Melinda A. Smith

Stroke Among Patients With Dizziness, Vertigo, and Imbalance in the Emergency Department: A Population-Based Study

Background and Purpose— Dizziness, vertigo, and imbalance are common presenting symptoms in the emergency department. Stroke is a leading concern even when these symptoms occur in isolation. The objective of the present study was to determine the “real-world” proportion of stroke among patients presenting to the emergency department with these dizziness symptoms (DS). Methods— From a population-based study, patients >44 years of age presenting with DS to the emergency department, or directly admitted to the hospital, were identified. Demographics, the frequency of new cerebrovascular events, and the frequency of isolated DS (ie DS with no other stroke screening term or accompanying neurologic signs or symptoms) were assessed. Multivariable logistic regression was used to evaluate the association of age, gender, ethnicity, and isolated DS with stroke/transient ischemic attack (TIA). The association of the presenting symptoms with stroke/TIA was also assessed. Results— Stroke/TIA was diagnosed in 3.2% (53 of 1666) of all patients with DS. Only 0.7% (9 of 1297) of those with isolated DS had a stroke/TIA. Patients with stroke/TIA were slightly older than those without stroke/TIA (69.3±11.7 vs 65.3±12.9, P=0.02). Male gender was associated with stroke/TIA, whereas isolated DS was negatively associated with stroke/TIA. Patients with imbalance (dizziness as referent) were more likely to have stroke/TIA. Conclusions— The proportion of cerebrovascular events in patients presenting with dizziness, vertigo, or imbalance is very low. Isolated dizziness, vertigo, or imbalance strongly predicts a noncerebrovascular cause. The symptom of imbalance is a predictor of stroke/TIA.

On the production of neurologists in the United States : an update

Based primarily on a survey of all neurology residency training programs in the United States conducted in 1985–1986, the average annual production (incidence) of general neurologists for 1980–1986 was 363.6 and of child neurologists for 1982–1986,53.8. About ¼ of these general neurologists and ⅓ of child neurologists are women; about ¼ of either are foreign medical graduates, predominantly foreign-born. Data routinely published by the AMA well match the questionnaire information. First postgraduate year of training was in internal medicine for ⅔ of general neurologists. Board certifications have recently averaged 290.9 (general) and 37.1 (child) per annum. From life-table calculations, prevalence of general neurologists in 1990 is estimated at 7,500 fully-trained and 5,500 board-certified, and of child neurologists near 1,100 trained and over 600 certified. The number of neurologists is predicted to plateau near the year 2020 at some 13,700 trained, including 1,700 child neurologists, and 9,800 certified (1,100 child). The maximal prevalence rate for all neurologists will be 4.75 per 100,000 population in 2010, declining then to 4.42 by 2050; those rates provide shortfalls of 30% and 35%, respectively, compared with previously calculated needs for neurologists.

Early care limitations independently predict mortality after intracerebral hemorrhage

Objective: Intracerebral hemorrhage (ICH) is associated with a high early mortality rate. We examined the impact of early do not resuscitate (DNR) orders and other limitations in aggressive care on mortality after ICH in a community-based study. Methods: Cases of spontaneous ICH from 2000 to 2003 were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project, with deaths ascertained through 2005. Charts were reviewed for early (<24 hours from presentation) DNR orders, withdrawal of care, or deferral of other life sustaining interventions, analyzed together as combined DNR (C-DNR). Multivariable Cox-proportional hazards models were used to examine the association between short- and long-term all-cause mortality and early C-DNR, adjusted for demographics and established predictors of mortality after ICH. Results: Of 18,393 subjects screened for cerebrovascular disease, 270 non-traumatic ICH cases were included. Cumulative mortality risk was 0.43 at 30 days and 0.55 over the study course. Early C-DNR was noted in 34% of cases and was associated with a doubling in the hazard of death both at 30 days (hazard ratio [HR] 2.17, 95% CI 1.38, 3.41) and at end of follow-up (HR 1.92, 95% CI 1.29, 2.87) despite adjustment for age, gender, ethnicity, Glasgow Coma Scale, ICH volume, intraventricular hemorrhage, and infratentorial hemorrhage. Conclusions: Early care limitations are independently associated with both short- and long-term all-cause mortality after intracerebral hemorrhage (ICH) despite adjustment for expected predictors of ICH mortality. Physicians should carefully consider the effect of early limitations in aggressive care to avoid limiting care for patients who may survive their acute illness.

Projected costs of ischemic stroke in the United States

Background: There are barriers to acute stroke care in minority groups as well as a higher incidence of ischemic stroke when compared with non-Hispanic whites. Objective: To estimate the future economic burden of stroke in non-Hispanic whites, Hispanics, and African Americans in the United States from 2005 to 2050. Methods: We used U.S. Census estimates of the race–ethnic group populations age 45 years and older. We obtained stroke epidemiology and service utilization data from the Northern Manhattan Stroke Study and the Brain Attack Surveillance in Corpus Christi project and other published data. We estimated costs directly from Medicare reimbursement or from studies that used Medicare reimbursement. Direct and indirect costs considered included ambulance services, initial hospitalization, rehabilitation, nursing home costs, outpatient clinic visits, drugs, informal caregiving, and potential lost earnings. Results: The total cost of stroke from 2005 to 2050, in 2005 dollars, is projected to be

Stroke Risk After Transient Ischemic Attack in a Population-Based Setting

1.52 trillion for non-Hispanic whites,

Ambient air pollution and risk for ischemic stroke and transient ischemic attack

313 billion for Hispanics, and

Access to Care, Acculturation, and Risk Factors for Stroke in Mexican Americans The Brain Attack Surveillance in Corpus Christi (BASIC) Project

379 billion for African Americans. The per capita cost of stroke estimates are highest in African Americans (

Gender comparisons of diagnostic evaluation for ischemic stroke patients

25,782), followed by Hispanics (

A population-based study of acute stroke and TIA diagnosis

17,201), and non-Hispanic whites (

Persistent ischemic stroke disparities despite declining incidence in Mexican Americans

15,597). Loss of earnings is expected to be the highest cost contributor in each race–ethnic group. Conclusions: The economic burden of stroke in African Americans and Hispanics will be enormous over the next several decades. Further efforts to improve stroke prevention and treatment in these high stroke risk groups are necessary.