Amy Y. X. Yu

Higher infant body fat with excessive gestational weight gain in overweight women

OBJECTIVE Gestational weight gain (GWG) is positively associated with birthweight and maternal prepregnancy body mass index (BMI) is directly related to infant fat mass (FM). This study examined whether differences exist in infant body composition based on 2009 GWG recommendations. STUDY DESIGN Body composition was measured in 306 infants, and GWG was categorized as appropriate or excessive. Analysis of covariance was used to investigate the effects of GWG and prepregnancy BMI and their interaction on infant body composition. RESULTS Within the appropriate group, infants from obese mothers had greater percent fat (%fat) and FM than offspring from normal and overweight mothers. Within the excessive group, infants from normal mothers had less %fat and FM than infants from overweight and obese mothers. A difference was found for %fat and FM within the overweight group between GWG categories. CONCLUSION Excessive GWG is associated with greater infant body fat and the effect is greatest in overweight women.

Endovascular Therapy in Acute Ischemic Stroke: Challenges and Transition from Trials to Bedside

Rapid and effective revascularization is the mainstay of acute ischemic stroke treatment. Until recently, intravenous recombinant tissue-type plasminogen activator (r-tPA) was the only established therapeutic option. Five recently published trials have now proven the benefit of endovascular treatment, changing dramatically the evaluation and treatment of acute ischemic stroke.1–5 Thrombectomy with stent retrievers is now recommended as the standard of care for acute ischemic strokes with a proximal large vessel occlusion in the anterior circulation.6,7 In this article, we review the current evidence on endovascular therapy in acute ischemic stroke and discuss the major challenges in the implementation of this therapy. We address the challenges of the generalizability of trial results to different patient populations, implementation of endovascular therapy in the acute setting for large populations within various geographical contexts, and approaches to evaluating future innovations in the field of neuroendovascular care. The 4 pillars of successful revascularization with endovascular therapy to achieve a good clinical outcome are the following: 1. Rapid neurovascular imaging is critical to identify the eligible patient. All 5 positive randomized controlled trials used varying imaging selection criteria, including a minimum of a noncontrast computed tomography (CT) head to identify a small core using the Alberta Stroke Program Early CT score (ASPECTS) score and a computed tomography (CT) angiography of the head and neck to ascertain a proximal vessel occlusion.8 Vascular imaging also serves the interventionalist for planning the endovascular procedure. 2. Retrievable stents are safe and effective. Retrievable stents were used in the large majority of patients in all 5 trials with reported number needed to treat of 2.5 to 7 for an independent outcome at 90 days across the trials. Moreover, patient safety was preserved with very low overall procedural complication rates. 3. Time is brain. Analogous to the onset-to-treatment time …

Evaluating pain, sedation, and delirium in the neurologically critically ill-feasibility and reliability of standardized tools: a multi-institutional study.

Objectives:To assess the feasibility and reliability of systematic evaluations of analgesia, sedation level, and delirium features in the neurologically critically ill and to determine whether delirium features are linked to clinical outcomes in this population. Design:Multicentered prospective observational study. Setting:Neurological, Neurosurgical, Neurosciences or Surgical Trauma ICUs from three hospitals (two in Canada and one in the United States). Patients:A convenience sample of adult NICU or neurologic, neurosurgical, neurosciences, or surgical trauma ICU patients admitted for greater than 12 hours from November 2011 to April 2012. Interventions:Systematic assessments were simultaneously and independently performed by a neurologist, intensivists, or trauma surgeon, and a nurse in three multispecialty ICUs. Pain was evaluated with the numeric rating scale or behavioral pain scale. Sedation was assessed using the Richmond Agitation-Sedation Scale. Patients with Richmond Agitation-Sedation Scale greater than or equal to −4 were screened for features of delirium with the Intensive Care Delirium Screening Checklist. Intraclass correlation coefficient was used to evaluate inter-rater reliability between the nurse and the physician for pain and sedation scales, and the kappa coefficient was calculated for concordance of the Intensive Care Delirium Screening Checklist items. Measurements and Main Results:151 patients had 439 assessments. Pain and sedation were always assessable with excellent inter-rater reliability (numeric rating scale intraclass correlation coefficient, 0.92; behavior pain scale intraclass correlation coefficient, 0.83; and Richmond Agitation-Sedation Scale intraclass correlation coefficient, 0.92). Patients were sufficiently alert for delirium screening 3/4 of the time; Intensive Care Delirium Screening Checklist items had good concordance (kappa coefficients between 0.58 and 0.91 for the eight Intensive Care Delirium Screening Checklist items). Nonevaluable items were most often orientation, hallucinations, and speech or mood content. Furthermore, each additional Intensive Care Delirium Screening Checklist item present in proportion to the total evaluable Intensive Care Delirium Screening Checklist score was associated with a 10% increase in ICU length of stay. Conclusions:Pain and sedation can be systematically assessed in the neurologically critically ill; the majority can also be screened for delirium features with excellent inter-rater reliability. Increased proportion of Intensive Care Delirium Screening Checklist items is associated with worse outcomes.

Adherence to antihypertensive agents after ischemic stroke and risk of cardiovascular outcomes

ABSTRACT Objective: To evaluate the relationship between antihypertensive (AH) drug adherence and cardiovascular (CV) outcomes among patients with a recent ischemic stroke and assess the validity of our approach. Methods: A cohort of 14,227 patients diagnosed with an ischemic stroke was assembled from individuals 65 years and older who were treated with AH agents from 1999 to 2007 in Quebec, Canada. A nested case-control design was used to evaluate the occurrence of nonfatal major CV outcomes and mortality. Each case was matched to 15 controls by age and cohort entry time. Medication possession ratio was used for AH agent adherence level. Adjusted conditional logistic regression models were used to estimate the rate ratio of CV events. The validity of the approach was assessed by evaluating the adherence level of CV-protective and non–CV-protective drugs. Results: Mean age was 75 years, 54% were male, 38% had coronary artery disease, 23% had diabetes, 47% dyslipidemia, and 14% atrial fibrillation or flutter. High adherence to AH therapy was mirrored by similar adherence to statins and antiplatelet agents and was associated with a lower risk of nonfatal vascular events compared with lower adherence (rate ratio 0.77 [0.70–0.86]). We observed a paradoxic link between adherence to several drugs and all-cause mortality. Conclusion: Adherence to AH agents is associated with adherence to other secondary preventive therapies and a risk reduction for nonfatal vascular events after an ischemic stroke. Overestimation of all-cause mortality reduction may be related to frailty and comorbidities, which may confound the apparent benefit of different drugs.

Multiphase CT angiography increases detection of anterior circulation intracranial occlusion

Objective: To evaluate whether the use of multiphase CT angiography (CTA) improves interrater agreement for intracranial occlusion detection between stroke neurology trainees and an expert neuroradiologist. Methods: A neuroradiologist and 2 stroke neurology fellows independently reviewed 100 prospectively collected single-phase and multiphase CTA scans from acute ischemic stroke patients with mild symptoms (NIH Stroke Scale score ≤5). The presence and location of a vascular occlusion(s) were documented. Interrater agreement single- and multiphase CTA was quantified using unweighted κ statistics. We assessed for any occlusions, anterior vs posterior occlusions, and pial vessel asymmetry. Results: Using multiphase CTA, the neuroradiologist detected 50 scans with anterior circulation occlusions and 15 scans with posterior circulation occlusions. Median reading time was 2 minutes per scan. Median reading time for the neurologists was 3 minutes per multiphase CTA scan. Interrater agreement was fair between the 2 neurologists and neuroradiologist when using single-phase CTA (κ = 0.45 and 0.32). Agreement improved minimally when stratified by anterior vs posterior circulation. When using multiphase CTA, agreement was high for detection of occlusion or asymmetry of pial vessels in the anterior circulation (κ = 0.80 and 0.84). Conclusions: Multiphase CTA improves diagnostic accuracy in minor ischemic stroke for detection of anterior circulation intracranial occlusion. Classification of evidence: This study provides Class II evidence that multiphase CTA, compared to single-phase CTA, improves the interrater agreement between stroke neurology trainees and an expert neuroradiologist for detecting anterior circulation intracranial vascular occlusion in patients with minor acute ischemic strokes.

Should minor stroke patients be thrombolyzed? A focused review and future directions.

Stroke is a leading cause of morbidity and mortality worldwide. Up to 80% of ischemic stroke patients may initially present with minor symptoms. Minor stroke and transient ischemic attack patients are typically treated conservatively with antiplatelet agents and general vascular prevention strategies. Yet a high proportion develop recurrent stroke or progression of stroke and up to one in four of these patients are disabled or dead at follow-up. Minor or rapidly improving symptoms are the top reasons for withholding thrombolytic therapy to time-eligible stroke patients as they are believed to be ‘too good to treat’. The benefits and risks of treating mild ischemic strokes are still unclear. The increasing use of computed tomography angiography and its ability to identify both proximal and distal intracranial occlusions may change this equation. In this review, we discuss the diagnosis and prognosis of mild strokes, the role of neurovascular imaging in treatment decision making, experience with thrombolysis in this patient population, and propose directions for future studies.

Use and Utility of Administrative Health Data for Stroke Research and Surveillance

Despite declining age-standardized stroke incidence in high-income countries, stroke incidence is rising in low- and middle-income countries.1 Globally, the absolute burden of stroke was high in 2010 with 16.9 million first-ever strokes, 5.9 million stroke-related deaths, and 102 million disability-adjusted life-years lost.1 These numbers are projected to increase. Surveillance provides an understanding of stroke frequency, burden, distribution, and determinants. These data are essential for monitoring trends over time, guiding judicious resource allocation, and for the design, implementation, and evaluation of interventions aimed at stroke prevention, treatment, and rehabilitation.2 Collecting data specifically for research purposes can be costly and time-consuming, limiting the sample size, period of follow-up, and geographical distribution of subjects. Surveillance requires continuous data collection in large geographic areas over years; therefore, attention has been paid to secondary use data. Health services utilization data, or administrative health data, provide a wealth of information for health services researchers and for stroke surveillance. However, the information collected and ascertainment methods are heterogeneous between countries and even between jurisdictions within a country, making the data vulnerable to selection and measurement bias. Comparing international data is also challenging.3 In this review, we discuss the strengths and weaknesses of administrative health data for stroke surveillance. Administrative health data are routinely generated through interactions with healthcare systems. They are collected for payment, monitoring, planning, priority setting, and evaluation of health services provision. Sources include, but are not limited to, hospitalizations, emergency department and ambulatory care visits, and physician billings. Unlike prospective clinical research data collection, administrative health data are accumulated in a distributed manner over a prolonged period of time. As a result, these data capture a large number of individuals and a wide range of demographic information, including race/ethnicities, geographical areas (eg, rural versus urban), and institutions (eg, community versus …

Temporal Trends in the Use and Comparative Effectiveness of Direct Oral Anticoagulant Agents Versus Warfarin for Nonvalvular Atrial Fibrillation: A Canadian Population‐Based Study

Background Direct oral anticoagulants (DOACs) are noninferior to warfarin for stroke prevention in atrial fibrillation (AF). We aimed to determine the population risk of stroke and death in incident AF, stratified by anticoagulation status and type, and the temporal trends of oral anticoagulation practice in the post‐DOAC approval period. Methods and Results We conducted a population‐based cohort study of incident nonvalvular AF cases using administrative health data in Alberta, Canada. We used Cox proportional hazards modeling with anticoagulation status as a time‐varying exposure and adjusted for age (continuous), sex, congestive heart failure, hypertension, diabetes mellitus, prior transient ischemic attack or ischemic stroke, myocardial infarction, peripheral artery disease, and chronic kidney disease. Primary outcome was the composite of stroke and death. Among 34 965 patients with incident AF (56.0% male, median age 73 years), relative to warfarin, DOAC use was associated with decreased risk of all stroke and death (hazard ratio: 0.90; 95% confidence interval, 0.83–0.97) and decreased hemorrhagic stroke (hazard ratio: 0.60; 95% confidence interval, 0.40–0.91]) but a similar risk of ischemic stroke (hazard ratio: 1.12; 95% confidence interval, 0.94–1.34]). During this time period, DOAC use increased rapidly, surpassing warfarin, but the total oral anticoagulation use in the population remained stable, even in the subgroup with the highest thromboembolic risk. Conclusions In a real‐world population‐based study of patients with incident AF, anticoagulation with DOACs was associated with decreased risk of stroke and death compared with warfarin. Despite a rapid uptake of DOACs in clinical practice, the total proportion of AF patients on anticoagulation has remained stable, even in high‐risk patients.

The future of endovascular treatment: Insights from the ESCAPE investigators

The ESCAPE trial demonstrated strong morbidity benefit and mortality reduction for endovascular stroke treatment. Following the release of the main results, the ESCAPE trial investigators convened at a 2-day close-out meeting in March 2015 in Banff, Alberta, Canada. Meeting discussions focused on system implications, procedural characteristics, and future directions. We report the proceedings of the meeting, which provide insights from the trialists into the issues of generalizability, treatment limitations, as well as future directions and opportunities in stroke care optimization.

History, Evolution, and Importance of Emergency Endovascular Treatment of Acute Ischemic Stroke

More than 800,000 people in North America suffer a stroke each year, with ischemic stroke making up the majority of these cases. The outcomes of ischemic stroke range from complete functional and cognitive recovery to severe disability and death; outcome is strongly associated with timely reperfusion treatment. Historically, ischemic stroke has been treated with intravenous thrombolytic agents with moderate success. However, five recently published positive trials have established the efficacy of endovascular treatment in acute ischemic stroke. In this review, we will discuss the history of stroke treatments moving from various intravenous thrombolytic drugs to intra-arterial thrombolysis, early mechanical thrombectomy devices, and finally modern endovascular devices. Early endovascular therapy failures, recent successes, and implications for current ischemic stroke management and future research directions are discussed.