Brain Attack Surveillance In Corpus Christi Research Articles

Mexican Americans are Less Likely to Return to Work Following Stroke: Clinical and Policy Implications

Greater poststroke disability and U.S. employment policies may disadvantage minority stroke survivors from returning to work. We explored ethnic differences in return to work among Mexican Americans (MAs) and non-Hispanic whites (NHWs) working at the time of their stroke. Stroke patients were identified from the population-based BASIC (Brain Attack Surveillance in Corpus Christi) study from August 2011 to December 2013. Employment status was obtained at baseline and 90-day interviews. Sequential logistic regression models were built to assess ethnic differences in return to work after accounting for the following: (1) age (<65 versus ≥65); (2) sex; (3) 90-day National Institutes of Health Stroke Scale (NIHSS); and (4) education (lower than high school versus high school or higher). Of the 729 MA and NHW stroke survivors who completed the baseline interview, 197 (27%) were working at the time of their stroke, of which 125 (63%) completed the 90-day outcome interview. Forty-nine (40%) stroke survivors returned to work by 90 days. MAs were less likely to return to work (OR = .45, 95% CI .22-.94) than NHWs. The ethnic difference became nonsignificant after adjusting for NIHSS (OR = .59, 95% CI .24-1.44) and further attenuated after adjusting for education (OR = .85, 95% CI .32- 2.22). The majority of stroke survivors did not return to work within 90 days of their stroke. MA stroke survivors were less likely to return to work after stroke than NHW stroke survivors which was due to their greater neurological deficits and lower educational attainment compared with that of NHW stroke survivors. Future work should focus on clinical and policy efforts to reduce ethnic disparities in return to work.

Abstract WP163: One in Three Stroke Survivors has Uncontrolled Blood Pressure 90 Days After Stroke

Background and Objectives: High blood pressure (BP) is a major modifiable cause of recurrent stroke. The prevalence of uncontrolled BP 90 days after stroke in contemporary populations of unselected stroke patients is unclear. We measured the prevalence and predictors of uncontrolled BP 90 days after stroke in a population-based stroke surveillance project. Methods: Prospective cohort study of 214 Mexican American or non-Hispanic white adults aged ≥45 years with ischemic or hemorrhagic stroke and completed outcome assessments 90 day after stroke in the Brain Attack Surveillance in Corpus Christi (BASIC) project from March 2011 through June 2012. Trained personnel conducted in-home examinations following a standardized protocol to measure BP 90 days after stroke using an automated arm monitor (OmROn model 700 series). BP was measured in triplicate and the third BP reading was used. BP control was defined as BP&lt;140/90 mm Hg. We investigated risk factors for uncontrolled BP 90 days after stroke using logistic regression and adjusting for ethnicity, age, sex, education, and insurance status as well as variables that were associated with uncontrolled BP. Results: Median age was 66 years (interquartile range [IQR], 58-77 years), and 93% of strokes were ischemic. Median systolic BP was 128.5 mm Hg (IQR, 114-145) and diastolic BP was 76 mm Hg (IQR, 68 to 84). Overall, BP was uncontrolled in 35.1% (95% CI, 29.9% to 41.7%) of stroke survivors 90 days after stroke, and this did not differ by ethnicity (Mexican American, 34.3% [95% CI, 26.8% to 42.7%] vs. non-Hispanic white, 36.3%; [95% CI, 26.6% to 47.2%]; Wald P=0.58). Uncontrolled BP 90 days after stroke was more likely in stroke survivors with older age (adjusted odds ratio [aOR], 1.03 per 1 year increase; 95% CI, 1.00 to 1.06; P=0.03), no health insurance (aOR, 3.08; 95% CI, 1.19 to 7.96; P=0.02, and hypertension (aOR, 2.24; 95% CI, 0.96 to 5.26; P=0.06). Conclusion: More than one third of stroke survivors has uncontrolled BP 90 days after stroke in this population-based study. Interventions designed to improve BP control and targeting older and uninsured stroke survivors are needed.

Abstract TMP64: Patients With Mild Cognitive Impairment Less Likely to Receive t-PA for Stroke

Background and Objectives: Many adults with mild cognitive impairment (MCI) live years with good quality of life and do not progress to dementia. It is unclear whether patients with pre-existing MCI (without dementia) are less likely to receive effective treatments for acute ischemic stroke than patients without MCI. We measured differences in intravenous (IV) tissue plasminogen activator (t-PA) treatment for ischemic stroke between MCI patients and cognitively normal patients in a population-based stroke surveillance project. Methods: Cross-sectional analysis of prospectively obtained data of 626 first-ever ischemic stroke subjects 45 years or older without dementia in the Brain Attack Surveillance in Corpus Christi (BASIC) project from 2008 to 2012. We compared receipt of IV t-PA from chart abstraction between subjects with prestroke MCI (Informant Questionnaire on Cognitive Decline in the Elderly [IQCODE] score &gt;3 and &lt;3.44, a valid measure of prestroke MCI) and those with normal cognition (IQCODE score ≤3). We examined associations between receipt of t-PA and cognitive status using logistic regression and adjusting for age and sex as well as variables that were significantly associated with both MCI and receipt of t-PA. Results: Stroke patients with MCI (median age, 70 years; interquartile range (IQR), 60-79 years; n=233) were more likely than cognitively normal patients (median age, 63 years; IQR, 55-73 years; n=393) to be older and women (both P&lt;0.01), and to have a do-not-resuscitate (DNR) order (P=0.01). Patients with MCI were less likely to receive IV t-PA for acute ischemic stroke compared with cognitively normal patients (6% vs. 10.7%; unadjusted odds ratio (OR), 0.53; 95% CI, 0.29-1.00; P=0.05). MCI patients remained significantly less likely to receive t-PA compared with cognitively normal patients after adjusting for age, sex, DNR status, and stroke severity (adjusted OR, 0.48; 95% CI, 0.23-0.97; P=0.04). Conclusion: Patients with MCI are less likely to receive t-PA for acute ischemic stroke compared with cognitively normal patients. Research is needed to determine whether these treatment differences are the result of differences in treatment eligibility, patient/ family preferences, or a less aggressive approach to MCI patients.

Abstract TP167: Short-Term Exposures to Ambient Air Pollution and Risk of Recurrent Ischemic Stroke

Background: Recurrent strokes are associated with poor outcomes and mortality. Short-term ambient air pollution may be an important environmental risk factor for stroke recurrence. Although associations between air pollution and stroke risk have been observed, the evidence for short-term effects of air pollution on risk of stroke recurrence is in its infancy. We investigated the association between short-term changes in ambient pollution (particulate matter &lt;2.5μm (PM 2.5 ) and ozone (O 3 )) and the risk of recurrent ischemic stroke among individuals living in a bi-ethnic community. Methods: We identified recurrent ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project, an ongoing population-based stroke surveillance study in Nueces County, Texas, between 2000 and 2012. Associations between lags of 0 to 3 days PM 2.5 and O 3 levels and odds of ischemic stroke were assessed using a time-stratified case-crossover design. Conditional logistic regression models were used to calculate odds ratios (ORs) for a 10 unit change in exposure. Results: There were 317 recurrent ischemic strokes with mean age of 72 years (SD=12). Median levels of PM 2.5 and O 3 over the study period were 7.7μg/m 3 (IQR: 5.6-10.7μg/m 3 ) and 35.2ppb (IQR: 25.0-46.1ppb), respectively. No associations were observed across the different lagged exposures (0 to 3 days) after adjusting for ambient temperature and relative humidity (Figure). Co-adjustment of both pollutants results did not change the results. Conclusion: No association between PM 2.5 and O 3 and risk of recurrences was observed. Research on the influence of air pollutants on risk of recurrence is still in its infancy, and more research is needed to understand the relation.

Abstract WP173: Mexican Americans Less Likely to Return to Work Following Stroke

Introduction: Lost earnings are the largest driver of the projected $2.2 trillion in stroke costs over the next 4 decades. Mexican Americans (MA) are more likely to have a working age stroke and suffer greater post-stroke disability than non-Hispanic whites (NHW). Thus, we explored ethnic differences in post-stroke return to work and whether sociodemographics and stroke severity contribute to ethnic differences. Methods: Ischemic stroke patients were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) study from August 2011-December 2013. Employment status was obtained at baseline and 90-day interviews conducted with patients or proxies. Sequential logistic regression models were built to assess ethnic difference in return to work after accounting for: 1) age (&lt;65 vs ≥65), sex; 2) 90-day NIH stroke score, and 3) education (&lt;high school vs. ≥high school). Results: Of the 729 MA and NHW stroke survivors who completed the baseline interview, 197 (27%) were working at the time of their stroke of which 125 completed the 90-day outcome interview. There were no ethnic differences in sex or the proportion over the age of 65. MAs had less education (5% vs. 24% college graduate, p&lt;0.01) and greater median 90-day stroke severity (2 vs. 1, p=0.02) than NHWs. Forty-nine (40%) stroke survivors returned to work. MAs were less likely to return to work (OR= 0.45, 95% CI 0.22-0.94) than NHWs. This difference remained after accounting for age and sex (OR=0.45, 95% CI 0.21-0.94). The ethnic difference was attenuated and became non-significant after adjusting for stroke severity (0.59, 95%CI 0.24-1.24) and further attenuated after accounting for education (0.85, 95% CI 0.32, 2.22). In the fully adjusted model, lower stroke severity and higher education were associated with return to work. Conclusion: MAs are less likely to return to work after stroke than NHWs. This finding is important given that MAs are younger and poorer at the time of their stroke suggesting a crucial public health problem. Future work should consider including return to work as part of patient centered outcomes and efforts to optimize stroke recovery.

Abstract TP201: Diabetes and the Risk of Death and Stroke Recurrence Following Ischemic Stroke

Background and Purpose: Diabetes mellitus (DM) is a well-established risk factor for ischemic stroke (IS), but the literature is inconsistent on the effect of DM on outcomes after IS. We sought to determine if DM increases the risk of mortality and recurrence after IS, and if these associations are greater in Mexican Americans (MA) than non-Hispanic whites (NHW). Methods: IS cases, all-cause mortality, and recurrent strokes were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project (2006-2012). Sociodemographics and clinical data were obtained from medical records and interviews. Cumulative mortality and stroke recurrence risk were estimated at 30 days and 1 year using Kaplan-Meier analysis and Cox proportional hazards models. Effect modification by ethnicity was examined. Results: There were 1,301 IS cases, 46% with a history of DM, median age 70 (IQR: 58-81), and 61% MA. Patients with DM were younger and more likely to be MA compared to patients without DM. Risk of 30-day and 1-year mortality was 8.4% and 20.5% for those with DM and 9.5% and 20.8% for those without DM, respectively. Risk of 30-day and 1-year stroke recurrence was 1.2% and 7.5% for those with DM and 1.5% and 5.8% for those without DM, respectively. Unadjusted, DM was not a significant predictor of mortality or recurrence (see table). After adjustment, DM predicted mortality (30-day HR=1.58, 95% CI: 0.98-2.53; 1-year HR=1.48, 95% CI: 1.10-2.00) but not stroke recurrence (1-year HR=1.28, 95% CI: 0.78-2.08). Effect modification by ethnicity was not significant (p&gt;0.2 for all models). Conclusions: Given that patients with DM were significantly younger than patients without DM, the crude association between DM and mortality revealed no difference. However, after accounting for age and other factors, patients with DM were 50% more likely to die at 1 year after IS compared to patients without DM.

Abstract TP142: Factors Influencing Post-stroke Discharge to Institutional Rehabilitation Settings versus Home

Introduction: We assessed relative impacts of sociodemographic, clinical, and geographic factors on discharge to rehabilitation or home in a population-based stroke study. Methods: Stroke survivors were identified from 2011-2013 in the Brain Attack Surveillance in Corpus Christi (BASIC) Project (death&lt;30 days or nursing home residence excluded). Sociodemographic factors (age, sex, ethnicity, insurance type), clinical factors (risk factors, comorbidities, NIH Stroke Scale), and discharge location (inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), home) were collected from medical records and interviews. Geographic factors were distance to nearest IRF/SNF and number of IRF/SNFs within 5 miles of the survivor’s home. Multinomial logistic regression models were used to calculate probabilities of discharge to IRF, SNF, and home for each factor set, fixing the other two factors at their means. High vs low probabilities (25 vs 75 percentile) of discharge to IRF, SNF, and home were compared to show the impact of each factor set. Results: Discharge location was available for 796/942 (85%) survivors; 15% were discharged to IRF, 26% SNF, and 59% home. Median age was 68 (IQR 58-79); 64% were Mexican American and 36% non-Hispanic white. High/low probabilities of discharge to IRF differed by 2% for sociodemographic factor variation, 7% for clinical factors, and 9% for geographic factors; probabilities of discharge to SNF differed by 22% for sociodemographic factor variation, 14% for clinical factors, and 6% for geographic factors; and probabilities of discharge home differed by 25% for sociodemographic factor variation, 24% for clinical factors, and 6% for geographic factors. Conclusion: The probability of discharge to IRF is most affected by variation in clinical factors; discharge to SNF by sociodemographic factors; and discharge home by sociodemographic and clinical factors. Geographic factors do not substantially affect discharge location.

Ethnic differences in ambient air pollution and risk of acute ischemic stroke

ObjectivesTo investigate the association between short-term changes in ambient pollution (particulate matter <2.5μm in aerodynamic diameter (PM2.5) and ozone (O3)) and the risk of ischemic stroke among individuals living in a bi-ethnic community and whether this association is modified by ethnicity. MethodsWe identified incident ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project between 2000 and 2012. Associations between PM2.5 (mean 24-h) and O3 (maximal 8-h) levels, measured on the same-day and lags of 1–3 days, and odds of ischemic stroke were assessed using a time-stratified case-crossover design and modeled using conditional logistic regression. We explored race/ethnicity (Mexican American versus non-Hispanic white) as a modifier by including interaction terms in the models. ResultsThere were 2948 ischemic strokes with median age 71 years (IQR: 59-80). We observed no overall associations between the air pollutants and odds of ischemic stroke at any lag. When stratified by ethnicity, higher O3 was consistently associated with greater odds of ischemic stroke for non-Hispanic whites, but not for Mexican Americans. Higher PM2.5 was generally associated with lower odds of ischemic stroke for non-Hispanic whites but modestly greater odds for Mexican Americans. ConclusionEthnic differences in the associations between ischemic stroke and short-term exposures to O3 and PM2.5 were suggested indicating that further study in diverse populations may be warranted.

Ethnic Differences in Poststroke Quality of Life in the Brain Attack Surveillance in Corpus Christi (BASIC) Project.

Mexican Americans (MAs) have an increased risk of stroke and experience worse poststroke disability than non-Hispanic whites, which may translate into worse poststroke quality of life (QOL). We assessed ethnic differences in poststroke QOL, as well as potential modification of associations by age, sex, and initial stroke severity. Ischemic stroke survivors were identified through the biethnic, population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from medical records, baseline interviews, and 90-day poststroke interviews. Poststroke QOL was measured at ≈90 days by the validated short-form stroke-specific QOL in 3 domains: overall, physical, and psychosocial (range, 0-5; higher scores represent better QOL). Tobit regression was used to model associations between ethnicity and poststroke QOL scores, adjusted for demographics, clinical characteristics, and prestroke cognition and function. Among 290 eligible stroke survivors (66% MA, 34% non-Hispanic whites, median age=69 years), median scores for overall, physical, and psychosocial poststroke QOL were 3.3, 3.8, and 2.7, respectively. Poststroke QOL was lower for MAs than non-Hispanic whites both overall (mean difference, -0.30; 95% confidence interval, -0.59, -0.01) and in the physical domain (mean difference, -0.47; 95% confidence interval, -0.81, -0.14) after multivariable adjustment. No ethnic difference was found in the psychosocial domain. Age modified the associations between ethnicity and poststroke QOL such that differences were present in older but not in younger ages. Disparities exist in poststroke QOL for MAs and seem to be driven by differences in older stroke patients. Targeted interventions to improve outcomes among MA stroke survivors are urgently needed.

Abstract W P300: Ethnic Differences in Post-Stroke Quality of Life in the Brain Attack Surveillance in Corpus Christi (BASIC) Project

Background: Mexican Americans (MAs) have worse stroke outcomes than non-Hispanic whites (NHWs), which could translate into worse quality of life (QOL). Our objective was to investigate ethnic differences in post-stroke QOL across multiple domains in a bi-ethnic community. Methods: Ischemic stroke survivors, identified through the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project in Nueces County, Texas, participated in in-person interviews 90 days post-stroke from May 2010 - June 2012. The validated short form stroke-specific QOL (SSQOL) was used to assess overall, physical, and psychosocial QOL; scores range from 1-5 with higher scores representing greater QOL. Tobit regression was used to model unadjusted associations between ethnicity and the 3 QOL domains. Models were then adjusted for the following demographic and clinical factors obtained from the medical record and patient interview: age, sex, education, insurance status, marital status, nursing home residence before stroke, prestroke modified Rankin scale, prestroke Informant Questionnaire on Cognitive Decline in the Elderly, initial NIH stroke scale, risk factors, BMI, and a comorbidity index. Results: A total of 335 ischemic strokes with complete data were identified (66% MA, 34% NHW). QOL was lower among MAs compared to NHWs, both overall (mean difference=-0.3, p=0.02) and in the physical domain (mean difference=-0.4, p=0.008); however, there was no difference in the psychosocial domain (p=0.22). After adjustment for demographic and clinical factors, MAs continued to experience poorer QOL compared to NHWs overall (mean difference=-0.5,p=0.049) and in the physical domain (mean difference=-0.3, p=0.006). Conclusions: Ethnic disparities in stroke outcome extend to QOL, with MAs experiencing substantially worse post-stroke QOL than NHWs. Interventions are urgently needed to improve stroke outcomes among the rapidly growing MA stroke population.

Abstract W MP98: Ethnic Differences in Stroke Quality of Care Between Mexican Americans and Non-Hispanic Whites: The BASIC Project

Background: Mexican Americans (MAs) have worse outcomes after stroke than non-Hispanic Whites (NHWs). We investigated ethnic differences in the quality of inpatient stroke care between MAs and NHWs to determine if quality differences may contribute to the observed outcome disparity. Methods: Cases of ischemic stroke were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project (February 2009- June 2012). Quality of inpatient stroke care was assessed with seven quality metrics based on the 2008 Joint Commission Primary Stroke Center definitions. Two summary measure of overall quality were also created (binary defect-free care and a continuous composite score: proportion of achieved eligible measures). Multilevel generalized linear regression models were used to assess ethnic differences in quality of care, both unadjusted and then adjusting for hospital-level effects, demographics and confounders. Results: A total of 757 individuals were included (480 MAs and 277 NHWs). MAs were less likely than NHWs to receive tPA (RR: 0.71, 95% confidence interval (CI) 0.53, 0.96, p=0.026), and MAs with atrial fibrillation were less likely to receive anticoagulant medications at discharge (RR 0.71, 95% CI 0.55, 0.91, p=0.008). There were no ethnic differences in the other individual quality measures, or in the two overall summary measures. Adjustment for hospital clustering, demographics, and other confounders (summary measures only) resulted in little to no change in the association between ethnicity and quality (Table). Conclusions: There were no ethnic differences in the overall quality of stroke care between MAs and NHWs, though ethnic differences were seen in indicators for tPA and anticoagulant at discharge for atrial fibrillation. Since less than 20% of the population were eligible for these two measures, factors other than quality are likely to be primarily responsible for ethnic differences in stroke outcome.

Abstract T P151: Ethnic Differences in Associations Between Short-Term Exposures to Ambient Air Pollution and the Risk of Acute Ischemic Stroke

Background: Air pollution may contribute to ethnic differences in stroke risk, but little research has been conducted in diverse US populations. We investigated the association between daily changes in ambient pollution (PM2.5 and ozone (O3)) and the risk of ischemic stroke among individuals living in a biethnic community and whether the association differed by ethnicity. Methods: We identified incident ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project between 2000 and 2012. Air pollutant data were obtained from a state website. The association between average daily levels of PM2.5 and O3, measured on the same-day and lags of 1-3 days, and odds of ischemic stroke was assessed using a time-stratified case-crossover study design. We explored race/ethnicity of Mexican American (MA) and non-Hispanic white (NHW) as an interaction of the associations between air pollution and stroke. Results: There were 2,948 ischemic strokes during the study period. Median age was 71 years (interquartile range: 59-80); 51% were women and 56% were MA. In models combining ethnic groups, an association between lag 1 O3 and stroke was found (OR: 1.05, 95% CI: 1.00-1.10); no other significant associations were noted. Ethnic differences in the associations between PM2.5 and O3 with stroke were suggested (Figure). When stratified by ethnicity, increases in O3 were consistently associated with increased odds of stroke for NHWs, but not for MAs. Increases in same-day PM2.5 were marginally associated with increases in the odds of stroke in MAs (OR: 1.12, 95% CI: 0.98-1.27), but not for NHWs. Conclusion: We observed an association between previous-day O3 and ischemic stroke, but found little evidence of an association between PM2.5 and ischemic stroke. Ethnic differences in the associations with both O3 and PM2.5 and stroke were also noted, suggesting that further study of environmental influences on stroke in diverse populations is warranted.

Abstract T P128: Ethnicity and the Availability of Rehabilitation Facilities in the Brain Attack Surveillance in Corpus Christi Project

Background: Mexican Americans (MAs) have worse stroke outcomes than non-Hispanic whites (NHWs). One explanation may be ethnic differences in post-stroke rehabilitation; despite its effectiveness, non-clinical factors such as geographic availability may influence use of certain rehabilitation venues. We investigated ethnic differences in availability of stroke rehabilitation venues in a bi-ethnic community. Methods: Stroke survivors were identified through the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project from 2011-2013 in Nueces County, a bi-ethnic, mostly urban community in southeast Texas with a population of 340,000. Addresses of inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) providing stroke rehabilitation were identified by phone/internet and geocoded. Availability was defined as distance to and supply of each type of venue in relation to the survivor’s home. Supply was calculated as the count of each type of venue within a given radius (defined as the 90th percentile of distribution of distances to reflect a reasonable market area). Associations between availability and ethnicity were modeled using linear regression adjusted for census tract-level median household income, proportion &lt;65 years, and population density as obtained from the 2012 American Community Survey. Results: A total of 942 survivors were eligible (62% MA, 38% NHW); 3 IRFs and 21 SNFs were identified. The average distances from the survivors’ homes to an IRF or SNF were 5 miles (SD=6) and 2 miles (SD=3), respectively. Supply was calculated within radii of 16 miles for IRFs and 4 miles for SNFs. The average count of rehabilitation venues within these radii was 2.6 IRFs (SD=0.9) and 7.9 SNFs (SD=4.7). There were no ethnic differences in the distance or supply of IRFs; however, MAs were on average 1 mile (CI:0.6-1.5) closer to and had 0.8 (CI:0.2,1.3) more SNFs within the radius than NHWs. Conclusions: Availability of rehabilitation venues was high for both ethnic groups; however, MAs have greater availability of SNFs compared to NHWs. Additional study is necessary to understand how the availability and quality of services within rehabilitation venues impact post-stroke rehabilitation among MA stroke survivors.

Abstract T P146: The Impact of Pre-stroke Depressive Symptoms, Fatalism, and Social Support on Disability after Stroke

Background: Fatalism and depression have been linked to post-stroke mortality and stroke recurrence. Our objective was to evaluate the impact of pre-stroke fatalism, depressive symptoms, and social support on neurological, functional, and cognitive outcomes after stroke. Methods: Ischemic strokes (2008 -2011) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. At baseline interviews, pre-stroke depressive symptoms, fatalism, and social support were assessed using Patient Health Questionnaire (PHQ-9; 0-27; higher worse), modified Mental Adjustment for Stroke and Pearlin scales (8-40; higher worse), and a 7-item social support scale (0 -14; higher better); respectively. Outcome among survivors was assessed at 90 days using the National Institutes of Health Stroke Scale (NIHSS; 0-44, higher worse); activities/ instrumental activities of daily living (ADL/IADL; 1-4, higher worse); and Modified Mini-Mental State Exam (3MSE; 0-100, lower worse). Regression models were used to evaluate associations of interest, adjusting for demographic and clinical factors. Results: Among 364 participants with outcome interviews and complete covariate data, mean age was 66, 49.5% were female and 58.8% were Mexican American. In adjusted models, higher pre-stroke fatalism (median 17; IQR 12, 20) was associated with poorer functional (0.17 point higher ADL/IADL score per IQR higher fatalism score; 95% CI 0.05, 0.30) and cognitive (2.81 point lower 3MSE per IQR higher fatalism score; 95% CI 0.95, 4.67) outcomes. Similarly, higher pre-stroke depressive symptoms (median 3; IQR 0, 9) were associated with poorer functional (0.16 point higher ADL/IADL per IQR higher PHQ-9; 95% CI .04, 0.28) and cognitive (2.28 point lower 3MSE per IQR higher PHQ-9; 95% CI 0.46, 4.10) outcomes. There were no significant associations between fatalism or depressive symptoms and NIHSS or between social support (median 10; IQR 7, 12) and 90-day outcomes. Conclusions: Among ischemic stroke survivors, pre-stroke fatalism and depressive symptoms, but not social support, impact 90-day functional and cognitive outcomes. These findings reinforce the importance of evaluating and addressing psychological factors in stroke care.

Abstract W MP108: Identifying Factors Predictive of Good Outcome among Patients with Severe Ischemic Stroke: the BASIC Project

Background: Utilizing a population-based stroke surveillance study, our objective was to identify possible socio-demographic, cultural and psychological factors that influence outcome among patients with severe stroke who survive at least 3 months. Methods: Ischemic strokes (IS) were identified utilizing the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Severe stroke was defined as the highest quartile of the initial NIH Stroke Scale (NIHSS ≥ 8). Functional outcome was assessed at 90 days using the ADL/IADL score (0-4, higher worse). Good outcome was defined as ADL/IADL &lt;3. Single predictor logistic regression models were used to identify predictors of good outcome among those with severe stroke. Backward elimination was then used to select a final set of predictors. Next, models including selected predictors and pre-stroke social support or pre-stroke depression (PHQ-9) were used to evaluate their association with good outcome among a subset of patients who were asked about these factors. Only patients who were able to answer their own questions were asked about depression and social support. Results: From Feb 2009 to Jun 2012, 646 IS patients completed a baseline interview and subsequent 90-day outcome interview. Of 168 with severe stroke, 68 had a good outcome at 3 months (ADL/IADL &lt;3). One year older age (OR=0.94, 95% confidence interval (CI) 0.91, 0.97), Mexican American ethnicity (OR 0.30, 95%CI: 0.13, 0.68), stroke history (OR 0.27, 95%CI: 0.11, 0.66) and higher pre-stroke modified Rankin of 4-5 (OR 0.28, 95%CI: 0.08, 0.93) were associated with lower odds of good outcome. Among the subset of severe stroke patients (N=93) asked about pre-stroke depression and social support, higher pre-stroke depression score was associated with lower odds of good outcome (OR: 0.89, 95%CI 0.79, 0.99) while greater pre-stroke social support was associated with higher odds of good outcome (OR: 1.45, 95% CI 1.13, 1.86). Conclusion: Among IS survivors with severe stroke, pre-stroke depression and social support are important predictors of good outcome. These factors should be considered in crafting interventions to improve stroke outcome. Mexican American ethnicity and history of prior stroke are strongly negatively associated with good stroke outcome.

Factors influencing sex differences in poststroke functional outcome.

Our objective was to identify factors that contribute to or modify the sex difference in poststroke functional outcome. Ischemic strokes (n=439) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project (2008-2011). Data were ascertained from interviews (baseline and 90 days post stroke) and medical records. Functional outcome was measured as an average of 22 activities of daily living (ADL)/instrumental ADL items (range, 1-4; higher scores worse function). Tobit regression was used to estimate sex differences and to identify confounding and modifying factors. Fifty-one percent were women. Median age was 71 (interquartile range, 59-80) years in women and 64 (interquartile range, 56-77) years in men. Median ADL/instrumental ADL score at 90 days was 2.7 (interquartile range, 1.8-3.6) in women and 2.0 (interquartile range, 1.3-3.1) in men (P<0.01); this difference remained after age-adjustment (P<0.001). Factors contributing to higher ADL/instrumental ADL scores in women included prestroke function, marital status, prestroke cognition, nursing home residence, stroke severity, history of stroke/transient ischemic attack, and body mass index; prestroke function was the largest contributor. Stroke severity modified the sex difference in outcome such that differences were apparent for mild to moderate but not severe strokes. After adjustment, women still had significantly worse functional outcome than men. These findings yield insight into possible strategies and subgroups to target to reduce the sex disparity in stroke outcome; demographics and prestroke and clinical factors explained only 41% of the sex difference in stroke outcome highlighting the need for future research to identify modifiable factors that contribute to sex differences.

Differences in Initial Stroke Severity Between Mexican Americans and Non-Hispanic Whites Vary by Age: The Brain Attack Surveillance in Corpus Christi (BASIC) Project

Background: A wide variety of racial and ethnic disparities in stroke epidemiology and treatment have been reported. Race-ethnic differences in initial stroke severity may be one important determinant of differences in the outcome after stroke. The overall goal of this study was to move beyond ethnic comparisons in the mean or median severity, and instead investigate ethnic differences in the entire distribution of initial stroke severity. Additionally, we investigated whether age modifies the relationship between ethnicity and initial stroke severity as this may be an important determinant of racial differences in the outcome after stroke. Methods: Ischemic stroke cases were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project. National Institutes of Health Stroke Scale (NIHSS) was determined from the medical record or abstracted from the chart. Ethnicity was reported as Mexican American (MA) or non-Hispanic white (NHW). Quantile regression was used to model the distribution of NIHSS score by age category (45-59, 60-74, 75+) to test whether ethnic differences exist over different quantiles of NIHSS (5 percentile increments). Crude models examined the interaction between age category and ethnicity; models were then adjusted for history of stroke/transient ischemic attack, hypertension, atrial fibrillation, coronary artery disease, and diabetes. Results were adjusted for multiple comparisons. Results: There were 4,366 ischemic strokes, with median age 72 (IQR: 61-81), 55% MA, and median NIHSS of 4 (IQR: 2-8). MAs were younger, more likely to have a history of hypertension and diabetes, but less likely to have atrial fibrillation compared to NHWs. In the crude model, the ethnicity-age interaction was not statistically significant. After adjustment, the ethnicity-age interaction became significant at the 85th and 95th percentiles of NIHSS distribution. MAs in the younger age category (45-59) were significantly less severe by 3 and 6 points on the initial NIHSS than NHWs, at the 85th and 95th percentiles, respectively. However, in the older age category (75+), there was a reversal of this pattern; MAs had more severe strokes than NHWs by about 2 points, though not reaching statistical significance. Conclusions: There was no overall ethnic difference in stroke severity by age in our crude model. However, several potentially important ethnic differences among individuals with the most severe strokes were seen in younger and older stroke patients that were not explained by traditional risk factors. Age should be considered in future studies when looking at the complex distributional relationship between ethnicity and stroke severity.

Prevalence of pre-stroke sleep apnea risk and short or long sleep duration in a bi-ethnic stroke population

BackgroundThe ethnic disparity in ischemic stroke between Mexican Americans (MAs) and non-Hispanic whites (NHWs) may be partly attributable to disparities in sleep and its disorders. We therefore assessed whether pre-stroke sleep apnea symptoms (SA risk) and pre-stroke sleep duration differed between MAs and NHWs. MethodsMA and NHW ischemic stroke survivors in the Brain Attack Surveillance in Corpus Christi (BASIC) project reported sleep duration and SA symptoms on the validated Berlin questionnaire, both with respect to their pre-stroke baseline. Log binomial and linear regression models were used to test the unadjusted and adjusted (demographics and vascular risk factors) associations of high-risk Berlin scores and sleep duration with ethnicity. ResultsAmong 862 subjects, 549 (63.7%) were MA and 514 (59.6%) had a high risk of pre-stroke SA. The MA and NHW subjects showed no ethnic difference, after adjustment for potential confounders, in pre-stroke SA risk (risk ratio (95% confidence interval (CI)): 1.06 (0.93, 1.20)) or in pre-stroke sleep duration (on average MAs slept 2.0 fewer minutes than NHWs, 95% CI: −18.8, 14.9 min). ConclusionsPre-stroke SA symptoms are highly prevalent, but ethnic differences in SA risk and sleep duration appear unlikely to explain ethnic stroke disparities.

Stroke risk after nonstroke emergency department dizziness presentations: a population-based cohort study.

Acute stroke is a serious concern in emergency department (ED) dizziness presentations. Prior studies, however, suggest that stroke is actually an unlikely cause of these presentations. Lacking are data on short- and long-term follow-up from population-based studies to establish stroke risk after presumed nonstroke ED dizziness presentations. From May 8, 2011 to May 7, 2012, patients ≥45 years of age presenting to EDs in Nueces County, Texas, with dizziness, vertigo, or imbalance were identified, excluding those with stroke as the initial diagnosis. Stroke events after the ED presentation up to October 2, 2012 were determined using the BASIC (Brain Attack Surveillance in Corpus Christi) study, which uses rigorous surveillance and neurologist validation. Cumulative stroke risk was calculated using Kaplan-Meier estimates. A total of 1,245 patients were followed for a median of 347 days (interquartile range [IQR] = 230-436 days). Median age was 61.9 years (IQR = 53.8-74.0 years). After the ED visit, 15 patients (1.2%) had a stroke. Stroke risk was 0.48% (95% confidence interval [CI] = 0.22-1.07%) at 2 days, 0.48% (95% CI = 0.22-1.07%) at 7 days, 0.56% (95% CI = 0.27-1.18%) at 30 days, 0.56% (95% CI = 0.27-1.18%) at 90 days, and 1.42% (95% CI = 0.85-2.36%) at 12 months. Using rigorous case ascertainment and outcome assessment in a population-based design, we found that the risk of stroke after presumed nonstroke ED dizziness presentations is very low, supporting a nonstroke etiology to the overwhelming majority of original events. High-risk subgroups likely exist, however, because most of the 90-day stroke risk occurred within 2 days. Vascular risk stratification was insufficient to identify these cases.

Brainstem infarction and sleep-disordered breathing in the BASIC sleep apnea study

BackgroundAssociation between cerebral infarction site and poststroke sleep-disordered breathing (SDB) has important implications for SDB screening and the pathophysiology of poststroke SDB. Within a large, population-based study, we assessed whether brainstem infarction location is associated with SDB presence and severity. MethodsCross-sectional study was conducted on ischemic stroke patients in the Brain Attack Surveillance in Corpus Christi (BASIC) project. Subjects underwent SDB screening (median 13days after stroke) with a well-validated cardiopulmonary sleep apnea-testing device (n=355). Acute infarction location was determined based on review of radiology reports and dichotomized into brainstem involvement or none. Logistic and linear regression models were used to test the associations between brainstem involvement and SDB or apnea/hypopnea index (AHI) in unadjusted and adjusted models. ResultsA total of 38 participants (11%) had acute infarction involving the brainstem. Of those without brainstem infarction, 59% had significant SDB (AHI⩾10); the median AHI was 13 (interquartile range (IQR) 6, 26). Of those with brainstem infarction, 84% had SDB; median AHI was 20 (IQR 11, 38). In unadjusted analysis, brainstem involvement was associated with over three times the odds of SDB (odds ratio (OR) 3.71 (95% confidence interval (CI): 1.52, 9.13)). In a multivariable model, adjusted for demographics, body mass index (BMI), hypertension, diabetes, coronary artery disease, atrial fibrillation, prior stroke/transient ischemic attack (TIA), and stroke severity, results were similar (OR 3.76 (95% CI: 1.44, 9.81)). Brainstem infarction was also associated with AHI (continuous) in unadjusted (p=0.004) and adjusted models (p=0.004). ConclusionsData from this population-based stroke study show that acute infarction involving the brainstem is associated with both presence and severity of SDB.