Was COVID-19 associated with worsening inequities in stroke treatment and outcomes?

Background COVID-19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID-19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non-Hispanic Black individuals; and 888 896 (77.8%) were non-Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34-1.69]

Differential Requirements for Clathrin-dependent Endocytosis at Sites of Cell–Substrate Adhesion

Little is known about the influences of cell–substrate attachment in clathrin-mediated endocytosis. We find that cell–substrate adhesion reduces the rate of endocytosis. In addition, we demonstrate that actin assembly is differentially required for efficient endocytosis, with a stronger requirement for actin dynamics at sites of adhesion

Prognosis and Decision Making in Severe Stroke

Context: An increasing number of deaths following severe stroke are due to terminal extubations. Variation in withdrawal-of-care practices suggests the possibility of unnecessary prolongation of suffering or of unwanted deaths. Objectives: To review the available evidence on prognosis in mechanically ventilated stroke patients and to provide an overall framework to optimize decision making for clinicians, patients, and families. Data Sources: Search of MEDLINE from 1980 through March 2005 for English-language articles addressing prognosis in mechanically ventilated stroke patients. From 689 articles identified, we selected 17 for further review. We also identified factors that influence, and decision-making biases that may result, in overuse or underuse of life-sustaining therapies, with a particular emphasis on mechanical ventilation. Evidence Synthesis: Overall mortality among mechanically ventilated stroke patients is high, with a 30-day death rate approximating 58% (range in literature, 46%-75%). Although data are limited, among survivors as many as one third may have no or only slight disability, yet many others have severe disability. One can further refine prognosis according to knowledge of stroke syndromes, early patient characteristics, use of clinical prediction rules, and the need for continuing interventions. Factors influencing preferences for life-sustaining treatments include the severity and pattern of future clinical deficits, the probability of these deficits, and the burdens of treatments. Decision-making biases that may affect withdrawal-of-treatment decisions include erroneous prognostic estimates, inappropriate methods of communicating evidence, misunderstanding patient values and expectations, and failing to appreciate the extent to which patients can physically and psychologically adapt. Conclusion: Although prognosis among mechanically ventilated stroke patients is generally poor, a minority do survive without severe disability. Prognosis can be assessed according to clinical presentation and patient characteristics. There is an urgent need to better understand the marked variation in the care of these patients and to reliably measure and improve the patient-centeredness of such decisions

A Cost-Effectiveness Analysis of Carotid Artery Stenting Compared With Endarterectomy

Endarterectomy and angioplasty with stenting have emerged as 2 alternative treatments for carotid artery stenosis. This study\u27s objective was to determine the cost-effectiveness of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) in symptomatic subjects who are suitable for either intervention. A Markov analysis of these 2 revascularization procedures was conducted using direct Medicare costs (2007 US$) and characteristics of a symptomatic 70-year-old cohort over a lifetime. In the base case analysis, CAS produced 8.97 quality-adjusted life-years, compared with 9.64 quality-adjusted life-years for CEA. The incremental cost of stenting was$17,700, and thus CAS was dominated by CEA. Sensitivity analyses show that the long-term probabilities of major stroke or mortality influenced the results. In the base case analysis, CEA for patients with symptomatic stenosis has a greater benefit than CAS, with lower direct costs. With 59% probability, CEA will be the optimal intervention when all of the model assumptions are varied simultaneously

Immediate and Sustained Decrease in Smoking Urges After Acute Insular Cortex Damage

Introduction: Smoking urges are fundamental aspects of nicotine dependence that contribute significantly to drug use and postquit relapse. Recent evidence has indicated that damage to the insular cortex disrupts smoking behaviors and claims to reduce urges associated with nicotine use, although tools that assess urge have yet to be used to validate these findings. We examined the effect of insular versus non-insular damage on urge using a well-accepted urge scale. Methods: This 3-month observational prospective cohort study consisted of 156 current smokers hospitalized for acute ischemic stroke (38 with insular infarctions, 118 with non-insular infarctions). During hospitalization, the Questionnaire of Smoking Urges (QSU)-brief was assessed retrospectively based on experiences before the stroke (baseline, T0), prospectively immediately following the stroke (T1) and once more via telephone at 3-month follow-up (T2), with higher scores indicating greater urge. Bivariate statistics and multivariable linear regression were used to evaluate differences in QSU-brief scores, relative to baseline, between exposure groups, controlling for age, baseline dependence, stroke severity, use of nicotine replacement, and damage to other mesocorticolimbic regions. Results: A greater reduction in QSU-brief score was seen in the insular group compared to the non-insular group from T0 to T1 (covariate-adjusted difference in means of -1.15, 95% CI: -1.85, -0.44) and similarly from T0 to T2 (covariate-adjusted difference in means of -0.93, 95% CI: -1.79, -0.07). Conclusions: These findings confirm the potential role of the insula in regulating nicotine-induced urges and support the growing evidence of its novelty as a key target for smoking cessation interventions. Implications: Human lesioning studies that evaluate the insula\u27s involvement in maintaining nicotine addiction make inferences of the insula\u27s role in decreasing urge, but do not use validated instruments that directly assess urges. This study corroborates prior findings using the continuous Questionnaire of Smoking Urges to quantify changes in urge from before lesion onset to immediate and 3-month follow-up time points

The Cost-Utility of CT Angiography and Conventional Angiography for People Presenting with Intracerebral Hemorrhage

<div><p>Objective</p><p>To determine the optimal imaging strategy for ICH incorporating CTA or DSA with and without a NCCT risk stratification algorithm.</p><p>Methods</p><p>A Markov model included costs, outcomes, prevalence of a vascular lesion, and the sensitivity and specificity of a risk stratification algorithm from the literature. The four imaging strategies were: (a) CTA screening of the entire cohort; (b) CTA only in those where NCCT suggested a high or indeterminate likelihood of a lesion; (c) DSA screening of the entire cohort and (d) DSA only for those with a high or indeterminate suspicion of a lesion following NCCT. Branch d was the comparator.</p><p>Results</p><p>Age of the cohort and the probability of an underlying lesion influenced the choice of optimal imaging strategy. With a low suspicion for a lesion (<12%), branch (a) was the optimal strategy for a willingness-to-pay of $100,000/QALY. Branch (a) remained the optimal strategy in younger people (<35 years) with a risk below 15%. If the probability of a lesion was >15%, branch (b) became preferred strategy. The probabilistic sensitivity analysis showed that branch (b) was the optimal choice 70–72% of the time over varying willingness-to-pay values.</p><p>Conclusions</p><p>CTA has a clear role in the evaluation of people presenting with ICH, though the choice of CTA everyone or CTA using risk stratification depends on age and likelihood of finding a lesion.</p></div

Base Case graphs.

<p>The base case analyses are presented on a two-dimensional graph showing the net costs and net QALYs for CTA of the entire cohort (diamond), CTA for high or indeterminate suspicion of a lesion on NCCT (square), DSA for the entire cohort (asterisk) and DSA for those with a high or indeterminate suspicion of a lesion on NCCT (triangle).</p

Probabilistic sensitivity analysis.

<p>Variables in the model were sampled simultaneously to show the probability that a given strategy was optimal strategy in relation to the willingness-to-pay (x-axis) using net monetary benefits calculations.</p

Influence Diagram.

<p>The health states following presentation with primary ICH or secondary ICH are depicted.</p