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Byun E, McCurry SM, Kwon S, Tsai CS, Jun J, Bammler TK, Becker KJ, Thompson HJ. Fatigue, Toll-Like Receptor 4, and Pro-Inflammatory Cytokines in Adults With Subarachnoid Hemorrhage: A 6-Month Longitudinal Study. Biol Res Nurs 2024; 26:192-201. [PMID: 37788710 DOI: 10.1177/10998004231203257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND Fatigue is prevalent in subarachnoid hemorrhage (SAH) survivors. Biological mechanisms underlying fatigue post-SAH are not clear. Inflammation may contribute to the development of fatigue. This study aimed to examine the associations between inflammatory markers and fatigue during the first 6 months post-SAH. Specific biomarkers examined included both early and concurrent expression of Toll-Like Receptor 4 (TLR4) messenger RNA (mRNA) and plasma concentrations of pro-inflammatory cytokines, Tumor Necrosis Factor-alpha (TNF-α), Interleukin (IL)1β, and IL6. METHODS We conducted a 6-month longitudinal study with a convenience sample of 43 SAH survivors. We collected blood samples on days 2, 3, and 7 and 2, 3, and 6 months post-SAH to assess biomarkers. Fatigue was assessed by the PROMIS Fatigue Scale at 2, 3, and 6 months. Linear mixed models were used to test the associations between early (days 2, 3, and 7) and concurrent (2, 3, and 6 months) TLR4 mRNA expression (TagMan gene expression assays) and TNF-α, IL1β, and IL6 plasma concentrations (multiplex assays) and concurrent fatigue. RESULTS 28% of SAH survivors experienced fatigue during the first 6 months post-SAH. Fatigue levels in SAH survivors were higher than those of the U.S. population and consistent during the 6 months. Experience of fatigue during the 6 months post-SAH was associated with higher IL1β plasma concentrations on day 7 and IL1β, IL6, and TNF-α plasma concentrations during the 6 months post-SAH. CONCLUSION Inflammation appears to underlie the development of fatigue in SAH survivors.
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Affiliation(s)
- Eeeseung Byun
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Susan M McCurry
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Suyoung Kwon
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Chi-Shan Tsai
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Jeehye Jun
- Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea
| | - Theo K Bammler
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
| | - Kyra J Becker
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Hilaire J Thompson
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
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2
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Chang VA, Tirschwell DL, Becker KJ, Schubert GB, Longstreth WT, Creutzfeldt CJ. Associations Between Measures of Disability and Quality of Life at Three Months After Stroke. J Palliat Med 2024; 27:18-23. [PMID: 37585623 DOI: 10.1089/jpm.2023.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
Background: The modified Rankin Scale (mRS), which measures degree of disability in daily activities, is the most common outcome measure in stroke research. Quality of life (QoL), however, is impacted by factors other than disability. The goal of this study was to assess the correlation between functional dependence and a more patient-centered QoL measure, the European QoL visual analog scale (EQ VAS). Methods: We reviewed prehospital and hospital records from 11 acute care hospitals in Seattle, Washington (USA) from June 2000 to January 2003 for this cohort study. Patients with a final diagnosis of stroke were contacted three to four months after stroke, and mRS and EQ VAS were assessed. Good QoL was defined as EQ VAS ≥65. Results: Of 760 patients with stroke, 346 were available at three to four months. Most (296, 85.5%) had ischemic stroke. Overall, mRS and QoL were negatively correlated (Spearman's ρ -0.53, p < 0.001). Percentage of good QoL decreased as mRS increased from 0 to 5 (88%, 70%, 52%, 50%, 31%, 20%, respectively, p < 0.001). However, 36% (n = 62) of patients with dependent mRS (3-5, n = 174) reported good QoL, and 30% (n = 52) of patients with independent mRS (0-2, n = 172) reported poor QoL. In multivariable analysis, older age, male gender, and absence of dementia, were associated with good QoL despite dependent mRS; atrial fibrillation was associated with poor QoL despite independent mRS. Conclusions: QoL decreases with increasing mRS, but exceptions exist with good QoL despite high mRS. To provide patient-centered care, clinicians and researchers should avoid equating disability with QoL after stroke.
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Affiliation(s)
- Victoria A Chang
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - David L Tirschwell
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Kyra J Becker
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Glenn B Schubert
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Will T Longstreth
- Department of Neurology, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington, Seattle, Washington, USA
- UW Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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3
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Harding BN, Avoundjian T, Heckbert SR, Whitney BM, Nance RM, Ruderman SA, Kalani R, Tirschwell DL, Ho EL, Becker KJ, Zunt J, Chow F, Huffer A, Mathews WC, Eron J, Moore RD, Marra CM, Burkholder G, Saag MS, Kitahata MM, Crane HM, Delaney JC. HIV Viremia and Risk of Stroke Among People Living with HIV Who Are Using Antiretroviral Therapy. Epidemiology 2021; 32:457-464. [PMID: 33591056 PMCID: PMC8012252 DOI: 10.1097/ede.0000000000001331] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rates of stroke are higher in people living with HIV compared with age-matched uninfected individuals. Causes of elevated stroke risk, including the role of viremia, are poorly defined. METHODS Between 1 January 2006 and 31 December 2014, we identified incident strokes among people living with HIV on antiretroviral therapy at five sites across the United States. We considered three parameterizations of viral load (VL) including (1) baseline (most recent VL before study entry), (2) time-updated, and (3) cumulative VL (copy-days/mL of virus). We used Cox proportional hazards models to estimate hazard ratios (HRs) for stroke risk comparing the 75th percentile ("high VL") to the 25th percentile ("low VL") of baseline and time-updated VL. We used marginal structural Cox models, with most models adjusted for traditional stroke risk factors, to estimate HRs for stroke associated with cumulative VL. RESULTS Among 15,974 people living with HIV, 139 experienced a stroke (113 ischemic; 18 hemorrhagic; eight were unknown type) over a median follow-up of 4.2 years. Median baseline VL was 38 copies/mL (interquartile interval: 24, 3,420). High baseline VL was associated with increased risk of both ischemic (HR: 1.3; 95% CI = 0.96-1.7) and hemorrhagic stroke (HR: 3.1; 95% CI = 1.6-5.9). In time-updated models, high VL was also associated with an increased risk of any stroke (HR: 1.8; 95% CI = 1.4-2.3). We observed no association between cumulative VL and stroke risk. CONCLUSIONS Our findings are consistent with the hypothesis that elevated HIV VL may increase stroke risk, regardless of previous VL levels.
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Affiliation(s)
| | | | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Robin M Nance
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Rizwan Kalani
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Emily L Ho
- Department of Medicine, University of Washington, Seattle, WA
| | - Kyra J Becker
- Department of Medicine, University of Washington, Seattle, WA
| | - Joseph Zunt
- Department of Medicine, University of Washington, Seattle, WA
| | - Felicia Chow
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Andrew Huffer
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Joseph Eron
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | | | | | - Greer Burkholder
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Michael S Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, WA
| | - Heidi M Crane
- Department of Medicine, University of Washington, Seattle, WA
| | - Joseph C Delaney
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
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4
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Crane HM, Nance RM, Avoundjian T, Harding BN, Whitney BM, Chow FC, Becker KJ, Marra CM, Zunt JR, Ho EL, Kalani R, Huffer A, Burkholder GA, Willig AL, Moore RD, Mathews WC, Eron JJ, Napravnik S, Lober WB, Barnes GS, McReynolds J, Feinstein MJ, Heckbert SR, Saag MS, Kitahata MM, Delaney JA, Tirschwell DL. Types of Stroke Among People Living With HIV in the United States. J Acquir Immune Defic Syndr 2021; 86:568-578. [PMID: 33661824 PMCID: PMC9680532 DOI: 10.1097/qai.0000000000002598] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Most studies of stroke in people living with HIV (PLWH) do not use verified stroke diagnoses, are small, and/or do not differentiate stroke types and subtypes. SETTING CNICS, a U.S. multisite clinical cohort of PLWH in care. METHODS We implemented a centralized adjudication stroke protocol to identify stroke type, subtype, and precipitating conditions identified as direct causes including infection and illicit drug use in a large diverse HIV cohort. RESULTS Among 26,514 PLWH, there were 401 strokes, 75% of which were ischemic. Precipitating factors such as sepsis or same-day cocaine use were identified in 40% of ischemic strokes. Those with precipitating factors were younger, had more severe HIV disease, and fewer traditional stroke risk factors such as diabetes and hypertension. Ischemic stroke subtypes included cardioembolic (20%), large vessel atherosclerosis (13%), and small vessel (24%) ischemic strokes. Individuals with small vessel strokes were older, were more likely to have a higher current CD4 cell count than those with cardioembolic strokes and had the highest mean blood pressure of the ischemic stroke subtypes. CONCLUSION Ischemic stroke, particularly small vessel and cardioembolic subtypes, were the most common strokes among PLWH. Traditional and HIV-related risk factors differed by stroke type/subtype. Precipitating factors including infections and drug use were common. These results suggest that there may be different biological phenomena occurring among PLWH and that understanding HIV-related and traditional risk factors and in particular precipitating factors for each type/subtype may be key to understanding, and therefore preventing, strokes among PLWH.
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Affiliation(s)
| | | | | | | | | | | | | | - Christina M. Marra
- Neurology, University of Washington, Seattle, USA
- Medicine, University of Washington, Seattle, USA
| | - Joseph R. Zunt
- Neurology, University of Washington, Seattle, USA
- Medicine, University of Washington, Seattle, USA
- Epidemiology, University of Washington, Seattle, USA
| | - Emily L. Ho
- Neurology, University of Washington, Seattle, USA
- Swedish Neuroscience Institute, Seattle, USA
| | | | | | | | | | | | | | | | | | - William B. Lober
- Clinical Informatics Research Group, University of Washington, Seattle, USA
| | - Greg S. Barnes
- Clinical Informatics Research Group, University of Washington, Seattle, USA
| | - Justin McReynolds
- Clinical Informatics Research Group, University of Washington, Seattle, USA
| | | | | | | | | | - Joseph A.C. Delaney
- Epidemiology, University of Washington, Seattle, USA
- University of Manitoba, Manitoba, Canada
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5
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DellaGiustina DN, Burke KN, Walsh KJ, Smith PH, Golish DR, Bierhaus EB, Ballouz RL, Becker TL, Campins H, Tatsumi E, Yumoto K, Sugita S, Deshapriya JDP, Cloutis EA, Clark BE, Hendrix AR, Sen A, Al Asad MM, Daly MG, Applin DM, Avdellidou C, Barucci MA, Becker KJ, Bennett CA, Bottke WF, Brodbeck JI, Connolly HC, Delbo M, de Leon J, Drouet d'Aubigny CY, Edmundson KL, Fornasier S, Hamilton VE, Hasselmann PH, Hergenrother CW, Howell ES, Jawin ER, Kaplan HH, Le Corre L, Lim LF, Li JY, Michel P, Molaro JL, Nolan MC, Nolau J, Pajola M, Parkinson A, Popescu M, Porter NA, Rizk B, Rizos JL, Ryan AJ, Rozitis B, Shultz NK, Simon AA, Trang D, Van Auken RB, Wolner CWV, Lauretta DS. Variations in color and reflectance on the surface of asteroid (101955) Bennu. Science 2020; 370:science.abc3660. [PMID: 33033157 DOI: 10.1126/science.abc3660] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/24/2020] [Indexed: 11/02/2022]
Abstract
Visible-wavelength color and reflectance provide information about the geologic history of planetary surfaces. Here we present multispectral images (0.44 to 0.89 micrometers) of near-Earth asteroid (101955) Bennu. The surface has variable colors overlain on a moderately blue global terrain. Two primary boulder types are distinguishable by their reflectance and texture. Space weathering of Bennu surface materials does not simply progress from red to blue (or vice versa). Instead, freshly exposed, redder surfaces initially brighten in the near-ultraviolet region (i.e., become bluer at shorter wavelengths), then brighten in the visible to near-infrared region, leading to Bennu's moderately blue average color. Craters indicate that the time scale of these color changes is ~105 years. We attribute the reflectance and color variation to a combination of primordial heterogeneity and varying exposure ages.
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Affiliation(s)
- D N DellaGiustina
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA. .,Department of Geosciences, University of Arizona, Tucson, AZ, USA
| | - K N Burke
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - K J Walsh
- Southwest Research Institute, Boulder, CO, USA
| | - P H Smith
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - D R Golish
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | | | - R-L Ballouz
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - T L Becker
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - H Campins
- Department of Physics, University of Central Florida, Orlando, FL, USA
| | - E Tatsumi
- Instituto de Astrofísica de Canarias and Departamento de Astrofísica, Universidad de La Laguna, Tenerife, Spain.,Department of Earth and Planetary Science, University of Tokyo, Tokyo, 113-0033, Japan
| | - K Yumoto
- Department of Earth and Planetary Science, University of Tokyo, Tokyo, 113-0033, Japan
| | - S Sugita
- Department of Earth and Planetary Science, University of Tokyo, Tokyo, 113-0033, Japan
| | - J D Prasanna Deshapriya
- LESIA (Laboratoire d'Etudes Spatiales et d'Instrumentation en Astrophysique), Observatoire de Paris, Université PSL (Paris Sciences & Lettres), CNRS (Centre National de la Recherche Scientifique), Université de Paris, Sorbonne Université, 92195 Meudon, France
| | - E A Cloutis
- Department of Geography, University of Winnipeg, Winnipeg, MB R3B 2E9, Canada
| | - B E Clark
- Department of Physics and Astronomy, Ithaca College, Ithaca, NY, USA
| | - A R Hendrix
- Planetary Science Institute, Tucson, AZ, USA
| | - A Sen
- Department of Physics and Astronomy, Ithaca College, Ithaca, NY, USA
| | - M M Al Asad
- Department of Earth, Ocean and Atmospheric Sciences, University of British Columbia, Vancouver, BC, Canada
| | - M G Daly
- The Centre for Research in Earth and Space Science, York University, Toronto, ON, Canada
| | - D M Applin
- Department of Geography, University of Winnipeg, Winnipeg, MB R3B 2E9, Canada
| | - C Avdellidou
- Université Côte d'Azur, Observatoire de la Côte d'Azur, CNRS, Laboratoire Lagrange, Nice, France
| | - M A Barucci
- LESIA (Laboratoire d'Etudes Spatiales et d'Instrumentation en Astrophysique), Observatoire de Paris, Université PSL (Paris Sciences & Lettres), CNRS (Centre National de la Recherche Scientifique), Université de Paris, Sorbonne Université, 92195 Meudon, France
| | - K J Becker
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - C A Bennett
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - W F Bottke
- Southwest Research Institute, Boulder, CO, USA
| | - J I Brodbeck
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - H C Connolly
- Department of Geology, Rowan University, Glassboro, NJ, USA
| | - M Delbo
- Université Côte d'Azur, Observatoire de la Côte d'Azur, CNRS, Laboratoire Lagrange, Nice, France
| | - J de Leon
- Instituto de Astrofísica de Canarias and Departamento de Astrofísica, Universidad de La Laguna, Tenerife, Spain
| | | | - K L Edmundson
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - S Fornasier
- LESIA (Laboratoire d'Etudes Spatiales et d'Instrumentation en Astrophysique), Observatoire de Paris, Université PSL (Paris Sciences & Lettres), CNRS (Centre National de la Recherche Scientifique), Université de Paris, Sorbonne Université, 92195 Meudon, France.,Institut Universitaire de France (IUF), 1 rue Descartes, 75231 Paris CEDEX 05, France
| | | | - P H Hasselmann
- LESIA (Laboratoire d'Etudes Spatiales et d'Instrumentation en Astrophysique), Observatoire de Paris, Université PSL (Paris Sciences & Lettres), CNRS (Centre National de la Recherche Scientifique), Université de Paris, Sorbonne Université, 92195 Meudon, France
| | - C W Hergenrother
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - E S Howell
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - E R Jawin
- Smithsonian Institution National Museum of Natural History, Washington, DC, USA
| | - H H Kaplan
- NASA Goddard Space Flight Center, Greenbelt, MD, USA
| | - L Le Corre
- Planetary Science Institute, Tucson, AZ, USA
| | - L F Lim
- Smithsonian Institution National Museum of Natural History, Washington, DC, USA
| | - J Y Li
- Planetary Science Institute, Tucson, AZ, USA
| | - P Michel
- Université Côte d'Azur, Observatoire de la Côte d'Azur, CNRS, Laboratoire Lagrange, Nice, France
| | - J L Molaro
- Planetary Science Institute, Tucson, AZ, USA
| | - M C Nolan
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - J Nolau
- Lockheed Martin Space, Littleton, CO, USA
| | - M Pajola
- Istituto Nazionale di Astrofisica (INAF), Osservatorio Astronomico di Padova, Padua, Italy
| | - A Parkinson
- Department of Geography, University of Winnipeg, Winnipeg, MB R3B 2E9, Canada
| | - M Popescu
- Astronomical Institute of the Romanian Academy, Bucharest, Romania.,Instituto de Astrofísica de Canarias and Departamento de Astrofísica, Universidad de La Laguna, Tenerife, Spain
| | - N A Porter
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - B Rizk
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - J L Rizos
- Instituto de Astrofísica de Canarias and Departamento de Astrofísica, Universidad de La Laguna, Tenerife, Spain
| | - A J Ryan
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - B Rozitis
- The School of Physical Sciences, The Open University, Milton Keynes, UK
| | - N K Shultz
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - A A Simon
- NASA Goddard Space Flight Center, Greenbelt, MD, USA
| | - D Trang
- University of Hawai'i at Mānoa, Hawai'i Institute of Geophysics and Planetology, Honolulu, HI, USA
| | - R B Van Auken
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - C W V Wolner
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - D S Lauretta
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
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6
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Thompson HJ, Rivara F, Becker KJ, Maier R, Temkin N. Impact of aging on the immune response to traumatic brain injury (AIm:TBI) study protocol. Inj Prev 2020; 26:471-477. [PMID: 31481600 PMCID: PMC8026101 DOI: 10.1136/injuryprev-2019-043325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) in older adults leads to considerable morbidity and mortality. Outcomes among older adults with TBI are disparately worse than in younger adults. Differences in immunological response to injury may account for at least some of this disparity. Understanding how ageing differentially affects the immune response to TBI and how older age and these immunological changes affect the natural history of recovery following TBI are the goals of this study. DESIGN/METHODS A prospective multiple cohort design is being used to assess the effects of ageing and TBI on immune makers and to test predictors of impairment and disability in older adults following mild TBI. Older adults (>55 years) with mild TBI are enrolled with three comparison groups: younger adults (21-54 years) with mild TBI, non-injured older adults (>55 years) and non-injured young adults (21-54 years). For the primary analysis, we will assess the association between immune markers and Glasgow Outcome Scale-Extended at 6 months, using logistic regression. Predictors of interest will be inflammatory biomarkers. Multivariate linear regression will be used to evaluate associations between biomarkers and other outcomes (symptoms, function and quality of life) at 3 and 6 months. Exploratory analyses will investigate the utility of biomarkers to predict outcome using receiver-operating characteristic curves. DISCUSSION A better understanding of the recovery trajectory and biological rationale for disparate outcomes following TBI in older adults could allow for development of specific interventions aimed at reducing or eliminating symptoms. Such interventions could reduce impairment and healthcare costs.
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Affiliation(s)
- Hilaire J Thompson
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Frederick Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Kyra J Becker
- Department of Neurology, University of Washington, Seattle, Washington, USA
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Ronald Maier
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington, USA
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7
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Lauretta DS, Hergenrother CW, Chesley SR, Leonard JM, Pelgrift JY, Adam CD, Al Asad M, Antreasian PG, Ballouz RL, Becker KJ, Bennett CA, Bos BJ, Bottke WF, Brozović M, Campins H, Connolly HC, Daly MG, Davis AB, de León J, DellaGiustina DN, Drouet d'Aubigny CY, Dworkin JP, Emery JP, Farnocchia D, Glavin DP, Golish DR, Hartzell CM, Jacobson RA, Jawin ER, Jenniskens P, Kidd JN, Lessac-Chenen EJ, Li JY, Libourel G, Licandro J, Liounis AJ, Maleszewski CK, Manzoni C, May B, McCarthy LK, McMahon JW, Michel P, Molaro JL, Moreau MC, Nelson DS, Owen WM, Rizk B, Roper HL, Rozitis B, Sahr EM, Scheeres DJ, Seabrook JA, Selznick SH, Takahashi Y, Thuillet F, Tricarico P, Vokrouhlický D, Wolner CWV. Episodes of particle ejection from the surface of the active asteroid (101955) Bennu. Science 2020; 366:366/6470/eaay3544. [PMID: 31806784 DOI: 10.1126/science.aay3544] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/22/2019] [Indexed: 11/02/2022]
Abstract
Active asteroids are those that show evidence of ongoing mass loss. We report repeated instances of particle ejection from the surface of (101955) Bennu, demonstrating that it is an active asteroid. The ejection events were imaged by the OSIRIS-REx (Origins, Spectral Interpretation, Resource Identification, and Security-Regolith Explorer) spacecraft. For the three largest observed events, we estimated the ejected particle velocities and sizes, event times, source regions, and energies. We also determined the trajectories and photometric properties of several gravitationally bound particles that orbited temporarily in the Bennu environment. We consider multiple hypotheses for the mechanisms that lead to particle ejection for the largest events, including rotational disruption, electrostatic lofting, ice sublimation, phyllosilicate dehydration, meteoroid impacts, thermal stress fracturing, and secondary impacts.
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Affiliation(s)
- D S Lauretta
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA.
| | - C W Hergenrother
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA.
| | - S R Chesley
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | | | | | - C D Adam
- KinetX Aerospace, Simi Valley, CA, USA
| | - M Al Asad
- Department of Earth, Ocean, and Atmospheric Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | - R-L Ballouz
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - K J Becker
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - C A Bennett
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - B J Bos
- NASA Goddard Space Flight Center, Greenbelt, MD, USA
| | - W F Bottke
- Southwest Research Institute, Boulder, CO, USA
| | - M Brozović
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - H Campins
- Department of Physics, University of Central Florida, Orlando, FL, USA
| | - H C Connolly
- Department of Geology, Rowan University, Glassboro, NJ, USA.,Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - M G Daly
- The Centre for Research in Earth and Space Science, York University, Toronto, ON, Canada
| | - A B Davis
- Smead Department of Aerospace Engineering Sciences, University of Colorado, Boulder, CO, USA
| | - J de León
- Instituto de Astrofísica de Canarias and Departamento de Astrofísica, Universidad de La Laguna, Tenerife, Spain
| | - D N DellaGiustina
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA.,Department of Geosciences, University of Arizona, Tucson, AZ, USA
| | | | - J P Dworkin
- NASA Goddard Space Flight Center, Greenbelt, MD, USA
| | - J P Emery
- Department of Earth and Planetary Sciences, University of Tennessee, Knoxville, TN, USA.,Department of Astronomy and Planetary Sciences, Northern Arizona University, Flagstaff, AZ, USA
| | - D Farnocchia
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - D P Glavin
- NASA Goddard Space Flight Center, Greenbelt, MD, USA
| | - D R Golish
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - C M Hartzell
- Department of Aerospace Engineering, University of Maryland, College Park, MD, USA
| | - R A Jacobson
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - E R Jawin
- Smithsonian Institution National Museum of Natural History, Washington, DC, USA
| | - P Jenniskens
- SETI (Search for Extraterrestrial Intelligence) Institute, Mountain View, CA, USA
| | - J N Kidd
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | | | - J-Y Li
- Planetary Science Institute, Tucson, AZ, USA
| | - G Libourel
- Université Côte d'Azur, Observatoire de la Côte d'Azur, CNRS (Centre national de la recherche scientifique), Laboratoire Lagrange, Nice, France
| | - J Licandro
- Instituto de Astrofísica de Canarias and Departamento de Astrofísica, Universidad de La Laguna, Tenerife, Spain
| | - A J Liounis
- NASA Goddard Space Flight Center, Greenbelt, MD, USA
| | - C K Maleszewski
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - C Manzoni
- London Stereoscopic Company, London, UK
| | - B May
- London Stereoscopic Company, London, UK
| | | | - J W McMahon
- Smead Department of Aerospace Engineering Sciences, University of Colorado, Boulder, CO, USA
| | - P Michel
- Université Côte d'Azur, Observatoire de la Côte d'Azur, CNRS (Centre national de la recherche scientifique), Laboratoire Lagrange, Nice, France
| | - J L Molaro
- Planetary Science Institute, Tucson, AZ, USA
| | - M C Moreau
- NASA Goddard Space Flight Center, Greenbelt, MD, USA
| | | | - W M Owen
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - B Rizk
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - H L Roper
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - B Rozitis
- School of Physical Sciences, Open University, Milton Keynes, UK
| | - E M Sahr
- KinetX Aerospace, Simi Valley, CA, USA
| | - D J Scheeres
- Smead Department of Aerospace Engineering Sciences, University of Colorado, Boulder, CO, USA
| | - J A Seabrook
- The Centre for Research in Earth and Space Science, York University, Toronto, ON, Canada
| | - S H Selznick
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - Y Takahashi
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - F Thuillet
- Université Côte d'Azur, Observatoire de la Côte d'Azur, CNRS (Centre national de la recherche scientifique), Laboratoire Lagrange, Nice, France
| | - P Tricarico
- Planetary Science Institute, Tucson, AZ, USA
| | - D Vokrouhlický
- Institute of Astronomy, Charles University, Prague, Czech Republic
| | - C W V Wolner
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
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8
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Byun E, McCurry SM, Opp M, Liu D, Becker KJ, Thompson HJ. Self-efficacy is associated with better sleep quality and sleep efficiency in adults with subarachnoid hemorrhage. J Clin Neurosci 2020; 73:173-178. [DOI: 10.1016/j.jocn.2019.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/01/2019] [Indexed: 01/21/2023]
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9
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Harding B, Avoundjian T, Heckbert SR, Whitney BM, Nance RM, Tirschwell DL, Kalani R, Ho EL, Becker KJ, Zunt J, Chow F, Huffer A, Mathews WC, Eron J, Moore R, Marra CM, Burkholder G, Saag M, Kitahata MM, Crane H, Delaney JC. Abstract WMP55: HIV Viral Load and Stroke Risk. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wmp55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Among people living with HIV (PLWH), elevated plasma HIV RNA (viral load, [VL]), indicative of increased inflammation, may be associated with greater risk of stroke.
Methods:
Among adult PLWH receiving clinical care at six Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) sites across the U.S. from January 2006 through January 2015, first ischemic or hemorrhagic stroke was identified from adjudicated clinical events. We considered baseline and time-updated VL. Baseline viral load was defined as the most recent viral load before 2006 or at CNICS cohort entry (if after 2006). Cox proportional hazards models were used to assess the relationship between baseline VL and time-updated VL and stroke. We estimated hazard ratios for risk of stroke (all stroke, and ischemic and hemorrhagic stroke separately) comparing the 75
th
percentile of VL (“high VL”) to the 25
th
percentile (“low VL”). All models were adjusted for age, sex, race/ethnicity, CNICS site, diabetes, treated hypertension, statin use, smoking, nadir CD4, BMI, hepatitis C virus coinfection, and baseline ART use. The hemorrhagic stroke model was also adjusted for FIB-4.
Results:
Among 16,648 PLWH over an average follow-up of 4.7 years, there were 146 total strokes (119 ischemic; 19 hemorrhagic). At baseline, the median VL was 41 copies/mL (IQR: 24, 3860). Individuals with high baseline VL were 1.57 times more likely to have a stroke than individuals with low baseline VL (95% CI: 1.22, 2.04). In addition, high baseline VL was associated with increased risk of ischemic stroke (HR: 1.48; 95% CI: 1.11, 1.97) and hemorrhagic stroke (HR: 2.5; 95% CI: 1.25, 4.98). The HR for all strokes comparing high VL and low VL individuals using time-updated VL was 1.84 (95% CI: 1.42-2.40).
Conclusion:
Our findings suggest that higher VL is associated with stroke risk after adjusting for traditional stroke risk factors, and may have a greater impact on incidence of hemorrhagic stroke. In addition to reducing HIV-related morbidity and mortality, improving HIV care may also reduce stroke risk.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Felicia Chow
- Univ of California San Francisco, San Francisco, CA
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10
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Byun E, Kohen R, Becker KJ, Kirkness CJ, Khot S, Mitchell PH. Stroke impact symptoms are associated with sleep-related impairment. Heart Lung 2019; 49:117-122. [PMID: 31839325 DOI: 10.1016/j.hrtlng.2019.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 10/16/2019] [Accepted: 10/23/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Sleep-related impairment is a common but under-appreciated complication after stroke and may impede stroke recovery. Yet little is known about factors associated with sleep-related impairment after stroke. OBJECTIVE The purpose of this analysis was to examine the relationship between stroke impact symptoms and sleep-related impairment among stroke survivors. METHODS We conducted a cross-sectional secondary analysis of a baseline (entry) data in a completed clinical trial with 100 community-dwelling stroke survivors recruited within 4 months after stroke. Sleep-related impairment and stroke impact domain symptoms after stroke were assessed with the Patient-Reported Outcomes Measurement Information System Sleep-Related Impairment scale and the Stroke Impact Scale, respectively. A multivariate regression was computed. RESULTS Stroke impact domain-mood (B = -0.105, t = -3.263, p = .002) - and fatigue (B = 0.346, t = 3.997, p < .001) were associated with sleep-related impairment. CONCLUSIONS Our findings suggest that ongoing stroke impact symptoms are closely related to sleep-related impairment. An intervention targeting both stroke impact symptoms and sleep-related impairment may be useful in improving neurologic recovery and quality of life in stroke survivors.
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Affiliation(s)
- Eeeseung Byun
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA.
| | - Ruth Kohen
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Kyra J Becker
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Catherine J Kirkness
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Sandeep Khot
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Pamela H Mitchell
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
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11
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Lauretta DS, DellaGiustina DN, Bennett CA, Golish DR, Becker KJ, Balram-Knutson SS, Barnouin OS, Becker TL, Bottke WF, Boynton WV, Campins H, Clark BE, Connolly HC, Drouet d'Aubigny CY, Dworkin JP, Emery JP, Enos HL, Hamilton VE, Hergenrother CW, Howell ES, Izawa MRM, Kaplan HH, Nolan MC, Rizk B, Roper HL, Scheeres DJ, Smith PH, Walsh KJ, Wolner CWV. The unexpected surface of asteroid (101955) Bennu. Nature 2019; 568:55-60. [PMID: 30890786 PMCID: PMC6557581 DOI: 10.1038/s41586-019-1033-6] [Citation(s) in RCA: 268] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/15/2019] [Indexed: 11/09/2022]
Abstract
NASA'S Origins, Spectral Interpretation, Resource Identification and Security-Regolith Explorer (OSIRIS-REx) spacecraft recently arrived at the near-Earth asteroid (101955) Bennu, a primitive body that represents the objects that may have brought prebiotic molecules and volatiles such as water to Earth1. Bennu is a low-albedo B-type asteroid2 that has been linked to organic-rich hydrated carbonaceous chondrites3. Such meteorites are altered by ejection from their parent body and contaminated by atmospheric entry and terrestrial microbes. Therefore, the primary mission objective is to return a sample of Bennu to Earth that is pristine-that is, not affected by these processes4. The OSIRIS-REx spacecraft carries a sophisticated suite of instruments to characterize Bennu's global properties, support the selection of a sampling site and document that site at a sub-centimetre scale5-11. Here we consider early OSIRIS-REx observations of Bennu to understand how the asteroid's properties compare to pre-encounter expectations and to assess the prospects for sample return. The bulk composition of Bennu appears to be hydrated and volatile-rich, as expected. However, in contrast to pre-encounter modelling of Bennu's thermal inertia12 and radar polarization ratios13-which indicated a generally smooth surface covered by centimetre-scale particles-resolved imaging reveals an unexpected surficial diversity. The albedo, texture, particle size and roughness are beyond the spacecraft design specifications. On the basis of our pre-encounter knowledge, we developed a sampling strategy to target 50-metre-diameter patches of loose regolith with grain sizes smaller than two centimetres4. We observe only a small number of apparently hazard-free regions, of the order of 5 to 20 metres in extent, the sampling of which poses a substantial challenge to mission success.
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Affiliation(s)
- D S Lauretta
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA.
| | - D N DellaGiustina
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - C A Bennett
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - D R Golish
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - K J Becker
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | | | - O S Barnouin
- The Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA
| | - T L Becker
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - W F Bottke
- Southwest Research Institute, Boulder, CO, USA
| | - W V Boynton
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - H Campins
- Department of Physics, University of Central Florida, Orlando, FL, USA
| | - B E Clark
- Department of Physics and Astronomy, Ithaca College, Ithaca, NY, USA
| | - H C Connolly
- Department of Geology, Rowan University, Glassboro, NJ, USA
| | | | - J P Dworkin
- NASA Goddard Space Flight Center, Greenbelt, MD, USA
| | - J P Emery
- Department of Earth and Planetary Sciences, University of Tennessee, Knoxville, TN, USA
| | - H L Enos
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | | | - C W Hergenrother
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - E S Howell
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - M R M Izawa
- Institute for Planetary Materials, Okayama University-Misasa, Misasa, Japan
| | - H H Kaplan
- Southwest Research Institute, Boulder, CO, USA
| | - M C Nolan
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - B Rizk
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - H L Roper
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - D J Scheeres
- Smead Department of Aerospace Engineering, University of Colorado, Boulder, CO, USA
| | - P H Smith
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
| | - K J Walsh
- Southwest Research Institute, Boulder, CO, USA
| | - C W V Wolner
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ, USA
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12
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Zierath D, Olmstead T, Stults A, Shen A, Kunze A, Becker KJ. Chemical Sympathectomy, but not Adrenergic Blockade, Improves Stroke Outcome. J Stroke Cerebrovasc Dis 2018; 27:3177-3186. [PMID: 30120036 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/06/2018] [Accepted: 07/04/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND A robust adrenergic response following stroke impairs lymphocyte function, which may prevent the development of autoimmune responses to brain antigens. We tested whether inhibition of the sympathetic response after stroke would increase the propensity for developing autoimmune responses to brain antigens. METHODS Male Lewis rats were treated with 6-hydroxydopamine (OHDA) prior to middle cerebral artery occlusion (MCAO), labetalol after MCAO, or appropriate controls. Behavior was assessed weekly and animals survived to 1 month at which time ELISPOT assays were done on lymphocytes from spleen and brain to determine the Th1 and Th17 responses to myelin basic protein (MBP), ovalbumin (OVA), and concanavalin A. A subset of animals was sacrificed 72 hours after MCAO for evaluation of infarct volume and lymphocyte responsiveness. Plasma C-reactive protein (CRP) was measured as a biomarker of systemic inflammation. RESULTS Despite similar initial stroke severity and infarct volumes, 6-OHDA-treated animals lost less weight and experienced less hyperthermia after stroke. 6-OHDA-treated animals also had decreased CRP in circulation early after stroke and experienced better neurological outcomes at 1 month. The Th1 and Th17 responses to MBP did not differ among treatment groups at 1 month, but the Th1 response to OVA in spleen was more robust in labetalol and less robust in 6-OHDA-treated animals. CONCLUSIONS Chemical sympathectomy with 6-OHDA, but not treatment with labetalol, decreased systemic markers of inflammation early after stroke and improved long-term outcome. An increase in Th1 and Th17 responses to MBP was not seen with inhibition of the sympathetic response.
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Affiliation(s)
- Dannielle Zierath
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Theresa Olmstead
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Astiana Stults
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Angela Shen
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Allison Kunze
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Kyra J Becker
- Department of Neurology, University of Washington School of Medicine, Seattle, WA.
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13
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Bernhardt J, Zorowitz RD, Becker KJ, Keller E, Saposnik G, Strbian D, Dichgans M, Woo D, Reeves M, Thrift A, Kidwell CS, Olivot JM, Goyal M, Pierot L, Bennett DA, Howard G, Ford GA, Goldstein LB, Planas AM, Yenari MA, Greenberg SM, Pantoni L, Amin-Hanjani S, Tymianski M. Advances in Stroke 2017. Stroke 2018; 49:e174-e199. [DOI: 10.1161/strokeaha.118.021380] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/02/2018] [Accepted: 03/12/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Julie Bernhardt
- From the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (J.B.)
| | - Richard D. Zorowitz
- MedStar National Rehabilitation Network and Department of Rehabilitation Medicine, Georgetown University School of Medicine, Washington, DC (R.D.Z.)
| | - Kyra J. Becker
- Department of Neurology, University of Washington, Seattle (K.J.B.)
| | - Emanuela Keller
- Division of Internal Medicine, University Hospital of Zurich, Switzerland (E.K.)
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Finland (D.S.)
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Germany (M.D.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (M.D.)
| | - Daniel Woo
- Department of Neurology, University of Cincinnati College of Medicine, OH (D.W.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Amanda Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.T.)
| | - Chelsea S. Kidwell
- Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.)
| | - Jean Marc Olivot
- Acute Stroke Unit, Toulouse Neuroimaging Center and Clinical Investigation Center, Toulouse University Hospital, France (J.M.O.)
| | - Mayank Goyal
- Department of Diagnostic and Interventional Neuroradiology, University of Calgary, AB, Canada (M.G.)
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison Blanche, CHU Reims, Reims Champagne-Ardenne University, France (L.P.)
| | - Derrick A. Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (D.A.B.)
| | - George Howard
- Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.)
| | - Gary A. Ford
- Oxford Academic Health Science Network, United Kingdom (G.A.F.)
| | | | - Anna M. Planas
- Department of Brain Ischemia and Neurodegeneration, Institute for Biomedical Research of Barcelona (IIBB), Consejo Superior de Investigaciones CIentíficas (CSIC), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (A.M.P.)
| | - Midori A. Yenari
- Department of Neurology, University of California, San Francisco (M.A.Y.)
- San Francisco Veterans Affairs Medical Center, CA (M.A.Y.)
| | - Steven M. Greenberg
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
| | - Leonardo Pantoni
- ‘L. Sacco’ Department of Biomedical and Clinical Sciences, University of Milan, Italy (L.P.)
| | | | - Michael Tymianski
- Departments of Surgery and Physiology, University of Toronto, ON, Canada (M.T.)
- Department of Surgery, University Health Network (Neurosurgery), Toronto, ON, Canada (M.T.)
- Krembil Research Institute, Toronto Western Hospital, ON, Canada (M.T.)
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14
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Ormseth CH, Falcone GJ, Jasak SD, Mampre DM, Leasure AC, Miyares LC, Hwang DY, James ML, Testai FD, Becker KJ, Tirschwell DL, Langefeld CD, Woo D, Sheth KN. Abstract WMP96: Racial Variation in Comfort Measures Only Status in Patients With Intracerebral Hemorrhage. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wmp96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Prior studies of critically ill patients found that non-whites are less likely to pursue comfort measures only status (CMOs). We sought to identify determinants of CMOs in a large multi-ethnic cohort study of intracerebral hemorrhage (ICH).
Methods:
We analyzed cases enrolled from 2010 to 2015 in the Ethnic/Racial Variations of ICH (ERICH) study, a multi-center study in the USA. Clinical, demographic and radiologic data on non-traumatic ICH patients were prospectively collected. Univariate and multivariate logistic regression was used to evaluate the association between ethnicity/race and CMOs after adjustment for potential confounders.
Results:
2705 ICH cases were included in this study (mean age 62 (14), female sex 1119 [41%]). Of these, 912 were black (34%), 893 Hispanic (33%) and 900 white (33%). CMOs patients comprised 276 (10%), 64 (7%), 79 (9%) and 133 (15%) of the entire cohort and the black, Hispanic and white cohorts, respectively (p<0.001) (Table 1). In multivariate analysis, black patients were half as likely as white patients to be made CMO (OR 0.50, 95% CI 0.34-0.75; p=0.001) and there was a trend for Hispanic patients to have CMOs less often than white patients (OR 0.72, 95% CI 0.49-1.06, p=0.093) (Table 2). Other factors associated with CMOs included age, premorbid modified Rankin Scale, dementia, admission Glasgow Coma Scale, ICH volume, intraventricular hematoma volume, lobar and brainstem bleeds and intubation.
Conclusion:
Black patients were less likely than white patients to be made CMO after controlling for potential confounders. Further investigation is warranted to understand the causes and implications of racial disparities in CMO decisions.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Fernando D Testai
- Neurology and Rehabilitation, Univ of Illinois at Chicago, Chicago, IL
| | | | | | - Carl D Langefeld
- Biostatistical Sciences, Wake Forest Univ Health Sciences, Winston-Salem, NC
| | - Daniel Woo
- Neurology and Rehabilitation, Univ of Cincinnati College of Medicine, Cincinnati, OH
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15
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Mossa-Basha M, Shibata DK, Hallam DK, de Havenon A, Hippe DS, Becker KJ, Tirschwell DL, Hatsukami T, Balu N, Yuan C. Added Value of Vessel Wall Magnetic Resonance Imaging for Differentiation of Nonocclusive Intracranial Vasculopathies. Stroke 2017; 48:3026-3033. [PMID: 29030476 DOI: 10.1161/strokeaha.117.018227] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/08/2017] [Accepted: 09/18/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Our goal is to determine the added value of intracranial vessel wall magnetic resonance imaging (IVWI) in differentiating nonocclusive vasculopathies compared with luminal imaging alone. METHODS We retrospectively reviewed images from patients with both luminal and IVWI to identify cases with clinically defined intracranial vasculopathies: atherosclerosis (intracranial atherosclerotic disease), reversible cerebral vasoconstriction syndrome, and inflammatory vasculopathy. Two neuroradiologists blinded to clinical data reviewed the luminal imaging of defined luminal stenoses/irregularities and evaluated the pattern of involvement to make a presumed diagnosis with diagnostic confidence. Six weeks later, the 2 raters rereviewed the luminal imaging in addition to IVWI for the pattern of wall involvement, presence and pattern of postcontrast enhancement, and presumed diagnosis and confidence. Analysis was performed on per-lesion and per-patient bases. RESULTS Thirty intracranial atherosclerotic disease, 12 inflammatory vasculopathies, and 12 reversible cerebral vasoconstriction syndrome patients with 201 lesions (90 intracranial atherosclerotic disease, 64 reversible cerebral vasoconstriction syndrome, and 47 inflammatory vasculopathy lesions) were included. For both per-lesion and per-patient analyses, there was significant diagnostic accuracy improvement with luminal imaging+IVWI when compared with luminal imaging alone (per-lesion: 88.8% versus 36.1%; P<0.001 and per-patient: 96.3% versus 43.5%; P<0.001, respectively). There was substantial interrater diagnostic agreement for luminal imaging+IVWI (κ=0.72) and only slight agreement for luminal imaging (κ=0.04). Although there was a significant correlation for both luminal and IVWI pattern of wall involvement with diagnosis, there was a stronger correlation for IVWI finding of lesion eccentricity and intracranial atherosclerotic disease diagnosis than for luminal imaging (κ=0.69 versus 0.18; P<0.001). CONCLUSIONS IVWI can significantly improve the differentiation of nonocclusive intracranial vasculopathies when combined with traditional luminal imaging modalities.
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Affiliation(s)
- Mahmud Mossa-Basha
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.).
| | - Dean K Shibata
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Danial K Hallam
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Adam de Havenon
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Daniel S Hippe
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Kyra J Becker
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - David L Tirschwell
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Thomas Hatsukami
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Niranjan Balu
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Chun Yuan
- From the Department of Radiology (M.M.-B., D.K.S., D.K.H., D.S.H., N.B., C.Y.), Department of Neurology (K.J.B., D.L.T.), and Department of Surgery (T.H.), University of Washington, Seattle; and Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
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Kirkness CJ, Cain KC, Becker KJ, Tirschwell DL, Buzaitis AM, Weisman PL, McKenzie S, Teri L, Kohen R, Veith RC, Mitchell PH. Randomized trial of telephone versus in-person delivery of a brief psychosocial intervention in post-stroke depression. BMC Res Notes 2017; 10:500. [PMID: 29017589 PMCID: PMC5633890 DOI: 10.1186/s13104-017-2819-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 09/30/2017] [Indexed: 11/13/2022] Open
Abstract
Background A psychosocial behavioral intervention delivered in-person by advanced practice nurses has been shown effective in substantially reducing post-stroke depression (PSD). This follow-up trial compared the effectiveness of a shortened intervention delivered by either telephone or in-person to usual care. To our knowledge, this is the first of current behavioral therapy trials to expand the protocol in a new clinical sample. 100 people with Geriatric Depression Scores ≥ 11 were randomized within 4 months of stroke to usual care (N = 28), telephone intervention (N = 37), or in-person intervention (N = 35). Primary outcome was response [percent reduction in the Hamilton Depression Rating Scale (HDRS)] and remission (HDRS score < 10) at 8 weeks and 12 months post treatment. Results Intervention groups were combined for the primary analysis (pre-planned). The mean response in HDRS scores was 39% reduction for the combined intervention group (40% in-person; 38% telephone groups) versus 33% for the usual care group at 8 weeks (p = 0.3). Remission occurred in 37% in the combined intervention groups at 8 weeks versus 27% in the control group (p = 0.3) and 44% intervention versus 36% control at 12 months (p = 0.5). While favouring the intervention, these differences were not statistically significant. Conclusions A brief psychosocial intervention for PSD delivered by telephone or in-person did not reduce depression significantly more than usual care. However, the comparable effectiveness of telephone and in-person follow-up for treatment of depression found is important given greater accessibility by telephone and mandated post-hospital follow-up for comprehensive stroke centers. Clinical Trial Registration URL: https://register.clinicaltrials.gov, unique identifier: NCT01133106, Registered 5/26/2010 Electronic supplementary material The online version of this article (doi:10.1186/s13104-017-2819-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catherine J Kirkness
- Biobehavioral Nursing and Health Informatics, University of Washington, Box 357266, Seattle, WA, 98195-7266, USA
| | - Kevin C Cain
- Biostatistics and School of Nursing, University of Washington, Box 357232, Seattle, WA, 98195-7232, USA
| | - Kyra J Becker
- Neurology, University of Washington, Box 359775, Seattle, WA, 98185-9775, USA
| | - David L Tirschwell
- Neurology, University of Washington, Box 359775, Seattle, WA, 98185-9775, USA
| | - Ann M Buzaitis
- UW Medicine, University of Washington, Box 359556, Seattle, WA, 98195-9556, USA
| | - Pamela L Weisman
- Biobehavioral Nursing and Health Informatics, University of Washington, Box 357266, Seattle, WA, 98195-7266, USA
| | - Sylvia McKenzie
- University of Washington School of Nursing, Box 357266, Seattle, WA, 98195-7266, USA
| | - Linda Teri
- Psychosocial and Community Health, University of Washington, Box 357263, Seattle, WA, 98195-7263, USA
| | - Ruth Kohen
- Psychiatry and Behavioural Sciences, University of Washington, Box 356560, Seattle, WA, 98195-356560, USA
| | - Richard C Veith
- Psychiatry and Behavioural Sciences, University of Washington, Box 356560, Seattle, WA, 98195-356560, USA
| | - Pamela H Mitchell
- Biobehavioral Nursing and Health Informatics, University of Washington, Box 357266, Seattle, WA, 98195-7266, USA. .,Biobehavioral Nursing & Health Systems, University of Washington, Box 357260, Seattle, WA, 98195-7260, USA.
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Starr JB, Tirschwell DL, Becker KJ. Labetalol Use Is Associated With Increased In-Hospital Infection Compared With Nicardipine Use in Intracerebral Hemorrhage. Stroke 2017; 48:2693-2698. [DOI: 10.1161/strokeaha.117.017230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 08/15/2017] [Accepted: 08/16/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Jordan B. Starr
- From the Departments of Anesthesiology and Pain Medicine (J.B.S.) and Neurology (D.L.T., K.J.B.), University of Washington, Seattle
| | - David L. Tirschwell
- From the Departments of Anesthesiology and Pain Medicine (J.B.S.) and Neurology (D.L.T., K.J.B.), University of Washington, Seattle
| | - Kyra J. Becker
- From the Departments of Anesthesiology and Pain Medicine (J.B.S.) and Neurology (D.L.T., K.J.B.), University of Washington, Seattle
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Hinkle JL, Becker KJ, Kim JS, Choi-Kwon S, Saban KL, McNair N, Mead GE. Poststroke Fatigue: Emerging Evidence and Approaches to Management: A Scientific Statement for Healthcare Professionals From the American Heart Association. Stroke 2017; 48:e159-e170. [PMID: 28546322 DOI: 10.1161/str.0000000000000132] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
At least half of all stroke survivors experience fatigue; thus, it is a common cause of concern for patients, caregivers, and clinicians after stroke. This scientific statement provides an international perspective on the emerging evidence surrounding the incidence, prevalence, quality of life, and complex pathogenesis of poststroke fatigue. Evidence for pharmacological and nonpharmacological interventions for management are reviewed, as well as the effects of poststroke fatigue on both stroke survivors and caregivers.
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Starr JB, Tirschwell DL, Becker KJ. Increased infections with β-blocker use in ischemic stroke, a β2-receptor mediated process? Neurol Sci 2017; 38:967-974. [DOI: 10.1007/s10072-017-2877-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 02/24/2017] [Indexed: 01/04/2023]
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Zierath D, Shen A, Stults A, Olmstead T, Becker KJ. Splenectomy Does Not Improve Long-Term Outcome After Stroke. Stroke 2017; 48:497-500. [PMID: 28087806 DOI: 10.1161/strokeaha.116.016037] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 11/10/2016] [Accepted: 11/23/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Immune responses to brain antigens after stroke contribute to poor outcome. We hypothesized that splenectomy would lessen the development of such responses and improve outcome. METHODS Male Lewis rats (275-350 g) underwent 2-hour middle cerebral artery occlusion immediately after splenectomy or sham splenectomy. Animals were survived to 4 weeks (672 hrs), and immune responses to myelin basic protein determined at euthanasia. Infarct volume was determined in a subset of animals euthanized at 72 hours. Behavioral outcomes were assessed to 672 hours. RESULTS Splenectomy was associated with worse neurological scores early after stroke, but infarct size at 72 hours was similar in both groups. Behavioral outcomes and immune responses to myelin basic protein were also similar among splenectomized and sham-operated animals 672 hours after middle cerebral artery occlusion. CONCLUSIONS Splenectomy did not alter the immune responses to brain antigens or improve outcome after stroke. Differences between this study and other studies of splenectomy and stroke are examined.
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Affiliation(s)
- Dannielle Zierath
- From the Department of Neurology, University of Washington School of Medicine Seattle
| | - Angela Shen
- From the Department of Neurology, University of Washington School of Medicine Seattle
| | - Astiana Stults
- From the Department of Neurology, University of Washington School of Medicine Seattle
| | - Theresa Olmstead
- From the Department of Neurology, University of Washington School of Medicine Seattle
| | - Kyra J Becker
- From the Department of Neurology, University of Washington School of Medicine Seattle.
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Abstract
Depression and fatigue are common after stroke and negatively impact the quality of life of stroke survivors. The biological bases of these symptoms are unknown, but an abundance of data point to a role for inflammation. This review highlights evidence supporting the contribution of inflammation to poststroke depression and poststroke fatigue. Potential treatments for poststroke depression and poststroke fatigue are explored, with a special emphasis on those that modulate the immune response.
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Affiliation(s)
- Kyra J Becker
- University of Washington School of Medicine, Seattle, WA, USA.
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Affiliation(s)
- Kyra J Becker
- University of Washington School of Medicine, Seattle, WA, USA.
| | - Marion Buckwalter
- Stanford University School of Medicine, Stanford University, Stanford, CA, USA
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Starr JB, Becker KJ, Tirschwell DL. Weekend Discharge and Stroke Quality of Care: Get With The Guidelines-Stroke Data from a Comprehensive Stroke Center. J Stroke Cerebrovasc Dis 2016; 25:2962-2967. [PMID: 27599907 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/26/2016] [Accepted: 08/07/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Get With The Guidelines-Stroke collects data on hospital compliance with evidence-based stroke quality of care indicators. Prior work has investigated a link between weekend hospital admission and increased mortality after stroke. There is, however, a paucity of work investigating a similar association between weekend hospital discharge and quality of care. We aimed to determine if weekend discharge affects care to enlighten opportunities for quality improvement. MATERIALS AND METHODS Through a retrospective analysis of records from a Comprehensive Stroke Center from July 2010 to June 2015, we identified patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Our quality of care indicators were dysphagia screening, rehabilitation assessment, smoking cessation counseling, stroke education, and weight reduction counseling. We created regression models to find adjusted differences in quality of care measure compliance for patients discharged on the weekend. RESULTS Our analysis included 2737 patients, of which 431 were discharged on the weekend. After adjustment, weekend discharge was significantly associated with reduced stroke education (odds ratio .67, confidence interval .51-0.88, P = .004) and reduced weight reduction counseling (odds ratio .65, confidence interval .45-0.93, P = .018). CONCLUSIONS Hospital discharge on the weekend was associated with an adjusted one-third decrease in odds of stroke education and weight reduction counseling. There is an opportunity for quality improvement in educating stroke patients before hospital discharge on the weekend.
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Affiliation(s)
- Jordan B Starr
- Department of Anesthesiology and Pain Medicine, University of Washington Seattle, Washington.
| | - Kyra J Becker
- Department of Neurology, University of Washington, Seattle, Washington
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24
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Khot SP, Davis AP, Crane DA, Tanzi PM, Lue DL, Claflin ES, Becker KJ, Longstreth WT, Watson NF, Billings ME. Effect of Continuous Positive Airway Pressure on Stroke Rehabilitation: A Pilot Randomized Sham-Controlled Trial. J Clin Sleep Med 2016; 12:1019-26. [PMID: 27092703 DOI: 10.5664/jcsm.5940] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/17/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) predicts poor functional outcome after stroke and increases the risk for recurrent stroke. Less is known about continuous positive airway pressure (CPAP) treatment on stroke recovery. METHODS In a pilot randomized, double-blind, sham-controlled trial, adult stroke rehabilitation patients were assigned to auto-titrating or sham CPAP without diagnostic testing for OSA. Change in Functional Independence Measure (FIM), a measure of disability, was assessed between rehabilitation admission and discharge. RESULTS Over 18 months, 40 patients were enrolled and 10 withdrew from the study: 7 from active and 3 from sham CPAP (p > 0.10). For the remaining 30 patients, median duration of CPAP use was 14 days. Average CPAP use was 3.7 h/night, with at least 4 h nightly use among 15 patients. Adherence was not influenced by treatment assignment or stroke severity. In intention-to-treat analyses (n = 40), the median change in FIM favored active CPAP over sham but did not reach statistical significance (34 versus 26, p = 0.25), except for the cognitive component (6 versus 2.5, p = 0.04). The on-treatment analyses (n = 30) yielded similar results (total FIM: 32 versus 26, p = 0.11; cognitive FIM: 6 versus 2, p = 0.06). CONCLUSIONS A sham-controlled CPAP trial among stroke rehabilitation patients was feasible in terms of recruitment, treatment without diagnostic testing and adequate blinding-though was limited by study retention and CPAP adherence. Despite these limitations, a trend towards a benefit of CPAP on recovery was evident. Tolerance and adherence must be improved before the full benefits of CPAP on recovery can be assessed in larger trials.
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Affiliation(s)
- Sandeep P Khot
- Department of Neurology, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Arielle P Davis
- Department of Neurology, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Deborah A Crane
- Department of Physical Medicine and Rehabilitation, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Patricia M Tanzi
- Department of Neurology, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Denise Li Lue
- Department of Physical Medicine and Rehabilitation, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Edward S Claflin
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
| | - Kyra J Becker
- Department of Neurology, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - W T Longstreth
- Department of Neurology, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Nathaniel F Watson
- Department of Neurology, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Martha E Billings
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
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25
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Mossa-Basha M, de Havenon A, Becker KJ, Hallam DK, Levitt MR, Cohen WA, Hippe DS, Alexander MD, Tirschwell DL, Hatsukami T, Amlie-Lefond C, Yuan C. Added Value of Vessel Wall Magnetic Resonance Imaging in the Differentiation of Moyamoya Vasculopathies in a Non-Asian Cohort. Stroke 2016; 47:1782-8. [PMID: 27272486 DOI: 10.1161/strokeaha.116.013320] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although studies have evaluated the differential imaging of moyamoya disease and atherosclerosis, none have investigated the added value of vessel wall magnetic resonance imaging (MRI). This study evaluates the added diagnostic value of vessel wall MRI in differentiating moyamoya disease, atherosclerotic-moyamoya syndrome (A-MMS), and vasculitic-MMS (V-MMS) with a multicontrast protocol. METHODS We retrospectively reviewed the carotid artery territories of patients with clinically defined vasculopathies (moyamoya disease, atherosclerosis, and vasculitis) and steno-occlusive intracranial carotid disease. Two neuroradiologists, blinded to clinical data reviewed the luminal imaging of each carotid, evaluating collateral extent and making a presumed diagnosis with diagnostic confidence. After 3 weeks, the 2 readers reviewed the luminal imaging+vessel wall MRI for the presence, pattern and intensity of postcontrast enhancement, T2 signal characteristics, pattern of involvement, and presumed diagnosis and confidence. RESULTS Ten A-MMS, 3 V-MMS, and 8 moyamoya disease cases with 38 affected carotid segments were included. There was significant improvement in diagnostic accuracy with luminal imaging+vessel wall MRI when compared with luminal imaging (87% versus 32%, P<0.001). The most common vessel wall MRI findings for moyamoya disease were nonenhancing, nonremodeling lesions without T2 heterogeneity; for A-MMS eccentric, remodeling, and T2 heterogeneous lesions with mild/moderate and homogeneous/heterogeneous enhancement; and for V-MMS concentric lesions with homogeneous, moderate enhancement. Inter-reader agreement was moderate to substantial for all vessel wall MRI characteristics (κ=0.46-0.86) and fair for collateral grading (κ=0.35). There was 11% inter-reader agreement for diagnosis on luminal imaging when compared with 82% for luminal imaging+vessel wall MRI (P<0.001). CONCLUSIONS Vessel wall MRI can significantly improve the differentiation of moyamoya vasculopathies when combined with traditional imaging techniques.
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Affiliation(s)
- Mahmud Mossa-Basha
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.).
| | - Adam de Havenon
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Kyra J Becker
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Danial K Hallam
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Michael R Levitt
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Wendy A Cohen
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Daniel S Hippe
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Matthew D Alexander
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - David L Tirschwell
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Thomas Hatsukami
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Catherine Amlie-Lefond
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Chun Yuan
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
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Becker KJ, Tanzi P, Zierath D, Buckwalter MS. Antibodies to myelin basic protein are associated with cognitive decline after stroke. J Neuroimmunol 2016; 295-296:9-11. [PMID: 27235342 DOI: 10.1016/j.jneuroim.2016.04.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 10/22/2022]
Abstract
B lymphocytes cause post-stroke cognitive decline in mice. We therefore evaluated the association between autoantibodies and post-stroke cognitive decline in a prospectively collected human cohort. The mini-mental state exam (MMSE) was administered 30, 90, 180, and 365days after stroke. Antibody titers to myelin basic protein (MBP), proteolipid protein, and several non-specific proteins were determined. Among 58 subjects with initial MMSE≥20 and at least 2 MMSE examinations in the year after stroke, cognitive decline (MMSE decrease ≥2) occurred in 10 (17%) subjects. In multivariate analysis, MBP antibody titers were the only independent predictor of cognitive decline (OR=9.02 [1.18, 68.90]; P=0.03).
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Affiliation(s)
- Kyra J Becker
- Department of Neurology, University of Washington School of Medicine, United States.
| | - Patricia Tanzi
- Department of Neurology, University of Washington School of Medicine, United States
| | - Dannielle Zierath
- Department of Neurology, University of Washington School of Medicine, United States
| | - Marion S Buckwalter
- Departments of Neurology and Neurological Sciences, and Neurosurgery, Stanford University School of Medicine, United States
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Becker KJ. Strain-Related Differences in the Immune Response: Relevance to Human Stroke. Transl Stroke Res 2016; 7:303-12. [PMID: 26860504 DOI: 10.1007/s12975-016-0455-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/31/2016] [Accepted: 02/02/2016] [Indexed: 02/07/2023]
Abstract
There are significant differences in the immune response and in the susceptibility to autoimmune diseases among rodent strains. It would thus be expected that the contribution of the immune response to cerebral ischemic injury would also differ among rodent strains. More importantly, there are significant differences between the immune responses of rodents and humans. All of these factors are likely to impact the successful translation of immunomodulatory therapies from experimental rodent models to patients with stroke.
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Affiliation(s)
- Kyra J Becker
- Department of Neurology, University of Washington School of Medicine, Harborview Medical Center, 325 9th Ave, Box 359775, Seattle, WA, 98104-2499, USA.
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Abstract
OBJECTIVES Patients admitted to the neurological or neurosurgical ICU are likely to have palliative care needs. The goals of this project are to encourage the ICU team to identify palliative care needs for patients and their families and potential ways to meet those needs. DESIGN Quality improvement project using a parallel-group prospective cohort design. SETTING Single neuro-ICU at a large, academic medical center. PATIENTS All patients admitted to the neuro-ICU from September 1, 2013, to November 30, 2013. INTERVENTIONS We developed a palliative care needs screening tool consisting of four questions: 1) Does the patient have distressing physical or psychological symptoms? 2) Are there specific support needs for patient or family? 3) Are treatment options matched with patient-centered goals? 4) Are there disagreements among teams and family? We implemented this daily screening tool on morning rounds for one of two neurocritical care services that alternate admitting days to a single neuro-ICU. We examined prevalence and nature of palliative care needs and actions to address those needs, comparing the services with and without screening. MEASUREMENTS AND MAIN RESULTS Over the 3-month period, 130 patients were admitted to the service with screening and 132 patients to the service without screening. The two groups did not differ with regard to age, gender, Glasgow Coma Scale, or diagnosis. Palliative care needs were identified in 62% of screened patients (80/130). Needs were mainly social support (53%) and establishing goals of care (28%). Screening was associated with more documented family conferences (p = 0.019) and a trend toward more palliative care consultations (p = 0.056). CONCLUSIONS We developed a brief palliative care needs screening tool that identified palliative care needs for 62% neuro-ICU patients. This tool was associated with actions to meet these needs, potentially improving care for patients and their families.
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Affiliation(s)
- Claire J Creutzfeldt
- 1Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA. 2Department of Pulmonary and Critical Care, University of Washington, Seattle, WA. 3Department of Neurocritical Care, University of Washington, Seattle, WA. 4Department of Neurology, University of Rochester, Rochester, NY
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Mossa-Basha M, Hwang WD, De Havenon A, Hippe D, Balu N, Becker KJ, Tirschwell DT, Hatsukami T, Anzai Y, Yuan C. Multicontrast High-Resolution Vessel Wall Magnetic Resonance Imaging and Its Value in Differentiating Intracranial Vasculopathic Processes. Stroke 2015; 46:1567-73. [PMID: 25953365 DOI: 10.1161/strokeaha.115.009037] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/08/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Although studies have attempted to differentiate intracranial vascular disease using vessel wall magnetic resonance imaging (VWI), none have incorporated multicontrast imaging. This study uses T1- and T2-weighted VWI to differentiate intracranial vasculopathies.
Methods—
We retrospectively reviewed patients with clinically defined intracranial vasculopathies causing luminal stenosis/irregularity who underwent VWI studies. Two blinded experts evaluated T1 precontrast and postcontrast and T2-weighted VWI characteristics, including the pattern of wall thickening; presence, pattern, and intensity of postcontrast enhancement; and T2 signal characteristics.
Results—
Twenty-one cases of atherosclerosis (intracranial atherosclerotic disease [ICAD]), 4 of reversible cerebral vasoconstriction syndrome, and 4 of vasculitis were identified, with a total of 118 stenotic lesions (81 ICAD, 22 reversible cerebral vasoconstriction syndrome, and 15 vasculitic lesions). There was substantial to excellent inter-reader agreement for the assessment of lesional T2 hyperintensity (
κ
=0.80), pattern of wall thickening (
κ
=0.87), presence (
κ
=0.90), pattern (
κ
=0.73), and intensity (
κ
=0.77) of enhancement. ICAD lesions were significantly more likely to have eccentric wall involvement (90.1%) than reversible cerebral vasoconstriction syndrome (8.2%;
P
<0.001) and vasculitic lesions (6.7%;
P
<0.001) and were also more likely to have T2 hyperintensity present than the other 2 vasculopathies (79% versus 0%;
P
<0.001). There were also significant differences in the presence, intensity, and pattern of enhancement between all lesion types. Combining T1 and T2 VWI increased the sensitivity of VWI in differentiating ICAD from other vasculopathies from 90.1% to 96.3%.
Conclusions—
Multicontrast VWI can be a complementary tool for intracranial vasculopathy differentiation, which often leads to more invasive workups when reversible cerebral vasoconstriction syndrome and vasculitis are in the differential diagnosis.
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Affiliation(s)
- Mahmud Mossa-Basha
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - William D. Hwang
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Adam De Havenon
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Daniel Hippe
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Niranjan Balu
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Kyra J. Becker
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - David T. Tirschwell
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Thomas Hatsukami
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Yoshimi Anzai
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
| | - Chun Yuan
- From the Departments of Radiology (M.M.-B., W.D.H., D.H., N.B., Y.A., C.Y.) Neurology (K.J.B., D.T.T.), and Vascular Surgery (T.H.), University of Washington, Seattle; Department of Neurology, University of Utah, Salt Lake City (A.D.H.)
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Morgenstern LB, Zahuranec DB, Sánchez BN, Becker KJ, Geraghty M, Hughes R, Norris G, Hemphill JC. Full medical support for intracerebral hemorrhage. Neurology 2015; 84:1739-44. [PMID: 25817842 DOI: 10.1212/wnl.0000000000001525] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 01/20/2015] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE This study tested the hypothesis that patients without placement of new do-not-resuscitate (DNR) orders during the first 5 days after intracerebral hemorrhage (ICH) have lower 30-day mortality than predicted by the ICH Score without an increase in severe disability at 90 days. METHODS This was a prospective, multicenter, observational cohort study at 4 academic medical centers and one community hospital. Adults (18 years or older) with nontraumatic spontaneous ICH, Glasgow Coma Scale score of 12 or less, who did not have preexisting DNR orders were included. RESULTS One hundred nine subjects were enrolled. Mean age was 62 years; median Glasgow Coma Scale score was 7, and mean hematoma volume was 39 cm(3). Based on ICH Score prediction, the expected overall 30-day mortality rate was 50%. Observed mortality was substantially lower at 20.2%, absolute average difference 29.8% (95% confidence interval: 21.5%-37.7%). At 90 days, 27.1% had died, 21.5% had a modified Rankin Scale score = 5 (severe disability). A good outcome (modified Rankin Scale score 0-3) was achieved by 29.9% and an additional 21.5% fell into the moderately severe disability range (modified Rankin Scale score = 4). CONCLUSIONS Avoidance of early DNR orders along with guideline concordant ICH care results in substantially lower mortality than predicted. The observed functional outcomes in this study provide clinicians and families with data to determine the appropriate goals of treatment based on patients' wishes.
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Affiliation(s)
- Lewis B Morgenstern
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine.
| | - Darin B Zahuranec
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Brisa N Sánchez
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Kyra J Becker
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Madeleine Geraghty
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Rebecca Hughes
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Gregory Norris
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - J Claude Hemphill
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
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Sulakvelidze N, Kelly AG, Ton TG, Becker KJ, Creutzfeldt CJ. Abstract T MP87: Information Framing And Decision-making After Malignant Middle Cerebral Artery Stroke. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tmp87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Objective:
In patients with malignant infarction of the middle cerebral artery (MCA), decompressive hemicraniectomy (DHC) reduces mortality and improves outcome but leaves many survivors severely disabled. In deciding whether to undergo this surgery, patients and surrogates look to providers for relevant prognostic information to help make treatment decisions based on their personal values. The goal of this study is to explore whether the way treatment information is framed influences decision-making regarding DHC.
Methods:
Ambulatory patients and their family members in hospital outpatient waiting rooms were recruited for this voluntary survey. Subjects were randomized to 1 of 5 different videos of a physician discussing treatment options for their loved one with a hypothetical acute malignant MCA ischemic stroke, each video with a different presentation format (positive or negative framing, reporting results in absolute or relative proportions, graphical display). Subjects were then asked to indicate their treatment decisions and to provide basic demographic data.
Results:
Fifty-three subjects were enrolled in the study, the majority of whom were insured (47; 88.7%), white (40; 78.4%) and independent (33; 64.7%). Half were 51 years or older (27; 50.9%) and had an income less than $50,000 annually (50.9%). Randomization arms did not differ according to age (p=0.5), functional status (p=0.3), income (p=0.9), insurance type (p=0.4) or race (p=0.8). Marital status differed slightly between arms (p=0.06). Controlling for marital status, subjects were most likely to choose surgery for their loved one (OR 6.9, 95% CI: 0.6, 77.8) after viewing video B (positive framing, relative risk reduction) and least likely (OR 0.8, 95% CI: 0.1-5.5) after viewing video C (negative framing, relative risk reduction) compared to those in the graphical group.
Conclusions:
Information framing may influence surrogate decision-making for DHC after malignant MCA ischemic stroke. Clinicians should consider this influence when counseling patients; formal decision aids or other methods to present results in a more standardized fashion may help mitigate these effects.
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Kirkness CJ, Becker KJ, Cain KC, Kohen R, Tirschwell DL, Teri L, Veith RR, Mitchell PH. Abstract W P125: Telephone versus In-person Psychosocial Behavioral Treatment in Post-Stroke Depression. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.wp125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
We previously showed that a brief psychosocial behavioral intervention delivered in-person by advanced practice nurses was effective in reducing post-stroke depression (PSD).
Purpose:
This randomized clinical trial compared a shortened (6 week) intervention by telephone or in-person to usual care in volunteers within 4 months of an ischemic or hemorrhagic stroke.
Methods:
100 stroke survivors who screened positive for depression (Geriatric Depression Score >11) were randomized to usual care (UC), telephone intervention (TI), or in-person intervention (IPI). Primary outcomes were percent reduction in the Hamilton Depression Rating Scale (HDRS) at 8 weeks, 21 weeks and 12 months following study entry. Outcome assessors were masked to randomization status.
Results:
All three groups had similar depression scores at baseline (HDRS mean 18 for UC and TI, 19 for IPI). The mean percent reduction in HDRS scores for telephone and in-person groups was 42% and 40% immediately following the intervention at 8 weeks compared to a 30% reduction in the usual care group. However the difference only trended toward significance, controlling for age, with older age associated with better response (p = 0.31). There was a greater early reduction in depression in the UC group than in our previous work (30% HDRS reduction vs 18% at 8 weeks). By 21 weeks and 12 months following entry there was no significant difference between groups in HDRS reduction (40% UC, 40% TI, 39% IPI and 37% UC, 42% TI and 44% IPI, respectively).
Conclusions:
A brief psychosocial intervention for PSD reduced depression somewhat more than usual care (p=.31) right after treatment but the difference between groups was even less at 21 weeks and one year following entry. The reduction in depression was slightly smaller than in our earlier study for the intervention groups, and the usual care group improved more. The comparability of telephone and in-person follow-up and treatment for depression is important given mandated post-hospital follow-up for comprehensive stroke centers. The improved response to brief therapy for older participants suggests tailoring of care to provide individualized follow-up.
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Affiliation(s)
| | | | | | - Ruth Kohen
- Psychiatry and Behavioral Science, Univ of Washington, Seattle, WA
| | | | - Linda Teri
- Psychosocial and Community Health, Univ of Washington, Seattle, WA
| | - Richard R Veith
- Psychiatry and Behavioral Sciences, Univ of Washington, Seattle, WA
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Sultan-Qurraie A, de Havenon A, Mossa-Basha M, Longstreth WT, Becker KJ, Tirschwell DL. Abstract T MP33: Younger Age And Anticoagulation Are Risk Factors For Pseudoaneurysm In Cases Of Cervical Arterial Dissection. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tmp33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Cervical artery dissection (CAD) is a frequent cause of ischemic stroke and pseudoaneurysm (PA) formation is a common complication. There is limited literature on the risk factors for PA formation. In particular, the influence of specific medical therapy for CAD_antiplatelet versus anticoagulation_is unknown. We hypothesized that anticoagulation in the treatment of CAD is a risk factor for PA formation.
Methods:
We retrospectively reviewed 250 cases of CAD admitted to a single hospital between 2011 and 2014. A neuroradiologist diagnosed CAD and PA by CTA. We reviewed patient charts for several risk factors: antithrombotic therapy, associated trauma, subsequent stroke, and age. Outcome (resolution or growth at 3 months) and largest size (at any point in time) of PA was recorded. Statistics were non-parametric.
Results:
35 patients had a diagnosis of CAD, PA, and follow-up vascular imaging at 3 months after onset. 27 patients presented concomitantly with CAD and PA; 8 patients later developed PA. Median patient age was 48 years, median PA length along longest axis was 8mm, 84% were treated with antiplatelets and 16% were treated with therapeutic anticoagulation. All patients treated with anticoagulation experienced PA growth versus 44% of those treated with antiplatelet agents (Fisher’s Exact p = 0.046). Younger age was also associated with PA growth (Wilcoxon rank sum test p = 0.0198) and there was a trend towards larger median pseudoaneurysm size in patients receiving anticoagulation (median size 17mm versus 5mm, p=0.09). Traumatic dissection and ischemic stroke were not associated with pseudoaneurysm development or size.
Discussion:
Our study finds that in the setting of CAD, treatment with anticoagulation and younger age are risk factors for PA growth; furthermore, patients on anticoagulation tend to have larger PAs. While the natural history of PAs is typically benign, many patients undergo invasive treatments and face the fear of other complications. Given the clinical equipoise surrounding CAD treatment, our findings may have important implications for patient care and should be replicated in a larger dataset.
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Bustamante A, Sobrino T, Giralt D, García-Berrocoso T, Llombart V, Ugarriza I, Espadaler M, Rodríguez N, Sudlow C, Castellanos M, Smith CJ, Rodríguez-Yánez M, Waje-Andreassen U, Tanne D, Oto J, Barber M, Worthmann H, Wartenberg KE, Becker KJ, Chakraborty B, Oh SH, Whiteley WN, Castillo J, Montaner J. Prognostic value of blood interleukin-6 in the prediction of functional outcome after stroke: a systematic review and meta-analysis. J Neuroimmunol 2014; 274:215-24. [PMID: 25091431 DOI: 10.1016/j.jneuroim.2014.07.015] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 11/24/2022]
Abstract
We aimed to quantify the association of blood interleukin-6 (IL-6) concentrations with poor outcome after stroke and its added predictive value over clinical information. Meta-analysis of 24 studies confirmed this association with a weighted mean difference of 3.443 (1.592-5.294) pg/mL, despite high heterogeneity and publication bias. Individual participant data including 4112 stroke patients showed standardized IL-6 levels in the 4th quartile were independently associated with poor outcome (OR=2.346 (1.814-3.033), p<0.0001). However, the additional predictive value of IL-6 was moderate (IDI=1.5%, NRI=5.35%). Overall these results indicate an unlikely translation of IL-6 into clinical practice for this purpose.
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Affiliation(s)
- Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain; Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Tomás Sobrino
- Department of Neurology, Clinical Neurosciences Research Laboratory, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Dolors Giralt
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Teresa García-Berrocoso
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Victor Llombart
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | | | - Marc Espadaler
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | | | - Cathie Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, UK
| | - Mar Castellanos
- Department of Neurology, Hospital Universitario Dr. Josep Trueta of Girona, Biomedical Research Institute of Girona, Spain
| | - Craig J Smith
- Stroke and Vascular Research Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, UK
| | - Manuel Rodríguez-Yánez
- Department of Neurology, Clinical Neurosciences Research Laboratory, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - David Tanne
- Sagol Neuroscience Center, Chaim Sheba Medical Center and Tel Aviv University, Israel
| | - Jun Oto
- University of Tokushima Graduate School, Japan
| | - Mark Barber
- Stroke Managed Clinical Network, NHS Lanarkshire, UK
| | - Hans Worthmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Katja E Wartenberg
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Germany
| | - Kyra J Becker
- Department of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, WA, United States
| | | | - Seung-Hun Oh
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | | | - José Castillo
- Department of Neurology, Clinical Neurosciences Research Laboratory, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain; Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain.
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35
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Creutzfeldt CJ, Tirschwell DL, Kim LJ, Schubert GB, Longstreth WT, Becker KJ. Seizures after decompressive hemicraniectomy for ischaemic stroke. J Neurol Neurosurg Psychiatry 2014; 85:721-5. [PMID: 23918640 DOI: 10.1136/jnnp-2013-305678] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The risk of seizures after malignant middle cerebral artery (MCA) infarction with decompressive hemicraniectomy (DHC) is uncertain. Also unknown is how this complication influences survivors' recovery and quality of life. METHODS We retrospectively reviewed medical charts of all patients admitted to Harborview Medical Center between 1 January 2002 and 31 June 2011 for space-occupying MCA ischaemic stroke and who underwent DHC. Survivors and their surrogates were invited to participate in a telephone or in-person interview. RESULTS Fifty-five patients were followed for a median of 311 days (IQR 134-727). Twenty-seven patients (49%) had seizures, 25 (45%) developed epilepsy and 21 (38%) achieved moderate disability or better (modified Rankin Scale score ≤3) by 1 year after stroke onset. The only factor significantly associated with seizure occurrence was male gender. Median time from stroke to first seizure was 222 days, with a cluster of first seizures within weeks after cranioplasty; only two of the first seizures occurred right around the time of stroke onset. Follow-up time was significantly longer for patients with seizures (605 days, IQR 297-882) than for those without (221 days, IQR 104-335). Of the 20 patients interviewed, 12 achieved moderate disability or better, 15 experienced a seizure with 6 indicating the seizure was a major drawback. Regardless, all 20 would have chosen DHC again. CONCLUSIONS In this case series, patients were at high risk of developing seizures after malignant MCA stroke with DHC, especially after cranioplasty. Assuming these findings are replicated, means should be sought to reduce the occurrence of this complication.
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Affiliation(s)
- C J Creutzfeldt
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - D L Tirschwell
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - L J Kim
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - G B Schubert
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - W T Longstreth
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - K J Becker
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
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Kunze A, Zierath D, Barclay T, Becker KJ. Abstract T MP119: Forced Swim Test as an Index of Post-Stroke Depression in Rats. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.tmp119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Depression is common after stroke. The Porsolt Forced Swim Test (FST) is used to screen for depression and response to therapy in rodent models. The duration of immobility is considered to be an indication of learned helplessness. In this study we aimed to characterize post-stroke depression using the FST.
Methods:
Male Lewis (N=6), Wistar (N=5), and Sprague Dawley (SD; N=11) rats were subjected to the FST (10 minutes) prior to 2 hours middle cerebral artery occlusion (MCAO) and then again at 28 days after MCAO. Sham-operated animals were used as controls. The latency to immobility and the duration of immobility were assessed along with the maximum velocity of movement. Blood was obtained at the time of sacrifice and assayed for interleukin (IL)-1α, IL-1β and IL-10. Statistics are non-parametric; data are displayed as median and interquartile range.
Results:
Prior to stroke, the latency to immobility was similar in all strains, but the duration of immobility was greater in Lewis rats (201 [159, 294] secs;
P
=0.039) than in Wistar (148 [106, 184] secs) and SD rats (136 [112, 200] secs). The maximal velocity of movement in Lewis rats (47 [42, 55] cm/sec;
P
=0.007) was faster than Wistar (29 [25, 41] cm/sec) and SD (39 [34, 46] cm/sec) rats. In comparison to strain matched sham-operated animals, stroke was associated with an
increase
in the period of immobility (P=0.088), a
decrease
in latency to immobility (
P
=0.019) and an
increase
in the maximal velocity of movements (
P
=0.033) in Lewis rats. No significant differences in FST behavior were seen in Wistar or SD rats. Plasma concentrations of IL-1α (P=0.001) and IL-10 (P=0.011) were highest in Lewis rats at the time of sacrifice. The duration of immobility was most highly correlated with IL-1β (r=0.663,
P
=0.003) and IL-10 (r=0.575,
P
=0.013).
Summary:
At baseline, Lewis rats exhibit more depressive behavior than Wistar and SD rats, and stroke appears to enhance these differences. The change in behavior on the FST is associated with an increase in markers of systemic inflammation. The FST could be used to study interventions for post-stroke depression.
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Sultan-Qurraie A, de Havenon A, Tirschwell DL, Sharma D, Ghodke B, Hallam D, Kim L, Becker KJ. Abstract T P21: Improved Ischemic Stroke Outcomes After Intra-Arterial Interventions Associated With Higher HDL Cholesterol. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.tp21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background/Objective:
The effect of pre-morbid lipid levels on neurologic outcome after Acute Ischemic Stroke (AIS) is variable in the published literature. In this study, we retrospectively use a cohort to evaluate the relationship of cholesterol subfractions to outcome.
Methods:
The cohort consists of AIS patients treated with IA therapy between September 2008 and December 2010. Favorable outcome for these analyses was defined as a modified Rankin Scale of ≤ 3 at time of discharge. Univariate associations with favorable outcome were sought for demographic, co-morbidity, stroke risk factor, and procedure related variables. Independent associations were identified by relative risk regression using generalized linear models with a logit link, a Poisson distribution for variance and robust standard errors. All analyses were performed in STATA.
Results:
The cohort included 42 patients; mean age was 62 years, 62% were women, median pre-procedure NIHSS was 16, 70% of patients achieved a mRS ≤ 3. Univariate analysis suggested significance of a number of variables with favorable outcome. In multivariate analysis only three variables-previous tobacco use, highest procedural SBP, and history of atrial fibrillation-remained significant. Adding LDL to the multivariate model did not show association, though adding HDL as a continuous variable did show an association. Results are shown in the table.
Conclusions:
In our cohort there was no association between favorable outcome at time of discharge and LDL, but higher HDL was associated with an increased chance of good outcome. While this association between HDL and outcome is reported for patients treated with intravenous tPA, it is novel for patients treated with IA therapy and warrants further study. Our data collection is ongoing and we aim to double the size of our dataset; the updated analyses will be presented at the meeting.
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Kunze A, Zierath D, Drogomiretskiy O, Jaspers B, Barclay T, Becker KJ. Abstract T P81: Long-Term Activity Levels Vary by Rat Strain Following Stroke: A Disruption of the Circadian Rhythm? Stroke 2014. [DOI: 10.1161/str.45.suppl_1.tp81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Assessment of long-term behavioral outcome after experimental cerebral ischemia is important for evaluating potential therapeutic interventions. In this study, we explored strain related differences in baseline behavior and in response to stroke.
Methods:
Spontaneous cage activity was monitored (cm moved per hr) and analyzed before and after 2 hour middle cerebral artery occlusion (MCAO) in male Lewis, Wistar, and Sprague Dawley (SD) rats using the Noldus PhenoTyper® cages and EthoVision® Software system. Stroke severity was assessed using the neuroscore, foot fault errors, and performance on the rotarod. Infarct volume at 24 hours was determined in a second cohort of animals. Animals were sacrificed 56 days after MCAO. Data are analyzed using non-parametric statistics.
Results:
Prior to stroke, the median distance moved per hour during the dark was similar among the 3 strains, but Lewis rats were more active during the light cycle (P=0.001). Neuroscores did not differ between strains at 3 hrs after MCAO nor did infarct volumes at 24 hours after MCAO. Lewis rats, however, performed worse on the rotarod in the month following MCAO (P<0.05 at each time point). Foot fault errors were similar throughout the study period. After stroke, Lewis rats became more active during the dark cycle while Wistar and SD rats became more active during the light cycle (Figure).
Summary:
The 3 strains of rats evaluated in this study had different patterns in the change in activity after MCAO. Lewis rats showed an increase in activity during the dark cycle while Wistar and SD rats showed an increase in activity during the light cycle. This observation suggests that there are genetic differences in the response to stroke that may alter the circadian rhythm after stroke.
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Kunze A, Zierath D, Tanzi P, Becker KJ. Abstract W P229: Reduction of Peroxiredoxin 5 Concentration in Patients following Ischemic Stroke. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.wp229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
There is a marked inflammatory response within the brain after stroke. Peroxiredoxins (PRXs) are endogenous anti-oxidant proteins, but recent data suggest that PRXs may be responsible for initiating inflammation in the brain following cerebral ischemia. In this study we evaluated the relationship between PRX5 and biomarkers of inflammation following ischemic stroke.
Methods:
In a prospective study of patients with ischemic stroke, PRX5 concentrations were determined by standard ELISA in plasma samples (N=98) obtained at 3 days after stroke onset. Relationships between stroke severity, biomarkers of inflammation and stroke outcome were explored.
Results:
At 3 days after stroke, PRX5 concentrations were significantly lower in patients with severe stroke (NIHSS ≥17; 37.6 ng/mL [28.5, 45.3]) as compared to patients with moderate stroke (NIHSS 6-16; 48.0 ng/mL [36.5, 88.6]) or mild stroke (NIHSS ≤5; [40.5, 76.3]);
P
=0.001. PRX5 was inversely correlated with the number of white blood cells, neutrophils, and monocytes as well as with plasma CRP, TNF-α, IL-6, IL-10 and IL-2. None of these correlations remained significant after controlling for stroke severity. Patients with higher plasma PRX5 at 3 days were more likely to have good outcome (mRS≤2) at 3 months (
P
=0.019), but this relationship was lost after controlling for stroke severity.
Discussion:
Plasma concentrations of PRX5 are decreased in patients with severe stroke and inversely correlated with biomarkers of inflammation. These data suggest that the initiator of systemic inflammation after stroke is not PRX5. Further, they show that severe brain injury leads to a loss of circulating anti-oxidant proteins.
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Keller E, Becker KJ. Advances in critical care/emergency medicine 2013. Stroke 2014; 45:359-60. [PMID: 24436241 DOI: 10.1161/strokeaha.113.004223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Emanuela Keller
- From the Neurocritical Care Unit, Department of Neurosurgery, University of Zurich, Zurich, Switzerland (E.K.); and Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle (K.B.)
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Zaidat OO, Castonguay AC, Nguyen TN, Becker KJ, Derdeyn CP, Nelson PK, Amarenco P, Brott TG. Impact of SAMMPRIS on the future of intracranial atherosclerotic disease management: polling results from the ICAD symposium at the International Stroke Conference. J Neurointerv Surg 2013; 6:225-30. [DOI: 10.1136/neurintsurg-2013-010667] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tirschwell DL, Becker KJ, Creutzfeldt CJ, Gallo M, Longstreth WT. Abstract TMP83: Propensity Score Matching to Estimate Supported Outcomes in Intracerebral Hemorrhage Patients with Withdrawal of Life Support. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.atmp83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Observational reports suggest that a self-fulfilling prognostic pessimism may lead to withdrawal of life support (WOLS) in patients with more severe intracerebral hemorrhages (ICHs) who might otherwise have acceptable clinical outcomes. Our objective was to estimate what outcomes in a cohort of ICH patients might have been if they did not have WOLS.
Methods:
Multivariate modeling was used to create a propensity score (PS) for WOLS in a Seattle single center cohort of ICH patients with hospital discharge modified Rankin Scale (mRS) as the primary outcome. Using nearest neighbor matching, individual ICH patients with WOLS were matched to individual ICH patients without WOLS and baseline variables and outcome were compared.
Results:
The cohort comprised 590 ICH patients with mean age of 67 years, 42% women, 76% white and 18% WOLS. Factors used to create the PS for WOLS included age, pre-ICH mRS, GCS, ICH volume, intraventricular hemorrhage, pre-existing hypertension, diabetes and atrial fibrillation, first temperature and intubation. Matches were possible for 78 WOLS/non-WOLS pairs. Groups were well matched on all PS factors, mean age (67 years), GCS (6.4), ICH volume (59cc) and % intubation (59). Discharge mRS in the both groups varied from 3-6 and was for the WOLS group 1.3%, 2.6%, 6.4% and 90% respectively; in the matched non-WOLS group discharge mRS was 6.4%, 32%, 24% and 37% respectively (difference p<0.0005). Using mRS <= 4 at discharge as an acceptable outcome, % in WOLS/non-WOLS were 4%/38% (difference p<0.0005).
Conclusions:
The proportion of ICH patients with WOLS that might have had an acceptable outcome without WOLS was ~38%. This discharge “acceptable outcome” of mRS <= 4 assumes eventual recovery to better function in many. The 34% absolute difference in WOLS/non-WOLS outcomes suggests that for every 3 fewer ICH patients with WOLS, one more patient might have an acceptable clinical outcome. This proportion would vary depending on an individual patient’s interpretation of what constitutes an acceptable outcome.
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Affiliation(s)
| | - Kyra J Becker
- Harborview Med Cntr - Univ. of Washington, Seattle, WA
| | | | - Marisa Gallo
- Harborview Med Cntr - Univ. of Washington, Seattle, WA
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Schepp SK, Becker KJ, Longstreth W, Tirschwell DL. Abstract TP397: Validation of a Pneumonia Score in Acute Stroke. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.atp397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION:
Accurate prediction of pneumonia (PNA) risk after stroke would 1) allow clinicians to target interventions to patients at highest risk, and 2) help researchers to determine the efficacy of those interventions. We previously derived a PNA risk score based on data available at the time of admission, purposefully leaving out information on swallowing function, which may not be available at time of admission. Items for the 11-point score and point values were: age > 75 (2), male (1), National Institutes of Health Stroke Scale score > 10 (2), mechanical ventilation (4), coronary artery disease (1), chronic obstructive pulmonary disease (1). In a retrospective single-hospital cohort of 1,924 patients with acute ischemic stroke and intracranial hemorrhage (ICH), we used medical records and discharge diagnosis codes to derive the score: C-statistic = .79 (95% CI, .76 - .81). In the current study, we tested whether the score could accurately predict PNA in two other cohorts.
METHODS:
The one cohort (n=398 with acute ischemic stroke or ICH) was obtained retrospectively and presented to various hospitals within the same city during a time period prior to the derivation cohort. Data on predictor variables and the outcome of PNA were obtained from medical records and discharge diagnosis codes. The other cohort (n=89 with acute ischemic stroke) was a subset of the derivation cohort. Data were collected prospectively, and the diagnosis of PNA was ascertained using rigorous criteria that included clinical, radiographic, and culture data.
RESULTS:
Within the retrospective cohort, PNA was diagnosed in 46 (12%), and the score achieved a C-statistic of .71 (95% CI, .66 -.75). Within the prospective cohort, pneumonia was diagnosed in 9 (10%), and the C-statistic for the score was .88 (95% CI, .79 -.94).
CONCLUSION:
The predictive value of the PNA score was validated in two additional cohorts, one with data collected retrospectively and the other, prospectively. The score performed best within the prospective cohort, but sample size was relatively small and the 89 patients were a subset of the derivation cohort. Further refinement and validation of the score is planned.
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Creutzfeldt CJ, Becker KJ, Schubert GB, Longstreth WT, Tirschwell DL. Abstract WP377: Outcome After Stroke - “Good” Or “Poor”? Stroke 2013. [DOI: 10.1161/str.44.suppl_1.awp377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The modified Rankin Scale (mRS) is a commonly used instrument to measure outcome in stroke research and is often dichotomized into good and poor outcome. Quality of life (QoL) is likely affected by factors besides level of disability. The goal of this study was to assess the correlation between the mRS and a more patient-centered QOL measure, the European QoL visual analog scale (EQVAS).
Methods:
The Medic One Stroke Study reviewed pre-hospital and hospital records from 11 acute care hospitals in the Seattle area from June 2000-January 2003. Subjects with a final hospital diagnosis of stroke were telephoned 3-4 months after stroke onset and both mRS (0-6, with 0 the best) and EQ VAS (0-100 with 100 best) were assessed.
Results:
We identified 574 patients with stroke: 420 ischemic stroke (IS), 121 intraparenchymal hemorrhage (IPH) and 33 subarachnoid hemorrhage (SAH). At three months after discharge, the proportion with mRS of ≤ 3 varied significantly with stroke type: 50% IS, 20% IPH, and 27% SAH (p<0.001). Similarly, good quality of life, defined as EuroQoL ≥ 75, occurred in 48% IS, 25% IPH, and 27% SAH (p<0.001). Spearman’s rho showed a strong correlation of 0.89 (p<0.001) between mRS and EuroQoL. Likelihood of good QoL progressively decreased with increasing mRS (82%, 58%, 33%, 31%, 21%, 11% for mRS 0-5, respectively, p<0.001), yet a number of patients with high mRS (4,5) still reported good QoL (16/102 = 16%). Among patients with low mRS (0,1), 32% did not achieve good QoL.
Conclusion:
Following stroke, QoL decreases with increasing mRS, but exceptions exist with good QoL despite high mRS scores. In the endeavor to advance patient-centeredness as a core component of quality health care, factors other than disability need further exploration, both by researchers doing clinical trials as well as by physicians making treatment recommendations.
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Kwok H, Schubert GB, Longstreth WT, Becker KJ, Tirschwell D. Abstract WMP64: Prehospital Triage To Comprehensive Stroke Centers: GCS Identifies Patients At Increased Risk For Death, ICH, Or SAH. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.awmp64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION:
Regionalization of stroke care is occurring nationwide, but evidence-based criteria for prehospital triage to comprehensive stroke centers are lacking. We assessed the hypothesis that a prehospital clinical decision rule can identify a group of patients more likely to require comprehensive stroke services--those with an increased risk of in-hospital mortality, ICH, or SAH.
METHODS:
This study represents a retrospective cohort of patients seen by an urban EMS system from 2000-2003. Subjects were included if they had either a prehospital diagnosis of “stroke/TIA” or a prehospital diagnosis of “decreased level of consciousness” or “headache” and signs and symptoms suggestive of a cerebrovascular event. The primary outcome was a composite of in-hospital mortality, ICH, or SAH. Multivariate logistic regression was used to derive a clinical prediction rule.
RESULTS:
In 1682 subjects, the discharge diagnoses included TIA (n = 282, 17%), ischemic stroke (n = 433, 26%), ICH (n = 102, 6%), and SAH (n = 30, 2%). There were 221 patients (13%) who experienced the primary outcome: 67 (4%) with non-fatal ICH or SAH and 154 (9%) who died. Using GCS score alone, the area under ROC curve was 0.72, and GCS ≤ 10 resulted in a sensitivity of 0.48 (95%CI 0.42, 0.55) and specificity of 0.88 (95%CI 0.87, 0.90). A six-point prehospital stroke triage score (PSTS) was also derived: nausea/vomiting (1 point), systolic BP ≥ 175 (1 point), GCS 7-10 (2 points) and GCS 3-6 (4 points). The area under ROC curve for the PSTS was 0.74. Test characteristics for PSTS and GCS were similar (Table).
CONCLUSION:
GCS alone performed similarly to a six-point clinical decision rule for the prehospital identification of patients at increased risk of death, ICH or SAH. GCS has potential utility as a criterion for the prehospital triage to comprehensive stroke centers.
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Sheth KN, Martini SR, Tirschwell DL, Becker KJ, Worrall BB, James ML, Sung G, Brown M, Langefeld C, Osborne J, Moomaw CJ, Woo D. Abstract 49: Withdrawal of Care in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.a49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Withdrawal of care (WOC) during hospitalization is the most common cause of death after intracerebral hemorrhage (ICH). Prior work suggests minority groups are less likely to choose WOC. Our goal was to evaluate for differences in rates of WOC among racial/ethnic groups from the ERICH cohort.
Methods:
ERICH is an ongoing multicenter study of genetic and environmental risk factors for spontaneous ICH. We analyzed data from the first 725 individuals. Baseline characteristics,do not resuscitate (DNR) status, intensive care procedures, and WOC were prospectively recorded. A central core analyzed all imaging. We compared characteristics among patients with and without eventual WOC and by race/ethnicity. Logistic regression was used to identify variables independently associated with WOC and associations are presented as the odds ratio (95% confidence interval).
Results:
9.9% (72/725) of patients underwent WOC. After controlling for age, ICH volume, initial Glasgow Coma Scale (GCS) score, and presence of intraventricular hemorrhage (IVH), there were no significant differences in WOC between non-Hispanic white, non-Hispanic black (OR 1.82; CI 0.78-4.25), and Hispanic (OR 2.16; CI 0.93-5.00) patients. There were also no differences in rates of DNR/DNI status across racial/ethnic groups. In multivariate analysis, patients who underwent WOC had larger ICH volume (1.75; 1.13-2.73); were older (1.43; 1.27-1.61), more likely to have IVH (3.21; 1.53-6.73), and had lower GCS (2.41; 1.63-3.56). While patients who underwent WOC were more likely to have a DNR/DNI order (12.7; 4.69-34.7), intubated patients were more likely to undergo WOC (4.09; 1.08-9.25), even after adjusting for ICH severity.
Conclusions:
In our cohort, we were able to model ICH severity and factors predictive of WOC. There were not significant racial/ethnic differences in WOC rates. Intubated patients are more likely to undergo care limitations, independent of ICH severity.
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Affiliation(s)
| | | | | | | | | | | | - Gene Sung
- Univ of Southern California, Los Angeles, CA
| | - Mark Brown
- Wake Forest Sch of Medicine, Winston-Salem, NC
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Abstract
Infection is common after stroke and is independently associated with a worse outcome. The predisposition to infection following stroke is in part related to a sympathetically mediated suppression of the peripheral immune response. The teleological explanation for this immune dysfunction is that it serves to prevent autoimmune responses to brain antigens. We believe that the systemic immune response in patients who develop infection, however, thwarts this seemingly protective response and predisposes to central nervous system autoimmunity. These autoimmune responses may mediate, at least in part, the worse outcome associated with post-stroke infection.
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Affiliation(s)
- Kyra J Becker
- University of Washington School of Medicine, Harborview Medical Center, Seattle, WA, USA.
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Donohue MM, Cain K, Zierath D, Shibata D, Tanzi PM, Becker KJ. Higher plasma fractalkine is associated with better 6-month outcome from ischemic stroke. Stroke 2012; 43:2300-6. [PMID: 22798324 DOI: 10.1161/strokeaha.112.657411] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Fractalkine (CX3CL1) is a unique chemokine that is constitutively expressed on neurons where it serves as an adhesion molecule for lymphocytes and monocytes. CX3CL1 may also be cleaved from the surface of these cells and enter the circulation to act as a traditional chemokine. CX3CL1 could thus influence the inflammatory response after stroke. We hypothesized that patients with higher plasma CX3CL1 after stroke would have a more robust inflammatory response and experience worse outcome. METHODS Plasma CX3CL1 concentrations were assessed in 85 patients who were part of a larger study evaluating immune responses after ischemic stroke; CX3CL1 values were available from Day 1 to Day 180 after stroke onset. CX3CL1 was correlated to measures of inflammation and its effect on outcome assessed. RESULTS At 1 day after stroke, CX3CL1 was lower in patients with severe strokes. At 180 days after stroke, CX3CL1 concentrations were lower in patients with poor outcome. The association of CX3CL1 and outcome at 180 days was independent of initial stroke severity. Plasma CX3CL1 at 180 days was inversely associated with systemic markers of inflammation, including white blood cell counts and high-sensitivity C-reactive protein. CONCLUSIONS In contrast to our original hypothesis, lower concentrations of CX3CL1 are associated with worse stroke outcome. In light of recent studies suggesting an immunomodulatory and neuroprotective role for CX3CL1 in a variety of neurodegenerative diseases, a therapeutic role for CX3CL1 in stroke recovery should be considered.
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Affiliation(s)
- Megan M Donohue
- Departments of Neurology, University of Washington School of Medicine, Seattle, WA, USA
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49
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Sultan-Qurraie A, Tirschwell DL, Longstreth WT, Becker KJ, Kay M. Abstract 3603: Emergency Pre-hospital Stroke Triage In Washington State, Understood Through A Cohort. Stroke 2012. [DOI: 10.1161/str.43.suppl_1.a3603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Washington State (WA) has legislated an emergency pre-hospital stroke triage system, with 3 levels of self-identified stroke centers. Our objective is to describe the new system using an existing cohort of pre-hospital patients and to extrapolate our findings to all of WA.
METHODS:
The cohort consisted of a population-based sample of patients whom emergency medical service (EMS) personnel treated over a 30-month period. All patients whose Seattle Fire Department records suggested a possible pre-hospital stroke diagnosis had hospital records reviewed for final diagnosis: TIA, ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or “not a stroke.” These patients were also classified according to the FAST (Face, Arm, Speech, Time last normal) stroke screen. The WA pre-hospital stroke triage tool divides patients into 4 groups: FAST-, FAST+/>6h (arrived at hospital > 6 or unknown hours after last known normal), FAST+/>3.5-6h (arrived in window for intra-arterial (IA) therapies) and FAST+/<=3.5h (arrived in window for IV tPA).
RESULTS:
The cohort included 1,682 possible stroke patients, mean age 76 years, 60% women. We applied the stroke triage tool to our cohort with results shown in the
Table
. Assuming similar stroke presentations and given the population of WA is ∼11 times that of Seattle, we estimate that ∼2500 patients/yr would be triaged as possible IV tPA candidates; ∼450 patients/yr would be triaged as possible IA candidates with possibly longer transport to a Level 1 stroke center. There was significant heterogeneity in final diagnoses by triage tool categorization (
Table
, P < 0.0005). The triage tool identified combined IV or IA candidates with a sensitivity of 90% (95% CI 83-94%), specificity 91% (90-93%) and C statistic of .90 (.88-.93). Of the 10% of IV or IA candidates missed, 81% had initial NIHSSs < 3.
CONCLUSION:
These are the first estimates of how the WA pre-hospital stroke triage tool will parse patients. Discrimination of acute ischemic stroke patients eligible for time dependent interventions was excellent; the low NIHSS scores in 81% of those missed suggests an even higher clinically relevant sensitivity. A small proportion (2.4%) of the possible stroke patients presenting to EMS will meet criteria for transport to Level 1 stroke centers, suggesting the additional burden on EMS should be minimal.
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Creutzfeldt CJ, Schubert GB, Tirschwell DL, Longstreth WT, Becker KJ. Abstract 155: Risk of Seizures after Malignant MCA Stroke and Decompressive Hemicraniectomy. Stroke 2012. [DOI: 10.1161/str.43.suppl_1.a155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Post-stroke seizures (PSS) have a devastating effect on morale and may further impair an already compromised quality of life. The reported incidence of PSS is 5-12%, but may be higher in patients with malignant MCA stroke requiring decompressive hemicraniectomy. Seizure prophylaxis for stroke survivors is not recommended, and little guidance exists about the use of prophylactic antiepileptic drugs (AEDs) after neurosurgical procedures. We aimed to determine the incidence of seizures after hemicraniectomy in stroke survivors and to identify risk factors for development of seizures after stroke. Via telephone interview, we explored patients own experience after their stroke.
Methods
We reviewed charts of patients aged 18-99 with malignant MCA infarction who underwent decompressive hemicraniectomy from Jan 1, 2002 to Dec 31, 2008. We looked for seizures that occurred after their stroke and for clinical and imaging factors related to those. All patients who consented to a telephone interview were contacted to inquire about seizure history. Seizure-free survival analysis was used, with log rank testing for associations.
Results
We identified 38 patients, mean follow-up time was 504 days (IQR 140-857). Nearly half of patients suffered a seizure (18/38) and the seizures were difficult to control in 9/18. Four patients suffered their first seizure during initial hospitalization. For 14/18, the first seizure occurred after or around cranioplasty and mostly at home. Perioperative seizure prophylaxis was variable and did not influence seizure occurrence. Older age showed a trend towards increased seizure risk (log rank p=.09). Neither gender, race, severity, location or hemorrhagic transformation were associated with development of post-stroke seizures. Modified Rankin Scale score (mRS) at discharge was 4 or above in all patients. By last follow-up, 17/38 patients had a mRS of 3 or better. Patients who suffered a seizure did not feel well prepared for the possibility of PSS, and for some the seizures were considered a major setback. Among those who responded to the questionnaire (n=14, 12 had seizures), all would have wanted to know whether or not they were at high risk for developing PSS, and would have opted to take anti-epileptic medications for seizure prophylaxis.
Conclusions
The frequency of seizures after malignant MCA stroke requiring decompressive hemicraniectomy is higher than expected, and the seizures often difficult to control.
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