Thrombolytic therapy in ischemic stroke patients with pre-stroke depression in the telestroke vs non-telestroke

Background and PurposeThrombolysis therapy remains the gold standard in acute ischemic stroke treatment, and rates of treatment with rtPA in ischemic stroke patients with comorbid depression has yet to be fully investigated. This study aims to examine clinical risk factors associated with inclusion or exclusion for rtPA in acute ischemic stroke populations with pre-stroke depression in the telestroke versus a non-telestroke setting.MethodsWe collected retrospective data from a regional stroke registry for pre-stroke depressed ischemic stroke patients from January 2010 to June 2016. Logistic regression was used to determine demographic and baseline clinical risk factors associated with inclusion and exclusion from rtPA.Results. In the adjusted analysis, increasing age (OR = 1.064, 95% CI, 1.006-1.125, P = 0.029), improved ambulation (OR = 3.513, 95% CI, (0.855–14.436, P = 0.018) and sleep apnea (OR = 4.458, 95% CI, 0.731–27.182, P = 0.05) were associated with inclusion for rtPA, while Caucasian race (OR = 0.119, 95% CI, 0.0168–0.908, P = 0.040), systolic blood pressure (OR = 0.945, 95% CI, 0.906–0.985, P = 0.008), and direct admission (OR = 0.028, 95% CI, 0.003–0.317, P = 0.004) were associated with exclusion from rtPA. In the telestroke setting, INR (OR = 1.016, 95% CI, 0–5.393, P = 0.163) was not significantly associated with rtPA inclusion or exclusion.ConclusionIdentifying contraindicators associated with exclusion from rtPA is significant to improve the use thrombolytic therapy in the telestroke and non telestroke settings.     

Effects of nighttime sleep duration and sex on the association between siesta and hypertension

ObjectiveTo examine the association between siesta and hypertension by sex and nighttime sleep duration among Chinese adults aged ≥35 years in Yinzhou, Ningbo City.MethodsAll data were obtained from physical examinations and structured questionnaires. A total of 44, 652 participants were included. Logistic regression models were applied to calculate odds ratios and 95% confidence intervals for the association between siesta and hypertension.ResultsWhen compared with no siesta, siesta durations of 60∼89 min (OR = 1.10, 95% CI:1.04–1.17) and ≥90 min (OR = 1.21, 95% CI:1.08–1.36) were associated with higher risk of hypertension in women. But no significant association was observed in men. Siesta durations of 30∼59 min (OR = 1.09, 95% CI:1.00–1.19) and 60–89 min (OR = 1.10, 95% CI:1.05–1.16) were associated with hypertension in people with 6∼8 h sleep, and this association appeared seemingly stronger with ≥90 min siesta either in short (<6 h) sleepers (OR = 1.20, 95% CI: 0.99–1.47) or in long (>8 h) sleepers (OR = 1.29, 95% CI: 1.00–1.68). However, in short sleepers, 60∼89 min siesta seemed to be associated with decreased risk of hypertension (OR = 0.95, 95% CI: 0.85–1.06); while in long sleepers, the same range of siesta seemed to be associated with increased risk of hypertension (OR = 1.11, 95% CI: 0.93–1.34).ConclusionLong siesta was associated with increased risk of hypertension in women but not in men. Not too long siesta may be related to decreased risk of hypertension in short sleepers but not in people with adequate or even long sleep. These findings warrant further examination with prospective studies and laboratory investigations.     

Association of ischemic and hemorrhagic strokes hospital admission with extreme temperature in Nanchang,China—A case-crossover study

Despite consistent evidence of a higher short-term risk of stroke mortality associated with ambient temperature, there are no findings on the association between extreme temperature and stroke. A total of 16,264 stroke hospital admissions were observed in three hospitals of Nanchang between 2008 and 2015. The case-crossover design was utilized for our study. Conditional logistic regression models were used to calculate the odds ratios. Extreme high temperature exposure during the 3 days before the stroke was associated with both ischemic (OR = 1.18; 95% CI: 1.07–1.36) and hemorrhagic stroke admissions (OR = 1.34; 95% CI: 1.26–1.42) as compared to 3-day control periods (1–3 days last week before the onset of stroke). Extreme low temperature was associated with hemorrhagic stroke admission (OR = 1.42; 95% CI: 1.28–1.58) but not ischemic stroke (OR = 1.06; 95% CI: 0.93–1.13). This study suggests that extreme high temperature might be a risk factor for both hemorrhagic and ischemic strokes, and that extreme low temperature might be a risk factor of hemorrhagic stroke. Further studies are necessary in order to clarify this relationship and provide evidence for stroke prevention.     

Effects of argatroban therapy for stroke patients: A meta-analysis

BackgroundThe therapeutic efficacy and safety of argatroban for stroke patients remain controversial. The purpose of this study was to collect all evidence and perform a meta-analysis to comprehensively evaluate the effects of argatroban for stroke patients compared with no-argatroban regimens.MethodsThe databases of PubMed, EMBASE and the Cochrane library were searched from their inception up to December 2020. Categorical outcomes were summarized as odds ratio (OR) and 95% confidence interval (CI); while continuous data were pooled as standardized mean difference (SMD) and 95%CI.ResultsA total of 11 studies were enrolled. Overall meta-analysis showed infusion of argatroban significantly improved neurological functions of stroke patients compared with control treatment, showing increased National Institutes of Health Stroke Scale (NIHSS) score change (SMD = 1.02; 95% CI, 0.58–1.46, p < 0.001), modified Barthel Index (SMD = 3.81; 95% CI, 2.72–4.89, p < 0.001) as well as a decreased incidence of early neurological deterioration (OR = 0.48; 95% CI: 0.28–0.84, p = 0.01). Argatroban treatment did not increase the risk of symptomatic intracerebral hemorrhage (p = 0.733), asymptomatic intracranial hemorrhage (p = 0.608), gastrointestinal bleeding (p = 0.601), major systemic hemorrhage (p = 0.582) and mortality (p = 0.797), except minor systemic hemorrhage (OR = 2.40; 95% CI: 1.15–5.02, p = 0.020). Subgroup analyses for NIHSS score change and complications obtained the similar conclusions.ConclusionArgatroban infusion may be an effective and safe therapeutic option to improve functional outcomes of stroke patients.     

Cognitive disorders associated with hospitalization of COVID-19: Results from an observational cohort study

IntroductionOur understanding of risk factors for COVID‑19, including pre-existing medical conditions and genetic variations, is limited. To what extent the pre-existing clinical condition and genetic background have implications for COVID-19 still needs to be explored.MethodsOur study included 389,620 participants of European descent from the UK Biobank, of whom 3,884 received the COVID-19 test and 1,091 were tested positive for COVID-19. We examined the association of COVID-19 status with an extensive list of 974 medical conditions and 30 blood biomarkers. Additionally, we tested the association of genetic variants in two key genes related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2), with COVID-19 or any other phenotypes.ResultsThe most significant risk factors for COVID-19 include Alzheimer’s disease (OR = 2.29, 95% CI: 1.25–4.16), dementia (OR = 2.16, 95% CI: 1.36–3.42), and the overall category of delirium, dementia, amnestic and other cognitive disorders (OR = 1.90, 95% CI: 1.24–2.90). Evidence suggesting associations of genetic variants in SARS-CoV-2 infection-related genes with COVID-19 (rs7282236, OR = 1.33, 95% CI: 1.14–1.54, p = 2.31 × 10⁻⁴) and other phenotypes, such as an immune deficiency (p = 5.65 × 10⁻⁵) and prostate cancer (p = 1.1 × 10⁻⁵), was obtained.ConclusionsOur unbiased and extensive search identified pre-existing Alzheimer’s disease and dementia as top risk factors for hospital admission due to COVID-19, highlighting the importance of providing special protective care for patients with cognitive disorders during this pandemic. We also obtained evidence suggesting a direct association of genetic variants with COVID-19.     

Predictors of Early Stroke or Death in Patients Undergoing Transcatheter Aortic Valve Implantation

Background/ObjectiveWhile postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI.MethodsA cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure.ResultsIncidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3–7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06–6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95–27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5–6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45–144.39]; p < .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99–21.29]; p = .002) were at significantly higher risk of death within the 30-day period.ConclusionIn this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.     

Study of association of severity of sleep disordered breathing and functional outcome in stroke patients

ObjectiveSleep disordered breathing (SDB) is a prevalent yet underrecognized condition that may have major adverse consequences for those affected by it. We performed a prospective observational study to seek a correlation of severity of SDB with the severity of stroke and its functional outcome.MethodsPatients with history of recent-onset stroke were recruited and underwent overnight polysomnography (PSG) after the acute phase of the stroke was over; for defining hypopneas, 3% and 4% desaturation limits were used, and the apnea−hypopnea index was respectively calculated as AHI_3% and AHI_4%. Stroke severity was graded using the Scandinavian Stroke Scale. Functional disability and neurological impairment was evaluated six weeks after the PSG using the Barthel Index (<80 = functional dependence; ≥80 = functional independence) and modified Rankins Scale (>2 = poor outcome; ≤2 = good outcome).ResultsA total of 50 patients were enrolled, 30 (60%) with ischemic stroke and 20 (40%) with hemorrhagic strokes. Of the patients, 39 (78%) had an AHI_4% of >5/h, 23 (46%) had an AHI_4% of >15/h, and 9 (18%) had an AHI_4% of >30/h. Multivariate analysis showed that body mass index (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.04–1.54, p = 0.019) and Scandinavian Stroke Scale score (stroke severity) (OR = 0.86; 95% CI = 0.76–0.96, p = 0.009) were significant risk factors for predicting SDB (AHI_4% > 15) in patients of stroke. When we looked for factors predicting outcomes, only AHI_4% (OR = 1.20; 95% CI 1.01–1.43, p value 0.041) was predictive of the functional dependence (based on Barthel Index) of the patient and AHI_4% (OR = 1.14; 95% CI 1.03–1.25, p = 0.008) and body mass index (OR = 0.75; 95% CI 0.59–0.96, p = 0.024) were found to be predictive of poor outcome (based on modified Rankins Scale). We obtained similar results, regardless of the hypopnea definition used.ConclusionIn conclusion, given the high frequency of SDB in stroke patients and its correlation with poor outcome, screening for obstructive sleep apnea in all stroke and transient ischemic attack patients may be warranted.     

Maternal sleep quality during early pregnancy,risk factors and its impact on pregnancy outcomes: a prospective cohort study

ObjectivesWe aimed to assess the prevalence of poor sleep quality during early pregnancy and its risk factors, and to explore the association between sleep quality and adverse pregnancy outcomes.MethodsThis was a prospective birth cohort study that included 4352 pregnant women. Sleep quality were assessed using the Pittsburgh Sleep Quality Index (PSQI). The risk factors for poor sleep quality were analyzed by a logistic regression model. Log-binomial regression models were used to analyze the association between sleep quality and pregnancy outcomes.ResultsThe prevalence of maternal poor sleep quality during early pregnancy was 34.14%. The multivariate logistic model showed that stillbirth history (OR = 2.45; 95% CI: 1.34, 4.47), history of induced abortion (OR = 1.26; 95% CI: 1.07, 1.49), general health-related quality of life (OR = 3.98; 95% CI: 2.97, 5.34), insufficient physical activity (OR = 1.18; 95% CI: 1.03, 1.36), smoking (OR = 1.59; 95% CI: 1.18, 2.15), and vegetarian (OR = 2.18; 95% CI: 1.54, 3.08) were risk factors for poor sleep quality, while taking folic acid consistently before pregnancy (OR = 0.83; 95% CI: 0.72,0.97) was the protective factor. After controlling for all the confounders, poor sleep quality during early pregnancy increased the risk of premature rupture of membranes by 12% (95% CI: 1.00, 1.25).ConclusionPregnant women with a history of stillbirth and induced abortion, general health-related quality of life, insufficient physical activity, smoking, and a vegetarian diet tended to have poor sleep quality. More attention should be paid to healthy lifestyle of pregnant women to improve sleep quality and better pregnancy outcomes.     

Medication errors in Parkinson's disease inpatients in the Basque Country

IntroductionParkinson's disease (PD) medication errors, including both missing dopaminergic drug doses and antidopaminergic usage, have been suggested as risk factors for prolonged hospital stays. The objective of this study was to evaluate the prevalence of such errors in PD patients admitted to public acute-care hospitals in the Basque Country over a two year period and their association with clinically relevant adverse health outcomes, such as length of hospital stay and mortality.MethodsAll PD patients admitted to any of the 11 public acute-care hospitals in the Basque Country in 2011–2012 were included. Medication errors involved incorrect timing or the complete omission of administration for dopaminergic drugs, and the administration of centrally acting antidopaminergics. A logistic regression and a competing risk analysis were applied to verify whether those errors affected intrahospital mortality and length of stay.ResultsThe study included 1628 patients admitted 2546 times. Medication errors, affecting almost one third of admissions and half of patients, were associated with higher mortality: inappropriately omitted dopaminergic drug doses OR = 1.92 CI 95% (1.34–2.76); inappropriate antiemetic administration OR = 2.15 CI 95% (1.36–3.39); and inappropriate antipsychotic administration OR = 1.91 CI 95% (1.33–1.73). Inappropriately omitted doses and both inappropriate antipsychotic and antiemetic administration were associated with a significant 4-day increase in median hospital stay.ConclusionMedication errors (missing dopaminergic drug doses and centrally acting antidopaminergic use) are not only associated with increased length of hospital stays in PD patients, but also with a higher mortality rate.     

Care-needs Certification in the National Long-Term Care Insurance is Useful for Assessment of Premorbid Function in Older Japanese Patients with Stroke

ObjectiveTo investigate the effects of premorbid long-term care insurance (LTCI) care-need certification on functional improvement during acute hospitalization in older patients with stroke.MethodsIn this single-center prospective cohort study, we assessed LTCI care-needs certification and the modified Rankin Scale (mRS) at the premorbid stage, on admission, and at hospital discharge in older patients with stroke. We also assessed adverse events during hospitalization. The main outcome was the presence of functional improvement during hospitalization (mRS on admission < mRS at discharge). Multivariate analysis was performed to investigate the relationship between functional improvement and premorbid LTCI care-need certification.ResultsIn total, 246 older patients with stroke were enrolled in this study. There was a significant independent association between premorbid LTCI care-needs certification (care level 1 = odds ratio [OR]: 0.26, 95% CI: 0.10–0.72, p = 0.01; Care level 2 = OR: 0.27, 95% CI: 0.10–0.73, p = 0.01; care level 3–5 = OR: 0.21, 95% CI: 0.08–0.56, p = 0.002; Not applicable = reference) and functional improvement.ConclusionsPremorbid LTCI care-need certification is associated with short-term functional improvement in older patients with stroke. Assessment of premorbid LTCI care-needs certification is valid for predicting functional improvement in older patients with stroke.     

Prevalence,causes and risk factors of hospital readmissions after acute stroke and transient ischemic attack: a systematic review and meta-analysis

Acute stroke and transient ischemic attack (TIA) is a great burden not only during hospitalization but also after hospital discharge. The objective of this meta-analysis was to evaluate the hospital readmissions, causes and risk factors after survival of acute stroke and TIA. Pubmed, Web of Science, Cochrane Library, OVID and EMBASE databases were searched to identify studies reporting hospital readmissions after acute stroke and TIA. The primary outcomes were hospital readmission rates during 30 days and 1 year after discharge. The primary causes and risk factors of hospital readmissions were also identified. Ten studies with 253,680 patients were eligible for inclusion. The pooled 30-day and 1-year hospital readmission rates were 17.4 % (95 % CI, 12.7–23.5 %) and 42.5 % (95 % CI, 34.1–51.3 %), respectively. The three major causes of 30-day hospital readmissions were infection (19.9 %), coronary artery disease (CAD) (17.8 %) and recurrent stroke (16.0 %) successively, while the three major causes were recurrent stroke (19.4 %), infection (19.3 %) and CAD (16.3 %) during 1 year’s follow-up. There were more patients with CAD in readmits group than that in control group (p = 0.030). The length of index admission, defined as any eligible admission to an acute care hospital assessed in the measure for the outcome, was longer (p = 0.000) and admission National Institutes of Health Stroke Score (NIHSS) was higher (p = 0.002) in readmits group than these in control group. In conclusion, there is high risk of early and long-term hospital readmissions after survival of acute stroke and TIA. These patients with coronary artery disease, longer length of index admission and higher NIHSS deserve deep attention after hospital discharge.     

Frailty and outcomes after craniotomy for brain tumor

Frailty has been associated with increased morbidity and mortality in a variety of surgical disciplines. Few data exist regarding the relationship of frailty with adverse outcomes in craniotomy for brain tumor resection. We assessed the relationship between frailty and the incidence of major post-operative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after elective craniotomy for brain tumor resection. A retrospective cohort study was conducted on 20,333 adult patients undergoing elective craniotomy for tumor resection in the 2012–2018 ACS-NSQIP Participant Use File. Multivariate logistic regression was performed using all covariates deemed eligible through clinical and statistical significance. 6,249 patients (30.7%) were low-frailty and 2,148 patients (10.6%) were medium-to-high frailty. In multivariate logistic regression adjusting for age, gender, BMI, ASA classification, smoking status, dyspnea, significant pre-operative weight loss, chronic steroid use, bleeding disorder, tumor type, and operative time, low frailty was associated with increased adjusted odds ratio of major complication (1.41, 95% CI: 1.23–1.60, p < 0.001), discharge destination other than home (1.32, 95% CI: 1.20–1.46, p < 0.001), 30-day readmission (1.29, 95% CI: 1.15–1.44, p < 0.001), and 30-day mortality (1.87, 95% CI: 1.41–2.47, p < 0.001). Moderate-to-high frailty was also associated with increased adjusted odds of major complication (1.61, 95% CI: 1.35–1.92, p < 0.001), discharge destination other than home (1.80, 95% CI: 1.58–2.05), 30-day readmission (1.39, 95% CI: 1.19–1.62, p < 0.001), and 30-day mortality (2.42, 95% CI: 1.74–3.38, p < 0.001).ConclusionsFrailty is associated with increased odds of major post-operative complication, discharge to destination other than home, 30-day readmission, and 30-day mortality.     

El bloqueo interatrial avanzado predice recurrencia de infarto cerebral embólico de origen no determinado

BackgroundAdvanced interatrial block (IAB) is an independent risk factor for ischaemic stroke. This study aimed to analyse whether advanced IAB predicts recurrence of embolic stroke of undetermined source (ESUS).Methods104 patients with a confirmed diagnosis of ESUS were followed up for a median period of 15 months (interquartile range, 10-48). We recorded data on clinical variables, P-wave characteristics, and presence of IAB on the electrocardiogram. Electrocardiogram findings were interpreted by a blinded, centralised rater at (XXXX2). ESUS recurrence was the primary outcome variable.ResultsMedian age was 47 years (range, 19-85); 50% of patients were women. IAB was detected in 36 patients (34.6%); IAB was partial in 29 cases (27.9%) and advanced in 7 (6.7%). Sixteen patients (15.4%) presented stroke recurrence; of these, 5 had partial and 4 had advanced IAB (P = .01; odds ratio [OR] = 9.44; 95% confidence interval [CI], 1.88-47.46; relative risk [RR] = 4.62; 95% CI, 2.01-10.61). Median P-wave duration was longer in patients with stroke recurrence (P = .009). The multivariate logistic regression analysis identified the following independent risk factors for stroke recurrence: advanced IAB (P < .001; OR = 10.86; 95% CI, 3.07-38.46), male sex (P = .028; OR = 4.6; 95% CI, 1.18-17.96), and age older than 50 years (P = .039; OR = 3.84; 95% CI, 1.06-13.88). In the Cox proportional hazards model, the risk variables identified were age older than 50 years (P = .002; hazard ratio, 7.04; 95% CI, 2.06-23.8) and P-wave duration (per ms) (P = .007; hazard ratio, 1.02; 95% CI, 1.01-1.04).ConclusionsAdvanced IAB and age older than 50 years predict ESUS recurrence.     

The Association of Psychiatric Comorbidities With Short-Term and Long-Term Outcomes Following Spinal Cord Stimulator Placement

BackgroundOutcomes after spinal cord stimulator (SCS) placement are affected by psychologic comorbidities. It is part of routine practice to do psychologic assessments prior to SCS trials to assess for the presence of maladaptive behavioral patterns. However, few studies have sought to quantify the effect of psychiatric comorbidities on complications, reoperation, and readmission rates. The purpose of this study was to assess the association of psychiatric comorbidities with postprocedural outcomes after SCS implantation.Materials and MethodsInclusion criteria included SCS placement between 2015 and 2020 (percutaneous approach or an open laminectomy-based approach) using Healthcare Corporation of America National Database. Data on psychiatric comorbidities present at the time of SCS implantation surgery were collected. Outcomes of interest included complication rates (defined as lead migration, fracture, malfunction, battery failure, postoperative pain, infection, dural puncture, or neurological injury), reoperation rates (defined as either revision or explant [ie, removal]), and readmission rates within 30-day and 1-year time after SCS implantation. We measured the association between psychiatric comorbidities and outcomes using multivariable regression and reported odds ratio (OR) and respective 95% confidence intervals.ResultsA total of 12,751 cases were included. The most common psychiatric comorbidities were major depressive disorder (16.1%) and anxiety disorder (13.4%). In unadjusted univariate analysis, patients with any psychiatric comorbidity had heightened rates of any complication (27.1% vs 19.4%), infection (5.9% vs 1.9%), lead displacement (2.2% vs 1.3%), surgical pain (2.1% vs 1.2%), explant (14.7% vs 8.8%), and readmission rates at one year (54.2% vs 33.8%) (all p < 0.001). In multivariable logistic regression, with each additional psychiatric comorbidity, a patient had increased odds of experiencing any complication (OR = 1.5, 95% CI = 1.36–1.57, p < 0.001), requiring a reoperation (OR = 1.5, 95% CI = 1.37–1.6, p < 0.001), and requiring readmission (OR = 1.7, 99% CI = 1.6–1.8, p < 0.001).ConclusionsThe presence of psychiatric comorbidities was found to be associated with postoperative complication rates, reoperation, and readmission rates after SCS placement. Furthermore, each consecutive increase in psychiatric comorbidity burden was associated with increased odds of complications, reoperation, and readmission. Future studies might consider examining the role of presurgical mental health screening (ie, patient selection, psychologic testing) and treatment in optimizing outcomes for patients with psychiatric comorbidities.     

Specific causes and predictors of readmissions following acute and chronic subdural hematoma evacuation

Patients treated with craniotomy for subdural hematoma (SDH) evacuation have a higher readmission incidence when compared to other neurosurgical patients. Factors predictive of readmission following craniotomy for SDH are incompletely understood. The National Surgical Quality Improvement (NSQIP) database was queried for all patients treated by craniotomy for SDH of any etiology (e.g. acute, chronic, spontaneous, traumatic) during the study period (2012–2014). Patients requiring repeat hospitalization within 30 days of surgery were identified and classified by reason for readmission. Binary logistic regression analysis was used to identify predictors of readmission. 1024 patients met inclusion criteria, among whom 109 (10.6%) were readmitted within 30 days. The most common causes of readmission were recurrent SDH (n = 27; 33.3%), seizure (n = 8; 9.9%), new neurological deficit (n = 6; 7.4%), stroke (n = 6; 7.4%), and altered mental status (AMS) (n = 6; 7.4%). Multivariable modeling identified hypertension requiring medication (OR = 2.78, P = 0.013) and abnormal INR (OR = 2.66, P = 0.035) as significantly associated with readmission following chronic SDH, while postoperative UTI (OR = 3.64, P = 0.01) and stroke (OR = 4.86, P = 0.018) were significant predictors of readmission following acute SDH. Readmission was associated with recurrent hemorrhage after chronic/spontaneous SDH, while seizures, AMS, and neurological deficits drove readmissions after acute/traumatic SDH. Careful management of anticoagulation and antihypertensive medications may be helpful in reducing the risk of readmission following craniotomy for chronic SDH.     

Sleep,suicide behaviors,and the protective role of sleep medicine

Objective/BackgroundSleep disturbance is associated with suicidal thoughts and behaviors. The relationship of specific sleep disorders to suicide attempts is less well established. Whether treating sleep disorders reduces suicide attempts remains controversial.MethodsSuicide attempts, treatment utilization, and psychiatric diagnoses were extracted from electronic medical records and a suicide attempt database from the U.S. Department of Veterans Affairs. The sample (N = 60,102) consisted of patients with any record of suicide attempt in FY13-14 and a 1:1 case-control of patients with no record of attempt, who were propensity score-matched based on age, gender, and prior year mental health treatment utilization. Associations among sleep disorders and suicide attempt were examined via logistic regression. Covariates included depression, anxiety, posttraumatic stress disorder (PTSD), bipolar, schizophrenia, substance use disorder (SUD), medical comorbidity, and obesity.ResultsInsomnia (OR = 5.62; 95% CI, 5.39–5.86), nightmares (odds ratio, OR = 2.49; 95% confidence interval, CI, 2.23–2.77), and sleep-related breathing disorders (OR = 1.37; 95% CI, 1.27–1.48) were positively associated with suicide attempt after accounting for age, gender, treatment utilization, and comorbid sleep disorders. Furthermore, when controlling for depression, anxiety, PTSD, bipolar, schizophrenia, substance use disorder (SUD), medical comorbidity, and obesity, insomnia (OR = 1.51, 95% CI, 1.43–1.59) remained positively associated with suicide attempt nightmares (OR = 0.96; 95% CI, 0.85–1.09) nor sleep-related breathing disorders (OR = 0.87, 95% CI = 0.79–0.94). Additionally, sleep medicine visits 180 days prior to index date were associated with decreased likelihood of suicide attempt for individuals with sleep disorders (OR = 0.86; 95% CI, 0.79–0.94).ConclusionInsomnia is associated with suicide attempt among veterans. Sleep medicine visits were associated with a reduced risk of suicide attempt in sleep disordered patients. The assessment and treatment of sleep disorders should be considered in context of strategies to augment suicide prevention efforts.     

CYP metabolic pathway related gene polymorphism increases the risk of embolic and atherothrombotic stroke and vulnerable carotid plaque in southeast China

ObjectiveTo investigate the association of CYP metabolic pathway-related genetic polymorphisms with the susceptibility to ischemic stroke and stability of carotid plaque in southeast China.MethodsWe consecutively enrolled 294 acute ischemic stroke patients with carotid plaque and 282 controls from Wenling First People's Hospital. The patients were divided into the carotid vulnerable plaque group and stable plaque group according to the results of carotid B-mode ultrasonography. Polymorphisms of CYP3A5 (G6986A, rs776746), CYP2C9*2 (C430T, rs1799853), CYP2C9*3 (A1075C, rs1057910), and EPHX2 (G860A, rs751141) were determined using polymerase chain reaction and mass spectrometry analysis.ResultsEPHX2 GG may reduce the susceptibility to ischemic stroke (OR = 0.520, 95% CI: 0.288 ∼ 0.940, P = 0.030) and AA+AG may increase the risk for ischemic stroke (OR = 1.748, 95% CI: 1.001 ∼ 3.052, P = 0.050). The distribution of CYP3A5 genotypes showed significant differences between the vulnerable plaque and stable plaque groups (P = 0.026). Multivariate logistic regression analysis found that CYP3A5 GG could reduce the risk of vulnerable plaques (OR = 0.405, 95% CI: 0.178 ∼ 0.920, P = 0.031).ConclusionEPHX2 G860A polymorphism may reduce the stroke susceptibility, while other SNPs of CYP genes are not associated with ischemic stroke in southeast China. Furthermore CYP3A5 polymorphism was related with carotid plaque instability.     

Increased stroke severity and mortality in patients with SARS-CoV-2 infection: An analysis from the N3C database

BackgroundStudies from early in the COVID-19 pandemic showed that patients with ischemic stroke and concurrent SARS-CoV-2 infection had increased stroke severity. We aimed to test the hypothesis that this association persisted throughout the first year of the pandemic and that a similar increase in stroke severity was present in patients with hemorrhagic stroke.MethodsUsing the National Institute of Health National COVID Cohort Collaborative (N3C) database, we identified a cohort of patients with stroke hospitalized in the United States between March 1, 2020 and February 28, 2021. We propensity score matched patients with concurrent stroke and SARS-COV-2 infection and available NIH Stroke Scale (NIHSS) scores to all other patients with stroke in a 1:3 ratio. Nearest neighbor matching with a caliper of 0.25 was used for most factors and exact matching was used for race/ethnicity and site. We modeled stroke severity as measured by admission NIHSS and the outcomes of death and length of stay. We also explored the temporal relationship between time of SARS-COV-2 diagnosis and incidence of stroke.ResultsOur query identified 43,295 patients hospitalized with ischemic stroke (5765 with SARS-COV-2, 37,530 without) and 18,107 patients hospitalized with hemorrhagic stroke (2114 with SARS-COV-2, 15,993 without). Analysis of our propensity matched cohort revealed that stroke patients with concurrent SARS-COV-2 had increased NIHSS (Ischemic stroke: IRR=1.43, 95% CI:1.33–1.52, p<0.001; hemorrhagic stroke: IRR=1.20, 95% CI:1.08–1.33, p<0.001), length of stay (Ischemic stroke: estimate = 1.48, 95% CI: 1.37, 1.61, p<0.001; hemorrhagic stroke: estimate = 1.25, 95% CI: 1.06, 1.47, p=0.007) and higher odds of death (Ischemic stroke: OR 2.19, 95% CI: 1.79–2.68, p<0.001; hemorrhagic stroke: OR 2.19, 95% CI: 1.79–2.68, p<0.001). We observed the highest incidence of stroke diagnosis on the same day as SARS-COV-2 diagnosis with a logarithmic decline in counts.ConclusionThis retrospective observational analysis suggests that stroke severity in patients with concurrent SARS-COV-2 was increased throughout the first year of the pandemic.