Process Evaluation of a Faith-Based Multicomponent Behavioral Intervention to Reduce Stroke Risk in Mexican Americans in a Catholic Church Setting: The SHARE (Stroke Health and Risk Education) Project.

Church-based stroke prevention programs for Hispanics are underutilized. The Stroke Health and Risk Education (SHARE) project, a multicomponent cluster-randomized trial, addressed key stroke risk factors among predominantly Mexican Americans in a Catholic Church setting. Process evaluation components (implementation, mechanisms of impact, and context) are described. Partner support promoted positive health behavior change. Motivational interviewing calls were perceived as helpful, however, barriers with telephone delivery were encountered. Intervention exposure was associated with theory constructs for targeted behaviors. We conclude that health behavior interventions to prevent stroke can be successfully implemented for Mexican Americans within a Catholic Church setting, with parish priest support.

Sleep-disordered breathing and poststroke outcomes.

OBJECTIVE: To examine the association between sleep-disordered breathing and stroke outcomes, and determine the contribution of sleep-disordered breathing to outcome disparities in Mexican Americans. METHODS: Ischemic stroke patients (n = 995), identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2015), were offered participation in a sleep-disordered breathing study including a home sleep apnea test (ApneaLink Plus). Sleep-disordered breathing (respiratory event index ≥10) was determined soon after stroke. Neurologic, functional, cognitive, and quality of life outcomes were assessed at 90 days poststroke. Regression models were used to assess associations between sleep-disordered breathing and outcomes, adjusted for sociodemographics, prestroke function and cognition, health-risk behaviors, stroke severity, and vascular risk factors. RESULTS: Median age was 67 years (interquartile range [IQR] = 59-78); 62.1% were Mexican American. Median respiratory event index was 14 (IQR = 6-25); 62.8% had sleep-disordered breathing. Sleep-disordered breathing was associated with worse functional outcome (mean difference in activities of daily living/instrumental activities of daily living score = 0.15, 95% confidence interval [CI] = 0.01-0.28) and cognitive outcome (mean difference in modified Mini-Mental State Examination = -2.66, 95% CI = -4.85 to -0.47) but not neurologic or quality of life outcomes. Sleep-disordered breathing accounted for 9 to 10% of ethnic differences in functional and cognitive outcome and was associated with cognitive outcome more strongly for Mexican Americans (ß = -3.97, 95% CI = -6.63 to -1.31) than non-Hispanic whites (ß = -0.40, 95% CI = -4.18 to 3.39, p-interaction = 0.15). INTERPRETATION: Sleep-disordered breathing is associated with worse functional and cognitive function at 90 days poststroke. These outcomes are reasonable endpoints for future trials of sleep-disordered breathing treatment in stroke. If effective, sleep-disordered breathing treatment may somewhat lessen ethnic stroke outcome disparities. ANN NEUROL 2019;86:241-250.

Off-Hour Admission and Outcomes in Patients with Acute Intracerebral Hemorrhage in the INTERACT2 Trial.

BACKGROUND: Conflicting data exist of an association between off-hour (weekend, holiday, or night-time) hospital admission and adverse outcome in intracerebral hemorrhage (ICH). We determined the association between off-hour admissions and poor clinical outcome, and of any differential effect of early intensive blood pressure (BP) lowering treatment between off- and on-hour admissions, among participants of the Intensive BP Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). METHODS: Subsidiary analysis of INTERACT2, a multinational, multicenter, clinical trial of patients with spontaneous ICH with elevated systolic BP, randomly assigned to intensive (target systolic BP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Primary outcome was death or major disability (modified Rankin scale of 3-6) at 90 days. Off-hour admission was defined as night-time (4:30 p.m. to 8:30 a.m.) on weekdays, weekends (Saturday and Sunday), and public holidays in each participating country. RESULTS: Of 2,794 patients with information on the primary outcome, 1,770 (63%) were admitted to study centers during off-hours. Off-hour admission was not associated with risk of poor outcome at 90 days (53% off-hour vs. 55% on-hour; p = 0.49), even after adjustment for comorbid risk factors (odds ratio 0.92; 95% CI 0.76-1.12). Consistency exists in the effects of intensive BP lowering between off- and on-hour admission (p = 0.85 for homogeneity). CONCLUSIONS: Off-hour admission was not associated with increased risks of death or major disability among trial protocol participants with acute ICH. Intensive BP lowering can provide similar treatment effect irrespective of admission hours.

Effects of early intensive blood pressure-lowering treatment on the growth of hematoma and perihematomal edema in acute intracerebral hemorrhage: the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT).

BACKGROUND AND PURPOSE: The Intensive Blood Pressure Reduction In Acute Cerebral Haemorrhage Trial (INTERACT) study suggests that early intensive blood pressure (BP) lowering can attenuate hematoma growth at 24 hours after intracerebral hemorrhage. The present analyses aimed to determine the effects of treatment on hematoma and perihematomal edema over 72 hours. METHODS: INTERACT included 404 patients with CT-confirmed intracerebral hemorrhage, elevated systolic BP (150 to 220 mm Hg), and capacity to start BP-lowering treatment within 6 hours of intracerebral hemorrhage. Patients were randomly assigned to an intensive (target systolic BP 140 mmHg) or standard guideline-based management of BP (target systolic BP 180 mm Hg) using routine intravenous agents. Baseline and repeat CTs (24 and 72 hours) were performed using standardized techniques with digital images analyzed centrally. Outcomes were increases in hematoma and perihematomal edema volumes over 72 hours. RESULTS: Overall, 296 patients had all 3 CT scans available for the hematoma and 270 for the edema analyses. Mean systolic BP was 11.7 mm Hg lower in the intensive group than in the guideline group during 1 to 24 hours. Adjusted mean absolute increases in hematoma volumes (mL) at 24 and 72 hours were 2.40 and 0.15 in the guideline group compared with -0.74 and -2.31 in the intensive group, respectively, an overall difference of 2.80 (95% CI, 1.04 to 4.56; P=0.002). Adjusted mean absolute increases in edema volumes (mL) at 24 and 72 hours were 6.27 and 10.02 in the guideline group compared with 4.19 and 7.34 in the intensive group, respectively, for an overall difference of 2.38 (95% CI, -0.45 to 5.22; P=0.10). CONCLUSIONS: Early intensive BP-lowering treatment attenuated hematoma growth over 72 hours in intracerebral hemorrhage. There were no appreciable effects on perihematomal edema.

Population-based analysis of the impact of expanding the time window for acute stroke treatment.

BACKGROUND AND PURPOSE: Currently, a major focus on expanding acute ischemic stroke treatment opportunities centers on the development of drugs and devices with longer time windows for use. We sought to determine the time intervals within which stroke patients present to establish whether time window expansion will translate into more treatment. METHODS: Data were derived from the Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study in an urban, southeast Texas county. This community does not contain an academic medical center, thus providing a "real-world" setting to capture patient arrival times. Onset time was recorded from the chart according to a prespecified methodology. RESULTS: From January 2000 to June 2005, 2347 patients with acute ischemic stroke were validated. The mean age was 71 years, and 53% were female. Thirty-one percent presented within 3 hours of symptom onset; 13% between 3 and 6 hours; and 15% between 6 and 12 hours. Forty-one percent presented beyond 12 hours from symptom onset. Nearly half of patients with moderate and severe strokes presented in the 0- to 3-hour time window, whereas only 28% of mildly affected patients presented early. CONCLUSIONS: This population-based study provides estimates of time to presentation in a representative community without tertiary referral bias. These data are useful for planning acute stroke therapy interventions and suggest that in addition to developing therapies with expanded time windows, research resources should also be devoted to reducing hospital presentation delays.

Stroke information reported on local television news: a national perspective.

BACKGROUND AND PURPOSE: Local television news commonly reports on health. This study aimed to characterize local TV news stroke reporting in America. METHODS: Content analysis of stroke stories reported on 122 US local television stations. All stroke stories were coded for main focus and discussion of risk factors, stroke signs and symptoms, recombinant tissue plasminogen activator, treatment within 3 hours, or recommendation to call 911. RESULTS: Of the 1799 health stories, only 13 stroke stories aired, and the median story length was 24 seconds (interquartile range 21 to 48). Stroke was the 22nd most common health topic. Few stroke stories discussed useful information about prevention or treatment of stroke. CONCLUSIONS: Stroke stories were nearly nonexistent in our sample, and those reported failed to discuss important messages needed to improve stroke prevention and treatment.

Stroke Ready Intervention: Community Engagement to Decrease Prehospital Delay.

BACKGROUND: Time-limited acute stroke treatments are underused, primarily due to prehospital delay. One approach to decreasing prehospital delay is to increase stroke preparedness, the ability to recognize stroke, and the intention to immediately call emergency medical services, through community engagement with high-risk communities. METHODS AND RESULTS: Our community-academic partnership developed and tested "Stroke Ready," a peer-led, workshop-based, health behavior intervention to increase stroke preparedness among African American youth and adults in Flint, Michigan. Outcomes were measured with a series of 9 stroke and nonstroke 1-minute video vignettes; after each video, participants selected their intended response (primary outcome) and symptom recognition (secondary outcome), receiving 1 point for each appropriate stroke response and recognition. We assessed differences between baseline and posttest appropriate stroke response, which was defined as intent to call 911 for stroke vignettes and not calling 911 for nonstroke, nonemergent vignettes and recognition of stroke. Outcomes assessments were performed before workshop 1 (baseline), at the conclusion of workshop 2 (immediate post-test), and 1 month later (delayed post-test). A total of 101 participants completed the baseline assessment (73 adults and 28 youths), 64 completed the immediate post-test, and 68 the delayed post-test. All participants were African American. The median age of adults was 56 (interquartile range 35-65) and of youth was 14 (interquartile range 11-16), 65% of adults were women, and 50% of youths were women. Compared to baseline, appropriate stroke response was improved in the immediate post-test (4.4 versus 5.2, P<0.01) and was sustained in the delayed post-test (4.4 versus 5.2, P<0.01). Stroke recognition did not change in the immediate post-test (5.9 versus 6.0, P=0.34), but increased in the delayed post-test (5.9 versus 6.2, P=0.04). CONCLUSIONS: Stroke Ready increased stroke preparedness, a necessary step toward increasing acute stroke treatment rates. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01499173.

Recommendations for improving the quality of care through stroke centers and systems: an examination of stroke center identification options: multidisciplinary consensus recommendations from the Advisory Working Group on Stroke Center Identification Options of the American Stroke Association.

BACKGROUND AND PURPOSE: The American Stroke Association (ASA) assembled a multidisciplinary group of experts to develop recommendations regarding the potential effectiveness of establishing an identification program for stroke centers and systems. "Identification" refers to the full spectrum of models for assessing and recognizing standards of quality care (self-assessment, verification, certification, and accreditation). A primary consideration is whether stroke center identification might improve patient outcomes. METHODS: In February 2001, ASA, with the support of the Stroke Council's Executive Committee, decided to embark on an evaluation of the potential impact of stroke center identification. HealthPolicy R&D was selected to prepare a comprehensive report. The investigators reported on models outside the area of stroke, ongoing initiatives within the stroke community (such as Operation Stroke), and state and federal activities designed to improve care for stroke patients. The investigators also conducted interviews with thought leaders in the stroke community, representing a diverse sampling of specialties and affiliations. In October 2001, the Advisory Working Group on Stroke Center Identification developed its consensus recommendations. This group included recognized experts in neurology, emergency medicine, emergency medical services, neurological surgery, neurointensive care, vascular disease, and stroke program planning. RESULTS: There are a variety of existing identification programs, generally falling within 1 of 4 categories (self-assessment, verification, certification, and accreditation) along a continuum with respect to intensity and scope of review and consumption of resources. Ten programs were evaluated, including Peer Review Organizations, trauma centers, and new efforts by the National Committee on Quality Assurance and the Joint Commission on the Accreditation of Healthcare Organizations to identify providers and disease management programs. The largest body of literature on clinical outcomes associated with identification programs involves trauma centers. Most studies support that trauma centers and systems lead to improved mortality rates and patient outcomes. The Advisory Working Group felt that comparison to the trauma model was most relevant given the need for urgent evaluation and treatment of stroke. The literature in other areas generally supports the positive impact of identification programs, although patient outcomes data have less often been published. In the leadership interviews, participants generally expressed strong support for pursuing some form of voluntary identification program, although concerns were raised that this effort could meet with some resistance. CONCLUSIONS: Identification of stroke centers and stroke systems competencies is in the best interest of stroke patients in the United States, and ASA should support the development and implementation of such processes. The purpose of a stroke center/systems identification program is to increase the capacity for all hospitals to treat stroke patients according to standards of care, recognizing that levels of involvement will vary according to the resources of hospitals and systems.

The impact of MRI on stroke management and outcomes: a systematic review.

RATIONALE, AIMS AND OBJECTIVES: Magnetic resonance imaging (MRI) is widely used in stroke evaluation and is superior to computed tomography for the detection of acute ischaemia. We sought to evaluate the evidence that conventional MRI influences doctor management or patient outcomes in routine care. METHODS: We systematically searched PubMED, EMBASE and proceedings of the International Stroke Conference. Studies were included if they included patients presenting with possible stroke syndromes and they reported MRI results and resulting changes in management or outcome. Multiple reviewers determined inclusion/exclusion for each study, abstracted study characteristics and assessed study quality. RESULTS: Of 1813 articles screened, nine studies met inclusion criteria. None were randomized controlled trials, cohort studies or case-control studies. We found little evidence that MRI affects outcomes - one single-centre case series presented three patients. The remaining articles were studies of diagnostic tests or vignette-based studies that described changes in doctor management attributed to MRI. In the studies that suggested MRI influenced management, it did so in two ways. First, MRI distinguished stroke from mimics (e.g. brain tumours), thus enabling more appropriate selection of therapies. Second, even when MRI confirmed a suspected stroke diagnosis, it sometimes provided information (on stroke mechanism, localization, timing or pathophysiology) that influenced management. CONCLUSIONS: The impact of MRI on management and outcomes in stroke patients has been inadequately studied. Further research is needed to understand how MRI may productively affect stroke management and outcomes.