Race-Ethnic Disparities in 30-Day Readmission After Stroke Among Medicare Beneficiaries in the Florida Stroke Registry

Objective: To examine racial/ethnic disparities in 30-day all-cause readmission after stroke. Methods: Thirty-day all-cause readmission was compared by race/ethnicity among Medicare fee-for-service beneficiaries discharged for ischemic stroke from hospitals in the Florida Stroke Registry from 2010 to 2013. We fit a Cox proportional hazards model that censored for death and adjusted for age, sex, length of stay, discharge home, and comorbidities to assess racial/ethnic differences in readmission. Results: Among 16,952 stroke patients (54% women, 75% white, 8% black, and 15% Hispanic), 30-day all-cause readmission was 15% (17.2% for blacks, 16.7% for Hispanics, 14.4% for whites, and 14.7% for others; P = .003). There was a median of 11 days between discharge and first readmission. In adjusted analyses, there was no significant difference in readmission for blacks (hazard ratio 1.15, 95% confidence interval 0.99-1.33), Hispanics (1.00, .90-1.13), and those of other race/ethnicity (.91, .71-1.16) compared with whites. Nearly 1 in 4 readmissions were attributable to acute cerebrovascular events: 16.6% ischemic stroke or transient ischemic attack, 1.5% hemorrhagic stroke, and 5.2% cerebral artery interventions. Interventions were more common among whites and those of other race than blacks and Hispanics (P = .029). Readmission due to pneumonia or urinary tract infection was 8.2%. Conclusions: Readmissions attributable to acute cerebrovascular events were common and generally occurred within 2 weeks of hospital discharge. Racial/ethnic disparities were present in readmissions for arterial interventions. Our results underscore the importance of postdischarge transitional care and the need for better secondary prevention strategies after ischemic stroke, particularly among minority populations.     

Predictors of 30-Day Readmission After Subarachnoid Hemorrhage

Background

Readmission within 30 days is increasingly evaluated as a measure of quality of care. There are few data on the rates of readmission after subarachnoid hemorrhage (SAH).

Objective

We sought to determine the predictors of 30-day readmission in patients with SAH.

Methods

We prospectively identified 283 patients with SAH admitted between 2006 and 2012. Readmission was determined by means of an automated query with confirmation in the electronic medical record.

Results

Overall, 21 (8 %) patients were readmitted for infection (n = 8), headache (n = 5), hydrocephalus (n = 4), cardiovascular causes (n = 2), medication-related complications (n = 1), and cerebral ischemia (n = 1). Readmission was associated with longer intensive care unit (ICU) length of stay (LOS) (15.4 [13.4–19.3] vs. 12.2 [8.2–18.5] days, P = 0.02), hospital LOS (22.2 [17.4–23.0] vs. 16.8 [12.0–24.1] days, P = 0.01), and placement of an external ventricular drain (EVD, OR 3.9, 95 % CI 1.3–12.0, P = 0.01). Readmission was not associated with admission neurologic grade, NIH Stroke scale at 14 days, modified Rankin scale at 3 months, history of cardiovascular disease, or radiographic cerebral infarction (P > 0.1).

Conclusions

Demographics, severity of neurologic injury, radiographic cerebral infarction, and outcomes were not associated with readmission after SAH. Markers of a more complicated hospital course (ICU and hospital LOS, EVD placement) were associated with 30-day readmission. Most readmissions were for infections acquired after discharge. Readmission within 30 days is difficult to predict, and, since the most common reason was infection acquired after discharge, it may be difficult to prevent without an integrated health system and coordinated care.     

The Association of Migraine with Ischemic Stroke

Migraine is a common, chronic–intermittent primary headache disorder affecting mostly women. The migraine pathophysiology involves both the neuronal and vascular systems, and in some patients, transient neurologic symptoms occur, which are known as migraine aura. A large body of literature supports an association between migraine and ischemic stroke, which is apparent mostly in young women with migraine with aura. Further increased risks have been observed particularly in smokers and women who use oral contraceptives. The vast majority of individual studies, as well as a recent meta-analysis, did not find an association between migraine without aura and ischemic stroke. Although there are several hypotheses about potential biological mechanisms linking migraine with aura to ischemic stroke, the precise causes remain unclear. Because the absolute risk of stroke is considerably low in patients with migraine, the vast majority of migraine patients will not experience a stroke event because of the migraine.     

Association of Urinary Incontinence with Cognition,Transfers and Discharge Destination in Acute Stroke Inpatient Rehabilitation

Background

Acute-stroke prognostic indicators remain controversial including relationship of urinary incontinence with outcomes in cognition, transfers, and discharge destination.

Influence of a Comorbid Diagnosis of Seizure on 30-Day Readmission Rates Following Hospitalization for an Index Stroke

Objective: To examine the association of a comorbid seizure diagnosis with early hospital readmission rates following an index hospitalization for stroke in the United States. Methods: Retrospective analysis of the 2014 National Readmission Database. The study population included adult patients (age >18 years old) with stroke, identified using the International Classification of Disease Ninth Revision, Clinical Modification (ICD-9-CM) codes 433.X1, 434.X1, and 436 for ischemic stroke as well as 430, 431, 432.0, 432.1, and 432.9 for hemorrhagic stroke. A subgroup of patients with a secondary discharge diagnosis of seizures was identified using the ICD-9-CM codes 780.39 and 345.X. We computed all-cause 30-day readmission rates for all strokes and by stroke type (ischemic versus hemorrhagic). Finally, we used a multivariable logistic regression model to examine the independent association between seizure and readmission by stroke type. Results: Of 271,148 stroke patients, 6.3% (16,970) had a secondary discharge diagnosis of seizures including 5.0% (11,562) of patients with ischemic stroke and 13.4% (5,409) with hemorrhagic stroke. Overall readmission rate for stroke patients was 11.9% (hemorrhagic stroke: 14.2% versus ischemic strokes: 11.6%). Thirty-day readmission rate was higher in patients with seizures for all strokes (15.6% versus 11.7%, P value <.001), ischemic strokes (15.0% versus11.4%, P value <.001), and hemorrhagic strokes (16.7% versus 13.8%, P value <.001). After adjusting for several patient-specific and healthcare system-specific confounders, hospitalized stroke patients with comorbid seizure diagnosis were more likely than those without seizures to be readmitted within 30 days (OR: 1.20, 95% CI: 1.14-1.25). Conclusion: The presence of a comorbid diagnosis of seizure disorder in a hospitalized stroke patient significantly raises the occurrence of early hospital readmission in the United States.     

医疗保险状态对急性缺血性脑卒中患者选择静脉内溶栓治疗的影响

目的探索医疗保险状态对急性缺血性脑卒中(AIS)患者选择静脉内溶栓治疗的影响。方法回顾性收集2012年5月至2016年1月收治的符合静脉内溶栓治疗指征的AIS患者293例,根据患者的医疗保险状态分为医保组256例和非医保组37例,比较两组的临床基线资料,并采用Logistic回归分析医疗保险状态与选择静脉内溶栓治疗的相关因素。结果医保组静脉内溶栓177/256例(69.1%);非医保组静脉内溶栓30/37例(81.1%),两组间比较差异无显著性(P=0.136)。医保组患者年龄更大(P0.001),合并有高血压病史(P=0.040)、冠心病史(P=0.008)和既往脑卒中史的比例更高(P=0.002),住院天数明显延长(P0.001),住院总费用增高(P=0.077)。多因素Logistic回归分析提示:高龄(P0.001)、血脂异常(P=0.005)、入院时美国国立卫生研究院卒中量表(NIHSS)评分高(P0.001)、发病至来院时间长(P=0.006)是AIS患者选择接受静脉内溶栓治疗的独立预测因素。在接受静脉内溶栓治疗的患者中,医保组与非医保组的溶栓开始时间差异无显著性(P=0.612)。结论年龄轻、高NIHSS评分、发病时间短且伴有血脂异常的AIS患者更倾向于接受静脉内溶栓治疗,是否有医疗保险不影响患者对静脉内溶栓治疗的选择;无论是否有医疗保险,患者接受静脉内溶栓治疗的开始时间相似;有医疗保险患者住院时间更长,住院总费用更高。     

特定温度模式与小动脉闭塞性缺血性卒中严重程度相关性的研究

目的 探讨寒冷和温暖两种不同温度模式下,气温与小动脉闭塞性缺血性卒中严重程度的相关性.方法 回顾性分析2018年1-12月于苏州大学附属第一医院神经内科住院治疗的小动脉闭塞性缺血性卒中患者的临床资料,记录患者住院当日平均温度、人口学特征、卒中严重程度(NIHSS评分)等资料,评估寒冷和温暖两种不同温度模式下卒中严重程度...     

Impact of a Pharmacist-Driven Poststroke Transitions of Care Clinic on 30 and 90-Day Hospital Readmission Rates

Background: Stroke impacts nearly 800,000 people annually and the risk of recurrent stroke and hospital readmission is increased early following the initial event. Due to the increase in morbidity and mortality associated with secondary events, a pharmacist-driven poststroke transitions of care clinic was created at Methodist University Hospital to provide risk factor modification in an effort to decrease risk of recurrence and hospital readmissions. Methods: A retrospective matched-cohort study was conducted between 9/1/2017 and 2/28/2019. Adult patients with a primary diagnosis of stroke, discharged to home, and attended a poststroke transitions of care clinic visit were included. Patients were matched on the basis of age ±3 years, race, gender, and type of stroke to those who did not receive pharmacist intervention during the same time period. The primary endpoint was 30-day hospital readmissions. Secondary endpoints included 90-day readmissions, 30 and 90-day emergency department visits, and recurrent stroke rates. Type and quantity of pharmacist interventions was also assessed. Results: One hundred and eighty-eight patients were included in the analysis. Baseline differences existed between the groups in the following: history of transient ischemic attack, stroke severity score, and insurance status. No significant difference was found in 30-day readmissions. There was a significant difference found in 90-day readmissions (5.3% versus 21.3%, P = .001). There were no significant differences in emergency department utilization at 30 or 90 days or stroke recurrence rates. Pharmacists made a mean of 3.5 interventions made during each visit. Conclusions: Although the primary goal to reduce 30-day readmission was not met, a pharmacist-driven poststroke transitions of care clinic significantly decreased 90-day hospital readmission rates.     

急性前循环缺血性卒中血管内治疗术后早期脑血流自动调节功能与预后关系研究

目的 使用传递函数分析（transfer function analysis,TFA）和Spearman相关性分析计算急性前循环
缺血性卒中血管内治疗术后患者早期脑血流自动调节（cerebral autoregulation,CA）功能,比较两种方
法得出的自动调节参数与临床预后的相关性。
方法 前瞻性纳入急性前循环缺血性卒中且进行了血管内治疗的患者,收集患者的影像、临床信息。
术后48 h内使用TCD联合无创动脉压,连续采集患者双侧大脑中动脉脑血流速度（flow velocity,FV）
和逐搏动脉压（arterial blood pressure,ABP）。使用TFA计算FV和ABP信号的极低频（0.02～0.07 Hz）、
低频（0.07～0.20 Hz）、高频（0.20～0.50 Hz）的相位差和增益;使用Spearman相关性分析计算平均血
流速度指数（mean flow velocity index,Mx）。根据患者90 d mRS评分分为预后良好（mRS≤2分）和预
后不良（mRS＞2分）,比较不同预后患者上述CA参数的差异,并用多因素分析评估不同方法计算的CA
参数对患者90d预后的影响。另外,分析CA参数与术后7 d NIHSS评分相对术前的改善（ΔNIHSS）、90 d
mRS评分、术前梗死体积、术后48 h增加的梗死体积等临床指标的相关性。
结果 共纳入52例患者,90 d预后良好18例,预后不良34例。与预后良好患者相比,预后不良患者
Mx较高[0.40（0.18～0.50）vs 0.26（0.05～0.36）,P =0.012],但两组各频段相位差和增益的差异均
无统计学意义。Mx与术后7 d的ΔNIHSS、90 d mRS评分、术前梗死体积、术后48 h增加的梗死体积
均为正相关性（r 值分别为0.299、0.382、0.561和0.286,P值分别为0.031、0.005、<0.001和0.040）,
极低频相位差与术前梗死体积、90 d mRS评分均呈负相关（r 值分别为-0.282、-0.276,P值分别
为0.043、0.048）。多因素回归分析提示Mx值是90 d预后不良的独立影响因素（OR 132.69,95%CI
5.71～3081.96,P =0.002）。
结论 急性前循环缺血性卒中血管内治疗术后早期CA功能相对保留与预后良好相关。相比于相位
差和增益,Mx与90 d临床结局有更强的相关性。     

急性前循环缺血性卒中血管内治疗术后早期脑血流自动调节功能与预后关系研究

目的 使用传递函数分析（transfer function analysis,TFA）和Spearman相关性分析计算急性前循环缺血性卒中血管内治疗术后患者早期脑血流自动调节（cerebral autoregulation,CA）功能,比较两种方法得出的自动调节参数与临床预后的相关性。方法 前瞻性纳入急性前循环缺血性卒中且进行了血管内治疗的患者,收集患者的影像、临床信息。术后48 h内使用TCD联合无创动脉压,连续采集患者双侧大脑中动脉脑血流速度（flow velocity,FV）和逐搏动脉压（arterial blood pressure,ABP）。使用TFA计算FV和ABP信号的极低频（0.02～0.07 Hz）、低频（0.07～0.20 Hz）、高频（0.20～0.50 Hz）的相位差和增益;使用Spearman相关性分析计算平均血流速度指数（mean flow velocity index,Mx）。根据患者90 d mRS评分分为预后良好（mRS≤2分）和预后不良（mRS＞2分）,比较不同预后患者上述CA参数的差异,并用多因素分析评估不同方法计算的CA参数对患者90d预后的影响。另外,分析CA参数与术后7 d NIHSS评分相对术前的改善（ΔNIHSS）、90 dmRS评分、术前梗死体积、术后48 h增加的梗死体积等临床指标的相关性。结果 共纳入52例患者,90 d预后良好18例,预后不良34例。与预后良好患者相比,预后不良患者Mx较高[0.40（0.18～0.50）vs 0.26（0.05～0.36）,P =0.012],但两组各频段相位差和增益的差异均无统计学意义。Mx与术后7 d的ΔNIHSS、90 d mRS评分、术前梗死体积、术后48 h增加的梗死体积均为正相关性（r 值分别为0.299、0.382、0.561和0.286,P值分别为0.031、0.005、<0.001和0.040）,极低频相位差与术前梗死体积、90 d mRS评分均呈负相关（r 值分别为-0.282、-0.276,P值分别为0.043、0.048）。多因素回归分析提示Mx值是90 d预后不良的独立影响因素（OR 132.69,95%CI5.71～3081.96,P =0.002）。结论 急性前循环缺血性卒中血管内治疗术后早期CA功能相对保留与预后良好相关。相比于相位差和增益,Mx与90 d临床结局有更强的相关性。     

Employment Status Prior to Ischemic Stroke and Weekly Variation of Stroke Onset

ObjectivesTo investigate the differences in clinical backgrounds, especially weekly variations of stroke occurrence, between hyper-acute ischemic stroke patients with and without regular employment (RE), as well as the impact of RE on outcome.Materials and methodsSymptomatic ischemic stroke patients with ≤4.5 h from onset to door were enrolled. First, we divided patients into the RE and non-RE group to analyze differences in clinical characteristics, especially relation between weekly variations of stroke occurrence and RE. Second, we divided the same patients into those with and without favorable outcomes (modified Rankin Scale score of 0 to 2 at 3 months from stroke onset) to analyze the impact of RE on outcomes.ResultsWe screened 1,249 consecutive symptomatic ischemic stroke patients and included 377 patients (284 [75%] males; median age, 67 years). Of these patients, 248 (66%) were included in RE group. First, RE was independently associated with occurrence of stroke on Monday in reference to Sunday or a public holiday (OR 2.562, 95% CI 1.004-6.535, p = 0.049). Second, RE (OR 2.888 95% CI 1.378-6.050, p = 0.005) was a factor independently associated with a favorable outcome.ConclusionsPatients with RE were more likely to have a hyper-acute ischemic stroke on Monday in reference to Sunday or a public holiday. However, RE before stroke onset appears to have a positive impact on outcome.     

院内缺血性卒中的诊疗现状与挑战

院内卒中是指因其他疾病住院的患者在住院期间发生的急性卒中,其中最常见的类型是缺血性卒中.与社区卒中相比,院内缺血性卒中的危险因素和发病机制更为复杂,除了栓塞、低灌注、高凝状态,医源性因素也是重要的致病原因之一.院内缺血性卒中患者的不良功能预后和死亡率均较社区患者显著增高,研究提示基础疾病较多、围手术期栓塞所致脑梗死范围...     

血尿酸水平与急性缺血性卒中病情严重程度和预后的关系研究

目的 探讨急性缺血性卒中患者血清UA水平与病情严重程度及预后的关系。 方法 回顾性收集在深圳市第二人民医院神经内科2014年1月-2017年12月住院的急性缺血性 卒中患者。根据血UA水平进行三分位数分组：低分位数组（3.85～298.80）μmol/L、中分位数组 （299.80～398.00）μmol/L和高分位数组（402.30～702.10）μmol/L。多因素回归分析急性缺血性卒中 患者中病情严重程度及临床预后的危险因素，分层分析不同人群UA水平与病情严重程度及临床预后 的关系。 结果 227例入组患者中，UA低分位数组75例、中分位数组72例，高分位数组80例。调整混杂因素后， 相比低分位数组，UA高分位数组患者入院NIHSS评分下降2.16分（β=-2.16，95%CI -3.53～-0.78， P =0.002），发生早期神经功能恶化（early neurological deterioration，END）的风险下降60%（OR 0.40， 95%CI 0.16～0.97，P =0.042）。分层分析发现，在男性和既往无卒中史的患者中，随着UA水平升高，入 院NIHSS评分降低，END减少，差异具有统计学意义。 结论 高UA水平是急性缺血性卒中严重程度的保护因素，能降低END；其对男性和新发急性缺血性 卒中患者的保护性更明显。     

缺血性脑卒中患者抑郁状态与影像学改变的关系

目的探讨缺血性脑卒中患者抑郁状态与卒中部位、病灶体积及脑白质病变之间的关系。方法对59例缺血性脑卒中患者随访12～18个月(平均13个月),采用24项Hamilton抑郁量表(HAMD)对患者进行评分,得分<8分为无抑郁症状,8～17分为抑郁状态,>17分为抑郁。于入组及随访结束时分别行头颅磁共振成像(MRI)及Hamilton评分检查。结果抑郁的发生与患者脑深部白质病变(DWML)、脑室周围白质病变(PWML)的程度无关及卒中病灶部位无关(P均>0.05),且与随访期间新发病灶无关(P>0.05),与病灶体积亦无关(P>0.05)。结论缺血性脑卒中患者卒中后抑郁的发生与卒中病灶部位及脑白质病变程度无关。     

The Ability for Basic Movement Scale II Can Predict Functional Outcome and Discharge Destination in Stroke Patients

Objectives: This study aims to identify whether the Ability for Basic Movement Scale II (ABMS II) at admission would predict the functional status and discharge destination in convalescent stroke patients. Methods: Ninety-four stroke patients admitted to convalescent rehabilitation ward were investigated. Their functions were evaluated by the ABMS II and Functional Independence Measure (FIM) at admission, FIM and Functional Ambulation Category at discharge. Furthermore, the age, gender, diagnosis, lesion side, onset type, interval between onset and convalescent admission, length of stay (LOS) and discharge destination were recorded. Discharge destination was divided into home and facility. Results: Multiple linear regression identified the ABMS II at admission as a significant predicator of discharge FIM in convalescent stroke patients (β = .747, P < .05). Binary logistic regression analysis showed the ABMS II significantly predicting basic walk ability (odds ratio 1.29) and home discharge (odds ratio 1.241) of these patients. Receiver operating characteristic analysis indicated that an optimal cutoff of 18 points of ABMS II predicted basic walk ability (area under the curve = .863, P < .05) and home discharge (area under the curve = .827, P < .05). Moreover, a significant negative correlation between the ABSM II at admission and LOS was found (Correlation coefficients −.680, P < .05). Conclusions: Higher score of the ABMS II at admission predicted better functional recovery, shorter LOS and more possibility to home in convalescent stroke patients. This new, easy scale is expected to be widely used for stroke patients.     

肿瘤合并缺血性卒中的研究现状及展望

2014年在Chin Med J(Engl)上发表的“1982-2010年中国主要死亡原因的变化趋势”指出,在中国居民死亡的主要原因中,肿瘤和卒中位列前二位[1]。2018年发表的《中国脑卒中防治报告(2017)》[2]显示,卒中在中国为第一位死亡原因,已成为中国疾病负担的首位原因,且患病率呈上升趋势。《中国急性缺血性脑卒中诊治指南2018》指出,急性缺血性卒中是最常见的卒中类型,占我国卒中的69.6%~70.8%[3]。2019年6月,Lancet杂志发表的一项病死原因调查研究分析了1990-2017年中国居民的死亡原因,结果显示卒中、缺血性心脏病、肺癌、慢性阻塞性肺疾病和肝癌分别位居我国病死率的前五位[4]。缺血性卒中和肿瘤是中国居民目前的主要死亡原因。肿瘤和缺血性卒中往往好发于高龄人群,且肿瘤患者罹患缺血性卒中的风险更高,而缺血性卒中的发生又必将影响针对恶性肿瘤的治疗,两者共同作用严重影响患者的生活质量和整体预后。     

责任动脉闭塞与夹层相关缺血性卒中复发的相关性分析

目的 寻找脑动脉夹层相关卒中复发的高风险影像学特征,探讨责任动脉闭塞与其复发的关系。方法 前瞻性连续性纳入2018年1月-2022年2月在郑州大学第一附属医院住院的首发脑动脉夹层相关卒中患者,通过MRI、MRA、CTA、HR-MRI及DSA等影像学方法评估血管闭塞、长节段夹层等影像学特征,长期随访其复发情况。通过单因素、多因素COX回归分析其复发的影响因素,构建Kaplan-Meier生存曲线评估血管闭塞与脑动脉夹层相关卒中复发的关系。结果 共纳入107例脑动脉夹层相关卒中患者,有10例（9.3%）患者复发。单因素及多因素COX回归分析提示,责任动脉闭塞是脑动脉夹层相关卒中复发患者预后不良的独立预测因子（HR 6.150,95%CI 1.227～30.810,P=0.027）,出血转化也与脑动脉夹层相关卒中复发显著相关（HR 12.605,95%CI 2.373～66.949,P=0.003）。Kaplan-Meier生存曲线提示,闭塞组与非闭塞组卒中复发率差异具有统计学意义（Log-rank P=0.001）。结论 责任动脉闭塞是脑动脉夹层相关卒中复发的危险因素,需要大样本研究进一步验证本研究结果,为二级预防提供更精准的帮助。     

卵圆孔未闭相关的缺血性卒中研究现状

卵圆孔作为胎儿时期的重要的生命通道,出生后随着左心房压力升高,其发生功能性闭合,一年后达到解剖上闭合。若大于3岁的幼儿卵圆孔仍不闭合称卵圆孔未闭（patent foramen ovale,PFO）,在右心房压增高的情况下,可出现自发或诱发的心房水平右向左分流。