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Papers by Jason Sico

Journal of the American College of Cardiology

Circulation: Cardiovascular Quality and Outcomes, 2018

Background: Ischemic stroke disproportionately affects women. Women have a higher lifetime risk o... more Background: Ischemic stroke disproportionately affects women. Women have a higher lifetime risk of stroke, experience worse functional recovery post-stroke, and are more likely to be institutionalized after stroke than men. Despite the pronounced differences in which stroke may affect women compared to men, stroke research specifically focusing on women has not been published until recently. For instance, stroke specific guidelines for women were not published until 2014. This study sought to determine whether differences in stroke risk exist between women and men across age strata using the Framingham Stroke Risk (FRS) score in a large cohort of Veterans. Methods: Study participants were Veterans receiving care within Veterans Health Administration facilities between April 2011 and May 2012 (N=57,072). In this secondary analysis, patients were excluded (n=39,978) based on age less than 55 years and prior history of stroke. FRS was calculated for each patient based on race- and sex-...

BMJ Case Reports, 2020

A 71-year-old man developed dysphagia, bilateral lower extremity muscle weakness and weight loss.... more A 71-year-old man developed dysphagia, bilateral lower extremity muscle weakness and weight loss. He was admitted to the hospital after a failed formal swallow evaluation, nearly 3 weeks after symptom onset. In addition to dysphagia and weakness, physical examination was notable for hypophonia, dysarthria, diplopia, horizontal ophthalmoparesis, ptosis, ataxia and hyporeflexia. Cerebrospinal fluid was notable for albuminocytological dissociation and serum anti-GQ1b antibody titre was elevated (1:200). A diagnosis of Miller-Fisher syndrome (MFS) was made, and the patient was treated with intravenous immunoglobulin (0.4 g/kg/day) for 5 days, which resulted in resolution of symptoms. This is an atypical case of MFS, in that the presenting symptom was progressive dysphagia rather than the ophthalmoplegia and ataxia that are normally seen in MFS. Patients who present with dysphagia should receive a thorough neurological examination, with particular attention to extraocular movements, refl...

Headache, Jan 17, 2018

In this secondary analysis of the Clusterbusters Medication Use survey, the use, effectiveness, a... more In this secondary analysis of the Clusterbusters Medication Use survey, the use, effectiveness, and tolerability of inhaled oxygen were investigated and compared with injectable sumatriptan. We also sought to understand the predictors of medication response. Inhaled oxygen is a mainstay abortive intervention in cluster headache but is not approved by the Food and Drug Administration (FDA). Unlike injectable sumatriptan, the only FDA-approved pharmacologic intervention for cluster headache, oxygen can be used multiple times a day, which is highly relevant for a condition with numerous daily attacks. In addition to obstacles in obtaining oxygen therapy, optimal oxygen delivery (ie, mask, flow rate) is not uniformly employed in cluster headache. These factors lead to underuse and imprecise therapeutic response rates. A secondary analysis was conducted using deidentified data from the Clusterbusters Medication Use survey, which was modeled after previously published surveys and availabl...

Cephalalgia : an international journal of headache, 2018

Objective To assess the association of neurologist ambulatory care with healthcare utilization an... more Objective To assess the association of neurologist ambulatory care with healthcare utilization and expenditure in headache. Methods This was a longitudinal cohort study from two-year duration panel data, pooled from 2002-2013, of adult respondents identified with diagnostic codes for headache in the Medical Expenditure Panel Survey. Those with a neurologist ambulatory care visit in year one of panel participation were compared with those who did not for the change in annual aggregate direct headache-related health care costs from year one to year two of panel participation, inflated to 2015 US dollars. Results were adjusted via multiple linear regression for demographic and clinical variables, utilizing survey variables for accurate estimates and standard errors. Results Eight hundred and eighty-seven respondents were included, with 23.3% (207/887) seeing a neurologist in year one. The neurologist group had higher year-one mean headache-related expenditures ($3032 vs. $1636), but ne...

Mycoses, 2006

An 84-year-old woman with a past medical history significant for haemolytic anaemia necessitating... more An 84-year-old woman with a past medical history significant for haemolytic anaemia necessitating chronic steroid therapy presented with skin induration and erythema initially thought to be cellulitis. After a rapid progression of symptoms and failure to respond to antibiotics, a clinical diagnosis of necrotising vasculitis was made. Necrotising cryptococcal vasculitis was confirmed by histopathology and culture.

Journal of Family Studies, 2010

Abstract The study aimed to examine the prevalence, patterns and characteristics of continued tob... more Abstract The study aimed to examine the prevalence, patterns and characteristics of continued tobacco smoking among Australian parents. The study utilised data from Wave 1 and Wave 2 of the Longitudinal Study of Australian Children (LSAC). Smoking was reported by 20% of mothers and 25% of fathers at Wave 1 (with a slight decrease at Wave 2). Continued smoking was more likely among parents who were younger, less educated, reported problematic alcohol use, more financial problems and had a partner who smoked. The study estimated at the Australian population level, 29,649 children under the age of 1, and 36,208 children aged 4–5 years live in a household where smoking occurs inside. The prevalence of parental smoking remains considerable, despite an increasing awareness of the adverse effects. Reducing the number of adults who smoke inside the home with dependent children is an important public health concern in urgent need of attention.

Dysphagia, 2010

There have been several case reports of risperidone-associated dysphagia. Risperidone-induced bul... more There have been several case reports of risperidone-associated dysphagia. Risperidone-induced bulbar palsy-like syndrome has not been previously described. We report on a 58-year-old gentleman with prior history of schizophrenia and remote chlorpromazine use with no history of extrapyramidal symptoms who experienced acute onset of dysphagia and facial diplegia with hyperprolactinemia while being treated with risperidone. To date there have been five reported cases of dysphagia associated with risperidone, occurring by such mechanisms as isolated pharyngeal dysfunction from pharyngeal constrictor palsy and dystonia, drug-induced parkinsonism, and acute dystonic reaction. These cases were associated either with initiation or up-titration of risperidone, with complete resolution of dysphagia after medication discontinuation or dose change. Our patient developed dysphagia within 2 weeks of taking risperidone and completely resolved 1 month after the medication was stopped. Unlike other reported cases, our patient also experienced symptomatic hyperprolactinemia, another known side effect of risperidone. Physicians should also be aware that risperidone can be associated with oropharyngeal dysphagia secondary to an acute bulbar palsy-like syndrome that places patients at increased risk of aspiration events and its associated morbidity and mortality.

Clinical Neurology and Neurosurgery, 2009

Nervous system infections by Cryptococcus neoformans may occur not only in congenital or acquired... more Nervous system infections by Cryptococcus neoformans may occur not only in congenital or acquired immunodeficiency syndromes, but also in immunocompetent hosts. Neurological manifestations of C. neoformans infection include meningitis and, less commonly, parenchymal CNS granulomatous disease. This paper provides detailed clinical descriptions of highly unusual neurological manifestations of cryptococcal nervous system infections. Medical records and diagnostic data including magnetic resonance imaging, histopathology, serology, and CSF analysis were reviewed. A conus medullaris abscess was found in a patient infected with the human immunodeficiency virus (HIV). A patient with Hodgkin's disease was diagnosed with cryptococcal meningitis and dermatitis mimicking ophthalmic zoster. An immunocompetent patient presented with recurrent cerebral infarctions in the setting of cryptococcal meningitis. Cryptococcal infections of the nervous system can cause severe neurological disability when diagnosis is delayed. Sensitive and specific tests are readily available and should be considered when an unusual clinical presentation is encountered.

Stroke, 2015

Introduction: Research protocols for stroke prevention trials commonly specify goals for preventi... more Introduction: Research protocols for stroke prevention trials commonly specify goals for preventive care. We report variability in goal achievement between 3 countries participating in an on-going stroke secondary prevention trial. Methods: The Insulin Resistance Intervention after Stroke (IRIS) trial is testing pioglitazone, compared with placebo, for prevention of stroke and myocardial infarction among non-diabetic patients with a recent ischemic stroke/TIA. Preventive care is provided by personal physicians, although achievement of prevention goals is monitored and reported to participants and their physicians annually. Goals are from the American Heart Association guidelines: blood pressure (BP) <140/90 mmHg, statin therapy, and anti-platelet or anticoagulation depending on clinical indications. At baseline and year 1, we compared the proportions of participants meeting these goals in the largest enrolling countries: Canada (CA), United Kingdom (UK) and United States (US). Re...

Circulation: Cardiovascular Quality and Outcomes, 2018

Introduction: While the burden of non-communicable diseases is increasing worldwide in developing... more Introduction: While the burden of non-communicable diseases is increasing worldwide in developing countries, less is known regarding the true prevalence of such neurologic illness as cerebrovascular disease throughout sub-Saharan Africa. We sought to understand the prevalence of stroke and other neurologic conditions at Mulago Hospital, Uganda’s largest tertiary care referral center, and their association with post-event mortality. Methods: Data was prospectively collected on 335 patients admitted to the neurology wards of Mulago Hospital from January 2009 to May 2011. Data were collected from the date of admission until discharge, including: demographic information, village of residence, admission/discharge diagnoses, HIV status, discharge disposition, and mortality data, without the benefit of an electronic medical record. Kaplan-Meier survival curves and multivariate COX proportional hazard model were used for unadjusted and adjusted analysis to predict survival. Results: A total...

Stroke, 2013

INTRODUCTION: Obstructive sleep apnea (OSA) is common among patients with stroke and TIA. Previou... more INTRODUCTION: Obstructive sleep apnea (OSA) is common among patients with stroke and TIA. Previously validated OSA screening instruments used in the general population are largely based on reported symptoms; when applied to those with cerebrovascular disease, they have shown poor correlation with the presence of OSA diagnosed via polysomnography (PSG). We sought to develop a cerebrovascular disease specific prediction model for OSA that is less reliant on symptomatology. Methods: We used data from a multi-site randomized, controlled strategy trial that included ischemic stroke and TIA patients at two VA hospitals. Data on patient demographics, vital signs, anthropomorphic measurements, past medical history, medications, stroke severity, and sleep questionnaires were obtained. All patients received PSG. Sleep apnea was defined as present if the apnea-hypopnea index (AHI) was ≥5. Because approximately half of subjects had OSA, discrimination was difficult; thus, AHI was used as the ou...

Stroke, 2015

Background: The Veterans Health Administration has multiple quality improvement activities direct... more Background: The Veterans Health Administration has multiple quality improvement activities directed at improving vascular risk factor control. We sought to examine facility quality of blood pressure (BP) control (<140/90 mm Hg), lipid control (LDL-cholesterol <100 mg/dL) and glycemic control (HbA1c <9%) in the one-year after hospitalization for ischemic stroke or acute myocardial infarction (AMI). Methods: We assembled a retrospective cohort of patients hospitalized with stroke or AMI (fiscal year 2011). Facilities were included if they admitted ≥25 stroke patients and ≥25 AMI patients. A facility-level consolidated measure of vascular risk factor control was calculated for the 3 processes of care (number of passes divided by number of opportunities). Results: A total of 2432 patients had a new stroke and 4873 had a new primary AMI (at 75 facilities). Stroke patients had worse vascular risk factor control than AMI patients (mean facility rate on consolidated measure: stroke...

Stroke, 2017

Background: Interventions that emphasize early evaluation and management of patients with TIA and... more Background: Interventions that emphasize early evaluation and management of patients with TIA and minor stroke have demonstrated reductions in recurrent vascular events. Objective: To identify processes of care that were associated with reduced risk of recurrent vascular events after TIA or minor stroke. Methods: We identified patients with a TIA or minor stroke cared for in a Department of Veterans Affairs (VA) Emergency Department or inpatient ward (fiscal year 2011). Recurrent vascular events included ischemic stroke, myocardial infarction, heart failure, arrhythmia or death within 90-days and 1-year of discharge. 32 processes of care were examined. Defect-free care was assessed for a set of 6 processes (brain imaging, carotid artery imaging, hypertension management, high or moderate potency statin, antithrombotics, and anticoagulation for atrial fibrillation); patients who received all processes for which they were eligible passed the defect-free measure. Multivariable logistic ...

Stroke, 2013

Introduction: Current guidelines recommend screening for coronary heart disease (CHD) using cardi... more Introduction: Current guidelines recommend screening for coronary heart disease (CHD) using cardiac stress testing for ischemic stroke patients at ‘high risk’ of future cardiac events. However, it is unknown whether high risk stroke patients routinely receive guideline concordant cardiac stress testing. Methods: Medical records were abstracted for a sample of 3965 Veterans from 131 Veterans Health Administration (VHA) facilities who were admitted for a confirmed diagnosis of ischemic stroke (fiscal year 2007). Patients with a history of CHD, receipt of cardiac stress testing within 18-months prior to stroke event, and patients who died during the index hospitalization were excluded (n=1628). Framingham Risk Scores (FRS) were calculated on the basis of: age, gender, systolic blood pressure, blood pressure treatment (yes/no), smoking status (smoker/non-smoker), diabetes, total cholesterol, and high-density lipoprotein cholesterol. FRS ≥20 was used to define patients at “high-risk” of ...

Stroke, 2013

Introduction: Three-quarters of people with stroke sustain a fall. Fall risk and risk for injury ... more Introduction: Three-quarters of people with stroke sustain a fall. Fall risk and risk for injury persists into the chronics phases of stroke recovery. Currently, the circumstances surrounding post-stroke falls are not well understood; identifying these circumstances is a key step in the development of fall prevention programs. Likewise, the consequences of falls during the chronic phases of stroke are largely unexplored. Objectives: The objectives of the study were to identify the circumstances and consequences of post-stroke fall events. Methods: This is a secondary analysis of data derived from a large trial. To be included in the trial and these analyses, participants had to have survived a stroke and had a diagnosis of hypertension or blood pressure >140/90 mmHg. Demographics and stroke characteristics were recorded. Patients were asked about falls prospectively over the one-year study period. Once a fall event was identified, chart review and interviews were used to obtain i...

Stroke, 2012

Introduction: Anemia is associated with higher mortality among patients with such non-stroke vasc... more Introduction: Anemia is associated with higher mortality among patients with such non-stroke vascular conditions as heart failure and myocardial infarction. Less is known regarding the relationship between anemia and mortality among patients with acute ischemic stroke. Methods: Medical records were abstracted for a sample of 3965 veterans from 131 Veterans Health Administration (VHA) facilities who were admitted for a confirmed diagnosis of ischemic stroke (fiscal year 2007). Hematocrit (Hct) values from 24-hours of admission were categorized into 6-tiers (≤27%, 28-32%, 33-37%, 38-42%, 43-47%, ≥48%). We excluded patients with: female gender (n=95), incomplete Hct data (n=94), thrombolysis (n=32), and inconsistent death dates (n=6). We used multivariate logistic regression to examine the relationship between anemia and in-hospital, 30-day, 60-day and one-year mortality using multivariate logistic regression models for each time point, adjusting for age, NIHSS, comorbidity (including ...

Journal of the American College of Cardiology

Circulation: Cardiovascular Quality and Outcomes, 2018

Background: Ischemic stroke disproportionately affects women. Women have a higher lifetime risk o... more Background: Ischemic stroke disproportionately affects women. Women have a higher lifetime risk of stroke, experience worse functional recovery post-stroke, and are more likely to be institutionalized after stroke than men. Despite the pronounced differences in which stroke may affect women compared to men, stroke research specifically focusing on women has not been published until recently. For instance, stroke specific guidelines for women were not published until 2014. This study sought to determine whether differences in stroke risk exist between women and men across age strata using the Framingham Stroke Risk (FRS) score in a large cohort of Veterans. Methods: Study participants were Veterans receiving care within Veterans Health Administration facilities between April 2011 and May 2012 (N=57,072). In this secondary analysis, patients were excluded (n=39,978) based on age less than 55 years and prior history of stroke. FRS was calculated for each patient based on race- and sex-...

BMJ Case Reports, 2020

A 71-year-old man developed dysphagia, bilateral lower extremity muscle weakness and weight loss.... more A 71-year-old man developed dysphagia, bilateral lower extremity muscle weakness and weight loss. He was admitted to the hospital after a failed formal swallow evaluation, nearly 3 weeks after symptom onset. In addition to dysphagia and weakness, physical examination was notable for hypophonia, dysarthria, diplopia, horizontal ophthalmoparesis, ptosis, ataxia and hyporeflexia. Cerebrospinal fluid was notable for albuminocytological dissociation and serum anti-GQ1b antibody titre was elevated (1:200). A diagnosis of Miller-Fisher syndrome (MFS) was made, and the patient was treated with intravenous immunoglobulin (0.4 g/kg/day) for 5 days, which resulted in resolution of symptoms. This is an atypical case of MFS, in that the presenting symptom was progressive dysphagia rather than the ophthalmoplegia and ataxia that are normally seen in MFS. Patients who present with dysphagia should receive a thorough neurological examination, with particular attention to extraocular movements, refl...

Headache, Jan 17, 2018

In this secondary analysis of the Clusterbusters Medication Use survey, the use, effectiveness, a... more In this secondary analysis of the Clusterbusters Medication Use survey, the use, effectiveness, and tolerability of inhaled oxygen were investigated and compared with injectable sumatriptan. We also sought to understand the predictors of medication response. Inhaled oxygen is a mainstay abortive intervention in cluster headache but is not approved by the Food and Drug Administration (FDA). Unlike injectable sumatriptan, the only FDA-approved pharmacologic intervention for cluster headache, oxygen can be used multiple times a day, which is highly relevant for a condition with numerous daily attacks. In addition to obstacles in obtaining oxygen therapy, optimal oxygen delivery (ie, mask, flow rate) is not uniformly employed in cluster headache. These factors lead to underuse and imprecise therapeutic response rates. A secondary analysis was conducted using deidentified data from the Clusterbusters Medication Use survey, which was modeled after previously published surveys and availabl...

Cephalalgia : an international journal of headache, 2018

Objective To assess the association of neurologist ambulatory care with healthcare utilization an... more Objective To assess the association of neurologist ambulatory care with healthcare utilization and expenditure in headache. Methods This was a longitudinal cohort study from two-year duration panel data, pooled from 2002-2013, of adult respondents identified with diagnostic codes for headache in the Medical Expenditure Panel Survey. Those with a neurologist ambulatory care visit in year one of panel participation were compared with those who did not for the change in annual aggregate direct headache-related health care costs from year one to year two of panel participation, inflated to 2015 US dollars. Results were adjusted via multiple linear regression for demographic and clinical variables, utilizing survey variables for accurate estimates and standard errors. Results Eight hundred and eighty-seven respondents were included, with 23.3% (207/887) seeing a neurologist in year one. The neurologist group had higher year-one mean headache-related expenditures ($3032 vs. $1636), but ne...

Mycoses, 2006

An 84-year-old woman with a past medical history significant for haemolytic anaemia necessitating... more An 84-year-old woman with a past medical history significant for haemolytic anaemia necessitating chronic steroid therapy presented with skin induration and erythema initially thought to be cellulitis. After a rapid progression of symptoms and failure to respond to antibiotics, a clinical diagnosis of necrotising vasculitis was made. Necrotising cryptococcal vasculitis was confirmed by histopathology and culture.

Journal of Family Studies, 2010

Abstract The study aimed to examine the prevalence, patterns and characteristics of continued tob... more Abstract The study aimed to examine the prevalence, patterns and characteristics of continued tobacco smoking among Australian parents. The study utilised data from Wave 1 and Wave 2 of the Longitudinal Study of Australian Children (LSAC). Smoking was reported by 20% of mothers and 25% of fathers at Wave 1 (with a slight decrease at Wave 2). Continued smoking was more likely among parents who were younger, less educated, reported problematic alcohol use, more financial problems and had a partner who smoked. The study estimated at the Australian population level, 29,649 children under the age of 1, and 36,208 children aged 4–5 years live in a household where smoking occurs inside. The prevalence of parental smoking remains considerable, despite an increasing awareness of the adverse effects. Reducing the number of adults who smoke inside the home with dependent children is an important public health concern in urgent need of attention.

Dysphagia, 2010

There have been several case reports of risperidone-associated dysphagia. Risperidone-induced bul... more There have been several case reports of risperidone-associated dysphagia. Risperidone-induced bulbar palsy-like syndrome has not been previously described. We report on a 58-year-old gentleman with prior history of schizophrenia and remote chlorpromazine use with no history of extrapyramidal symptoms who experienced acute onset of dysphagia and facial diplegia with hyperprolactinemia while being treated with risperidone. To date there have been five reported cases of dysphagia associated with risperidone, occurring by such mechanisms as isolated pharyngeal dysfunction from pharyngeal constrictor palsy and dystonia, drug-induced parkinsonism, and acute dystonic reaction. These cases were associated either with initiation or up-titration of risperidone, with complete resolution of dysphagia after medication discontinuation or dose change. Our patient developed dysphagia within 2 weeks of taking risperidone and completely resolved 1 month after the medication was stopped. Unlike other reported cases, our patient also experienced symptomatic hyperprolactinemia, another known side effect of risperidone. Physicians should also be aware that risperidone can be associated with oropharyngeal dysphagia secondary to an acute bulbar palsy-like syndrome that places patients at increased risk of aspiration events and its associated morbidity and mortality.

Clinical Neurology and Neurosurgery, 2009

Nervous system infections by Cryptococcus neoformans may occur not only in congenital or acquired... more Nervous system infections by Cryptococcus neoformans may occur not only in congenital or acquired immunodeficiency syndromes, but also in immunocompetent hosts. Neurological manifestations of C. neoformans infection include meningitis and, less commonly, parenchymal CNS granulomatous disease. This paper provides detailed clinical descriptions of highly unusual neurological manifestations of cryptococcal nervous system infections. Medical records and diagnostic data including magnetic resonance imaging, histopathology, serology, and CSF analysis were reviewed. A conus medullaris abscess was found in a patient infected with the human immunodeficiency virus (HIV). A patient with Hodgkin&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease was diagnosed with cryptococcal meningitis and dermatitis mimicking ophthalmic zoster. An immunocompetent patient presented with recurrent cerebral infarctions in the setting of cryptococcal meningitis. Cryptococcal infections of the nervous system can cause severe neurological disability when diagnosis is delayed. Sensitive and specific tests are readily available and should be considered when an unusual clinical presentation is encountered.

Stroke, 2015

Introduction: Research protocols for stroke prevention trials commonly specify goals for preventi... more Introduction: Research protocols for stroke prevention trials commonly specify goals for preventive care. We report variability in goal achievement between 3 countries participating in an on-going stroke secondary prevention trial. Methods: The Insulin Resistance Intervention after Stroke (IRIS) trial is testing pioglitazone, compared with placebo, for prevention of stroke and myocardial infarction among non-diabetic patients with a recent ischemic stroke/TIA. Preventive care is provided by personal physicians, although achievement of prevention goals is monitored and reported to participants and their physicians annually. Goals are from the American Heart Association guidelines: blood pressure (BP) <140/90 mmHg, statin therapy, and anti-platelet or anticoagulation depending on clinical indications. At baseline and year 1, we compared the proportions of participants meeting these goals in the largest enrolling countries: Canada (CA), United Kingdom (UK) and United States (US). Re...

Circulation: Cardiovascular Quality and Outcomes, 2018

Introduction: While the burden of non-communicable diseases is increasing worldwide in developing... more Introduction: While the burden of non-communicable diseases is increasing worldwide in developing countries, less is known regarding the true prevalence of such neurologic illness as cerebrovascular disease throughout sub-Saharan Africa. We sought to understand the prevalence of stroke and other neurologic conditions at Mulago Hospital, Uganda’s largest tertiary care referral center, and their association with post-event mortality. Methods: Data was prospectively collected on 335 patients admitted to the neurology wards of Mulago Hospital from January 2009 to May 2011. Data were collected from the date of admission until discharge, including: demographic information, village of residence, admission/discharge diagnoses, HIV status, discharge disposition, and mortality data, without the benefit of an electronic medical record. Kaplan-Meier survival curves and multivariate COX proportional hazard model were used for unadjusted and adjusted analysis to predict survival. Results: A total...

Stroke, 2013

INTRODUCTION: Obstructive sleep apnea (OSA) is common among patients with stroke and TIA. Previou... more INTRODUCTION: Obstructive sleep apnea (OSA) is common among patients with stroke and TIA. Previously validated OSA screening instruments used in the general population are largely based on reported symptoms; when applied to those with cerebrovascular disease, they have shown poor correlation with the presence of OSA diagnosed via polysomnography (PSG). We sought to develop a cerebrovascular disease specific prediction model for OSA that is less reliant on symptomatology. Methods: We used data from a multi-site randomized, controlled strategy trial that included ischemic stroke and TIA patients at two VA hospitals. Data on patient demographics, vital signs, anthropomorphic measurements, past medical history, medications, stroke severity, and sleep questionnaires were obtained. All patients received PSG. Sleep apnea was defined as present if the apnea-hypopnea index (AHI) was ≥5. Because approximately half of subjects had OSA, discrimination was difficult; thus, AHI was used as the ou...

Stroke, 2015

Background: The Veterans Health Administration has multiple quality improvement activities direct... more Background: The Veterans Health Administration has multiple quality improvement activities directed at improving vascular risk factor control. We sought to examine facility quality of blood pressure (BP) control (<140/90 mm Hg), lipid control (LDL-cholesterol <100 mg/dL) and glycemic control (HbA1c <9%) in the one-year after hospitalization for ischemic stroke or acute myocardial infarction (AMI). Methods: We assembled a retrospective cohort of patients hospitalized with stroke or AMI (fiscal year 2011). Facilities were included if they admitted ≥25 stroke patients and ≥25 AMI patients. A facility-level consolidated measure of vascular risk factor control was calculated for the 3 processes of care (number of passes divided by number of opportunities). Results: A total of 2432 patients had a new stroke and 4873 had a new primary AMI (at 75 facilities). Stroke patients had worse vascular risk factor control than AMI patients (mean facility rate on consolidated measure: stroke...

Stroke, 2017

Background: Interventions that emphasize early evaluation and management of patients with TIA and... more Background: Interventions that emphasize early evaluation and management of patients with TIA and minor stroke have demonstrated reductions in recurrent vascular events. Objective: To identify processes of care that were associated with reduced risk of recurrent vascular events after TIA or minor stroke. Methods: We identified patients with a TIA or minor stroke cared for in a Department of Veterans Affairs (VA) Emergency Department or inpatient ward (fiscal year 2011). Recurrent vascular events included ischemic stroke, myocardial infarction, heart failure, arrhythmia or death within 90-days and 1-year of discharge. 32 processes of care were examined. Defect-free care was assessed for a set of 6 processes (brain imaging, carotid artery imaging, hypertension management, high or moderate potency statin, antithrombotics, and anticoagulation for atrial fibrillation); patients who received all processes for which they were eligible passed the defect-free measure. Multivariable logistic ...

Stroke, 2013

Introduction: Current guidelines recommend screening for coronary heart disease (CHD) using cardi... more Introduction: Current guidelines recommend screening for coronary heart disease (CHD) using cardiac stress testing for ischemic stroke patients at ‘high risk’ of future cardiac events. However, it is unknown whether high risk stroke patients routinely receive guideline concordant cardiac stress testing. Methods: Medical records were abstracted for a sample of 3965 Veterans from 131 Veterans Health Administration (VHA) facilities who were admitted for a confirmed diagnosis of ischemic stroke (fiscal year 2007). Patients with a history of CHD, receipt of cardiac stress testing within 18-months prior to stroke event, and patients who died during the index hospitalization were excluded (n=1628). Framingham Risk Scores (FRS) were calculated on the basis of: age, gender, systolic blood pressure, blood pressure treatment (yes/no), smoking status (smoker/non-smoker), diabetes, total cholesterol, and high-density lipoprotein cholesterol. FRS ≥20 was used to define patients at “high-risk” of ...

Stroke, 2013

Introduction: Three-quarters of people with stroke sustain a fall. Fall risk and risk for injury ... more Introduction: Three-quarters of people with stroke sustain a fall. Fall risk and risk for injury persists into the chronics phases of stroke recovery. Currently, the circumstances surrounding post-stroke falls are not well understood; identifying these circumstances is a key step in the development of fall prevention programs. Likewise, the consequences of falls during the chronic phases of stroke are largely unexplored. Objectives: The objectives of the study were to identify the circumstances and consequences of post-stroke fall events. Methods: This is a secondary analysis of data derived from a large trial. To be included in the trial and these analyses, participants had to have survived a stroke and had a diagnosis of hypertension or blood pressure >140/90 mmHg. Demographics and stroke characteristics were recorded. Patients were asked about falls prospectively over the one-year study period. Once a fall event was identified, chart review and interviews were used to obtain i...

Stroke, 2012

Introduction: Anemia is associated with higher mortality among patients with such non-stroke vasc... more Introduction: Anemia is associated with higher mortality among patients with such non-stroke vascular conditions as heart failure and myocardial infarction. Less is known regarding the relationship between anemia and mortality among patients with acute ischemic stroke. Methods: Medical records were abstracted for a sample of 3965 veterans from 131 Veterans Health Administration (VHA) facilities who were admitted for a confirmed diagnosis of ischemic stroke (fiscal year 2007). Hematocrit (Hct) values from 24-hours of admission were categorized into 6-tiers (≤27%, 28-32%, 33-37%, 38-42%, 43-47%, ≥48%). We excluded patients with: female gender (n=95), incomplete Hct data (n=94), thrombolysis (n=32), and inconsistent death dates (n=6). We used multivariate logistic regression to examine the relationship between anemia and in-hospital, 30-day, 60-day and one-year mortality using multivariate logistic regression models for each time point, adjusting for age, NIHSS, comorbidity (including ...