The Lipid Paradox Among Acute Ischemic Stroke Patients-A Retrospective Study of Outcomes and Complications.

BACKGROUND AND OBJECTIVES: The Studies have suggested hypercholesterolemia is a risk factor for cerebrovascular disease. However, few of the studies with a small number of patients had tested the effect of hypercholesterolemia on the outcomes and complications among acute ischemic stroke (AIS) patients. We hypothesized that lipid disorders (LDs), though risk factors for AIS, were associated with better outcomes and fewer post-stroke complications. MATERIALS AND METHOD: We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2003-2014) in adult hospitalizations for AIS to determine the outcomes and complications associated with LDs, using ICD-9-CM codes. In 2014, we also aimed to estimate adjusted odds of AIS in patients with LDs compared to patients without LDs. The multivariable survey logistic regression models, weighted to account for sampling strategy, were fitted to evaluate relationship of LDs with AIS among 2014 hospitalizations, and outcomes and complications amongst AIS patients from2003-2014. RESULTS AND CONCLUSIONS: In 2014, there were 28,212,820 (2.02% AIS and 5.50% LDs) hospitalizations. LDs patients had higher prevalence and odds of having AIS compared with non-LDs. Between 2003-2014, of the total 4,224,924 AIS hospitalizations, 451,645 (10.69%) had LDs. Patients with LDs had lower percentages and odds of mortality, risk of death, major/extreme disability, discharge to nursing facility, and complications including epilepsy, stroke-associated pneumonia, GI-bleeding and hemorrhagic-transformation compared to non-LDs. Although LDs are risk factors for AIS, concurrent LDs in AIS is not only associated with lower mortality and disability but also lower post-stroke complications and higher chance of discharge to home.

Risk factors and outcomes of intravenous tissue plasminogen activator and endovascular thrombectomy utilization amongst pediatrics acute ischemic stroke.

BACKGROUND: Pediatric stroke is a debilitating disease. There are several risk factors predisposing children to this life-threatening disease. Although, published literature estimates a relatively high incidence of pediatric stroke, treatment guidelines on intravenous tissue plasminogen activator and endovascular thrombectomy utilization remain a dilemma. There is a lack of large population-based studies and clinical trials evaluating the efficacy and safety outcomes associated with these treatments in this unique population. AIM: We sought to determine the prevalence of risk factors, concurrent utilization of intravenous tissue plasminogen activator and endovascular thrombectomy, and associated outcomes in pediatric stroke hospitalizations. METHODS: We performed a retrospective analysis of the Nationwide Inpatient Sample data (2003-2014) in pediatric (1-21 years of age) acute ischemic stroke hospitalizations using ICD-9-CM codes. The multivariable survey logistic regression model was weighted to account for sampling strategy, evaluate predictors of hemorrhagic conversion, and treatment outcomes (mortality, morbidity, and discharge disposition) amongst pediatric stroke hospitalizations. RESULTS: In this analysis, 9109 patients between 1 and 21 years of age were admitted during 2003-2014 for acute ischemic stroke. Of these 9109 patients, 119 (1.30%) received endovascular thrombectomy alone, 256 (2.82%) intravenous recombinant tissue plasminogen activator, and 69 (0.75%) both endovascular thrombectomy and intravenous recombinant tissue plasminogen activator. We found overall high prevalence of conditions like epilepsy (19.59%), atrial septal defect (11.76%), sickle cell disease (8.63%), and moyamoya disease (5.41%) in pediatric acute ischemic stroke patients. Unadjusted analysis showed high prevalence of all-cause in-hospital mortality in combined endovascular thrombectomy and intravenous recombinant tissue plasminogen activator utilization group, and higher prevalence of hemorrhagic conversion and morbidity in endovascular thrombectomy utilization group compared to other groups (p < 0.0001). Multivariate adjusted analysis showed that children with endovascular thrombectomy utilization (aOR: 19.19; 95% CI: 2.50-147.29, p = 0.005), intravenous recombinant tissue plasminogen activator utilization (aOR: 8.85; 95% CI: 1.92-40.76, p = 0.005), and both (endovascular thrombectomy and intravenous recombinant tissue plasminogen activator) utilization (aOR: 7.55; 95% CI: 1.16-49.31, p = 0.035) had higher odds of hemorrhagic conversion compared to no-treatment group. CONCLUSION: We found various risk factors associated with pediatric stroke. The early identification can be useful to formulate preventive strategies and influence the incidence of pediatric stroke. Our study results showed that use of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy increase risk of mortality and hemorrhagic conversion, but we suggest to have more clinical studies to evaluate the idea candidates for utilization of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy based on risk: benefit ratio.

Risk Factors and Incidence of Acute Ischemic Stroke: A Comparative Study Between Young Adults and Older Adults.

Introduction Approximately 5-10% of strokes occur in adults of less than 45 years of age. The rising prevalence of stroke risk factors may increase stroke rates in young adults (YA). We aimed to compare risk factors and outcomes of acute ischemic stroke (AIS) among YA. Methods Adult hospitalizations for AIS and concurrent risk factors were found in the Nationwide Inpatient Sample database. Weighted analysis using chi-square and multivariable survey logistic regression was performed to evaluate AIS-related outcomes and risk factors among YA (18-45 years) and older patients. Results A total of 4,224,924 AIS hospitalizations were identified from 2003 to 2014, out of which 198,378 (4.7%) were YA. Prevalence trend of YA with AIS showed incremental pattern over time (2003: 4.36% to 2014: 4.7%; pTrend<0.0001). In regression analysis, the risk factors associated with AIS in YA were obesity (adjusted odds ratio {aOR}: 2.26; p<0.0001), drug abuse (aOR: 2.56; p<0.0001), history of smoking (aOR: 1.20; p<0.0001), infective endocarditis (aOR: 2.08; p<0.0001), cardiomyopathy (aOR: 2.11; p<0.0001), rheumatic fever (aOR: 4.27; p=0.0014), atrial septal disease (aOR: 2.46; p<0.0001), ventricular septal disease (aOR: 4.99; p<0.0001), HIV infection (aOR: 4.36; p<0.0001), brain tumors (aOR: 7.89; p<0.0001), epilepsy (aOR: 1.43; p<0.0001), end stage renal disease (aOR: 2.19; p<0.0001), systemic lupus erythematous (aOR: 3.76; p<0.0001), polymyositis (aOR: 2.72; p=0.0105), ankylosis spondylosis (aOR: 2.42; p=0.0082), hypercoagulable state (aOR: 4.03; p<0.0001), polyarteritis nodosa (aOR: 5.65; p=0.0004), and fibromuscular dysplasia (aOR: 2.83; p<0.0001). Conclusion There is an increasing trend in AIS prevalence over time among YA. Both traditional and non-traditional risk factors suggest that greater awareness is needed, with prevention strategies for AIS among young adults.

Multidisciplinary Approach and Outcomes of Tele-neurology: A Review.

In rural and underserved areas, there are restrictions in healthcare due to the lack of availability of neurologists; patients have to travel long distances to receive the required care. Considering the fact that neurological conditions have large mortality and disability rates, there is a need for innovative services like tele-neurology. It is an important tool in improving the health and quality of life by using different ways of communication between neurologists and patients, or neurologists and other providers. We examine the current types of facilities available in tele-neurology, as well as outcomes, barriers, limitations, legal litigations, and the multidisciplinary nature based on prior studies. We have also suggested recommendations for the future of tele-neurology including effective-accessibility and inexpensive-utilization in developing countries. There are various tele-health programs created by The Veterans Health Administration including a clinical video tele-health (CVT) system. This system allows direct patient care of veterans by neurologists. The University of South Carolina implemented a web-based tele-stroke program in which acute ischemic stroke patients were treated in the Emergency Department (ED) of rural hospitals by neurologists, after consulting with rural ED physicians. With growing technology and popularity of tele-neurology, there are now international collaborative efforts in tele-medicine that are looking to be adapted to tele-neurology. Thus, tele-neurology can provide quality neurological care with patient satisfaction, as well as time and cost savings. The tele-stroke group established by TRUST-tPA trial (Therapeutic Trial Evaluating Efficacy of Telemedicine (TELESTROKE) of Patients With Acute Stroke) has 10 community hospital-emergency rooms that were connected to a stroke center. It was found that tele-stroke is appropriate in places where there is no way for a patient to access a stroke unit within a 4.5-hour time window. Like other tele-neurology subtypes, tele-epilepsy and pediatric tele-neurology also offer more follow-up care to people of remote areas which have limited access. There are other subtypes like mental health, chronic neurological care, and hospitalist which are very effective in improving outcome and quality of life of people living in remote areas. Tele-neurology has effectively reduced travel costs and times; there is high patient satisfaction and reduced disparity for general and specialized neurological care. But there are certain limitations like large equipment costs, certain bandwidth requirement, and trained staff to use the equipment. Transmission of patient information using public internet raises the concern of legality. There should be sufficient encryption to satisfy the Health Insurance Portability and Accountability Act (HIPAA) requirements to ensure patient confidentiality and safety of personal data. The adaptation of tele-neurology is a powerful and innovative way to enhance healthcare in areas with a shortage of specialists. Implementation of this tool is limited due to cost burden, lack of expertise to implement necessary technology, legal litigations, and suitable financial and professional incentives for the users. This review focuses on the trajectory of utilization and the issues to be addressed in order to provide the full benefits of tele-neurology to undeserved communities in the future.

Acute Inflammatory Demyelinating Polyneuroradiculopathy with Ipilimumab in Metastatic Melanoma: A Case Report and Review of Literature.

Ipilimumab (Bristol-Myers Squibb Co., New York, NY) is a novel anticancer medication used for the treatment of metastatic melanoma. The exact mechanism of its action remains unclear; however, data from previous clinical trials postulates the immunomodulatory activity of ipilimumab to enhance therapeutic effectiveness. Ipilimumab was approved by the Food and Drug Administration (FDA) in March 2011 for use in stage III and IV of unresectable metastatic melanoma. We report a single case of acute inflammatory demyelinating polyneuroradiculopthy (AIDP) in the patient treated with ipilimumab for recurrent metastatic melanoma. The patient presented with multiple falls that started after the third infusion of ipilimumab. Other symptoms were hoarseness of voice, motor deficits in his right arms, and tingling in both hands. The deficits progressed into near complete loss of movement and sensation in all four extremities over the course of two weeks. However, his bladder and bowel functions were intact. There was no history of fever, recent travel, exposure to sick contacts, insect bites, or gastrointestinal symptoms. Along with strong immune-mediated pharmacological response towards cancer cells, ipilimumab also induces immune-related adverse events (irAEs) within normal tissues by the mechanism of molecular mimicry.

Carotid Endarterectomy in Patients With Thrombocytopenia: Analysis of the National Surgical Quality Improvement Program Registry.

BACKGROUND: Carotid endarterectomy (CEA) is infrequently performed in patients with mild to moderate thrombocytopenia. OBJECTIVE: To determine whether preoperative thrombocytopenia is associated with a higher rate of complications after CEA. METHODS: We analyzed patient characteristics, comorbid conditions, operative details, and 30-day postoperative outcomes for patients who underwent CEA in the CEA-targeted American College of Surgeons National Surgical Quality Improvement Program Registry. Thrombocytopenia was defined based on the preprocedure platelet count of ≤150  000 platelets/µL. The odds ratios (ORs) for selected outcomes were calculated using logistic regression with stepwise forward selection with age, sex, symptomatic status, and high-risk individuals as potential confounders. RESULTS: Thrombocytopenia was present in 896 of 8658 patients (10.3%) who underwent CEA: mild (100 000-149 000 platelets/µL) and moderate (50 000-99 000 platelets/µL) in 805 patients (89.8%) and 91 patients (10.2%), respectively. The adjusted rates of myocardial infarction/arrhythmia (3.7% vs 1.8%; OR: 1.9; 95% confidence interval [CI]: 1.3-2.8; P = .001), unplanned intubations (2.6% vs 1.2%; OR: 2.2; 95% CI: 1.4-3.5; P = .001), ventilator requirement >48 hours (1.5% vs 0.7%; OR: 2.1; 95% CI: 1.1-3.8; P = .02), deep venous thrombosis/thrombophlebitis (0.7% vs 0.2%; OR: 3.7; 95% CI: 1.4-9.7; P = .01), and surgical deep incisional infections (0.3% vs 0.1%; OR: 4.3; 95% CI: 1.1-17.4; P = .04) post-CEA were higher among patients with thrombocytopenia compared with those without thrombocytopenia. Thrombocytopenia did not significantly contribute to 1-month mortality or stroke. CONCLUSION: The higher rate of postprocedure complications in patients with preoperative thrombocytopenia needs to be recognized for adequate risk stratification before CEA.

A National Perspective of Do-Not-Resuscitate Order Utilization Predictors in Intracerebral Hemorrhage.

Nontraumatic intracerebral hemorrhage (ICH) is associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders are linked to poorer outcomes in patients with ICH, possibly due to less active management. Demographic, regional, and social factors, not related to ICH severity, have not been adequately looked at as significant predictors of DNR utilization. We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database in 2011 for adult ICH admissions and DNR status. We generated hierarchical 2-level multivariate regression models to estimate adjusted odds ratios. We analyzed 25 768 ICH hospitalizations, 18% of which (4620 hospitalizations) had DNR orders, corresponding to national estimates of 126 254 and 22 668, respectively. In multivariable regression, female gender, white or Hispanic/Latino ethnicity, no insurance coverage, and teaching hospitals were significantly associated with increased DNR utilization after adjusting for confounders. There was also significantly more interhospital variability in the lowest quartile of hospital volume. In conclusion, demographic factors and insurance status are significantly associated with increased DNR utilization, with more individual hospital variability in low-volume hospitals. The reasons for this are likely qualitative and linked to patient, provider, and hospital practices.

A Nationwide Analysis of Outcomes of Weekend Admissions for Intracerebral Hemorrhage Shows Disparities Based on Hospital Teaching Status.

BACKGROUND AND PURPOSE: With the "weekend effect" being well described, the Brain Attack Coalition released a set of "best practice" guidelines in 2005, with the goal to uniformly provide standard of care to patients with stroke. We attempted to define a "weekend effect" in outcomes among patients with intracranial hemorrhage (ICH) over the last decade, utilizing the Nationwide Inpatient Sample (NIS) data. We also attempted to analyze the trend of such an effect. MATERIALS AND METHODS: We determined the association of ICH weekend admissions with hospital outcomes including mortality, adverse discharge, length of stay, and cost compared to weekday admissions using multivariable logistic regression. We extracted our study cohort from the NIS, the largest all-payer data set in the United States. RESULTS: Of 485 329 ICH admissions from 2002 to 2011, 27.5% were weekend admissions. Overall, weekend admissions were associated with 11% higher odds of in-hospital mortality. When analyzed in 3-year groups, excess mortality of weekend admissions showed temporal decline. There was higher mortality with weekend admissions in nonteaching hospitals persisted (odds ratios 1.16, 1.13, and 1.09, respectively, for 3-year subgroups). Patients admitted during weekends were also 9% more likely to have an adverse discharge (odds ratio 1.09; 95% confidence interval: 1.07-1.11; P < .001) with no variation by hospital status. There was no effect of a weekend admission on either length of stay or cost of care. CONCLUSION: Nontraumatic ICH admissions on weekends have higher in-hospital mortality and adverse discharge. This demonstrates need for in-depth review for elucidating this discrepancy and stricter adherence to standard-of-care guidelines to ensure uniform care.