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Barone V, Foschi M, Pavolucci L, Rondelli F, Rinaldi R, Nicodemo M, D’Angelo R, Favaretto E, Brusi C, Cosmi B, Degli Esposti D, D’Addato S, Bacchelli S, Giostra F, Pomata DP, Spinardi L, Faccioli L, Faggioli G, Donti A, Borghi C, Cortelli P, Guarino M. Enhancing stroke risk prediction in patients with transient ischemic attack: insights from a prospective cohort study implementing fast-track care. Front Neurol 2024; 15:1407598. [PMID: 38859972 PMCID: PMC11163114 DOI: 10.3389/fneur.2024.1407598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024] Open
Abstract
Background and aims Fast-track care have been proved to reduce the short-term risk of stroke after transient ischemic attack (TIA). We aimed to investigate stroke risk and to characterize short- and long-term stroke predictors in a large cohort of TIA patients undergoing fast-track management. Methods Prospective study, enrolling consecutive TIA patients admitted to a Northern Italy emergency department from August 2010 to December 2017. All patients underwent fast-track care within 24 h of admission. The primary outcome was defined as the first stroke recurrence at 90 days, 12 and 60 months after TIA. Stroke incidence with 95% confidence interval (CI) at each timepoint was calculated using Poisson regression. Predictors of stroke recurrence were evaluated with Cox regression analysis. The number needed to treat (NNT) of fast-track care in preventing 90-day stroke recurrence in respect to the estimates based on baseline ABCD2 score was also calculated. Results We enrolled 1,035 patients (54.2% males). Stroke incidence was low throughout the follow-up with rates of 2.2% [95% CI 1.4-3.3%] at 90 days, 2.9% [95% CI 1.9-4.2%] at 12 months and 7.1% [95% CI 5.4-9.0%] at 60 months. Multiple TIA, speech disturbances and presence of ischemic lesion at neuroimaging predicted stroke recurrence at each timepoint. Male sex and increasing age predicted 90-day and 60-month stroke risk, respectively. Hypertension was associated with higher 12-month and 60-month stroke risk. No specific TIA etiology predicted higher stroke risk throughout the follow-up. The NNT for fast-track care in preventing 90-day stroke was 14.5 [95% CI 11.3-20.4] in the overall cohort and 6.8 [95% CI 4.6-13.5] in patients with baseline ABCD2 of 6 to 7. Conclusion Our findings support the effectiveness of fast-track care in preventing both short- and long-term stroke recurrence after TIA. Particular effort should be made to identify and monitor patients with baseline predictors of higher stroke risk, which may vary according to follow-up duration.
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Affiliation(s)
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
- Department of Neuroscience, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Lucia Pavolucci
- Department of Neuroscience, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | | | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | | | | | - Elisabetta Favaretto
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carlotta Brusi
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniela Degli Esposti
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sergio D’Addato
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Bacchelli
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabrizio Giostra
- Emergency Department, Medicina d’Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniela Paola Pomata
- Emergency Department, Medicina d’Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, DIMEC – University of Bologna, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Donti
- Pediatric Cardiology and Adult Congenital Heart Disease Program, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudio Borghi
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
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Zhang J, Li J, Ding Y. Diagnostic value of cervical vascular ultrasound in large arterial lesions of the neck in patients with transient ischemic attack. Int J Neurosci 2024:1-7. [PMID: 38708961 DOI: 10.1080/00207454.2024.2352041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/30/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE To assess the diagnostic value of cervical vascular ultrasound in identifying large arterial lesions in patients with transient ischemic attack (TIA). METHODS The current study matched 84 TIA patients (disease group) with 66 healthy controls (control group). The baseline patient profiles and biochemical indices of the patients were analyzed. All patients received color Doppler ultrasonography, and outcome measures of its diagnostic efficiency included plaque status, plaque properties, and the degree of carotid stenosis. The patients in the disease group were assigned to group A (TIA of the internal carotid artery system, n = 40) and group B (TIA of the vertebrobasilar artery system, n = 44), and the plaque distribution of the patients was analyzed. RESULTS TIA patients had higher rates of diabetes, hypertension, hyperlipidemia, obesity, and smoking compared to controls (p < 0.05). Their serum TC, LDL-C, and FBG levels were significantly elevated, while HDL-C levels were decreased (p < 0.05). TIA patients had more plaques, especially soft plaques, than controls (p < 0.05). They also showed higher rates of moderate to severe carotid stenosis (p < 0.05). TIA involving the internal carotid artery system was associated with a higher risk of plaques at the entrance of the subclavian artery compared to TIA involving the vertebrobasilar artery system (p < 0.05). CONCLUSION The diagnostic value of cervical vascular ultrasound in patients with TIA is remarkable, and it provides a reliable monitoring approach as well as an essential screening modality for TIA. The rational use of this technique will markedly benefit the diagnosis, treatment, and prevention of TIA.
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Affiliation(s)
- Jianjun Zhang
- Functional Section Department, The Third People's Hospital of Hefei, Hefei, China
| | - Jiaju Li
- Functional Section Department, The Third People's Hospital of Hefei, Hefei, China
| | - Ying Ding
- Functional Section Department, The Third People's Hospital of Hefei, Hefei, China
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Caproni S, Ottavi P, Borghetti V, Taddei G, Conti C, Riva A, Di Schino C, Costantini F, Colosimo C. Transient ischemic attack and minor stroke as "surgeons affairs": a narrative review. Neurol Sci 2023; 44:4233-4245. [PMID: 37542547 DOI: 10.1007/s10072-023-06985-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/26/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE The scope of this paper is to review the subtypes of transient ischemic attack (TIA) and minor stroke (mS) in which a surgical treatment is needed, discussing the importance and the timing of a multidisciplinary approach, in order to achieve an optimized management and prevent major strokes or other critical complications. MATERIALS AND METHODS The keywords "transient ischemic attack," "minor stroke," "surgical treatment," "vascular surgery," "heart surgery," "neurosurgery," and "multidisciplinary" were searched using MEDLINE, EMBASE, and Scopus. Relevant search results were discussed by the authors for references inclusion. RESULTS Notwithstanding that best medical therapy is usually the first choice for the most part of cases, there are specific but recurrent etiologies that must be properly recognized because of a potential surgical approach, even in urgency. In fact, symptomatic carotid stenosis, or particular cases of hemodynamic cerebrovascular events, should be promptly referred to vascular surgeon, since increasing evidences highlighted a benefit from an early artery revascularization. In addition, beyond arrhythmic causes, cardioembolic events due to bacterial endocarditis and atrial myxoma should be quickly diagnosed, possibly in emergency department, because they are a presumptive urgency for heart surgery. In addition to the above-mentioned conditions, in patients suffering from vertebrobasilar TIA or mS, clinicians should keep in mind the Bow Hunter disease, because surgical artery decompression can represent the only suitable treatment in selected cases. CONCLUSIONS TIA and mS require a multidisciplinary in order to discuss therapeutic options, comparing risks and benefits and determining the best timing for an optimized management.
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Affiliation(s)
- S Caproni
- Neurology and Stroke Unit, Neuroscience Department, "S. Maria" University Hospital, via Tristano di Joannuccio 1, 05100, Terni, Italy.
| | - P Ottavi
- Vascular Surgery, Cardio-Thoraco-Vascular Department, "S. Maria" University Hospital, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - V Borghetti
- Heart Surgery, Cardio-Thoraco-Vascular Department, "S. Maria" University Hospital, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - G Taddei
- Neurosurgery, Surgery Department, "S. Maria Goretti" Hospital, Via Lucia Scaravelli, 04100, Latina, Italy
| | - C Conti
- Neurosurgery, Neuroscience Department, "S. Maria" University Hospital, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - A Riva
- Neurology, Medicine Department, "Università Politecnica delle Marche", Via Conca 71, 60126, Ancona, Italy
| | - Chiara Di Schino
- Neurology and Stroke Unit, Neuroscience Department, "S. Maria" University Hospital, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - F Costantini
- Neurology and Stroke Unit, Neuroscience Department, "S. Maria" University Hospital, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - C Colosimo
- Neurology and Stroke Unit, Neuroscience Department, "S. Maria" University Hospital, via Tristano di Joannuccio 1, 05100, Terni, Italy
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Hamedani AG, De Lott LB, Willis AW. Nationwide trends in emergency department utilisation for acute retinal ischaemia in the USA, 2011-2018. Br J Ophthalmol 2023; 107:1490-1495. [PMID: 35760457 PMCID: PMC10196936 DOI: 10.1136/bjo-2022-321418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Guidelines recommend urgent evaluation for transient monocular vision loss (TMVL) and retinal artery occlusion (RAO), but emergency department (ED) utilisation for these conditions is unknown. METHODS We performed a retrospective longitudinal cross-sectional analysis of the Nationwide Emergency Department Sample (2011-2018), a database of all ED visits from a representative 20% sample of US hospital-based EDs. We identified patients aged 40 and older with a primary diagnosis of TMVL or RAO and calculated the weighted number of total visits and admission rate by year. We used joinpoint regression to analyse time trends and logistic regression to measure differences according to demographic characteristics and comorbidities. RESULTS There were an estimated 2451 ED visits for TMVL and 2472 for RAO annually in the USA from 2011 to 2018. Approximately 36% of TMVL and 51% of RAO patients were admitted. The admission rate decreased by an average of 4.9% per year for TMVL (95% CI -7.5% to -2.3%) and 2.2% per year for RAO (95% CI -4.1% to -0.4%), but the total number of ED visits did not change significantly over time. Elixhauser Comorbidity Index and hyperlipidaemia were associated with increased odds of hospital admission for both TMVL and RAO. There were also differences in admission rate by insurance payer and hospital region. CONCLUSION Of the estimated 48 000 patients with TMVL or RAO annually in the USA, few are evaluated in the ED, and admission rates are less than for transient ischaemic attack or ischaemic stroke and are decreasing over time.
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Affiliation(s)
- Ali G Hamedani
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA, USA
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Allison W Willis
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
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Shahjouei S, Seyedmirzaei H, Abedi V, Zand R. Transient Ischemic Attack Outpatient Clinic: Past Journey and Future Adventure. J Clin Med 2023; 12:4511. [PMID: 37445546 DOI: 10.3390/jcm12134511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
A transient ischemic attack (TIA), a constellation of temporary neurological symptoms, precedes stroke in one-fifth of patients. Thus far, many clinical models have been introduced to optimize the quality, time to treatment, and cost of acute TIA care, either in an inpatient or outpatient setting. In this article, we aim to review the characteristics and outcomes of outpatient TIA clinics across the globe. In addition, we discussed the main challenges for outpatient management of TIA, including triage and diagnosis, and the system dynamics of the clinics. We further reviewed the potential developments in TIA care, such as telemedicine, predictive analytics, personalized medicine, and advanced imaging.
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Affiliation(s)
- Shima Shahjouei
- Department of Neurology, Milton S. Hershey Medical Center, Penn State Health, Hershey, PA 17033, USA
- Department of Neurology, Neurosurgery, and Translational Medicine, Barrow Neurological Institute, St. Joseph Hospital, Phoenix, AZ 85013, USA
| | - Homa Seyedmirzaei
- School of Medicine, Children's Medical Center Hospital, Tehran University of Medical Sciences, Dr. Qarib St., Tehran 14155-34793, Iran
- Interdisciplinary Neuroscience Research Program (INRP), Tehran University of Medical Sciences, Keshavarz Blvd., Tehran 14166-34793, Iran
| | - Vida Abedi
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033, USA
| | - Ramin Zand
- Department of Neurology, College of Medicine, The Pennsylvania State University, Hershey, PA 17033, USA
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Claus JJ, Berghout BBP, Ikram MK, Wolters FJ. Validity of stroke severity assessment using medical records in a population-based cohort. J Stroke Cerebrovasc Dis 2023; 32:106992. [PMID: 36801651 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 02/20/2023] Open
Abstract
OBJECTIVES Stroke severity is an important prognostic indicator of morbidity and mortality, but often not recorded outside of specialised stroke centres. We aimed to develop a scoring rule and validate standardised assessment of the National Institutes of Health Stroke Scale (NIHSS) from medical records. METHODS We developed a standardised assessment of the NIHSS from medical records. Four trained raters independently assessed the charts of 100 patients with first-ever stroke, randomly selected from the population-based Rotterdam Study cohort. Interrater agreement was determined using the intraclass correlation coefficient (ICC), and Fleiss' kappa for major versus minor stroke. We validated the scoring method against 29 prospective, clinical NIHSS ratings, using Kendall's tau and Cohen's kappa. RESULTS Of 100 included patients with stroke (mean age 80 years, 62% women), 71 (71%) were admitted to hospital and 9 (9%) were seen in outpatient clinic, whereas 20 (20%) were treated exclusively by their general practitioner or nursing home physician. Interrater agreement for retrospective, chart-based NIHSS ratings was excellent when assessed continuously (ICC: 0.90), and for minor versus major stroke (for NIHSS>3: κ=0.79, NIHSS>5: κ=0.78). Interrater agreement was good both for hospital-based and out-of-hospital settings (ICC: 0.97 and 0.75 respectively). Overall, assessment from medical records was in excellent agreement with prospective NIHSS ratings (τ=0.83; NIHSS>3: κ=0.93, and NIHSS>5: κ=0.93). However, for severe stroke (NIHSS>10) retrospective assessment tended to underestimate severity by 1-3 points on the NIHSS, which was accompanied by a somewhat lower interrater agreement for those more severe cases (NIHSS>10: κ=0.62). CONCLUSIONS Assessment of stroke severity according to the NIHSS on the basis of medical records is feasible and reliable in population-based cohorts of patients with stroke. These findings facilitate more individualised risk estimates in observational studies that lack prospective ascertainment of stroke severity.
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Affiliation(s)
- Jacqueline J Claus
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC, Rotterdam, the Netherlands
| | - Brian B P Berghout
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC, Rotterdam, the Netherlands
| | - M Kamran Ikram
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC, Rotterdam, the Netherlands
| | - Frank J Wolters
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands.
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Blauenfeldt RA, Damgaard D, Simonsen CZ. Stressed systems: Stroke unit bed occupancy and impact on reperfusion therapy in acute ischemic stroke. Front Neurol 2023; 14:1147564. [PMID: 37064203 PMCID: PMC10100068 DOI: 10.3389/fneur.2023.1147564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/09/2023] [Indexed: 04/18/2023] Open
Abstract
Objectives We observed a decrease in the number of patients who were offered reperfusion therapy. We aimed to investigate if whether hospital system pressure measured as the percentage of stroke bed occupancy influenced decisions on treatment and disposition. Design Data from a regional quality of stroke care database were obtained and linked to the organizational data monitoring of the hourly inpatient stroke bed occupancy rate. Logistic regression was used to analyze the relationship. Results A total of 15,025 admissions were included from 1 January 2019 to 24 August 2022. Of these, 5,659 (38%) had an acute ischemic stroke. The rates of reperfusion therapy treatment were the highest in 2019 (36.2%) and 2020 (34.1%) and declined afterward (30.0% in 2021). In the logistic regression analysis, an occupancy rate of ≥85% in the hour of the first admission was associated with reduced odds of admission at the stroke unit within 3 h from the symptom onset [adjusted odds ratio: 0.80, 95% confidence interval: (0.71-0.90), p < 0.001] and a reduced odds of receiving reperfusion therapy (adjusted odds ratio: 0.83 (0.73-0.95), p = 0.007). Conclusion An increased bed occupancy level in the hour of the first hospital admission for stroke patients was strongly associated with decreased odds of receiving reperfusion therapy.
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Affiliation(s)
- Rolf A. Blauenfeldt
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- *Correspondence: Rolf A. Blauenfeldt
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Heidinger M, Lang W, Boehme C, Knoflach M, Kiechl S, Willeit P, Kleyhons R, Tuerk S. Reconstruction of pseudonymized patient-trajectories in Austria's stroke cohort using medical record-linkage of in-patient routine documentation to establish a nation-wide acute stroke cohort of 102,107 pseudonymized patients between 2015 and 2019. Eur Stroke J 2022; 7:456-466. [PMID: 36478759 PMCID: PMC9720851 DOI: 10.1177/23969873221107619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/26/2022] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Administrative health data are increasingly used for disease surveillance, quality assurance and research purposes. In Austria, reporting of a standardized dataset is mandatory for each patient. PATIENTS AND METHODS Routine documentation includes administrative and medical data, including admission and discharge characteristics, disease-diagnosis using ICD-10, medical procedure codes, and coding of involved hospital departments. Since 2015, a three-step pseudonymization on these data is provided including a pseudonym using secure hash algorithm 256, a non-recalculable record-ID, and age-groups of 5 years, allowing the reconstruction of individual patient-trajectories. We included persons aged ⩾20 years with an in-patient treatment in Austrian hospitals for acute stroke or transient ischemic attack (TIA) between 01.01.2015 and 31.12.2019 using medical record-linkage. RESULTS This totals 102,107 patients (49.3% women) with 107,055 treatment episodes. An ischemic stroke (IS) occurred in 60.9% (n = 65,133), 27.1% (n = 29,019) had a TIA, 3.3% (n = 3488) a subarachnoid hemorrhage, and 8.8% (n = 9415) an intracerebral hemorrhage (ICH). The study period covers 35.2 million person-years at risk, with a hospitalization rate for acute stroke of 221.8 per 100,000 person-years (95% CI 220.2-223.3), and 185.1 per 100,000 person-years (95% CI 183.7-186.5) for IS. Unscheduled re-admissions within 1 year occurred in 29.2% (95% CI 28.8-29.7) after IS, and 41.7% (95% CI 40.0-43.3) after ICH. Recurrent stroke occurred in 5.3% (95% CI 5.1-5.5) after IS, and 5.6% (95% CI 4.9-6.4) after ICH. DISCUSSION We present herein the details of a novel methodology to establish a nation-wide unselected Austrian stroke cohort, and to reconstruct pseudonymized individual longitudinal patient-trajectories on a national level. This approach shows potential applications in epidemiological research, quality assessment and outcome measurement. CONCLUSION This novel approach opens new research fields, facilitates international comparison, and is needed for national benchmarking to assess the achievement of goals according to the Stroke Action Plan for Europe and augment the quality of Austria's integrated stroke care.
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Affiliation(s)
- Martin Heidinger
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, St. John’s of
God Hospital, Vienna, Austria
- Austrian Stroke Society, Vienna,
Austria
| | - Christian Boehme
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Austrian Stroke Society, Vienna,
Austria
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- VASCage – Research Centre on Vascular
Ageing and Stroke, Innsbruck, Austria
| | - Stefan Kiechl
- Austrian Stroke Society, Vienna,
Austria
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- VASCage – Research Centre on Vascular
Ageing and Stroke, Innsbruck, Austria
| | - Peter Willeit
- Austrian Stroke Society, Vienna,
Austria
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- Department of Public Health and Primary
Care, University of Cambridge, Cambridge, UK
| | - Rainer Kleyhons
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
| | - Silvia Tuerk
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
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Heidinger M, Boehme C, Knoflach M, Lang W, Kiechl S, Willeit P, Kleyhons R, Tuerk S. Hospitalization rates, stroke unit care, and recurrence rates in Austria's stroke cohort Epidemiologic analysis of 102,107 patients in a nation-wide acute stroke cohort between 2015 and 2019. Eur Stroke J 2022; 7:467-475. [PMID: 36478757 PMCID: PMC9720856 DOI: 10.1177/23969873221108846] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/03/2022] [Indexed: 01/29/2024] Open
Abstract
INTRODUCTION Continuous analysis of key epidemiologic data is irremissible to adapt health-care systems to trends in stroke epidemiology. We present data from 2015 to 2019 on quality indicators of stroke care, including rates on hospitalization, stroke unit care and recurrence rates using medical record-linkage of in-patient routine documentation. PATIENTS AND METHODS We included stroke/TIA patients admitted to Austrian hospitals between 2015 and 2019 aged ⩾20 years using medical record-linkage. RESULTS In our cohort of 102,107 patients with 107,055 treatment episodes, we could show a significant decrease in 1-year cumulative age-adjusted hospitalization rates per 100,000 in TIA (86.3 [95% CI 84.1-88.5] vs 75.4 [95% CI 73.4-77.4], RR 0.87 [95% CI 0.85-0.90]), ischemic stroke (187.3 [95% CI 184.0-190.5] vs 173.4 [95% CI 170.4-176.5], RR 0.93 [95% CI 0.91-0.94]), and intracerebral hemorrhage (28.5 [95% CI 27.3-29.8] vs 22.8 [95% CI 21.7-23.9], RR 0.80 [95% CI 0.76-0.84]). In ischemic stroke the rate of stroke unit care increased significantly (55.7% vs 69.3%; RR 1.14 [95% CI 1.12-1.17]), and acute 1-year recurrences decreased significantly. DISCUSSION We found a decline of the annual age-adjusted cumulative hospitalization rates in stroke/TIA, a higher age of disease manifestation and less severe strokes, which is probably attributable to improved primary and secondary prevention in Austria. The proportion of patients treated at stroke units increased significantly, however a geographical and age-dependency is still evident. CONCLUSION Age-adjusted hospitalization rates of stroke/TIA patients decreased, and stroke unit care is increasing but the goal of the Stroke Action Plan for Europe is yet to be reached.
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Affiliation(s)
- Martin Heidinger
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
| | - Christian Boehme
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- VASCage – Research Centre on Vascular
Ageing and Stroke, Innsbruck, Austria
- Austrian Stroke Society, Vienna,
Austria
| | - Wilfried Lang
- Austrian Stroke Society, Vienna,
Austria
- Department of Neurology, St. John’s of
God Hospital, Vienna, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- VASCage – Research Centre on Vascular
Ageing and Stroke, Innsbruck, Austria
- Austrian Stroke Society, Vienna,
Austria
| | - Peter Willeit
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- Austrian Stroke Society, Vienna,
Austria
- Department of Public Health and Primary
Care, University of Cambridge, Cambridge, UK
| | - Rainer Kleyhons
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
| | - Silvia Tuerk
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
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Low-to-Moderate Risk Transient Ischemic Attack Patients Can Be Safely Discharged From the Emergency Department to a Nurse Practitioner-Led Clinic. J Neurosci Nurs 2022; 54:231-236. [PMID: 36179660 DOI: 10.1097/jnn.0000000000000677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT BACKGROUND: Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety. The purpose of this quality improvement project was to determine whether the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days. METHODS: The sample included all adults presenting to the emergency department with TIA at a low-to-moderate risk for stroke. Risks were defined by the ABCD2 score and noninvasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within 7 days. These patients were compared with those who were admitted before clinic launch. Medical record reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey. RESULTS: Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic and admission groups were 72.8 and 75.2 years, respectively (P = .37). Women comprised 45% of patients in the clinic group, compared with 51.2% in the admission group (P = .58). The mean ABCD2 scores were 4.08 and 3.95 in the clinic and admission groups, respectively (P = .63). The median clinic follow-up time was 6 days. There was no stroke incidence in the clinic group and 1 in the admission group within 90 days post TIA. Patient satisfaction score metrics for the NP exceeded the institutional benchmark of 90%. CONCLUSION: Referral to an NP-led clinic in patients with low- to moderate-risk TIA was equally safe as hospital admission.
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Mbonde AA, O'Carroll CB, Dulamea OA, Anghel D, Chong BW, Dumitrascu OM. Current Guidelines on Management of Amaurosis Fugax and Transient Ischemic Attacks. Asia Pac J Ophthalmol (Phila) 2022; 11:168-176. [PMID: 35213421 DOI: 10.1097/apo.0000000000000511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ABSTRACT Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without associated infarction. Consequently, a TIA encompasses amaurosis fugax (AF) that is a term used to denote momentary visual loss from transient retinal ischemia. In this review, we use the word TIA to refer to both cerebral TIAs (occurring in the brain) and AF (occurring in the retina). We summarize the key components of a comprehensive evaluation and management of patients presenting with cerebral and retinal TIA.All TIAs should be treated as medical emergencies, as they may herald permanent disabling visual loss and devastating hemispheric or vertebrobasilar ischemic stroke. Patients with suspected TIA should be expeditiously evaluated in the same manner as those with an acute stroke. This should include a detailed history and examination followed by specific diagnostic studies. Imaging of the brain and extracranial and intracranial blood vessels forms the cornerstone of diagnostic workup of TIA. Cardiac investigations and serum studies to evaluate for etiological risk factors are also recommended.The management of all TIAs, whether cerebral or retinal, is similar and should focus on stroke prevention strategies, which we have categorized into general and specific measures. General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes. Specific management measures require the identification of a specific TIA etiology, such as moderate-severe (greater than 50% of stenosis) symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation.
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Affiliation(s)
- Amir A Mbonde
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Cumara B O'Carroll
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Octaviana A Dulamea
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Daniela Anghel
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Brian W Chong
- Department of Neuroradiology, Mayo Clinic College of Medicine and Science, Phoenix, AZ, US
| | - Oana M Dumitrascu
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
- Department of Ophthalmology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
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12
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Ranta A, Hunter R. Should TIA and Minor Stroke Patients Be Kept Out of the Hospital? Neurology 2021; 96:353-354. [PMID: 33472918 DOI: 10.1212/wnl.0000000000011456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/22/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Annemarei Ranta
- From the Department of Neurology (A.R.), Wellington Regional Hospital; Department of Medicine (A.R.), University of Otago, Wellington, New Zealand; and Research Department of Primary Care and Population Health (R.H.), University College London, UK.
| | - Rachael Hunter
- From the Department of Neurology (A.R.), Wellington Regional Hospital; Department of Medicine (A.R.), University of Otago, Wellington, New Zealand; and Research Department of Primary Care and Population Health (R.H.), University College London, UK
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