BACKGROUND AND PURPOSE:The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural ...areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata.
METHODS:Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme.
RESULTS:There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis4.2% versus 9.2%, adjusted odds ratio, 0.55 95% CI, 0.51–0.59, P<0.001; endovascular therapy1.63% versus 2.41%, adjusted odds ratio, 0.64 0.57–0.73, P<0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%, P<0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 0.94–1.0, P=0.086; large towns, 1.05 1.01–1.09, P=0.009; small towns, 1.10 1.06–1.15, P<0.001; micropolitan rural, 1.16 1.11–1.21, P<0.001; and remote rural 1.21 1.15–1.27, P<0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 1.00–1.26, P<0.001) to 2017 (adjusted odds ratio, 1.27 1.13–1.42, P<0.001).
CONCLUSIONS:Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.
Poststroke depression (PSD) is common, affecting approximately one third of stroke survivors at any one time after stroke. Individuals with PSD are at a higher risk for suboptimal recovery, recurrent ...vascular events, poor quality of life, and mortality. Although PSD is prevalent, uncertainty remains regarding predisposing risk factors and optimal strategies for prevention and treatment. This is the first scientific statement from the American Heart Association on the topic of PSD. Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific Statements Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion. This multispecialty statement provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice.
Little is known about the contribution of obesity to the higher mortality risk among stroke survivors. We assessed the independent association between body mass index (BMI) and mortality among stroke ...survivors.
Cross-sectional and prospective data from a nationally representative survey of noninstitutionalized civilian U.S. population aged 25 or older (n=20 050) with a baseline history of stroke (n=644) followed up from survey participation (1988-1994) through mortality assessment in 2000. Relationships between BMI and mortality attributable to all causes or cardiovascular causes were examined after adjusting for established prognosticators after stroke.
Stroke survivors were more likely to be overweight (BMI 25 to 29 kg/m2) or obese (BMI > or =30 kg/m2 than those without stroke (64.3% versus 53.2%, P=0.003). In multivariable analysis, overall risk for all-cause mortality increased per kg/m2 of higher BMI (P=0.030), but an interaction between age and BMI (P=0.009) revealed that the association of higher BMI with mortality risk was strongest in younger individuals and declined linearly with increasing age, such that in the elderly, overweightness and obesity had a protective effect. The results were similar for the cardiovascular mortality outcome.
Higher BMI after stroke is associated with a greater risk of all-cause and cardiovascular death among younger individuals. Younger stroke survivors may especially benefit from more vigorous efforts to monitor and treat obesity.
OBJECTIVES/GOALS: We created an online, competency-based training program for Healthcare Delivery Science (HDS) that incorporates a wide range of disciplines and best educational practices. ...METHODS/STUDY POPULATION: In collaboration with a curriculum design expert and thirteen content experts from multiple schools and departments, we reviewed and adapted a published set of competencies for learning health system researchers. We followed educational best practices to collaboratively create learning objectives, aligned content with the objectives, and created quiz questions that addressed the objectives. After recording the coursework and building the program in a learning management system, we tested, evaluated, and revised the courses. RESULTS/ANTICIPATED RESULTS: The systematic approach resulted in a novel set of eight online courses: Introduction to Healthcare Delivery Science, Research Methods, Dissemination & Implementation Science, Behavioral Economics, Leadership & Management, Quality Improvement, Systems Engineering, and Multi-Stakeholder Engagement. The courses are applicable to learners from diverse fields, including medicine, public health, pharmacy, engineering, health system administration, and translational science. Students can earn digital badges for individual courses and a certificate of completion for the entire set of courses. DISCUSSION/SIGNIFICANCE: Compared to previously available offerings, the new training program offers a more comprehensive view of this important field. Next, we plan to develop additional courses and create a Masters program that includes synchronous learning and a complementary experiential component for hands-on application of HDS principles.
In the United States, 32% of beverages consumed by adults and 19% of beverages consumed by children in 2007 to 2010 contained low-calorie sweeteners (LCSs). Among all foods and beverages containing ...LCSs, beverages represent the largest proportion of LCS consumption worldwide. The term LCS includes the 6 high-intensity sweeteners currently approved by the US Food and Drug Administration and 2 additional high-intensity sweeteners for which the US Food and Drug Administration has issued no objection letters. Because of a lack of data on specific LCSs, this advisory does not distinguish among these LCSs. Furthermore, the advisory does not address foods sweetened with LCSs. This advisory reviews evidence from observational studies and clinical trials assessing the cardiometabolic outcomes of LCS beverages. It summarizes the positions of government agencies and other health organizations on LCS beverages and identifies research needs on the effects of LCS beverages on energy balance and cardiometabolic health. The use of LCS beverages may be an effective strategy to help control energy intake and promote weight loss. Nonetheless, there is a dearth of evidence on the potential adverse effects of LCS beverages relative to potential benefits. On the basis of the available evidence, the writing group concluded that, at this time, it is prudent to advise against prolonged consumption of LCS beverages by children. (Although water is the optimal beverage choice, children with diabetes mellitus who consume a balanced diet and closely monitor their blood glucose may be able to prevent excessive glucose excursions by substituting LCS beverages for sugar-sweetened beverages SSBs when needed.) For adults who are habitually high consumers of SSBs, the writing group concluded that LCS beverages may be a useful replacement strategy to reduce intake of SSBs. This approach may be particularly helpful for persons who are habituated to a sweet-tasting beverage and for whom water, at least initially, is an undesirable option. Encouragingly, self-reported consumption of both SSBs and LCS beverages has been declining in the United States, suggesting that it is feasible to reduce SSB intake without necessarily substituting LCS beverages for SSBs. Thus, the use of other alternatives to SSBs, with a focus on water (plain, carbonated, and unsweetened flavored), should be encouraged.
Little is known about the effects of a healthy lifestyle on mortality after stroke. This study assessed whether five healthy lifestyle factors had independent and dose dependent associations with ...all-cause and cardiovascular mortality after stroke.
In a nationally representative sample of the US population (n=15,299) with previous stroke (n=649) followed from survey participation (1988-1994) through to mortality assessment (2000), the relationship between five factors (eating ≥5 servings of fruits/vegetables per day, exercising >12 times/month, having a body mass index of 18.5-29.9 mg/kg(2), moderate alcohol use 1 drink/day for women and 2 drinks/day for men and not smoking) and all-cause and cardiovascular mortality was assessed.
Mean age was 67.0 years (SE 1.1 years) and 53% were women. After adjusting for covariates, abstaining from smoking (HR 0.57, CI 0.34 to 0.98) and exercising regularly (HR 0.66, CI 0.44 to 0.99) were associated with lower all-cause mortality but no individual factors had independent associations with cardiovascular mortality. All-cause mortality decreased with higher numbers of healthy behaviours (1-3 factors vs none: HR 0.12, CI 0.03 to 0.47; 4-5 factors vs none: HR 0.04, CI 0.01 to 0.20; 4-5 factors vs 1-3 factors: HR 0.38, CI 0.22 to 0.66; trend p=0.04). Similar effects were observed for cardiovascular mortality (4-5 factors vs none: HR 0.08, CI 0.01 to 0.66; 1-3 factors vs none: HR 0.15, CI 0.02 to 1.15; 4-5 factors vs 1-3 factors: HR 0.53, CI 0.28 to 0.98; trend p=0.18).
Regular exercise and abstinence from smoking were independently associated with lower all-cause mortality after stroke. Combinations of healthy lifestyle factors were associated with lower all-cause and cardiovascular mortality in a dose dependent fashion.
Background Little is known about the effect of region of origin on all-cause mortality, cardiovascular mortality, and stroke mortality among Black individuals. We examined associations between ...nativity and mortality (all-cause, cardiovascular, and stroke) in Black individuals in the United States. Methods and Results Using the National Health Interview Service 2000 to 2014 data and mortality-linked files through 2015, we identified participants aged 25 to 74 years who self-identified as Black (n=64 717). Using a Cox regression model, we examined the association between nativity and all-cause, cardiovascular, and stroke mortality. We recorded 4329 deaths (205 stroke and 932 cardiovascular deaths). In the model adjusted for age and sex, compared with US-born Black individuals, all-cause (hazard ratio HR, 0.44 95% CI, 0.37-0.53) and cardiovascular mortality (HR, 0.66 95% CI, 0.44-0.87) rates were lower among Black individuals born in the Caribbean, South America, and Central America, but stroke mortality rates were similar (HR, 1.01 95% CI, 0.52-1.94). African-born Black individuals had lower all-cause mortality (HR, 0.43 95% CI, 0.27-0.69) and lower cardiovascular mortality (HR, 0.42 95% CI, 0.18-0.98) but comparable stroke mortality (HR, 0.48 95% CI, 0.11-2.05). When the model was further adjusted for education, income, smoking, body mass index, hypertension, and diabetes, the difference in mortality between foreign-born Black individuals and US-born Black individuals was no longer significant. Time since migration did not significantly affect mortality outcomes among foreign-born Black individuals. Conclusions In the United States, foreign-born Black individuals had lower all-cause mortality, a difference that was observed in recent and well-established immigrants. Foreign-born Black people had age- and sex-adjusted lower cardiovascular mortality than US-born Black people.
The purpose of this study was to provide the first correlative study of the hyperdense middle cerebral artery sign (HMCAS) and gradient-echo MRI blooming artifact (BA) with pathology of retrieved ...thrombi in acute ischemic stroke.
Noncontrast CT and gradient-echo MRI studies before mechanical thrombectomy in 50 consecutive cases of acute middle cerebral artery ischemic stroke were reviewed blinded to clinical and pathology data. Occlusions retrieved by thrombectomy underwent histopathologic analysis, including automated quantitative and qualitative rating of proportion composed of red blood cells (RBCs), white blood cells, and fibrin on microscopy of sectioned thrombi.
Among 50 patients, mean age was 66 years and 48% were female. Mean (SD) proportion was 61% (±21) fibrin, 34% (±21) RBCs, and 4% (±2) white blood cells. Of retrieved clots, 22 (44%) were fibrin-dominant, 13 (26%) RBC-dominant, and 15 (30%) mixed. HMCAS was identified in 10 of 20 middle cerebral artery stroke cases with CT with mean Hounsfield Unit density of 61 (±8 SD). BA occurred in 17 of 32 with gradient-echo MRI. HMCAS was more commonly seen with RBC-dominant and mixed than fibrin-dominant clots (100% versus 67% versus 20%, P=0.016). Mean percent RBC composition was higher in clots associated with HMCAS (47% versus 22%, P=0.016). BA was more common in RBC-dominant and mixed clots compared with fibrin-dominant clots (100% versus 63% versus 25%, P=0.002). Mean percent RBC was greater with BA (42% versus 23%, P=0.011).
CT HMCAS and gradient-echo MRI BA reflect pathology of occlusive thrombus. RBC content determines appearance of HMCAS and BA, whereas absence of HMCAS or BA may indicate fibrin-predominant occlusive thrombi.
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