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Social History Matters-The Impact of Illicit Drug Use on tPA Use and In-Hospital Mortality in Acute Ischemic Stroke.

ABSTRACT: AIMS:The objective of this descriptive study was to compare time to medical evaluation, intravenous tissue plasminogen activator (IV tPA) use, and short-term outcomes in illicit drug users compared to non-users presenting with acute ischemic stroke (AIS). STUDY DESIGN:This is a retrospective study performed from our stroke registry using deidentified patient information. PLACE AND DURATION OF STUDY:Tulane Medical Center Primary Stroke Center (PSC). Consecutive AIS patients presenting to our PSC from July 2008 to December of 2010 were identified from our prospectively collected stroke registry. METHODOLOGY:Patients were categorized as toxicology positive (TP) or toxicology negative (TN). We compared baseline characteristics, clinical presentation, tPA use, and short-term outcomes in TP and TN patients. RESULTS:Two hundred and sixty-three patients met inclusion criteria (median age 63, 35.4% female, 66.5% Black). Nearly 40% of toxicology screens were positive. Stroke severity was similar with the median National Institute of Health Stroke Scale (NIHSS) of 6 in both groups; however, a higher proportion of TN patients were treated with IV tPA (32.1% vs. 21.2%). After adjustment for time from last seen normal to emergency department arrival (LSN-to-ED arrival), the odds of being treated with tPA for TP patients were similar to TN patients (OR 0.69, 95% CI 0.36-1.31, p=0.255). After adjustment for age, NIHSS, glucose, and tPA, the odds of in-hospital mortality in TP patients was 3 times that of TN patients (OR 3.17, 95% CI 1.07-9.43, p=0.038). CONCLUSION:We found that the disparities observed in tPA use were attenuated after adjustment for time from LSN-to-ED arrival, suggesting an area for future intervention. Additionally, we found that TP patients may be at higher risk for in-hospital mortality. Further study on the role of substance abuse in time to ED arrival, tPA use, and outcome in AIS patients is warranted.

SUBMITTER: Marx MH

PROVIDER: S-EPMC4245033 | biostudies-literature | 2014 May

REPOSITORIES: biostudies-literature

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Social History Matters-The Impact of Illicit Drug Use on tPA Use and In-Hospital Mortality in Acute Ischemic Stroke.

Marx Matthew H M MH Albright Karen C KC Shaban Amir A Boehme Amelia K AK Beasley T Mark TM Martin-Schild Sheryl S

International neuropsychiatric disease journal 20140501 3

<h4>Aims</h4>The objective of this descriptive study was to compare time to medical evaluation, intravenous tissue plasminogen activator (IV tPA) use, and short-term outcomes in illicit drug users compared to non-users presenting with acute ischemic stroke (AIS).<h4>Study design</h4>This is a retrospective study performed from our stroke registry using deidentified patient information.<h4>Place and duration of study</h4>Tulane Medical Center Primary Stroke Center (PSC). Consecutive AIS patients ...[more]

PMID: 25436216

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Project description:Background and aimsStroke is the second leading cause of death around the globe. Studies examining the predictors of in-hospital mortality and the impact of complications on early outcome of acute ischemic stroke are scant. The aim of this study was to identify predictors of in-hospital mortality in patients with acute ischemic stroke.MethodsThis was a prospective, single-center study of patients with acute ischemic stroke consecutively admitted to the Neurology Department of a general hospital during a 2-year period (from January 1, 2010 to December 31, 2011). Prospective data from this single-center study included variables related to sociodemographics, comorbidities, and medical complications, together with in-hospital mortality. Since stroke mortality may impact differently by sex and is also influenced by hospital length of stay, we proceeded to stratify by these variables.ResultsSix-hundred and seventy-three patients were included. Overall, in-hospital mortality rate was 7.13%. Stratifying by length of stay in-hospital (< 7 days and ≥ 7 days), we observed that within the first week, overall mortality was related to a history of previous stroke, higher stroke severity, and to cardiovascular and respiratory complications. After 7 days, the main factor independently associated with overall in-hospital mortality was stroke severity (National Institutes of Health Stroke Scale (NIHSS) ≥ 14, odds ratio (OR): 17.15; 95% CI, 3.06-96.07).Stratifying by sex, we observed that females had a worse outcome if there was a history of prior stroke (OR: 3.29; 95% CI, 1.19-9.10), higher stroke severity (NIHSS ≥ 14, OR: 16.63; 95% CI, 4.66-59.31), and cardiovascular complications (OR: 29.70; 95% CI, 5.70-154.8). Among men, stroke severity (NIHSS ≥ 14, OR: 23.19; 95% CI, 5.69-94.56), respiratory infections (OR: 3.84; 95% CI, 1.32-11.20), and older age had significant negative impact.ConclusionsStroke severity and potentially modifiable complications (respiratory infections and cardiovascular complications) confer an increased risk of in-hospital death in both women and men, particularly during the first week of admission.

Project description:Background and Purpose- Thrombolytic treatment of acute ischemic stroke with tPA (tissue-type plasminogen activator) is hampered by its narrow therapeutic window and potential hemorrhagic complication. Vepoloxamer is a nonionic surfactant that exerts potent hemorheologic and antithrombotic properties in various thrombotic diseases. The current study investigated the effect of vepoloxamer on tPA treatment in a rat model of embolic stroke. Methods- Male Wistar rats subjected to embolic middle cerebral artery occlusion were treated with the combination of vepoloxamer and tPA, vepoloxamer alone, tPA alone, or saline initiated 4 hours after middle cerebral artery occlusion. Results- Monotherapy with tPA did not reduce infarct volume, and adversely potentiated microvascular thrombosis and vascular leakage compared with the saline treatment. Vepoloxamer monotherapy reduced infarct volume by 25% and improved brain perfusion. However, the combination treatment with vepoloxamer and tPA significantly reduced infarct volume by 32% and improved neurological function, without increasing the incidence of gross hemorrhage. Compared with vepoloxamer alone, the combination treatment with vepoloxamer and tPA robustly reduced secondary thrombosis and tPA-augmented microvascular leakage and further improved brain perfusion, which was associated with substantial reductions of serum active PAI-1 (plasminogen activator inhibitor-1) level and tPA-upregulated PAI-1 in the ischemic brain. Mechanistically, exosomes derived from platelets of ischemic rats treated with tPA-augmented cerebral endothelial barrier permeability and elevated protein levels of PAI-1 and TF (tissue factor) in the endothelial cells, whereas exosomes derived from platelets of rats subjected to the combination treatment with vepoloxamer and tPA diminished endothelial permeability augmented by tPA and fibrin and reduced PAI-1 and TF levels in the endothelial cells. Conclusions- The combination treatment with vepoloxamer and tPA exerts potent thrombolytic effects in rats subjected to acute ischemic stroke. Vepoloxamer reduces tPA-aggravated prothrombotic effect of platelet-derived exosomes on cerebral endothelial cells, which may contribute to the therapeutic effect of the combination treatment.

Project description:BackgroundA number of studies assessed the association of tissue plasminogen activator(TPA) gene polymorphisms with ischemic stroke, but the results were contradictory. We aimed to explore the role of TPA -7351C/T SNP in the susceptibility to ischemic stroke through a meta-analysis.MethodsThe PubMed, MEDLINE, EMBASE, China Biological Medicine Database and WANFANG DATA databases were searched until August 2012. The strict selection criteria and exclusion criteria were determined, and odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the strength of associations. Stroke subtype was determined using Trial of Org 10172 in Acute Treatment criteria (TOAST). Statistical analyses were performed using the STATA12.0 software.ResultsA total of 2,299 ischemic stroke cases and 1,948 controls in seven case-control studies were included in the meta-analysis. Significant association between -7351C/T polymorphism in the TPA gene and ischemic stroke was observed in all comparison models (TT+CT versus CC, TT versus CT+CC and T versus C). In the subgroup analysis by ethnicity, TT homozygote carriers had a 142% increased risk of ischemic stroke compared with the C allele carriers among East-Asians (TT versus CT+CC: OR?=?2.42, 95% CI?=?1.07-5.48), but not in South-Asians and Caucasians, and significantly increased risks were found for T versus C among both East-Asians (OR?=?1.33, 95% CI?=?1.05-1.68) and Caucasians(OR?=?1.16, 95% CI?=?1.02-1.31). Further stratification for stroke subtype in three Caucasian studies showed the association between -7351C/T polymorphism and Large-artery atherosclerosis (LAA), but not Small-vessel occlusion (SVO) and Cardioembolism (CE).ConclusionsThis meta-analysis suggested that the -7351C/T polymorphism in TPA gene would be a risk factor for ischemic stroke, especially among East-Asians compared with Caucasians, but not in South-Asians, and it may play a role in the pathogenesis of LAA in Caucasians, but not in SVO and CE.

Dataset Information

Social History Matters-The Impact of Illicit Drug Use on tPA Use and In-Hospital Mortality in Acute Ischemic Stroke.

Publications

Social History Matters-The Impact of Illicit Drug Use on tPA Use and In-Hospital Mortality in Acute Ischemic Stroke.

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