Malik M Adil

Diagnosis of Stroke by Emergency Medical Dispatchers and Its Impact on the Prehospital Care of Patients

BACKGROUND Emergency medical dispatchers represent the first line of communication with a patient, and their decision plays an important role in the prehospital care of stroke. We evaluated the rate and accuracy of stroke diagnosis by dispatchers and its influence in the prehospital care of potential stroke patients. METHODS We analyzed the 2009 National Emergency Medical Services Information System. Study population was based on the diagnosis of stroke made by emergency medical technicians (EMT). This was then divided in those coded as stroke/cerebrovascular accident versus others reported by dispatchers and compared with each other. RESULTS In all, 67,844 cases were identified as stroke by EMT, but transportation time was available for 52,282 cases that represented the final cohort. Cases identified as stroke by dispatchers were 27,566 (52.7%). When this group compared with stroke cases not identified by dispatchers, we found that the mean age was significantly higher (71.2 versus 68.6 years, P<.0001); advanced life support was dispatched more frequently (84% versus 72.8%, P<.0001), dispatchers offered help and instructions to the caller more frequently, and they arrived at a facility at a shorter time (41.8 versus 49.8 minutes, P<0001). Sensitivity and specificity for the diagnosis of stroke by dispatchers were 34.61 and 99.46, respectively. CONCLUSIONS Recognition of symptoms and diagnosis of a potential stroke by dispatchers positively affect the care of patients by decreasing the arrival time to a hospital and providing the highest level of prehospital care possible. Education is needed to increase dispatchers detection of stroke cases.

Rate of utilization and determinants of withdrawal of care in acute ischemic stroke treated with thrombolytics in USA

Background:Our current practices for utilization of thrombolytics are based on results of clinical trials with no or restricted use of “withdrawal of care” among treated patients. The increasing use of “withdrawal of care” in routine practice may lead to suboptimal outcomes among acute ischemic stroke patients. Methods:We determined the frequency of “withdrawal of care” and determined demographic and clinical characteristics, and in-hospital outcomes among thrombolytic-treated ischemic stroke patients stratified by use of “withdrawal of care” using National Inpatient Sample data files from 2002 to 2010. Results:“Withdrawal of care” during hospitalization was instituted in 4287 (3.3%) of the 130,437 acute ischemic stroke patients treated with thrombolytics. In the stepwise logistic regression analysis, women [odds ratio (OR) 1.2, 95% confidence interval (CI), (1.0–1.5)], presence of atrial fibrillation [OR 1.2, 95% CI, (1.0–1.5)], hemiplegia/hemiparesis [OR 1.4, 95% CI, (1.1–1.7)], aphasia [OR 1.2, 95% CI, (1.0–1.5)], and postthrombolytic intracerebral hemorrhage (OR 1.5, 95% CI, 1.1–1.8) were significant predictors of “withdrawal of care” among thrombolytic-treated ischemic stroke patient. Hospitals located in the west region [OR 1.7, 95% CI, (1.2–2.4)], and teaching hospitals [OR 1.4, 95% CI, (1.0–1.8)] were more likely to use withdrawal of care. In-hospital mortality (61% vs. 9.0%, P⩽0.0001) were higher among those with “withdrawal of care.” Conclusions:Several individual-related and institution-related factors were associated with the use of “withdrawal of care” among thrombolytic-treated ischemic stroke patients. The excessively high mortality and resource utilization mandates a more evidence based policy for “withdrawal of care” in these patients.

The effect of duty hour regulations on outcomes of neurological surgery in training hospitals in the United States: duty hour regulations and patient outcomes

OBJECT The effects of sleep deprivation on performance have been well documented and have led to changes in duty hour regulation. New York State implemented stricter duty hours in 1989 after sleep deprivation among residents was thought to have contributed to a patients death. The goal of this study was to determine if increased regulation of resident duty hours results in measurable changes in patient outcomes. METHODS Using the Nationwide Inpatient Sample (NIS), patients undergoing neurosurgical procedures at hospitals with neurosurgery training programs were identified and screened for in-hospital complications, in-hospital procedures, discharge disposition, and in-hospital mortality. Comparisons in the above outcomes were made between New York hospitals and non-New York hospitals before and after the Accreditation Council for Graduate Medical Education (ACGME) regulations were put into effect in 2003. RESULTS Analysis of discharge disposition demonstrated that 81.9% of patients in the New York group 2000-2002 were discharged to home compared with 84.1% in the non-New York group 2000-2002 (p = 0.6, adjusted multivariate analysis). In-hospital mortality did not significantly differ (p = 0.7). After the regulations were implemented, there was a nonsignificant decrease in patients discharged to home in the non-New York group: 84.1% of patients in the 2000-2002 group compared with 81.5% in the 2004-2006 group (p = 0.6). In-hospital mortality did not significantly change (p = 0.9). In New York there was no significant change in patient outcomes with the implementation of the regulations; 81.9% of patients in the 2000-2002 group were discharged to home compared with 78.0% in the 2004-2006 group (p = 0.3). In-hospital mortality did not significantly change (p = 0.4). After the regulations were in place, analysis of discharge disposition demonstrated that 81.5% of patients in the non-New York group 2004-2006 were discharged to home compared with 78.0% in the New York group 2004-2006 (p = 0.01). In-hospital mortality was not significantly different (p = 0.3). CONCLUSIONS Regulation of resident duty hours has not resulted in significant changes in outcomes among neurosurgical patients.

Thrombolysis for Ischemic Stroke Associated With Infective Endocarditis Results From the Nationwide Inpatient Sample

Background and Purpose— Cerebral ischemic events are highly prevalent and associated with high rates of death and disability in patients with infective endocarditis (IE). However, the role of thrombolysis in these patients remains unclear. We sought to determine the rates and outcomes of acute ischemic stroke patients with IE treated with intravenous thrombolysis (IVT). Methods— We determined the rates of post-thrombolytic intracerebral hemorrhage and favorable outcome among acute ischemic stroke patients with IE treated with IVT. Patients were identified using Nationwide Inpatient Sample data from 2002 to 2010. We compared the rates of various outcomes with ischemic stroke patients without IE treated with IVT. Results— There were 222 patients (mean age 59±18 years; 46% women) who were treated with IVT for acute ischemic stroke associated with IE and 134 048 patients (mean age 69±15 years; 49% women) who were treated for stroke without IE. The rate of post-thrombolytic intracerebral hemorrhage was significantly higher in patients with IE compared with those without IE (20% versus 6.5%; P=0.006). There was a significantly lower rate of favorable outcome in the IE group (10% versus 37%; P=0.01). Conclusions— High rates of post-thrombolytic intracerebral hemorrhage and low rates of favorable outcome mandate caution in using IVT in acute ischemic stroke patients with IE.

Outcomes of Thrombolytic Treatment for Acute Ischemic Stroke in Dialysis-Dependent Patients in the United States

OBJECTIVE To determine the outcomes of dialysis-dependent renal failure patients who had ischemic stroke and were treated with intravenous (IV) thrombolytics in the United States. METHODS We analyzed the data from Nationwide Inpatient Sample (2002-2009) for all thrombolytic-treated patients presenting with acute ischemic stroke with or without dialysis dependence. Patients were identified using the International Classification of Disease, Ninth Revision, Clinical Modification codes. Baseline characteristics, in-hospital complications including secondary intracerebral hemorrhage (ICH), sepsis, pneumonia, pulmonary embolism, deep venous thrombosis, urinary tract infections, and discharge outcomes (mortality, minimal disability, and moderate-to-severe disability) were compared between the groups. RESULTS Of the 82,142 patients with ischemic stroke who receive thrombolytic treatment, 1072 (1.3%) was dialysis dependent. The ICH rates did not differ significantly between patients with ischemic stroke with or without dialysis who received thrombolytics (5.2% versus 6.1%). The in-hospital mortality rate was higher in dialysis-dependent patients treated with thrombolytics (22% versus 11%, P≤.0001). After adjusting for age, sex, and comorbidities, dialysis dependence was associated with higher rates of in-hospital mortality in patients treated with thrombolytics (odds ratio, 1.92; 95% confidence interval, 1.33-2.78, P=.0005). CONCLUSIONS The 2-fold higher odds of in-hospital mortality associated with administration of IV thrombolytics in dialysis-dependent patients who present with acute ischemic stroke warrant a careful assessment of risk-benefit ratio in this population.

Acute Renal Failure Is Associated With Higher Death and Disability in Patients With Acute Ischemic Stroke Analysis of Nationwide Inpatient Sample

Background and Purpose— Acute renal failure (ARF) in setting of acute ischemic stroke (AIS) is associated with worse outcome. We sought to determine the prevalence of ARF and effect on outcomes of patients with AIS. Methods— Data from all patients admitted to US hospitals between 2002 and 2010 with a primary discharge diagnosis of ischemic stroke and secondary diagnosis of ARF were included. The effect of ARF on rates of intracerebral hemorrhage and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. Results— Of 7 068 334 patients with AIS, 372 223 (5.3%) had ARF during hospitalization. Dialysis was required in 2364 (0.6%) of 372 223 patients. Patients with AIS with ARF had higher rates of moderate to severe disability (41.3% versus 30%; P<0.0001), intracerebral hemorrhage (1.0% versus 0.5%; P<0.0001), and in-hospital mortality (8.4% versus 2.9%; P<0.0001) compared with those without ARF. After adjusting for confounding factors, patients with AIS with ARF had higher odds of moderate to severe disability (odds ratio, 1.3; 95% confidence interval, 1.3–1.4; P<0.0001), intracerebral hemorrhage (odds ratio, 1.4; 95% confidence interval, 1.3–1.6; P<0.0001), and death (odds ratio, 2.2; 95% confidence interval, 2.0–2.2; P<0.0001). Conclusions— ARF in patients with AIS is associated with significantly higher rates of moderate to severe disability at discharge and in-hospital mortality.

Factors Associated With Length of Hospitalization in Patients Admitted With Transient Ischemic Attack in United States

Background and Purpose— Approximately 70% of all patients presenting with transient ischemic attack are admitted to the hospital in United States. The duration and cost of hospitalization and associated factors are poorly understood. This article seeks to identify the proportion and determinants of prolonged hospitalization and to determine the impact on hospital charges using nationally representative data. Methods— We determined the national estimates of length of stay, mortality, and charges incurred in patients admitted with transient ischemic attack (diagnosis-related code 524 or 069) using Nationwide Inpatient Sample data from 2002 to 2010. Nationwide Inpatient Sample is the largest all-payer inpatient care database in the United States and contains data from ≈1000 hospitals, which is a 20% stratified sample of US community hospitals. All the variables pertaining to hospitalization were compared in 3 groups on the basis of length of hospital stay (⩽1, 2–6, and ≥7 days). Results— A total of 949 558 patients were admitted with the diagnosis of transient ischemic attack during the study period. The length of hospitalization was ⩽1, 2 to 6, and ≥7 days in 232 732 (24.4%), 662 909 (70%), and 53 917 (5.6%) patients, respectively. The mean hospitalization charges were

Incident Cancer in a Cohort of 3,247 Cancer Diagnosis Free Ischemic Stroke Patients

10 876,

Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial Results on the Performance of Carotid Artery Stent Placement and Carotid Endarterectomy in the United States.

17 187, and

Transient Ischemic Attack Requiring Hospitalization of Children in the United States Kids’ Inpatient Database 2003 to 2009

38 200 for patients hospitalized for ⩽1, 2 to 6, and ≥7 days, respectively. The use of thrombolytics (0.03%, 0.09%, and 0.1%; P<0.0001) for ischemic stroke was very low among the 3 strata defined by length of hospitalization. In the multivariate analysis, the following factors were associated with length of hospitalization of ≥2 days: age >65 years (odds ratio [OR], 1.5), women (OR, 1.2), admission to teaching hospitals (OR, 1.1), renal failure (OR, 1.7), hypertension (OR, 1.1), diabetes mellitus (OR, 1.2), chronic lung disease (OR, 1.4), congestive heart failure (OR, 1.4), atrial fibrillation (OR, 1.5), ischemic stroke occurrence (OR, 1.4), Medicare/Medicaid insurance (OR, 1.3), and hospital location in Northeast US region (OR, 1.5; all P values <0.025). Conclusions— Approximately 75% of patients admitted with transient ischemic attack stay in the hospital for ≥2 days, with the most important determinants being pre-existing medical comorbidities. Longer duration of hospital stay is associated with 2- to 5-fold greater hospitalization charges.