David L. Tirschwell

Background: As low and middle-income countries such as Vietnam experience the health transition from infectious to chronic diseases, the morbidity and mortality from stroke will rise. In line with the recommendation of the Institute of Medicine’s report on “Promoting Cardiovascular Health in the Developing World” to “improve local data”, we sought to investigate patient characteristics and clinical predictors of mortality among stroke inpatients at Da Nang Hospital in Vietnam. Methods: A stroke registry was developed and implemented at Da Nang Hospital utilizing the World Health Organization’s Stroke STEPS instrument for data collection. Results: 754 patients were hospitalized for stroke from March 2010 through February 2011 and admitted to either the intensive care unit or cardiology ward. Mean age was 65 years, and 39% were female. Nearly 50% of strokes were hemorrhagic. At 28-day follow-up, 51.0% of patients with hemorrhagic stroke died whereas 20.3% of patients with ischemic stroke died. A number of factors were independently associated with 28-day mortality; the two strongest independent predictors were depressed level of consciousness on presentation and hemorrhagic stroke type. While virtually all patients completed a CT during the admission, evidence-based processes of care such as anti-thrombotic therapy and carotid ultrasound for ischemic stroke patients were underutilized. Conclusions: This cohort study highlights the high mortality due in part to the large proportion of hemorrhagic strokes in Vietnam. Lack of hypertension awareness and standards of care exacerbated clinical outcomes. Numerous opportunities for simple, inexpensive interventions to improve outcomes or reduce recurrent stroke have been identified.

Background: Viet Nam is experiencing a health transition from infectious to chronic disease. Data on cardiovascular diseases, including strokes, are limited. Methods: Data were randomly collected from six communities in Da Nang, Viet Nam, on participant demographics, medical history, blood pressure, anthropometrics and health behavior using World Health...

Our knowledge of the pharmacogenetics of warfarin and clopidogrel continues to expand as we learn more about the individual genetic variations that contribute to the drugs’ efficacy and toxicity. We aim to review the recent developments in the field and discuss the clinical implications for the treatment of ischemic stroke patients. Despite recent advances, there is still insufficient data to suggest that routine genetic testing improves outcomes in patients treated with warfarin or clopidogrel for prevention of stroke.

Objective To assess the relationship between selected maternal and infant characteristics and risk of type 1 diabetes mellitus, specifically characteristics identified from birth records that may pertain to the hygiene or overload hypotheses. Design Population-based case-control study. Setting Washington State from 1987 to 2005. Participants All children younger than 19 years hospitalized for type 1 diabetes (International Classification of Diseases, Ninth Revisioncodes 250.x1 and 250.x3) identified (n = 1852) from hospital discharge data and linked with their birth certificates. Controls (n = 7408) were randomly selected from birth records, frequency matched on year of birth. Main Exposures Maternal factors included age, race, educational attainment, marital status, use of Medicaid insurance, body mass index, prepregnancy weight, prior births, timing and adequacy of prenatal care, and cesarean delivery. Infant factors included birth weight, size for gestational age, and gestational age. Main Outcome Measure The main outcome was first hospitalization for type 1 diabetes mellitus; adjusted odds ratios were estimated for the association of selected maternal and infant characteristics with type 1 diabetes. Results Consistent with the hygiene hypothesis, type 1 diabetes was negatively associated with having older siblings (for ≥3 siblings, odds ratio [OR], 0.56; 95% confidence interval [CI], 0.45-0.70) and with indicators of lower economic status or care access, such as an unmarried mother (OR, 0.79; 95% CI, 0.69-0.91), inadequate prenatal care (OR, 0.53; 95% CI, 0.40-0.71), or Medicaid insurance (OR, 0.67; 95% CI, 0.58-0.77). Related to the overload hypothesis, maternal body mass index of 30 or higher (OR, 1.29; 95% CI, 1.01-1.64) was associated with increased risk of diabetes. Conclusion Environmental factors related to decreased antigenic stimulation in early life and maternal obesity may be associated with type 1 diabetes.

Little is known about the burden of cross‐cultural care for stroke patients. This article compares the perceived burden for caregivers of stroke survivors in Korea and the United States. A brief interview was conducted to determine specific problem areas for caregivers. Caregiver burden (using the Sense of Competence Questionnaire) and social support (using the ENRICHD Social Support Inventory) also were measured. The overall‐sense‐of‐burden‐from‐caregiving score was significantly higher in the Korean cohort than in the American cohort, as was the scale regarding satisfaction with the relationship with the recipient of care. The primary predictors of overall burden for the combined sample were caregiver and patient depression and insufficient social support. Lower perceived social support among Korean caregivers was strongly related to caregiver depression, while it was more strongly related to increased hours of caregiving in the American sample. These findings can help rehabilitation nurses plan supportive interventions that incorporate cultural values for stroke survivors and their caregivers.

To perform a health maintenance organization-based case-control study to evaluate the association of total and high density lipoprotein (HDL) cholesterol with the risk of stroke subtypes and in patient subgroups. Cases had a confirmed incident ischemic stroke (n = 1,242) or hemorrhagic stroke (n = 313). Controls (n = 6,455) were identified in a companion myocardial infarction study. Risk of stroke was modeled using logistic regression. The highest total cholesterol quintile was associated with an increased risk of ischemic stroke compared to the lowest quintile (OR = 1.6, 95% CI 1.3 to 2.0) with the strongest subtype associations for atherosclerotic stroke (OR = 3.2) and lacunar stroke (OR = 2.4). The highest HDL cholesterol quintile was associated with a decreased risk of ischemic stroke compared to the lowest quintile (OR = 0.8, CI 0.6 to 1.0). Subgroup analyses suggested that the total cholesterol association was more important for patients < 66 years of age and those with HDL < 50 mg/dL; the HDL association was more important for patients without diabetes or atrial fibrillation. The second through fourth total cholesterol quintiles were associated with a decreased risk of hemorrhagic stroke compared to the lowest quintile (OR = 0.7, CI 0.5 to 1.0). Higher total and lower HDL cholesterol levels were associated with increased risk of ischemic stroke, especially certain stroke subtypes and patient subgroups. The lowest levels of total cholesterol were associated with an increased risk of all hemorrhagic strokes.

Background and Purpose— Research based on administrative data has advantages, including large numbers, consistent data, and low cost. This study was designed to compare different methods of stroke classification using administrative data. Methods— Administrative hospital discharge data and medical record review of 206 patients were used to evaluate 3 algorithms for classifying stroke patients. These algorithms were based on all (algorithm 1), the first 2 (algorithm 2), or the primary (algorithm 3) administrative discharge diagnosis code(s). The diagnoses after review of medical record data were considered the gold standard. Then, using a large administrative data set, we compared patients with a primary discharge diagnosis of stroke with patients with their stroke discharge diagnosis code in a nonprimary position. Results— Compared with the gold standard, algorithm 1 had the highest κ for classifying ischemic stroke, with a sensitivity of 86%, specificity of 95%, positive predictive value of 90%, and κ=0.82. Algorithm 3 had the highest κ values for intracerebral hemorrhage and subarachnoid hemorrhage. For intracerebral hemorrhage, the sensitivity was 85%, specificity was 96%, positive predictive value was 89%, and κ=0.82. For subarachnoid hemorrhage, those values were 90%, 97%, 94%, and 0.88, respectively. Nonprimary position ischemic stroke patients had significantly greater comorbidity and 30-day mortality (odds ratio, 3.2) than primary position ischemic stroke patients. Conclusions— Stroke classification in these administrative data were optimal using all discharge diagnoses for ischemic stroke and primary discharge diagnosis only for intracerebral and subarachnoid hemorrhage. Selecting ischemic stroke patients on the basis of primary discharge diagnosis may bias administrative samples toward more benign, unrepresentative outcomes and should be avoided.

The authors abstracted the records of 43 patients treated with intra-arterial urokinase for acute ischemic stroke to identify predictors of serious complications. Sixteen (37%) had such a complication. Higher urokinase dose (>1.5 × 10⁶ U), higher mean arterial blood pressure before treatment (>130 mm Hg), basilar occlusive strokes, and severe strokes were most predictive of these complications. Although urokinase is no longer manufactured, these findings identify patients at risk for complications from other intra-arterial thrombolytics.