Risk of stroke after emergency department visits for neurologic complaints.

Stroke ranks as the third leading cause of death in the United States. It is now estimated that there are more than 700 000 incident strokes annually and 4.4 million stroke survivors.1 2 The economic burden of stroke was estimated by the American Heart Association to be $51 billion (direct and indirect costs) in 1999.3 Despite the advent of treatment of selected patients with acute ischemic stroke with tissue plasminogen activator and the promise of other experimental therapies, the best approach to reducing the burden of stroke remains prevention.4 5 High-risk or stroke-prone individuals can be identified and targeted for specific interventions.6 This is important because epidemiological data suggest a substantial leveling off of prior declines in stroke-related mortality and a possible increase in stroke incidence.7 8 The Stroke Council of the American Heart Association formed an ad hoc writing group to provide a clear and concise overview of the evidence regarding various established and potential stroke risk factors. The writing group was chosen based on expertise in specific subject areas, and it used literature review, reference to previously published guidelines, and expert opinion to summarize existing evidence and formulate recommendations (Table 1⇓). View this table: Table 1. Levels of Evidence and Grading of Recommendations As given in Tables 2 through 4⇓⇓⇓, risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented, less well documented).5 The tables give the estimated prevalence, population attributable risk, relative risk, and risk reduction with treatment for each factor when known. Population attributable risk reflects the proportion of ischemic strokes in the population that can be attributed to a particular risk factor and is given by the formula 100×[prevalence(relative risk−1)/prevalence(relative risk−1)+1]). …

Abstracts of literature

A subset of undifferentiated vertigo cases can be attributed to dangerous central causes such as posterior circulation ischemic stroke (PCIS) or transient ischemic attack (TIA). Due to a lack of validated clinical risk scoring tools, there is currently high heterogeneity in emergency department (ED) neuroimaging practices for patients presenting with undifferentiated vertigo. Therefore, this study assessed the utility of head and neck CT with angiography (CTA) for risk stratifying ED patients presenting with vertigo. The primary objective of this study was to compare 30-day stroke and TIA outcomes between ED vertigo patients who received CTA at their index visit versus those who did not. The impact of index visit CTA on secondary outcomes of interest was also measured, including ED length of stay (LOS), hospital LOS, and 30-day ED revisit rate. This retrospective study analyzed ED visit data across four tertiary care ED's over a one-year period. Adult patients presenting with a chief complaint of vertigo were eligible for study inclusion. Administrative data of the variables of interest was gathered from Canadian medical databases. Regression modeling was used to adjust for predetermined variables to evaluate the association between index visit CTA imaging, and stroke or TIA diagnosis at 30 days. A 30-day diagnosis for stroke or TIA was found in 20.7% of the CTA group, and in 1.2% of the No CTA group. The odds ratio (OR) was 22.3 (95% confidence interval (CI): 15.03-33.02) unadjusted, and 18.3 (95% CI: 14.85-22.45) after adjustment. The CTA group had a longer average ED LOS (+114 minutes), a shorter average total hospital LOS within 30 days (-2.2 days), and a higher 30-day ED revisit rate when compared to the No CTA group (4.0% versus 1.5%). Patients who received CTA at their index visit had 18.3 times greater odds of TIA or stroke diagnosis at 30-days, stayed longer in the ED, were more likely to revisit the ED within 30 days, and had a shorter mean hospital stay.

Clinical Prediction Rules to Stratify Short-Term Risk of Stroke Among Patients Diagnosed in the Emergency Department With a Transient Ischemic Attack

Data on the association between visit-to-visit variability (VVV) in blood pressure (BP) and the risk of stroke among hypertensive patients with chronic kidney disease (CKD) is limited. We aimed to evaluate the relation of VVV in BP with the risk of stroke, and examine any possible effect modifiers in hypertensive patients with mild-to-moderate CKD. This is a post-hoc analysis of the China Stroke Primary Prevention Trial. A total of 3091 patients with estimated glomerular filtration rate 30-60 ml/min per 1.73 m and/or proteinuria at baseline, without occurring stroke and with BP measurements of at least two visits from randomization to the 12-month visit were included. The main VVV in BP was expressed as SD. The primary outcome was first stroke. The median subsequent treatment duration was 3.7 years. After multivariable adjustment, including baseline SBP and mean SBP during the first 12-month follow-up, there was a significantly positive relationship of SD SBP with the risk of subsequent first stroke (per SD increment; odds ratio, 1.41; 95% confidence interval: 1.17-1.69) and first ischemic stroke (odds ratio, 1.55; 95% confidence interval: 1.26-1.90). Results were consistent across various subgroups, including age, sex, baseline SBP, treatment compliance, and mean SBP, concomitant usage of calcium channel blocker during the first 12-month follow-up period. Similar trends were also found for coefficient of variation SBP, and SD or coefficient of variation DBP. However, there was no significant association between BP variability and first hemorrhagic stroke. In hypertensive adults with mild-to-moderate CKD, visit-to-visit variability in BP was significantly associated with the risk of subsequent first stroke.

OBJECT Patients with CSF shunts are medically complex and frequently present to the emergency department (ED) with suspected shunt malfunction. After adequate evaluation in the ED and proper disposition, some patients return to the ED within a short period of time. In this study, the authors examined the reasons for ED revisits within 7 days of the index ED visit to discern possible preventable returns. METHODS There were 3080 index ED visits made by patients with shunted hydrocephalus between 2010 and 2013. Index ED visits preceded by another ED visit or neurosurgical procedure within 60 days were excluded. Index ED visits for reasons unrelated to shunt function and those that led directly to admissions and shunt revision surgeries were also excluded. The remaining 1509 ED visits were eligible for analysis in this study. Final dispositions from the index ED visit included home (1176 cases), admission to the neurosurgery service for observation (134 cases), and admission to other services (199 cases). Subsequent events within 7 days, including ED revisits, hospital admissions, and shunt-related surgery were recorded, and reasons for the ED revisits were categorized based on whether the visit was related to shunt function concerns. Clinical and socioeconomic factors were analyzed for their association with ED revisits by using statistical methods. RESULTS Of the 1176 patients discharged home from the ED after shunt function evaluation, 101 (8.6%) returned to the ED within 7 days. Of the 134 patients admitted to the neurosurgery service for observation only, 8 (6.0%) returned to the ED within 7 days of discharge. Of the 199 patients admitted to hospital services other than neurosurgery, 13 (6.5%) returned to the ED within 7 days of discharge. The reasons for ED revisits vary (total of 122 visits combining the 3 groups), but at least 60% of the revisits were clearly unrelated to shunt function. A younger age, daytime arrival to the ED, and living within the metropolitan area were identified as risk factors for ED revisits. CONCLUSIONS Children with CSF shunts are medically complex and use ED services often. After an index ED visit at which shunt function was deemed to be the chief concern, the purpose of the subsequent return to the ED within 7 days was often for complaints unrelated to shunt function. Caution is warranted when attempting to classify these complex patients as having potential preventable return-to-system events.

To assess in a cohort of young adults admitted with alcohol intoxication (AI) to the Emergency Department (ED): how many patients are readmitted to the ED or to a Psychiatric Department (PD) inpatient unit; and which characteristics are associated with further ED and PD inpatient admissions. In 630 patients aged 18 to 30 years admitted for AI in 2006 to 2007 to the ED of a Swiss tertiary hospital, further ED and PD inpatient admissions through 2013 were assessed. Patient characteristics at the index (initial) ED visit were assessed using administrative and medical records. Proportion of subjects with at least 1 further ED admission, 1 further ED admission with AI, and any PD admission over the study period.Associations between patients' characteristics at index visit and readmissions were assessed using backward selection multivariate regression analyses. Mean age was 24, 66% were male, 60% had any ED/PD admissions during the study period, 17.9% a PD admission, and 13.8% were re-admitted to ED with AI. Disruptive behavior at the index visit was associated with further ED (odds ratio [OR] 1.69 [1.13; 2.54]) and PD admissions (OR 2.41 [1.44; 4.05]). Psychiatric diagnosis was associated with any further ED admission (OR 2.07 [1.41; 3.05]), with further ED admission with AI (OR 4.56 [2.36; 8.81]) and with PD admission (OR 3.92 [2.40; 6.41]). Female sex predicted any further ED admission (OR 1.65 [1.14; 2.39]). Young adults presenting with alcohol intoxication have high rates of subsequent inpatient emergency and psychiatric admissions. Being female, presenting with disruptive behavior, and having a psychiatric diagnosis at the ED visit were predictors of further admissions.

The purpose of this study was to evaluate the subsequent health resource utilization (HRU) between patients with migraine who received opioid medications at their emergency department (ED) visits ("opioid recipients") versus patients with migraine who did not receive opioid medications at their ED visits ("non-recipients"). Previous studies have found that opioid use is common among patients with migraine at emergency settings. Medication overuse, especially the use of opioids, is associated with migraine progression, which can ultimately lead to substantial health resource use and costs. There is limited evidence on opioid use specifically in emergency settings and its impact on future HRU among people with migraine. This retrospective cohort study used electronic health record data from the Baylor Scott & White Health between December 2013 and April 2017. Adult patients who had at least 6months of continuous enrollment before (baseline or pre-index) and after (follow-up) the first date they had an ED visit with a diagnosis of migraine (defined as index date) were enrolled in the study. Opioid use and HRU during follow-up period between opioid recipients and non-recipients were summarized and compared. A total of 788 patients met the eligibility criteria and were included in this study. During the 6-month follow-up period, compared to patients with migraine who were non-recipients at their index ED visits, opioid recipients had significantly more all-cause (3.6 [SD=6.3] vs. 1.9 [SD=4.8], p<0.0001) and migraine-related (1.6 [SD=4.2] vs. 0.6 [SD=2.1], p<0.0001) opioid prescriptions (RXs), and more all-cause (2.6 [SD=4.3] vs. 1.6 [SD=2.6], p=0.002) and migraine-related (0.6 [SD=1.4] vs. 0.3 [SD=0.8], p=0.001) ED visits. In addition, opioid recipients had higher risk of future migraine-related ED visits controlling for covariates (HR=1.49, 95% CI=1.09-2.03, p=0.013). Factors that were significantly (p<0.05) related to future migraine-related ED visits include previous opioid use (HR=2.12, 95% CI=1.24-3.65, p=0.007), previous ED visits (HR=2.38, 95% CI=1.23-4.58, p=0.010), hypertension (HR=1.46, 95% CI=1.07-2.00, p=0.017), age between 45 and 64years (HR=0.68, 95% CI=0.48-0.97, p=0.033), female sex (HR=1.82, 95% CI=1.12-2.86, p=0.015), and tobacco use disorder (HR=1.45, 95% CI=1.07-1.97, p=0.017). Sub-analyses were restricted to the group of patients who were opioid naïve at baseline (n=274, defined as having ≤1 opioid RXs during the 6-month pre-index period). Patients who were baseline opioid naïve but received opioids during their index ED visits were more likely to have future migraine-related ED visits compared to patients who were baseline opioid naïve and did not receive any opioids during their index ED visits, controlling for covariates (HR=2.90, 95% CI=1.54-5.46, p=0.001). Opioid use among patients with migraine presenting to the ED is associated with increased future HRU, which highlights the need for optimizing migraine management in emergency settings.

Bisphosphonates have been associated with an increased risk of atrial fibrillation and may thus be associated with an increased risk of ischemic stroke. This would have substantial clinical and public health implications. We found no evidence of an association between bisphosphonate use and risk of ischemic stroke. Bisphosphonates have been associated with an increased risk of atrial fibrillation in some studies and may be associated with an increased risk of ischemic stroke. However, data regarding these possibilities are limited. We conducted a population-based case-control study of 6,257 female cases of ischemic stroke and 31,285 age- and gender-matched population controls. Data on bisphosphonate use, other medication use, comorbidity, and ischemic stroke were obtained from medical databases. Current bisphosphonate use was defined as at least one redeemed prescription within 90 days before diagnosis/index date. We estimated the odds ratio (OR) of ischemic stroke among users and nonusers of bisphosphonates using conditional logistic regression, controlling for potential confounding factors. One hundred eighty-two (2.9%) cases and 901 (2.9%) controls were current users of bisphosphonates. Etidronate and alendronate were prescribed with similar frequency among cases and controls. The adjusted OR of ischemic stroke for bisphosphonate users compared with nonusers was 0.97 (95% confidence interval [CI], 0.82-1.15). New and continuing bisphosphonate users had adjusted ORs for ischemic stroke of 1.16 (95% CI, 0.69-1.96) and 0.97 (95% CI, 0.81-1.16), respectively. Excluding patients with known atrial fibrillation/flutter yielded an OR of 1.00 (95% CI, 0.85-1.19). The OR for ischemic stroke was 0.59 (95% CI, 0.32-1.09) among patients with a history of previous hospitalization for cardiovascular disease and 1.07 (95% CI, 0.88-1.18) among those without (P < 0.001). The OR for former users was 1.23 (95% CI, 1.01-1.49). We found no evidence of an association of oral bisphosphonate use with the risk of ischemic stroke.

The importance of carotid plaque ulceration as a cause of cerebral ischemic symptoms remains uncertain. Moreover, its prominence in symptomatic patients with severe carotid stenosis is unknown. The association between angiographically defined plaque ulceration and risk of subsequent stroke was assessed using Cox proportional hazards regression in 659 patients with severe (70% to 99%) carotid stenosis from the North American Symptomatic Carotid Endarterectomy Trial. Treatment assignment (medical versus surgical) and degree of ipsilateral stenosis were identified as having a significant influence on the results. The risk of ipsilateral stroke at 24 months for medically treated patients with ulcerated plaques increased incrementally from 26.3% to 73.2% as the degree of stenosis increased from 75% to 95%. For patients with no ulcer, the risk of stroke remained constant at 21.3% for all degrees of stenosis. The net result yielded relative risks of stroke (ulcer versus no ulcer) ranging from 1.24 (95% confidence interval, 0.61 to 2.52) to 3.43 (95% confidence interval, 1.49 to 7.88). Conversely, for surgically treated patients with antecedent presence of an ulcerated plaque, the risk of stroke increased slightly at the highest degrees of stenosis. Overall, carotid endarterectomy reduced the risk of ipsilateral stroke at 24 months by at least 50%. Similar results were obtained for risk of major ipsilateral stroke and risk of all strokes and death. The presence of angiographically defined ulceration for medically treated symptomatic patients is associated with an increased risk of stroke. The risk of stroke more than doubles at higher degrees of stenosis. Carotid endarterectomy is beneficial in substantially reducing the risk of stroke, regardless of plaque ulceration and degree of severe carotid stenosis.

Background: Most prior estimates of transient ischemic attack (TIA) incidence and post-TIA stroke risk are derived from case-based cohorts recruited in hospitals or TIA clinics, but are less well described in population-based cohorts. We report the incidence, clinical features of first-ever TIA, risk and timing for subsequent stroke in the community-based Framingham Study (FHS) cohort. Methods: Longitudinal follow-up (1948-2015) of all FHS participants free of stroke or TIA at age 35-94. Medical records, evaluation by a study neurologist and review of brain imaging were used to establish diagnosis of TIA and stroke. We examined the annual age- and sex-specific incidence rates of TIA. Each case was randomly assigned 5 age- and gender- matched controls, stroke- and TIA-free prior to the date of TIA. Cox models were used to examine the risk of subsequent stroke. Results: 435 participants (229 women, 71.9±11.2 years) suffered a first-ever TIA over 366,209 person-years of follow-up. The overall crude incidence was 1.19/1,000 person-years. Incidence increased with age, peaking in the 85-94 years group (4.88/1,000 person-years). Age-adjusted annual incidence was 1.04/1,000 person-years for women and 1.41 for men. The most common symptom was unilateral weakness (47.4%) followed by sensory (36.5%) disturbances. Most TIAs were referable to the anterior circulation (~69%), 13% to retinal ischemia, 18% to the vertebrobasilar distribution. Symptoms lasted &lt; 1hour in 66% of subjects. Over 4.27±6.18 years of follow-up 149 patients (34.3%) had a stroke, occurring within the first week in 18.8%, 1 week-3 months in 16%, 3-12 months in 10%, and ~50% beyond 12 months. Compared to controls, persons with TIA had a 4-fold higher 5-year risk of stroke, adjusting for age, sex, hypertension, diabetes, atrial fibrillation, coronary artery disease and current smoking (Odds Ratio 4.45, 95% CI 3.28-6.03, p&lt;0.001). Conclusion: TIA incidence increases with age, is higher in men, and is a strong independent predictor of subsequent stroke which occurs in &gt;30% of TIA patients. Although the risk is high early on, ~50% of strokes occur beyond 12 months. Our findings highlight the need for both early intervention but also continued surveillance in this high-risk patient population.

The burden of stroke to the health care system in the United States continues to increase. Stroke-related hospital admissions grew from 580 000 in 1988 to 820 000 in 1997, an 18.6% increase after age adjustment.1 More effective stroke prevention provides the primary means of reducing these alarming statistics. This can be accomplished through better implementation of known preventive strategies2 and through research into new approaches to stroke prevention. Diet can affect stroke risk, with epidemiological studies indicating an inverse relationship between fruit and vegetable consumption and cardiovascular events.2 For example, one study including individuals free of cardiovascular disease at baseline found that the relative risk (RR) of stroke was reduced by 31% (RR, 0.69; 95% CI, 0.52 to 0.92) for persons in the highest quintile of fruit and vegetable intake.3 Analysis of data from the National Health and Nutrition Examination Survey (NHANES) Epidemiologic Follow-up Study supports these results.4 The study included 9608 adults aged 25 to 74 years who were free of cardiovascular disease at a baseline evaluation between 1971 and 1975. Consumption of fruits and vegetables ≥3 times per day compared with <1 time per day was associated with a 27% lower stroke incidence (RR, 0.73; 95% CI, 0.57 to 0.95) after adjustment for potential confounders, suggesting the benefit is not attributable to a healthy-user effect. The results reinforce present recommendations for an intake of 5 servings of fruits and vegetables daily. Because fruits and vegetables contain antioxidants, antioxidant food supplements might be expected to have similar benefits. However, a 3-year study of patients with coronary heart disease, low levels of high-density lipoprotein cholesterol, and normal levels of low-density lipoprotein cholesterol found no reduction in cardiovascular end points (death, myocardial infarction, stroke, and revascularization procedures) with the use of antioxidant supplements (800 IU …

Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease

This study examined medical emergency department utilization for patterns among uninsured patients with psychiatric disorders. Billing records of 15,672 uninsured adult patients treated in the emergency department of an academic medical center in southeast Texas over a 12-month period were analyzed for information on demographic characteristics, diagnosis, number of emergency department visits, and hospitalization. Overall, 11.8% of the population was diagnosed as having at least one psychiatric disorder during an emergency department visit. Patients with psychiatric disorders had an increased risk of having multiple emergency department visits and hospitalization compared with patients without psychiatric disorders. The risk of multiple emergency department visits was particularly high for patients with either bipolar disorder or psychotic disorders. Uninsured patients with psychiatric disorders appear to be heavy users of medical emergency department services. These findings may be helpful in developing more efficient strategies to serve the mental health needs of the uninsured.

INTRODUCTION: The consequences of chronic pancreatitis (CP) may not only be localized to the pancreas or restricted to the gastrointestinal tract but could also be systemic. However, its correlations with cerebrovascular disease has not yet been fully explored. Using a large database, we aimed to evaluate the epidemiology and risk of stroke in CP patients in the United States and identify underlying associations. METHODS: A multi-institutional database (Explorys Inc, Cleveland, OH, USA), an aggregate of electronic health record data from 26 major integrated US healthcare systems, was surveyed. A cohort of patients with a Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) diagnosis of “chronic pancreatitis” between 2016 and 2020 was identified. Subsequently, individuals who developed a new diagnosis of stroke after at least 30 days of being diagnosed with CP were identified. Age-, race-, gender- and comorbidities-based distributions were described. RESULTS: There was a total of 39,328,760 individuals in the database (2016–2020) with 72,370 (0.18%) who had CP. There were 650 (0.90%) new strokes after at least 30 days amongst CP patients. Baseline characteristics of patients with CP and control group are shown in Table 1. Compared to the general population, patients with CP were at a significantly increased risk of both ischemic and embolic strokes. Within the CP cohort, patients who developed stroke were more likely to be elderly (>65 years old), Caucasian, and had a history of several risk factors including smoking, diabetes, hypertension, hyperlipidemia, and coronary artery disease (Table 2). CONCLUSION: This is the largest study to date to evaluate the risk of stroke among CP patients. Compared to the general population, patients with history of CP were significantly associated with increased risk of both ischemic and embolic strokes seondary to higher prevalence of comorbidities and possibly related to chronic inflammatory status that accelerates atherosclerosis. More prospective studies are needed to validate these findings and further delineate this risk association.Table 1.: Baseline characteristics of patients with chronic pancreatitis and control groupTable 2.: Risk and Clinical Predictors of Stroke among Patients with Chronic Pancreatitis.