Racial difference in mortality among COVID-19 hospitalizations in California.

In the US, racial disparities in hospital outcomes are well documented. We explored whether race was associated with all-cause in-hospital mortality and intensive care unit (ICU) admission among COVID-19 patients in California. This was a retrospective analysis of California State Inpatient Database during 2020. Hospitalizations ≥ 18 years of age for COVID-19 were included. Cox proportional hazards with mixed effects were used for associations between race and in-hospital mortality. Logistic regression was used for the association between race and ICU admission. Among 87,934 COVID-19 hospitalizations, majority were Hispanics (56.5%), followed by White (27.3%), Asian, Pacific Islander, Native American (9.9%), and Black (6.3%). Cox regression showed higher mortality risk among Hispanics, compared to Whites (hazard ratio, 0.91; 95% CI 0.87-0.96), Blacks (hazard ratio, 0.87; 95% CI 0.79-0.94), and Asian, Pacific Islander, Native American (hazard ratio, 0.89; 95% CI 0.83-0.95). Logistic regression showed that the odds of ICU admission were significantly higher among Hispanics, compared to Whites (OR, 1.70; 95% CI 1.67-1.74), Blacks (OR, 1.70; 95% CI 1.64-1.78), and Asian, Pacific Islander, Native American (OR, 1.82; 95% CI 1.76-1.89). We found significant disparities in mortality among COVID-19 hospitalizations in California. Hispanics were the worst affected with the highest mortality and ICU admission rates.

Virological evidence of the impact of non-pharmaceutical interventions against COVID-19 in Ecuador, a resource-limited setting.

Ecuador had substantial COVID-19-mortality during 2020 despite early implementation of non-pharmaceutical interventions (NPIs). Resource-limited settings like Ecuador have high proportions of informal labour which entail high human mobility, questioning efficacy of NPIs. We performed a retrospective observational study in Ecuador's national reference laboratory for viral respiratory infections during March 2020-February 2021 using stored respiratory specimens from 1950 patients, corresponding to 2.3% of all samples analysed within the Ecuadorian national surveillance system per week. During 2020, detection of SARS-CoV-2 (Pearson correlation; r = -0.74; p = 0.01) and other respiratory viruses (Pearson correlation; r = -0.68; p = 0.02) by real-time RT-PCR correlated negatively with NPIs stringency. Among respiratory viruses, adenoviruses (Fisher's exact-test; p = 0.026), parainfluenzaviruses (p = 0.04), enteroviruses (p < 0.0001) and metapneumoviruses (p < 0.0001) occurred significantly more frequently during months of absent or non-stringent NPIs (characterized by <55% stringency according to the Oxford stringency index data for Ecuador). Phylogenomic analyses of 632 newly characterized SARS-CoV-2 genomes revealed 100 near-parallel SARS-CoV-2 introductions during early 2020 in the absence of NPIs. NPI stringency correlated negatively with the number of circulating SARS-CoV-2 lineages during 2020 (r = -0.69; p = 0.02). Phylogeographic reconstructions showed differential SARS-CoV-2 dispersion patterns during 2020, with more short-distance transitions potentially associated with recreational activity during non-stringent NPIs. There were also fewer geographic transitions during strict NPIs (n = 450) than during non-stringent or absent NPIs (n = 580). Virological evidence supports that NPIs had an effect on virus spread and distribution in Ecuador, providing a template for future epidemics in resource-limited settings and contributing to a balanced assessment of societal costs entailed by strict NPIs.

Hospital Outcomes Among COVID-19 Hospitalizations With Myocarditis from the California State Inpatient Database.

Many case reports have indicated that myocarditis could be a prognostic factor for predicting morbidity and mortality among patients with COVID-19. In this study, using a large database we examined the association between myocarditis among COVID-19 hospitalizations and in-hospital mortality and other adverse hospital outcomes. The present study was a retrospective analysis of data collected in the California State Inpatient Database during 2020. All hospitalizations for COVID-19 were included in the analysis and grouped into those with and without myocarditis. The outcomes were in-hospital mortality, cardiac arrest, cardiogenic shock, mechanical ventilation, and acute respiratory distress syndrome. Propensity score matching, followed by conditional logistic regression, was performed to find the association between myocarditis and outcomes. Among 164,417 COVID-19 hospitalizations, 578 (0.4%) were with myocarditis. After propensity score matching, the rate of in-hospital mortality was significantly higher among COVID-19 hospitalizations with myocarditis (30.0% vs 17.5%, p <0.001). Survival analysis with log-rank test showed that 30-day survival rates were significantly lower among those with myocarditis (39.5% vs 46.3%, p <0.001). Conditional logistic regression analysis showed that the odds of cardiac arrest (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.16 to 3.14), cardiogenic shock (OR 4.13, 95% CI 2.14 to 7.99), mechanical ventilation (OR 3.30, 95% CI 2.47 to 4.41), and acute respiratory distress syndrome (OR 2.49, 95% CI 1.70 to 3.66) were significantly higher among those with myocarditis. Myocarditis was associated with greater rates of in-hospital mortality and adverse hospital outcomes among patients with COVID-19, and early suspicion is important for prompt diagnosis and management.

Management and Outcomes of ST-Segment Elevation Myocardial Infarction in Hospitalized Frail Patients in the United States.

Cardiovascular diseases and frailty are common conditions of aging populations and often coexist. In this study, we examined the in-hospital management, outcomes, and resource use of frail patients hospitalized for ST-segment elevation myocardial infarction (STEMI). This was a retrospective analysis of the 2005-2014 data from the Nationwide Inpatient Sample. Patients were classified into to versus 'nonfrail' using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. The primary outcome was STEMI management, whereas secondary outcomes were in-hospital mortality, length of stay, and cost. Outcomes were compared between frail and nonfrail patients using propensity score-matched analysis. There were 1,360,597 STEMI hospitalizations, of which 36,316 (2.7%) were frail. Propensity score-matched analysis showed that in in-hospital management options for STEMI, the odds of overall revascularization (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.55 to 0.65), percutaneous coronary intervention (OR, 0.53; 95% CI, 0.49 to 0.57), and coronary angiography (OR, 0.59; 95% CI, 0.55 to 0.64) were significantly lower for frail patients. The odds of receiving coronary artery bypass grafting (OR, 1.66; 95% CI, 1.48 to 1.86) and overall hemodynamic support (OR, 1.26; 95% CI, 1.15 to 1.39) were significantly higher for frail patients. In-hospital mortality (18.7% vs 8.2%, p <0.001), length of stay (7.7 vs 3.7 days, p <0.001) and costs ($90,060 vs $63,507, p <0.001) were significantly higher in frail patients. Our findings suggest that collaborative efforts by cardiologists and cardiovascular surgeons for identifying frailty in patients with STEMI and incorporating frailty in risk estimation measures may improve management strategies, resource use and optimize patient outcomes.

The Effects of Body Mass Index on In-hospital mortality following first ischemic or hemorrhagic stroke events: Does the "obesity paradox" apply?

BACKGROUND: While it is widely held that obesity is a risk factor for stroke, its role in mortality after stroke is less understood. We aim to examine effects of Body Mass Index (BMI) on in-hospital mortality after non-subarachnoid, subarachnoid, and ischemic stroke. METHODS: Retrospective cohort study. Patients aged ≥18 years, who were hospitalized in Florida hospitals between 2008 and 2012 with a diagnosis of first-time stroke as reported by the Agency for Health Care Administration (AHCA). The main independent variable was BMI category, which was divided into non-overweight/non-obese, obese, and morbidly obese. The primary outcome was the adjusted odds ratio (aOR) for in-hospital mortality for subarachnoid and non-subarachnoid hemorrhagic stroke, and ischemic stroke. Logistic regression modeling was utilized to examine the association between each BMI category and in-hospital mortality, while controlling for several potential confounders. This study was reported in line with the STROCSS criteria. RESULTS: Of the 333,367 patients included in the database, 150,153 (45.0%) patients met inclusion criteria. After adjusting for age, gender, ethnicity and other possible confounders, obese patients were 21% less likely to die during their hospitalization following a first ischemic stroke (0.79 aOR, 0.69-0.92, 95% CI, p = 0.002), and 32% less likely following a first non-subarachnoid hemorrhage (0.68 aOR, 0.57-0.82, 95% CI, p = 0.0001) compared to non-overweight/non-obese counterparts. CONCLUSION: Obese patients are less likely to die during hospitalization following first-time non-subarachnoid hemorrhage and ischemic stroke than non-overweight/non-obese patients. These findings support the "obesity paradox" concept, though more research is needed for recurrent stroke patients.

An association between electronic nicotine delivery systems use and a history of stroke using the 2016 behavioral risk factor surveillance system.

ABSTRACT: Electronic nicotine delivery systems (ENDS) are growing in use and many of the health implications with these devices remain unknown. This study aims to assess, using a survey representative of the USA general population, if an association exists between a history of ENDS use and a history of stroke.This cross-sectional study was a secondary data analysis using the 2016 behavioral risk factor surveillance system survey. The main exposure variable of the study was a self-reported history of ENDS use. The main outcome was a self-reported history of stroke. Covariates included sex, race, traditional cigarette use, smokeless tobacco use, chronic kidney disease, diabetes, myocardial infarction, and coronary artery disease. Unadjusted and adjusted logistic regression analyses were done. Adjusted odds ratios (AOR) and their corresponding 95% confidence intervals (CI) were calculated.Of the 486,303 total behavioral risk factor surveillance system survey participants, 465,594 met the inclusion criteria for this study of ENDS use and stroke. This study shows that current ENDS use was positively associated with a history of stroke. AOR of some daily ENDS use with stroke was 1.28 (95% CI: 1.02-1.61) and AOR of current daily ENDS use with stroke was 1.62 (95% CI: 1.18-2.31). The majority (55.9%) of current daily ENDS users reported former traditional cigarette smoking. Female sex, non-white ethnicity, elderly age, chronic kidney disease, coronary artery disease, diabetes, and traditional cigarette use characteristics were all also associated with increased odds of reporting a stroke.This study found a statistically significant and positive association between ENDS use and a history of stroke. Further research is warranted to investigate the reproducibility and temporality of this association. Nevertheless, this study contributes to the growing body of knowledge about the potential cardiovascular concerns related to ENDS use and the need for large cohort studies.

Leveraging mobile phone surveys during the COVID-19 pandemic in Ecuador and Sri Lanka: Methods, timeline and findings.

Effective and rapid decision making during a pandemic requires data not only about infections, but also about human behavior. Mobile phone surveys (MPS) offer the opportunity to collect real-time data on behavior, exposure, knowledge, and perception, as well as care and treatment to inform decision making. The surveys aimed to collect coronavirus disease 2019 (COVID-19) related information in Ecuador and Sri Lanka using mobile phones. In Ecuador, a Knowledge, Attitudes and Practices (KAP) survey was conducted. In Sri Lanka, an evaluation of a novel medicine delivery system was conducted. Using the established mobile network operator channels and technical assistance provided through The Bloomberg Philanthropies Data for Health Initiative (D4H), Ministries of Health fielded a population-based COVID-19-specific MPS using Surveda, the open source data collection tool developed as part of the initiative. A total of 1,185 adults in Ecuador completed the MPS in 14 days. A total of 5,001 adults over the age of 35 in Sri Lanka completed the MPS in 44 days. Both samples were adjusted to the 2019 United Nations Population Estimates to produce population-based estimates by age and sex. The Ecuador COVID-19 MPS found that there was compliance with the mitigation strategies implemented in that country. Overall, 96.5% of Ecuadorians reported wearing a face mask or face covering when leaving home. Overall, 3.8% of Sri Lankans used the service to receive medicines from a government clinic. Among those who used the medicine delivery service in Sri Lanka, 95.8% of those who used a private pharmacy received their medications within one week, and 69.9% of those using a government clinic reported the same. These studies demonstrate that MPS can be conducted quickly and gather essential data. MPS can help monitor the impact of interventions and programs, and rapidly identify what works in mitigating the impact of COVID-19.

Disparities and Temporal Trends in the Use of Anticoagulation in Patients With Ischemic Stroke and Atrial Fibrillation.

Background and Purpose- Ischemic stroke (IS) secondary to atrial fibrillation (AF) is largely preventable with the use of anticoagulation. We sought to identify race-ethnicity and sex disparities with the use of direct oral anticoagulants (DOACs), aspirin, and warfarin in IS patients with AF and to identify temporal trends in the utilization of these medications. Methods- The FLiPER-AF Stroke Study (Florida Puerto Rico Atrial Fibrillation) included 24 040 IS cases enrolled in the Florida-Puerto Rico Collaboration to Reduce Stroke Registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the effect of race-ethnicity and sex on utilization of DOACs, aspirin, and warfarin for stroke prevention in AF after adjustment for sociodemographic, hospital, and clinical factors. Results- Among 24 040 IS cases, 54% were women and 10% black, 12% FL-Hispanics, 4% PR-Hispanic, and 74% whites. From 2010 to 2016, DOAC use increased from 0% to 36%, warfarin use decreased from 51% to 17%, and aspirin use remained relatively stable (42%-40%). After adjustment, blacks had higher odds of warfarin (odds ratio, 1.22; 95% CI, 1.07-1.40) prescription at discharge compared with whites. Men had higher rates of aspirin (42.1% versus 38.8%), warfarin (33.6% versus 28.9%), and DOAC (21.3% versus 19.3%) use compared with women. After adjustment, women had lower odds of being discharged on aspirin (odds ratio, 0.92; 95% CI, 0.86-0.98) or warfarin (odds ratio, 0.91; 95% CI, 0.84-0.99). There was no sex difference in use of DOACs. Conclusions- Our study confirmed the increasing use of DOACs, downtrending use of warfarin, whereas aspirin use remained similar over the years. There are sex and race-ethnicity disparities in anticoagulation use in IS patients with AF. It is critical to understand underlying drivers of these disparities to develop better practice strategies for stroke prevention in patients with AF. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT03627806.

Association between Race and Cancer-Related Mortality among Patients with Colorectal Cancer in the United States: A Retrospective Cohort Study.

Colorectal cancer (CRC) is the third most common cause of mortality in the United States (US). Differences in CRC mortality according to race have been extensively studied; however, much more understanding with regard to tumor characteristics' effect on mortality is needed. The objective was to investigate the association between race and mortality among CRC patients in the US during 2007⁻2014. A retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) Program, which collects cancer statistics through selected population-based cancer registries during in the US, was conducted. The outcome variable was CRC-related mortality in adult patients (≥18 years old) during 2007⁻2014. The independent variable was race of white, black, Asian/Pacific Islander (API), and American Indian/Alaska Native (others). The covariates were, age, sex, marital status, health insurance, tumor stage at diagnosis, and tumor size and grade. Bivariate analysis was performed to identify possible confounders (chi-square tests). Unadjusted and adjusted logistic regression models were used to study the association between race and CRC-specific mortality. The final number of participants consisted of 70,392 patients. Blacks had a 32% higher risk of death compared to whites (adjusted odds ratio (OR) 1.32; 95% confidence interval (CI) 1.22⁻1.43). Corresponding OR for others were 1.41 (95% CI 1.10⁻1.84). API had nonsignificant adjusted odds of mortality compared to whites (0.95; 95% CI 0.87⁻1.03). In conclusion, we observed a significant increased risk of mortality in black and American Indian/Alaska Native patients with CRC compared to white patients.

Disparities and Temporal Trends in Stroke Care Outcomes in Patients with Atrial Fibrillation: The FLiPER-AF Stroke Study.

BACKGROUND AND PURPOSE: Atrial Fibrillation (AF) is the most common cardiac cause of ischemic stroke. However, the relation between AF and stroke care outcomes in diverse populations is understudied. We aimed to evaluate sex and race-ethnic disparities associated with AF in hospital stroke outcomes utilizing data from the FLorida PuErto Rico Atrial Fibrillation (FLiPER-AF) Stroke Study. METHODS: The study included 104,308 ischemic stroke cases with available information on AF status enrolled in a state-wide stroke registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the association between AF and stroke outcomes and the modification effects on the associations by sex and by race-ethnicity, adjusted for socio-demographic status, vascular risk factors and stroke severity. RESULTS: AF was present in 23% of ischemic stroke cases. AF was associated with worse disability at discharge (OR=1.11, 95% CI, 1.04-1.18), less discharge to home (OR=0.89, 0.85-0.92), and longer length of hospital stay (LOS>6 days, OR=1.53, 1.46-1.60). Interaction analyses showed that the association between AF and less discharge to home was stronger in women than men (p for interaction <0.001), as well as in FL-whites than in FL-blacks, FL-Hispanics or PR-Hispanics (p for interaction=0.002). The association between AF and prolonged LOS was more prominent in PR-Hispanics than in FL-blacks, FL-Hispanics, or FL-whites (p for interaction <0.001). From 2010 to 2016, the effects of AF on hospital length of stay attenuated (p for interaction<0.001). CONCLUSIONS: AF was associated with poor disability at discharge, less discharge to home, and prolonged hospital length of stay for acute stroke care. The effect of AF on length of stay attenuated over time. Sex and race-ethnic disparities were observed in the effect of AF on being less discharge to home and prolonged hospital stay. Further research is needed to identify and modify the biologic and systems of care contributors to these disparities.

Association between Marital Status and In-Hospital Death in Acute Myocardial Infarction Patients in Puerto Rico.

OBJECTIVE: The purpose of this study was to determine if there is an association between marital status (single, married, divorced/separated, and widowed) and inhospital mortality in patients with acute myocardial infarction (AMI) from Puerto Rico in 2007, 2009, and 2011. METHODS: This study was a secondary data analysis of information retrieved from the Puerto Rican Cardiovascular Surveillance System obtained from the University of Puerto Rico for the residents of Puerto Rico during the study years. The sample included individuals aged 18 or older who presented with an incidental AMI. Univariate and multivariate logistic regression models were used to assess the association between marital status and in hospital mortality after an AMI. Covariates included age, sex, social history, and comorbidities. RESULTS: Among the study participants, 414 were single, 1,811 were married, 153 were separated/divorced, and 472 were widowed. Widowed status was more common in the elderly population, age groups 75-84 and ≥85, than any other marital status representing 37.9% and 30.7% respectively (p-value < 0.001). The adjusted OR were 0.6 (95% confidence interval (CI) 0.3-1.4), 0.6 (95% CI 0.2-2.0), and 0.9 (95% CI 0.5-1.7) for single, divorced/separated, and widowed patients respectively when compared with married patients. CONCLUSION: No noticeable association was found between marital status and inhospital mortality in patients with incidental AMI in Puerto Rico during the years of 2007, 2009, and 2011. Further research may be required to investigate mortality rates during the time period following hospital discharge.

The association between race and survival in glioblastoma patients in the US: A retrospective cohort study.

BACKGROUND: Glioblastoma is the most common primary brain cancer in adults with an incidence of 3.4 per 100,000, making up about 15% of all brain tumors. Inconsistent results have been published in regard differences in survival between white and black glioblastoma patients. The objective of this to study the association between race and in Glioblastoma patients in the USA during 2010-2014. METHODS AND FINDINGS: The National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database were used to evaluate race/ethnicity (White non-Hispanic, Black non-Hispanic, Asian/Pacific Islanders non-Hispanic (API)) and Hispanic) adults patients with first-time diagnosis of glioblastoma (International Classification of Diseases for Oncology, 3rd Edition [ICD-O-3], codes C711-C714, and histology type 9440/3) from 2010-2014. The primary outcome was 3-year overall survival which was defined as months from diagnosis to death due to any cause and cancer, Kaplan-Meier (KM) and log-rank test were used to compare overall survival times across race groups. Cox proportional hazard models were used to determine the independent effect of race on 3-year survival. Age, gender, health insurance coverage, primary site, tumor size, extent of surgery and year of diagnosis were included in the adjusted model. The 3-year overall survival for API-non Hispanic (NH) patients decreased by 25% compared with White NH glioblastoma patients (hazard ratio (HR) 0.75; 95% confidence interval (CI) 0.62-0.90)) after adjusting for age, gender, health insurance, primary site, tumor size, and extent of the surgery. Black NH (HR 0.95; 95% CI 0.80-1.13) and Hispanic (HR 1.01, 95% CI 0.84-1.21) exhibited similar mortality risks compared with White NH patients. CONCLUSION: Compared with White NH, API NH with glioblastoma have a better survival. The findings from this study can help increase the accuracy of the prognostic outlook for white, black and API patients with GBM.

Predictors of Thrombolysis Administration in Mild Stroke: Florida-Puerto Rico Collaboration to Reduce Stroke Disparities.

BACKGROUND AND PURPOSE: Mild stroke is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable among different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD registry (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). METHODS: Among 73 712 prospectively enrolled patients with a final diagnosis of ischemic stroke or TIA from January 2010 to April 2015, we identified 7746 cases with persistent neurological symptoms and National Institutes of Health Stroke Scale ≤5 who arrived within 4 hours of symptom onset. Multilevel logistic regression analysis with generalized estimating equations was used to identify independent predictors of thrombolytic administration in the subgroup of patients without contraindications to thrombolysis. RESULTS: We included 6826 cases (final diagnosis mild stroke, 74.6% and TIA, 25.4%). Median age was 72 (interquartile range, 21); 52.7% men, 70.3% white, 12.9% black, 16.8% Hispanic; and median National Institutes of Health Stroke Scale, 2 (interquartile range, 3). Patients who received thrombolysis (n=1281, 18.7%) were younger (68 versus 72 years), had less vascular risk factors (hypertension, diabetes mellitus, and dyslipidemia), had lower risk of prior vascular disease (myocardial infarction, peripheral vascular disease, and previous stroke), and had a higher presenting median National Institutes of Health Stroke Scale (4 versus 2). In the multilevel multivariable model, early hospital arrival (arrive by 0-2 hours versus ≥3.5 hours; odds ratio [OR], 8.16; 95% confidence interval [CI], 4.76-13.98), higher National Institutes of Health Stroke Scale (OR, 1.87; 95% CI, 1.77-1.98), aphasia at presentation (OR, 1.35; 95% CI, 1.12-1.62), faster door-to-computed tomography time (OR, 1.81; 95% CI, 1.53-2.15), and presenting to an academic hospital (OR, 2.02; 95% CI, 1.39-2.95) were independent predictors of thrombolysis administration. CONCLUSIONS: Mild acutely presenting stroke patients are more likely to receive thrombolysis if they are young, white, or Hispanic and arrive early to the hospital with more severe neurological presentation. Identification of predictors of thrombolysis is important in design of future studies to assess the use of thrombolysis for mild stroke.

Cigarette Smoking and its Association with In-Hospital Mortality in Hemorrhagic Stroke Patients / Tabaquismo y su asociación con mortalidad intrahospitalaria en pacientes con ictus hemorrágico

Abstract Backgroud: Smoking is a well-known reversible risk factor associated with acute ischemic stroke (AIS), however, some data showed that in-hospital mortality rates among smoker's patients with hemorrhagic stroke is lower when compared with non-smokers patients. The objective of this analysis was to assess in-hospital patient mortality rate between smokers and non-smokers patients with confirmed diagnosis of hemorrhagic stroke. Methods and Results: We analyzed all the data from patients diagnosed with hemorrhagic stroke that were registered in the Florida Stroke database from 2008-2012. Among the 21,013 patients diagnosed with hemorrhagic stroke, 10.9% of patients were smokers. A Multivariable model was used to estimate the adjusted odds ratio of in-hospital mortality rate in smokers versus non-smokers. Smoking was associated with lower in-hospital mortality in hemorrhagic patients. (UOR= 0.71 vs. AOR= 0.75). Other risk factors like hypertension, BMI>40 and hyperlipidemia, remained significantly associated after modeling, and some others like gender, race, health insurance coverage, and diabetes became insignificant. The difference between unadjusted and adjusted odds ratios for smoking (0.71 versus 0.75) indicates no presence of substantial confounding by age and other control variables. Conclusions: Among patients hospitalized for hemorrhagic stroke, smoking is a risk factor for early age of onset, even among those with few vascular risk factors. The persistent association with lower in-hospital mortality after adjusted analyses probably represents other unmeasured confounding, although a biological effect of smoking cannot be excluded. Further clinical and prospective population-based studies are needed to explore variables that contribute to outcomes in these patients.

Resumen Antecedentes: El fumar es un factor de riesgo tradicional claramente identificado con un mayor riesgo de desarrollar accidente cerebrovascular (ACV). A pesar de existir un riesgo más elevado de desarrollar ACV, algunos reportes han demostrado que pacientes ya hospitalizados con diagnóstico de ACV hemorrágico tienen una mortalidad intrahospitalaria menor a sus pares no fumadores, situación conocida como la paradoja del tabaquismo. El objetivo de este estudio es analizar la mortalidad Intrahospitalaria de Pacientes con Accidente Cerebrovascular Hemorrágico entre aquellos pacientes fumadores versus los no fumadores. Métodos y resultados: Este estudio epidemiológico observacional analítico de casos y controles incluyó a todos los pacientes con diagnóstico de accidente cerebrovascular hemorrágico incluidos en el "Registro de Accidentes Cerebrovasculares de Florida" entre el año 2008 y 2012. Entre los 21.013 pacientes diagnosticados con accidente cerebrovascular hemorrágico, el 10,9% de los pacientes fueron fumadores. Se utilizaron modelos multivariables para estimar la tasa de probabilidad ajustada de mortalidad intrahospitalaria en fumadores versus no fumadores. El tabaquismo se asoció con una menor mortalidad hospitalaria en pacientes hemorrágicos. (UOR = 0,71 frente a AOR = 0,75). Como se observa en las tablas, muchos de los factores de confusión, la hipertensión, IMC> 40, y la hiperlipidemia, tuvieron asociación significativa después del modelamiento estadístico mientras que otros factores como el sexo, la raza, el tipo de seguro de salud y la presencia de diabetes no tuvieron una asociación estadísticamente significativa. La diferencia entre las tasas de probabilidad no ajustadas y ajustadas para el tabaquismo (0,71 frente a 0,75 respectivamente) indica que no hay presencia de factores de confusión sustanciales por edad y otras variables de control. Conclusiones: Entre los pacientes hospitalizados por accidente cerebrovascular hemorrágico, el tabaquismo es un factor de riesgo para el desarrollo del mismo, especialmente en pacientes jóvenes, incluso entre aquellos con pocos factores de riesgo vascular, sin embargo, la asociación persistente con menor mortalidad intrahospitalaria después de los análisis ajustados probablemente represente otra confusión no medida, aunque no se puede excluir un efecto biológico del tabaquismo. Se necesitan más estudios clínicos basados en la población para explorar las variables que contribuyen a los resultados en estos pacientes.

Disparities and Trends in Door-to-Needle Time: The FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities).

BACKGROUND AND PURPOSE: In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45. METHODS: Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45. RESULTS: DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72-0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57-0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%). CONCLUSIONS: In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.

Association of ventricular arrhythmia and in-hospital mortality in stroke patients in Florida: A nonconcurrent prospective study.

Stroke remains one of the leading causes of death in the United States. Current evidence identified electrocardiographic abnormalities and cardiac arrhythmias in 50% of patients with an acute stroke. The purpose of this study was to assess whether the presence of ventricular arrhythmia (VA) in adult patients hospitalized in Florida with acute stroke increased the risk of in-hospital mortality.Secondary data analysis of 215,150 patients with ischemic and hemorrhagic stroke hospitalized in the state of Florida collected by the Florida Agency for Healthcare Administration from 2008 to 2012. The main outcome for this study was in-hospital mortality. The main exposure of this study was defined as the presence of VA. VA included the ICD-9 CM codes: paroxysmal ventricular tachycardia (427.1), ventricular fibrillation (427.41), ventricular flutter (427.42), ventricular fibrillation and flutter (427.4), and other - includes premature ventricular beats, contractions, or systoles (427.69). Differences in demographic and clinical characteristics and hospital outcomes were assessed between patients who developed versus did not develop VA during hospitalization (χ and t tests). Binary logistic regression was used to estimate unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) between VA and in-hospital mortality.VA was associated with an increased risk of in-hospital mortality after adjusting for all covariates (odds ratio [OR]: 1.75; 95% CI: 1.6-1.2). There was an increased in-hospital mortality in women compared to men (OR: 1.1; 95% CI: 1.1-1.14), age greater than 85 years (OR: 3.9, 95% CI: 3.5-4.3), African Americans compared to Whites (OR: 1.1; 95% CI: 1.04-1.2), diagnosis of congestive heart failure (OR: 2.1; 95% CI: 2.0-2.3), and atrial arrhythmias (OR: 2.1, 95% CI: 2.0-2.2). Patients with hemorrhagic stroke had increased odds of in-hospital mortality (OR: 9.0; 95% CI: 8.6-9.4) compared to ischemic stroke.Identifying VAs in stroke patients may help in better target at risk populations for closer cardiac monitoring during hospitalization. The impact of implementing methods of quick assessment could potentially reduce VA associated sudden cardiac death.

Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study.

BACKGROUND: Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race-ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals. METHODS AND RESULTS: Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P<0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%). CONCLUSIONS: Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico.

The association between race/ethnicity and the prevalence of stroke among United States adults in 2015: a secondary analysis study using Behavioural Risk Factor Surveillance System (BRFSS).

BACKGROUND: Worldwide, stroke is considered the second leading cause of death, accounting for 11.8% of all deaths in 2013. In the Unites States (US), approximately 795,000 people have a stroke every year. Stroke has many different risk factors that vary by race/ethnicity. There is limited contemporary published literature about the prevalence of stroke among racial/ethnic groups in the US adult population. OBJECTIVE: This study aimed to determine the association between race/ethnicity and the prevalence of stroke among US adults in 2015. METHODS: This study was an observational, non-concurrent prospective of the Behavioural Risk Factor Surveillance System (BRFSS) in 2015 to assess the association between race/ethnicity and the prevalence of stroke. The final study sample was 432,814 US adults ≥ 18 years old. Variables were excluded from the model if there were missing, refused, or did not know responses to the variables of interest. A binary logistic regression analysis was used to obtain odds ratios (OR) and 95% confidence intervals (CI) for the association between race/ethnicity and stroke. The Chi-square test was used to study bivariate associations between categorical variables. The collinearity was assessed. A p-value of <0.05 was considered statistically significant. Statistical analysis was completed using STATA version 14 (Stata Corp, College Station, TX). RESULTS: The highest proportion of participants (43%) were ≥ 44 years old with a balanced distribution of males and females. The highest proportion of stroke was found among Hispanics (4.2%) and non-Hispanic Blacks (4.1%) as compared to 3.2% among non-Hispanic Whites (p<0.001). Furthermore, Hispanics and Blacks were significantly more likely to develop stroke (OR=1.57, 95% CI=1.28-1.91; and OR=1.30, 95% CI=1.16-1.45, respectively) after adjusting for confounding variables. CONCLUSION: Hispanics and Blacks had a higher prevalence of stroke in comparison with non-Hispanic Whites. Further studies are needed to verify these findings and to determine which factors may influence the stroke differences among these racial/ethnic groups.

Effects of Percutaneous Transluminal Angioplasty on Diastolic Function in Patients With Chronic Occlusion of Lower-Extremity Artery.

OBJECTIVE: We investigated whether successful revascularization of total occlusion of a large lower-extremity artery is associated with improvement of left ventricular (LV) diastolic function. BACKGROUND: Total occlusion of a large lower-extremity artery might affect the systemic vascular resistance and increase the afterload, because the left ventricle must work harder to eject blood into a smaller vascular bed. Chronic elevation of afterload is a cause of LV diastolic dysfunction. METHODS: This is a single-center retrospective analysis of 20 patients (10 men, age 69.6 ± 12.3 years) with chronic total occlusions (CTOs) of the aorto-iliac and femoropopliteal segments who underwent a successful endovascular revascularization. Baseline and postprocedural evaluation of diastolic function was performed, and the primary endpoint was improvement in LV diastolic function, which was defined as any decrease of the baseline E/E' ratio or any increase of the baseline E' velocity after the index procedure. RESULTS: There was a significant effect of successful revascularization on the E/A ratio (from 1.5 ± 1.1 to 1.0 ± 0.3; P=.046) because of a significant increase of A velocity (from 86.3 ± 30.4 cm/s to 98.3 ± 21.8 cm/s; P=.03). The E' velocity (from 7.4 ± 2.0 cm/s to 8.3 ± 2.3 cm/s; P=.07) did not show a significant increase, but there was a significant reduction in E/E' ratio (from 14.6 ± 3.9 to 12.4 ± 3.3; P=.02). Logistic regression analysis did not identify possible predictors of improvement in LV diastolic function. CONCLUSION: Our results showed that a successful revascularization was associated with improvement in the echocardiographic parameters of LV diastolic function in patients with CTO of large lower-extremity artery, and these changes may be related to the afterload reduction.

Gender disparities in Puerto Ricans hospitalized with an initial acute myocardial infarction: A population-based perspective.

OBJECTIVE: The published literature suggests differences in presenting symptoms for acute myocardial infarction (AMI), management, and outcomes according to gender and age. However, limited information exists on this topic among Hispanics. METHODS: In Puerto Rican patients hospitalized with an initial AMI, we examined differences in presenting symptoms, effective cardiac therapies, and in-hospital mortality as a function of gender and age groups. We reviewed the medical records of patients hospitalized with a validated AMI in 12 greater San Juan, Puerto Rico hospitals during 2007. RESULTS: The average age of 1,415 patients hospitalized with a first AMI was 66 years and 45 % were women. Chest pain (81%) was the most prevalent acute presenting symptom with significant differences in its frequency between women (77%) and men (85%)(p<0.001). Right arm pain, shortness-of-breath/dyspnea, and sweating/ diaphoresis were most prevalent in patients 55-64 years old (45%), compared with patients 75 years and older (29%)(p<0.005). Relative to men and patients < 55 years old, coronary angiography/thrombolytic therapy and percutaneous coronary interventions were used less frequently in women and older patients (>75 years old). During hospitalization for AMI the in-hospital death rate was higher in women (8.6%) than men (6.0%), and increased with advancing age (p<0.05). CONCLUSION: These findings suggest significant gender and age differences in presenting symptoms, management, and early mortality in Puerto Ricans hospitalized with an initial AMI. It remains of considerable importance that health care personnel become aware of these gender and age differences to improve the management and outcomes of these patients.