Analysis of Hospitalization Costs in Patients Suffering from Cerebral Infarction along with Varied Comorbidities.

OBJECTIVE: This study aimed to study the influence of comorbidities on hospitalization costs for inpatients with cerebral infarction. METHODS: The data from the medical records pertaining to 76,563 inpatients diagnosed with cerebral infarction were collected from public hospital records for the period between 1 January 2020 and 30 December 2020 in Gansu Province. EpiData 3.1 software was used for data collation, and SPSS 25.0 was used for data analysis. Numbers and percentages were calculated for categorical variables, the chi-squared test was used to compare differences between groups, and multiple independent-sample tests (Kruskal-Wallis H test, test level α = 0.05) and multiple linear regression were used to analyze the influence of different types of comorbidity on hospitalization costs. RESULTS: Among the 76,563 cerebral infarction inpatients, 41,400 were male (54.07%); the average age of the inpatients was 67.68 ± 10.75 years (the 60~80-year-old group accounted for 65.69%). Regarding the incidence of varied chronic disease comorbidities concomitant with cerebral infarction, hypertension was reported as the most frequent, followed by heart disease and chronic pulmonary disease. The average hospitalization cost of cerebral infarction inpatients is US $1219.66; the hospitalization cost increases according to the number of comorbidities with which a patient suffers (H = 404.506, p < 0.001); Regarding the types of comorbidities, the hospitalization cost of cancer was the highest, at US $1934.02, followed by chronic pulmonary disease (US $1533.02). Regarding the cost of hospitalization for combinations of comorbidities, cerebral infarction + chronic pulmonary disease was the most costly (US $1718.90), followed by cerebral infarction + hypertension + chronic pulmonary disease (US $1530.60). In the results of multiple linear regression analysis, cerebral infarction with chronic pulmonary disease had significant effects on hospitalization costs (ß = 0.181, p < 0.001), drug costs (ß = 0.144, p < 0.001) and diagnosis costs (ß = 0.171, p < 0.001). CONCLUSIONS: Comorbidities are significantly associated with high hospitalization costs for cerebral infarction patients. Furthermore, relevant health departments should build preventative and control systems to reduce the risk of comorbidities, as well as to improve hospital clinical pathway management and to strengthen and refine the cost-control management of cerebral infarction from the perspective of comorbidities.

Clinical evidence and GRADE assessment for breviscapine injection (DengZhanHuaSu) in patients with acute cerebral infarction.

ETHNOPHARMACOLOGICAL RELEVANCE: Breviscapine injections (DengZhanHuaSu, DZHS) is a famous Chinese patent medicine authorized by China Food and Drug Administration, which is widely used to treat acute cerebral infarction (ACI) in China. AIM OF THE STUDY: In the present study, meta-analysis has been performed in determining the efficacy and safety of DZHS combined with conventional treatment (CT) for ACI and GRADE assessment. MATERIALS AND METHODS: Randomized controlled trials (RCTs) testing the use of DZHS for treating ACI were screened by searching the databases of the Cochrane Library, PubMed, Embase, and Web of Science as well as four Chinese databases. Meta-analysis was carried out with RevMan 5.3 and Stata 16.0 software. The quality of research evidence was assessed by the GRADEprofiler (GRADEpro version: 3.6). RESULTS: Forty-three studies (n = 4618) were included. When compared to the control groups, the total effective rate of the national institutes of health stroke scale (NIHSS) was higher in the experimental group with DZHS (RR = 1.23, 95% CI = 1.19 to 1.28, P < 0.001; RR = 1.29, 95% CI = 1.21 to 1.38, P < 0.001); clinical symptoms and signs were improved in the experimental group with DZHS (RR = 1.17, 95% CI = 1.10 to 1.24, P < 0.001; RR = 1.25, 95% CI = 1.11 to 1.42, P < 0.001); the incidence of adverse reactions was reduced in the experimental group with DZHS (RR = 0.50, 95% CI = 0.26 to 0.98, P = 0.044); and the NIHSS score was decreased in the experimental group with DZHS (WMD = -3.30, 95% CI = -3.86 to -2.73, P < 0.001). CONCLUSIONS: DZHS combined with CT is conditionally recommended to improve the total effective rate of the NIHSS, clinical symptoms, and neurological deficits and reduce the incidence of adverse reactions, and no serious adverse reactions were noted. The GRADE assessment indicates that the overall certainty quality of evidence is low. Further large-scale, well-designed and high-quality RCTs are needed to confirm the positive results. PROSPERO registration No. CRD42019128856.

Cerebral small vessel disease score and atherosclerosis burden - A population study in community-dwelling older adults.

OBJECTIVE: Cerebral small vessel disease (cSVD) and large artery atherosclerosis (LAA) are related to different pathogenetic mechanisms. However, relationships between single biomarkers of cSVD and LAA affecting isolated vascular beds have been reported. Using the Atahualpa Project cohort, we aimed to assess the association between cSVD score categories and LAA burden in community-dwelling older adults. PATIENTS AND METHODS: Atahualpa individuals aged ≥60 years undergoing assessment of the cSVD score and LAA in the peripheral, carotid extracranial, and intracranial vascular beds (n = 333) were included. Multivariate models were fitted to assess independent associations between the cSVD score and LAA burden. RESULTS: The cSVD score was 0 points in 62 % individuals, 1 point in 19 %, 2 points in 13 %, and 3-4 points in 7 %. LAA involved the extracranial carotid bed in 43 % individuals, the intracranial bed in 36 %, and the peripheral bed in 20 %. One vascular bed was involved in 111 (33 %) individuals, two beds in 75 (23 %), and three beds in 23 (7 %). The remaining 124 (37 %) had no atherosclerosis. Ordinal logistic regression models showed progressively greater associations between higher categories of cSVD score and the odds of having more beds involved with LAA. Multinomial logistic regression models showed associations between categories of cSVD score and LAA burden, but only when two or three vascular beds were involved. CONCLUSION: This study demonstrates robust associations between the cSVD score and LAA, which become evident at the upper end of the spectrum of cSVD score (3-4 points) and LAA burden (2-3 vascular beds involved).

Endoscopic Surgery Without Decompressive Craniectomy in Large Putaminal Intracerebral Hemorrhage: Assessment of Efficacy and Safety.

BACKGROUND: Decompressive craniectomy (DC) is performed conventionally for large putaminal intracerebral hemorrhage (ICH). However, DC causes local skull defect and leads to post-surgical cranioplasty. The aim of this study is to investigate the effectiveness and safety of an endoscopic procedure to treat large putaminal ICH without DC. METHODS: This retrospective study included 112 large putaminal ICH patients who underwent hematoma evacuations with either an endoscopic procedure (group A) or with DC (group B) between January 2009 and June 2017. The efficacy was evaluated by mean modified Rankin Scale (mRS) three months after surgery. Safety was evaluated by mortality rate and postoperative complications. Univariate and multivariate logistic regression analyses were performed to determine the risk factors for clinical outcomes. RESULTS: The study included 49 patients in group A and 63 in group B. The mRS scores in both groups were similar after 3 months' follow-up (p = 0.709). There was no difference in the mortality rate between the two groups (p = 0.538). The rate of complications was lower in group A than that in group B (p = 0.024). Smaller preoperative midline shift (p = 0.008) and absent intraventricular extension (p = 0.044) have contributed significantly to better outcomes. CONCLUSION: Endoscopic hematoma evacuation without DC is safe and effective for patients with large putaminal ICH and deserves further investigation, preferably in a randomized controlled setting.

Effect of an Integrated Payment System on the Direct Economic Burden and Readmission of Rural Cerebral Infarction Inpatients: Evidence from Anhui, China.

Rural China is piloting an integrated payment system, which prepays a budget to a medical alliance rather than a single hospital. This study aims to evaluate the effect of this reform on the direct economic burden and readmission rates of cerebral infarction inpatients. The settlement records of 78,494 cerebral infarction inpatients were obtained from the New Rural Cooperative Medical Scheme (NRCMS) database in Dingyuan and Funan Counties in the Anhui Province. The direct economic burden was estimated by total costs, out-of-pocket expenditures, the out-of-pocket ratio, and the compensation ratio of the NRCMS. Generalized additive models and multivariable linear/logistic regression were applied to measure the changes of the dependent variables along with the year. Within the county, the total costs positively correlated to the year (ß = 313.10 in 2015; 163.06 in 2016). The out-of-pocket expenditures, out-of-pocket ratios, and the length-of-stay positively correlated to the year in 2015 (ß = 105.10, 0.01, and 0.18 respectively), and negatively correlated to the year in 2016 (ß = -58.40, -0.03, and -0.30, respectively). The odds ratios of the readmission rates were less than one within the county (0.70 in 2015; 0.53 in 2016). The integrated payment system in the Anhui Province has considerably reduced the direct economic burden for the rural cerebral infarction inpatients, and the readmission rate has decreased within the county. Inpatients' health outcomes should be given further attention, and the long-term effect of this reform model awaits further evaluation.

Assessment of cerebral infarction after transient cerebral ischemic attack by ABCD2 score combined with the position of intracranial vascular stenosis.

This study aims to investigate the value of the ABCD score combined with the position of the offending vessel stenosis in predicting the risk of transient ischemic attack (TIA) to develop into cerebral infarction.The ABCD score and head magnetic resonance imaging + magnetic resonance angiography (MRA) results of 192 patients with TIA were retrospectively analyzed. With the 7th day as the endpoint time, these patients were divided into 3 groups, according to ABCD scores: low-risk group (n = 105), moderate-risk group (n = 60), and high-risk group (n = 27). Blood vessels were screened using head MRA results, and patients were accordingly divided into 2 groups: proximal vascular stenosis group (n = 71) and nonproximal vascular stenosis group (n = 171). Then, the association of the position of the intracranial vascular stenosis and ABCD score with short-term prognosis was analyzed.Based on the ABCD score, the incidence of cerebral infarction after 1 week was significantly higher in the high-risk group (85.7%) than in the moderate-risk group (16.7%) and low-risk group (1.9%), and the differences were statistically significant (P < .05). When the ABCD score was ≥4 points, the incidence of cerebral infarction after 1 week was significantly higher in the proximal vascular stenosis group (59.1%) than in the nonproximal vascular stenosis group (30.8%), and the difference was statistically significant (P < .05). When the ABCD score was <4 points, the incidence of cerebral infarction after 1 week in the proximal stenosis group (2%) was not significantly different from that in the nonproximal stenosis group (1.9%, P > .05).The ABCD score combined with proximal offending vessel stenosis can improve the short-term prediction of cerebral infarction in patients with TIA.

Noninvasive assessment of left-ventricular diastolic electromechanical coupling in hypertensive heart disease.

BACKGROUND: There is a need to stratify patients who may develop heart failure because of the current "heart failure pandemic". We hypothesized that noninvasive assessment of diastolic electromechanical coupling by electrocardiography and Doppler echocardiography may be clinically useful for risk stratification of hypertensive patients who may develop heart failure. METHODS: We measured the time from the peak to end of the T wave (TpTe) as an electrophysiological parameter, and peak early diastolic mitral flow (E) and lateral annular (e') velocities as mechanical parameters in 109 patients with hypertension. Relationships between these parameters and their association with the prognosis were evaluated. RESULTS: The e' was inversely correlated with TpTe (p < 0.001) and QTc (p < 0.014), whereas E/e' was positively correlated with TpTe (p < 0.001) and QTc (p < 0.001). The TpTe predicted patients with E/e' > 12. There were 24 cardiovascular events during follow-up (57 ± 20 months), and Kaplan-Meier analysis showed that outcome was worse (p = 0.003) in patients with higher E/e' than lower E/e'; however, there was no difference between patients with longer TpTe (≧72 ms) and shorter TpTe (< 72 ms). CONCLUSION: The correlation of TpTe with e' and E/e' in hypertensive patients suggests that these parameters reflect diastolic ventricular electromechanical coupling. The E/e' predicted outcome, and an elevated E/e' should be suspected when TpTe is prolonged (> 72 ms). Noninvasive evaluation of diastolic electromechanical coupling is clinically useful in patients with hypertension for predicting their outcome.

Impact of Leukoaraiosis Burden on Hemispheric Lateralization of the National Institutes of Health Stroke Scale Deficit in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: The National Institutes of Health Stroke Scale (NIHSS) awards higher deficit scores for infarcts in the dominant hemisphere when compared with otherwise similar infarcts in the nondominant hemisphere. This has been shown to adversely affect stroke recognition, therapeutic decisions, and outcome. However, factors modifying the association between infarct side and deficit severity are incompletely understood. Thus, we sought to determine whether age and age-related leukoaraiosis alter the relation between NIHSS deficit score and the side and volume of infarction. METHODS: We studied 238 patients with supratentorial, nonlacunar ischemic infarcts prospectively included in our stroke registry between January 2013 and January 2014. NIHSS deficit severity was assessed at the time of presentation. Infarct volumes were assessed by manual planimetry on diffusion-weighted imaging. Leukoaraiosis burden was graded on fluid-attenuated inversion recovery images according to the Fazekas scale and dichotomized to none-to-mild (0-2) versus severe (3-6). Multivariable linear regression with backward elimination was used to identify independent predictors of the admission NIHSS. RESULTS: Left-hemispheric infarction (P<0.001), severe leukoaraiosis (P=0.001), their interaction term (P=0.005), infarct volume (P<0.001), and sex (P=0.013) were independently associated with the NIHSS deficit. Analysis of the individual NIHSS components showed that severe leukoaraiosis was associated with an increase of the lateralizing components of the NIHSS in patients with right-hemispheric infarction (P<0.05). CONCLUSIONS: Severe leukoaraiosis substantially attenuates the classic hemispheric lateralization of the NIHSS deficit by relating to greater NIHSS scores of components that are typically assigned to left hemisphere function.

Assessment of bilateral cerebral peduncular infarction: Magnetic resonance imaging, clinical features, and prognosis.

BACKGROUND: Bilateral cerebral peduncular infarction (BCPI) is an extremely rare neurological disorder, and related literature is scarce. This study investigated the clinical manifestations, magnetic resonance imaging (MRI) features and prognosis of BCPI. METHOD: We retrospectively reviewed the clinical features, MRI and magnetic resonance angiography manifestations, and prognosis of 14 patients with BCPI, confirmed by diffusion-weighted MRI from 5050 cerebral infarction patients at our medical center from January 2007 to June 2013. RESULT: Eleven of the 14 (78.6%) patients had quadriplegia and 9 (64.3%) had decreased consciousness. At the most severe stage, the National Institutes of Health Stroke Scale scores ranged from grades 4 to 26 (mean grade, 18.9). Eleven (78.6%) cases were caused by large artery atherosclerosis. Besides the bilateral cerebral peduncle, the pons (85.7%) and cerebellum (42.9%) were the other infarct locations. Twelve (85.7%) patients had vertebrobasilar artery occlusion or severe stenosis, and 12 (85.7%) did not have collateral patency of the posterior cerebral artery. Thirteen (92.9%) patients had poor prognosis and 9 of them died. OCCLUSION: BCPI is a very rare disorder and associated with severe vertebrobasilar artery stenosis or occlusion without collateral patency of the posterior communicating artery. It has a very poor prognosis.

Leukoaraiosis Burden Significantly Modulates the Association Between Infarct Volume and National Institutes of Health Stroke Scale in Ischemic Stroke.

BACKGROUND AND PURPOSE: The National Institutes of Health Stroke Scale (NIHSS) provides a reliable, quantitative measure of ischemic stroke severity and is predicted by the infarct size. We sought to determine whether leukoaraiosis severity affects the association between infarct size and NIHSS. METHODS: NIHSS and diffusion-weighted imaging-defined infarct volumes from 312 prospectively enrolled patients with supratentorial, ischemic strokes were analyzed. Leukoaraiosis severity was graded according to the Fazekas scale and conceptually defined as absent (0; n=44), mild (1-2; n=106), moderate (3-4; n=105), and severe (5-6; n=57). ANCOVA was used to describe the effect of leukoaraiosis on the association between infarct volume and NIHSS. Multivariable linear regression models were constructed to assess whether the association of leukoaraiosis and infarct volume on NIHSS was independent of other clinically relevant covariates. RESULTS: Overall, there was a significant correlation between the infarct volume and NIHSS (r=0.591; P<0.001). This correlation significantly attenuated with increasing leukoaraiosis severity from r=0.786 (P<0.001; absent leukoaraiosis) to r=0.498 (P<0.001; severe leukoaraiosis) and as shown by ANCOVA (P<0.001). Leukoaraiosis (coefficient, 0.107; 95% confidence interval, 0.036-0.179; P=0.016) and infarct volume (coefficient, 0.360; 95% confidence interval, 0.305-0.416; P<0.001) were independently associated with a greater NIHSS deficit in the fully adjusted multivariable model. CONCLUSIONS: Leukoaraiosis significantly modulates the association between infarct volume and NIHSS. The clinical implications of these findings need further exploration in prospective studies but may be relevant to mitigate outcome differences in patients with stroke by aiding treatment decisions that rely on the NIHSS.

Long-term exposure to fine particulate matter, residential proximity to major roads and measures of brain structure.

BACKGROUND AND PURPOSE: Long-term exposure to ambient air pollution is associated with cerebrovascular disease and cognitive impairment, but whether it is related to structural changes in the brain is not clear. We examined the associations between residential long-term exposure to ambient air pollution and markers of brain aging using magnetic resonance imaging. METHODS: Framingham Offspring Study participants who attended the seventh examination were at least 60 years old and free of dementia and stroke were included. We evaluated associations between exposures (fine particulate matter [PM2.5] and residential proximity to major roadways) and measures of total cerebral brain volume, hippocampal volume, white matter hyperintensity volume (log-transformed and extensive white matter hyperintensity volume for age), and covert brain infarcts. Models were adjusted for age, clinical covariates, indicators of socioeconomic position, and temporal trends. RESULTS: A 2-µg/m(3) increase in PM2.5 was associated with -0.32% (95% confidence interval, -0.59 to -0.05) smaller total cerebral brain volume and 1.46 (95% confidence interval, 1.10 to 1.94) higher odds of covert brain infarcts. Living further away from a major roadway was associated with 0.10 (95% confidence interval, 0.01 to 0.19) greater log-transformed white matter hyperintensity volume for an interquartile range difference in distance, but no clear pattern of association was observed for extensive white matter. CONCLUSIONS: Exposure to elevated levels of PM2.5 was associated with smaller total cerebral brain volume, a marker of age-associated brain atrophy, and with higher odds of covert brain infarcts. These findings suggest that air pollution is associated with insidious effects on structural brain aging even in dementia- and stroke-free persons.

Predictability of the future development of aggressive behavior of cranial dural arteriovenous fistulas based on decision tree analysis.

OBJECT: The severity of clinical signs and symptoms of cranial dural arteriovenous fistulas (DAVFs) are well correlated with their pattern of venous drainage. Although the presence of cortical venous drainage can be considered a potential predictor of aggressive DAVF behaviors, such as intracranial hemorrhage or progressive neurological deficits due to venous congestion, accurate statistical analyses are currently not available. Using a decision tree data mining method, the authors aimed at clarifying the predictability of the future development of aggressive behaviors of DAVF and at identifying the main causative factors. METHODS: Of 266 DAVF patients, 89 were eligible for analysis. Under observational management, 51 patients presented with intracranial hemorrhage/infarction during the follow-up period. RESULTS: The authors created a decision tree able to assess the risk for the development of aggressive DAVF behavior. Evaluated by 10-fold cross-validation, the decision tree's accuracy, sensitivity, and specificity were 85.28%, 88.33%, and 80.83%, respectively. The tree shows that the main factor in symptomatic patients was the presence of cortical venous drainage. In its absence, the lesion location determined the risk of a DAVF developing aggressive behavior. CONCLUSIONS: Decision tree analysis accurately predicts the future development of aggressive DAVF behavior.

A quantitative assessment of the association between 1425G/A polymorphism in PRKCH and risk of stroke.

Previous studies suggested an association between 1425G/A polymorphism in PRKCH and stroke risk, but the results were inconsistent. To obtain a more precise estimation, we carried out a meta-analysis to analyze the effect of 1425G/A SNP in PRKCH on stroke risk. We searched PubMed, ISI Web of Science, Chinese Biomedical Database, China National Knowledge Infrastructure and WANFANG Data for all eligible case-control studies through April 2014. The odds ratios (ORs), together with the 95% confidence intervals (CIs), were calculated to evaluate the strength of association between 1425G/A SNP and stroke risk. Overall, seven eligible studies involving a total of 4,574 cases and 5,471 controls were included in our meta-analysis. The results showed that the variant genotypes of 1425G/A polymorphism in PRKCH were significantly associated with a higher risk of stroke in all genetic models (GA vs. GG: OR 1.35, 95% CI 1.24-1.47, P < 0.001; AA vs. GG: OR 1.50, 95% CI 1.24-1.82, P < 0.001; GA/AA vs. GG: OR 1.37, 95% CI 1.26-1.49, P < 0.001; AA vs. GA/GG: OR 1.35, 95% CI 1.12-1.62, P = 0.002; A vs. G: OR 1.29, 95% CI 1.21-1.39, P < 0.001). In the subgroup analysis, significantly increased risks were also observed for ischemic stroke, larger sample size (>1,000) and population-based studies. The result of our meta-analysis indicated that the 1425G/A SNP in PRKCH may contribute to susceptibility of stroke, especially for ischemic stroke.

Risk assessment of the outcome for cerebral infarction in tuberculous meningitis.

INTRODUCTION: Cerebral infarction in tuberculous meningitis is a major risk factor for permanent disability. This study assessed the clinical presentation of tuberculous meningitis and risks factors for cerebral infarction. OBSERVATION: Thirty-eight adult patients with tuberculous meningitis were studied between 2002 and 2006. Clinical, radiological, and laboratory data of patients with cerebral infarction were compared with those of patients without cerebral infarction. Patients with cerebral infarction were significantly older (65.1 vs 52.1years), had higher risk assessment scores (3.7 vs 2.2), and more often had basal meningeal enhancement on imaging (92.3% vs 60.0%), mild to moderate sequelae (69.2% vs 4%), an overall poor brain outcome (69.2% vs 8%), aspirin prescription (84% vs 8%), and neurosurgical intervention for hydrocephalus (54.0% vs 16.0%). Cerebral infarction patients were also more likely to have experienced doctor-related delays in antituberculosis (61.5% vs 36%) and corticosteroid (61.5% vs 32%) therapy. DISCUSSION AND CONCLUSION: The Framingham risk score would be an option for tuberculous meningitis patients to access cerebral infarction risk. Contrast-enhanced brain imaging is helpful for exploring basal meningeal enhancement, in order to obtain an early diagnosis. Antituberculosis, corticosteroid, and aspirin therapies should be started immediately when tuberculous meningitis is suspected.

Use of secondary stroke prevention medicines in Australia: national trends, 2003-2009.

OBJECTIVE: To examine recent trends in the use of secondary stroke prevention medicines by transient ischaemic attack (TIA) and ischaemic stroke survivors. DESIGN, SETTING AND PARTICIPANTS: Retrospective observational study of patients aged ≥ 65 years who were hospitalised with a TIA or ischaemic stroke between January 2000 and December 2009. Use of antihypertensive, antithrombotic and lipid-lowering medicines by patients was determined monthly, using claims data from the Australian Government Department of Veterans' Affairs, commencing in January 2003. MAIN OUTCOME MEASURE: Monthly prevalence of use of secondary stroke prevention medicines. RESULTS: Between 2003 and 2009, small increases in use (less than 2% relative increase annually) were observed for antihypertensive and antithrombotic medicines among 19 019 patients. There was a 9% relative increase in use of lipid-lowering therapy each year. The proportion of patients dispensed all three recommended medicine classes nearly doubled over the 7-year period. By December 2009, about 80% of patients were dispensed an antihypertensive, 75% received an antithrombotic and 60% were dispensed lipid-lowering therapy. Almost half of the population were dispensed all three recommended classes by the end of the study period. CONCLUSIONS: Increased use of secondary stroke prevention medicines was shown in this study, in accordance with national stroke guideline recommendations and initiatives supporting quality use of medicines in Australia. There may be opportunity to further increase use of these medicines among older Australians who have had a TIA or ischaemic stroke.

[Quality parameters in the treatment of acute stroke: comparison of various regional treatment concepts]. / Qualitätsparameter der akuten Schlaganfallversorgung: Gegenüberstellung unterschiedlicher regionaler Versorgungskonzepte.

BACKGROUND: The long-term prognosis of stroke patients is still dependent in particular on the timing of a correct diagnosis, immediate initiation of a suitable specific therapy and competent treatment in a stroke unit. Therefore, nationwide attempts are being made to establish a comprehensive coverage of the necessary specific competence and infrastructural requirements. Divergent regional circumstances and economic viewpoints determine the characteristics of the various healthcare concepts and the interplay between participating cooperation partners. This article compares the development with respect to three qualitative treatment parameters exemplified by four regional healthcare models during the time period 2008-2011. METHODS: The hospitalization rates for patients with transitory ischemic attacks, ischemic and hemorrhagic stroke, the case numbers for stoke unit treatment and the rates of systemic thrombolysis and mechanical thrombectomy in the regions of Berlin, the Ruhr Area, Ostwestfalen-Lippe and southeast Bayern (TEMPiS) are presented based on the data from the DRG statistical reports for the years 2008 and 2011. RESULTS: The average hospitalization rates for ischemic stroke patients (brain infarct ICD 163) in the time period from 2008 to 2011 were 294 per 100,000 inhabitants for the Ruhr Area, 257 per 100,000 inhabitants for Ostwestfalen-Lippe and 265 per 100,000 inhabitants each for Berlin and southeast Bayern. The complex stroke treatment quota for southeast Bayern in 2008 was 31 % and 47 % in 2011 and the respective quotas for the other regions studied were 42-44 % and 58-59 %. The rate of systemic thrombolysis in 2008 ranged between 4.2 % and 7.4 % and in 2011 the increase in the range for the 4 regions studied was between 41 % and 145 %. In 2011 the thrombectomy quota of 2 % in the Ruhr Area was the only one which was above the national average of 1.3 % of all brain infarcts. DISCUSSION: Stroke is a common disease in the four regions studied. For the established forms of therapy, complex treatment of stroke and systemic thrombolysis, the positive effect of structurally improved approaches in the four different regional treatment concepts could be confirmed during the course of the observational time period selected. Mechanical thrombectomy which is currently still considered to be an individual healing attempt, was used significantly more often in the Ruhr Area in 2011 than in the other three regions studied. A standardized referral procedure had previously been established in the metropolitan regions.

Cardiovascular and cerebrovascular diseases in ankylosing spondylitis: current insights.

Patients with ankylosing spondylitis (AS) suffer from an increased cardiovascular (CV) risk. The evidence for increased atherosclerotic disease is nowadays convincing, while the precise contribution of the so-called AS-specific (related) cardiac manifestations toward the increased CV risk still needs to be determined. Such studies should be performed in the near future, since they might have clinical consequences-for example, mandatory echocardiographic screening of AS patients. There appears to be a clear contribution of the "traditional" CV risk factors, as well as the underlying chronic inflammatory process, to the increased atherosclerotic risk in AS. Furthermore, there is accumulating evidence for an etiological role of inflammation in the AS-related cardiac manifestations. Nowadays, CV risk management appears necessary for AS patients, and this should consist of, on the one hand, assessment and treatment, if necessary, of the "traditional" CV risk factors, and, on the other hand, effective suppression of the inflammatory process.

Lifestyle factors on the risks of ischemic and hemorrhagic stroke.

BACKGROUND: The joint effects of different lifestyle factors on stroke risk are still to some extent unclear, especially regarding hemorrhagic stroke. METHODS: We prospectively investigated the association of different indicators of lifestyle (smoking, body mass index, physical activity, and vegetable and alcohol consumption) with total and type-specific stroke incidence among 36 686 Finnish participants who were 25 to 74 years old and free of coronary heart disease and stroke at baseline. RESULTS: During a mean follow-up period of 13.7 years, 1478 people developed an incident stroke event (1167 ischemic and 311 hemorrhagic). The multivariate-adjusted (age, sex, education, family history of stroke, history of diabetes mellitus, systolic blood pressure, and serum total cholesterol level) hazard ratios associated with adherence to 0 to 1 (reference group), 2, 3, 4, and 5 healthy lifestyle indicators were 1, 0.66, 0.57, 0.51, and 0.33 (P < .001 for trend) for total stroke; 1, 0.67, 0.60, 0.50, and 0.30 (P < .001 for trend) for ischemic stroke; and 1, 0.63, 0.49, 0.49, and 0.40 (P < .001 for trend) for hemorrhagic stroke, respectively. These inverse associations were similar in both men and women. The partial population attributable risk percentages associated with adherence to 3, 4, and 5 healthy lifestyle indicators were 26.3%, 43.8%, and 54.6% for total stroke; 22.7%, 45.3%, and 59.7% for ischemic stroke; and 35.0%, 35.0%, and 36.1% for hemorrhagic stroke, respectively. CONCLUSION: Healthy lifestyle factors are associated with a lower risk of stroke, and there is a graded inverse association between the number of healthy lifestyle indicators and the risks of total, ischemic, and hemorrhagic stroke.

Neurocritical care in developing countries.

Neurocritical illness heavily burdens the developing world. In spite of a lack of resources for population-based health in most developing countries, there is an increasing demand for resource-intense strategies for acute neurological care. Factors including rising individual incomes in emerging economies, need for neurointensive care in humanitarian emergencies, growth of private hospitals, the rising burden of noncommunicable disease, and the practice of neurocritical care by specialists outside of neurology are discussed. Possible steps to improve the global practice of neurocritical care include: (1) emphasis on prevention of neurocritical illness through traffic safety and adequate outpatient treatment; (2) standardization of training requirements and skill sets; (3) guidelines on cost-effective measures including medications, equipment, and devices; (4) strengthening of surveillance systems and registries for both noncommunicable and communicable neurological diseases; (5) expanded use of teleneurology; (6) educational exchanges of neurointensive health care workers; and (7) monitoring of neurological intensive care unit death rates due to nosocomial infections, neurological disease, and other causes. A summary of reported mortality rates among neurocritically ill patients in African countries in recent years is provided as an illustrative example.

Evaluation of admission characteristics, hospital length of stay and costs for cerebral infarction in a medium-sized city in China.

BACKGROUND AND PURPOSE: Stroke is a heavy economic and health burden for the patients and society. This study aimed to evaluate hospital length of stay (LOS) by admission characteristics and costs correlated with medical insurance status for cerebral infarction in a medium-sized city in China. METHODS: A total of 557 consecutive patients with principal diagnosis of cerebral infarction were enrolled. Admission characteristics, LOS, and costs were retrospectively analyzed. RESULTS: The mean LOS was 18.5 days (median, 16 days). Our analysis demonstrated that medical insurance status, stroke severity (National Institutes of Health Stroke Scale score, Functional Independence Measure cognitive and motor score, Glasgow coma scale), Oxfordshire Community Stroke Project (OCSP) classification, some comorbidities (coronary heart disease, chronic obstructive pulmonary disease, and hyperlipemia), and raised leukocytes were the main explanatory factors for LOS by stepwise multiple regression model. The mean per patient costs were US $983.0, and mean daily costs US $67.0. Drugs were the most expensive cost subtype, all subtypes costs except non-medical care were significantly higher in patients with state medicine than in those with new cooperative medical scheme (NCMS) (P < 0.001). CONCLUSION: Stroke severity, OCSP classification, raised leukocytes on admission, some comorbidities, and medical insurance status may help to predict LOS for patients with cerebral infarction. Healthcare expenditures were heavy burdens to inhabitants. State medicine patients could shorten unnecessary LOS to improve the resources allocation and cost-efficiency.