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.
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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.
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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…)
MedicalResearch.com Interview with:
Saleh A Almenawer, MD
Neurosurgeon, Hamilton Health Sciences
McMaster University
Hamilton, ON CanadaMedical 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.
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MedicalResearch.com Interview with:
Mathew J. Reeves BVSc, PhD, FAHA
Professor, Department of Epidemiology and Biostatistics,
Michigan State University
East Lansing, MI 48824Medical 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.
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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.
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[caption id="attachment_18704" align="alignleft" width="149"] Dr. Charuhas Thakar[/caption]
MedicalResearch.com Interview with:
Charuhas V. Thakar, MD, FASN
Professor of Medicine
Director, Division of Nephrology and Hypertension
University...
MedicalResearch.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.
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MedicalResearch.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.
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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.
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MedicalResearch.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.
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MedicalResearch.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.
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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.
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MedicalResearch.com Interview with:
Dr. Bernadette Boden-Albala MPH, DrPHAssociate Dean of Program Development
NYU’s College of Global Public Health
Medical Research: What is the background for this study? What are the main findings?
Response: Stroke is a leading cause of morbidity and mortality globally and in the US. The US Food and Drug Administration has approved tissue plasminogen activator (tPA) as treatment for acute ischemic strokes within 3 hours of the onset of stroke symptoms. However, less than 25% of eligible stroke patients arrive to an emergency department (ED) in time to receive treatment with tPA. Our study, the Stroke Warning Information and Faster Treatment (SWIFT), compares the effect of an interactive intervention (II) with enhanced educational (EE) materials on recurrent stroke arrival times.
The II group included in-hospital interactive group sessions consisting of a community placed preparedness PowerPoint presentation; a stroke survivor preparedness narrative video; and the use of role-playing techniques to describe stroke symptoms. Both groups received standardized educational materials focused on being prepared to recognize and react to stroke symptoms plus a medical alert bracelet so medical professionals would recognize them as SWIFT participants.
We found that at follow-up, 42 percent of these patients arrived to the emergency room within 3 hours compared to only 28 percent at baseline, a 49 percent increase in the proportion of all patients arriving within three hours of symptom onset. Among Hispanics, there was a 63 percent increase. While there was no difference in the proportion arriving within 3 hours between intervention groups, the intensive intervention appeared to be more beneficial in those with early recurrent events within the first 30 days. (more…)
MedicalResearch.com Interview with:
Professor Phyo Kyaw Myint MBBS MD FRCP(Edin) FRCP(Lond)
Clinical Chair in Medicine of Old Age
Epidemiology Group, Division of Applied Health Sciences
University of Aberdeen
Scotland
Medical Research: What is the background for this study? What are the main findings?
Response: The research was carried out by academics from the Universities of Aberdeen, Manchester, Cambridge and East Anglia, as well as the Lancashire Teaching Hospital, the Medical Research Council Epidemiology Unit, Cambridge and the Academic Medical Centre, Amsterdam. It has been published online in the journal Heart. The team base their findings on almost 21,000 adults taking part in the EPIC-Norfolk study, which is tracking the impact of diet on the long term health of 25,000 men and women in Norfolk, England, using food frequency and lifestyle questionnaires. The researchers also carried out a systematic review of the available international published evidence on the links between chocolate and cardiovascular disease, involving almost 158,000 people—including the EPIC study participants.
The EPIC-Norfolk participants (9214 men and 11 737 women) were monitored for an average of almost 12 years, during which time 3013 (14%) people experienced either an episode of fatal or non-fatal coronary heart disease or stroke. Around one in five (20%) participants said they did not eat any chocolate, but among the others, daily consumption averaged 7 g, with some eating up to 100 g.
Higher levels of consumption were associated with younger age and lower weight (BMI), waist: hip ratio, systolic blood pressure, inflammatory proteins, diabetes and more regular physical activity —all of which add up to a favourable cardiovascular disease risk profile. Eating more chocolate was also associated with higher energy intake and a diet containing more fat and carbs and less protein and alcohol.
The calculations showed that compared with those who ate no chocolate higher intake was linked to an 11% lower risk of cardiovascular disease and a 25% lower risk of associated death. It was also associated with a 9% lower risk of hospital admission or death as a result of coronary heart disease, after taking account of dietary factors. And among the 16,000 people whose inflammatory protein (CRP) level had been measured, those eating the most chocolate seemed to have an 18% lower risk than those who ate the least. The highest chocolate intake was similarly associated with a 23% lower risk of stroke, even after taking account of other potential risk factors.
Of nine relevant studies included in the systematic review, five studies each assessed coronary heart disease and stroke outcome, and they found a significantly lower risk of both conditions associated with regular chocolate consumption. And it was linked to a 25% lower risk of any episode of cardiovascular disease and a 45% lower risk of associated death.
The study concluded that cumulative evidence suggests higher chocolate intake is associated with a lower risk of future cardiovascular events.
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MedicalResearch.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.
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MedicalResearch.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. (more…)
MedicalResearch.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.
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MedicalResearch.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.
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MedicalResearch.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.
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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.
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MedicalResearch.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.
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MedicalResearch.com Interview with:
Michael D Hill, MD MSc FRCPC
Calgary Stroke Program
Professor, Dept Clinical Neurosciences
Hotchkiss Brain Institute
University of Calgary, Cumming School of Medicine
Foothills Hospital, Calgary, Canada
Medical Research: What is the background for this study? What are the main findings?Dr. Hill: Major ischemic stroke with blocked proximal arteries results in 60-80% death and disability. Recent studies of endovascular treatment were neutral. Evolution of technology has resulted in advances in the devices. Key features of past trials of endovascular therapy were, underdeveloped imaging paradigms for patient selection, slow treatment times and poor reperfusion rates.
Medical Research: What should clinicians and patients take away from your report?Dr. Hill: Simply, endovascular therapy for major ischemic stroke over and above best medical care (ie. IV tPA) is effective . It reduces disability and saves lives. The NNT is very low 4, making it one of the largest proven effect sizes in all of medicine. BUT, it applies only under selected conditions.
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MedicalResearch.com Interview with:
Daniel G. Hackam, MD, PhD, FRCPC
Division of Clinical Pharmacology, Department of Medicine
Western University, London, Ontario, Canada.
MedicalResearch: What is...
MedicalResearch.com Interview with:
Dr. May Nour MD PhD
Neurology Fellow
UCLAMedical 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.
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MedicalResearch.com Interview with:
Michael D Hill, MD MSc FRCPC
Calgary Stroke Program
Professor, Dept Clinical Neurosciences
Hotchkiss Brain Institute
University of Calgary, Cumming School of Medicine
Calgary, Canada
Medical Research: What is the background for this study? What are the main findings?
Dr. Hill: ESCAPE examine endovascular therapy for major acute ischemic stroke.
The study found that among acute stroke patients with proximal occlusions (blocked ICA or MCA), good collaterals and fast endovascular treatment, there was a substantial reduction in morbidity (24% absolute reduction) and in mortality (a 9% absolute and 50% relative reduction in death).
Medical Research: What should clinicians and patients take away from your report?Dr. Hill: The finding are a major and compelling validation of endovascular treatment of major ischemic stroke. In combination with results from other studies - MRCLEAN, SWIFT-prime, EXTEND-IA, we believe that the standard of care for major acute ischemic stroke has been definitively changed.
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MedicalResearch.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. (more…)
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. (more…)
MedicalResearch.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".
(more…)
MedicalResearch.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.
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. (more…)
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