S Claiborne Johnston

University of Texas at Austin, Austin, Texas, United States

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Publications (408)3204.98 Total impact

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    ABSTRACT: Endovascular treatment is increasingly being used in acute stroke care. However, although stent retrievers show improved flow restoration rates, their clinical benefits have been uncertain. To assess the incremental effect of using stent retrievers compared with intravenous tissue plasminogen activator (IV tPA; alteplase) alone or placebo/control. We conducted a pooled analysis of 4 studies using stent retrievers (Solitaire), IV tPA, or placebo/control. We applied the ischemic stroke risk score (www.sorcan.ca/iscore) to each participant to adjust for differences in baseline characteristics. We used a shift analysis to account for the potential benefits across the entire modified Rankin scale score at 90 days, adjusting for time-to-treatment, baseline Alberta Stroke Program Early CT score, and ischemic stroke risk score. Of the 915 participants in this analysis, 312 (34.1%) patients received placebo, 312 (34.1%) received tPA alone, 131 (14.4%) received stent retrievers alone, and 160 (17.5) received combined therapy (IV tPA plus stent retrievers). The shift analysis revealed that more patients remained independent at 90 days if receiving stent retrievers alone (number needed to treat 3.5) or combined with tPA (number needed to treat 3.1) compared with tPA alone. After adjustment, participants receiving stent retrievers alone (odds ratio, 2.95; 95% confidence interval, 1.48-5.89) or combined with tPA (odds ratio, 4.45; 95% confidence interval, 2.40-8.27) were more likely to be independent at 90 days compared with tPA alone. Patients with acute ischemic stroke who received IV tPA or revascularization therapies had a higher likelihood of achieving independence at 3 months. Stent retriever technology combined with tPA was associated with the greatest benefit compared with placebo, tPA alone, or endovascular therapy alone. ASPECTS, the Alberta Stroke Program Early CT scoreESCAPE, The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic StrokeiScore, ischemic stroke risk scoreIV, intravenousMR CLEAN, Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the NetherlandsmRS, modified Rankin scaleNIHSS, National Institutes of Health Stroke ScaleNINDS, National Institute of Neurological Diseases and StrokesICH, symptomatic intracerebral hemorrhageSTAR, the Solitaire Flow Restoration Thrombectomy for Acute RevascularizationSWIFT, Solitaire flow restoration device vs the Merci Retriever in patients with acute ischemic stroketPA, tissue plasminogen activator (alteplase)WHO, World Health Organization.
    Neurosurgery 09/2015; 77(3):454-61. DOI:10.1227/NEU.0000000000000826 · 3.62 Impact Factor
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    ABSTRACT: Objective: We aimed to investigate whether the efficacy and safety of clopidogrel plus aspirin vs aspirin alone were consistent between patients with and without intracranial arterial stenosis (ICAS), in the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial. Methods: We assessed the interaction of the treatment effects of the 2 antiplatelet therapies among patients with and without ICAS, identified by magnetic resonance angiography (MRA) in CHANCE (ClinicalTrials.gov identifier NCT00979589). Results: Overall, 1,089 patients with MRA images available in CHANCE were included in this subanalysis, 608 patients (55.8%) with ICAS and 481 (44.2%) without. Patients with ICAS had higher rates of recurrent stroke (12.5% vs 5.4%; p < 0.0001) at 90 days than those without. But there was no statistically significant treatment by presence of ICAS interaction on either the primary outcome of any stroke (hazard ratio for clopidogrel plus aspirin vs aspirin alone: 0.79 [0.47–1.32] vs 1.12 [0.56–2.25]; interaction p = 0.522) or the safety outcome of any bleeding event (interaction p = 0.277). Conclusions: The results indicated higher rate of recurrent stroke in minor stroke or high-risk TIA patients with ICAS than in those without. However, there was no significant difference in the response to the 2 antiplatelet therapies between patients with and without ICAS in the CHANCE trial. Classification of evidence: This study provides Class II evidence that for patients with acute minor stroke or TIA with and without ICAS identified by MRA, clopidogrel plus aspirin is not significantly different than aspirin alone in preventing recurrent stroke.
    Neurology 09/2015; DOI:10.1212/WNL.0000000000001972 · 8.29 Impact Factor
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    ABSTRACT: The risk of recurrent ischemia is high in the acute period after ischemic stroke and transient ischemic attack. Aspirin is recommended by guidelines for this indication, but more intensive antiplatelet therapy may be justified. We aim to evaluate whether ticagrelor, a potent antiplatelet agent that blocks the P2Y12 receptor without requiring metabolic activation, reduces the risk of major vascular events compared with aspirin when randomization occurs within 24 h after symptom onset of a nonsevere ischemic stroke or high-risk transient ischemic attack. Acute Stroke or Transient Ischemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (SOCRATES) is a randomized, double-blind, event-driven trial and will include an estimated 13 600 participants randomized in 33 countries worldwide to collect 844 primary events. The primary endpoint is the composite of stroke (ischemic or hemorrhagic), myocardial infarction, and death. Time to the first primary endpoint will be compared in the treatment groups during 90-day follow-up, with major hemorrhage serving as the primary safety endpoint. Participants will be followed for an additional 30 days after the randomized treatment period. The SOCRATES trial fulfills an important clinical need by evaluating a potent antiplatelet agent as a superior alternative to current standard of care in patients presenting acutely with ischemic stroke or transient ischemic attack. © 2015 World Stroke Organization.
    International Journal of Stroke 08/2015; DOI:10.1111/ijs.12610 · 3.83 Impact Factor
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    ABSTRACT: To determine the association of lipoprotein-associated phospholipase A2 (Lp-PLA2) measured in the acute period and the short-term risk of recurrent vascular events in patients with TIA or minor stroke. We measured Lp-PLA2 activity (Lp-PLA2-A) in a subset of 3,201 participants enrolled in the CHANCE (Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events) trial. Participants with TIA or minor stroke were enrolled within 24 hours of symptom onset and randomized to single or dual antiplatelet therapy. In the current analysis, the primary outcome was defined as the composite of ischemic stroke, myocardial infarction, or death within 90 days. The composite endpoint occurred in 299 of 3,021 participants (9.9%). The population average Lp-PLA2-A level was 209 ± 59 nmol/min/mL (95% confidence interval [CI] 207-211). Older age, male sex, and current smoking were associated with higher Lp-PLA2-A levels. Lp-PLA2-A was significantly associated with the primary endpoint (adjusted hazard ratio 1.07, 95% CI 1.01-1.13 for every 30 nmol/min/mL increase). Similar results were seen for ischemic stroke alone. Adjustment for low-density lipoprotein cholesterol attenuated the association between Lp-PLA2-A and the primary endpoint (adjusted hazard ratio 1.04, 95% CI 0.97-1.11 for every 30 nmol/min/mL increase). Higher levels of Lp-PLA2-A in the acute period are associated with increased short-term risk of recurrent vascular events. © 2015 American Academy of Neurology.
    Neurology 08/2015; DOI:10.1212/WNL.0000000000001938 · 8.29 Impact Factor
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    ABSTRACT: We compared the effect of clopidogrel plus aspirin vs aspirin alone on functional outcome and quality of life in the Clopidogrel in High-risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial of aspirin-clopidogrel vs aspirin alone after acute minor stroke or TIA. Participants were assessed at 90 days for functional outcome using the modified Rankin Scale (mRS) and quality of life using the EuroQol-5 Dimension (EQ-5D). Poor functional outcome was defined as mRS score of 2-6 at 90 days and poor quality of life as EQ-5D index score of 0.5 or less. Poor functional outcome occurred in 254 patients (9.9%) in the clopidogrel-aspirin group, as compared with 299 (11.6%) in the aspirin group (p = 0.046). Poor quality of life occurred in 142 (5.5%) in the clopidogrel-aspirin group and in 175 (6.8%) in the aspirin group (p = 0.06). Disabling stroke at 90 days occurred in 166 (6.5%) in the clopidogrel-aspirin group and in 219 (8.5%) in the aspirin group (p = 0.01). In stratified analysis by subsequent stroke, there was no difference in 90-day functional outcome and quality of life between the 2 groups. In patients with minor stroke or TIA, the combination of clopidogrel and aspirin appears to be superior to aspirin alone in improving the 90-day functional outcome, and this is consistent with a reduction in the rate of disabling stroke in the dual antiplatelet arm. This study provides Class II evidence that for patients with acute minor stroke or TIA, clopidogrel plus aspirin compared to aspirin alone improves 90-day functional outcome (absolute reduction of poor outcome 1.70%, 95% confidence interval 0.03%-3.42%). © 2015 American Academy of Neurology.
    Neurology 08/2015; 85(7):573-9. DOI:10.1212/WNL.0000000000001844 · 8.29 Impact Factor
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    ABSTRACT: Background and purposeThe Totaled Health Risks in Vascular Events (THRIVE) score is a previously validated ischemic stroke outcome prediction tool. Although simplified scoring systems like the THRIVE score facilitate ease-of-use, when computers or devices are available at the point of care, a more accurate and patient-specific estimation of outcome probability should be possible by computing the logistic equation with patient-specific continuous variables.Methods We used data from 12 207 subjects from the Virtual International Stroke Trials Archive and the Safe Implementation of Thrombolysis in Stroke – Monitoring Study to develop and validate the performance of a model-derived estimation of outcome probability, the THRIVE-c calculation. Models were built with logistic regression using the underlying predictors from the THRIVE score: age, National Institutes of Health Stroke Scale score, and the Chronic Disease Scale (presence of hypertension, diabetes mellitus, or atrial fibrillation). Receiver operator characteristics analysis was used to assess model performance and compare the THRIVE-c model to the traditional THRIVE score, using a two-tailed Chi-squared test.ResultsThe THRIVE-c model performed similarly in the randomly chosen development cohort (n = 6194, area under the curve = 0·786, 95% confidence interval 0·774–0·798) and validation cohort (n = 6013, area under the curve = 0·784, 95% confidence interval 0·772–0·796) (P = 0·79). Similar performance was also seen in two separate external validation cohorts. The THRIVE-c model (area under the curve = 0·785, 95% confidence interval 0·777–0·793) had superior performance when compared with the traditional THRIVE score (area under the curve = 0·746, 95% confidence interval 0·737–0·755) (P < 0·001).Conclusion By computing the logistic equation with patient-specific continuous variables in the THRIVE-c calculation, outcomes at the individual patient level are more accurately estimated. Given the widespread availability of computers and devices at the point of care, such calculations can be easily performed with a simple user interface.
    International Journal of Stroke 07/2015; 10(6). DOI:10.1111/ijs.12529 · 3.83 Impact Factor
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    ABSTRACT: The aim of this guideline is to provide a focused update of the current recommendations for the endovascular treatment of acute ischemic stroke. Where there is overlap, the recommendations made here supersede those of previous guidelines. This focused update analyzes results from 8 randomized clinical trials of endovascular treatment and other relevant data published since 2013. It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations. Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee (MOC). Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statement Oversight Committee and Stroke Council Leadership Committee. Evidence-based guidelines are presented for the selection of patients with acute ischemic stroke for endovascular treatment, the endovascular procedure and for systems of care to facilitate endovascular treatment. Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke. Systems of care should be organized to facilitate the delivery of this care. © 2015 American Heart Association, Inc.
    Stroke 06/2015; 46(10). DOI:10.1161/STR.0000000000000074 · 5.72 Impact Factor
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    ABSTRACT: The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment. © 2015 American Heart Association, Inc.
    Stroke 06/2015; 46(8). DOI:10.1161/STR.0000000000000070 · 5.72 Impact Factor
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    ABSTRACT: To investigate the prevalence, knowledge, and treatment of TIA in a Chinese adult population. We conducted a complex, multistage, probability sampling-designed, cross-sectional, nationwide survey of 98,658 Chinese adults in 2010. Possible TIA cases were first identified by symptoms recall or self-reported history of TIA through face-to-face interviews, and the final diagnosis was then made by expert neurologists through phone interviews or record review. The age-standardized prevalence of TIA was 2.27%. Clinically, only 16.0% of the participants were diagnosed before the study. The prevalence of TIA was higher in women and in patients who were older, had less education, were current smokers, lived in rural or undeveloped areas, and had a history of stroke, hypertension, myocardial infarction, dyslipidemia, or diabetes. Based on the survey responses, approximately 3.08% of Chinese adults had knowledge of TIA. Among patients with TIA, only 5.02% received treatment and 4.07% received guideline-recommended therapy. TIA is prevalent and an estimated 23.9 million people in China may have experienced a TIA. Public knowledge on TIA is very limited. TIA appears to be largely undiagnosed and untreated in China. There is an urgent need to develop strategies to improve the identification and appropriate management of TIA. © 2015 American Academy of Neurology.
    Neurology 05/2015; 84(23). DOI:10.1212/WNL.0000000000001665 · 8.29 Impact Factor
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    Yilong Wang · Yuesong Pan · Xingquan Zhao · Hao Li · David Wang · S Claiborne Johnston · Liping Liu · Xia Meng · Anxin Wang · Chunxue Wang ·
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    ABSTRACT: Background: The Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial showed that the combined treatment of clopidogrel and aspirin decreases the 90-day risk of stroke without increasing hemorrhage in comparison with aspirin alone, but provided insufficient data to establish whether the benefit persisted over a longer period of time beyond the trial termination. We report the 1-year follow-up outcomes of this trial. Methods and results: The trial was a randomized, double-blind, placebo-controlled trial conducted at 114 centers in China. We randomly assigned 5170 patients within 24 hours after onset of minor stroke or high-risk transient ischemic attack to clopidogrel-aspirin therapy (loading dose of 300 mg of clopidogrel on day 1, followed by 75 mg of clopidogrel per day for 90 days, plus 75 mg of aspirin per day for the first 21 days) or to the aspirin-alone group (75 mg/d for 90 days). The primary outcome was stroke event (ischemic or hemorrhagic) during 1-year follow-up. Differences in outcomes between groups were assessed by using the Cox proportional hazards model. Stroke occurred in 275 (10.6%) patients in the clopidogrel-aspirin group, in comparison with 362 (14.0%) patients in the aspirin group (hazard ratio, 0.78; 95% confidence interval, 0.65-0.93; P=0.006). Moderate or severe hemorrhage occurred in 7 (0.3%) patients in the clopidogrel-aspirin group and in 9 (0.4%) patients in the aspirin group (P=0.44). Conclusions: The early benefit of clopidogrel-aspirin treatment in reducing the risk of subsequent stroke persisted for the duration of 1-year of follow-up. Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00979589.
    Circulation 05/2015; 369(1). DOI:10.1161/CIRCULATIONAHA.114.014791 · 14.43 Impact Factor
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    S. Claiborne Johnston · Susan Desmond-Hellmann · Stewart Hauser · Eric Vermillion · Nilo Mia ·
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    ABSTRACT: Background: The United States (US) Department of Health and Human Services and the Office of Naval Research negotiate institutional rates for payments of overhead costs associated with administration and space usage, commonly known as indirect rates. Such payments account for a large proportion of spending by the National Institutes of Health (NIH). Little has been published about differences in rates and their predictors. Methods: Negotiated indirect rates for on-campus research grants were requested from the Council on Governmental Relations for the 100 institutions with greatest NIH funding in 2010. NIH funding, cost of living (ACCRA Index for 2008), public vs. private status, negotiating governmental organization (Department of Health and Human Services or Office of Naval Research), US Census Region, and year were assessed as predictors of institutional indirect rates using generalized estimating equations with all variables included in the model. Results: Overall, 72 institutions participated, with 207 reported indirect rates for the years 2006, 2008, and 2010. Indirect rates ranged from 36.3% to 78%, with an average of 54.5%. Mean rates increased from 53.6% in 2006 to 55.4% in 2010 (p<0.001). In multivariable models, private institutions had 6.2% (95% CI 3.7%-8.7%; p<0.001) higher indirect rates than public institutions. Rates in the Northeast were highest (Midwest 4.0% lower; West 4.9% lower; South 5.2% lower). Greater NIH funding (p = 0.025) and cost of living (p = 0.034) also predicted indirect rates while negotiating governmental organization did not (p = 0.414). Conclusions: Negotiated indirect rates for governmental research grants to academic centers vary widely. Although the association between indirect rates and cost of living may be justified, the cause of variation in rates by region, public-private status, and NIH funding levels is unclear.
    PLoS ONE 03/2015; 10(3):e0121273. DOI:10.1371/journal.pone.0121273 · 3.23 Impact Factor
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    ABSTRACT: Objectives The objective of this study was to examine prehospital provider recognition of stroke by race and sex.Methods Diagnoses at emergency department (ED) and hospital discharge from a statewide database in California were linked to prehospital diagnoses from an electronic database from two counties in Northern California from January 2005 to December 2007 using probabilistic linkage. All patients 18 years and older, transported by ambulances (n = 309,866) within the two counties, and patients with hospital-based discharge diagnoses of stroke (n = 10,719) were included in the study. Logistic regression was used to analyze the independent association of race and sex with the correct prehospital diagnosis of stroke.ResultsThere were 10,719 patients discharged with primary diagnoses of stroke. Of those, 3,787 (35%) were transported by emergency medical services providers. Overall, 32% of patients ultimately diagnosed with stroke were identified in the prehospital setting. Correct prehospital recognition of stroke was lower among Hispanic patients (odds ratio [OR] = 0.77, 95% confidence interval [CI] 0.61 to 0.96), Asians (OR = 0.66, 95% CI 0.55 to 0.80), and others (OR = 0.71, 95% CI = 0.53 to 0.94), when compared with non-Hispanic whites, and in women compared with men (OR = 0.82, 95% CI = 0.71 to 0.94). Specificity for recognizing stroke was lower in females than males (OR = 0.84, 95% CI = 0.78 to 0.90).Conclusions Significant disparities exist in prehospital stroke recognition.
    Academic Emergency Medicine 02/2015; 22(3). DOI:10.1111/acem.12595 · 2.01 Impact Factor
  • C G McDougall · S C Johnston · A Gholkar · A S Turk ·

    American Journal of Neuroradiology 11/2014; 36(1). DOI:10.3174/ajnr.A4205 · 3.59 Impact Factor
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    Jay Chol Choi · S Claiborne Johnston · Anthony S Kim ·
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    ABSTRACT: Despite the absence of definitive data from randomized clinical trials on the comparative effectiveness of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for asymptomatic carotid stenosis, the use of CAS has been expanding and seems to be displacing the use of CEA in some parts of the United States. We used comprehensive hospital discharge data from January 2010 to December 2012 to identify patients who had CEA or CAS for asymptomatic carotid stenosis at all academic medical centers that participate in the University HealthSystem Consortium. In-hospital death and postoperative stroke after CAS and after CEA were compared using multivariable logistic regression, propensity score matching, and a grouped-treatment approach using multilevel mixed-effects models to adjust for baseline characteristics of patients selected for these procedures. We identified 17 716 patients with asymptomatic carotid stenosis treated with CEA and 3962 treated with CAS at 186 University HealthSystem Consortium hospitals. Postoperative stroke or in-hospital death was more frequent after CAS (4.0% versus 1.5%; P<0.001), and patients with CAS were more likely to have these adverse outcomes even after adjusting for baseline characteristics using multivariable analysis (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.1-3.1; P<0.001) and propensity score matching (OR, 2.5; 95% CI, 1.9-3.4; P<0.001). In a multilevel mixed-effects model, hospitals that performed a higher proportion of all carotid revascularization cases using CAS had significantly higher rates of adverse outcomes (OR, 3.7; 95% CI, 1.8-7.6; P<0.001) after adjusting for patient-level variables. For asymptomatic carotid stenosis, CAS is associated with a substantially higher risk of postoperative stroke or in-hospital death than CEA even after adjustment for baseline differences in hospital and patient characteristics. © 2014 American Heart Association, Inc.
    Stroke 11/2014; 46(1). DOI:10.1161/STROKEAHA.114.006209 · 5.72 Impact Factor
  • Sharon N Poisson · David Glidden · S Claiborne Johnston · Heather J Fullerton ·
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    ABSTRACT: Objective: To determine what the trends in stroke mortality have been over 2 decades in young adults. Methods: In this cohort study, we analyzed death certificate data for ischemic and hemorrhagic stroke (intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) in adults aged 20-44 in the United States for 1989 through 2009, covering approximately 2.2 billion person-years. Poisson regression was used to calculate and compare time trend data between groups and to compare trends in young adults to those in adults over age 45. Results: Mortality from stroke in young adults declined by 35% over the study period, with reductions in all 3 stroke subtypes (ischemic stroke decreased by 15%, ICH by 47%, and SAH by 50%). Black race was a risk factor for all 3 stroke subtypes (relative risk 2.4 for ischemic stroke, 4.0 for ICH, and 2.1 for SAH), but declines in all stroke subtypes were more dramatic in black compared to white participants (p < 0.001 for all stroke subtypes). Conclusions: Although hospitalizations for stroke in young patients have been increasing, the apparent decrease in mortality rates and in racial disparities suggests that recognition and treatment in this group may be improving.
    Neurology 10/2014; 83(23). DOI:10.1212/WNL.0000000000001042 · 8.29 Impact Factor
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    ABSTRACT: Importance Statin use during hospitalization is associated with improved survival and a better discharge disposition among patients with ischemic stroke. It is unclear whether inpatient statin use has a similar effect among patients with intracerebral hemorrhage (ICH).Objective To determine whether inpatient statin use in ICH is associated with improved outcomes and whether the cessation of statin use is associated with worsened outcomes.Design, Setting, and Participants Retrospective cohort study of 3481 patients with ICH admitted to any of 20 hospitals in a large integrated health care delivery system over a 10-year period. Detailed electronic medical and pharmacy records were analyzed to explore the association between inpatient statin use and outcomes.Main Outcomes and Measures The primary outcome measures were survival to 30 days after ICH and discharge to home or inpatient rehabilitation facility. We used multivariable logistic regression, controlling for demographics, comorbidities, initial severity, and code status. In addition, we used instrumental variable modeling to control for confounding by unmeasured covariates at the individual patient level.Results Among patients hospitalized for ICH, inpatient statin users were more likely than nonusers to be alive 30 days after ICH (odds ratio [OR], 4.25 [95% CI, 3.46-5.23]; P < .001) and were more likely than nonusers to be discharged to their home or an acute rehabilitation facility (OR, 2.57 [95% CI, 2.16-3.06]; P < .001). Patients whose statin therapy was discontinued were less likely than statin users to survive to 30 days (OR, 0.16 [95% CI, 0.12-0.21]; P < .001) and were less likely than statin users to be discharged to their home or an acute rehabilitation facility (OR, 0.26 [95% CI, 0.20-0.35]; P < .001). Instrumental variable models of local treatment environment (to control for confounding by unmeasured covariates) confirmed that a higher probability of statin therapy was associated with a higher probability of 30-day survival (with an increase in probability of 0.15 [95% CI, 0.04-0.25]; P = .01) and a better chance of being discharged to home or an acute rehabilitation facility (with an increase in probability of 0.13 [95% CI, 0.02-0.24]; P = .02).Conclusions and Relevance Inpatient statin use is associated with improved outcomes after ICH, and the cessation of statin use is associated with worsened outcomes after ICH. Given the association between statin cessation and substantially worsened outcomes, the risk-benefit balance of discontinuing statin therapy in the acute setting of ICH should be carefully considered.
    JAMA Neurology 09/2014; 71(11). DOI:10.1001/jamaneurol.2014.2124 · 7.42 Impact Factor
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    ABSTRACT: AimsTo examine the health-related quality of life (HRQOL) in patients with transient ischemic attack (TIA) or minor stroke and assess the impact of recurrent stroke on HRQOL.Methods Health-related quality of life data on patients participated in the Clopidogrel in High-risk patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial were analyzed. The available 90-day EuroQoL data (EQ-5D) were used to calculate EQ-5D index score. Poor HRQOL was defined as an EQ-5D index score ≤0.5. The characteristics of HRQOL and factors predicting poor HRQOL in these patients were then explored.ResultsAmong the total 5170 patients enrolled, 90-day HRQOL data were obtained from 5104 patients for analysis. The mean EQ-5D index score at day 90 was 0.88 ± 0.21 for all patients, but only 0.42 ± 0.35 for those with recurrent strokes. Poor 90-day HRQOL was found in 294 (5.8%) patients. Patients with poor HRQOL had more strokes during follow-up than patients with good HRQOL (94.9 vs. 4.7%, P < 0.001). Age, history of hypertension and diabetes, and NIHSS at baseline were independent risk factors for predicting poor HRQOL. Stroke recurrence, NIHSS at baseline, age, and minor stroke on admission became independent risk factors once stroke recurrence was added into the model.Conclusions Stroke recurrence was associated with poor HRQOL in patients with TIA or minor strokes. Interventions focusing on controlling risk factors and prevention of worsening of neurological function may prevent poor HRQOL in these patients.
    CNS Neuroscience & Therapeutics 09/2014; 20(12). DOI:10.1111/cns.12329 · 3.93 Impact Factor
  • Benjamin P. George · Vinayak Venkataraman · E. Ray Dorsey · S. Claiborne Johnston ·
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    ABSTRACT: Background Medical devices are often introduced prior to randomized-trial evidence of efficacy and this slows completion of trials. Alternative regulatory approaches include restricting device use outside of trials prior to trial evidence of efficacy (like the drug approval process) or restricting out-of-trial use but permitting coverage within trials such as Medicare's Coverage with Study Participation (CSP).Methods We compared the financial impact to manufacturers and insurers of three regulatory alternatives: (1) limited regulation (current approach), (2) CSP, and (3) restrictive regulation (like the current drug approval process). Using data for patent foramen ovale closure devices, we modeled key parameters including recruitment time, probability of device efficacy, market adoption, and device cost/price to calculate profits to manufacturers, costs to insurers, and overall societal impact on health.ResultsFor manufacturers, profits were greatest under CSP—driven by faster market adoption of effective devices—followed by restrictive regulation. Societal health benefit in total quality-adjusted life years was greatest under CSP. Insurers’ expenditures for ineffective devices were greatest with limited regulation. Findings were robust over a reasonable range of probabilities of trial success.Conclusions Regulation restricting out-of-trial device use and extending limited insurance coverage to clinical trial participants may balance manufacturer and societal interests. Clin Trans Sci 2014; Volume #: 1–8
    Clinical and Translational Science 08/2014; 7(5). DOI:10.1111/cts.12199 · 1.43 Impact Factor
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    Luciano A. Sposato · Bruce Ovbiagele · S. Claiborne Johnston · Marc Fisher · Gustavo Saposnik ·
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    ABSTRACT: Objective: A better understanding of the manuscript peer-review process could improve the likelihood that research of the highest quality is funded and published. To this end, we aimed to assess consistency across reviewers' recommendations, agreement between reviewers' recommendations and editors' final decisions, and reviewer- and editor-level factors influencing editorial decisions at the journal Stroke. Methods: We analyzed all initial original contributions submitted to Stroke from January 2004 through December 2011. All submissions were linked to the final editorial decision (accept vs reject). We assessed the level of agreement between reviewers (intraclass correlation coefficient). We compared the initial editorial decision (accept, minor revision, major revision, and reject) across reviewers' recommendations. We performed a logistic regression analysis to identify reviewer- and editor-related factors associated with acceptance as the final decision. Results: Of 12,902 original submissions to Stroke during the 8-year study period, the level of agreement between reviewers was between fair and moderate (intraclass correlation coefficient = 0.55, 95% confidence interval [CI] = 0.09-0.75). Likelihood of acceptance was <5% if at least 1 reviewer recommended a rejection. In the multivariate analysis, higher reviewer-assigned priority scores were related to greater odds of acceptance (odds ratio [OR] = 26.3, 95% CI = 23.2-29.8), whereas higher number of reviewers (OR = 0.54 per additional reviewer, 95% CI = 0.50-0.59) and suggestions for reviewers by authors versus no suggestions (OR = 0.83, 95% CI = 0.73-0.94) had lesser odds of acceptance. Interpretation: This analysis of the peer-review process at Stroke identified several factors that might be targeted to improve the consistency and fairness of the overall process.
    Annals of Neurology 08/2014; 76(2). DOI:10.1002/ana.24218 · 9.98 Impact Factor
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    Jacob S Elkins · S Claiborne Johnston · Mitchell S V Elkind ·

    Stroke 07/2014; 45(9). DOI:10.1161/STROKEAHA.114.006592 · 5.72 Impact Factor

Publication Stats

17k Citations
3,204.98 Total Impact Points

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  • 2014-2015
    • University of Texas at Austin
      Austin, Texas, United States
    • University of Toronto
      • Division of Neurology
      Toronto, Ontario, Canada
  • 2-2015
    • University of California, San Francisco
      • • Department of Neurology
      • • Department of Anesthesia and Perioperative Care
      • • Division of Hospital Medicine
      • • Department of Epidemiology and Biostatistics
      San Francisco, California, United States
  • 2012
    • Kaiser Permanente
      • Department of Neurology
      Oakland, California, United States
  • 2007
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 2004
    • Sutter Medical Center
      Sacramento, California, United States
    • Johns Hopkins University
      Baltimore, Maryland, United States