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Background and Purpose— Stroke preparedness interventions are limited by the lack of psychometrically sound intermediate end points. We sought to develop and assess the reliability and validity of the video-Stroke Action Test (video-STAT) an English and a Spanish video-based test to assess people’s ability to recognize and react to stroke signs. Methods— Video-STAT development and testing was divided into 4 phases: (1) video development and community-generated response options, (2) pilot testing in community health centers, (3) administration in a national sample, bilingual sample, and neurologist sample, and (4) administration before and after a stroke preparedness intervention. Results— The final version of the video-STAT included 8 videos: 4 acute stroke/emergency, 2 prior stroke/nonemergency, 1 nonstroke/emergency, and 1 nonstroke/nonemergency. Acute stroke recognition and action response were queried after each vignette. Video-STAT scoring was based on the acute stroke vignettes only (score range 0–12 best). The national sample consisted of 598 participants, 438 who took the video-STAT in English and 160 who took the video-STAT in Spanish. There was adequate internal consistency (Cronbach α=0.72). The average video-STAT score was 5.6 (SD=3.6), whereas the average neurologist score was 11.4 (SD=1.3). There was no difference in video-STAT scores between the 116 bilingual video-STAT participants who took the video-STAT in English or Spanish. Compared with baseline scores, the video-STAT scores increased after a stroke preparedness intervention (6.2 versus 8.9, P Conclusions— The video-STAT yields reliable scores that seem to be valid measures of stroke preparedness.

Background and Purpose— Do-not-resuscitate (DNR) orders are common after stroke, though there are limited data on trends over time. We investigated time trends in DNR orders in a community with a large minority population. Methods— Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the BASIC study (Brain Attack Surveillance in Corpus Christi) from June 2007 through October 2016. Cox proportional hazards models were used to assess time to DNR orders, with an interaction term added to allow separate hazard ratios for early (≤24 hours) and late (>24 hours) DNR. Stroke type–specific calendar trends were assessed with an interaction term between calendar year (linear) and stroke type. Results— Two thousand six hundred seventy-two cases were included (ICH, 14%). Mean age was 69, 50% were female, and race-ethnicity was Mexican American (58%), non-Hispanic white (37%), and African American (5%). Overall, 16% had a DNR order during the hospitalization. For ICH, DNR orders (early and late) were stable over the study period. However, early DNR orders became more common over time after ischemic stroke (hazard ratio for 2016 versus 2007: 1.89; 95% CI, 1.06–3.39), with no change over time for late DNR orders after ischemic stroke. Mexican Americans (hazard ratio, 0.65; 95% CI, 0.50–0.86) and African Americans (hazard ratio, 0.17; 95% CI, 0.04–0.71) were less likely than non-Hispanic whites to have early DNR orders, though there were no race-ethnic differences in late DNR orders. There was no change in race-ethnic difference in DNR orders over the time of the study (interaction P >0.60). Conclusions— Despite revised national guidelines cautioning against early DNR orders in ICH, presence of DNR orders after ICH was stable between 2007 and 2016, with only slight increases in early DNR orders after ischemic stroke. Mexican Americans and African Americans remain less likely than non-Hispanic whites to have early DNR orders after stroke.

Introduction: Multiple comorbid conditions (MCC) explain variation in stroke outcomes beyond the damage caused by the stroke. Mexican Americans (MAs) and non-Hispanic Whites (NHWs) may have a different spectrum and severity of MCC, which may contribute to ethnic differences in stroke outcomes. We sought to determine the clustering of MCC in ischemic stroke patients as well as ethnic differences. Methods: MA and NHWs with ischemic stroke (2008-2017) from the Brain Attack Surveillance in Corpus Christi Project were studied. Twenty-two prestroke comorbidities (prevalence >1%) were identified using ICD codes and medical records from acute hospitalizations. Latent class analysis was used to identify comorbidity clusters (class). Multinomial logistic regression was used to assess age-adjusted ethnic differences in class membership. Results: Of 1,670 patients, 49% were male, 68% were MA, mean age was 69 (SD=13). MAs were younger, more likely to be obese, and have hypertension, diabetes, and renal and liver failure, but less likely to have arrhythmia and chronic pulmonary disease. Three latent classes were identified (Figure). Class 1 had a high prevalence of uncomplicated hypertension and diabetes but low prevalence of other comorbidities. Class 2 and 3 had similarly higher prevalence for most comorbidities, except that the prevalence of renal failure, and complicated hypertension and diabetes in Class 2 and arrhythmia in Class 3 were relatively higher. Compared with NHWs, MAs were more likely to be in Class 1 (OR 1.72, 95%CI: 1.15-2.56) and Class 2 (OR 2.18, 95%CI: 1.63-3.10) versus Class 3. Conclusion: Distinct MCC clusters, patterned by ethnicity, were identified. Efforts to target specific minority populations to reduce stroke disparities may benefit from addressing the ethnic-specific MCC clusters.

Introduction: Post-stroke sleep apnea (SA) affects the majority of stroke patients and is associated with poorer stroke outcomes. To select appropriate endpoints for a future SA treatment trial in stroke patients, we assessed the predictive ability between a variety of important outcome measures and SA severity, as measured by the apnea-hypopnea index (AHI), within a population-based stroke study. Methods: Ischemic stroke patients enrolled in the Brain Attack Surveillance in Corpus Christi (BASIC) project were offered SA screening shortly after stroke with a portable sleep apnea test (ApneaLink Plus). Apnea-hypopnea index (AHI) was calculated as the sum of apneas and hypopneas during the nocturnal recording. Subjects had baseline information collected from chart abstraction and interview, and had 3-month outcomes assessed in-person including an activities of daily living (ADL)/instrumental ADL(IADL) scale, NIHSS, Modified Mini-Mental State exam (3MS), and 12-item Stroke-specific Quality of Life scale (SSQOL). Predictive R 2 (a measure of how well models predict responses for new observations) from linear regression models was used to compare predictive ability of models with and without AHI, adjusted for significant predictors of outcome. Results: Within 455 subjects, the predictive R 2 was 31.7% for ADL/IADL, 23.2% for SSQOL, 25.0% for the 3MS, and 11.7% for NIHSS in the model without AHI. When AHI was included in the models, the predictive R 2 increased to 32.8% for ADL/IADL and increased to 11.9% for NIHSS; however, the predictive R 2 decreased by 0.1% for SSQOL and decreased by 0.2% for 3MS. Conclusions: In future trials that test SA treatment’s effect on stroke outcomes at 3 months, improvement is most likely to be observed from a functional outcome, such as that measured by the ADL/IADL scale.

Introduction: Obstructive sleep apnea (OSA) is highly prevalent in stroke survivors. Untreated OSA is associated with an increased risk of adverse cardiovascular outcomes and OSA treatment may improve neurological recovery in stroke survivors, yet OSA in stroke patients remains poorly characterized. To our knowledge, this is the first study aiming to identify OSA phenotypes in stroke survivors. Methods: Patients (n=451) with ischemic strokes and OSA (apnea-hypopnea index (AHI) ≥ 10 using a cardiopulmonary screening device (ApneaLink Plus)) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project. Latent class analysis was performed based on the following variables: age, sex, race/ethnicity, AHI, pre-stroke snoring, pre-stroke tiredness/fatigue, pre-stroke sleep duration, prior stroke history, initial NIHSS, BMI, hypertension, diabetes, atrial fibrillation, coronary artery disease, and congestive heart failure. Results: A model with 3 phenotype clusters provided the best fit. Cluster 1 (n=55, 12%) was defined by higher NIHSS scores and high prevalence of snoring. Patients in cluster 2 (n=253, 56%) were younger and had relatively low NIHSS scores. Cluster 3 (n=143, 32%) included patients with severe OSA and higher prevalence of medical comorbidities. Conclusion: Ischemic stroke survivors with OSA can be categorized into three clinical phenotype clusters characterized by differences in stroke severity, OSA severity, patient age and medical comorbidities. This highlights the heterogeneity of post-stroke OSA. Awareness of the different faces of OSA in patients with ischemic stroke may help clinicians identify OSA in their patients, and informs research concerning the pathophysiology and prognostication of post-stroke OSA.

Background: It is unclear whether blood pressure is associated with cognitive function after stroke. Methods: Cross-sectional analysis of prospectively obtained data of 432 subjects (mean age, 66; 46% female) with stroke (92% ischemic; median NIH stroke score, 3 [IQR, 2-6]) aged 45 or older without dementia from the population-based Brain Attack Surveillance in Corpus Christi project in 2011-2013. We examined associations between systolic and diastolic blood pressure (BP) and cognitive performance each measured 90 days after stroke. BP measured 3 times using standard protocol and averaged. Cognition was assessed using 4 tests: Modified Mini-Mental Status Examination (3MSE), animal fluency test, Trails A and B. Linear or tobit regression adjusted associations for age, education, and race/ethnicity as well as variables that were significantly associated with both BP and cognition. Results: Systolic BP was not significantly associated with cognitive performance (Model 1) unless diastolic BP was included in the model (Model 3)(Table). Both higher systolic BP and lower diastolic BP each were significantly associated with worse cognitive performance for all 4 tests (Model 3). Diastolic BP remained significantly associated with cognitive performance after adjusting for age, education, and race/ethnicity but systolic BP did not (Model 4). With further adjustment for clinical factors, diastolic BP did not remain independently associated with cognition (Model 5). Lower cognitive performance was significantly associated with older age, less education, Mexican American ethnicity, diabetes, higher stroke severity, more depressive symptoms, and lower BMI. Conclusion: Patients with higher systolic BP and lower diastolic BP are more likely to have worse cognitive performance after stroke but sociodemographic and clinical factors may explain these associations.

Introduction: Advance directives are often promoted as a way to ensure that patient wishes are followed; however, the impact of advance directives on actual care is controversial, and little is known about the impact on in-hospital stroke treatment. We explored the association between pre-stroke advance directives and transition to comfort measures only (CMO) during stroke hospitalization among patients with surrogate-decision makers. Methods: Ischemic stroke and intracerebral hemorrhage (ICH) stroke cases from the Brain Attack Surveillance in Corpus Christi (BASIC) project and their surrogate decision makers from the Outcomes Among Surrogate Decision Makers in Stroke (OASIS) were enrolled. Patient records were abstracted for time to CMO. Surrogates were asked about patient pre-stroke advance directives (advance directive, living will, or durable power of attorney for health care). Cox-proportional-hazards models assessed the relationship between advance directives and time to CMO (censored at death, discharge, or 30 days). Based on the available sample size, adjustment factors were pre-specified and included age, NIHSS, and stroke type. Results: 144 stroke patients were included (ischemic 76%; ICH 24%; age ≥75 45%; female 52%; Mexican American (MA) 59%, NIHSS mean (SD) 13(11)). 22% of cases transitioned to CMO during the hospitalization (median time to CMO 3 days); 39% of patients had an advance directive. Younger individuals, MAs and men were less likely to have advance directives. After adjusting for stroke type, age, and NIHSS, advance directives were not associated with time to CMO (Table). Conclusions: Fewer than half of stroke patients had advance directives; however, the presence of advance directives did not appear to impact in-hospital transitions to CMO, suggesting limited utility of advance directives. Further study in larger samples is needed to determine the best way to ensure patient wishes are followed after stroke.

Background and Purpose— We examined the contribution of stroke risk factors to midlife (age 45–59 years) Mexican American and non-Hispanic White ischemic stroke (IS) rate disparities from 2000 to 2010. Methods— Incident IS cases (n=707) and risk factors were identified from the Brain Attack Surveillance in Corpus Christi Project, Nueces County, TX (2000–2010). US Census data (2000–2010) were used to estimate the population at-risk for IS, and the Behavioral Risk Factor Surveillance System (2000–2010) was used to estimate risk factor prevalence in the stroke-free population. Poisson regression models combined IS counts (numerator) and population at-risk counts (denominator) classified by ethnicity and risk factor status to estimate unadjusted and risk factor–adjusted associations between ethnicity and IS rates. Separate models were run for each risk factor and extended to include an interaction term between ethnicity and risk factor. Results— The crude rate ratio (RR) for ethnicity (Mexican American versus non-Hispanic White) was 2.01 (95% confidence interval [CI], 1.71–2.36) and was attenuated in models that adjusted for diabetes mellitus (RR: 1.50; 95% CI, 1.26–1.78) and hypertension (RR: 1.84; 95% CI, 1.50–2.26). In addition, diabetes mellitus had a stronger association with IS rates among Mexican Americans (RR: 6.42; 95% CI, 5.31–7.76) compared with non-Hispanic Whites (RR: 4.07; 95% CI, 3.68–4.51). Conclusions— The higher prevalence of diabetes mellitus and hypertension and stronger association of diabetes mellitus with IS among midlife Mexican Americans likely contribute to persistent midlife ethnic stroke disparities.

Background and Purpose— The Stroke Health and Risk Education Project was a cluster-randomized, faith-based, culturally sensitive, theory-based multicomponent behavioral intervention trial to reduce key stroke risk factor behaviors in Hispanics/Latinos and European Americans. Methods— Ten Catholic churches were randomized to intervention or control group. The intervention group received a 1-year multicomponent intervention (with poor adherence) that included self-help materials, tailored newsletters, and motivational interviewing counseling calls. Multilevel modeling, accounting for clustering within subject pairs and parishes, was used to test treatment differences in the average change since baseline (ascertained at 6 and 12 months) in dietary sodium, fruit and vegetable intake, and physical activity, measured using standardized questionnaires. A priori, the trial was considered successful if any one of the 3 outcomes was significant at the 0.05/3 level. Results— Of 801 subjects who consented, 760 completed baseline data assessments, and of these, 86% completed at least one outcome assessment. The median age was 53 years; 84% subjects were Hispanic/Latino; and 64% subjects were women. The intervention group had a greater increase in fruit and vegetable intake than the control group (0.25 cups per day [95% confidence interval: 0.08, 0.42], P =0.002), a greater decrease in sodium intake (−123.17 mg/d [−194.76, −51.59], P =0.04), but no difference in change in moderate- or greater-intensity physical activity (−27 metabolic equivalent–minutes per week [−526, 471], P =0.56). Conclusions— This multicomponent behavioral intervention targeting stroke risk factors in predominantly Hispanics/Latinos was effective in increasing fruit and vegetable intake, reaching its primary end point. The intervention also seemed to lower sodium intake. Church-based health promotions can be successful in primary stroke prevention efforts. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01378780.

Introduction: Do-not-resuscitate (DNR) orders are common after stroke and have recently received increased attention. However, there has been little study of trends in DNR status. We investigated time trends in DNR use after stroke in a community with a large minority population. Methods: Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) study from June 2007 through October 2016. Demographics, clinical characteristics, and DNR status were collected from medical charts by trained abstractors. Race-ethnic differences in DNR orders were assessed with logistic regression models and adjusted for potential confounders. Time trends were assessed with a linear term for time (years) and further explored with interaction terms between time and race-ethnicity or time and stroke type. Results: After excluding cases with missing DNR status and recurrent events, 2,860 cases were available. Mean age was 69 (range 45-102), 50% were female, and race-ethnicity was Mexican American (MA, 58%), non-Hispanic White (NHW, 37%), and African American (AA, 5%). Overall, 17% had a DNR order during the hospitalization. Time trends in DNR orders differed for IS and ICH (interaction p=0.04, see Table). However, change in DNR status over time within each stroke type was modest (non-significant increase over time for IS and non-significant decrease for ICH). MAs were less likely than NHWs to have DNR orders (p=0.007) There was no evidence of interaction between time and race-ethnicity (p=0.57), suggesting that the race-ethnic disparity is stable over time. Conclusions: Use of DNR orders after stroke has been largely stable over the past 10 years, with only slight differences in time trends comparing IS to ICH. Mexican Americans remain less likely than NHWs to use DNR orders after stroke with no evidence of change over time.

Objective: Post-stroke sleep-disordered breathing (SDB) is prevalent and may be linked to poor stroke recovery but population-based studies in diverse populations are lacking. Our objective was to examine the association between SDB measured soon after stroke and stroke outcomes and to determine whether associations vary by ethnicity in the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Methods: Ischemic stroke (IS) patients were offered SDB screening with the ApneaLink Plus™; SDB was defined as apnea-hypopnea index (AHI) ≥ 10 events per hour. Patient data were collected from interviews and medical records. Functional, neurologic, cognitive, and quality of life (QOL) outcomes were ascertained at 90-days by patient or proxy interviews. Regression models were used to examine associations between SDB and outcomes adjusted for confounders. Interaction terms were used to investigate differences by ethnicity. Results: 232 NHW and 393 MA IS patients had a successful SDB screening and completed a 90-day interview. Median age was 65 years (IQR:58-75) among MAs and 67 (IQR:58-77) among NHWs. Post-stroke SDB was 68.7% in MAs [median AHI: 16 (IQR:8-26)] and 52.6% in NHWs [median AHI: 10 (IQR:6-23)]. Patients with SDB were more likely to be MA and to have diabetes, hypertension, and higher BMI but less likely to smoke than those without SDB. SDB was associated with worse functional, neurologic, cognitive, and QOL outcomes in MAs but not NHWs (Table). Conclusions: SDB is associated with worse stroke outcomes in MAs but not NHWs, the reasons for which should be explored. SDB treatment in MAs may improve outcomes in this subgroup and lessen ethnic stroke outcome disparities.

Introduction: Overall ischemic stroke (IS) incidence has declined in the US, but has remained stable among midlife (age 45-59) adults and is higher in midlife Mexican Americans (MAs). We examined the contribution of stroke risk factors to ethnic differences in IS rates among midlife MAs and non-Hispanic Whites (NHWs) in a population-based study. Methods: Incident IS (N=823) counts and corresponding risk factors were identified from the BASIC Project, Nueces County, Texas (2000-2010). US Census data (2000) for Nueces County was used to estimate the population at-risk for stroke, and the Texas Behavioral Risk Factor Surveillance System for Public Health Region 11(2000-2010) was used to estimate prevalence of risk factors in the stroke free population. Poisson regressions were run combining stroke counts (numerator) and population at-risk counts (denominator) classified by ethnicity and risk factor status to estimate unadjusted and risk factor adjusted associations between ethnicity and IS rates. Separate models were run for each risk factor (diabetes, hypertension, coronary heart disease, high cholesterol, education < high school, no health insurance, current smoking, BMI>30), and extended to include an interaction term between ethnicity and risk factor. Results: The crude ethnic IS rate ratio (RR) comparing MAs with NHWs was 2.13 (95% CI: 1.84-2.47). The ethnic RR was lower in models that adjusted for diabetes (RR:1.54; 95% CI: 1.31-1.78), hypertension (RR: 1.92; 95% CI: 1.65-2.22), and education < high school (RR: 2.02; 95% CI: 1.72-2.38) compared to the crude association. Ethnicity significantly modified associations between diabetes, smoking, health insurance, education and IS rates. Associations between diabetes and IS rates was greater among MAs (RR: 6.82, 95% CI: 5.76-8.07) compared with NHWs (RR: 4.40, 95% CI: 3.33-5.81), while smoking associations were greater in NHWs (MA RR: 2.61, 95% CI: 2.20-3.10; NHW RR: 3.49, 95% CI: 2.73-4.46). Socioeconomic variables increased IS risk in NHWs but were insignificant or protective in MAs. Conclusion: Traditional stroke risk factors may contribute to midlife ethnic stroke disparities; particularly diabetes, given its high prevalence and stronger association with IS among midlife MAs as compared with NHWs.

Background: Race/ethnic disparities in stroke recurrence have persisted in the last decade in the USA. These disparities are often attributed to ethnic differences in risk factor prevalence and socioeconomic status. Methods: Incident ischemic stroke (IS) cases were ascertained in the Brain Attack Surveillance in Corpus Christi (BASIC) study, in Texas, USA in 2000-2011. Cases validated by stroke physicians were followed until death or a maximum of 5 years to determine 5-year cumulative stroke recurrence risk. Multivariable regression analyses and effect decomposition analyses (EDA) were used to examine the degree to which ethnic disparities are explained by education and biological risk factors. Results: There were 3,184 incident IS cases and 340 recurrent strokes (see Table). The ethnic difference in 5-year recurrence rate was 4.4% (p=0.004) greater in Mexican Americans (MA) than non-Hispanic whites (NHW). The age- and sex-adjusted hazard ratio (HR) of 1.43 (95%CI: 1.13, 1.79) comparing MA to NHW was attenuated after adjustment for education (HR=1.35, 95%CI: 0.91, 2.00), and further adjustment for biological factors (HR=1.28, 95%CI: 0.85, 1.92). EDA revealed that 57% of the recurrence risk disparity was due to differential associations (HR) between observed risk factors and recurrence (see Table). The remaining 43% was due to ethnic differences in risk factor prevalence. Conclusions: Ethnic differences in the strength of the associations between risk factors and recurrence, most notably education, diabetes, atrial fibrillation and hypertension explained 57% of the recurrence risk disparity. Further investigation of why some risk factors are more strongly associated with stroke recurrence in one ethnic group compared with others could yield valuable information on ethnic-specific stroke pathogenesis and secondary prevention strategies.

Background: We evaluated 3-month neurologic, functional, cognitive, and quality of life (QOL) outcomes in intracerebral hemorrhage (ICH) overall, and by sex and ethnicity in a population-based community study. Methods: Spontaneous ICH patients were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project from November 2008 to December 2013. Demographics and Glasgow Coma Scale were abstracted from medical records. Outcomes assessed included neurologic (National Institute of Health Stroke Scale (NIHSS): range, 0-42), functional (activities of daily living/instrumental activities of daily living: range 1-4, higher worse), cognitive (Modified Mini-Mental State Examination (mMMSE): range, 0-100), and QOL (Short-form Stroke Specific QOL scale: range, 0-5, higher better). Ethnic and sex differences were assessed with Tobit regression adjusted for age, sex or ethnicity, and presenting Glasgow Coma Scale. Results: A total of 245 patients completed baseline interviews, with 103 (42%) dying prior to follow-up, leaving 142 eligible for outcome assessment. 3-month follow up was completed on 100 (neurologic), 107 (functional), 79 (cognitive), and 83 (QOL) participants. Median age was 66 (interquartile range (IQR), 58.0-77.0). The overall median 3-month NIHSS was 2.0 (IQR, 1.0-6.0), with other baseline characteristics and outcomes shown in Table 1. Cognitive outcomes were worse in Mexican Americans (MA) compared to non-Hispanic Whites (NHW) after multivariable adjustment (MA scoring 13.3 mMMSE points lower than NHW (95% CI: 5.8, 20.7; p=.0005)). There was no difference by sex or ethnicity in neurological, functional, or QOL outcomes either before or after adjustment. Conclusions: In this population-based study, ICH survivors have remarkably favorable neurologic, functional, cognitive and QOL outcomes. There is an important disparity for worse cognitive outcome in MAs compared with NHWs.

Background and Purpose— Mexican Americans (MAs) were previously found to have lower mortality after ischemic stroke than non-Hispanic whites. We studied mortality trends in a population-based design. Methods— Active and passive surveillance were used to find all ischemic stroke cases from January 2000 to December 2011 in Nueces County, TX. Deaths were ascertained from the Texas Department of Health through December 31, 2012. Cumulative 30-day and 1-year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2011 and to calculate projected ethnic differences. Results— There were 1974 ischemic strokes among non-Hispanic whites and 2439 among MAs. Between 2000 and 2011, model estimated mortality declined among non-Hispanic whites at 30 days (7.6% to 5.6%; P =0.24) and 1 year (20.8% to 15.5%; P =0.02). Among MAs, 30-day model estimated mortality remained stagnant at 5.1% to 5.2% ( P =0.92), and a slight decline from 17.4% to 15.3% was observed for 1-year mortality ( P =0.26). Although ethnic differences in 30-day ( P =0.01) and 1-year ( P =0.06) mortality were apparent in 2000, they were not so in 2011 (30-day mortality, P =0.63; 1-year mortality, P =0.92). Conclusions— Overall, mortality after ischemic stroke has declined in the past decade, although significant declines were only observed for non-Hispanic whites and not MAs at 1 year. The survival advantage previously documented among MAs vanished by 2011. Renewed stroke prevention and treatment efforts for MAs are needed.

Background and Purpose— Our objective was to compare neurological, functional, and cognitive stroke outcomes in Mexican Americans (MAs) and non-Hispanic whites using data from a population-based study. Methods— Ischemic strokes (2008–2012) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from patient or proxy interviews (conducted at baseline and 90 days poststroke) and medical records. Ethnic differences in neurological (National Institutes of Health Stroke Scale: range, 0–44; higher scores worse), functional (activities of daily living/instrumental activities of daily living score: range, 1–4; higher scores worse), and cognitive (Modified Mini-Mental State Examination: range, 0–100; lower scores worse) outcomes were assessed with Tobit or linear regression adjusted for demographics and clinical factors. Results— A total of 513, 510, and 415 subjects had complete data for neurological, functional, and cognitive outcomes and covariates, respectively. Median age was 66 (interquartile range, 57–78); 64% were MAs. In MAs, median National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living, and Modified Mini-Mental State Examination score were 3 (interquartile range, 1–6), 2.5 (interquartile range, 1.6–3.5), and 88 (interquartile range, 76–94), respectively. MAs scored 48% worse (95% CI, 23%–78%) on National Institutes of Health Stroke Scale, 0.36 points worse (95% CI, 0.16–0.57) on activities of daily living/instrumental activities of daily living score, and 3.39 points worse (95% CI, 0.35–6.43) on Modified Mini-Mental State Examination than non-Hispanic whites after multivariable adjustment. Conclusions— MAs scored worse than non-Hispanic whites on all outcomes after adjustment for confounding factors; differences were only partially explained by ethnic differences in survival. These findings in combination with the increased stroke risk in MAs suggest that the public health burden of stroke in this growing population is substantial.

Background and Objectives: High blood pressure (BP) is a major modifiable cause of recurrent stroke. The prevalence of uncontrolled BP 90 days after stroke in contemporary populations of unselected stroke patients is unclear. We measured the prevalence and predictors of uncontrolled BP 90 days after stroke in a population-based stroke surveillance project. Methods: Prospective cohort study of 214 Mexican American or non-Hispanic white adults aged ≥45 years with ischemic or hemorrhagic stroke and completed outcome assessments 90 day after stroke in the Brain Attack Surveillance in Corpus Christi (BASIC) project from March 2011 through June 2012. Trained personnel conducted in-home examinations following a standardized protocol to measure BP 90 days after stroke using an automated arm monitor (OmROn model 700 series). BP was measured in triplicate and the third BP reading was used. BP control was defined as BP Results: Median age was 66 years (interquartile range [IQR], 58-77 years), and 93% of strokes were ischemic. Median systolic BP was 128.5 mm Hg (IQR, 114-145) and diastolic BP was 76 mm Hg (IQR, 68 to 84). Overall, BP was uncontrolled in 35.1% (95% CI, 29.9% to 41.7%) of stroke survivors 90 days after stroke, and this did not differ by ethnicity (Mexican American, 34.3% [95% CI, 26.8% to 42.7%] vs. non-Hispanic white, 36.3%; [95% CI, 26.6% to 47.2%]; Wald P=0.58). Uncontrolled BP 90 days after stroke was more likely in stroke survivors with older age (adjusted odds ratio [aOR], 1.03 per 1 year increase; 95% CI, 1.00 to 1.06; P=0.03), no health insurance (aOR, 3.08; 95% CI, 1.19 to 7.96; P=0.02, and hypertension (aOR, 2.24; 95% CI, 0.96 to 5.26; P=0.06). Conclusion: More than one third of stroke survivors has uncontrolled BP 90 days after stroke in this population-based study. Interventions designed to improve BP control and targeting older and uninsured stroke survivors are needed.

Background and Purpose— We sought to describe the association of spirituality, optimism, fatalism, and depressive symptoms with initial stroke severity, stroke recurrence, and poststroke mortality. Methods— Stroke cases from June 2004 to December 2008 were ascertained in Nueces County, TX. Patients without aphasia were queried on their recall of depressive symptoms, fatalism, optimism, and nonorganizational spirituality before stroke using validated scales. The association between scales and stroke outcomes was studied using multiple linear regression with log-transformed National Institutes of Health Stroke Scale and Cox proportional hazards regression for recurrence and mortality. Results— Six hundred sixty-nine patients participated; 48.7% were women. In fully adjusted models, an increase in fatalism from the first to third quartile was associated with all-cause mortality (hazard ratio, 1.41; 95% CI, 1.06–1.88) and marginally associated with risk of recurrence (hazard ratio, 1.35; 95% CI, 0.97–1.88), but not stroke severity. Similarly, an increase in depressive symptoms was associated with increased mortality (hazard ratio, 1.32; 95% CI, 1.02–1.72), marginally associated with stroke recurrence (HR, 1.22; 95% CI, 0.93–1.62), and with a 9.0% increase in stroke severity (95% CI, 0.01–18.0). Depressive symptoms altered the fatalism–mortality association such that the association of fatalism and mortality was more pronounced for patients reporting no depressive symptoms. Neither spirituality nor optimism conferred a significant effect on stroke severity, recurrence, or mortality. Conclusions— Among patients who have already had a stroke, self-described prestroke depressive symptoms and fatalism, but not optimism or spirituality, are associated with increased risk of stroke recurrence and mortality. Unconventional risk factors may explain some of the variability in stroke outcomes observed in populations and may be novel targets for intervention.

Background and Purpose— Few patients arrive early enough at hospitals to be eligible for emergent stroke treatment. There may be barriers specific to underserved, urban populations that need to be identified before effective educational interventions to reduce delay times can be developed. Methods— A survey of respondents' likely action in a hypothetical stroke situation was given to 253 community volunteers in the catchment areas of a large urban community hospital. Concurrently, 100 structured interviews were conducted in the same hospital with patients with acute stroke or a proxy. Results— In this predominantly urban, black population, if faced with a hypothetical stroke, 89% of community volunteers surveyed said they would call 911 first, and few felt any of the suggested potential barriers applied to them. However, only 12% of patients with stroke interviewed actually called 911 first (OR, 63.9; 95% CI, 29.5 to 138.2). Instead, 75% called a relative/friend. Eighty-nine percent of patients with stroke reported significant delay in seeking medical attention, and almost half said the reason for the delay was thinking the symptoms were not serious and/or they would self-resolve. For those arriving by ambulance, only 25% did so because they thought it would be faster, whereas 35% cited having no other transportation options. Conclusions— In this predominantly black urban population, although 89% of community volunteers report the intent of calling 911 during a stroke, only 12% of actual patients with stroke did so. Further research is needed to determine and conquer the barriers between behavioral intent and actual behavior to call 911 for witnessed stroke.

Background and Purpose— The purpose of this study was to evaluate stroke patient–proxy agreement with respect to social determinants of health, including depression, optimism, and spirituality, and to explore approaches to minimize proxy-introduced bias. Methods— Stroke patient–proxy pairs from the Brain Attack Surveillance in Corpus Christi Project were interviewed (n=34). Evaluation of agreement between patient–proxy pairs included calculation of intraclass correlation coefficients, linear regression models ( ProxyResponse =α 0 +α 1 PatientResponse +δ, where α 0 =0 and α 1 =1 denotes no bias) and κ statistics. Bias introduced by proxies was quantified with simulation studies. In the simulated data, we applied 4 approaches to estimate regression coefficients of stroke outcome social determinants of health associations when only proxy data were available for some patients: (1) substituting proxy responses in place of patient responses; (2) including an indicator variable for proxy use; (3) using regression calibration with external validation; and (4) internal validation. Results— Agreement was fair for depression (intraclass correlation coefficient, 0.41) and optimism (intraclass correlation coefficient, 0.48) and moderate for spirituality (κ, 0.48 to 0.53). Responses of proxies were a biased measure of the patients’ responses for depression, with α 0 =4.88 (CI, 2.24 to 7.52) and α 1 =0.39 (CI, 0.09 to 0.69), and for optimism, with α 0 =3.82 (CI, −1.04 to 8.69) and α 1 =0.81 (CI, 0.41 to 1.22). Regression calibration with internal validation was the most accurate method to correct for proxy-induced bias. Conclusion— Fair/moderate patient–proxy agreement was observed for social determinants of health. Stroke researchers who plan to study social determinants of health may consider performing validation studies so corrections for proxy use can be made.

Background and Purpose— Currently, a major focus on expanding acute ischemic stroke treatment opportunities centers on the development of drugs and devices with longer time windows for use. We sought to determine the time intervals within which stroke patients present to establish whether time window expansion will translate into more treatment. Methods— Data were derived from the Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study in an urban, southeast Texas county. This community does not contain an academic medical center, thus providing a “real-world” setting to capture patient arrival times. Onset time was recorded from the chart according to a prespecified methodology. Results— From January 2000 to June 2005, 2347 patients with acute ischemic stroke were validated. The mean age was 71 years, and 53% were female. Thirty-one percent presented within 3 hours of symptom onset; 13% between 3 and 6 hours; and 15% between 6 and 12 hours. Forty-one percent presented beyond 12 hours from symptom onset. Nearly half of patients with moderate and severe strokes presented in the 0- to 3-hour time window, whereas only 28% of mildly affected patients presented early. Conclusions— This population-based study provides estimates of time to presentation in a representative community without tertiary referral bias. These data are useful for planning acute stroke therapy interventions and suggest that in addition to developing therapies with expanded time windows, research resources should also be devoted to reducing hospital presentation delays.

Background: Fatalism and depression have been linked to post-stroke mortality and stroke recurrence. Our objective was to evaluate the impact of pre-stroke fatalism, depressive symptoms, and social support on neurological, functional, and cognitive outcomes after stroke. Methods: Ischemic strokes (2008 -2011) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. At baseline interviews, pre-stroke depressive symptoms, fatalism, and social support were assessed using Patient Health Questionnaire (PHQ-9; 0-27; higher worse), modified Mental Adjustment for Stroke and Pearlin scales (8-40; higher worse), and a 7-item social support scale (0 -14; higher better); respectively. Outcome among survivors was assessed at 90 days using the National Institutes of Health Stroke Scale (NIHSS; 0-44, higher worse); activities/ instrumental activities of daily living (ADL/IADL; 1-4, higher worse); and Modified Mini-Mental State Exam (3MSE; 0-100, lower worse). Regression models were used to evaluate associations of interest, adjusting for demographic and clinical factors. Results: Among 364 participants with outcome interviews and complete covariate data, mean age was 66, 49.5% were female and 58.8% were Mexican American. In adjusted models, higher pre-stroke fatalism (median 17; IQR 12, 20) was associated with poorer functional (0.17 point higher ADL/IADL score per IQR higher fatalism score; 95% CI 0.05, 0.30) and cognitive (2.81 point lower 3MSE per IQR higher fatalism score; 95% CI 0.95, 4.67) outcomes. Similarly, higher pre-stroke depressive symptoms (median 3; IQR 0, 9) were associated with poorer functional (0.16 point higher ADL/IADL per IQR higher PHQ-9; 95% CI .04, 0.28) and cognitive (2.28 point lower 3MSE per IQR higher PHQ-9; 95% CI 0.46, 4.10) outcomes. There were no significant associations between fatalism or depressive symptoms and NIHSS or between social support (median 10; IQR 7, 12) and 90-day outcomes. Conclusions: Among ischemic stroke survivors, pre-stroke fatalism and depressive symptoms, but not social support, impact 90-day functional and cognitive outcomes. These findings reinforce the importance of evaluating and addressing psychological factors in stroke care.

We thank Chen and colleagues1 for their sincere interest in our article,2 including their attention to the supplementary material. We disagree with their assertion that the activity of daily living (ADL) and instrumental activity of daily living (IADL) subscores should be treated as ordinal variables; these subscores have 22 and 46 distinct values, respectively, such that an analysis that treats these variables as ordinal is unwarranted.3 Although an ordinal regression analysis …

Background: Recently, two publications, one from California and one from Taiwan, utilizing administrative data have shown an independent, strong association between traumatic brain injury (TBI) and ischemic stroke (IS). The California analysis suggested TBI was a stronger risk factor for IS than hypertension. To begin the process of assessing whether TBI is really associated with IS with more definitive study types, we assessed the feasibility of obtaining TBI information in a population-based stroke study and characterized the history of TBI among IS patients including the time interval from TBI to stroke. Methods: As part of the Brain Attack Surveillance in Corpus Christi Project (BASIC), IS patients (n=439) who completed an interview were asked whether they had ever had a TBI that caused them to lose consciousness. For those IS patients who did have a TBI, we further questioned them as to the number and dates of TBIs and the length of loss of consciousness for the longest event. These questions closely followed the US Department of Defense characterization of TBI. Descriptive statistics were used to summarize history of TBI. Results: From 1/2/12 thru 7/7/13, 101 of the 439 (23%) IS stroke patients reported a history of at least one TBI that caused them to lose consciousness. Among patients with TBI, 67% had one TBI, 21% had 2 TBI’s, 10% had 3 or more TBI’s. The median length of time between the last reported TBI and stroke onset was 32 years (Q1: 7 years, Q3: 46 years); 3% had a TBI within 30 days prior to their IS and 9% had TBI within 1 year prior to their IS. The median NIHSS of IS patients with TBI was 3 (Q1: 1, Q3: 8) compared with a median NIHSS of 4 (Q1: 2, Q3: 9) among IS patients without TBI. Conclusion: It is feasible to obtain TBI information in this population-based stroke surveillance study where a history of TBI is very common in IS patients. The long interval between TBI to IS suggests a lack of association in most cases. A case-control study would be needed to confirm or refute the striking association of TBI and IS previously seen in administrative data. Further, a population-based study with detailed data collection would allow for discovery of associated mechanisms linking TBI to stroke such as dissection, coagulation disorders and intoxications.

Background/Objective: As a primary, pre-specified objective of the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project we studied trends in mortality following ischemic stroke among Mexican Americans (MAs) and non Hispanic whites (NHWs). MAs were previously found to have lower mortality following stroke than NHWs. Methods: We performed active and passive surveillance, and using source documentation, validated all ischemic stroke cases from January, 2000-December, 2010. Deaths were ascertained from the Texas Department of Health through December 31, 2011. Cumulative 30 day and 1 year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Pre-specified adjustment factors were: age, sex, prior stroke or TIA, atrial fibrillation, diabetes, heart disease, hypertension, smoking, high cholesterol and stroke severity. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2010, and to calculate projected ethnic differences. Results: There were 1,822 ischemic strokes among NHWs and 2,211 among MAs. Between 2000 and 2010, 30 day and 1 year mortality declined among NHWs, from 8.6% to 5.9% (p=0.14), and 21.7% to 17.0% (p=0.06), respectively. Among MAs, 30 day mortality remained stagnant at 5.6% (p=0.98), and a slight decline from 18.3% to 16.4% was observed for 1 year mortality (p=0.41). While, the ethnic differences in 30 day (p=0.01) and 1 year (p=0.07) mortality were robust in 2000, they were not so in 2010 (30 day, p=0.76; 1 year p=0.78). See figure. MAs are projected to have higher post-stroke mortality by 2022. Conclusions: Overall, mortality following ischemic stroke has declined in the last decade. However, the survival advantage previously documented among MAs vanished by 2010. Further, faster declines in mortality among NHWs than MAs imply a reversal of the survival advantage by approximately 2022.

Objective: As a primary, pre-specified objective of the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project we studied trends in stroke occurrence among Mexican Americans (MAs) and non Hispanic whites (NHWs) in Corpus Christi, Texas. Previous work suggested higher stroke rates in MAs compared with NHWs. Methods: We performed active and passive surveillance, and using source documentation, validated all stroke cases from January, 2000-December, 2010 in this community. Yearly population counts were obtained from the 2000, 2010 US Census and intercensal estimates. Incidence rates of total stroke (completed ischemic and intracerebral hemorrhage) were calculated per 10,000 population. Poisson regression models using the stroke counts within categories of race/ethnicity, age (45-59; 60-74, and 75+) and sex as the outcome and (log) population counts as the offset were used to estimate adjusted rates, rate ratios and time trends. Time trends were modeled as a linear term of years since 2000. The models used data from the entire study period to estimate incidence rates in 2000 and 2010. Results: There were 3,086 strokes in MAs and 2,328 in NHWs. Between 2000 and 2010 stroke incidence declined by 3.8% per year (95%CI: 3.0%, 4.6%) (see Figure). In 2000 the incidence rate was 54.2/10,000, it was 35.9/10,000 in 2010. For those aged 45-59; 60-74, and 75+, the yearly declines were 0.6% (95%CI: 1.2%, 2.3%); 6.1% (95%CI: 4.8%, 7.5%); and 3.9% (95%CI: 2.6%, 5.1%) per year, respectively. The decline in stroke incidence was not significantly different by ethnicity in any age group. Within each age category, the ethnicity rate ratios in 2000 vs. 2010 were: 45-59, 2.23 vs 2.15 (p=0.87); 60-74, 1.58 vs 1.77 (p=0.45); and 75 or older, 1.17 vs 1.02 (p=0.29). Conclusions: Stroke occurrence rates have declined dramatically in the last decade in both MAs and NHWs, particularly in those 60 and older. However, the disparity between MA and NHW stroke rates persists among those

Background and Purpose— Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (tPA) use for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. Methods— Systematic chart abstraction was performed on consecutive hospitalized patients with ischemic stroke from all 7 acute care hospitals in the District of Columbia from February 1, 2008, to January 31, 2009. Results— Of 1044 patients with ischemic stroke, 74% were black, 19% non-Hispanic white, and 5% received intravenous tPA. Blacks were one third less likely than whites to receive intravenous tPA (3% versus 10%, P P =0.004) and also less likely to be tPA-eligible (5% versus 13%, P P =0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% versus 76%, P =0.62). Conclusions— In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with intravenous tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population.

Background and Purpose— Vascular conditions are becoming the greatest cause of morbidity and mortality in developing countries. Few studies exist in Latin America. We aimed to perform a rigorous stroke surveillance study in Durango, Mexico. Methods— Active and passive surveillance were used to identify all patients with potential stroke presenting to Durango Municipality hospitals from August 2007 to July 2008. Exclusion criteria were subjects younger than 25 years old, stroke attributable to head trauma, and non-Durango Municipality residents. Brain Attack Surveillance in Durango-trained neurologists validated cases as stroke using source documentation. Stroke hospitalization rates were defined to include patients examined in the emergency department or admitted to the hospital. Results— Abstractors identified 435 potential cases; 309 (71%) were validated as stroke. Of the validated stroke cases, the median age was 71 and 49% were female. Subtypes were 61.5% ischemic stroke, 20.7% intracerebral hemorrhage, 7.4% subarachnoid hemorrhage, and 10.4% undetermined. Overall initial NIHSS was a median of 11 (interquartile range, 7–17); in-hospital mortality was 39%. When adjusted to the world population, the age-adjusted hospitalization rate of first-ever stroke was 118.2 per 100 000; rates by type were: ischemic stroke, 69.1 (95% CI, 57.5–80.7); intracerebral hemorrhage, 26.7 (95% CI, 19.6–33.8); subarachnoid hemorrhage, 9.5 (95% CI, 5.3–13.8); and unknown, 12.3 (95% CI, 7.4–17.3). Of 190 patients with validated ischemic stroke, 44.2% received lipid testing and 7.4% received carotid imaging and echocardiography; 1.1% received tissue plasminogen activator. Conclusion— To our knowledge, this is the first estimate of stroke hospitalization rates in a Mexican community and it provides information important for design of interventions to prevent and treat stroke. This information is critical to reduce Mexico’s stroke burden.