Factors and Behaviors Related to Successful Transition of Care After Hospitalization for Ischemic Stroke

BACKGROUND: Our objective is to describe adoption of the posthospitalization behaviors associated with successful transition of care and related baseline characteristics. METHODS: This study includes 550 participants in the Transition of Care Stroke Disparities Study, a prospective observational cohort derived from the Florida Stroke Registry. Participants had an ischemic stroke (2018-2021), discharged home or to rehabilitation, with modified Rankin Scale score=0-3 (44% women, 24% Black, 48% White, 26% Hispanic, 35% foreign-born). We collected baseline sociodemographic and clinical characteristics. A structured telephone interview at 30-day postdischarge evaluated outcomes including medication adherence, medical appointment attendance, outpatient therapy, exercise, diet modification, toxic habit cessation, and a calculated composite adequate transition of care measure. Multivariable analyses assessed the association of baseline characteristics with 30-day behaviors. RESULTS: At 30 days, medication adherence was achieved by 89%, medical appointments by 82%, outpatient therapy by 76%, exercise by 71%, diet modification by 68%, toxic habit cessation by 35%, and adequate transition of care measure by 67%. Successful adequate transition of care participants were more likely to be used full-time (42% versus 31%, CONCLUSIONS: One in 3 patients did not attain adequate 30-day transition of care behaviors. Their achievement varied substantially among different measures and was influenced by multiple socioeconomic and clinical factors. Interventions aimed at facilitating transition of care from hospital after stroke are needed. REGISTRATION: URL: https://clinicaltrials.gov/; Unique identifier: NCT03452813

Ten-Year Review of Antihypertensive Prescribing Practices After Stroke and the Associated Disparities From the Florida Stroke Registry

BACKGROUND: Guideline-based hypertension management is integral to the prevention of stroke. We examine trends in antihypertensive medications prescribed after stroke and assess how well a prescriber\u27s blood pressure (BP) medication choice adheres to clinical practice guidelines (BP-guideline adherence). METHODS AND RESULTS: The FSR (Florida Stroke Registry) uses statewide data prospectively collected for all acute stroke admissions. Based on established guidelines, we defined optimal BP-guideline adherence using the following hierarchy of rules: (1) use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker as first-line antihypertensive among diabetics; (2) use of thiazide-type diuretics or calcium channel blockers among Black patients; (3) use of beta blockers among patients with compelling cardiac indication; (4) use of thiazide, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, or calcium channel blocker class as first line in all others; (5) beta blockers should be avoided as first line unless there is a compelling cardiac indication. A total of 372 254 cases from January 2010 to March 2020 are in the FSR with a diagnosis of acute ischemic stroke, hemorrhagic stroke, transient ischemic attack, or subarachnoid hemorrhage; 265 409 with complete data were included in the final analysis. Mean age was 70±14 years; 50% were women; and index stroke subtypes were 74% acute ischemic stroke, 11% intracerebral hemorrhage, 11% transient ischemic attack, and 4% subarachnoid hemorrhage. BP-guideline adherence to each specific rule ranged from 48% to 74%, which is below quality standards of 80%, and was lower among Black patients (odds ratio, 0.7 [95% CI, 0.7-0.83]; CONCLUSIONS: This large data set demonstrates consistently low rates of BP-guideline adherence over 10 years. There is an opportunity for monitoring hypertensive management after stroke

Impact of Time to Treatment on Endovascular Thrombectomy Outcomes in the Early Versus Late Treatment Time Windows

BACKGROUND: The impact of time to treatment on outcomes of endovascular thrombectomy (EVT) especially in patients presenting after 6 hours from symptom onset is not well characterized. We studied the differences in characteristics and treatment timelines of EVT-treated patients participating in the Florida Stroke Registry and aimed to characterize the extent to which time impacts EVT outcomes in the early and late time windows. METHODS: Prospectively collected data from Get With the Guidelines-Stroke hospitals participating in the Florida Stroke Registry from January 2010 to April 2020 were reviewed. Participants were EVT patients with onset-to-puncture time (OTP) of ≤24 hours and categorized into early window treated (OTP ≤6 hours) and late window treated (OTP \u3e6 and ≤24 hours). Association between OTP and favorable discharge outcomes (independent ambulation, discharge home and to acute rehabilitation facility) as well as symptomatic intracerebral hemorrhage and in-hospital mortality were examined using multilevel-multivariable analysis with generalized estimating equations. RESULTS: Among 8002 EVT patients (50.9% women; median age [±SD], 71.5 [±14.5] years; 61.7% White, 17.5% Black, and 21% Hispanic), 34.2% were treated in the late time window. Among all EVT patients, 32.4% were discharged home, 23.5% to rehabilitation facility, 33.7% ambulated independently at discharge, 5.1% had symptomatic intracerebral hemorrhage, and 9.2% died. As compared with the early window, treatment in the late window was associated with lower odds of independent ambulation (odds ratio [OR], 0.78 [0.67-0.90]) and discharge home (OR, 0.71 [0.63-0.80]). For every 60-minute increase in OTP, the odds of independent ambulation reduced by 8% (OR, 0.92 [0.87-0.97]; CONCLUSIONS: In routine practice, just over one-third of EVT-treated patients independently ambulate at discharge and only half are discharged to home/rehabilitation facility. Increased time from symptom onset to treatment is significantly associated with lower chance of independent ambulation and ability to be discharged home after EVT in the early time window

Medically Refractory Multiple Sclerosis Is Successfully Treated with Plasmapheresis in a Super Morbidly Obese Pregnant Patient

Multiple sclerosis (MS) is a relapse remitting immune-mediated demyelinating neurological disorder that primarily affects women of childbearing age. In most patients, the hormonal changes during pregnancy are protective against MS relapses. When relapses do occur, treatment options are limited to use of intravenous steroids and plasmapheresis rescue therapy. We present a case of steroid refractory MS-transverse myelitis with quadriplegia in a 25-year-old pregnant super morbidly obese woman. Our clinical case is unique because the severity of her relapse early in pregnancy, which was intractable and resistant to steroids. This may have been a rebound demyelination due to the discontinuation of fingolimod; a newly recognized entity by the FDA. Our case report therefore seeks to raise awareness about a potential complication of discontinuing MS disease modifying therapies, highlighting that these rebound relapses can be steroid resistant and occur despite the usual protective hormonal influence of early pregnancy and that plasma exchange is a valid treatment option. Finally, we discuss the challenges of determining exchange volumes for plasmapheresis in the super morbid obese population to secure good maternal and fetal outcomes

Predictors of hyperglycaemic crises and their associated mortality in Jamaica

The objective of the study was to determine the clinical characteristics and mortality of patients with hyperglycaemic hyperosmolar syndrome (HHS) and diabetic ketoacidosis (DKA) at a Jamaican tertiary care hospital. In a retrospective study of 1560 admissions for diabetes during the period 1998–2002, 980 dockets were reviewed and 164 individuals met the ADA diagnostic criteria for DKA or HHS. Patients with HHS were older than DKA patients (64.5 years [95% CI: 60.7–68.4] versus 35.9 years [95% CI: 30.2–41.6]), but were not more likely to be non-compliant with medications, infected, or male. Overall, 24% had a mixed DKA/HHS syndrome. Most DKA patients had type 2 diabetes (62%). Only 2% of HHS and 6% of DKA/HHS patients had type 1 diabetes. Syndrome specific mortality was: DKA 6.7%, HHS 20.3%, and DKA/HHS 25% ( p for trend = 0.013). Mortality increased significantly with age, especially in patients ≥50 years. Significant univariate predictors of mortality were altered mental status on admission, co-existing medical disease, increasing age, older age at onset of diabetes, acute stressors, and DKA/HHS. In multivariate models, only altered mental status was significant (OR = 3.59; 95% CI: 1.24–10.41). Hence, hyperglycaemic crises in a Jamaican tertiary care hospital are associated with significant mortality especially in patients who are older or with altered mental status

Prevalence of Vertebral Artery Origin Stenosis in a Multirace-Ethnic Posterior Circulation Stroke Cohort: Miami Stroke Registry (MIAMISR)

Vertebral artery origin stenosis is an important etiology for stroke in the posterior circulation. Data from the Oxford Vascular Study and New England Registry show a prevalence of vertebral artery origin disease of 26-32%. These populations are largely comprised of Caucasians. The prevalence of vertebral artery origin disease in multirace-ethnic stroke population is unknown. The study aims to assess the prevalence of vertebral artery origin stenosis in a multirace population with posterior circulation stroke. The Miami Stroke Registry is a prospective registry which offers enrollment to consecutive patients admitted with a diagnosis of stroke/transient ischemic attack. Baseline demographics, vascular risk factors, and stroke topography in the posterior circulation were analyzed. All vascular imaging studies were reviewed for the presence of vertebral artery origin stenosis, and stroke etiology was adjudicated by TOAST classification. Mean age of the population was 63 ± 13 years; 149 (70%) were men. Among cases, 123 were Hispanic (58%), almost one third 70 (32%) were of African descent, and 15 (7%) were white. The most common stroke etiology was small vessel occlusion (27%), followed by large artery intracranial disease 25% (posterior cerebral arteries, basilar and vertebral arteries), cardioembolic 19%, and cryptogenic 16%. Vertebral artery origin stenosis/occlusion was present in 28 (13.1%) patients, of whom only 2 (0.9%) were bilateral; it was attributed as the direct cause of stroke in 11 (5.2%) patients. We found a lower prevalence of vertebral artery origin stenosis in a predominately non-white population with posterior circulation stroke than previously reported. Vertebral artery origin stenosis was a direct cause of posterior circulation stroke in only 5.2% of patients

Leading with inclusion during the COVID-19 pandemic: Stronger together

Inclusion is the deliberate practice of ensuring that each individual is heard, all personal traits are respected, and all can make meaningful contributions to achieve their full potential. As coronavirus disease 2019 spreads globally and across the United States, we have viewed this pandemic through the lens of equity and inclusion. Here, we discuss how this pandemic has magnified preexisting health and social disparities and will summarize why inclusion is an essential tool to traverse this uncertain terrain and discuss strategies that can be implemented at organizational and individual levels to improve inclusion and address inequities moving forward

Adherence to Blood Pressure Guidelines Predicts Hospital Readmission After Acute Stroke: The Florida Stroke Registry (S6.005)

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