Developing a Stroke Risk Prediction Model Using Cardiovascular Risk Factors: The Suita Study.

INTRODUCTION: Stroke remains a major cause of death and disability in Japan and worldwide. Detecting individuals at high risk for stroke to apply preventive approaches is recommended. This study aimed to develop a stroke risk prediction model among urban Japanese using cardiovascular risk factors. METHODS: We followed 6,641 participants aged 30-79 years with neither a history of stroke nor coronary heart disease. The Cox proportional hazard model estimated the risk of stroke incidence adjusted for potential confounders at the baseline survey. The model's performance was assessed using the receiver operating characteristic curve and the Hosmer-Lemeshow statistics. The internal validity of the risk model was tested using derivation and validation samples. Regression coefficients were used for score calculation. RESULTS: During a median follow-up duration of 17.1 years, 372 participants developed stroke. A risk model including older age, current smoking, increased blood pressure, impaired fasting blood glucose and diabetes, chronic kidney disease, and atrial fibrillation predicted stroke incidence with an area under the curve = 0.76 and p value of the goodness of fit = 0.21. This risk model was shown to be internally valid (p value of the goodness of fit in the validation sample = 0.64). On a risk score from 0 to 26, the incidence of stroke for the categories 0-5, 6-7, 8-9, 10-11, 12-13, 14-15, and 16-26 was 1.1%, 2.1%, 5.4%, 8.2%, 9.0%, 13.5%, and 18.6%, respectively. CONCLUSION: We developed a new stroke risk model for the urban general population in Japan. Further research to determine the clinical practicality of this model is required.

The Lifelong Health Support 10: a Japanese prescription for a long and healthy life.

BACKGROUND: Although the age-adjusted incidence and mortality of cancer and cardiovascular disease (CVD) have been decreasing steadily in Japan, both diseases remain major contributors to morbidity and mortality along with the aging society. Herein, we aim to provide a prescription of 10 health tips for long and healthy life named the "Lifelong Health Support 10 (LHS10)." METHOD: The LHS10 was developed by the preventive medicine specialists at the National Cerebral and Cardiovascular Center in Suita, where it has been used for health guidance to prevent CVD, cancer, and cognitive decline in addition to their major risk factors such as hypertension, diabetes, and obesity. It consisted of the lifestyle modification recommendations of the 2014 Japanese Society of Hypertension guidelines and the 2017 Japan Atherosclerosis Society Guidelines for preventing atherosclerotic CVD. Further, it came in line with other international lifestyle modification guidelines. In this narrative review, we summarized the results of several Japanese epidemiological studies investigating the association between the LHS10 items and the risk of cancer, CVD, and other chronic diseases including dementia, diabetes, and chronic kidney disease. RESULTS: The LHS10 included avoiding smoking and secondhand smoke exposure, engaging in physical activity, refraining from excessive alcohol drinking, reducing fried foods and sugary soft drinks, cutting salt in food, consuming more vegetables, fruits, fish, soy foods, and fibers, and maintaining proper body weight. All items of the LHS10 were shown to reduce the risk of cancer, CVD, and other chronic diseases. CONCLUSIONS: The LHS10 can be a helpful tool for health guidance.

Stair climbing and incident atrial fibrillation: a prospective cohort study.

BACKGROUND: A protective role for physical activity against the development of atrial fibrillation (AF) has been suggested. Stair climbing is a readily available form of physical activity that many people practice. Herein, we investigated the association between stair climbing and the risk of AF in a Japanese population. METHODS: In this prospective cohort study, we used data of 6,575 people registered in the Suita Study, aged 30-84 years, and had no history of AF. The frequency of stair climbing was assessed by a baseline questionnaire, while AF was diagnosed during the follow-up using a 12-lead ECG, health records, check-ups, and death certificates. We used the Cox regression to calculate the hazard ratios and 95% confidence intervals of AF incidence for climbing stairs in 20-39%, 40-59%, and ≥60% compared with <20% of the time. RESULTS: Within 91,389 person-years of follow-up, 295 participants developed AF. The incidence of AF was distributed across the stair climbing groups <20%, 20-39%, 40-59%, and ≥60% as follows: 3.57, 3.27, 3.46, and 2.63/1,000 person-years, respectively. Stair climbing ≥60% of the time was associated with a reduced risk of AF after adjustment for age and sex 0.69 (0.49, 0.96). Further adjustment for lifestyle and medical history did not affect the results 0.69 (0.49, 0.98). CONCLUSION: Frequent stair climbing could protect from AF. From a preventive point of view, stair climbing could be a simple way to reduce AF risk at the population level.

Identification of 5-Hydroxymethylfurfural (5-HMF) as an Active Component Citrus Jabara That Suppresses FcεRI-Mediated Mast Cell Activation.

Jabara (Citrus jabara Hort. ex Y. Tanaka) is a type of citrus fruit known for its beneficial effect against seasonal allergies. Jabara is rich in the antioxidant narirutin whose anti-allergy effect has been demonstrated. One of the disadvantages in consuming Jabara is its bitter flavor. Therefore, we fermented the fruit to reduce the bitterness and make Jabara easy to consume. Here, we examined whether fermentation alters the anti-allergic property of Jabara. Suppression of degranulation and cytokine production was observed in mast cells treated with fermented Jabara and the effect was dependent on the length of fermentation. We also showed that 5-hydroxymethylfurfural (5-HMF) increases as fermentation progresses and was identified as an active component of fermented Jabara, which inhibited mast cell degranulation. Mast cells treated with 5-HMF also exhibited reduced degranulation and cytokine production. In addition, we showed that the expression levels of phospho-PLCγ1 and phospho-ERK1/2 were markedly reduced upon FcεRI stimulation. These results indicate that 5-HMF is one of the active components of fermented Jabara that is involved in the inhibition of mast cell activation.

The Criteria of Thickened Liquid for Dysphagia Management in Japan.

In Japan, the viscosity of thickened liquids is different among hospitals and nursing homes. In order to standardize viscosity of thickened liquids, the dysphagia diet committee of the Japanese Society of Dysphagia Rehabilitation developed the Japanese Dysphagia Diet 2013 (JDD2013). To decide on a definition of thickened liquids, the committee reviewed categories from other countries. Especially, the criteria of the USA and Australia were used as references. The definition had three levels: mildly thick, moderately thick, and extremely thick. Then a sensory evaluation by health care workers was carried out to decide the viscosity range of each level, and a draft document was made. After collecting public comments, follow-up experiments using thickened water with thickeners using xanthan gum were performed, and the JDD2013 (Thickened Liquid) was determined. The JDD2013 (Thickened Liquid) evaluated the drinking properties, visual properties, and viscosity values of each level. The shear rate of 50 s-1 was adopted to measure the viscosity with a cone and plate type viscometer to duplicate the measurement criteria used by the USA. We also set the values of the JDD2013 with the Line Spread Test to promote the use of guidelines in clinical practice. We believe the JDD2013 standards help hospitals and other settings that care for people with dysphagia to use the same thickness level and the same labels. In the future, the JDD2013 levels will be compared with new international guidelines to help with international understanding of the JDD2013 levels.

Sleep duration and atrial fibrillation risk in the context of predictive, preventive, and personalized medicine: the Suita Study and meta-analysis of prospective cohort studies.

Background: Short and long sleep durations are common behaviors that could predict several cardiovascular diseases. However, the association between sleep duration and atrial fibrillation (AF) risk is not well-established. AF is preventable, and risk prevention approaches could reduce its occurrence. Investigating whether sleep duration could predict AF incidence for possible preventive interventions and determining the impact of various lifestyle and clinical characteristics on this association to personalize such interventions are essential. Herein, we investigated the association between sleep duration and AF risk using a prospective cohort study and a meta-analysis of epidemiological evidence. Methods: Data of 6898 people, aged 30-84 years, from the Suita Study, were analyzed. AF was diagnosed during the follow-up by ECG, medical records, checkups, and death certificates, while a baseline questionnaire was used to assess sleep duration. The Cox regression was used to compute the hazard ratios (HRs) and 95% confidence intervals (CIs) of AF risk for daily sleep ≤ 6 (short sleep), ≥ 8 (long sleep), and irregular sleep, including night-shift work compared with 7 h (moderate sleep). Then, we combined our results with those from other eligible prospective cohort studies in two meta-analyses for the short and long sleep. Results: In the Suita Study, within a median follow-up period of 14.5 years, short and irregular sleep, but not long sleep, were associated with the increased risk of AF in the age- and sex-adjusted models: HRs (95% CIs) = 1.36 (1.03, 1.80) and 1.62 (1.16, 2.26) and the multivariable-adjusted models: HRs (95% CIs) = 1.34 (1.01, 1.77) and 1.63 (1.16, 2.30), respectively. The significant associations between short and irregular sleep and AF risk remained consistent across different ages, sex, smoking, and drinking groups. However, they were attenuated among overweight and hypertensive participants. In the meta-analyses, short and long sleep durations were associated with AF risk: pooled HRs (95% CIs) = 1.21 (1.02, 1.42) and 1.18 (1.03, 1.35). No signs of significant heterogeneity across studies or publication bias were detected. Conclusion: Short, long, and irregular sleep could be associated with increased AF risk. In the context of predictive, preventive, and personalized medicine, sleep duration should be considered in future AF risk scores to stratify the general population for potential personalized lifestyle modification interventions. Sleep management services should be considered for AF risk prevention, and these services should be individualized according to clinical characteristics and lifestyle factors. Supplementary Information: The online version contains supplementary material available at 10.1007/s13167-022-00275-4.

Weight Change Since Age 20 and the Risk of Cardiovascular Disease Mortality: A Prospective Cohort Study.

AIM: Weight change could have many health outcomes. This study aimed to investigate the association between weight change and mortality risk due to total cardiovascular disease (CVD), ischemic heart disease (IHD), and stroke among Japanese. METHODS: We used Suita Study data from 4,746 people aged 30-79 years in this prospective cohort study. Weight change was defined as the difference between baseline weight and weight at age 20. We used Cox proportional hazards models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) of total CVD, IHD, and stroke mortality for 1) participants with a weight change (＞10, 5 to 10, -5 to -10, and ＜-10 kg) compared to those with stable weight (-4.9 to 4.9 kg) and 2) participants who moved from one body mass index category (underweight, normal weight, or overweight) to another compared to those with normal weight at age 20 and baseline. RESULTS: Within a median follow-up period of 19.9 years, the numbers of total CVD, IHD, and stroke mortality were 268, 132, and 79, respectively. Weight loss of ＞10 kg was associated with the increased risk of total CVD mortality 2.07 (1.29, 3.32) and stroke mortality 3.02 (1.40, 6.52). Moving from normal weight at age 20 to underweight at baseline was associated with the increased risk of total CVD, IHD, and stroke mortality: 1.76 (1.12, 2.77), 2.10 (1.13, 3.92), and 2.25 (1.05, 4.83), respectively. CONCLUSION: Weight loss, especially when moving from normal to underweight, was associated with the increased risk of CVD mortality.

Liver enzymes, alcohol consumption and the risk of diabetes: the Suita study.

AIM: We aimed to investigate the combined impact of liver enzymes and alcohol consumption on the diabetes risk. METHODS: Data on 5972 non-diabetic participants aged 30-79 years from the Suita study were analyzed. Diabetes incidence was surveyed every 2 years. Current daily alcohol consumption was defined as light drinking (< 23.0 g ethanol/day in men and < 11.5 g in women), moderate drinking (23.0-45.9 g and 11.5-22.9 g), and heavy drinking (≥ 46.0 g and ≥ 23.0 g). The nondrinkers category included both never-drinkers and former drinkers. RESULTS: During the median follow-up of 13 years, 597 incident diabetes cases were diagnosed. Higher levels of γ-glutamyltransferase (GGT), alanine aminotransferase (GPT), and aspartate aminotransferase (GOT) were associated with an increased diabetes risk, and current light drinkers had a lower risk of diabetes than nondrinkers. No sex differences were observed in these associations. Compared to nondrinkers having the lowest quartiles of liver enzymes, nondrinkers and current moderate/heavy drinkers having the highest quartiles had an increased risk of diabetes. However, no association was observed for current light drinkers having the highest quartiles of liver enzymes; the multivariable hazard ratios (95% CIs) in current light drinkers with the highest quartile of liver enzymes were 1.27 (0.68-2.37) for GGT, 1.05 (0.59-1.89) for GPT, and 0.76 (0.40-1.47) for GOT, respectively. CONCLUSION: High liver enzymes were associated with an increased diabetes risk. No increased diabetes risk was observed in current light drinkers, even in these who had high levels of liver enzymes.

Mild Hypertensive Retinopathy and Risk of Cardiovascular Disease: The Suita Study.

AIMS: This study aimed to investigate the association of mild hypertensive retinopathy with cardiovascular disease (CVD) risk. METHODS: A total of 7,027 residents aged 30-79 years without a history of CVD participated in the annual health checkups and retinal photography assessments. Retinal microvascular abnormalities were graded using the standard protocols and classified according to the Keith-Wagener-Barker classification. Mild hypertensive retinopathy was defined as grades 1 and 2. Cox proportional hazard model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for total CVD and its subtypes according to the presence and absence of mild hypertensive retinopathy. RESULTS: During a median follow-up of 17 years, 351 incident stroke and 247 coronary heart disease (CHD) cases were diagnosed. After adjustment for traditional cardiovascular risk factors, mild hypertensive retinopathy was positively associated with risk of CVD (multivariable HR=1.24; 95% CI, 1.04-1.49) and stroke (1.28; 1.01-1.62) but not with risk of CHD (1.19; 0.89-1.58). Generalized arteriolar narrowing and enhanced arteriolar wall reflex were positively associated with CVD risk, the multivariable HR (95% CI) was 1.24 (1.00-1.54) and 1.33 (1.02-1.74), respectively. Moreover, mild hypertensive retinopathy was positively associated with stroke risk in normotensive participants. CONCLUSION: Mild hypertensive retinopathy was positively associated with CVD and stroke risk in the urban Japanese population. Especially, generalized arteriolar narrowing and enhanced arteriolar wall reflex were positively associated with CVD risk. These findings suggested that retinal photography could be helpful for cardiovascular risk stratification in the primary cardiovascular prevention.

Serum uric acid levels and the risk of diabetes mellitus in premenopausal and postmenopausal women: the Suita study.

OBJECTIVE: The association between serum uric acid levels and the risk of diabetes mellitus in women stratified by menopausal status is not well-established. Therefore, we investigated this association among a cohort of Japanese urban women. METHODS: We conducted a prospective cohort study on 3,304 women (1,252 premenopausal and 2,052 postmenopausal), aged 30 to 79 years, with no prior cardiovascular disease or diabetes mellitus, and enrolled from a general urban population. Cox proportional hazard model was used to calculate hazard ratios and 95% confidence intervals (CIs) for incident diabetes mellitus according to serum uric acid quartiles. RESULTS: During 13.8 years of median follow-up, 219 incident diabetes mellitus cases were diagnosed. The incidence rate per 1,000 person-years was 3.42 in premenopausal women and 6.19 in postmenopausal women. After adjustment for potential risk factors, the multivariable hazard ratios (95% CIs) of the highest versus lowest serum uric acid quartiles were 1.56 (0.77-3.16) in premenopausal women, 2.00 (1.19-3.34) in postmenopausal women, and 1.81 (1.21-2.73) in all women. The interaction based on menopausal status was not significant ( P = 0.872). The corresponding population attributable fractions (95% CIs) were 13.3% (-8.9% to 31.1%), 19.1% (5.3%-30.9%), and 17.0% (5.6%-27.0%), respectively. CONCLUSIONS: Serum uric acid levels were positively associated with the risk of diabetes mellitus in postmenopausal women, but not in premenopausal women. However, the lack of an association in premenopausal women may have been due to limited power, so further research is required to confirm this menopausal status-specific association.

Analysing breast cancer microarrays from African Americans using shrinkage-based discriminant analysis.

Breast cancer tumours among African Americans are usually more aggressive than those found in Caucasian populations. African-American patients with breast cancer also have higher mortality rates than Caucasian women. A better understanding of the disease aetiology of these breast cancers can help to improve and develop new methods for cancer prevention, diagnosis and treatment. The main goal of this project was to identify genes that help differentiate between oestrogen receptor-positive and -negative samples among a small group of African-American patients with breast cancer. Breast cancer microarrays from one of the largest genomic consortiums were analysed using 13 African-American and 201 Caucasian samples with oestrogen receptor status. We used a shrinkage-based classification method to identify genes that were informative in discriminating between oestrogen receptor-positive and -negative samples. Subset analysis and permutation were performed to obtain a set of genes unique to the African-American population. We identified a set of 156 probe sets, which gave a misclassification rate of 0.16 in distinguishing between oestrogen receptor-positive and -negative patients. The biological relevance of our findings was explored through literature-mining techniques and pathway mapping. An independent dataset was used to validate our findings and we found that the top ten genes mapped onto this dataset gave a misclassification rate of 0.15. The described method allows us best to utilise the information available from small sample size microarray data in the context of ethnic minorities.

Psychiatric Neural Networks and Precision Therapeutics by Machine Learning.

Learning and environmental adaptation increase the likelihood of survival and improve the quality of life. However, it is often difficult to judge optimal behaviors in real life due to highly complex social dynamics and environment. Consequentially, many different brain regions and neuronal circuits are involved in decision-making. Many neurobiological studies on decision-making show that behaviors are chosen through coordination among multiple neural network systems, each implementing a distinct set of computational algorithms. Although these processes are commonly abnormal in neurological and psychiatric disorders, the underlying causes remain incompletely elucidated. Machine learning approaches with multidimensional data sets have the potential to not only pathologically redefine mental illnesses but also better improve therapeutic outcomes than DSM/ICD diagnoses. Furthermore, measurable endophenotypes could allow for early disease detection, prognosis, and optimal treatment regime for individuals. In this review, decision-making in real life and psychiatric disorders and the applications of machine learning in brain imaging studies on psychiatric disorders are summarized, and considerations for the future clinical translation are outlined. This review also aims to introduce clinicians, scientists, and engineers to the opportunities and challenges in bringing artificial intelligence into psychiatric practice.

Impact of an antimicrobial stewardship in a 126-bed community hospital with close communication between pharmacists working on post-prescription audit, ward pharmacists, and the antimicrobial stewardship team.

BACKGROUND: Antimicrobial stewardship (AS) is defined as coordinated interventions to improve and measure the appropriate use of antimicrobial agents. However, available resources for AS differ depending on the size of the clinical setting. Therefore, AS programs based on guidelines need to be selected in order to implement AS in small- to medium-sized hospitals. The present study compared the impact of AS in a 126-bed community hospital between pre- and post-AS periods. METHODS: The present study was retrospectively performed by selecting data on eligible patients from electronic medical records stored in the central database of the hospital. The roles of the AS team included weekly rounds and recommendations on the appropriate use of antimicrobials, and pharmacists working on post-prescription audits and pharmaceutical care at the bedside closely communicated with the AS team to assist with its implementation. As process measurements, the order rate of culture examinations, the conducting rate of de-escalation, antimicrobial use density (AUD), days of therapy (DOT), and the AUD/DOT ratio of carbapenems and tazobactam-piperacillin (TAZ/PIPC) were measured. Thirty-day mortality and recurrence rates were examined as clinical outcomes. RESULTS: A total of 535 patients (288 in the pre-AS period and 247 in the post-AS period) were enrolled in the present study. The recommendation rate to prescribers significantly increased (p < 0.01) from 10.4% in the pre-AS period to 21.1% in the post-AS period. The order rate of culture examinations increased from 56.3 to 73.3% (p < 0.01). The conducting rate of de-escalation increased from 10.2 to 30.8% (p < 0.05). The AUD of carbapenems and TAZ/PIPC significantly decreased (p < 0.05). The DOT of carbapenems (p < 0.01) and TAZ/PIPC (p < 0.05) also significantly decreased. The AUD/DOT ratio of carbapenem significantly increased from 0.37 to 0.60 (p < 0.01). Thirty-day mortality rates were 11.2 and 14.2%, respectively, and were not significantly different. The 30-day recurrence rate significantly decreased (p < 0.05) from 14.7 to 7.5%. CONCLUSIONS: The implementation of AS in this hospital improved the appropriate use of antimicrobials without negatively affecting clinical outcomes. These results may be attributed to close communication between pharmacists working on post-prescription audits and pharmaceutical care at the bedside and the AS team.

Predictors of hospital readmission after stroke: a systematic review.

BACKGROUND AND PURPOSE: Risk-standardized hospital readmission rates are used as publicly reported measures reflecting quality of care. Valid risk-standardized models adjust for differences in patient-level factors across hospitals. We conducted a systematic review of peer-reviewed literature to identify models that compare hospital-level poststroke readmission rates, evaluate patient-level risk scores predicting readmission, or describe patient and process-of-care predictors of readmission after stroke. METHODS: Relevant studies in English published from January 1989 to July 2010 were identified using MEDLINE, PubMed, Scopus, PsycINFO, and all Ovid Evidence-Based Medicine Reviews. Authors of eligible publications reported readmission within 1 year after stroke hospitalization and identified ≥ 1 predictors of readmission in risk-adjusted statistical models. Publications were excluded if they lacked primary data or quantitative outcomes, reported only composite outcomes, or had < 100 patients. RESULTS: Of 374 identified publications, 16 met the inclusion criteria for this review. No model was specifically designed to compare risk-adjusted readmission rates at the hospital level or calculate scores predicting a patient's risk of readmission. The studies providing multivariable models of patient-level and/or process-of-care factors associated with readmission varied in stroke definitions, data sources, outcomes (all-cause and/or stroke-related readmission), durations of follow-up, and model covariates. Few characteristics were consistently associated with readmission. CONCLUSIONS: This review identified no risk-standardized models for comparing hospital readmission performance or predicting readmission risk after stroke. Patient-level and system-level factors associated with readmission were inconsistent across studies. The current literature provides little guidance for the development of risk-standardized models suitable for the public reporting of hospital-level stroke readmission performance.

Postendarterectomy mortality in octogenarians and nonagenarians in the USA from 1993 to 1999.

BACKGROUND: Relatively little is known about trends in the utilization or outcomes of carotid endarterectomy (CEA) in the very elderly. We determined trends in the rates of CEA and perioperative (in-hospital and 30-day) and long-term (1-, 2-, 3-, 4- and 5-year) mortality in a US national sample of patients >or=80 years of age. METHODS: All fee-for-service Medicare patients (80-89 and >or=90 years of age) who had a CEA [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): 38.12] from 1993 to 1999 were identified using the Centers for Medicare and Medicaid Services Inpatient Standard Analytic Files. Demographic characteristics and comorbid conditions were determined using ICD-9-CM diagnostic codes within the year prior to the index hospitalization for CEA. RESULTS: A total of 140,376 CEA were performed in patients aged 80-89 years and 6,446 in those aged >or=90 years during this 7-year period. The annual number of operations increased from 13,115 in 1993 to 21,582 in 1999 for octogenarians, and from 481 in 1993 to 1,257 in 1999 for nonagenarians. Perioperative mortality was 2.2% in octogenarians and 3.3% in nonagenarians. Long-term mortality increased by approximately 10% per year after the operation, and was 43% in octogenarians and 56% in nonagenarians at 5 years. Perioperative mortality rates remained relatively stable over the 7-year period for both age groups although comorbidities increased. CONCLUSIONS: The number of CEA performed in the very elderly in the USA increased from 1993 to 1999. Perioperative mortality rates were high compared with trial results, while long-term survivorship was comparable to that of similarly-aged peers in the USA.

CDC's Multiple Approaches to Safeguard the Health, Safety, and Resilience of Ebola Responders.

Over 27,000 people were sickened by Ebola and over 11,000 people died between March of 2014 and June of 2016. The US Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) was one of many public health organizations that sought to stop this outbreak. This agency deployed almost 2,000 individuals to West Africa during that timeframe. Deployment to these countries exposed these individuals to a wide variety of dangers, stressors, and risks.Being concerned about the at-risk populations in Africa, and also the well-being of its professionals who willingly deployed, the CDC did several things to help safeguard the health, safety, and resilience of these team members before, during, and after deployment.The accompanying special report highlights innovative pre-deployment training initiatives, customized screening processes, and post-deployment outreach efforts intended to protect and support the public health professionals fighting Ebola. Before deploying, the CDC team members were expected to participate in both internally-created and externally-provided trainings. These ranged from pre-deployment briefings, to Preparing for Work Overseas (PFWO) and Public Health Readiness Certificate Program (PHRCP) courses, to Incident Command System (ICS) 100, 200, and 400 courses.A small subset of non-clinical deployers also participated in a three-day training designed in collaboration with the Center for the Study of Traumatic Stress (CSTS; Bethesda, Maryland USA) to train individuals to assess and address the well-being and resilience of themselves and their teammates in the field during a deployment. Participants in this unique training were immersed in a Virtual Reality Environment (VRE) that simulated deployment to one of seven different types of emergencies.The CDC leadership also requested a pre-deployment screening process that helped professionals in the CDC's Occupational Health Clinic (OHC) determine whether or not individuals were at an increased risk of negative outcomes by participating in a rigorous deployment at that time.When deployers returned from the field, they received personalized invitations to participate in a voluntary, confidential, post-deployment operational debriefing one-on-one or in a group.Implementing these approaches provided more information to clinical decision makers about the readiness of deployers. It provided deployers with a greater awareness of the kinds of challenges they were likely to face in the field. The post-deployment outreach efforts reminded staff that their contributions were appreciated and there were resources available if they needed help processing any of the potentially-traumatizing things they may have experienced.

Elderly women have lower rates of stroke, cardiovascular events, and mortality after hospitalization for transient ischemic attack.

BACKGROUND AND PURPOSE: Patients with transient ischemic attack (TIA) are at increased risk for stroke, cardiovascular events, and death, yet little is known about whether these risks differ for men and women. We determined whether there are sex-based differences in these outcomes 30 days and 1 year after TIA using a national sample of elderly patients. METHODS: Rates of 30-day and 1-year hospitalization for TIA (International Classification of Diseases, 9th Revision Code 435), stroke (International Classification of Diseases, 9th Revision Codes 433, 434, and 436), coronary artery disease (International Classification of Diseases, 9th Revision Codes 410 to 414), all-cause readmission, and mortality were determined for fee-for-service Medicare patients >or=65 years of age discharged with a TIA in 2002. Cox proportional hazards models and random-effects logistic models compared outcomes with risk adjustment for demographics, medical history, comorbidities, and prior hospitalizations. RESULTS: The study included 122063 TIA hospitalizations (mean age, 79.0+/-7.6 years; 62% women; 86% white). Men were younger but had higher rates of cardiac comorbidities than women. Women had lower unadjusted rates of stroke, coronary artery disease, and mortality at 30 days and 1 year after TIA admission. These relationships persisted in risk-adjusted analyses at 30 days for stroke (hazard ratio, 0.70; 95% CI, 0.64 to 0.77), coronary artery disease (hazard ratio, 0.86; 0.74 to 1.00), and mortality (odds ratio, 0.74; 0.68 to 0.82) as well as at 1 year for stroke (hazard ratio, 0.85; 0.81 to 0.89), coronary artery disease (hazard ratio, 0.81; 0.77 to 0.86), and mortality (odds ratio, 0.78; 0.75 to 0.81). CONCLUSIONS: These data suggest that women have a better prognosis than men within the first year after hospital discharge for a TIA. Additional research is needed to identify factors that may explain these sex-related differences in outcomes.

Stroke patient outcomes in US hospitals before the start of the Joint Commission Primary Stroke Center certification program.

BACKGROUND AND PURPOSE: The Joint Commission (JC) began certifying Primary Stroke Centers in November 2003. Cross-sectional studies assessing the impact of certification could be biased if these centers had better outcomes before the start of the program. We determined whether hospitals certified within the first years of the JC program had better outcomes than noncertified hospitals before the start of the certification program. METHODS: The study sample included Medicare fee-for-service beneficiaries >or=65 years of age discharged with ischemic stroke in 2002 from 5070 hospitals, 317 of which were JC-certified by June 2007. Hierarchical logistic regression and Cox proportional hazards models were used to compare in-hospital mortality, 30-day mortality, and 30-day readmission for patients treated at future JC-certified versus noncertified hospitals. RESULTS: Among 366 551 patients, 18% (66 300) were treated at hospitals with centers that were JC-certified within the first few years of the program. These patients were younger, more likely to be white and male, and had fewer comorbidities and hospitalizations within the prior year. Unadjusted in-hospital mortality (4.7% versus 5.5%), 30-day mortality (9.8% versus 11.3%), and readmissions (13.8% versus 14.6%) were lower in the future JC-certified hospitals (all P<0.001). These differences remained after risk adjustment (in-hospital mortality: OR, 0.93; 95% CI, 0.90 to 0.96; 30-day mortality: OR, 0.92; 95% CI, 0.87 to 0.96; 30-day readmission: hazard ratio, 0.97; 95% CI, 0.95 to 0.99). CONCLUSIONS: JC Primary Stroke Center-certified hospitals had better outcomes than noncertified hospitals even before the program began. Cross-sectional studies assessing the effects of stroke center certification need to account for these pre-existing differences.

Hospital arrival time and intravenous t-PA use in US Academic Medical Centers, 2001-2004.

BACKGROUND AND PURPOSE: Prompt care-seeking behavior is a focus of US national public stroke educational campaigns. We determined whether the time between symptom onset and hospital arrival and the receipt of intravenous tissue-type plasminogen activator (IV t-PA) changed for ischemic stroke patients evaluated at US academic centers between 2001 and 2004. METHODS: Medical records were abstracted for consecutive ischemic stroke patients admitted from the Emergency Department within 48 hours of symptom onset at 35 academic medical centers participating in the University HealthSystem Consortium Ischemic Stroke Benchmarking Project between January 1, 2001 and March 31, 2001, and 32 centers between January 1, 2004 and June 30, 2004. Demographic and clinical characteristics of patients who presented within and after 2 hours of symptom onset were compared. Multivariate logistic regression was used to compare time to arrival by year and to identify patient characteristics associated with earlier hospital arrival. RESULTS: The study included 428 patients from 2001 and 481 from 2004. Although there was no difference in the percentage of patients who arrived within 2 hours between the 2 periods (37% in 2001 vs 38% in 2004, P=0.63), the percentage of these patients treated with IV t-PA increased (14.0% to 37.5%, P<0.0001). In risk-adjusted analysis, black patients had a lower odds of arriving within 2 hours (odds ratio=0.55; 95% CI, 0.39 to 0.78), whereas those with severe strokes were more likely to arrive promptly (odds ratio=2.17; 95% CI, 1.49 to 3.15). CONCLUSIONS: There was no change in the proportion of stroke patients arriving at hospitals within 2 hours of symptom onset between 2001 and 2004; however, the rate of IV t-PA use increased, indicating system-level improvements of in-hospital care.

Utilization of intravenous tissue plasminogen activator for ischemic stroke: are there sex differences?

BACKGROUND: We evaluated whether there were sex-related differences in the administration of intravenous tissue plasminogen activator (IV-tPA) to patients with acute ischemic stroke admitted to US academic medical centers. METHODS: Medical records were abstracted for consecutive ischemic stroke patients admitted to 32 academic medical centers from January through June, 2004, as part of the University HealthSystem Consortium Ischemic Stroke Benchmarking Project. Multivariate logistic models were used to test for sex-related differences in the receipt of IV-tPA with adjustment for demographic and clinical factors. RESULTS: The study included 1,234 patients (49% women; mean age 66.6 years; 56% white). IV-tPA was given to 7% (6.5% of women versus 7.5% of men, p = 0.49). Women and men were equally likely to receive IV-tPA in risk-adjusted analyses (OR 1.02, 95% CI 0.64-1.64). Approximately 77% of women and men who did not receive IV-tPA did not meet the 3-hour treatment window or their time of onset was unknown. CONCLUSIONS: Women admitted to academic hospitals receive IV-tPA as often as men; however, a substantial percentage of both women and men are not arriving within the 3-hour time window required for diagnostic assessment and administration of intravenous thrombolytic therapy. Additional efforts are needed to improve the rapid identification, evaluation and treatment of stroke patients.