Trends in Diversity, Equity and Inclusion Publications in Neurological Journals: 2015-2020

BACKGROUND: Contemporary information on health equity related efforts by scientific neurological journals, as measured by publications related to diversity, equity and inclusion (DEI) and health disparities related to social determinants of health (SDH) are lacking. OBJECTIVE: To assess the yearly rates of DEI and SDH related publications in the highest cited general neurology and neurological sub-specialty journals and compare them to the highest cited medical journals over a 6-year period. METHODS: We included publications from 15 general neurology and neurological subspecialty journals between January 1 2015 to December 31 2020. For comparison we included the 15 most cited medical journals as measured by H-Index. We performed a PubMed search in each of the listed journals using key MeSH terms. Two-proportions Z-test and chi-square trend analyses were used to compare differences between journal types. RESULTS: Total yearly proportion of DEI and SDH related publications in neurological journals was 3.9% compared to 6.2% in the highest cited medical journals for years 2015 to 2020 (p=0.001). There was no change in overall trend in publications related to DEI and SDH topics in neurological (ρ = -0.082, p=0.45) or highest cited medical journals between 2015 and 2020 (ρ = -0.065, p=0.54). CONCLUSION: Neurological journals had a significantly lower yearly proportion of DEI and SDH related publications compared to top-cited medical journals. Despite heightened awareness of racial/ethnic health disparities and inequities driven by SDH there was no change in related publications in neurological journals between 2015-2020

Scoping Review of Racial, Ethnic, and Sex Disparities in the Diagnosis and Management of Hemorrhagic Stroke

BACKGROUND AND OBJECTIVES: In the United States, Black, Hispanic, and Asian Americans suffer from excessively high incidence rates of hemorrhagic stroke compared to White Americans. Women suffer from higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity. METHODS: We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke. RESULTS: After reviewing 6161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control following intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life-care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care. DISCUSSION: Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke

Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk.

OBJECTIVES: Guidelines recommend to initiate anticoagulation within 4-14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation such as infarct size, hemorrhagic transformation, or high risk features on echocardiography. METHODS: We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days) and outcomes were recurrent stroke/TIA/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days. RESULTS: Among 2084 patients, 1289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the three groups: 0-3 days [10.3% (64/617)], 4-14 days [(9.7%) 52/535)], >14 days [10.2% (14/137), p=0.933]. In adjusted models, patients started on anticoagulation between 4-14 days did not have a lower rate of sICH (vs. 0-3 days) (OR 1.49 95% CI 0.50 – 4.43) neither did they have a lower rate of recurrent ischemic events (vs. > 14 days) (OR 0.76 95% CI 0.36 – 1.62, p = 0.482). INTERPRETATION: In this multicenter real world cohort, the recommended (4-14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation

Early ischaemic and haemorrhagic complications after atrial fibrillation-related ischaemic stroke: analysis of the IAC study.

INTRODUCTION: Predictors of long-term ischemic and hemorrhagic complications in atrial fibrillation (AF) have been studied, but there is limited data on predictors of early ischemic and hemorrhagic complications after AF associated ischemic stroke. We sought to determine these predictors. METHODS: The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter retrospective study across that pooled data from consecutive patients with ischemic stroke in the setting of AF from stroke registries across 8 comprehensive stroke centers in the United States. The co-primary outcomes were recurrent ischemic event (stroke/TIA/systemic arterial embolism) and delayed symptomatic intracranial hemorrhage (d-sICH) within 90 days. We performed univariate analyses and cox regression analyses including important predictors on univariate analyses to determine independent predictors of early ischemic events (stroke/TIA/systemic embolism) and d-sICH. RESULTS: Out of 2084 patients, 1520 patients qualified; 104 patients (6.8%) had recurrent ischemic events and 23 patients (1.5%) had d-sICH within 90 days from the index event. In cox-regression models, factors associated with a trend for recurrent ischemic events were prior stroke or TIA (HR 1.42, 0.96 – 2.10) and ipsilateral arterial stenosis with 50–99% narrowing (HR 1.54, 0.98 – 2.43). Those associated with sICH were female sex (HR 2.68, 1.06– 6.83), history of hyperlipidemia (HR 2.91, 1.08 – 7.84), and early hemorrhagic transformation (HR 5.35, 2.22 – 12.92). CONCLUSION: In patients with ischemic stroke and AF, predictors of d-sICH are different than those of recurrent ischemic events therefore recognizing these predictors may help inform early stroke versus d-sICH prevention strategies

Anticoagulation Type and Early Recurrence in Cardioembolic Stroke: The IAC Study.

BACKGROUND AND PURPOSE: In patients with acute ischemic stroke and atrial fibrillation (AF), treatment with low molecular weight heparin (LMWH) increases early hemorrhagic risk without reducing early recurrence and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage (d-sICH). METHODS: We included consecutive patients with acute ischemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and d-sICH between each of the following groups in separate cox-regression analyses: 1) DOAC versus warfarin and 2) Bridging with heparin/LMWH versus no bridging, adjusting for pertinent confounders to test these associations. RESULTS: We identified 1,289 patients who met the “bridging versus no bridging” analysis inclusion criteria and 1,251 patients who met the “DOAC versus warfarin” analysis inclusion criteria. In adjusted cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of d-sICH (HR 2.74 95% CI 1.01 – 7.42) but a similar rate of recurrent ischemic events (HR 1.23 95% CI 0.63 – 2.40). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (HR 0.51 95% CI 0.29 – 0.87) but not d-sICH (HR 0.57 95% CI 0.22 – 1.48). CONCLUSION: Our study suggests that patients with ischemic stroke and AF would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies

Factors associated with therapeutic anticoagulation status in patients with ischemic stroke and atrial fibrillation.

BACKGROUND AND PURPOSE: Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF. METHODS: The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR <2) anticoagulation status. We used binary logistic regression models to determine factors independently associated with anticoagulation status after adjustment for pertinent confounders. In particular, we sought to determine whether atherosclerosis with 50% or more luminal narrowing in an artery supplying the infarct (a marker for a competing atherosclerotic mechanism) and small stroke size (≤ 10 mL; implying a competing small vessel disease mechanism) related to anticoagulant status. RESULTS: Of the 2084 patients enrolled in the IAC study, 382 patients met the inclusion criteria. The mean age was 77.4 ± 10.9 years and 52.4% (200/382) were men. A total of 222 (58.1%) subjects presented with subtherapeutic INR. In adjusted models, small stroke size (OR 1.74 95% CI 1.10 – 2.76, p = 0.019) and atherosclerosis with 50% or more narrowing in an artery supplying the infarct (OR 1.96 95% CI 1.06 – 3.63, p = 0.031) were independently associated with INR ≥2 at the time of their index stroke. CONCLUSION: Small stroke size (≤ 10 ml) and ipsilateral atherosclerosis with 50% or more narrowing may indicate a competing stroke mechanism. There may be important opportunities to improve stroke prevention strategies for patients with AF by targeting additional ischemic stroke mechanisms to improve patient outcomes