Brain food

Food studies are a staple (pun intended) of medical conferences, and International Stroke Conference 2009 is no exception. As usual, tea and coffee are front and center in the research, though fast food gives them a run for their money. Without further ado:

--Three cups of green or black tea per day lower one's risk of ischemic stroke by 21%, according to a meta-analysis of tea studies from around the world. Pooled results of the 10 studies that examined tea consumption and ischemic stroke found black tea reduced risk by 24%, and green tea by 21%.

--Lest you think you need to swap your morning cuppa joe for tea, take heart: Coffee is also associated with reduced stroke prevalence, an analysis of national health survey data (NHANES III) found. The more you drink, the lower your risk--despite the fact that many heavy coffee drinkers also smoke. Stroke prevalence went from 5% for those who drank 1-2 cups per day, to 2.9% for those who drank more than six cups a day. Cardiac disease, diabetes and hypertension also declined as cups of coffee went up. Could it be that the fountain of youth spurts coffee instead of water?

--To avoid temptation, you might want to skip buying that coffee (or tea) at a fast food restaurant: People who live in neighborhoods with lots of fast food restaurants have a higher stroke risk. Specifically, for each fast food restaurant in a neighborhood, the relative risk rose by 1%. Authors cautioned that this is a correlation--they don't know if the fast food causes the higher risk, or if fast food restaurants are merely a marker of unhealthy neighborhoods. Admittedly, these results seem sort of obvious, but it's interesting that they held up even after researchers controlled for demographic and socioeconomic factors.

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posted by Jessica Berthold at 9:30 AM   0 Comments

Stroke 2009: Young and dismissed

It's a small study, but no less disturbing for that. Apparently, if you are unlucky enough to have a stroke at the ripe old age of 34, you have the additional bad luck of possibly being misdiagnosed because you don't fit the typical profile of a middle age-to-older patient.

Researchers reviewed data on 57 stroke patients, age 16-50 years, from the Young Stroke Registry at Wayne State's Comprehensive Stroke Center, and found 14% were misdiagnosed and sent home. They were told they were having vertigo, or migraine, or alcohol intoxication, but were later found to have had a stroke.

The study didn't compare this rate of misdiagnosis to that of a more typical (i.e., older) stroke population, but some of the specific examples are chilling. An 18-year-old guy was told the numbness on his left side was due to being drunk; a 37-year-old who had trouble speaking was told she was having a seizure; and a 48-year-old with blurred vision, an off-balance walk and trouble speaking was told she had an inner ear disorder.

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posted by Jessica Berthold at 9:00 AM   0 Comments

Stroke news of the obvious

And in our special conference issue of Stroke News of the Obvious...a study out of UNC that finds it takes longer to care for stroke patients in emergency departments that are overcrowded than those that are not. Specifically, it takes longer to triage the patients to ED rooms, physician assessment and hospital beds. "ED clinicians may need to attend to methods of increasing the efficiency of personnel and care processing during periods of overcrowding," the study authors smartly concluded.

Separately, stroke survivors are more likely to fall if they have impaired mobility, have a history of falling, and are still experiencing pain and injury from a previous fall...versus people who can get around just fine, haven't ever fallen, and are feeling healthy to boot. Also, older stroke survivors are more likely to fall than younger ones.

And finally, stroke patients who have heart failure are more likely to die in the hospital than stroke patients without heart failure. (I'm going to go out on a limb and say that adding a serious condition to anyone's health profile is, most likely, going to put her at a disadvantage vs. someone without that extra condition.) Stroke + heart failure patients also stayed in the hospital longer and required more intensive care than those with stroke alone.

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posted by Jessica Berthold at 3:45 PM   3 Comments

Post-stroke depression: cultural differences

I went to a session far too early this morning on cross-cultural differences in post-stroke emotional distress. It focused mainly on post-stroke depression in both patients and caregivers, though there was some mention of post-stroke anger as well. The upshot seemed to be that there isn't a great deal of research in this area; most of the info about cultural differences comes from the general depression research, or research on depression related to diseases other than stroke. Some interesting tidbits:

--Research on depression in caregivers of patients with dementia suggests that Asian and Hispanic American caregivers are more prone to depression than whites, while African American caregivers are less prone to it. One study on stroke patient caregivers found African American caregivers had a 3.7 times lower risk for depression than whites.

--There is some evidence that genetic differences in ethnicities may affect both the likelihood of getting depression and response to treatment, but it's complicated. Several genes seem to be involved, such that a mutation in any single gene accounts for only a small portion of the disease risk.

--There is some evidence that while somatic symptoms of depression may be the same between cultures, cognitive symptoms may be different. For example, Westerners are more likely to report psychological symptoms than the Chinese. Treatment response appears to be the same among different cultures, however.

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posted by Jessica Berthold at 3:07 PM   0 Comments

Gender differences in stroke

Several studies were presented at Stroke 2009 today on gender differences in stroke. Here are summaries of two, with more to come:

--A meta-analysis of 18 studies, presented by Archit Bhatt, MD, found that women with acute stroke have 30% lower odds of getting tPA treatment than men. When the analysis pulled out four studies that specified the patients had arrived at the hospital within the 3-hour tPA window, women were still 19% less likely to get treatment--but the difference was no longer statistically significant.

--Louise McCullough, MD, et al reported her findings that women arrived at the emergency department of a single stroke center later than men, despite having strokes of similar severity. Yet unlike Dr. Bhatt's study, Dr. McCullough found that, once the women got to the ED, they were treated just as quickly and often as men. She suggested a number of reasons why women may arrive at the ED later, including the fact that women may not be recognizing their stroke symptoms, or are more likely to be older/living alone when having stroke (thus an observer may not be around to help them get to the ED).

These results are interesting in tandem. Clearly, if women get to the ED later, they are less likely to be eligible for tPA (due to the three-hour time window), which could partly explain Dr. Bhatt's finding that women are less likely to get tPA than men.

The take-home message for internists, I think, is to really hammer home those stroke signs and symptoms with patients, particularly those who are at high risk.

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posted by Jessica Berthold at 1:57 PM   0 Comments

Stroke '09: Local color

These folks gave a talk to media and bystanders, complete with ambulance and stretcher props, about San Diego's emergency stroke response system. To hear them tell it, a call to 9-1-1 sets into motion a highly choreographed series of events-- a neurologist being paged, a radiologist securing a machine for imaging, a nurse clearing a bed for possible admission, so that everyone is ready to go when the patient arrives. Of course, one would like to think this happens everywhere, but there are many areas of the country which don't have well-oiled stroke plans.

I was a little disappointed that we didn't get a tour of the ambulance-- or better yet, a quick spin through town-- but left feeling that, if I had to have a stroke somewhere, San Diego seems like a good place to do it. (Admittedly, I say this having no real sense of how this city stacks up vs. other places in overall stroke care. And having no real desire to have a stroke, ever.) California in general seems committed to a tidy stroke response, according to Dr. James Dunford, the city's emergency medical director: There's a statewide task force underway to help all of the state's communities develop organized stroke response plans, he said.

(Pictured left to right: Dr. Patrick Lyden, medical director of UCSD Stroke Center; Dr. James Dunford, emergency medical director for the city of San Diego and an emergency department doctor at UCSD; and Vicky Powell, a stroke survivor who benefitted from UCSD's emergency response system.)

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posted by Jessica Berthold at 6:21 PM   0 Comments

Stroke '09: Reaching the underserved

One of the biggest issues in stroke care is how to help patients in "neurologically underserved" hospitals-- places that either don't have access to a specialist, or where a specialist isn't always available to help in the emergency department. (A situation, btw, which can occur in urban hospitals as well as those in rural areas.) Telemedicine (consultation with stroke experts via audio and video feeds) and "drip and ship" (transferring patients to regional stroke centers after they get tPA) are two increasingly common ways to deal with the issue. And both got a vote of confidence in new studies presented at Stroke '09.

Catalina Ionita, MD, University at Buffalo Neurosurgery, Inc., compared outcomes of thrombolyzed stroke patients at a telemedicine "hub" hospital (Millard Fillmore Gates Hospital in Buffalo, NY), with those of the 10 "spoke" hospitals it served. While there were some differences in terms of length of stay and stroke severity, the clinical outcomes were basically the same for patients treated at both-- suggesting that access to a top-notch stroke team via telemedicine is essentially as good as being seen by one personally.

A second study gave a boost to the growing practice of "drip and ship", whereby patients get tPA treatment at a community hospital, and are then transferred to a regional stroke center for follow-up care. Outcomes were similar for patients given tPA at community hospitals and then transferred, vs. those given tPA at the regional stroke center from the start. That's good news, since the alternative to drip and ship is to immediately transfer a community hospital patient to a regional center for tPA, which can be problematic given the 3-hour window for administering the treatment.

Labels: Stroke 2009, telemedicine, tPA

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posted by Jessica Berthold at 3:29 PM   2 Comments

Stroke 2009: Time is brain

Not surprisingly, the first abstract presented to the media here at Stroke 2009 dealt with the perennial issue of tPA timing.

Dr. Jeffrey Saver, director of UCLA's Stroke Center, reported on his huge registry study which found that patients who arrived at hospitals within an hour of stroke symptom onset were more than twice as likely to get tPA as those who arrived in the second or third hour. About 30% of the 100,000+ patients studied arrived within that first hour.

The bad news, however, was that doctors took 15 minutes longer to actually treat these first-hour patients than those who arrived later, perhaps thinking they had a bit of a time cushion to ensure that treatment was the right decision. Current guidelines recommend a "door to needle" time for tPA of 60 minutes from hospital arrival-- and for these patients, the average time was 90 minutes.

"There's a natural tendency for physicians to say we have some extra time to learn about the nature of stroke and make a more deliberate decision...but we are trying to highlight (that for) patients who get to hospitals early, we need to match that effort, and treat those patients more quickly," Dr. Saver said. "For every ten minutes that tPA is delayed, one less patient benefits from it."

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posted by Jessica Berthold at 12:23 PM   0 Comments