the impact on structural changes in the brain is not well understood. We studied older adults living in the greater Boston area and throughout New England and New York and we looked at the air pollution levels and how far they lived from major roads. We then linked this information to findings from MRI studies of structural brain images. Although air pollution levels in this area are fairly low compared to levels observed in other parts of the world, we found that people who lived in areas with higher levels of air pollution had smaller brain volumes, and higher risk of silent strokes. The magnitude of association that we observed for a 2 µg/m3 increase in fine particulate matter (PM2.5) (a range commonly observed across urban areas) was approximately equivalent to one year of brain aging. The association with silent strokes is of concern, because these are associated with increased risk of overt strokes, walking problems, and depression.
Author Interviews, BMJ, Stroke, Toxin Research / 26.03.2015

MedicalResearch.com Interview with: Dr Anoop Shah Cardiology Research fellow Centre of Cardiovascular sciences University Of Edinburgh Edinburgh Medical Research: What is the background for this study? What are the main findings? Response: Stroke accounts for five million deaths each year and is a major cause of disability. The incidence of stroke is increasing, particularly in low and middle income countries, where two thirds of all strokes occur. The global burden of stroke related disability is therefore high and continues to rise. This has been primarily attributed to an aging population in high income countries and the accumulation of risk factors for stroke, such as smoking, hypertension, and obesity, in low and middle income countries. The impact of environmental factors on morbidity and mortality from stroke, however, might be important and is less certain. From 103 studies and across 6.2 million fatal and non-fatal strokes, our findings suggest a strong association between short term exposure to both gaseous (except ozone) and particulate air pollution, and admissions to hospital for stroke or mortality from stroke. These associations were strongest in low and middle income countries, suggesting the need for policy changes to reduce personal exposure to air pollutants especially in highly polluted regions.
Author Interviews, Heart Disease, Stroke, UCSD / 20.03.2015

Jonathan L. Halperin, M.D. The Robert and Harriet Heilbrunn Professor of Medicine Mount Sinai School of MedicineMedicalResearch.com Interview with: Jonathan L. Halperin, M.D. The Robert and Harriet Heilbrunn Professor of Medicine Mount Sinai School of Medicine Dr. Halperin is a member of the Steering Committee for the GLORIA-AF program and a consultant to Boehringer Ingelheim, which sponsored this research. Medical Research: What is the background for this study? What are the main findings? Dr. Halperin: The two analyses come from the GLORIA-AF Registry Program, a global, prospective, observational study supported by Boehringer Ingelheim, which is designed to characterize the population of newly diagnosed patients with non-valvular atrial fibrillation (NVAF) at risk for stroke, and to study patterns, predictors and outcomes of different treatment regimens for stroke risk reduction in non-valvular atrial fibrillation patients. The data is based on treatment trends in 3,415 patients who entered the registry from November 2011 to February 2014 in North America. All patients had a recent diagnosis of NVAF, and 86.2 percent had a CHA2DS2-VASc score of 2 or higher. Results from the first analysis demonstrated that patients with the paroxysmal (occasional) form of non-valvular atrial fibrillation and at a high risk for stroke (CHA2DS2-VASc score of 2 or higher) were given an anticoagulant medication less often than those with persistent or permanent forms of NVAF, and a CHA2DS2-VASc score of 2 or higher. This pattern runs counter to NVAF guidelines calling for patients to receive oral anticoagulant therapy based on their risk of stroke, rather than the type of atrial fibrillation. In the second analysis, researchers found that despite high stroke risk, a considerable number of patients receive only aspirin or no medication.
Author Interviews, Brain Injury, Stroke / 22.02.2015

Bruno Meloni PhD Centre for Neuromuscular and Neurological Disorders The University of Western Australia, Nedlands, Western Australia, AustraliaMedicalResearch.com Interview with: Bruno Meloni PhD Centre for Neuromuscular and Neurological Disorders The University of Western Australia, Nedlands, Western Australia, Australia MedicalResearch: What is the background for this study? A/Prof Meloni: Due to the lack of clinically available neuroprotective drugs to minimize brain injury after stroke we had been working in the neuroprotection field for some years within the Stroke Research Group at the WA Neuroscience Research Institute. With respect to the latest findings, we were using arginine-rich peptides for several years as delivery vehicles to introduce experimental “neuroprotective peptides” into brain cells and the brain. Peptides are small chains of amino acids and the building blocks of protein.  Arginine is one of the twenty amino acids naturally produced in the body.  Arginine-rich peptides have an unique property in that they can transverse cell membranes and gain entry into cells, and even cross the blood brain barrier, which is unusual as most drugs able unable to do so. Using in vitro neuronal cell culture stroke models we soon discovered that poly-arginine and arginine-rich peptides on their own possessed potent neuroprotective properties.  Furthermore, we showed that as the length of the poly-arginine peptide increased so did the peptides neuroprotective properties.  Excitingly, the poly-arginine peptides were even more potent than the ”neuroprotective peptides” we had been working with and peptides developed by other overseas researchers. We have now confirmed using a laboratory animal stroke model that poly-arginine peptides could reduce brain damage when administered up to 1-hour after the stroke.
AHA Journals, Author Interviews, Stroke, UCLA / 15.02.2015

Dr. May Nour MD PhD Neurology Fellow UCLA MedicalResearch.com Interview with: Dr. May Nour MD PhD Neurology Fellow UCLA Medical Research: What is the background for this study? What are the main findings? Dr. Nour: In October of 2014, results from the MR CLEAN trial were the first to demonstrate better functional outcomes in stroke patients as a result of endovascular therapy. Among patients whose stroke was caused by clot blocking a large vessel responsible for delivering blood to the vital tissue of the brain, the use of endovascular therapy, primarily utilizing second-generation clot retrieval devices, showed improved outcomes in most cases evaluated in combination with medical therapy, when compared to medical therapy alone. Currently, the standard of care involves delivery of intravenous tissue plasminogen activator (IV tPA) within a short time window (up to 3-4.5 hrs) with the intention of dissolving, rather than physically removing the clot as in the case of endovascular retrieval.
Author Interviews, NEJM, Stroke / 12.02.2015

MedicalResearch.com Interview with: Dr Bruce Campbell MBBS(Hons), BMedSc, PhD, FRACP Consultant Neurologist, Head of Hyperacute Stroke Department of Neurology     Royal Melbourne Hospital NHMRC Early Career Research Fellow Melbourne Brain Centre @ RMH Department of Medicine University of Melbourne Australia MedicalResearch: What is the background for this study? What are the main findings? Dr. Campbell: EXTEND-IA was a randomised trial comparing standard thrombolysis with tPA plus endovascular stent-thrombectomy versus tPA alone in ischemic stroke patients selected for the presence of major vessel occlusion and salvageable brain tissue using CT perfusion imaging. It was designed in 2011 at a time when there was uncertainty about the effectiveness of endovascular therapy which deepened in 2013 with the publication of 3 neutral trials. The recent publication of the Dutch MR-CLEAN study showing improved outcomes with stent-thrombectomy was a major advance and prompted a data safety and monitoring committee review of the EXTEND-IA data leading to early termination of the trial for efficacy.
The key findings from EXTEND-IA were that the addition of stent-thrombectomy to tPA led to a dramatic increase in restoration of blood flow to the brain from 34% to 89%. This translated to markedly improved outcomes at 3 months with 71% of stent-thrombectomy patients compared with 40% of tPA-only patients regaining independence. The 3 trials released today were remarkably consistent in their outcomes and this provides a solid evidence base to recommend stent-thrombectomy as the new standard of care for patients with large vessel ischemic stroke.
Patients who were treated with stent-thrombectomy in EXTEND-IA had more than double the rate of reperfusion (restoration of blood flow to the brain) compared to the standard tPA patients and this translated to a 31% absolute increase in the proportion of patients living independently at 3 months.
Author Interviews, Heart Disease, JACC, Obstructive Sleep Apnea, Stroke / 01.02.2015

Dmitry Yaranov, MD Danbury Hospital Western Connecticut Health NetworkMedicalResearch.com Interview with: Dmitry Yaranov, MD Danbury Hospital Western Connecticut Health Network Medical Research: What is the background for this study? What are the main findings? Dr. Yaranov: Obstructive sleep apnea (OSA) is an independent risk factor for ischemic stroke (CVA) that is not included in the usual cardioembolic risk assessments for patients with atrial fibrillation. The aim of this study was to investigate the impact of OSA on CVA rate in patients with atrial fibrillation. We found that Obstructive sleep apnea in patients with atrial fibrillation is an independent predictor of CVA and this association may have important clinical implications in CVA risk stratification.
Author Interviews, Lancet, Stroke / 20.01.2015

MedicalResearch.com Interview with: Prof. dr. Diederik van de Beek Department of Neurology, Academic Medical Center, University of Amsterdam The Netherlands MedicalResearch.com: What is the background for this study? What are the main findings? Dr. van de Beek: In adults with acute stroke, infections occur commonly and are associated with an unfavourable functional outcome. In the Preventive Antibiotics in Stroke Study (PASS) we aimed to establish whether or not preventive antimicrobial therapy with a third-generation cephalosporin, ceftriaxone, improves functional outcome in patients with acute stroke. PASS is an investigator-initiated, randomised, open-label, masked-endpoint trial that was undertaken between 2010 and 2014 in 30 Dutch centres and enrolled 2550 patients with ischaemic or haemorrhagic stroke. Randomly assigned in a 1:1 ratio to either preventive antibiotic therapy or a control group, all patients received standard stroke unit care. Starting within 24 h after stroke onset, patients in the preventive antibiotic group were given additional treatment with ceftriaxone administered intravenously at a dose of 2 g every 24 h for 4 days. The main findings were that preventive ceftriaxone did not improve 3-month functional outcome on the modified Rankin Scale (adjusted common odds ratio 0·95 [95% CI 0·82–1·09]); however, clinically diagnosed post-stroke infections were significantly reduced (adjusted odds ratio 0·55 [0·44–0·70]). Preventive antibiotic therapy with ceftriaxone is a safe treatment.
AHA Journals, Author Interviews, Heart Disease, Stroke / 17.01.2015

Jonathan Thigpen, PharmD Assistant Professor Clinical and Administrative Sciences Notre Dame of Maryland University School of PharmacyMedicalResearch.com Interview with: Jonathan Thigpen, PharmD Assistant Professor Clinical and Administrative Sciences Notre Dame of Maryland University School of Pharmacy Medical Research: What is the background for this study? What are the main findings? Dr. Thigpen: This effort assessed the accuracy of International Classification of Disease 9th Edition (ICD-9) stroke codes in identifying valid stroke events in a cohort of atrial fibrillation (AF) patients. The initial electronic search yielded 1,812 events across three stroke centers (Boston Medical Center, Geisinger Health System, and University of Alabama). All ICD-9 identified stroke events were vetted through manual chart review with final adjudication by a stroke neurologist. Atrial fibrillation was verified by evidence via electrocardiogram at stroke admission, 6 months prior to, or 90 days after stroke admission. In addition to assessing the accuracy of the stroke codes alone, we also assessed the accuracy of stroke and Atrial fibrillation codes combined as well as the accuracy of stroke codes when seeking for stroke associated with Atrial fibrillation. These additional steps give readers insight as to the accuracy and reliability of using ICD-9 codes alone to create a stroke plus AF cohort. We feel that this effort is extremely important given the increasing reliance on ICD-9 codes as a means of identifying stroke events and covariates in research, especially research using administrative data. The positive predictive value (PPV) of stroke codes alone was 94.2%. PPVs did not differ across clinical site or by type of event (ischemic vs. intracranial hemorrhage). PPV of stroke codes did differ by event coding position (primary vs. other; 97.2% vs. 83.7%) and by ischemic stroke code (433 vs. 434; 85.2% vs. 94.4%). When combined with validation of Atrial fibrillation codes, the PPV of stroke codes decreased to 82.2%. After excluding ischemic stroke due to a different mechanism (eg, vascular procedure, tumor, sepsis) the PPV dropped further to 72.8%. As a separate exercise, manual review confirmed 33 (7.2%) ischemic strokes in 458 events coded as "without infarction".
Author Interviews, Erasmus, NEJM, Stroke / 02.01.2015

Diederik Dippel MD, PhD Senior Consultant in Neurology Erasmus MC University Medical Center  Rotterdam The NetherlandsMedicalResearch.com Interview with: Diederik Dippel MD, PhD Senior Consultant in Neurology Erasmus MC University Medical Center Rotterdam The Netherlands Medical Research: What is the background for this study? What are the main findings? Dr. Dippel: MR CLEAN is the first randomized clinical trial to show that intra-arterial treatment of ischemic stroke to get the clot out, really works. It leads to more recovery and less handicap. Previous studies had shown that intra-arterial treatment leads to recanalization, but the final proof that the treatment leads to recovery more often than standard treatment was lacking. With standard treatment, less than 1 out of 5 recovers without handicap, but with this new treatment, this will be 1 out of 3. The treatment did not lead to more complications than standard treatment. The rate of symptomatic intracranial hemorrhage was similar in both arms. Our study differs from previous, neutral trials.
  • First, we required patients to have an intracranial arterial occlusion confirmed by neuro-imaging.
  • Second, we used third generation thrombectomy devices, such as retrievable stents in most of the cases.
  • Third, our trial was conducted in a country with a very good infrastructure, which allowed rapid transfer to intervention centers, which are spread throughout the country. Our rate of iv tPA in Dutch hospitals is over 11% on average.
  • Last, all intervention centers participated, and almost no patients were treated outside the trial. Moreover, reimbursement of the treatment was conditional on participation in the trial.
Author Interviews, Heart Disease, Stroke / 28.12.2014

MedicalResearch.com Interview with: Torben Bjerregaard Larsen Associate professor, MD, PhD, FESC Aalborg University Hospital Department of Cardiology Aalborg Thrombosis Research Unit Denmark Medical Research: What is the background for this study? What are the main findings? Dr. Larsen: Heart failure is a major public health issue with an increasing prevalence. Heart failure is associated with an increased risk of stroke, also in patients without concomitant atrial fibrillation. However, recent prospective randomized controlled trials investigating the effect of antithrombotic therapy in heart failure patients in sinus rhythm revealed that the benefit of warfarin in reducing stroke was counterbalanced by an increased risk of bleeding. Whether subgroups within the heart failure population would benefit from antithrombotic therapy is currently unknown. Therefore, possible subgroups with a higher risk of stroke within the heart failure population must be identified. We investigated whether female sex was associated with a higher risk of stroke, since female sex has been associated with an increased stroke risk among patients with atrial fibrillation. In our study, we found an association between female sex and decreased stroke risk in heart failure patients in sinus rhythm which persisted after adjustment for concomitant cardiovascular risk factors. This association was attenuated with increasing age which could possibly be due to competing risks of death, since competing risk of death was substantial among males in the older age groups.
Author Interviews, Education, Stroke / 26.12.2014

dr-gustavo-saposnikMedicalResearch.com Interview with: Gustavo Saposnik, MD, MSc., FAHA, FRCPC Director, Stroke Outcomes Research Center Co-Director, Stroke Program - Research & Innovation Associate Professor & Clinician Scientist Departments of Medicine (Neurology) and Health Policy, Management and Evaluation (HPME) St. Michael’s Hospital University of Toronto Medical Research: What is the background for this study? What are the main findings? Dr. Saposnik: There is some controversy around worse outcomes at the beginning of academic year. Physicians recently graduated from medical schools begin their training and assume responsibilities for patient care in teaching hospitals, usually bearing the first-line duty for managing patients. Consequently, less experienced staff having new roles may influence access to care and contribute to adverse outcomes in patients managed at the beginning of academic year - the so-called “July Effect”. for example, increase of medication errors and in-hospital mortality in July has been reported from teaching hospitals. In our large cohort study, comprising 10,319 stroke patients, 882 (8.5%) were admitted in July. Those patients were 28% less likely to receive thrombolysis (clot-buster treatment) (12% vs. 16%; odds ratio (OR), 0.72; 95% confidence interval (CI), 0.59-0.89) and 22% less likely to receive stroke unit care (62% vs. 68%; 0.78; 0.68-0.90). July admissions were not associated with either of higher death at 30 days (adjusted OR, 95% CI; 0.88, 0.74-1.03) or poor functional outcome (0.92, 0.74-1.14). Results remained consistent in the sensitivity analysis by including both July and August as part of the ‘July effect’.