Andrea D. Boan

Lowering of Blood Pressure for Recurrent Stroke Prevention

Hypertension is the premier modifiable risk factor for stroke.1,2 Indeed, ≤50% of strokes may be attributable to hypertension, and the relationship of hypertension with stroke also comprises distinct independent links between both systolic and diastolic hypertension and the occurrence of both primary and recurrent strokes.3 Furthermore, the underlying pathophysiological rationale and clinical trial evidence for lowering blood pressure (BP) in people with hypertension to safely prevent a primary stroke of any type are overwhelmingly clear.4 However, when it comes to recurrent stroke prevention, questions surrounding BP treatment linger, including what exactly to do, when precisely to do it, and whether the approach should vary by type of patient. This comparative lack of clarity about the nature of the BP-lowering strategy after a stroke has arisen because of theoretical efficacy/safety concerns related to the acuity and type of index stroke, as well as the paucity of published hypertension treatment trials for recurrent stroke prevention.5,6 As such, expert consensus recommendations for BP lowering to avert vascular events either do not specifically or adequately address recurrent stroke prevention (Eighth Joint National Committee,7 American Heart Association guidelines for managing BP in coronary artery disease)8 or are largely based on a paucity of clinical trials or reviews that did not specifically address key issues of acuity, stroke type, or BP-lowering intensity.9 Nonetheless, some expert opinion suggests that management of high vascular risk patients with hypertension remains aggressive for now until specific compelling trial evidence is available.10 The importance of optimizing recurrent stroke prevention to lessen the personal and societal burden of stroke cannot be overemphasized. Approximately 25% of stroke cases are recurrent events, often occurring within the first year of a prior stroke or transient ischemic attack (TIA),11 and the case mortality …

Thirty-year survival for black and white hypertensive individuals in the Evans County Heart Study and the Hypertension Detection and Follow-up Program

The Evans County Heart Study (ECHS), initiated in 1960, was one of the first major studies to document cardiovascular disease (CVD) risks for African Americans and Caucasians with elevated blood pressures. In the early 1970s, the Hypertension Detection and Follow-up Program (HDFP), with a site in Georgia (HDFP-GA) was one of the first major studies to demonstrate that treating hypertension with stepped care (SC), versus referred care (RC), has better short-term outcomes. With this background, study objectives were to evaluate 30-year survival and cardiovascular outcomes of the HDFP-GA and to compare outcomes of these patients with 1619 hypertensive individuals (30-69 years of age) from the ECHS. HDFP-GA patients included 688 individuals (black [n=267]; white [n=421]) randomized to RC (n=341) and SC (n=347). The ECHS was comprised of 733 black and 886 white hypertensives. All-cause mortality and CVD mortality were assessed in the HDFP-GA and compared to the ECHS hypertensives. After 30-years of follow-up, 65.7% of the HDFP-GA cohort had died compared with a similar 65.8% of the ECHS hypertensives. However, CVD mortality rates, while similar for the SC and RC arms, were lower than in the HDFP-GA total study group than the hypertensive participants of ECHS (32.6% vs. 40.3% p<.001). CVD survival rates for both SC and RC HDFP-GA arms were significantly better than population-based hypertensive individuals in the ECHS, with consistent benefits in all four race-sex groups. These results identify the importance of long-term follow-up of individuals in hypertension studies and trials that include CVD outcomes.

Persistent Racial Disparity in Stroke Hospitalization and Economic Impact in Young Adults in the Buckle of Stroke Belt

Background and Purpose— Mounting evidence points to a decline in stroke incidence. However, little is known about recent patterns of stroke hospitalization within the buckle of the stroke belt. This study aims to investigate the age- and race-specific secular trends in stroke hospitalization rates, inpatient stroke mortality rates, and related hospitalization charges during the past decade in South Carolina. Methods— Patients from 2001 to 2010 were identified from the State Inpatient Hospital Discharge Database with a primary discharge diagnosis of stroke (International Classification of Diseases, Ninth Revision codes: 430–434, 436, 437.1). Age- and race-stroke–specific hospitalization rates, hospital charges, charges associated with racial disparity, and 30-day stroke mortality rates were compared between blacks and whites. Results— Of the 84 179 stroke hospitalizations, 31 137 (37.0%) were from patients aged <65 years and 29 846 (35.5%) were blacks. Stroke hospitalization rates decreased in the older population (aged ≥65 years) for both blacks and whites (P<0.001) but increased among the younger group (aged <65 years; P=0.004); however, this increase was mainly driven by a 17.3% rise among blacks (P=0.001), with no difference seen among whites (P=0.84). Of hospital charges totaling

Racial Differences in Poststroke Rehabilitation Utilization and Functional Outcomes

2.77 billion,

The Paradox of the Dead Donor Rule: Increasing Death on the Waiting List

453.2 million (16.4%) are associated with racial disparity (79.6% from patients aged <65 years). Thirty-day stroke mortality rates decreased in all age-race-stroke–specific groups (P<0.001). Conclusions— The stroke hospitalization rate increased in the young blacks only, which results in a severe and persistent racial disparity. It highlights the urgent need for a racial disparity reduction in the younger population to alleviate the healthcare burden.

Patient Awareness and Perception of Stroke Symptoms and the Use of 911

OBJECTIVE To examine racial differences in poststroke rehabilitation utilization and functional outcomes. DESIGN Observational follow-up study. SETTING Designated stroke center. PARTICIPANTS Stroke survivors (N=162; 106 whites and 56 blacks) surveyed at 1 year poststroke. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Twenty-question measure of activities of daily living (ADL) and instrumental activities of daily living (IADL) performance, life participation, and driving. One-year follow-up data collected from stroke survivors as part of the Stroke Education and Prevention-South Carolina Project were examined for racial disparities in rehabilitation utilization and functional outcomes. RESULTS Analyses revealed no significant differences between blacks and whites for rehabilitation utilization. In multivariate comparisons controlling for stroke severity, blacks were less likely to report independence in overall functional performance and domain-specific measures of toileting, walking, transportation, laundry, and shopping. Blacks also reported less independence in driving at 1-year follow-up. CONCLUSIONS Blacks were less likely to report independence in performing ADL and IADL at 1 year poststroke after controlling for stroke severity. Racial disparities were reported in ADL and IADL performance despite a lack of racial differences in rehabilitation utilization. Future studies are needed to further understand the reason for this disparity in reported functional independence.

Hypertension and stroke: an appraisal of the evidence and implications for clinical management

James Bernat has been a leading advocate of donation after brain death (DBD) (Bernat 2014) and donation after circulatory death (DCD) (Bernat et al. 2010), as well as an eminent scholar regarding their philosophical foundations. He points out that brain death is still widely misunderstood—the misunderstanding is that those who are brain dead are not really dead. According to a seminal survey, two-thirds of Americans believe that patients diagnosed as brain dead are not legally dead (Siminoff, Burant, and Youngner 2004). Bernat argues that the biophilosophical justification for DBD is incomplete and that a more firmly grounded justification for DBD will improve public understanding of what brain death means through education; the latter seems unlikely because widespread confusion and misunderstanding has persisted 30 years after adoption of the Uniform Determination of Death Act (UDDA) (UDDA 1981). A brain-dead donor’s beating heart, rhythmic respiration, warm skin, and urine flow from a Foley catheter simply do not appear to be “real death” to most families and health professionals.

Prevalence of Autism Spectrum Disorders among Children with Intellectual Disability.

BACKGROUND Response to stroke symptoms and the use of 911 can vary by race/ethnicity. The quickness with which a patient responds to such symptoms has implications for the outcome and treatment. We sought to examine a sample of patients receiving a Remote Evaluation of Acute isCHemic stroke (REACH) telestroke consult in South Carolina regarding their awareness and perception of stroke symptoms related to the use of 911 and to assess possible racial/ethnic disparities. METHODS As of September 2013, 2325 REACH telestroke consults were conducted in 13 centers throughout South Carolina. Telephone surveys assessing use of 911 were administered from March 2012-January 2013 among 197 patients receiving REACH consults. Univariate and multivariate logistic regression was performed to assess factors associated with use of 911. RESULTS Most participants (73%) were Caucasian (27% were African-American) and male (54%). The mean age was 66 ± 14.3 years. Factors associated with use of 911 included National Institutes of Health Stroke Scale scores >4 (odds ratio [OR], 5.4; 95% confidence interval [CI], 2.63-11.25), unknown insurance which includes self-pay or not charged (OR, 2.90; 95% CI, 1.15-7.28), and perception of stroke-like symptoms as an emergency (OR, 4.58; 95% CI, 1.65-12.67). African-Americans were significantly more likely than Caucasians to call 911 (62% vs. 43%, P = .02). CONCLUSIONS African-Americans used 911 at a significantly higher rate. Use of 911 may be related to access to transportation, lack of insurance, or proximity to the hospital although this information was not available. Interventions are needed to improve patient arrival times to telemedicine equipped emergency departments after stroke.

Antihypertensive Medication Persistence 1‐Year Post‐Stroke Hospitalization

ABSTRACT While elevated blood pressure has long been associated with cardiovascular and renal outcomes, the association of hypertension and increased stroke risks is perhaps the strongest and best recognized. Furthermore, the reduction of blood pressure with antihypertensive agents has been well documented with lower stroke risks. The specific recommendations for high blood pressure management for stroke prevention have been somewhat unclear due to the study design and the quality of the evidence based on clinical study results. Further complicating the assessment process is the consideration of stroke as a primary outcome of randomized control trials. This appraisal and review describes the assessment of the evidence and trial results for management of hypertension and stroke risk reduction with consideration of the impact of The Systolic Blood Pressure Intervention Trial (SPRINT). While evidence clearly identifies the benefit of intense hypertension treatment for the primary and secondary prevention of stroke, evidence gaps still remain.

Identification of ADHD in youth with epilepsy

Autism spectrum disorders (ASD) often co-occur with intellectual disability (ID) and are associated with poorer psychosocial and family-related outcomes than ID alone. The present study examined the prevalence, stability, and characteristics of ASD estimates in 2,208 children with ASD and ID identified through the South Carolina Autism and Developmental Disabilities Network. The prevalence of ASD in ID was 18.04%, relative to ASD rates of 0.60%-1.11% reported in the general South Carolina population. Compared to children with ASD alone, those with comorbid ID exhibited increased symptom severity and distinct DSM-IV-TR profiles. Further work is needed to determine whether current screening, diagnostic, and treatment practices adequately address the unique needs of children and families affected by comorbid ASD and ID diagnoses.