Browsing by Author "Flaherty, Matthew L."

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    Gender and Time to Arrival among Ischemic Stroke Patients in the Greater Cincinnati/Northern Kentucky Stroke Study
    (Elsevier, 2016-03) Madsen, Tracy E.; Sucharew, Heidi; Katz, Brian; Alwell, Kathleen A.; Moomaw, Charles J.; Kissela, Brett M.; Flaherty, Matthew L.; Woo, Daniel; Khatri, Pooja; Ferioli, Simona; Mackey, Jason; Martini, Sharyl; De Los Rios La Rosa, Felipe; Kleindorfer, Dawn O.; Department of Neurology, IU School of Medicine
    Background Some studies of stroke patients report longer pre-hospital delays in women, but others conflict; studies vary in their inclusion of factors including age and stroke severity. We aimed to investigate the relationship between gender and time to emergency department (ED) arrival and the influence of age and stroke severity on this relationship. Methods Ischemic stroke patients ≥ 20 years old who presented to 15 hospitals within a 5-county region of Greater Cincinnati/Northern Kentucky during 2010 were included. Time from symptom onset to ED arrival and covariates were abstracted by study nurses and reviewed by study physicians. Data were analyzed using logistic regression with time to arrival dichotomized at ≤ 3 hours, in the overall sample and then stratified by NIHSS and age. Results 1991 strokes (55% women) were included. Time to arrival was slightly longer in women (geometric mean 337 minutes [95%CI 307–369] vs. 297 [95%CI 268–329], p =0.05), and 24% of women vs. 27% of men arrived within 3 hours (p=0.15). After adjusting for age, race, NIHSS, living situation, and other covariates, gender was not associated with delayed time to arrival (OR=1.00, 95%CI 0.78–1.28). This did not change across age or NIHSS categories. Conclusions After adjusting for factors including age, NIHSS, and living alone, women and men with ischemic stroke had similar times to arrival. Arrival time is not likely a major contributor to differences in outcome between men and women.
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    Prehospital neurological deterioration in stroke
    (BMJ Publishing Group, 2018-08) Slavin, Sabreena J.; Sucharew, Heidi; Alwell, Kathleen; Moomaw, Charles J.; Woo, Daniel; Adeoye, Opeolu; Flaherty, Matthew L.; Ferioli, Simona; McMullan, Jason; Mackey, Jason; De Los Rios La Rosa, Felipe; Martini, Sharyl; Kissela, Brett M.; Kleindorfer, Dawn O.; Neurology, School of Medicine
    BACKGROUND AND PURPOSE: Patients with stroke can experience neurological deterioration in the prehospital setting. We evaluated patients with stroke to determine factors associated with prehospital neurological deterioration (PND). METHODS: Among the Greater Cincinnati/Northern Kentucky region (population ~1.3 million), we screened all 15 local hospitals' admissions from 2010 for acute stroke and included patients aged ≥20. The GCS was compared between emergency medical services (EMS) arrival and hospital arrival, with decrease ≥2 points considered PND. Data obtained retrospectively included demographics, medical history and medication use, stroke subtype (eg, ischaemic stroke (IS), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH)) and IS subtype (eg, small vessel, large vessel, cardioembolic), seizure at onset, time intervals between symptom onset, EMS arrival and hospital arrival, EMS level of training, and blood pressure and serum glucose on EMS arrival. RESULTS: Of 2708 total patients who had a stroke, 1092 patients (median (IQR) age 74 (61-83) years; 56% women; 21% black) were analysed. PND occurred in 129 cases (12%), including 9% of IS, 24% of ICH and 16% of SAH. In multivariable analysis, black race, atrial fibrillation, haemorrhagic subtype and ALS level of transport were associated with PND. CONCLUSION: Haemorrhage and atrial fibrillation is associated with PND in stroke, and further investigation is needed to establish whether PND can be predicted. Further studies are also needed to assess whether preferential transport of patients with deterioration to hospitals equipped with higher levels of care is beneficial, identify why race is associated with deterioration and to test therapies targeting PND.
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    Sex differences in cardiovascular risk profiles of ischemic stroke patients with diabetes in the Greater Cincinnati/Northern Kentucky Stroke Study
    (Wiley, 2017) Madsen, Tracy E.; Khoury, Jane C.; Alwell, Kathleen A.; Moomaw, Charles J.; Demel, Stacie L.; Flaherty, Matthew L.; Woo, Daniel; Mackey, Jason; De Los Rios La Rosa, Felipe; Martini, Sharyl; Ferioli, Simona; Adeoye, Opeolu; Khatri, Pooja; Kissela, Brett M.; Kleindorfer, Dawn O.; Department of Neurology, School of Medicine
    Background The aim of the present study was to compare sex-specific associations between cardiovascular risk factors and diabetes mellitus (DM) among patients with acute ischemic stroke (AIS) in the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS). Methods The GCNKSS ascertained AIS cases in 2005 and 2010 among adult (age ≥ 20 years) residents of a biracial population of 1.3 million. Past and current stroke risk factors were compared between those with and without DM using Chi-squared tests and multiple logistic regression analysis to examine sex-specific profiles. Results There were 3515 patients with incident AIS; 1919 (55%) were female, 697 (20%) were Black, and 1146 (33%) had DM. Among both women and men with DM, significantly more were obese and had hypertension, high cholesterol, and coronary artery disease (CAD) compared with those without DM. For women with AIS, multivariable sex-specific adjusted analyses revealed that older age was associated with decreased odds of having DM (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.80–0.98). For women with CAD, the odds of DM were increased (aOR 1.76, 95% CI 1.33–2.32). Age and CAD were not significant factors in differentiating the profiles of men with and without DM. Conclusions Women with DM had strokes at a younger age, whereas no such age difference existed in men. Compared with men, women with DM were also more likely to have CAD than those without DM, suggesting a sex difference in the association between DM and vascular disease. These findings may suggest a need for more aggressive risk factor management in diabetic women.
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    Sex-specific stroke incidence over time in the Greater Cincinnati/Northern Kentucky Stroke Study
    (Wolters Kluwer, 2017-09-05) Madsen, Tracy E.; Khoury, Jane; Alwell, Kathleen; Moomaw, Charles J.; Rademacher, Eric; Flaherty, Matthew L.; Woo, Daniel; Mackey, Jason; La Rosa, Felipe De Los Rios; Martini, Sharyl; Ferioli, Simona; Adeoye, Opeolu; Khatri, Pooja; Broderick, Joseph P.; Kissela, Brett M.; Kleindorfer, Dawn; Neurology, School of Medicine
    OBJECTIVE: Recent data suggest stroke incidence is decreasing over time, but it is unknown whether incidence is decreasing in women and men to the same extent. METHODS: Within our population of 1.3 million, all incident strokes among residents ≥20 years old were ascertained at all hospitals during July 1993-June 1994 and calendar years 1999, 2005, and 2010. A sampling scheme was used to ascertain out-of-hospital cases. Sex-specific incidence rates per 100,000 among black and white participants, age- and race-adjusted, were standardized to the 2000 US Census population. Trends over time by sex were compared; a Bonferroni correction was applied for multiple comparisons. RESULTS: Over the 4 study periods, there were 7,710 incident strokes; 57.2% (n = 4,412) were women. Women were older than men (mean ± SE 72.4 ± 0.34 vs 68.2 ± 0.32, p < 0.001). Incidence of all strokes decreased over time in men (263 [confidence interval 246-281] to 192 [179-205], p < 0.001) but not in women (217 [205-230] to 198 [187-210], p = 0.15). Similar sex differences were seen for ischemic stroke (men, 238 [223-257] to 165 [153-177], p < 0.01; women, 193 [181-205] to 173 [162-184], p = 0.09). Incidence of all strokes and of ischemic strokes was similar between women and men in 2010. Incidence of intracerebral hemorrhage and subarachnoid hemorrhage were stable over time in both sexes. CONCLUSIONS: Decreases in stroke incidence over time are driven by a decrease in ischemic stroke in men. Contrary to previous study periods, stroke incidence rates were similar by sex in 2010. Future research is needed to understand why the decrease in ischemic stroke incidence is more pronounced in men.
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    Stable incidence but declining case-fatality rates of subarachnoid hemorrhage in a population
    (American Academy of Neurology, 2016-11-22) Mackey, Jason; Khoury, Jane C.; Alwell, Kathleen; Moomaw, Charles J.; Kissela, Brett M.; Flaherty, Matthew L.; Adeoye, Opeolu; Woo, Daniel; Ferioli, Simona; De Los Rios La Rosa, Felipe; Martini, Sharyl; Khatri, Pooja; Broderick, Joseph P.; Zuccarello, Mario; Kleindorfer, Dawn; Neurology, School of Medicine
    Objective: To characterize temporal trends in subarachnoid hemorrhage (SAH) incidence and outcomes over 5 time periods in a large population-based stroke study in the United States. Methods: All SAHs among residents of the Greater Cincinnati/Northern Kentucky region at least 20 years of age were identified and verified via study physician review in 5 distinct year-long study periods between 1988 and 2010. We abstracted demographics, care patterns, and outcomes, and we compared incidence and case-fatality rates across the study periods. Results: The incidence of SAH in the 5 study periods (age-, race-, and sex-adjusted to the 2000 US population) was 8.8 (95% confidence interval 6.8–10.7), 9.2 (7.2–11.2), 10.0 (8.0–12.0), 9.0 (7.1–10.9), and 7.7 (6.0–9.4) per 100,000, respectively; the trend in incidence rates from 1988 to 2010 was not statistically significant (p = 0.22). Advanced neurovascular imaging, endovascular coiling, and neurologic intensive care unit availability increased significantly over time. All-cause 5-day (32%–18%, p = 0.01; for trend), 30-day (46%–25%, p = 0.001), and 90-day (49%–29%, p = 0.001) case-fatality rates declined from 1988 to 2010. When we included only proven or highly likely aneurysmal SAH, the declines in case-fatality were no longer statistically significant. Conclusions: Although the incidence of SAH remained stable in this population-based region, 5-day, 30-day, and 90-day case-fatality rates declined significantly. Advances in surgical and medical management, along with systems-based changes such as the emergence of neurocritical care units, are potential explanations for the reduced case-fatality.
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    Substance Use and Performance of Toxicology Screens in the Greater Cincinnati Northern Kentucky Stroke Study
    (American Heart Association, 2022-10) Madsen, Tracy E.; Cummings, Olivia W.; De Los Rios La Rosa, Felipe; Khoury, Jane C.; Alwell, Kathleen; Woo, Daniel; Ferioli, Simona; Martini, Sharyl; Adeoye, Opeolu; Khatri, Pooja; Flaherty, Matthew L.; Mackey, Jason; Mistry, Eva A.; Demel, Stacie L.; Coleman, Elisheva; Jasne, Adam S.; Slavin, Sabreena J.; Walsh, Kyle; Star, Michael; Broderick, Joseph P.; Kissela, Brett M.; Kleindorfer, Dawn O.; Neurology, School of Medicine
    Background Though stroke risk factors such as substance use may vary with age, less is known about trends in substance use over time or about performance of toxicology screens in young adults with stroke. Methods Using the Greater Cincinnati Northern Kentucky Stroke Study, a population-based study in a 5-county region comprising 1.3 million people, we reported the frequency of documented substance use (cocaine/marijuana/opiates/other) obtained from electronic medical record review, overall and by race/gender subgroups among physician-adjudicated stroke events (ischemic and hemorrhagic) in adults 20–54 years old. Secondary analyses included heavy alcohol use and cigarette smoking. Data were reported for 5 one-year periods spanning 22 years (1993/4–2015), and trends over time were tested. For 2015, to evaluate factors associated with performance of toxicology screens, multiple logistic regression was performed. Results Overall, 2152 strokes were included: 74.5% were ischemic, mean age was 45.7±7.6, 50.0% were women, and 35.9% were Black. Substance use was documented in 4.4%, 10.4%, 19.2%, 24.0% and 28.8% of cases in 1993/4, 1999, 2005, 2010 and 2015, respectively (ptrend<0.001). Between 1993/4 and 2015, documented substance use increased in all demographic subgroups. Adjusting for gender, comorbidities, and NIHSS, predictors of toxicology screens included Black race (aOR 1.58, 95%CI 1.02–2.45), younger age (aOR 0.70, 95%CI 0.53–0.91, per 10 years), current smoking (aOR 1.62, 95%CI 1.06–2.46) and treatment at an academic hospital (aOR 1.80, 95%CI 1.14–2.84). After adding chart reported substance use to the model, only chart reported substance abuse and age were significant. Conclusions In a population-based study of young adults with stroke, documented substance use increased over time, and documentation of substance use was higher among Black compared with White individuals. Further work is needed to confirm race-based disparities and trends in substance use given the potential for bias in screening and documentation. Findings suggest a need for more standardized toxicology screening.
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    Temporal Trends of Sex Differences in Transient Ischemic Attack Incidence Within a Population
    (Elsevier, 2019-07-01) Madsen, Tracy E.; Khoury, Jane C.; Alwell, Kathleen; Moomaw, Charles J.; Rademacher, Eric; Flaherty, Matthew L.; Woo, Daniel; De Los Rios La Rosa, Felipe; Mackey, Jason; Martini, Sharyl; Ferioli, Simona; Adeoye, Opeolu; Khatri, Pooja; Broderick, Joseph P.; Kissela, Brett M.; Kleindorfer, Dawn; Neurology, School of Medicine
    Objective: Previously we reported that ischemic stroke incidence is declining over time for men but not women. We sought to describe temporal trends of sex differences in incidence of transient ischemic attack (TIA) within the same large, biracial population. Methods: Among the population of 1.3 million in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS) region, TIAs among area residents (≥20 years old) were identified at all local hospitals. Out of hospital cases were ascertained using a sampling scheme. First-ever cases and first within each study period for a patient were included in incidence rates. All cases were physician-adjudicated. Incidence rates (during 7/93-6/94 and calendar years 1999, 2005, and 2010) were calculated using the age-, race-, and sex-specific number of TIAs divided by the GCNKSS population in that group; rates were standardized to the 2010 U.S. population. T-tests with Bonferroni correction were used to compare rates over time. Results: There were a total of 4746 TIA events; 53% were female, and 12% were black. In males, incidence decreased from 153 (95%CI 139-167) per 100,000 in 1993/4 to 117 (95%CI 107-128) in 2010 (p<0.05 for trend test) but was similar over time among females (107 (95%CI 97-116) to 102 (95%CI 94-111), p>0.05). Conclusions: Within the GCNKSS population, TIA incidence decreased significantly over time in males but not females, data which parallels trends in ischemic stroke in the GCNKSS over the same time period. Future research is needed to determine if these sex differences in incidence over time continue past 2010.
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    Trends Over Time in Stroke Incidence by Race in the Greater Cincinnati Northern Kentucky Stroke Study
    (Wolters Kluwer, 2024) Madsen, Tracy E.; Ding, Lili; Khoury, Jane C.; Haverbusch, Mary; Woo, Daniel; Ferioli, Simona; De Los Rios La Rosa, Felipe; Martini, Sharyl R.; Adeoye, Opeolu; Khatri, Pooja; Flaherty, Matthew L.; Mackey, Jason; Mistry, Eva A.; Demel, Stacie; Coleman, Elisheva; Jasne, Adam; Slavin, Sabreena; Walsh, Kyle B.; Star, Michael; Broderick, Joseph P.; Kissela, Brett; Kleindorfer, Dawn O.; Neurology, School of Medicine
    Background and objectives: Understanding the current status of and temporal trends of stroke epidemiology by age, race, and stroke subtype is critical to evaluate past prevention efforts and to plan future interventions to eliminate existing inequities. We investigated trends in stroke incidence and case fatality over a 22-year time period. Methods: In this population-based stroke surveillance study, all cases of stroke in acute care hospitals within a 5-county population of southern Ohio/northern Kentucky in adults aged ≥20 years were ascertained during a full year every 5 years from 1993 to 2015. Temporal trends in stroke epidemiology were evaluated by age, race (Black or White), and subtype (ischemic stroke [IS], intracranial hemorrhage [ICH], or subarachnoid hemorrhage [SAH]). Stroke incidence rates per 100,000 individuals from 1993 to 2015 were calculated using US Census data and age-standardized, race-standardized, and sex-standardized as appropriate. Thirty-day case fatality rates were also reported. Results: Incidence rates for stroke of any type and IS decreased in the combined population and among White individuals (any type, per 100,000, 215 [95% CI 204-226] in 1993/4 to 170 [95% CI 161-179] in 2015, p = 0.015). Among Black individuals, incidence rates for stroke of any type decreased over the study period (per 100,000, 349 [95% CI 311-386] in 1993/4 to 311 [95% CI 282-340] in 2015, p = 0.015). Incidence of ICH was stable over time in the combined population and in race-specific subgroups, and SAH decreased in the combined groups and in White adults. Incidence rates among Black adults were higher than those of White adults in all time periods, and Black:White risk ratios were highest in adults in young and middle age groups. Case fatality rates were similar by race and by time period with the exception of SAH in which 30-day case fatality rates decreased in the combined population and White adults over time. Discussion: Stroke incidence is decreasing over time in both Black and White adults, an encouraging trend in the burden of cerebrovascular disease in the US population. Unfortunately, however, Black:White disparities have not decreased over a 22-year period, especially among younger and middle-aged adults, suggesting the need for more effective interventions to eliminate inequities by race.