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Objective: Out-of-hospital mortality rates surged during the early COVID-19 pandemic. While expecting a return to pre-pandemic levels, the evolving patterns of out-of-hospital mortality in Canada remain uncertain. We investigated whether these rates returned to pre-pandemic levels. Methods: This retrospective study, employing linked administrative data, analyzed out-of-hospital mortality trends among adult residents in Ontario, Alberta, and Nova Scotia. Interrupted time series analysis assessed trends in age- and sex-standardized rates/100,000/quarter during pre-pandemic (April 2014–March 2020) and pandemic periods (April 2020–March 2022), while considering April to June 2020 as the pandemic onset period. Crude mortality rates were also examined, stratified by sex and age groups. Results: Pre-pandemic, Ontario’s standardized out-of-hospital mortality rates were rising, while Alberta’s and Nova Scotia’s remained stable. At the pandemic onset, all provinces experienced significant increases in standardized out-of-hospital mortality rates/100,000 (Ontario: β14.6, 95% CI [3.97, 25.22]; Alberta: 21.3, 95% CI [9.26, 33.34]; Nova Scotia: 10.5, 95% CI [1.06, 19.88]). During the pandemic, standardized out-of-hospital mortality rates/100,000/quarter remained above pre-pandemic levels, with no significant departure from the increased pandemic onset levels (Ontario: − 1.6, 95% CI [− 3.63, 0.52]; Alberta: 0.45, 95% CI [− 1.47, 2.36]; Nova Scotia: − 0.06, 95% CI [− 2.18, 2.06]). Crude out-of-hospital mortality rates increased most prominently among individuals aged 18 to 45 in Alberta and Ontario, and among males across all provinces. Conclusion: The sustained increase in out-of-hospital mortality, observed from the pandemic’s onset, spanning more than 2 years, potentially suggests its persistent direct and indirect effects on population health in Canada.

BACKGROUND: Secondary prevention after stroke and transient ischemic attack (TIA) has focused on high early risk of recurrence, but survivors of stroke can have substantial long-term morbidity and mortality. We quantified long-term morbidity and mortality for patients who had no early complications after stroke or TIA and community-based controls. METHODS: This longitudinal case-control study included all ambulatory or hospitalized patients with stroke or TIA (discharged from regional stroke centres in Ontario from 2003 to 2013) who survived for 90 days without recurrent stroke, myocardial infarction, all-cause admission to hospital, admission to an institution or death. Cases and controls were matched on age, sex and geo graphic location. The primary composite outcome was death, stroke, myocardial infarction, or admission to long-term or continuing care. We calculated 1-, 3- and 5-year rates of composite and individual outcomes and used cause-specific Cox regression to estimate long-term hazards for cases versus controls and for patients with stroke versus those with TIA. RESULTS: Among patients who were initially stable after stroke or TIA (n = 26366), the hazard of the primary outcome was more than double at 1 year (hazard ratio [HR] 2.4, 95% confidence interval [CI] 2.3-2.5), 3 years (HR 2.2, 95% CI 2.1-2.3) and 5 years (HR 2.1, 95% CI 2.1-2.2). Hazard was highest for recurrent stroke at 1 year (HR 6.8,95% CI 6.1-7.5), continuing to 5 years (HR 5.1, 95% CI 4.8-5.5), and for admission to an institution (HR 2.1, 95% CI 1.9-2.2). Survivors of stroke had higher mortality and morbidity, but 31.5% (1789/5677) of patients with TIA experienced an adverse event within 5 years. INTERPRETATION: Patients who survive stroke or TIA without early complications are typically discharged from secondary stroke prevention services. However, these patients remain at substantial long-term risk, particularly for recurrent stroke and admission to an institution. Novel approaches to prevention, potentially embedded in community or primary care, are required for long-term management of these initially stable but high-risk patients., Much of the risk of recurrent stroke accrues early after the index event, (1-3) with population-based estimates ranging from 3.2% to 18.5% at 90 days after stroke (4) and 0.6% [...]

BACKGROUND: Variations in the prevalence of traditional cardiac risk factors only partially account for geographic variations in the incidence of cardiovascular disease. We examined the extent to which preventive ambulatory health care services contribute to geographic variations in cardiovascular event rates. METHODS: We conducted a cohort study involving 5.5 million patients aged 40 to 79 years in Ontario, Canada, with no hospital stays for cardiovascular disease as of January 2008, through linkage of multiple population-based health databases. The primary outcome was the occurrence of a major cardiovascular event (myocardial infarction, stroke or cardiovascular-related death) over the following 5 years. We compared patient demographics, cardiac risk factors and ambulatory health care services across the province's 14 health service regions, known as Local Health Integration Networks (LHINs), and evaluated the contribution of these variables to regional variations in cardiovascular event rates. RESULTS: Cardiovascular event rates across LHINs varied from 3.2 to 5.7 events per 1000 person-years. Compared with residents of high-rate LHINs, those of low-rate health regions received physician services more often (e.g., 4.2 v. 3.5 mean annual family physician visits, p value for LHIN-level trend = 0.01) and were screened for risk factors more often. Low-rate LHINs were also more likely to achieve treatment targets for hypercholesterolemia (51.8% v. 49.6% of patients, p = 0.03) and controlled hypertension (67.4% v. 53.3%, p = 0.04). Differences in patient and health system factors accounted for 74.5% of the variation in events between LHINs, of which 15.5% was attributable to health system factors alone. INTERPRETATION: Preventive ambulatory health care services were provided more frequently in health regions with lower cardiovascular event rates. Health system interventions to improve equitable access to preventive care might improve cardiovascular outcomes., The Canadian Heart Health Strategy and Action Plan and similar cardiovascular health promotion efforts in other countries have been introduced to reduce the incidence of cardiovascular disease (CVD). (1-3) However, [...]

ABSTRACT:Background:The Passive Surveillance Stroke Severity (PaSSV) Indicator was derived to estimate stroke severity from variables in administrative datasets but has not been externally validated.Methods:We used linked administrative datasets to identify patients with first hospitalization for acute stroke between 2007-2018 in Alberta, Canada. We used the PaSSV indicator to estimate stroke severity. We used Cox proportional hazard models and evaluated the change in hazard ratios and model discrimination for 30-day and 1-year case fatality with and without PaSSV. Similar comparisons were made for 90-day home time thresholds using logistic regression. We also linked with a clinical registry to obtain National Institutes of Health Stroke Scale (NIHSS) and compared estimates from models without stroke severity, with PaSSV, and with NIHSS.Results:There were 28,672 patients with acute stroke in the full sample. In comparison to no stroke severity, addition of PaSSV to the 30-day case fatality models resulted in improvement in model discrimination (C-statistic 0.72 [95%CI 0.71–0.73] to 0.80 [0.79–0.80]). After adjustment for PaSSV, admission to a comprehensive stroke center was associated with lower 30-day case fatality (adjusted hazard ratio changed from 1.03 [0.96–1.10] to 0.72 [0.67–0.77]). In the registry sample (N = 1328), model discrimination for 30-day case fatality improved with the inclusion of stroke severity. Results were similar for 1-year case fatality and home time outcomes.Conclusion:Addition of PaSSV improved model discrimination for case fatality and home time outcomes. The validity of PASSV in two Canadian provinces suggests that it is a useful tool for baseline risk adjustment in acute stroke.

Inequities in stroke care and outcomes have been documented both within and among countries based on factors, such as race, geography, and socioeconomic status. Research can help us to identify, understand, and address inequities, and this article offers considerations for scientists working in this area. These include designing research aimed at identifying the underlying causes of inequities, recognizing the importance of the social determinants of health, considering interventions that go beyond the individual patient and provider to include policies and systems, acknowledging the role of structural racism, performing community-engaged participatory research, considering intersecting social identities, learning from cross-national comparisons, maintaining the data sources needed for inequities research, using terminology that advances health equity, and improving diversity across the research enterprise.

There has been a plethora of studies focused on female-specific risk factors and sex differences in stroke published in the past year. This article summarizes several of those novel studies which provide new knowledge about the field of stroke in women. The Nurses’ Health Study II provides new data on the association between laparoscopically proven endometriosis and future stroke, accounting for the mediation effects of hysterectomy and oophorectomy. In a cohort of women from China, the relationship between hysterectomy, oophorectomy, and stroke is further clarified, accounting for the age at which the procedure is performed. The UK Biobank study provides new information on the relationship between oral contraceptive and hormone replacement therapy and stroke, with analytical techniques that focus on the timing of events related to duration of exposure. Finally, 2 new meta-analyses address the question of whether sex differences exist in the presentation of stroke symptoms.

Background: There is a paucity of the literature on the relationship between frailty and excess mortality due to the COVID-19 pandemic. Methods: The entire community-dwelling adult population of Ontario, Canada, as of January 1st, 2018, was identified using the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort. Residents of long-term care facilities were excluded. Frailty was categorized through the Johns Hopkins Adjusted Clinical Groups (ACG® System) frailty indicator. Follow-up was until December 31st, 2020, with March 11th, 2020, indicating the beginning of the COVID-19 pandemic. Using multivariable Cox models with patient age as the timescale, we determined the relationship between frailty status and pandemic period on all-cause mortality. We evaluated the modifier effect of frailty using both stratified models as well as incorporating an interaction between frailty and the pandemic period. Results: We identified 11,481,391 persons in our cohort, of whom 3.2% were frail based on the ACG indicator. Crude mortality increased from 0.75 to 0.87% per 100 person years from the pre- to post-pandemic period, translating to ~ 13,800 excess deaths among the community-dwelling adult population of Ontario (HR 1.11 95% CI 1.09–1.11). Frailty was associated with a statistically significant increase in all-cause mortality (HR 3.02, 95% CI 2.99–3.06). However, all-cause mortality increased similarly during the pandemic in frail (aHR 1.13, 95% CI 1.09–1.16) and non-frail (aHR 1.15, 95% CI 1.13–1.17) persons. Conclusion: Although frailty was associated with greater mortality, frailty did not modify the excess mortality associated with the pandemic.

Background: Systems of stroke care delivery have been promoted as a means of improving the quality of stroke care, but little is known about their effectiveness. We assessed the effect of the Ontario Stroke System, a province-wide strategy of regionalized stroke care delivery, on stroke care and outcomes in Ontario, Canada. Methods: We used population-based provincial administrative databases to identify all emergency department visits and hospital admissions for acute stroke and transient ischemic attack from Jan. 1, 2001, to Dec. 31, 2010. Using piecewise regression analyses, we assessed the effect of the full implementation of the Ontario Stroke System in 2005 on the proportion of patients who received care at stroke centres, and on rates of discharge to long-term care facilities and 30-day mortality after stroke. Results: We included 243 287 visits by patients with acute stroke or transient ischemic attack. The full implementation of the Ontario Stroke System in 2005 was associated with an increase in rates of care at stroke centres (before implementation: 40.0%; after implementation: 46.5%), decreased rates of discharge to long-term care facilities (before implementation: 16.9%; after implementation: 14.8%) and decreased 30-day mortality for hemorrhagic (before implementation: 38.3%; after implementation: 34.4%) and ischemic stroke (before implementation: 16.3%; after implementation: 15.7%). The system's implementation was also associated with marked increases in the proportion of patients who received neuroimaging, thrombolytic therapy, care in a stroke unit and antithrombotic therapy. Interpretation: The implementation of an organized system of stroke care delivery was associated with improved processes of care and outcomes after stroke., Stroke is a leading cause of death and disability worldwide. (1,2) Guidelines recommend that eligible patients receive care in a stroke unit, undergo neuroimaging and receive thrombolytic therapy, antithrombotic agents [...]

OBJECTIVE--To compare recent trends in cardiovascular disease (CVD) outcomes among men and women with diabetes with those in the nondiabetic population. RESEARCH DESIGN AND METHODS--We conducted a retrospective cohort study [...]

Propensity score–based analysis is increasingly being used in observational studies to estimate the effects of treatments, interventions, and exposures. We introduce the concept of the propensity score and how it can be used in observational research. We describe 4 different ways of using the propensity score: matching on the propensity score, inverse probability of treatment weighting using the propensity score, stratification on the propensity score, and covariate adjustment on the propensity score (with a focus on the first 2). We provide recommendations for the use and reporting of propensity score methods for the conduct of observational studies in neurologic research.

Background: Neurovascular imaging for patients with high-risk transient ischemic attack (TIA) or minor stroke in the emergency department (ED) with computed tomography angiography (CTA) of the head and neck is the guideline-recommended standard of care, but it is underutilized in routine practice. We conducted a quality initiative to improve adherence to guidelines. Methods: Between January 2017 and March 2019, we implemented a decision support tool integrated into the electronic ordering system to guide ED physicians to order a CTA on patients with high-risk TIA or minor stroke defined as ongoing neurological deficits in the ED or resolved motor or speech deficits in the preceding 48 h. Data were collected retrospectively pre-intervention and prospectively post-intervention. We used an interrupted time-series analysis for the before–after comparison of the use of CTA among patients who met criteria (main process measure) and those who did not meet criteria (balancing measure). Results: Among 861 patients with TIA or minor stroke, the proportion of patients with high-risk events imaged with a CTA in the ED increased from 12.0% pre-intervention to 77.0% post-intervention and this shift was sustained over 11 months. CTA use in those without high-risk events increased to a lesser extent (15.3% versus 42.9%). The interrupted time-series analysis showed a step change immediately post-intervention where the increase in CTA use in patients with high-risk events was 51.7% higher than its use in those without high-risk events (p< 0.001). Compared to pre-intervention, the median ED length of stay increased by 2 h and neurology consultation in the ED was more frequent (5.8% versus 19.5%) post-intervention. Conclusion: We provide a detailed framework that improved adherence to acute imaging guidelines for patients with TIA or minor stroke and anticipate that our approach could improve acute imaging for such patients in most EDs.

ABSTRACT:Background:Contemporary data on temporal trends in acute stroke incidence, specific to stroke type and age, are lacking. We sought to evaluate temporal trends in incidence of ischemic stroke and intracerebral hemorrhage over 15 years in a large population.Methods:We used linked administrative data to identify all emergency department visits and hospital admissions for first-ever ischemic stroke or intracerebral hemorrhage in Ontario, Canada from 2003–2017. We evaluated annual age-/sex-standardized incidence per 100,000 person-years for ischemic stroke and intracerebral hemorrhage across the study period. We used negative binomial regression to determine incidence rate ratios for each year compared to 2003, with assessment of modification by age, sex, or stroke type.Results:Our cohort had 163,574 people with stroke (88% ischemic stroke). For ischemic stroke and intracerebral hemorrhage combined, age-/sex-standardized incidence decreased between 2003 and 2011 (standardized rate 109.4 to 85.8 per 100,000; 22%), then increased until 2017 (standardized rate 96.8 per 100,000; 13%). The pattern of change was similar for ischemic stroke and intracerebral hemorrhage, and for men and women, but was modified by age. For those aged 60 and above, adjusted incidence rate ratios decreased from 2003 to 2011 then subsequently increased, whereas for those aged <60 years incidence rate ratios increased throughout the entire study time period, particularly after 2011.Conclusions:Acute stroke incidence decreased from 2003 to 2011 but subsequently increased until 2017. Among those aged <60, incidence increased continuously from 2003 to 2017 but especially after 2011. The underlying reasons for these changes should be determined.

Every 10 minutes someone in Canada suffers a "brain attack," making stroke the most common serious neurological condition requiring hospital admission. Each year, about 50 000 Canadians are admitted to [...]

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ABSTRACT:Background:Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada.Methods:We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers.Results:Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT).Conclusions:Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.

ABSTRACT:Background:Stroke survivors have higher unmet health care needs than the general population. However, it is unclear whether such needs have changed over time, and whether these have been affected by the introduction of integrated systems of stroke care.Methods:We used data from the Canadian Community Health Surveys between 2000 and 2014. We developed multivariable log-binomial generalized estimating equations to obtain adjusted risk ratios (aRRs) of unmet health care needs in stroke survivors compared to the general population, and over time. We conducted a difference in differences analysis to determine the association between the implementation of integrated systems of stroke care and unmet health care needs.Results:Data from 350,084 respondents were included in the study; 8072 (2.3%) were stroke survivors. Compared to the general population, stroke survivors were more likely to report unmet health care needs (aRR 1.27; 95% CI, 1.22–1.32). The unmet health care needs reported by stroke survivors were lower after compared to before 2006 (15.8% vs. 31.9%, P< 0.001). After accounting for temporal trends, there was no association between the implementation of integrated systems of stroke care and change in unmet health care needs of stroke survivors. However, this requires cautious interpretation due to limitations in the data available for this study.Conclusions:Unmet health care needs of stroke survivors have reduced over time but remain higher than the general population. Future research should focus on identifying stroke- and policy-related factors to mitigate disparities in health care access for stroke survivors.

ABSTRACT:Background:Women are more likely to be admitted to nursing home after stroke than men. Differences in patient characteristics and outcomes by sex after institutionalization are less understood. We examined sex differences in the characteristics and care needs of patients admitted to nursing home following stroke and their subsequent survival.Methods:We identified patients with stroke newly admitted to nursing home between April 2011 and March 2016 in Ontario, Canada, with follow-up until March 2018 using linked administrative data. We calculated prevalence ratios and 95% confidence intervals (CIs) for the primary outcomes of dependence for activities of daily living, cognitive impairment, frailty, health instability, and symptoms of depression or pain, comparing women to men. The secondary outcome was all-cause mortality.Results:Among 4831 patients, 60.9% were women. Compared to men, women were older (median age [interquartile range, IQR]: 84 [78, 89] vs. 80 [71, 86]), more likely to be frail (prevalence ratio 1.14, 95% CI [1.08, 1.19]), have unstable health (1.45 [1.28, 1.66]), and experience symptoms of depression (1.25 [1.11, 1.40]) or pain (1.21 [1.13, 1.30]), and less likely to have aggressive behaviors (0.87 [0.80, 0.94]). Overall median survival was 2.9 years. In a propensity-score-matched cohort, women had lower mortality than men (hazard ratio 0.85, 95% CI [0.77, 0.94]), but in the age-stratified survival analysis, the survival advantage in women was limited to those aged 75 years and older.Conclusions:Despite lower subsequent mortality, women admitted to nursing home after stroke required more care than men. Pain and depression are two treatable symptoms that disproportionately affect women.

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IMPORTANCE: The risk for low-trauma fracture is increased by more than 30% after ischemic stroke, but existing fracture risk scores do not account for history of stroke as a high-risk condition. OBJECTIVE: To derive a risk score to predict the probability of fracture within 1 year after ischemic stroke and validate it in a separate cohort. DESIGN, SETTING, AND PARTICIPANTS: Prognostic study of a cohort from the Ontario Stroke Registry, a population-based sample of adults in Ontario, Canada, who were hospitalized with ischemic stroke from July 1, 2003, to March 31, 2012, with 1 year of follow-up. A population-based validation cohort consisted of a sample of 13 698 consecutive stroke admissions captured across 5 years: April 2002 to March 2003, April 2004 to March 2005, April 2008 to March 2009, April 2010 to March 2011, and April 2012 to March 2013. EXPOSURES: Predictor variables were selected based on biological plausibility and association with fracture risk. Age, sex, and modified Rankin score were abstracted from the medical records part of the Ontario Stroke Audit, and other characteristics were abstracted from administrative health data. MAIN OUTCOMES AND MEASURES: Incidence of low-trauma fracture within 1 year of discharge, based on administrative health data. RESULTS: The Fracture Risk after Ischemic Stroke (FRAC-Stroke) Score was derived in 20 435 patients hospitalized for ischemic stroke (mean [SD] age, 71.6 [14.0] years; 9564 [46.8%] women) from the Ontario Stroke Registry discharged from July 1, 2003, to March 31, 2012, using Fine-Gray competing risk regression. Low-trauma fracture occurred within 1 year of discharge in 741 of the 20 435 patients (3.6%) in the derivation cohort. Age, discharge modified Rankin score (mRS), and history of rheumatoid arthritis, osteoporosis, falls, and previous fracture were associated with the cumulative incidence of low trauma fracture in the derivation cohort. Model discrimination in the validation cohort (n = 13 698) was good (C statistic, 0.70). Discharge mRS was an important discriminator of risk (relative integrated discrimination improvement, 8.7%), with highest risk in patients with mRS 3 and 4 but lowest in bedbound patients (mRS 5). From the lowest to the highest FRAC-Stroke quintile, the cumulative incidence of 1-year low-trauma fracture increased from 1.3% to 9.0% in the validation cohort. Predicted and observed rates of fracture were similar in the external validation cohort. Analysis was conducted from July 2016 to January 2019. CONCLUSIONS AND RELEVANCE: The FRAC-Stroke score allows the clinician to identify ischemic stroke survivors at higher risk of low-trauma fracture within 1 year of hospital discharge. This information might be used to select patients for interventions to prevent fractures.

Cancer is a leading cause of morbidity and mortality worldwide, with an estimated 16.9 million people living with cancer in the United States alone.1Cancer is associated with an increased risk of stroke for various reasons, including direct tumor effects, hypercoagulable states, infection, and the effects of chemotherapy, radiation, and immunotherapy.2-5An estimated 10% of people with stroke have underlying cancer, which is in turn associated with worse outcomes after stroke.6-8For all these reasons, it is important for clinicians to understand how best to manage stroke in the context of an underlying malignancy.

AbstractBackgroundVertigo is common in the emergency department (ED). Most aetiologies are peripheral and do not require hospitalization, but many patients still fear falling. Some patients may be taking opioid analgesic medications (for other reasons); the risk of falls leading to fractures among patients with vertigo could be potentiated by the simultaneous use of opioids.ObjectivesTo examine the risk of fractures in discharged ED patients with peripheral vertigo who were being prescribed opioids during the same time period.MethodsLinked administrative databases from Ontario were used to compare discharged ED patients aged ≥65 with peripheral vertigo to patients with urinary tract infection (UTI) from 2006 to 2011. We used Cox regression analysis with an interaction term to estimate the modifying effect of an opioid prescription on the hazard of fracture within 90 days.ResultsThere were 13,012 patients with a peripheral vertigo syndrome and 76,885 with a UTI. Thirteen percent of the vertigo cohort and 25% of the UTI cohort had access to a filled opioid prescription. Compared to vertigo patients who did not fill an opioid prescription, the adjusted hazard of fracture among vertigo patients who did fill a prescription was 3.59 (95% CI 1.97–6.13). Among UTI patients who filled an opioid prescription the hazard ratio was 1.68 (95% CI 1.43–1.97) compared to UTI patients who did not.ConclusionsPatients discharged from the ED with peripheral vertigo who were also being prescribed opioids had a higher hazard of subsequent fracture compared to those who were not, and the effect was much greater than among UTI patients. These results suggest that in the acutely vertiginous older patient, opioid analgesic medications should be modified, where possible.

Abstract Serious adverse drug events can prompt personal-injury lawsuits. However, the extent to which biomedical publication regarding drug-induced harm can influence the legal process has not been well characterized. Using [...]

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Background and purposeTo systematically review and meta-analyse the data on impact of timing of endovascular treatment in aneurysmal subarachnoid haemorrhage (SAH) to determine if earlier treatment is associated with improved clinical outcomes and reduced case fatality.MethodsWe searched MEDLINE, Cochrane database, EMBASE and Web of Science to identify studies for inclusion. The measures of effect utilised were unadjusted/adjusted ORs. Effect estimates were combined using random effects models for each outcome (poor outcome, case fatality); heterogeneity was assessed using the I2index. Subgroup and sensitivity analyses were performed to account for heterogeneity and risk of bias.Results16 studies met the inclusion criteria. Treatment <1 day was associated with a reduced odds of poor outcome compared with treatment >1 day (OR=0.40 (95% CI 0.28 to 0.56; I2=0%)) but not when compared with treatment at 1–3 days (OR=1.16 (95% CI 0.47 to 2.90; I2=81%)). Treatment at <2 days and at <3 days were associated with similar odds of poor outcome compared with later treatment (OR=1.20 (95% CI 0.70 to 2.05; I2=73%; OR=0.71 (95% CI 0.36 to 1.37; I2=71%)). Early treatment was associated with similar odds of case fatality compared with later treatment, regardless of how early/late treatment were defined (OR=1.80 (95% CI 0.88 to 3.67; I2=34%) for treatment <1 day vs days 1–3; OR=1.71 (95% CI 0.72 to 4.03; I2=54%) for treatment <2 days vs later; OR=0.90 (95% CI 0.31 to 2.68; I2=48%) for treatment <3 days vs later).ConclusionsIn only 1 of the analyses was there a statistically significant result, which favoured treatment <1 day. The inconsistent results and heterogeneity within most analyses highlight the lack of evidence for best timing of endovascular treatment in SAH patients.

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AbstractAmong those aged 80 years and older in Ontario, Canada, stroke and dementia incidence declined concomitantly from 2002-03 to 2013-14. This study aimed to report the concurrent temporal trends of stroke and dementia prevalence in Ontario among the same age demographic. The prevalence of both stroke and dementia increased from 2003-04 to 2012-13 in both sexes and the magnitude in which prevalence of dementia increased over time exceeded that of stroke. The substantial increase in the prevalence of dementia may be because of increased recognition and diagnoses of dementia and increased survival of stroke patients who are at higher risk of developing dementia.

•Language discordance (when a patient's primary spoken language differs from the primary language of the health system) is associated with worse post-stroke functional outcomes and greater neurovascular risk compared to language concordant participants.•Language concordance is a simple, readily available marker to identify those at risk of worse outcome.•Adaptive care models, treatments and education strategies may be needed to mitigate barriers influenced by language discordance.

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IMPORTANCE: A sizeable minority of strokes occur in hospitalized patients. However, little is known about the presentation, care, and outcomes of stroke in this subgroup of patients. OBJECTIVE: To examine stroke care delivery and outcomes for patients with in-hospital vs community-onset stroke. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of all patients older than 18 years with acute stroke seen in the emergency department or admitted to the hospital at participating centers (all regional stroke centers in Ontario, Canada) between July 1, 2003, and March 31, 2012, including those with stroke onset during hospitalization for another cause. MAIN OUTCOMES AND MEASURES: We compared processes of stroke care delivery, including time to neuroimaging and rates of thrombolysis, as well as outcomes, including death and disability, in those with in-hospital vs community-onset stroke. We used multiple logistic regression models to adjust for age, sex, comorbid conditions, and stroke type and severity. RESULTS: The study sample included 973 patients with in-hospital stroke and 28 837 with community-onset stroke. Patients with in-hospital stroke compared with those with community-onset stroke had significantly longer waiting times from symptom recognition to neuroimaging (median, 4.5 vs 1.2 hours; P &lt; .001; for &lt;2 hours, 32% vs 63%; adjusted odds ratio [AOR] = 0.21; 95% CI, 0.18-0.24), lower use of thrombolysis (12% vs 19% of those with ischemic stroke; AOR = 0.54; 95% CI, 0.43-0.67; P &lt; .001), and longer time from stroke recognition to administration of thrombolysis (median, 2.0 vs 1.2 hours; P &lt; .001). After adjustment for age, stroke severity, and other factors, mortality rates at 30 days and 1 year after stroke were similar in those with in-hospital stroke and community-onset stroke; however, those with in-hospital stroke had a longer median length of stay following stroke onset (17 vs 8 days; P &lt; .001), were more likely to be dead or disabled at discharge (77% vs 65% with modified Rankin Scale score of 3-6; AOR = 1.64; 95% CI, 1.38-1.96; P &lt; .001), and were less likely to be discharged home from the hospital (35% vs 44%; AOR = 0.76; 95% CI, 0.64-0.90; P &lt; .001). CONCLUSIONS AND RELEVANCE: Compared with those with community-onset stroke, patients with in-hospital stroke had delays in investigations and treatment, suggesting a need for a standardized approach to the recognition and management of in-hospital stroke, with the aim of ensuring access to rapid acute stroke care.

Language barriers may lead to poor quality of care, particularly for conditions like acute stroke for which diagnosis and treatment decision making rely on taking an accurate patient history. The purpose of this study was to determine the impact of patient language barriers on quality of stroke care and clinical outcomes.

The CArdiovascular HEalth in Ambulatory care Research Team (CANHEART) is conducting a unique, population-based observational research initiative aimed at measuring and improving cardiovascular health and the quality of ambulatory cardiovascular care provided in Ontario, Canada. A particular focus will be on identifying opportunities to improve the primary and secondary prevention of cardiovascular events in Ontario’s diverse multiethnic population.

The purpose of this study was to determine the proportion of emergency department (ED) patients with a diagnosis of peripheral vertigo who received computed tomography (CT) head imaging in the ED and to examine whether strokes were missed using CT imaging.

For patients with atrial fibrillation and ischemic stroke (IS), current guidelines recommend oral anticoagulation (OAC) alone for secondary prevention of IS. In a large prospective cohort of patients with acute IS and atrial fibrillation, we determine the association between antithrombotic regimen on discharge and risk of major vascular events.