251 results on '"Joshua Z. Willey"'
Search Results
2. Treatment and Outcomes of Thrombolysis Related Hemorrhagic Transformation: A Multi-Center Study in China
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Junfeng Liu, Yanan Wang, Jing Li, Shanshan Zhang, Qian Wu, Chenchen Wei, Ting Cui, Bo Wu, Joshua Z. Willey, and Ming Liu
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acute ischemic stroke ,hemorrhagic transformation ,thrombolysis ,treatment ,outcomes ,Neurosciences. Biological psychiatry. Neuropsychiatry ,RC321-571 - Abstract
ObjectiveTo investigate the current management of thrombolysis related hemorrhagic transformation (HT) in real-world practice, and whether these treatments would reduce the risk of 3-month death and hematoma expansion after HT.MethodsA multicenter retrospective study was performed in three comprehensive stroke centers in China (West China Hospital, The First People’s Hospital of Ziyang, and Mianyang Central Hospital) between January 1st 2012 and December 31th 2020. Participants were patients diagnosed with HT after intravenous thrombolytics on brain computed tomography (CT) within 36 h after stroke onset. The treatment after thrombolysis related HT included aggressive therapy (procoagulant, neurosurgical treatment) and dehydration therapy (mannitol or glycerin and fructose). The primary clinical outcome was 3-month death. The primary radiographic outcome was hematoma expansion, defined as a 33% increase in the hematoma volume using the (A × B × C)/2 method on follow-up imaging.ResultsOf 538 patients with ischemic stroke receiving thrombolysis included during the study period, 94 patients (17.4%) were diagnosed with HT, 50% (47/94) of whom were symptomatic HT. The 3-month death was 31.5% (29/92), with two patients having been lost to follow up. A total of 68 patients (72.3%) had follow-up brain CT scans after HT detection for evaluating hematoma expansion, of whom 14.7% (10/68) had hematoma expansion. Among the 10 patients with hematoma expansion, 7 patients were from symptomatic HT group, and 3 patients were from the asymptomatic hematoma group. In regard to escalation in therapy, six patients received neurosurgical treatment and three patients had a fresh frozen plasma infusion. In addition, dehydration therapy was the most common management after HT diagnosis [87.2% (82 of 94)]. In the multivariable models, refusing any treatment after HT diagnosis was the sole factor associated with increased 3-month death (odds ratio, 13.6; 95% CI, 3.98–56.9) and hematoma expansion risk (odds ratio, 8.54; 95% CI, 1.33–70.1). In regard to the effects of aggressive therapy, a non-significant association of receiving hemostatic/neurosurgery therapy with a lower 3-month death and hematoma expansion risk was observed (all P > 0.05).ConclusionRefusing any treatment after HT detection had a significant trend of increasing 3-month death and hematoma expansion risk after HT. Our finding of hematoma expansion among patients with asymptomatic HT in non-western populations suggests an opportunity for intervention. Very few patients after thrombolysis related HT diagnosis received procoagulant or neurosurgical therapies. Large multicenter studies enrolling diverse populations are needed to examine the efficacy of these therapies on different HT subtypes.
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- 2022
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3. Inpatient Neurology Consultations During the Onset of the SARS-CoV-2 New York City Pandemic: A Single Center Case Series
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Sara Radmard, Samantha E. Epstein, Hannah J. Roeder, Andrew J. Michalak, Steven D. Shapiro, Amelia Boehme, Tommy J. Wilson, Juan C. Duran, Jennifer M. Bain, Joshua Z. Willey, and Kiran T. Thakur
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neurology ,novel coronavirus ,COVID-19 ,severe acute respiratory syndrome coronavirus 2 ,inpatient consults ,Neurology. Diseases of the nervous system ,RC346-429 - Abstract
Objective: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily causes respiratory illness. However, neurological sequelae from novel coronavirus disease 2019 (COVID-19) can occur. Patients with neurological conditions may be at higher risk of developing worsening of their underlying problem. Here we document our initial experiences as neurologic consultants at a single center quaternary hospital at the epicenter of the COVID-19 pandemic.Methods: This was a retrospective case series of adult patients diagnosed with SARS-CoV-2 who required neurological evaluation in the form of a consultation or primary neurological care from March 13, 2020 to April 1, 2020.Results: Thirty-three patients (ages 17–88 years) with COVID-19 infection who required neurological or admission to a primary neurology team were included in this study. The encountered neurological problems associated with SARS-CoV-2 infection were encephalopathy (12 patients, 36.4%), seizure (9 patients, 27.2%), stroke (5 patients, 15.2%), recrudescence of prior neurological disease symptoms (4 patients, 12.1%), and neuromuscular (3 patients, 9.1%). The majority of patients who required evaluation by neurology had elevated inflammatory markers. Twenty-one (63.6%) patients were discharged from the hospital and 12 (36.4%) died from COVID-19 related complications.Conclusion: This small case series of our initial encounters with COVID-19 infection describes a range of neurological complications which are similar to presentations seen with other critical illnesses. COVID-19 infection did not change the overall management of neurological problems.
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- 2020
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4. Types of Sedentary Behavior and Risk of Cardiovascular Events and Mortality in Blacks: The Jackson Heart Study
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Jeanette M. Garcia, Andrea T. Duran, Joseph E. Schwartz, John N. Booth, Steven P. Hooker, Joshua Z. Willey, Ying Kuen Cheung, Chorong Park, Stephen K. Williams, Mario Sims, Daichi Shimbo, and Keith M. Diaz
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black ,all‐cause mortality ,cardiovascular disease ,moderate‐to‐vigorous physical activity ,occupational sedentary behavior ,television viewing ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Previous cross‐sectional studies have shown conflicting results regarding the effects of television viewing and occupational sitting on cardiovascular disease (CVD) risk factors. The purpose of this study was to compare the association of both television viewing and occupational sitting with CVD events and all‐cause mortality in blacks. Methods and Results Participants included 3592 individuals enrolled in the Jackson Heart Study, a community‐based study of blacks residing in Jackson, Mississippi. Television viewing (4 h/day) and occupational sitting (never/seldom, sometimes, often/always) were self‐reported. Over a median follow‐up of 8.4 years, there were 129 CVD events and 205 deaths. The highest category of television viewing (>4 h/day) was associated with a greater risk for a composite CVD events/all‐cause mortality end point compared with the lowest category (
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- 2019
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5. Absence of July Phenomenon in Acute Ischemic Stroke Care Quality and Outcomes
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Marco Gonzalez‐Castellon, Christine Ju, Ying Xian, Adrian Hernandez, Gregg C. Fonarow, Lee Schwamm, Eric E. Smith, Deepak L. Bhatt, Matthew Reeves, and Joshua Z. Willey
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ischemic stroke ,thrombolysis ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
BackgroundLower care quality and an increase in adverse outcomes as a result of new medical trainees is a concept well rooted in popular belief, termed the “July phenomenon.” Whether this phenomenon occurs in acute ischemic stroke has not been well studied. Methods and ResultsWe analyzed data from patients admitted with ischemic stroke in 1625 hospitals participating in the Get With The Guidelines–Stroke program for the 5‐year period between January 2009 and December 2013. We compared acute stroke treatment processes and in‐hospitals outcomes among the 4 quarters (first quarter: July–September, last quarter: April–June) of the academic year. Multivariable logistic regression models were used to evaluate the relationship between academic year transition and processes measures. A total of 967 891 patients were included in the study. There was a statistically significant, but modest (
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- 2018
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6. Quantile Coarsening Analysis of High-Volume Wearable Activity Data in a Longitudinal Observational Study
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Ying Kuen Cheung, Pei-Yun Sabrina Hsueh, Ipek Ensari, Joshua Z. Willey, and Keith M. Diaz
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citizen science ,cluster analysis ,physical activity ,sedentary behavior ,walking ,Chemical technology ,TP1-1185 - Abstract
Owing to advances in sensor technologies on wearable devices, it is feasible to measure physical activity of an individual continuously over a long period. These devices afford opportunities to understand individual behaviors, which may then provide a basis for tailored behavior interventions. The large volume of data however poses challenges in data management and analysis. We propose a novel quantile coarsening analysis (QCA) of daily physical activity data, with a goal to reduce the volume of data while preserving key information. We applied QCA to a longitudinal study of 79 healthy participants whose step counts were monitored for up to 1 year by a Fitbit device, performed cluster analysis of daily activity, and identified individual activity signature or pattern in terms of the clusters identified. Using 21,393 time series of daily physical activity, we identified eight clusters. Employment and partner status were each associated with 5 of the 8 clusters. Using less than 2% of the original data, QCA provides accurate approximation of the mean physical activity, forms meaningful activity patterns associated with individual characteristics, and is a versatile tool for dimension reduction of densely sampled data.
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- 2018
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7. Amyloid β-Related Angiitis Causing Coma Responsive to Immunosuppression
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Shennan A. Weiss, David Pisapia, Stephan A. Mayer, Joshua Z. Willey, and Kiwon Lee
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Pathology ,RB1-214 - Abstract
Introduction. Amyloid-beta-related angiitis (ABRA) is a form of CNS vasculitis in which perivascular beta-amyloid in the intracerebral vessels is thought to act as a trigger for inflammation mediated by CD68+ macrophages and CD3+ T lymphocytes. Patients with severe ABRA may develop coma responsive to immunosuppressive treatment. Case Presentation. A 57-year-old man presented to the neurological intensive care unit febrile, obtunded, and with a left hemiparesis. He had suffered from intermittent left arm weakness and numbness for several months prior. Serum and cerebrospinal fluid studies showed a lymphocytic leukocytosis in the cerebrospinal fluid (CSF), but no other evidence of infection, and the patient underwent a brain biopsy. Histopathological examination demonstrated amyloid angiopathy, with an extensive perivascular lymphocytic infiltrate, indicative of ABRA. The patient was started on cyclophosphamide and steroids. Following a week of treatment he awakened and over several weeks made a significant neurological recovery. Conclusions. ABRA can have a variety of clinical presentations, including impairments in consciousness and coma. Accurate pathological diagnosis, followed by aggressive immunosuppression, can lead to impressive neurological improvements. This diagnosis should be considered in patients with paroxysmal recurrent neurological symptoms and an accelerated progression.
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- 2012
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8. Decline in stroke alerts and hospitalisations during the COVID-19 pandemic
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Tina Burton, Tracy Madsen, Malveeka Sharma, Vasileios-Arsenios Lioutas, Judith Clark, Jillian O'Sullivan, Mitchell S. V. Elkind, Joshua Z. Willey, Randolph S. Marshall, Magdy H. Selim, David Greer, David L. Tirschwell, Amelia Boehme, and Hugo J. Aparicio
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Neurology. Diseases of the nervous system ,RC346-429 - Abstract
Introduction Patients with stroke-like symptoms may be underutilising emergency medical services and avoiding hospitalisation during the COVID-19 pandemic. We investigated a decline in admissions for stroke and transient ischaemic attack (TIA) and emergency department (ED) stroke alert activations.Methods We retrospectively compiled total weekly hospital admissions for stroke and TIA between 31 December 2018 and 21 April 2019 versus 30 December 2019 and 19 April 2020 at five US tertiary academic comprehensive stroke centres in cities with early COVID-19 outbreaks in Boston, New York City, Providence and Seattle. We collected available data on ED stroke alerts, stroke severity using the National Institutes of Health Stroke Scale (NIHSS) and time from symptom onset to hospital arrival.Results Compared with 31 December 2018 to 21 April 2019, a decline in stroke/TIA admissions and ED stroke alerts occurred during 30 December 2019 to 19 April 2020 (p trend
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9. Neurological Dashboards and Consultation Turnaround Time at an Academic Medical Center.
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Benjamin Kummer, Joshua Z. Willey, Michael J. Zelenetz, Yiping Hu, Soumitra Sengupta, Mitchell S. V. Elkind, and George Hripcsak
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- 2019
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10. Pulsatility and flow patterns across macro- and microcirculatory arteries of continuous-flow left ventricular assist device patients
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Eric J. Stöhr, Ruiping Ji, Giulio Mondellini, Lorenzo Braghieri, Koichi Akiyama, Francesco Castagna, Alberto Pinsino, John R. Cockcroft, Ronald H. Silverman, Samuel Trocio, Oksana Zatvarska, Elisa Konofagou, Iason Apostolakis, Veli K. Topkara, Hiroo Takayama, Koji Takeda, Yoshifumi Naka, Nir Uriel, Melana Yuzefpolskaya, Joshua Z. Willey, Barry J. McDonnell, and Paolo C. Colombo
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Pulmonary and Respiratory Medicine ,Transplantation ,Surgery ,Cardiology and Cardiovascular Medicine - Published
- 2023
11. Risk Factors for New Neurologic Diagnoses in Hospitalized Patients With COVID-19
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Kiran T. Thakur, Victoria T. Chu, Christine Hughes, Carla Y. Kim, Shannon Fleck-Derderian, Catherine E. Barrett, Elizabeth Matthews, Alanna Balbi, Amanda Bilski, Mashina Chomba, Ori Lieberman, Samuel D. Jacobson, Sachin Agarwal, David Roh, Soojin Park, Vivian Ssonko, Wendy G. Silver, Wendy D. Vargas, Andrew Geneslaw, Michelle Bell, Brandon Waters, Agam Rao, Jan Claassen, Amelia Boehme, Joshua Z. Willey, Mitchell S.V. Elkind, Magdalena E. Sobieszczyk, Jason Zucker, Andrea McCollum, and James Sejvar
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Neurology (clinical) ,Research Article - Abstract
Background and ObjectivesThere have been numerous reports of neurologic manifestations identified in hospitalized patients infected with SARS-CoV-2, the virus that causes COVID-19. Here, we identify the spectrum of associated neurologic symptoms and diagnoses, define the time course of their development, and examine readmission rates and mortality risk posthospitalization in a multiethnic urban cohort.MethodsWe identify the occurrence of new neurologic diagnoses among patients with laboratory-confirmed SARS-CoV-2 infection in New York City. A retrospective cohort study was performed on 532 cases (hospitalized patients with new neurologic diagnoses within 6 weeks of positive SARS-CoV-2 laboratory results between March 1, 2020, and August 31, 2020). We compare demographic and clinical features of the 532 cases with 532 controls (hospitalized COVID-19 patients without neurologic diagnoses) in a case-control study with one-to-one matching and examine hospital-related data and outcomes of death and readmission up to 6 months after acute hospitalization in a secondary case-only analysis.ResultsAmong the 532 cases, the most common new neurologic diagnoses included encephalopathy (478, 89.8%), stroke (66, 12.4%), and seizures (38, 7.1%). In the case-control study, cases were more likely than controls to be male (58.6% vs 52.8%, p = 0.05), had baseline neurologic comorbidities (36.3% vs 13.0%, p < 0.0001), and were to be treated in an intensive care unit (62.0% vs 9.6%, p < 0.0001). Of the 394 (74.1%) cases who survived acute hospitalization, more than half (220 of 394, 55.8%) were readmitted within 6 months, with a mortality rate of 23.2% during readmission.DiscussionHospitalized patients with SARS-CoV-2 and new neurologic diagnoses have significant morbidity and mortality postdischarge. Further research is needed to define the effect of neurologic diagnoses during acute hospitalization on longitudinal post-COVID-19–related symptoms including neurocognitive impairment.
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- 2022
12. Dolichoectasia: a brain arterial disease with an elusive treatment
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Edgar R. Lopez-Navarro, Soojin Park, Joshua Z. Willey, and Jose Gutierrez
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Psychiatry and Mental health ,Neurology (clinical) ,Dermatology ,General Medicine - Published
- 2022
13. Stroke epidemiology and outcomes in the modern era of left ventricular assist devices
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Chinwe Ibeh, Kara R. Melmed, Melana Yuzefpolskaya, Paolo C. Colombo, and Joshua Z. Willey
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Cardiology and Cardiovascular Medicine - Published
- 2022
14. Presence of Intracardiac Thrombus at the Time of Left Ventricular Assist Device Implantation Is Associated With an Increased Risk of Stroke and Death
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Ryan T. Demmer, Paolo C. Colombo, Hiroo Takayama, L. Witer, Gabriel Sayer, Justin Fried, Azka Javaid, L. Braghieri, Heidi Lumish, G.M. Mondellini, Claudio A. Bravo, Nir Uriel, Veli K. Topkara, Joshua Z. Willey, Yoshifumi Naka, Koji Takeda, Melana Yuzefpolskaya, and Yuji Kaku
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Article ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,parasitic diseases ,medicine ,Operative report ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,Stroke ,Retrospective Studies ,Heart Failure ,Intracardiac thrombus ,business.industry ,Hazard ratio ,Thrombosis ,Middle Aged ,medicine.disease ,Confidence interval ,Treatment Outcome ,Increased risk ,Heart failure ,Ventricular assist device ,Cardiology ,Female ,Heart-Assist Devices ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background Heart failure predisposes to intracardiac thrombus (ICT) formation. There are limited data on the prevalence and impact of preexisting ICT on postoperative outcomes in left ventricular assist device patients. We examined the risk for stroke and death in this patient population. Methods and Results We retrospectively studied patients who were implanted with HeartMate (HM) II or HM3 between February 2009 and March 2019. Preoperative transthoracic echocardiograms, intraoperative transesophageal echocardiograms and operative reports were reviewed to identify ICT. There were 525 patients with a left ventricular assist device (median age 60.6 years, 81.8% male, 372 HMII and 151 HM3) included in this analysis. An ICT was identified in 44 patients (8.4%). During the follow-up, 43 patients experienced a stroke and 55 died. After multivariable adjustment, presence of ICT increased the risk for the composite of stroke or death at 6-month (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.00–3.33, P = .049). Patients with ICT were also at higher risk for stroke (HR 2.45, 95% CI 1.14–5.28, P = .021) and death (HR 2.36, 95% CI 1.17–4.79 P = .016) at 6 months of follow-up. Conclusions The presence of ICT is an independent predictor of stroke and death at 6 months after left ventricular assist device implantation. Additional studies are needed to help risk stratify and optimize the perioperative management of this patient population.
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- 2021
15. Physical Activity Is Inversely Associated With Severe Intracranial Stenosis in Stroke-Free Participants of NOMAS
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Dixon Yang, Minghua Liu, Joshua Z. Willey, Farid Khasiyev, Sarah E. Tom, Tatjana Rundek, Ying K. Cheung, Clinton B. Wright, Ralph L. Sacco, Mitchell S.V. Elkind, and Jose Gutierrez
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Advanced and Specialized Nursing ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine - Abstract
Background: Although protective in secondary stroke prevention of intracranial arterial stenosis (ICAS), it is uncertain if the benefits of leisure time physical activity (LTPA) extend to asymptomatic ICAS or extracranial carotid stenosis (ECAS). Therefore, we sought to determine LTPA’s relationship with ECAS and ICAS in a stroke-free, race-ethnically diverse cohort. Methods: This cross-sectional study included participants from the magnetic resonance imaging substudy of the Northern Manhattan Study, of whom 1274 had LTPA assessments at enrollment. LTPA was represented continuously as metabolic equivalent score (MET-score) and ordinally as model-based cluster analysis (LTPA-cluster), both based on the same LTPA assessments. We evaluated ECAS sonographically using carotid intima-media thickening and number of carotid plaques. ICAS was assessed with time-of-flight magnetic resonance angiograph and defined as ≥50% or ≥70% stenosis. We applied regression analyses to evaluate the association between LTPA with ECAS and ICAS, adjusting for confounders. Results: Of 1274 included participants (mean age 71±9 years; 60% women; 65% Hispanic), the mean MET-score was 10±16 and 60% were in a LTPA-cluster with any activity. Among those with carotid ultrasound (n=1234), the mean carotid intima-media thickening was 0.97±0.09 mm, and 56% of participants had at least one carotid plaque identified. Among those with magnetic resonance angiograph (n=1211), 8% had ≥50% ICAS and 5% had ≥70% ICAS. For ICAS, MET-score was associated with ≥70% ICAS (adjusted odds ratio per unit increase in MET-score [95% CI, 0.97 [0.94–0.99]) but not with ECAS measures (carotid intima-media thickening, adjusted β-estimate per unit increase in MET-score [95% CI], 0.002 [−0.003 to 0.006] or number of plaques, adjusted β-estimate [95% CI], 0.0001 [−0.0001 to 0.0003]). Substituting MET-score with LTPA-clusters replicated the association between ≥70% ICAS and LTPA (adjusted odds ratio per each increased LTPA-cluster [95% CI], 0.83 [0.70–0.99]). Conclusions: In this diverse stroke-free population, we found LTPA most strongly associated with asymptomatic ≥70% ICAS. Given the high-risk nature of ≥70% ICAS, these findings may emphasize the role of LTPA in people at risk for ICAS.
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- 2022
16. Cerebral vasoreactivity in HeartMate 3 patients
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L. Braghieri, Hiroo Takayama, G.M. Mondellini, Nir Uriel, Veli K. Topkara, John R. Cockcroft, Koji Takeda, Barry J. McDonnell, Koichi Akiyama, Eric J. Stöhr, Joshua Z. Willey, A.M. Amlani, Ruiping Ji, Alberto Pinsino, Yoshifumi Naka, Melana Yuzefpolskaya, and Paolo C. Colombo
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Male ,Pulmonary and Respiratory Medicine ,Middle Cerebral Artery ,medicine.medical_specialty ,Ultrasonography, Doppler, Transcranial ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Diastole ,Internal medicine ,medicine ,Homeostasis ,Humans ,Lung transplantation ,Heart Failure ,Transplantation ,business.industry ,Stroke Volume ,Equipment Design ,Middle Aged ,Vasodilation ,Regional Blood Flow ,Cerebrovascular Circulation ,Pulsatile Flow ,Cardiology ,Female ,Surgery ,Heart-Assist Devices ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery - Abstract
While rates of stroke have declined with the HeartMate3 (HM3) continuous- flow (CF) left ventricular assist device (LVAD), the impact of non-pulsatile flow and artificial pulse physiology on cerebrovascular function is not known. We hypothesized that improved hemodynamics and artificial pulse physiology of HM3 patients would augment cerebrovascular metabolic reactivity (CVR) compared with HeartMate II (HMII) CF-LVAD and heart failure (HF) patients.Mean, peak systolic and diastolic flow velocities (MFV, PSV, MinFV, respectively) and cerebral pulsatility index were determined in the middle cerebral artery (MCA) before and after a 30 sec breath-hold challenge in 90 participants: 24 healthy controls; 30 HF, 15 HMII, and 21 HM3 patients.In HM3 patients, breath-holding increased MFV (Δ8 ± 10 cm/sec, p.0001 vs baseline) to levels similar to HF patients (Δ9 ± 8 cm/sec, p.05), higher than HMII patients (Δ2 ± 8 cm/sec, p.01) but lower than healthy controls (Δ13 ± 7 cm/sec, p.05). CF-LVAD altered the proportion of systolic and diastolic flow responses as reflected by a differential cerebral pulsatility index (p = .03). Baseline MFV was not related to CVR (rCompared with HMII, HM3 patients have a significantly improved CVR. However, CVR remains lower in HM3 and HF patients than in healthy controls, therefore suggesting that changes in cerebral hemodynamics are not reversed by CF-LVAD therapy. Further research on the mechanisms and the long-term impact of altered cerebral hemodynamics in this unique patient population are warranted.
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- 2021
17. Pre-existing cerebrovascular disease in pregnancy: a case series of neurologic and obstetric outcomes
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Ms. Sarah L WYCKOFF, Gular MAMMADLI, Stephanie E PURISCH, Anita P LASALA, Joshua Z WILLEY, Whitney A BOOKER, and Eliza C MILLER
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Obstetrics and Gynecology - Published
- 2023
18. Increased Aortic Stiffness Is Associated With Higher Rates of Stroke, Gastrointestinal Bleeding and Pump Thrombosis in Patients With a Continuous Flow Left Ventricular Assist Device
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Hannah Rosenblum, John R. Cockcroft, Eric J. Stöhr, Veli K. Topkara, Barry J. McDonnell, Yoshifumi Naka, A.M. Zuver, Sofia Shames, G.M. Mondellini, Joshua Z. Willey, Melana Yuzefpolskaya, Azka Javaid, Koji Takeda, Ruiping Ji, Alberto Pinsino, Hiroo Takayama, A. Reshad Garan, and Paolo C. Colombo
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Male ,Gastrointestinal bleeding ,medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Vascular Stiffness ,0302 clinical medicine ,Internal medicine ,medicine ,Humans ,In patient ,030212 general & internal medicine ,Stroke ,Retrospective Studies ,Heart Failure ,business.industry ,Thrombosis ,medicine.disease ,medicine.anatomical_structure ,Blood pressure ,Heart failure ,Ventricular assist device ,Vascular resistance ,Cardiology ,Female ,Aortic stiffness ,Heart-Assist Devices ,Gastrointestinal Hemorrhage ,Cardiology and Cardiovascular Medicine ,business - Abstract
In the general population, increased aortic stiffness is associated with an increased risk of cardiovascular events. Previous studies have demonstrated an increase in aortic stiffness in patients with a continuous flow left ventricular assist device (CF-LVAD). However, the association between aortic stiffness and common adverse events is unknown.Forty patients with a HeartMate II (HMII) (51 $ 11 years; 20% female; 25% ischemic) implanted between January 2011 and September 2017 were included. Two-dimensional transthoracic echocardiograms of the ascending aorta, obtained before HMII placement and early after heart transplant, were analyzed to calculate the aortic stiffness index (AO-SI). The study cohort was divided into patients who had an increased vs decreased AO-SI after LVAD support. A composite outcome of gastrointestinal bleeding, stroke, and pump thrombosis was defined as the primary end point and compared between the groups. While median AO-SI increased significantly after HMII support (AO-SI 4.4-6.5, P = .012), 16 patients had a lower AO-SI. Patients with increased (n = 24) AO-SI had a significantly higher rate of the composite end point (58% vs 12%, odds ratio 9.8, P.01). Similarly, those with increased AO-SI tended to be on LVAD support for a longer duration, had higher LVAD speed and reduced use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers.Increased aortic stiffness in patients with a HMII is associated with a significantly higher rates of adverse events. Further studies are warranted to determine the causality between aortic stiffness and adverse events, as well as the effect of neurohormonal modulation on the conduit vasculature in patients with a CF-LVAD.
- Published
- 2021
19. Cognition predicts days-alive-out-of-hospital after LVAD implantation
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Marykay A. Pavol, Amelia K. Boehme, Melana Yuzefpolskaya, Chinwe Ibeh, Joanne R. Festa, Joshua Z. Willey, Mathew S. Maurer, and Jesus M. Casida
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medicine.medical_specialty ,Biomedical Engineering ,Medicine (miscellaneous) ,Bioengineering ,030204 cardiovascular system & hematology ,Biomaterials ,03 medical and health sciences ,Cognition ,0302 clinical medicine ,Quality of life ,medicine ,Humans ,030212 general & internal medicine ,Retrospective Studies ,Heart Failure ,Out of hospital ,business.industry ,General Medicine ,equipment and supplies ,medicine.disease ,Hospitals ,Treatment Outcome ,Heart failure ,Emergency medicine ,Heart-Assist Devices ,business - Abstract
Objective: Cognition influences hospitalization rates for a variety of patient groups but this association has not been examined in heart failure (HF) patients undergoing left ventricular assist device (LVAD) implantation. We used cognition to predict days-alive-out-of-hospital (DAOH) in patients after LVAD surgery. Methods: We retrospectively identified 59 HF patients with cognitive assessment prior to LVAD. Cognitive tests of attention, memory, language, and visual motor speed were averaged into one score. DAOH was converted to a percentage based on total days from LVAD surgery to either heart transplant or 900 days post-LVAD. Variables significantly associated with DAOH in univariate analyses were included in a linear regression model to predict DAOH. Results: A linear regression model including LVAD type (continuous or pulsatile flow) and cognition significantly predicted DAOH (F(2,54) = 6.44, p = 0.003, R2 = .19). Inspection of each variable revealed that cognition was a significant predictor in the model (β = .11, SE = .04, p = 0.007) but LVAD type was not ( p = 0.08). Conclusions: Cognitive performance assessed prior to LVAD implantation predicted how much time patients spent out of the hospital following surgery. Further studies are warranted to identify the impact of pre-LVAD cognition on post-LVAD hospitalization.
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- 2021
20. Predictors of atrial fibrillation on implantable cardiac monitoring for cryptogenic stroke
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Emily Howe, Joshua Z. Willey, Ellie J. Coromilas, Elaine Wan, Amar D Desai, Yiyi Zhang, Hasan Garan, Jose Dizon, and Angelo B. Biviano
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Male ,medicine.medical_specialty ,Cryptogenic stroke ,030204 cardiovascular system & hematology ,Article ,03 medical and health sciences ,Loop recorder ,Electrocardiography ,0302 clinical medicine ,Risk Factors ,Physiology (medical) ,Internal medicine ,medicine ,Implantable loop recorder ,Humans ,030212 general & internal medicine ,Stroke ,Aged ,Ischemic Stroke ,Retrospective Studies ,Ejection fraction ,business.industry ,Proportional hazards model ,Atrial fibrillation ,medicine.disease ,Institutional review board ,Thrombosis ,Electrophysiology ,Etiology ,Cardiology ,Electrocardiography, Ambulatory ,Female ,Cardiology and Cardiovascular Medicine ,business ,Arrhythmia - Abstract
Background Since the CRYSTAL-AF trial, implantation and usage of implantable loop recorder (ICM) after cryptogenic stroke (CS) for detection of atrial fibrillation (AF) has increased. However, it is unclear which CS patients would most benefit from long term ICM monitoring. This study aims to determine the risk factors in patients that would confer maximum benefit from ICM placement following CS. Methods A Columbia University Institutional Review Board (IRB) approved retrospective analysis of medical records of 125 patients with CS followed by implantation of ICM was evaluated. Univariable and multivariable time-to-event analyses were performed on demographics, hours of activity and variability (HRV), stroke location, thrombosis etiology, and CHA2DS2 − VASc score. The primary outcome was presence of ICM-detected AF defined as AF lasting at least 2 min. Results One hundred twenty-five patients (mean 67.6 years ± 2.4 years, 60% male) were followed for at least 3 months. Twenty-two patients (18%) were found to have clinically verified detected AF; median of time to detection was 95 days. Upon univariable demographic analysis followed by multivariable Cox regression analysis, individuals with age 75 or older (HR: 3.987, p = 0.0046) or LVEF 40% and lower (HR: 3.056, p = 0.0213) had significantly higher risk of AF. Diabetics also had a lower AF detection in multivariable analysis (HR: 0.128, p = 0.0466). Conclusions Age 75 or older and LVEF ≤40% were the factors on multivariable analysis that predicted AF detection. Diabetes is a possible significant factor which should be evaluated further. CHA2DS2 − VASc score was notably not predictive of AF detected on ICM. Supplementary Information The online version contains supplementary material available at 10.1007/s10840-021-00985-1.
- Published
- 2021
21. Utility of the AM-PAC '6 Clicks' Basic Mobility and Daily Activity Short Forms to Determine Discharge Destination in an Acute Stroke Population
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Lorenzo O, Casertano, Clare C, Bassile, Jacqueline S, Pfeffer, Theresa M, Morrone, Joel, Stein, Joshua Z, Willey, and Ashwini K, Rao
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Adult ,Male ,Stroke ,Occupational Therapy ,Activities of Daily Living ,Stroke Rehabilitation ,Humans ,Female ,Patient Discharge ,Aged ,Retrospective Studies ,Skilled Nursing Facilities - Abstract
Importance: The American Heart Association and American Stroke Association recommend early identification of level of rehabilitative care as a priority after stroke. Objective: To evaluate the utility of the Activity Measure for Post-Acute Care (AM-PAC) “6 Clicks” Daily Activity and Basic Mobility forms to determine the next level of rehabilitation after hospitalization for adults with stroke. Design: Retrospective cohort design using medical records from 2015 to 2016. Setting: Major urban hospital. Participants: Patients admitted to the stroke service, with a confirmed stroke, who were seen by a physical or occupational therapist; who had a 6 Clicks Basic Mobility or Daily Activity score at initial evaluation; and who were discharged to home, an acute inpatient rehabilitation facility (IRF), or a subacute skilled nursing facility (SNF). Outcomes and Measures: Length of stay and discharge destination. Results: Seven hundred four participants (M age = 68.28 yr; 51.21% female) were included. Analysis of variance and receiver operating characteristic curves were performed. Daily Activity scores were highest for home discharge, lower for IRF discharge, and lowest for SNF discharge; Basic Mobility showed a similar pattern. Cutoff values distinguishing home from further inpatient rehabilitation were 44.50 for Basic Mobility and 39.40 for Daily Activity scores (area under the curve [AUC] = .82 for both forms), with scores of 34.59 (AUC = 0.64) and 31.32 (AUC = 0.67) separating IRF from SNF, respectively. Conclusions and Relevance: Therapists should incorporate 6 Clicks scores into their discharge planning. What This Article Adds: This research demonstrates the utility of an outcome measure in the acute care setting that assists in planning discharge destination for patients with stroke.
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- 2022
22. Mechanical thrombectomy after acute ischemic stroke in patients with left ventricular assist devices: A nationwide analysis
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Chinwe Ibeh, Grace K Mandigo, Jonathan A Sisti, Sean D Lavine, and Joshua Z Willey
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Neurology ,equipment and supplies - Abstract
Introduction: Left ventricular assist devices (LVADs) are an established, durable, and life-saving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population, but LVO trials largely excluded patients on mechanical circulatory support, and large-scale analyses of outcomes following these interventions in the LVAD population are lacking. Methods: Using the National Inpatient Sample, we identified all adult patients hospitalized with acute ischemic stroke (AIS) from 2005 to 2018. Regression models adjusting for patient demographics, hospital factors, and clinical severity were used to compare outcomes following MT in patients with and without LVAD. Subgroup analyses were also performed in LVAD patients experiencing stroke in the post-operative setting and stroke in the setting of pre-existing devices. Results: Of the 1,633,234 AIS hospitalizations identified, 794 occurred in patients with LVADs. Around 61% were post-operative. Post-stroke in-hospital mortality was higher among patients with LVADs (23.3% vs 7.23%, P Conclusion: Our data suggest MT is not a futile treatment approach in patients with pre-existing LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.
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- 2022
23. The Role of the Vulnerable Carotid Plaque in Embolic Stroke of Unknown Source
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Joshua Z. Willey and Gerard Pasterkamp
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Stroke ,Embolic Stroke ,Carotid Arteries ,Humans ,Carotid Stenosis ,Cardiology and Cardiovascular Medicine ,Magnetic Resonance Imaging ,Plaque, Atherosclerotic - Published
- 2022
24. Carotid artery structure and hemodynamics and their association with adverse vascular events in left ventricular assist device patients
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M. Mabasa, Joshua Z. Willey, Barry J. McDonnell, E.A. Royzman, Michael Eugene Kiyatkin, A.M. Zuver, Antonia Gaudig, Azka Javaid, Paolo C. Colombo, Melana Yuzefpolskaya, and Eric J. Stöhr
- Subjects
Nephrology ,Gastrointestinal bleeding ,medicine.medical_specialty ,medicine.medical_treatment ,0206 medical engineering ,Biomedical Engineering ,Medicine (miscellaneous) ,Hemodynamics ,02 engineering and technology ,030204 cardiovascular system & hematology ,Biomaterials ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,Stroke ,business.industry ,equipment and supplies ,medicine.disease ,020601 biomedical engineering ,Cardiac surgery ,Stenosis ,Ventricular assist device ,Cardiology ,Carotid artery structure ,Cardiology and Cardiovascular Medicine ,business - Abstract
Left ventricular assist devices (LVADs) are associated with major vascular complications including stroke and gastrointestinal bleeding (GIB). These adverse vascular events may be the result of widespread vascular dysfunction resulting from pre-LVAD abnormalities or continuous flow during LVAD therapy. We hypothesized that pre-existing large artery atherosclerosis and/or abnormal blood flow as measured in carotid arteries using ultrasonography are associated with a post-implantation composite adverse outcome including stroke, GIB, or death. We retrospectively studied 141 adult HeartMate II patients who had carotid ultrasound duplex exams performed before and/or after LVAD surgery. Structural parameters examined included plaque burden and stenosis. Hemodynamic parameters included peak-systolic, end-diastolic, and mean velocity as well as pulsatility index. We examined the association of these measures with the composite outcome as well as individual subcomponents such as stroke. After adjusting for established risk factors, the composite adverse outcome was associated with pre-operative moderate-to-severe carotid plaque (OR 5.08, 95% CI 1.67-15.52) as well as pre-operative internal carotid artery stenosis (OR 9.02, 95% CI 1.06-76.56). In contrast, altered hemodynamics during LVAD support were not associated with the composite outcome. Our findings suggest that pre-existing atherosclerosis possibly in combination with LVAD hemodynamics may be an important contributor to adverse vascular events during mechanical support. This encourages greater awareness of carotid morphology pre-operatively and further study of the interaction between hemodynamics, pulsatility, and structural arterial disease during LVAD support.
- Published
- 2021
25. Safety and Hospital Costs Averted Using a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Strokes: The RAVEN Clinic
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Mitchell S.V. Elkind, Amelia K. Boehme, Bernard P. Chang, Joshua Z. Willey, Steven D. Shapiro, and Eliza C. Miller
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medicine.medical_specialty ,business.industry ,030208 emergency & critical care medicine ,Original Articles ,Minor (academic) ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Emergency medicine ,Medicine ,Transient (computer programming) ,Neurology (clinical) ,business ,Outpatient management ,Stroke ,030217 neurology & neurosurgery - Abstract
Study Objective: Patients presenting to emergency departments (ED) with transient ischemic attack and minor strokes (TIAMS) are often admitted for evaluation, though experience in other countries have suggested that an expedited outpatient care models may be a safe alternative. We hypothesized that a rapid access clinic for select TIAMS was feasible and would avert hospitalization costs. Methods: This retrospective analysis included patients presenting to our institution’s ED with TIAMS and NIHSS ≤5 in calendar year 2017. We referred low-risk patients with TIAMS to a Rapid Access Vascular Evaluation-Neurology (RAVEN) clinic within 24 hours of ED discharge. We identified admitted patients who met RAVEN criteria at ED presentation. Rates of follow-up to the RAVEN clinic were recorded. Financial data collected included total hospital costs and time spent in the ED, as well hospital length of stay for admitted patients with low-risk TIAMS. Results: In 2017, 149 patients were referred to RAVEN clinic and 50 patients were admitted. Of the RAVEN patients 99 (94%) appeared as scheduled. None had clinical changes between ED discharge and clinical evaluation. One patient required hospitalization at the RAVEN evaluation. When compared to RAVEN patients, admitted patients had significantly higher $7,719 (SD 354) total hospital costs and were hospitalized for 2 days on average. Overall, the RAVEN strategy averted approximately $764,000 in hospitalization costs and 208 hospital bed-days in accounting year 2017. Conclusions: For select patients presenting with TIAMS without disabling deficits, a rapid outpatient evaluation may be feasible while averting significant total hospital costs and preserving inpatient hospital beds.
- Published
- 2020
26. Clinical Impact of Hematoma Expansion in Left Ventricular Assist Device Patients
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Yoshifumi Naka, E. Sander Connolly, Melana Yuzefpolskya, Nir Uriel, Kara Melmed, G.M. Mondellini, Sachin Agarwal, Joshua Z. Willey, David Roh, Soojin Park, Amelia K. Boehme, Jan Claassen, and Paolo C. Colombo
- Subjects
Male ,medicine.medical_specialty ,Heart Ventricles ,medicine.medical_treatment ,Population ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Hematoma ,Interquartile range ,Internal medicine ,Humans ,Medicine ,Hospital Mortality ,Prospective Studies ,education ,Stroke ,Aged ,Cerebral Hemorrhage ,Retrospective Studies ,Aged, 80 and over ,Intracerebral hemorrhage ,education.field_of_study ,business.industry ,Retrospective cohort study ,Odds ratio ,Middle Aged ,equipment and supplies ,medicine.disease ,030220 oncology & carcinogenesis ,Ventricular assist device ,Cardiology ,Female ,Surgery ,Heart-Assist Devices ,Neurology (clinical) ,business ,030217 neurology & neurosurgery - Abstract
Background Hematoma expansion (HE) is associated with poor outcome in patients with intracerebral hemorrhage (ICH), but the impact on patients with an left ventricular assist device (LVAD) is unknown. We aimed to define the occurrence of HE in the LVAD population and to determine the association between HE and mortality. Methods We performed a retrospective cohort study of LVAD patients and intentionally matched anticoagulated controls without LVAD admitted to Columbia University Irving Medical Center with ICH between 2008 and 2019. We compared HE occurrence between patients with an LVAD and those without an LVAD using regression modeling, adjusting for factors known to influence HE. We evaluated pump thrombosis following anticoagulation reversal. We examined the association between HE and hospital mortality using Poisson regression modeling adjusting for factors associated with poor outcome. Results Among 605 patients with an LVAD, we identified 28 patients with ICH meeting the study’s inclusion criteria. Our LVAD ICH cohort was predominantly male (71%), with a mean age of 56 ± 10 years. The median baseline hematoma size was 20.1 mL3 (interquartile range [IQR], 8.6–46.9 mL3), and the median ICH score was 1 (IQR, 1–2). There was no significant difference in occurrence of HE in LVAD patients and matched non-LVAD patients (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.4–4.2). There was an association between HE and in-hospital mortality in LVAD patients (adjusted OR, 4.8; 95% CI, 1.4–6.2). Conclusions HE occurrence appears to be similar in LVAD and non-LVAD patients. HE has a significant impact on LVAD ICH mortality, underscoring the importance of adequate coagulopathy reversal and blood pressure management in these patients.
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- 2020
27. Abstract WMP16: Race, Gender, And Cognition In Heart Failure
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Chinwe Ibeh, Marykay Pavol, and Joshua Z Willey
- Subjects
Advanced and Specialized Nursing ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine - Abstract
Background: Cognitive impairment is prevalent in the heart failure (HF) population, eventually complicating the disease course in over 50%. Disease management and risk factor control are thought to play a role. Disparities in healthcare utilization and access may also contribute. We hypothesize gender, ethnic and racial disparities in HF contribute to accelerated cognitive decline. Methods: We performed a cross-sectional analysis of study participants age ≥ 60 years in the biannual NHANES survey. Medical history, clinical variables, and Digit Symbol Substitution Test (DSST) scores from cycles 1999, 2001, 2011, and 2013 were extracted. The DSST assesses visuomotor, attention, and processing speed, and in prior studies was found to be strongly associated with vascular-related cognitive impairment. Survey-weighted regression models adjusting for age, race, gender, education, vascular risk factors and history of stroke were used to generate nationally representative estimates. Results: 6,651 study participants representing 51,841,223 adults ≥ 60 years were included, 7% with prevalent HF. Participants with HF were older (73.8 vs 70.0, P Conclusions: Women with HF experience greater levels of HF-related cognitive impairment. These differences may be a consequence of known differential rates of early HF detection and disease maintenance across genders.
- Published
- 2022
28. Abstract TMP64: Outcomes After Mechanical Thrombectomy In Patients With Left Ventricular Assist Devices
- Author
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Chinwe Ibeh, Sean D Lavine, Grace K Mandigo, Jonathan A Sisti, and Joshua Z Willey
- Subjects
Advanced and Specialized Nursing ,Neurology (clinical) ,equipment and supplies ,Cardiology and Cardiovascular Medicine - Abstract
Background: Left ventricular assist devices (LVADs) are an established durable and lifesaving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population but LVO trials largely excluded patients on mechanical circulatory support and large-scale analyses of outcomes following these interventions in the LVAD population are lacking. Methods: Using the National Inpatient Sample (2012 - 2018) we identified all adult patients hospitalized with acute ischemic stroke (AIS). The presence of LVAD, the use of MT, and additional covariates were extracted. Descriptive statistics and multivariable regression models were used to compare outcomes following MT in patients with and without LVADs. Results: Of the 798,059 AIS hospitalizations identified, 366 occurred in patients with LVADs. LVAD patients were younger (mean age 59.6 [13.2] vs 70.1 [14.3], p Conclusion: Our data suggests MT is not a futile treatment approach in patients with LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.
- Published
- 2022
29. Abstract WP189: Ethnic And Racial Disparities In Prevalent Stroke Among Patients With Heart Failure
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Chinwe Ibeh, Eliza C Miller, Randolph S Marshall, and Joshua Z Willey
- Subjects
Advanced and Specialized Nursing ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine - Abstract
Background: Ethnic and racial disparities in healthcare contribute to cardiovascular morbidity and mortality. Stroke is prevalent among patients with heart failure (HF) and is associated with worse long-term outcomes. We hypothesized that disparities in cardiovascular risk profiles contribute to differences in stroke prevalence among patients with HF. Methods: We performed a cross-sectional analysis of study participants age ≥ 60 in the biannual NHANES survey. Medical history and clinical variables were obtained from cycles 1999, 2001, 2011, and 2013. We created survey-weighted regression models to generate nationally representative estimates. Results: A total of 20,315 study participants representing 212,156,242 adults were included, 2.5% with prevalent HF. Compared to those without HF, participants with HF were more often of White race (72.8% vs 68.3%, P = 0.02) and less often of Hispanic ethnicity (10.4% vs 14.3%, P = 0.04). Stroke was 10 times more prevalent among individuals with HF (20% vs 2%, P Conclusion: People of Hispanic ethnicity with HF have a higher prevalence of stroke which is not explained by vascular risk profiles and warrants further investigation.
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- 2022
30. Contributors
- Author
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Harold P. Adams, Opeolu Adeoye, Gregory W. Albers, Andrei V. Alexandrov, Sepideh Amin-Hanjani, Hongyu An, Craig S. Anderson, Josef Anrather, Hugo J. Aparicio, Ken Arai, Jaroslaw Aronowski, Kunakorn Atchaneeyasakul, Heinrich Audebert, Roland N. Auer, Issam A. Awad, Hakan Ay, Selva Baltan, Ramani Balu, Mandana Behbahani, Oscar R. Benavente, Eric M. Bershad, Jimmy V. Berthaud, Spiros L. Blackburn, Leo H. Bonati, Julian Bösel, Marie Germaine Bousser, Joseph P. Broderick, Martin M. Brown, Wendy Brown, John C.M. Brust, Cheryl Bushnell, Patrícia Canhão, Louis R. Caplan, Julián Carrión-Penagos, Mar Castellanos, Michelle R. Caunca, Hugues Chabriat, Angel Chamorro, Jieli Chen, Jun Chen, Michael Chopp, Greg Christorforids, E. Sander Connolly, Steven C. Cramer, Brett L. Cucchiara, Alexandra L. Czap, Mark J. Dannenbaum, Patricia H. Davis, Ted M. Dawson, Valina L. Dawson, Arthur L. Day, T. Michael De Silva, Diana Aguiar de Sousa, Victor J. Del Brutto, Gregory J. del Zoppo, Colin P. Derdeyn, Marco R. Di Tullio, Hans Christoph Diener, Michael N. Diringer, Bruce H. Dobkin, Imanuel Dzialowski, Mitchell S.V. Elkind, Jordan Elm, Valery L. Feigin, José Manuel Ferro, Thalia S. Field, Marlene Fischer, Myriam Fornage, Karen L. Furie, Lidia Garcia-Bonilla, Steven L. Giannotta, Y. Pierre Gobin, Mark P. Goldberg, Larry B. Goldstein, Nicole R. Gonzales, David M. Greer, James C. Grotta, Ruiming Guo, Jose Gutierrez, Peter Harmel, George Howard, Virginia J. Howard, Jee-Yeon Hwang, Costantino Iadecola, Reza Jahan, Glen C. Jickling, Anne Joutel, Scott E. Kasner, Mira Katan, Christopher P. Kellner, Muhib Khan, Chelsea S. Kidwell, Helen Kim, Jong S. Kim, Charles E. Kircher, Timo Krings, Rita V. Krishnamurthi, Tobias Kurth, Maarten G. Lansberg, Elad I. Levy, David S. Liebeskind, Sook-Lei Liew, David J. Lin, Benjamin Lisle, Eng H. Lo, Patrick D. Lyden, Takakuni Maki, Georgios A. Maragkos, Miklos Marosfoi, Louise D. McCullough, Jason M. Meckler, James Frederick Meschia, Steven R. Messé, J Mocco, Maxim Mokin, Michael A. Mooney, Lewis B. Morgenstern, Michael A. Moskowitz, Michael T. Mullen, Steffen Nägel, Maiken Nedergaard, Justin A. Neira, Sarah Newman, Patrick J. Nicholson, Bo Norrving, Martin O’Donnell, Dimitry Ofengeim, Jun Ogata, Christopher S. Ogilvy, Emanuele Orrù, Santiago Ortega-Gutiérrez, Matthew Maximillian Padrick, Kaushik Parsha, Mark Parsons, Neil V. Patel, Virendra I. Patel, Ludmila Pawlikowska, Adriana Pérez, Miguel A. Perez-Pinzon, John M. Picard, Sean P. Polster, William J. Powers, Volker Puetz, Jukka Putaala, Margarita Rabinovich, Bruce R. Ransom, Jorge A. Roa, Gary A. Rosenberg, Christina P. Rossitto, Tatjana Rundek, Jonathan J. Russin, Ralph L. Sacco, Apostolos Safouris, Edgar A. Samaniego, Lauren H. Sansing, Nikunj Satani, Ronald J. Sattenberg, Jeffrey L. Saver, Sean I. Savitz, Christian Schmidt, Sudha Seshadri, Vijay K. Sharma, Frank R. Sharp, Kevin N. Sheth, Omar K. Siddiqi, Aneesh B. Singhal, Christopher G. Sobey, Clemens J. Sommer, Robert F. Spetzler, Christopher J. Stapleton, Ben A. Strickland, Hua Su, José I. Suarez, Hiroo Takayama, Joseph Tarsia, Turgut Tatlisumak, Ajith J. Thomas, John W. Thompson, Georgios Tsivgoulis, Elizabeth Tournier-Lasserve, Gabriel Vidal, Ajay K. Wakhloo, Babette B. Weksler, Joshua Z. Willey, Max Wintermark, Lawrence K.S. Wong, Guohua Xi, Jinchong Xu, Shadi Yaghi, Takenori Yamaguchi, Tuo Yang, Masahiro Yasaka, Darin B. Zahuranec, Feng Zhang, John H. Zhang, Zhitong Zheng, R. Suzanne Zukin, and Richard M. Zweifler
- Published
- 2022
31. Stroke and Other Vascular Syndromes of the Spinal Cord
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Hiroo Takayama, Virendra I. Patel, and Joshua Z. Willey
- Published
- 2022
32. Post-traumatic Stress Disorder Following Acute Stroke
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Tyler H Wen, Ian M. Kronish, Bernard P. Chang, Joshua Z. Willey, and Katharina Schultebraucks
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medicine.medical_specialty ,business.industry ,Traumatic stress ,Psychological intervention ,030208 emergency & critical care medicine ,General Medicine ,Emergency department ,030204 cardiovascular system & hematology ,medicine.disease ,Crowding ,03 medical and health sciences ,0302 clinical medicine ,Increased risk ,mental disorders ,Emergency medicine ,Medicine ,Mental health care ,cardiovascular diseases ,business ,Stroke ,Acute stroke - Abstract
Stroke is a devastating event that annually affects over 800,000 million individuals in the USA and is associated with significant individual and social costs. In this narrative review, we summarize current evidence regarding post-traumatic stress disorder (PTSD) following acute stroke. In addition to the long-term physical consequences, it is increasingly recognized that psychological distress is common after stroke and transient ischemic attack (TIA). Nearly 1 in 4 survivors of TIA and stroke report elevated symptoms of PTSD in the first year following their cerebrovascular event. Those individuals with PTSD symptoms are at elevated risk for not only sustained psychological distress but also increased risk for non-adherence to medication. Factors in the emergency department, such as crowding, may influence the development of PTSD following acute stroke and TIA. We also summarize the rationale and clinical importance of developing and implementing quantitative predictive models of post-stroke PTSD symptoms in the ED setting. The potential of promising early interventions to prevent PTSD critically hinges on the accurate and precise identification of patients at risk for PTSD. Predictive modeling of PTSD risk may greatly facilitate the prospective management of mental health care in ED patients after stroke.
- Published
- 2020
33. Stroke epidemiology and outcomes in the modern era of left ventricular assist devices
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Chinwe, Ibeh, Kara R, Melmed, Melana, Yuzefpolskaya, Paolo C, Colombo, and Joshua Z, Willey
- Subjects
Heart Failure ,Stroke ,Quality of Life ,Heart Transplantation ,Humans ,Thrombosis ,Heart-Assist Devices ,Retrospective Studies - Abstract
The care for the patients with end-stage heart failure has been revolutionized by the introduction of durable left ventricular assist devices, providing a substantial improvement in patient survival and quality of life and an alternative to heart transplantation. The newest devices have lower instances of mechanical dysfunction and associated pump thrombosis. Despite these improvements in complications, the use of continuous flow assist devices is still associated with high rates of thrombotic and hemorrhagic complications, most notably stroke in approximately 10% of continuous flow assist devices patients per year. With the newest HeartMate 3 devices, there have been lower observed rates of stroke, which has in part been achieved by both improvements in pump technology and knowledge of the risk factors for stroke and neurological complications. The therapeutic options available to clinicians to reduce the risk of stroke, including management of hypertension and antithrombotics, will be reviewed in this manuscript.
- Published
- 2021
34. Biomarkers of Coagulation and Inflammation in COVID-19-Associated Ischemic Stroke
- Author
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Khadean Moncrieffe, Jorge Luna, Jenelys Fernandez-Torres, David Flomenbaum, Joseph Dardick, Ava L. Liberman, Avinash Malaviya, Daniel L. Labovitz, Nikunj K. Patel, Charles Esenwa, Joshua Z. Willey, Aaron Lord, Joshua A. Benton, Koto Ishida, Inessa Goldman, Peter Mabie, Andrea Lendaris, Aureliana Toma, Shadi Yaghi, Natalie T Cheng, Jose Torres, Kathryn Kirchoff-Torres, Jennifer A. Frontera, Jenny Lu, Ainie Soetanto, Amelia K. Boehme, Thomas Snyder, Ryan Holland, Johanna Seiden, and David J. Altschul
- Subjects
Male ,2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Myocardial Infarction ,Inflammation ,Blood Sedimentation ,Severity of Illness Index ,Fibrin Fibrinogen Degradation Products ,Machine Learning ,Leukocyte Count ,medicine ,ischemic stroke ,Cluster Analysis ,Humans ,Thrombophilia ,Hospital Mortality ,Aged ,Retrospective Studies ,Advanced and Specialized Nursing ,Aged, 80 and over ,Venous Thrombosis ,L-Lactate Dehydrogenase ,business.industry ,Interleukin-6 ,SARS-CoV-2 ,COVID-19 ,Fibrinogen ,Middle Aged ,mortality ,C-Reactive Protein ,Logistic Models ,Coagulation ,Ischemic stroke ,Immunology ,Ferritins ,ComputingMethodologies_DOCUMENTANDTEXTPROCESSING ,Biomarker (medicine) ,biomarker ,Female ,Partial Thromboplastin Time ,Brief Reports ,Neurology (clinical) ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Pulmonary Embolism - Abstract
Supplemental Digital Content is available in the text., Background and Purpose: We sought to determine if biomarkers of inflammation and coagulation can help define coronavirus disease 2019 (COVID-19)–associated ischemic stroke as a novel acute ischemic stroke (AIS) subtype. Methods: We performed a machine learning cluster analysis of common biomarkers in patients admitted with severe acute respiratory syndrome coronavirus 2 to determine if any were associated with AIS. Findings were validated using aggregate data from 3 large healthcare systems. Results: Clustering grouped 2908 unique patient encounters into 4 unique biomarker phenotypes based on levels of c-reactive protein, D-dimer, lactate dehydrogenase, white blood cell count, and partial thromboplastin time. The most severe cluster phenotype had the highest prevalence of AIS (3.6%, P
- Published
- 2021
35. Neurological Outcomes of Patients With Mycotic Aneurysms in Infective Endocarditis
- Author
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Hang Shi, Richard L. Zampolin, Joshua Z. Willey, Farid Khasiyev, Charles Esenwa, Ives A Valenzuela, Neal S. Parikh, Jose Gutierrez, Sean D. Lavine, and Harsh Shah
- Subjects
medicine.medical_specialty ,Subarachnoid hemorrhage ,business.industry ,Original Articles ,030204 cardiovascular system & hematology ,Mycotic aneurysm ,medicine.disease ,Neurovascular bundle ,Surgery ,Natural history ,03 medical and health sciences ,0302 clinical medicine ,Bacterial endocarditis ,Cardiothoracic surgery ,Infective endocarditis ,Medicine ,Neurology (clinical) ,business ,Medical therapy ,030217 neurology & neurosurgery - Abstract
Background and Purpose: Mycotic aneurysms (MA) are rare neurovascular complications of infective endocarditis (IE). The natural history and outcomes of MA under contemporary medical therapy have not been well characterized. The purpose of this study is to describe treatments and outcomes of patients with ruptured and unruptured MA in IE, specifically in relation to medical versus surgical/endovascular treatment. Methods: Retrospective chart review was performed at 3 US academic medical centers of adult patients with IE and MA. Information was collected regarding risk factors, imaging, treatments, and outcomes, including ischemic stroke, intracerebral hemorrhage, MA size changes, and inhospital mortality. Results: Thirty-five patients with IE had 63 MA. Nineteen patients had at least one ruptured MA; 13 patients underwent invasive treatment and 6 received antibiotics alone. Of 19 patients on antibiotics alone (6 with at least one ruptured MA and 13 with unruptured MA), 14 underwent repeat imaging and 5 had enlarging MA. Of 16 patients treated invasively, 2 had unruptured MA initially treated with antibiotics but ultimately underwent intervention. No MA ruptured after aneurysm discovery. Fifteen patients underwent cardiothoracic surgery (CTS), of which 11 had unsecured MA and 4 had secured MA. No patients suffered perioperiative neurological events attributable to their MA. Three patients treated with antibiotics alone and 3 patients treated invasively died from causes unrelated to their MAs. Conclusions: For patients with unruptured MA, treatment with antibiotics alone may have similar outcomes to invasive treatment. Further investigation is warranted to determine the risk of undergoing CTS with unsecured MA.
- Published
- 2021
36. Stroke patterns and cannulation strategy during veno-arterial extracorporeal membrane support
- Author
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Koji Takeda, Amir Masoumi, Mia Nishikawa, Paul Kurlansky, Joshua Z. Willey, Yuming Ning, Yuji Kaku, Daniel Brodie, Justin Fried, and Hiroo Takayama
- Subjects
Male ,medicine.medical_specialty ,Biomedical Engineering ,Medicine (miscellaneous) ,Femoral artery ,Extracorporeal ,Biomaterials ,Extracorporeal Membrane Oxygenation ,Axillary artery ,medicine.artery ,Internal medicine ,Ascending aorta ,Catheterization, Peripheral ,medicine ,Humans ,cardiovascular diseases ,Stroke ,Ischemic Stroke ,Retrospective Studies ,Aorta ,business.industry ,Incidence (epidemiology) ,Cardiogenic shock ,Middle Aged ,medicine.disease ,Cardiac surgery ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Objectives Stroke has potentially devastating consequences for patients receiving veno-arterial extracorporeal membrane support (VA-ECMO). Arterial cannulation sites for VA-ECMO include the ascending aorta, axillary artery, and femoral artery. However, the influence of cannulation site on stroke risk has not been well described. The purpose of this study was to investigate the association between occurrence and patterns of stroke with ECMO arterial cannulation sites. Methods We retrospectively reviewed 414 consecutive patients who received VA-ECMO support for cardiogenic shock between March 2007 and May 2018. Patients were categorized by cannulation strategy. The rates, subtype and location of strokes as assessed by neuroimaging during and after VA-ECMO support were analyzed. Results Median age was 61 years (IQR 50-69); 67% were men. 77 patients were cannulated via the ascending aorta (17%), 31 via the axillary artery (7%), and 306 (69%) via the femoral artery. In total, 26 patients (6.3%) developed 30 stroke lesions at a median of 6.0 (IQR 3.1-8.7) days after ECMO cannulation. Ischemic stroke was the most common subtype (64%), followed by hemorrhagic transformation (20%) and hemorrhagic stroke (16%). Location by CT was right hemispheric in 38%, left hemispheric in 24%, bilateral in 21%, and vertebrobasilar in 17%. The incidence of stroke was similar across cannulation strategies: aorta (n=5, 6.5%), axillary artery (n=2, 6.5%), and femoral artery (n=19, 6.2%), (p=0.99). Conclusions Incidence of stroke does not appear to differ among patients cannulated via the ascending aorta, axillary artery, or femoral artery. Ischemic stroke was the most common subtype of stroke.
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- 2021
37. Potential Neurologic Manifestations of COVID-19
- Author
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Craig J. Smith, Kiran T. Thakur, Anna S. Nordvig, K. Fong, Joshua Z. Willey, Wendy Vargas, Amelia K. Boehme, and Mitchell S.V. Elkind
- Subjects
0301 basic medicine ,Pediatrics ,medicine.medical_specialty ,Lydia Becker Institute ,viruses ,Population ,Anosmia ,Anorexia ,Review ,medicine.disease_cause ,03 medical and health sciences ,0302 clinical medicine ,ResearchInstitutes_Networks_Beacons/lydia_becker_institute_of_immunology_and_inflammation ,Pandemic ,medicine ,education ,Stroke ,Coronavirus ,education.field_of_study ,business.industry ,Meningoencephalitis ,virus diseases ,Ageusia ,medicine.disease ,030104 developmental biology ,Neurology (clinical) ,medicine.symptom ,business ,030217 neurology & neurosurgery - Abstract
Purpose of ReviewNeurologic complications are increasingly recognized in the coronavirus disease 2019 (COVID-19) pandemic. COVID-19 is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This coronavirus is related to severe acute respiratory syndrome coronavirus (SARS-CoV) and other human coronavirus-related illnesses that are associated with neurologic symptoms. These symptoms raise the question of a neuroinvasive potential of SARS-CoV-2.Recent FindingsPotential neurologic symptoms and syndromes of SARS-CoV-2 include headache, fatigue, dizziness, anosmia, ageusia, anorexia, myalgias, meningoencephalitis, hemorrhage, altered consciousness, Guillain-Barré syndrome, syncope, seizure, and stroke. In addition, we discuss neurologic effects of other coronaviruses, special considerations for management of neurologic patients, and possible long-term neurologic and public health sequelae.SummaryAs SARS-CoV-2 is projected to infect a large part of the world's population, understanding the potential neurologic implications of COVID-19 will help neurologists and others recognize and intervene in neurologic morbidity during and after the pandemic of 2020.
- Published
- 2021
38. A Multilevel Analysis of Surgical Category and Individual Patient-Level Risk Factors for Postoperative Stroke
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Amelia K. Boehme, Joshua Z. Willey, Randolph S. Marshall, Rebecca Hazan, Alexander E Merkler, Hooman Kamel, Mitchell S.V. Elkind, Benjamin R Kummer, Shadi Yaghi, and William Middlesworth
- Subjects
medicine.medical_specialty ,Postoperative stroke ,business.industry ,Multilevel model ,Physical therapy ,medicine ,Original Articles ,Neurology (clinical) ,medicine.disease ,business ,Stroke - Abstract
Background and Purpose:Many studies supporting the association between specific surgical procedure categories and postoperative stroke (POS) do not account for differences in patient-level characteristics between and within surgical categories. The risk of POS after high-risk procedure categories remains unknown after adjusting for such differences in patient-level characteristics.Methods:Using inpatients in the American College of Surgeons National Surgical Quality Initiative Program database, we conducted a retrospective cohort study between January 1, 2000, and December 31, 2010. Our primary outcome was POS within 30 days of surgery. We characterized the relationship between surgical- and individual patient-level factors and POS by using multivariable, multilevel logistic regression that accounted for clustering of patient-level factors with surgical categories.Results:We identified 729 886 patients, 2703 (0.3%) of whom developed POS. Dependent functional status (odds ratio [OR]: 4.11, 95% confidence interval [95% CI]: 3.60-4.69), history of stroke (OR: 2.35, 95%CI: 2.06-2.69) or transient ischemic attack (OR: 2.49 95%CI: 2.19-2.83), active smoking (OR: 1.20, 95%CI: 1.08-1.32), hypertension (OR: 2.11, 95%CI: 2.19-2.82), chronic obstructive pulmonary disease (OR: 1.39 95%CI: 1.21-1.59), and acute renal failure (OR: 2.35, 95%CI: 1.85-2.99) were significantly associated with POS. After adjusting for clustering, patients who underwent cardiac (OR: 11.25, 95%CI: 8.52-14.87), vascular (OR: 4.75, 95%CI: 3.88-5.82), neurological (OR: 4.60, 95%CI: 3.48-6.08), and general surgery (OR: 1.40, 95%CI: 1.15-1.70) had significantly greater odds of POS compared to patients undergoing other types of surgical procedures.Conclusions:Vascular, cardiac, and neurological surgery remained strongly associated with POS in an analysis accounting for the association between patient-level factors and surgical categories.
- Published
- 2019
39. Transcranial Doppler is an effective method in assessing cerebral blood flow patterns during peripheral venoarterial extracorporeal membrane oxygenation
- Author
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Koji Takeda, Joshua Z. Willey, Yoshifumi Naka, Christine Chan, Hiroo Takayama, Arthur R. Garan, M. Cevasco, Paolo C. Colombo, Hirohisa Ikegami, and Michael Salna
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,Shock, Cardiogenic ,Femoral artery ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Extracorporeal Membrane Oxygenation ,0302 clinical medicine ,Axillary artery ,medicine.artery ,Internal medicine ,Catheterization, Peripheral ,Extracorporeal membrane oxygenation ,Humans ,Medicine ,Stroke ,Aged ,Monitoring, Physiologic ,business.industry ,Cardiogenic shock ,Ultrasonography, Doppler ,Middle Aged ,medicine.disease ,Transcranial Doppler ,Femoral Artery ,030228 respiratory system ,Cerebral blood flow ,Cerebrovascular Circulation ,Middle cerebral artery ,Cardiology ,Axillary Artery ,Female ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Blood Flow Velocity - Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF. Methods Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes. Results The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits. Conclusions TCD appears to be an effective tool for indirect monitoring of CBF in patients with ECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF.
- Published
- 2019
40. CrossTalk proposal: Blood flow pulsatility in left ventricular assist device patients is essential to maintain normal brain physiology
- Author
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Eric J. Stöhr, Paolo C. Colombo, Barry J. McDonnell, and Joshua Z. Willey
- Subjects
0301 basic medicine ,Ventricular function ,Physiology ,business.industry ,medicine.medical_treatment ,Pulsatile flow ,Blood flow ,CrossTalk ,medicine.disease ,03 medical and health sciences ,Crosstalk (biology) ,030104 developmental biology ,0302 clinical medicine ,Blood pressure ,Heart failure ,Ventricular assist device ,medicine ,Heart-Assist Devices ,business ,030217 neurology & neurosurgery - Abstract
Article published in The Journal of Physiology, available at https://doi.org/10.1113/JP276729
- Published
- 2018
41. Abstract P187: When A Global Crisis Closes Your Clinic: A Telemedicine Approach for Transient Ischemic Attack and Minor Stroke Care During the Covid-19 Pandemic
- Author
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Bernard P. Chang, Joshua Z. Willey, Eliza C. Miller, Ian M. Kronish, and Rachelle Dugue
- Subjects
Advanced and Specialized Nursing ,medicine.medical_specialty ,Telemedicine ,Coronavirus disease 2019 (COVID-19) ,business.industry ,Minor stroke ,Emergency department ,medicine.disease ,Migraine with aura ,Pandemic ,Emergency medicine ,medicine ,cardiovascular diseases ,Neurology (clinical) ,medicine.symptom ,Medical diagnosis ,Cardiology and Cardiovascular Medicine ,business ,Stroke - Abstract
Introduction: Recent work has demonstrated the safety and feasibility of rapid outpatient evaluation for presentations of TIA and non-disabling stroke. Our outpatient TIA and stroke clinic, Rapid Access Vascular Evaluation-Neurology (RAVEN) clinic, instituted in 2016, encountered unprecedented challenges in operations during the COVID-19 surge in New York City, leading to the creation of a telemedicine approach to minimize patient and staff exposure risk. To date, few virtual TIA/stroke clinics have reported on safety and feasibility outcomes. Hypothesis: We hypothesized that rapid follow-up of patients with suspected TIA and minor stroke via telemedicine would be feasible and safe during the pandemic. Methods/Results: We performed a retrospective chart review of patients with TIA and minor stroke who were referred to the virtual clinic from the emergency department (ED) between March and June 2020 (the local peak of the COVID-19 pandemic) when RAVEN in-person visits were suspended. A total of 24 patients were discharged early from the ED and referred for RAVEN evaluation with 20 patients evaluated as scheduled; 4 were lost to RAVEN follow-up. Ultimately, 60% of these patients were diagnosed with TIA or minor stroke after completing their remote evaluation; the rest were diagnosed as stroke mimics (seizure, migraine with aura, neuropathy, peripheral vertigo, stroke recrudescence). The median NIHSS calculated at initial ED evaluation was 1 with a maximum NIHSS of 5. A new medical intervention for secondary prevention was prescribed for 70% of patients prior to ED discharge. Amongst patients contacted by phone 3-5 months post-RAVEN evaluation, 4 of 15 had an increased modified Rankin score. Of the 24 patients referred for RAVEN evaluation, 7 returned to the ED within 90 days, with 3 patients citing neurologic complaints. On follow-up via phone conducted 2-5 months after RAVEN evaluation, 3 of 17 patients self-reported either a positive COVID-19 test or suspected COVID-19 diagnosis over the study period. Conclusion: A telemedicine-based approach to evaluate TIA and stroke in the RAVEN model helped limit patient infection risk, optimize resource allocation, establish accurate, timely diagnoses, and effectively implement secondary prevention strategies.
- Published
- 2021
42. Abstract P843: Stroke Patient Monitoring Used in Adult Emergency Department During Covid-19 Acting Both Rapidly and Safely
- Author
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Alsacia Pasci-Sepulveda, Crismely Perdomo, Joshua Z. Willey, and Kyra Lizardo
- Subjects
Advanced and Specialized Nursing ,medicine.medical_specialty ,Coronavirus disease 2019 (COVID-19) ,Remote patient monitoring ,business.industry ,medicine.medical_treatment ,Psychological intervention ,Emergency department ,Thrombolysis ,medicine.disease ,Neurovascular bundle ,Emergency medicine ,Pandemic ,medicine ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,Stroke - Abstract
Introduction: The healthcare system was facing two challenges: acute patients presenting to the adult emergency department diagnosed with Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)/ COVID-19 and how to treat life-threating emergencies. Emergency, neurovascular and multidisciplinary teams, therefore, had to be ready to treat these emergencies rapidly and safely. The goals were to balance substantial needs and preserve resources during this extraordinary time for incoming acutely ill patients. Background: The World Health Organization (WHO) defined COVID-19 as a pandemic. New York City was the epicenter for the 2019-2020 COVID -19 pandemic. There were 30,000 confirmed cases resulting in over 2,500 hospitalizations as of March 30, 2020. Hence, it was vital to develop new monitoring protocols, based upon the expert opinion of the stroke and multidisciplinary leadership at New York Presbyterian Hospital that required minimum monitoring and criteria for admission necessary to safely care for complex stroke patients. Purpose: This quality improvement project evaluated patient outcomes after the implementation of the modified stroke protocol. Methods: Retrospective data review was conducted for patients who presented via the Emergency Department with stroke symptoms, and were treated with intravenous thrombolysis (IVT) between 3/30 and 6/30/2020, with a focus on whether patients required a higher level of care or developed hemorrhagic transformation post IVT. Results: The sample consisted of 10 patients (60% female), median age 54 (range 37-73). Length of stay ranged from 2 to 12 days. Two patients (20%) were SARS-CoV-2 positive. None (0%) of the patients developed hemorrhagic transformation. None (0%) of the patients admitted to non-ICU units required critical care transfer or interventions within 24 hours of receiving IVT. Six (60%) patients were discharged to home. Conclusions: Using the modified patient monitoring protocol post IVT none of the patients developed symptomatic hemorrhagic transformation and did not require transfer to higher level of care within 24 hours. If there is another wave of the COVID-19 pandemic, this protocol could be adopted and its effectiveness and safety can continue to be evaluated.
- Published
- 2021
43. Predicting post-LVAD outcome: Is there a role for cognition?
- Author
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Amelia K. Boehme, Jesus M. Casida, Shunichi Nakagawa, Marykay A. Pavol, Paolo C. Colombo, Melana Yuzefpolskaya, Joanne R. Festa, Ronald M. Lazar, and Joshua Z. Willey
- Subjects
Male ,medicine.medical_specialty ,Biomedical Engineering ,Medicine (miscellaneous) ,Bioengineering ,030204 cardiovascular system & hematology ,Neuropsychological Tests ,Outcome (game theory) ,Biomaterials ,03 medical and health sciences ,0302 clinical medicine ,Cognition ,Internal medicine ,Medicine ,Humans ,030212 general & internal medicine ,Assisted Circulation ,Stroke ,Retrospective Studies ,Heart Failure ,business.industry ,General Medicine ,Middle Aged ,medicine.disease ,Prognosis ,Survival Analysis ,Treatment Outcome ,Heart failure ,Cardiology ,Female ,Heart-Assist Devices ,business - Abstract
Background: Cognition has been found to influence risk of stroke and death for a variety of patient groups but this association has not been examined in heart failure (HF) patients undergoing left ventricular assist device (LVAD) implant. We aimed to study the relationship between cognition, stroke, and death in a cohort of patients who received LVAD therapy. It was hypothesized that cognitive test results obtained prior to LVAD placement would predict stroke and death after surgery. Methods: We retrospectively identified 59 HF patients who had cognitive assessment prior to LVAD placement. Cognitive assessment included measures of attention, memory, language, and visualmotor speed and were averaged to produce one z-score variable per patient. Survival analyses, censored for transplant, evaluated predictors for stroke and death within a follow-up period of 900 days. Results: For patients with stroke or death during the follow up period, the average cognitive z-score predicted post-LVAD stroke (HR = 0.513, 95% CI = 0.31–0.86, p = 0.012) and death (HR = 0.166, 95% CI = 0.06–0.47, p = 0.001). Cognitive performances were worse in the patients who suffered stroke or died. No other variable predicted stroke and death within the follow up period when the cognitive variable was in the model. Conclusion: Cognitive performance was predictive of post-LVAD risk of stroke and death. Results are consistent with findings from other studies in non-LVAD samples and may reflect early signs of neurologic vulnerability. Further studies are needed to clarify the relationship between cognition and LVAD outcomes in order to optimize patient selection, management, and advanced care planning.
- Published
- 2020
44. Decline in stroke alerts and hospitalisations during the COVID-19 pandemic
- Author
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Judith Clark, David M. Greer, Jillian O'Sullivan, Malveeka Sharma, Magdy Selim, Tina Burton, Vasileios-Arsenios Lioutas, Amelia K. Boehme, Randolph S. Marshall, Tracy E. Madsen, Hugo J. Aparicio, Mitchell S.V. Elkind, Joshua Z. Willey, and David L. Tirschwell
- Subjects
Male ,Emergency Medical Services ,medicine.medical_specialty ,Clinical Neurology ,Hospitals, Community ,lcsh:RC346-429 ,Time-to-Treatment ,Acute care ,Health care ,Pandemic ,Emergency medical services ,medicine ,Humans ,cardiovascular diseases ,Pandemics ,Letter to the Editor ,Stroke ,lcsh:Neurology. Diseases of the nervous system ,Retrospective Studies ,business.industry ,SARS-CoV-2 ,Public health ,Brief Report ,COVID-19 ,Retrospective cohort study ,Emergency department ,Middle Aged ,medicine.disease ,Los Angeles ,United States ,infection ,Hospitalization ,Ischemic Attack, Transient ,Emergency medicine ,Female ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business - Abstract
IntroductionPatients with stroke-like symptoms may be underutilising emergency medical services and avoiding hospitalisation during the COVID-19 pandemic. We investigated a decline in admissions for stroke and transient ischaemic attack (TIA) and emergency department (ED) stroke alert activations.MethodsWe retrospectively compiled total weekly hospital admissions for stroke and TIA between 31 December 2018 and 21 April 2019 versus 30 December 2019 and 19 April 2020 at five US tertiary academic comprehensive stroke centres in cities with early COVID-19 outbreaks in Boston, New York City, Providence and Seattle. We collected available data on ED stroke alerts, stroke severity using the National Institutes of Health Stroke Scale (NIHSS) and time from symptom onset to hospital arrival.ResultsCompared with 31 December 2018 to 21 April 2019, a decline in stroke/TIA admissions and ED stroke alerts occurred during 30 December 2019 to 19 April 2020 (p trend ConclusionAt these five large academic US hospitals, admissions for stroke and TIA declined during the COVID-19 pandemic. There was a trend for fewer ED stroke alerts at three of the five centres with available 2019 and 2020 data. Acute stroke therapies are time-sensitive, so decreased healthcare access or utilisation may lead to more disabling or fatal strokes, or more severe non-neurological complications related to stroke. Our findings underscore the indirect effects of this pandemic. Public health officials, hospital systems and healthcare providers must continue to encourage patients with stroke to seek acute care during this crisis.
- Published
- 2020
45. Inpatient Neurology Consultations During the Onset of the SARS-CoV-2 New York City Pandemic: A Single Center Case Series
- Author
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Jennifer M. Bain, Tommy J. Wilson, Amelia K. Boehme, Joshua Z. Willey, Andrew J. Michalak, Juan Carlos Duran, Steven D. Shapiro, Sara Radmard, Samantha Epstein, Kiran T. Thakur, and Hannah J. Roeder
- Subjects
Pediatrics ,medicine.medical_specialty ,Neurology ,Coronavirus disease 2019 (COVID-19) ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Encephalopathy ,novel coronavirus ,Disease ,030204 cardiovascular system & hematology ,Single Center ,lcsh:RC346-429 ,03 medical and health sciences ,0302 clinical medicine ,Pandemic ,Medicine ,Stroke ,lcsh:Neurology. Diseases of the nervous system ,Original Research ,business.industry ,COVID-19 ,inpatient consults ,medicine.disease ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,severe acute respiratory syndrome coronavirus 2 - Abstract
Objective: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily causes respiratory illness. However, neurological sequelae from novel coronavirus disease 2019 (COVID-19) can occur. Patients with neurological conditions may be at higher risk of developing worsening of their underlying problem. Here we document our initial experiences as neurologic consultants at a single center quaternary hospital at the epicenter of the COVID-19 pandemic. Methods: This was a retrospective case series of adult patients diagnosed with SARS-CoV-2 who required neurological evaluation in the form of a consultation or primary neurological care from March 13, 2020 to April 1, 2020. Results: Thirty-three patients (ages 17-88 years) with COVID-19 infection who required neurological or admission to a primary neurology team were included in this study. The encountered neurological problems associated with SARS-CoV-2 infection were encephalopathy (12 patients, 36.4%), seizure (9 patients, 27.2%), stroke (5 patients, 15.2%), recrudescence of prior neurological disease symptoms (4 patients, 12.1%), and neuromuscular (3 patients, 9.1%). The majority of patients who required evaluation by neurology had elevated inflammatory markers. Twenty-one (63.6%) patients were discharged from the hospital and 12 (36.4%) died from COVID-19 related complications. Conclusion: This small case series of our initial encounters with COVID-19 infection describes a range of neurological complications which are similar to presentations seen with other critical illnesses. COVID-19 infection did not change the overall management of neurological problems.
- Published
- 2020
46. Smoking-Cessation Pharmacotherapy for Patients with Stroke and TIA: Systematic Review
- Author
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Joshua Z. Willey, Setareh Salehi Omran, Hooman Kamel, Neal S. Parikh, and Mitchell S.V. Elkind
- Subjects
medicine.medical_specialty ,Subarachnoid hemorrhage ,medicine.medical_treatment ,Article ,law.invention ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Randomized controlled trial ,law ,Seizures ,Physiology (medical) ,Internal medicine ,medicine ,Humans ,cardiovascular diseases ,Varenicline ,Stroke ,Bupropion ,Randomized Controlled Trials as Topic ,Transient ischemic attack (TIA) ,business.industry ,Smoking ,Vasospasm ,General Medicine ,medicine.disease ,Nicotine replacement therapy ,Tobacco Use Cessation Devices ,nervous system diseases ,Observational Studies as Topic ,Neurology ,chemistry ,Ischemic Attack, Transient ,030220 oncology & carcinogenesis ,Smoking cessation ,Surgery ,Female ,Smoking Cessation ,Neurology (clinical) ,business ,030217 neurology & neurosurgery - Abstract
Data regarding the efficacy and safety of smoking-cessation pharmacotherapy after stroke are lacking. We systematically reviewed data on this topic by searching Medline, Cochrane, and Clinicaltrials.gov to identify randomized clinical trials (RCT) and observational studies that assessed the efficacy and safety of nicotine replacement therapy (NRT), varenicline, and bupropion in patients with stroke and TIA. We included studies that reported rates of smoking cessation, worsening or recurrent cerebrovascular disease, seizures, or neuropsychiatric events. We identified 2 RCTs and 6 observational studies; 3 included ischemic stroke and TIA, 2 subarachnoid hemorrhage (SAH), and 3 did not specify. Four studies assessed efficacy; cessation rates ranged from 33% to 66% with pharmacological therapy combined with behavioral interventions versus 15% to 46% without, but no individual study demonstrated a statistically significant benefit. Safety data for varenicline and buopropion in ischemic stroke were scarce. Patients with SAH who received NRT had more seizures (9% vs 2%; P = 0.024) and delirium (19% vs 7%; P = 0.006) in one study, but less frequent vasospasm in 3 studies. In conclusion, combined with behavioral interventions, smoking-cessation therapies resulted in numerically higher cessation rates. Limited safety data may prompt caution regarding seizures and delirium in patients with subarachnoid hemorrhage.
- Published
- 2020
47. Disability After Minor Stroke and Transient Ischemic Attack in the POINT Trial
- Author
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J. Donald Easton, Brett Cucchiara, Michael A. Ross, S. Claiborne Johnston, Shelagh B. Coutts, Jordan J. Elm, Joshua Z. Willey, and Michelle H. Biros
- Subjects
Male ,Myocardial Infarction ,030204 cardiovascular system & hematology ,Cardiorespiratory Medicine and Haematology ,Disability Evaluation ,0302 clinical medicine ,Recurrence ,Risk Factors ,Stroke ,Aspirin ,Ischemic Attack ,Minor stroke ,Middle Aged ,Clopidogrel ,stroke ,Treatment Outcome ,Ischemic Attack, Transient ,diabetes mellitus ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,Intracranial Hemorrhages ,medicine.drug ,medicine.medical_specialty ,aspirin ,Clinical Trials and Supportive Activities ,Clinical Sciences ,Article ,03 medical and health sciences ,transient ,Sex Factors ,Double-Blind Method ,Recurrent stroke ,Clinical Research ,Predictive Value of Tests ,Internal medicine ,Diabetes mellitus ,medicine ,Humans ,In patient ,cardiovascular diseases ,Aged ,Advanced and Specialized Nursing ,Neurology & Neurosurgery ,business.industry ,Neurosciences ,medicine.disease ,Brain Disorders ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Platelet Aggregation Inhibitors - Abstract
Background and Purpose— While combination aspirin and clopidogrel reduces recurrent stroke compared with aspirin alone in patients with transient ischemic attack (TIA) or minor stroke, the effect on disability is uncertain. Methods— The POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) randomized patients with TIA or minor stroke (National Institutes of Health Stroke Scale score ≤3) within 12 hours of onset to dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel versus aspirin alone. The primary outcome measure was a composite of stroke, myocardial infarction, or vascular death. We performed a post hoc exploratory analysis to examine the effect of treatment on overall disability (defined as modified Rankin Scale score >1) at 90 days, as well as disability ascribed by the local investigator to index or recurrent stroke. We also evaluated predictors of disability. Results— At 90 days, 188 of 1964 (9.6%) of patients enrolled with TIA and 471 of 2586 (18.2%) of those enrolled with stroke were disabled. Overall disability was similar between patients assigned DAPT versus aspirin alone (14.7% versus 14.3%; odds ratio, 0.97 [95% CI, 0.82–1.14]; P =0.69). However, there were numerically fewer patients with disability in conjunction with a primary outcome event in the DAPT arm (3.0% versus 4.0%; odds ratio, 0.73 [95% CI, 0.53–1.01]; P =0.06) and significantly fewer patients in the DAPT arm with disability attributed by the investigators to either the index event or recurrent stroke (5.9% versus 7.4%; odds ratio, 0.78 [95% CI, 0.62–0.99]; P =0.04). Notably, disability attributed to the index event accounted for the majority of this difference (4.5% versus 6.0%; odds ratio, 0.74 [95% CI, 0.57–0.96]; P =0.02). In multivariate analysis, age, subsequent ischemic stroke, serious adverse events, and major bleeding were significantly associated with disability in TIA; for those with stroke, female sex, hypertension, or diabetes mellitus, National Institutes of Health Stroke Scale score, recurrent ischemic stroke, subsequent myocardial infarction, and serious adverse events were associated with disability. Conclusions— In addition to reducing recurrent stroke in patients with acute minor stroke and TIA, DAPT might reduce stroke-related disability. Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT00991029.
- Published
- 2020
48. Abstract 104: Disability After Minor Stroke and TIA in the POINT Trial
- Author
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Michelle H. Biros, Shelagh B. Coutts, J. Donald Easton, Brett Cucchiara, Michael A. Ross, Joshua Z. Willey, Jordan Elm, and S. Claiborne Johnston
- Subjects
Advanced and Specialized Nursing ,medicine.medical_specialty ,Aspirin ,business.industry ,Minor stroke ,medicine.disease ,Clopidogrel ,Internal medicine ,medicine ,Cardiology ,cardiovascular diseases ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,Stroke ,medicine.drug - Abstract
Background and Purpose: To assess the effect of combination antiplatelet therapy with aspirin and clopidogrel versus aspirin alone on disability following TIA or minor stroke and to identify factors associated with disability. Methods: The POINT trial randomized patients with TIA or minor stroke (NIHSS≤3) within 12 hours of onset to dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel versus aspirin alone. The primary outcome measure was a composite of stroke, MI, or vascular death. We performed a post-hoc exploratory analysis to examine the effect of treatment on overall disability (defined as mRS>1) at 90 days as well as disability ascribed by the local investigator to index or recurrent stroke. We also evaluated predictors of disability. Results: At 90 days, 188/1964 (9.6%) of patients enrolled with TIA and 471/2586 (18.2%) of those enrolled with stroke were disabled. Overall disability was similar between patients assigned DAPT versus aspirin alone (14.7% vs. 14.3%, OR 0.97, 95%CI 0.82-1.14, p=0.69). However, there were numerically fewer patients with disability in conjunction with a primary outcome event in the DAPT arm (3.0% vs. 4.0%, OR 0.73, 95%CI 0.53-1.01, p=0.06), and significantly fewer patients in the DAPT arm with disability attributed by the investigators to either the index event or recurrent stroke (5.9% vs. 7.4%, OR 0.78, 95% CI 0.62-0.99, p=0.04). Notably, disability attributed to the index event accounted for the majority of this difference (4.5% vs. 6.0%, OR 0.74 95% CI 0.57-0.96, p=0.02). In multivariate analysis of patients enrolled with TIA, disability was significantly associated with age, subsequent ischemic stroke, serious adverse events, and major bleeding. In patients enrolled with stroke, disability was associated with female sex, hypertension, diabetes, NIHSS score, recurrent ischemic stroke, subsequent myocardial infarction, and serious adverse events. Conclusions: In addition to reducing recurrent stroke in patients with acute minor stroke and TIA, dual antiplatelet therapy might reduce stroke-related disability.
- Published
- 2020
49. Creatinine versus cystatin C for renal function-based mortality prediction in an elderly cohort: The Northern Manhattan Study
- Author
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Mitchell S.V. Elkind, Ralph L. Sacco, Clinton B. Wright, Yeseon P. Moon, Joshua Z. Willey, Sumit Mohan, Myles Wolf, S. Ali Husain, and Ken Cheung
- Subjects
Male ,Physiology ,030232 urology & nephrology ,Kidney ,Kidney Function Tests ,Biochemistry ,Cohort Studies ,chemistry.chemical_compound ,Elderly ,Mathematical and Statistical Techniques ,0302 clinical medicine ,Chronic Kidney Disease ,Medicine and Health Sciences ,Ethnicities ,030212 general & internal medicine ,Prospective cohort study ,Hispanic People ,Geriatric Nephrology ,education.field_of_study ,Multidisciplinary ,Framingham Risk Score ,Middle Aged ,Curve Fitting ,Nephrology ,Creatinine ,Area Under Curve ,Cohort ,Medicine ,Female ,Research Article ,Glomerular Filtration Rate ,Cohort study ,Risk ,medicine.medical_specialty ,Science ,Population ,Renal function ,Research and Analysis Methods ,03 medical and health sciences ,Internal medicine ,medicine ,Humans ,Cystatin C ,Mortality ,education ,Aged ,Renal Physiology ,business.industry ,Proportional hazards model ,Biology and Life Sciences ,chemistry ,Geriatrics ,Age Groups ,People and Places ,Population Groupings ,business ,Mathematical Functions ,Biomarkers - Abstract
Background Estimated glomerular filtration rate (eGFR) is routinely utilized as a measure of renal function. While creatinine-based eGFR (eGFRcr) is widely used in clinical practice, the use of cystatin-C to estimate GFR (eGFRcys) has demonstrated superior risk prediction in various populations. Prior studies that derived eGFR formulas have infrequently included high proportions of elderly, African-Americans, and Hispanics. Objective Our objective as to compare mortality risk prediction using eGFRcr and eGFRcys in an elderly, race/ethnically diverse population. Design The Northern Manhattan Study (NOMAS) is a multiethnic prospective cohort of elderly stroke-free individuals consisting of a total of 3,298 participants recruited between 1993 and 2001, with a median follow-up of 18 years. Participants We included all Northern Manhattan Study (NOMAS) participants with concurrent measured creatinine and cystatin-C. Main measures The eGFRcr was calculated using the CKD-EPI 2009 equation. eGFRcys was calculated using the CKD-EPI 2012 equations. The performance of each eGFR formula in predicting mortality risk was tested using receiver-operating characteristics, calibration and reclassification. Net reclassification improvement (NRI) was calculated based on the Reynolds 10 year risk score from adjusted Cox models with mortality as an outcome. The primary hypothesis was that eGFRcys would better predict mortality than eGFRcr. Results Participants (n = 2988) had a mean age of 69±10.2 years and were predominantly Hispanic (53%), overweight (69%), and current or former smokers (53% combined). The mean eGFRcr (74.68±18.8 ml/min/1.73m2) was higher than eGFRcys (51.72±17.2 ml/min/1.73m2). During a mean of 13.0±5.6 years of follow-up, 53% of the cohort had died. The AUC of eGFRcys (0.73) was greater than for eGFRcr (0.67, p for difference
- Published
- 2020
50. Clinical risk factors for acute ischaemic and haemorrhagic stroke in patients with infective endocarditis
- Author
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Ives A Valenzuela, Jose Gutierrez, Joshua Z. Willey, Isaac George, Lauren Dunn, Bradley Klein, Kathryn M Sundheim, Madeleine D Hunter, Robert Sorabella, and Sang M. Han
- Subjects
medicine.medical_specialty ,Univariate analysis ,Heart disease ,business.industry ,Retrospective cohort study ,Odds ratio ,030204 cardiovascular system & hematology ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Infective endocarditis ,Internal medicine ,Internal Medicine ,medicine ,Endocarditis ,Risk assessment ,business ,Stroke ,030217 neurology & neurosurgery - Abstract
Background Stroke as a complication of infective endocarditis portends a poor prognosis, yet risk factors for stroke subtypes have not been well defined. Aim To identify risk factors associated with ischaemic and haemorrhagic strokes. Methods A retrospective patient chart review was performed at a single US academic centre to identify risk factors and imaging for patients who were 18 years or older with infectious endocarditis (IE) and stroke diagnoses. Differences in patient characteristics by stroke status were assessed using univariate analysis, χ2 or student's t-test as well as logistic regression models for multivariable analyses and correlation matrices to identify possible collinearity between variables and to obtain odds ratios (OR) and their 95% confidence intervals. Results A final sample of 1157 participants was used for this analysis. The total number of non-surgical strokes was 178, with a prevalence of 15.4% (78% ischaemic, 10% parenchymal haemorrhages, 8% subarachnoid haemorrhages and 4% mixed ischaemic/haemorrhagic). Multivariate risk factors for ischaemic stroke included prior stroke (OR 2.0, 1.3-3.1), Staphylococcus infection (OR 2.0, 1.3-3.0), mitral vegetations (OR 2.2, 1.4-3.3) and valvular abscess (OR 2.7, 1.7-4.3). Risk factors for haemorrhagic stroke included fungal infection (OR 6.4, 1.2-34.0), male gender (OR 3.5, 1.4-8.3) and rheumatic heart disease (OR 3.3, 1.1-10.4). Conclusion Among patients with IE, there exist characteristics that relate differentially to ischaemic and haemorrhagic stroke risk.
- Published
- 2018
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