Biomedical subjects

L B Morgenstern

Publications and source records attributed to L B Morgenstern.

At least 37 records · Page 2Linked to original sources

PubMed2001

What have we learned from clinical neuroprotective trials?

Although no neuroprotective agent is yet available for acute stroke patients, the information we have gleaned from clinical neuroprotective trials is incredibly valuable. We know that these agents are biologically active, potentially safe, and likely to have a primary role in the acute treatment of the stroke patient. The ischemic cascade has been attacked from a myriad of directions, and we now appreciate some of the advantages and limitations of preclinical models. We can use this knowledge to design more effective trials in the future.

Brain Ischemia↗

PubMed2000

Phenylpropanolamine and the risk of hemorrhagic stroke.

BACKGROUND: Phenylpropanolamine is commonly found in appetite suppressants and cough or cold remedies. Case reports have linked the use of products containing phenylpropanolamine to hemorrhagic stroke, often after the first use of these products. To study the association, we designed a case-control study. METHODS: Men and women 18 to 49 years of age were recruited from 43 U.S. hospitals. Eligibility criteria included the occurrence of a subarachnoid or intracerebral hemorrhage within 30 days before enrollment and the absence of a previously diagnosed brain lesion. Random-digit dialing identified two matched control subjects per patient. RESULTS: There were 702 patients and 1376 control subjects. For women, the adjusted odds ratio was 16.58 (95 percent confidence interval, 1.51 to 182.21; P=0.02) for the association between the use of appetite suppressants containing phenylpropanolamine and the risk of a hemorrhagic stroke and 3.13 (95 percent confidence interval, 0.86 to 11.46; P=0.08) for the association with the first use of a product containing phenylpropanolamine. All first uses of phenylpropanolamine involved cough or cold remedies. For men and women combined, the adjusted odds ratio was 1.49 (95 percent confidence interval, 0.84 to 2.64; P=0.17) for the association between the use of a product containing phenylpropanolamine and the risk of a hemorrhagic stroke, 1.23 (95 percent confidence interval, 0.68 to 2.24; P=0.49) for the association with the use of cough or cold remedies that contained phenylpropanolamine, and 15.92 (95 percent confidence interval, 1.38 to 184.13; P=0.03) for the association with the use of appetite suppressants that contained phenylpropanolamine. An analysis in men showed no increased risk of a hemorrhagic stroke in association with the use of cough or cold remedies containing phenylpropanolamine. No men reported the use of appetite suppressants. CONCLUSIONS: The results suggest that phenylpropanolamine in appetite suppressants, and possibly in cough and cold remedies, is an independent risk factor for hemorrhagic stroke in women.

Adolescent↗

PubMed2000

Predicting prognosis after stroke: a placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial.

BACKGROUND: Physicians are often asked to predict outcome after acute stroke. Very little information is available that can reliably predict the likelihood of severe disability or death. OBJECTIVE: To develop a practical method for predicting a poor outcome after acute ischemic stroke. METHODS: Data from the placebo arms of Parts 1 and 2 of the National Institute of Neurological Disorders and Stroke rt-PA [recombinant tissue plasminogen activator] Stroke Trial were used to identify variables that could predict a poor outcome, defined as moderately severe disability, severe disability, or death (Modified Rankin Scale score >3) 3 months after stroke. RESULTS: Baseline variables that predicted poor outcome were the NIH Stroke Scale (NIHSS) >17 plus atrial fibrillation, yielding a positive predictive value (PPV) of 96% (95% CI, 88 to 100%). The best predictor at 24 hours was NIHSS >22, yielding a PPV of 98% (95% CI, 93 to 100%). The best predictor at 7 to 10 days was NIHSS >16, yielding a PPV of 92% (95% CI, 85 to 99%). CONCLUSIONS: Patients with a severe neurologic deficit after acute ischemic stroke, as measured by the NIHSS, have a poor prognosis. During the first week after acute ischemic stroke, it is possible to identify a subset of patients who are highly likely to have a poor outcome. These findings require confirmation in a separate study.

Aged↗

PubMed2000

Comparison of stroke hospitalization rates among Mexican-Americans and non-Hispanic whites.

The authors performed a prospective, community-based pilot stroke surveillance project in Nueces County, TX. Mexican-Americans showed a trend toward higher completed ischemic stroke hospitalization rates compared with non-Hispanic whites. Mexican-Americans were more commonly uninsured (p = 0.007) and were less likely to receive neuroimaging (p = 0.001). Additional studies are needed to confirm this finding and to determine the role of stroke risk factors and access to care variables.

Aged↗

PubMed2000

Thrombolysis for acute stroke: is it for everyone?

To date, there is only one US Food and Drug Administration-approved treatment for stroke. Many patients have benefited after receiving rt-PA within 3 hours of acute stroke. Although the risk of hemorrhagic conversion is real, the patients at high risk for this complication are often the same patients most at risk for poor outcome secondary to their ischemic events. In this article, we review the data supporting the use of thrombolytics, both intravenously and intra-arterially, as well as patient selection criteria. Furthermore, we provide a framework for administering rt-PA and discuss the future of thrombolytic therapy.

Fibrinolytic Agents↗

PubMed2000

Stroke in Hispanic Americans.

The Hispanic American population is the fastest growing minority group with increasing representation among the older age strata. Current ethnic-specific cerebrovascular disease data regarding stroke outcomes and risk factor status reveal significant differences compared with other race/ethnic groups. The authors discuss the literature on stroke incidence and mortality among Hispanic populations. Traditional risk factors, access to care and stroke mechanism differences are also discussed. Advances in Hispanic American specific stroke prevention and treatment efforts demand further investigation to better define Hispanic American stroke prevention and acute treatment strategies.

Adult↗

PubMed2000

Utility of magnetic resonance imaging in acute intracerebral hemorrhage.

The authors determine whether magnetic resonance imaging (MRI) during acute hospitalization for spontaneous intracerebral hemorrhage (ICH) provides new diagnostic information. ICD-9 codes were used to identify consecutive patients with spontaneous ICH at Hermann Hospital, Houston, Texas, between January 1995 and August, 1997. Two investigators employed rigorous criteria to determine whether the MRI findings led to a specific new diagnosis. Two hundred ninety-one patients met inclusion and exclusion criteria. Sixty-seven (23%) patients underwent brain MRI during the acute hospitalization. MRI provided a new diagnosis in 15 of these 67 patients (22%). Amyloid angiopathy and vascular malformation (four each) were the most frequently identified etiologies. The yield of MRI was low in basal ganglia and thalamic hemorrhage. Two of 23 (9%) patients with deep ICH and 13 of 44 (30%) patients with lobar and infratentorial hemorrhage had etiology determined by MRI. Timing of MRI did not affect yield.

Brain↗

PubMed2000

Activation of emergency medical services for acute stroke in a nonurban population: the T.L.L. Temple Foundation Stroke Project.

BACKGROUND AND PURPOSE: Activating emergency medical services (EMS) is the most important factor in reducing delay times to hospital arrival for stroke patients. Determining who calls 911 for stroke would allow more efficient targeting of public health initiatives. METHODS: The T.L.L. Temple Foundation Stroke Project is an acute stroke surveillance and intervention project in nonurban East Texas. Prospective case ascertainment allowed chart abstraction and structured interviews for all hospitalized stroke patients to determine if EMS was activated, and if so, by whom. RESULTS: Of 429 validated strokes, 38.0% activated EMS by calling 911. Logistic regression analysis comparing those who called 911 with those who did not activate EMS found that individuals who were employed were 81% less likely to have EMS activated (OR 0.19, 95% CI 0.04 to 0.63). Of the 163 cases in which 911 was called, the person activating EMS was: self (patient), 4.3%; family member of significant other, 60. 1%; paid caregiver, 18.4%; and coworker or other, 12.9%. Significant associations between the variables age group (P=0.02), insurance status (P=0.007), and living alone (P=0.05) with who called 911 was found on chi(2) analysis. CONCLUSIONS: Educational efforts directed at patients themselves at risk for stroke may be of low yield. To increase the use of time dependent acute stroke therapy, interventions may wish to concentrate on family, caregivers, and coworkers of high-risk patients. Large employers may be good targets to increase utilization of EMS services for acute stroke.

Acute Disease↗

PubMed1999

Effects of tissue plasminogen activator for acute ischemic stroke at one year. National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group.

BACKGROUND: In 1995, the two-part National Institute of Neurological Disorders and Stroke (NINDS) Recombinant Tissue Plasminogen Activator Stroke Trial found that patients who were treated with tissue plasminogen activator (t-PA) within three hours after the onset of symptoms of acute ischemic stroke were at least 30 percent more likely than patients given placebo to have minimal or no disability three months after the stroke. It was unknown, however, whether the benefit would be sustained for longer periods. METHODS: In the NINDS Trial, a total of 624 patients with stroke were randomly assigned to receive either t-PA or placebo. We collected outcome data over a period of 12 months after the occurrence of stroke. The primary outcome measure was a "favorable outcome," defined as minimal or no disability as measured by the Barthel index, the modified Rankin Scale, and the Glasgow Outcome Scale. We assessed the treatment effect using a global statistic. RESULTS: Using an intention-to-treat analysis for the combined results of the two parts of the trial at 6 months and 12 months, we found that the global statistic favored the t-PA group (odds ratio for a favorable outcome at 6 months, 1.7; 95 percent confidence interval, 1.3 to 2.3; odds ratio at 12 months, 95 percent confidence interval, 1.7; 1.2 to 2.3). The patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at 12 months than were the placebo-treated patients (absolute increase in the proportion with a favorable outcome, 11 to 13 percentage points). There was no significant difference in mortality at 12 months between the t-PA group and the placebo group (24 percent vs. 28 percent, P=0.29). There was no interaction between the type of stroke identified at base line and treatment with respect to the long-term response. The rate of recurrent stroke at 12 months was similar in the two groups. CONCLUSIONS: During 12 months of follow-up, the patients with acute ischemic stroke who were treated with t-PA within three hours after the onset of symptoms were more likely to have minimal or no disability, than the patients given placebo. These results indicate a sustained benefit of t-PA for such patients.

Activities of Daily Living↗

PubMed1999

Brain tumor masquerading as stroke.

Discriminating brain tumor from stroke in patients presenting with acute focal neurologic signs and symptoms is crucial to avoid improper treatment, or delay correct treatment of the brain tumor patient. Data from the era before computed tomography (CT) suggests that 3% of patients with brain tumors are initially thought to have had a stroke. Our goal was to see if this has improved in the CT era. We reviewed hospital charts of all patients admitted to the Johns Hopkins Hospital with a brain tumor during a one year period. Eleven (4.9%) of the 224 patients discharged with a diagnosis of brain tumor were initially thought to have had a stroke. Seven had primary brain tumors and 4 had metastatic tumors. Patients who were originally misdiagnosed were significantly older (p = 0.01) and more likely to have a Glioblastoma Multiforme (p = 0.04) than those correctly diagnosed. Eighty-two percent of those misdiagnosed had no prior history of cancer compared to 59% of patients correctly diagnosed. Distinguishing the acute presentation of brain tumor and stroke remains an important diagnostic consideration. Physicians should recognize that while CT is frequently employed for acute neurologic deficits to exclude intracranial hemorrhage, CT may not be sufficient to exclude brain tumor. A prospective study is needed to confirm these findings.

Aged↗

PubMed1999

Greater stroke rate during hospitalization for acute heart disease among Mexican Americans than non-Hispanic whites.

BACKGROUND AND PURPOSE: This study compared the risk for stroke during acute myocardial infarction (AMI), percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) between Mexican Americans (MAs) and non-Hispanic whites. METHODS: We examined the age-specific rate ratios (RR) of acute stroke during hospitalization for AMI, CABG and PTCA in a population-based study in Corpus Christi, Tex. by searching the cardiac surveillance data for ICD-9 codes for stroke (430-437). ICD-9 stroke codes were validated by comparing medical chart abstraction with ICD-9 discharge diagnoses. RESULTS: Stroke codes were found in 220 of the 5,697 admissions for AMI, CABG and PTCA. In the 45- to 59-year age-group MAs had a RR of 2.66 (95% CI 1.36-5.23) relative to non-Hispanic whites. In the 60- to 74-year age-group the RR was 1.52 (95% CI 1.11-2.08). There were no significant differences in the 25- to 44-year age-group. These ethnic relationships were found in nondiabetics but not in diabetics. Women in the 45- to 59-year age-group had a RR of 1.88 (95% CI 1.09-3.25) compared with men, but there were no significant sex differences in the 25- to 44- or 59- to 74-year age-groups. Stroke ICD-9 codes have a poor positive predictive value for acute stroke ranging from 10 to 76%. The stroke misclassifications were nondifferential with respect to ethnicity or sex. CONCLUSIONS: MAs have a higher stroke rate complicating acute heart disease in Corpus Christi. A rigorous stroke surveillance project is needed to study the burden of stroke in MAs, the United States' largest Hispanic population.

Adult↗

PubMed1999

Serum glucose level and diabetes predict tissue plasminogen activator-related intracerebral hemorrhage in acute ischemic stroke.

BACKGROUND AND PURPOSE: Five pretreatment variables (P<0.1 univariate analysis), including serum glucose (>300 mg/dL), predicted symptomatic intracerebral hemorrhage (ICH) in the National Institute of Neurological Disorders and Stroke rtPA trial. We retrospectively studied stroke patients treated <3 hours from onset with intravenous rtPA at 2 institutions to evaluate the role of these variables in predicting ICH. METHODS: Baseline characteristics, including 5 prespecified variables (age, baseline glucose, smoking status, National Institutes of Health Stroke Scale [NIHSS] score, and CT changes [>33% middle cerebral artery territory hypodensity]), were reviewed in 138 consecutive patients. Variables were evaluated by logistic regression as predictors of all hemorrhage (including hemorrhagic transformation) and symptomatic hemorrhage on follow-up CT scan. Variables significant at P<0.25 level were included in a multivariate analysis. Diabetes was substituted for glucose in a repeat analysis. RESULTS: Symptomatic hemorrhage rate was 9% (13 of 138). Any hemorrhage rate was 30% (42 of 138). Baseline serum glucose (5.5-mmol/L increments) was the only independent predictor of both symptomatic hemorrhage [OR, 2.26 (CI, 1.05 to 4.83), P=0.03] and all hemorrhage [OR, 2.26 (CI, 1.07 to 4.69), P=0.04]. Serum glucose >11.1 mmol/L was associated with a 25% symptomatic hemorrhage rate. Baseline NIHSS (5-point increments) was an independent predictor of all hemorrhage only [OR, 12.42 (CI, 1.64 to 94.3), P=0.01]. Univariate analysis demonstrated a trend for nonsmoking as a predictor of all hemorrhage [OR, 0.45 (CI, 0.19 to 1. 08), P=0.07]. Diabetes was also an independent predictor of ICH when substituted for glucose in repeat analysis. CONCLUSIONS: Serum glucose and diabetes were predictors of ICH in rtPA-treated patients. This novel association requires confirmation in a larger cohort.

Acute Disease↗

PubMed1999

Race/ethnicity and location of stroke mortality: implications for population-based studies.

BACKGROUND AND PURPOSE: Stroke community surveillance projects often focus on hospital data rates. We hypothesized that not including strokes which occurred in nursing homes or at home would differentially affect race/ethnic stroke rates. METHODS: Texas vital statistics data were studied to compare age-specific (45 to 59, 60 to 74, and >/=75 years) location of stroke death for African Americans (AAs), Hispanic Americans (HAs), and non-Hispanic whites (NHWs). Rate ratios are reported with 95% CIs; NHW is used as the referent group. RESULTS: During 1991 to 1996, there were 52 996 stroke deaths in Texas for individuals aged 45 years and older. HAs in the oldest age group (>/=75 years) were 33% more likely than NHWs to die in the hospital, and HAs aged 45 to 59 and 60 to 74 years were 4% and 10%, respectively, more likely to die in the hospital. AAs aged >/=75 years were 19% more likely to die in the hospital. HAs aged 60 to 74 years were 35% less likely to die in a nursing home, whereas HAs aged >/=75 years were 43% less likely than NHWs to die in a nursing home. AAs aged >/=75 were 33% less likely to die in a nursing home. Death at home was 19% more likely in HAs aged 60 to 74 years. Significant gender differences are also reported. CONCLUSIONS: Using hospital data alone would overestimate stroke mortality in the HA and AA groups. Stroke community surveillance projects should account for ethnic and gender differences in location of death to avoid bias in race/ethnic and gender comparisons.

Age Factors↗

PubMed1998

Intravenous tissue plasminogen activator for acute ischemic stroke: feasibility, safety, and efficacy in the first year of clinical practice.

BACKGROUND AND PURPOSE: The feasibility, safety, and efficacy of intravenous tissue plasminogen activator (t-PA) for patients with acute ischemic stroke in clinical practice need to be assessed. METHODS: We initiated a prospective open-label study at a university hospital and two community hospitals in Houston, Tex, immediately after the publication of the National Institute of Neurological Disorders and Stroke (NINDS) t-PA study. A total of 30 patients, age 32 to 90 years, were treated with 0.9 mg/kg of intravenous t-PA (maximum dose, 90 mg) within 3 hours of acute ischemic stroke between December 1995 and December 1996. RESULTS: Six percent (6%) of all patients hospitalized with ischemic stroke received intravenous t-PA at the university hospital and 1.1% at the community hospitals. The rates of total, symptomatic, and fatal intracerebral hemorrhage were 10%, 7%, and 3%. Thirty-seven percent (37%) of patients recovered to fully independent function. The average time from stroke onset to emergency department arrival was 57 minutes; emergency department arrival to computed tomography scan 41 minutes; and computed tomography scan to administration of treatment 59 minutes. CONCLUSIONS: When treatment guidelines are carefully followed in an urban hospital setting, intravenous t-PA for acute ischemic stroke is feasible and shows safety and efficacy comparable to the results of the NINDS study.

Activities of Daily Living↗

PubMed1998

Cost-effectiveness of tissue plasminogen activator for acute ischemic stroke. NINDS rt-PA Stroke Study Group.

Tissue plasminogen activator (tPA) has been shown to improve 3-month outcome in stroke patients treated within 3 hours of symptom onset. The costs associated with this new treatment will be a factor in determining the extent of its utilization. Data from the NINDS rt-PA Stroke Trial and the medical literature were used to estimate the health and economic outcomes associated with using tPA in acute stroke patients. A Markov model was developed to estimate the costs per 1,000 patients eligible for treatment with tPA compared with the costs per 1,000 untreated patients. One-way and multiway sensitivity analyses (using Monte Carlo simulation) were performed to estimate the overall uncertainty of the model results. In the NINDS rt-PA Stroke Trial, the average length of stay was significantly shorter in tPA-treated patients than in placebo-treated patients (10.9 versus 12.4 days; p = 0.02) and more tPA patients were discharged to home than to inpatient rehabilitation or a nursing home (48% versus 36%; p = 0.002). The Markov model estimated an increase in hospitalization costs of $1.7 million and a decrease in rehabilitation costs of $1.4 million and nursing home cost of $4.8 million per 1,000 eligible treated patients for a health care system that includes acute through long-term care facilities. Multiway sensitivity analysis revealed a greater than 90% probability of cost savings. The estimated impact on long-term health outcomes was 564 (3 to 850) quality-adjusted life-years saved over 30 years of the model per 1,000 patients. Treating acute ischemic stroke patients with tPA within 3 hours of symptom onset improves functional outcome at 3 months and is likely to result in a net cost savings to the health care system.

Acute Disease↗

PubMed1998

Neurologists' attitudes regarding rt-PA for acute ischemic stroke.

We studied the attitudes of 238 Texas neurologists regarding the use of recombinant tissue plasminogen activator (rt-PA). The results show that 38 (16%) had treated stroke patients with rt-PA, and 97% of these would do so again. In the group that had not treated patients, 60% would treat if a suitable candidate presented. We conclude that soon after FDA approval of rt-PA, two-thirds of survey respondents were using or were planning to use this therapy. Those neurologists who have used rt-PA for stroke report a positive experience.

Health Care Surveys↗

PubMed1998

Critical factors determining access to acute stroke care.

OBJECTIVE: Our objective was to assess gender, ethnic, and access-to-care factors critical in delay time (DT) for presentation to the hospital for acute stroke. BACKGROUND: Little information is available on the effect of gender, ethnicity, and access issues on DT. DESIGN: Demographic, access-to-care, and DT information was obtained from emergency department (ED) documentation of stroke patients admitted from July 1995 through June 1997 at Hermann Hospital, Houston, TX. Univariate and multivariate regression analyses were performed. RESULTS: Of the 241 eligible patients, 126 were African American (AA), 82 were non-Hispanic white (NHW), and 33 were Hispanic American (HA). Median DT from symptom onset to presentation to the ED was 222 minutes for AAs, 280 minutes for HAs, and 230 minutes for NHWs. A multivariate regression model estimated DT to ED arrival decreased with ambulance transport (p = 0.003) and increased in patients with a primary care physician (p = 0.145) and in women (p = 0.052). DT to see an ED physician after hospital arrival decreased with ambulance transport (p < 0.001), hemorrhage patients (p = 0.006), and worse stroke severity (p = 0.038), and increased in women (p = 0.041). DT to see a neurologist decreased with hemorrhage (p = 0.002) and ambulance arrival (p = 0.010). Neurologists saw patients within 3 hours of symptom onset in 34% of NHWs, 28% of AAs, and 18% of HAs. CONCLUSION: Gender and access-to-care issues may be important determinants of delay in acute stroke care. Less than 20% of HAs presented to the ED within 3 hours of symptom onset.

Acute Disease↗

PubMed1998

Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinical trial.

OBJECTIVE: To perform a single-center pilot investigation of early hematoma removal in patients with intracerebral hemorrhage (ICH). BACKGROUND: Considerable debate remains regarding the utility of surgical clot evacuation for ICH. METHODS: This was a prospective trial of open craniotomy within 12 hours of ICH symptom onset versus best medical therapy. Patients were eligible if they had a nontraumatic ICH >9 mL with significant neurologic impairment and were prepared for surgery within 12 hours of symptom onset. The study included a prospective registry of patients and a randomized trial. RESULTS: The registry group included 34 medical and seven surgical patients. The surgical group had larger hemorrhages (median, 96 mL) and a lower Glasgow Coma Scale (GCS) score (median, 10) compared with the medical group (33 mL; GCS score, 13). Six-month mortality was less in the medical group (36%) compared with the surgical group (54%). In the randomized series, median ICH volumes were similar in the surgical group (n = 17; 49 mL) compared with the medical group (n = 17; 44 mL). Median GCS score was also similar (medical, 10; surgical, 11). Mortality was lower in the surgical group (6%) compared with the medical group (24%) at 1 month, but similar at 6 months (surgical group, 17%; medical group, 24%). CONCLUSION: A trial of early surgery for ICH is feasible. This study represents the largest prospective, randomized series of surgery for ICH. A modest early mortality benefit for surgery is possible, but long-term benefit for surgery was not established in this single-center pilot investigation.

Adult↗