Jenifer H Voeks

Medical University of South Carolina, Charleston, South Carolina, United States

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Publications (62)383.77 Total impact

  • Daniel T. Lackland · Jenifer H. Voeks · Andrea D. Boan
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    ABSTRACT: While elevated blood pressure has long been associated with cardiovascular and renal outcomes, the association of hypertension and increased stroke risks is perhaps the strongest and best recognized. Furthermore, the reduction of blood pressure with antihypertensive agents has been well documented with lower stroke risks. The specific recommendations for high blood pressure management for stroke prevention have been somewhat unclear due to the study design and the quality of the evidence based on clinical study results. Further complicating the assessment process is the consideration of stroke as a primary outcome of randomized control trials. This appraisal and review describes the assessment of the evidence and trial results for management of hypertension and stroke risk reduction with consideration of the impact of The Systolic Blood Pressure Intervention Trial (SPRINT). While evidence clearly identifies the benefit of intense hypertension treatment for the primary and secondary prevention of stroke, evidence gaps still remain.
    No preview · Article · Jan 2016 · Expert Review of Cardiovascular Therapy
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    ABSTRACT: Objective: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated a higher periprocedural stroke and death (S+D) rate among patients randomized to carotid artery stenting (CAS) than to carotid endarterectomy (CEA). Herein, we seek factors that affect the CAS-CEA treatment differences and potentially to identify a subgroup of patients for whom CAS and CEA have equivalent periprocedural S+D risk. Methods: Patient and arterial characteristics were assessed as effect modifiers of the CAS-CEA treatment difference in 2502 patients by the addition of factor-by-treatment interaction terms to a logistic regression model. Results: Lesion length and lesions that were contiguous or were sequential and noncontiguous extending remote from the bulb were identified as influencing the CAS-to-CEA S+D treatment difference. For those with longer lesion length (≥12.85 mm), the risk of CAS was higher than that of CEA (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.19-9.78). Among patients with sequential or remote lesions extending beyond the bulb, the risk for S+D was higher for CAS relative to CEA (OR, 9.01; 95% CI, 1.20-67.8). For the 37% of patients with lesions that were both short and contiguous, the odds of S+D in those treated with CAS was nonsignificantly 28% lower than for CEA (OR, 0.72; 95% CI, 0.21-2.46). Conclusions: The higher S+D risk for those treated with CAS appears to be largely isolated to those with longer lesion length and/or those with sequential and remote lesions. In the absence of those lesion characteristics, CAS appears to be as safe as CEA with regard to periprocedural risk of S+D.
    No preview · Article · Nov 2015 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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    ABSTRACT: Background and purpose: Prior meta-analysis showed that carotid endarterectomy benefits decline with increasing surgical delay following symptoms. For symptomatic patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), we assessed if differences in time between symptoms and carotid endarterectomy or carotid artery stenting are associated with differences in risk of periprocedural stroke or death. Methods: We analyzed the 1180 symptomatic patients in CREST who received their assigned procedure and had clearly defined timing of symptoms. Patients were classified into 3 groups based on time from symptoms to procedure: <15, 15 to 60, and >60 days. Results: For carotid endarterectomy, risk of periprocedural stroke or death was not significantly different for the 2 later time periods relative to the earliest time period (hazard ratio, 0.74; 95% confidence interval, 0.22-2.49 for 15-60 days and hazard ratio, 0.91; 95% confidence interval, 0.25-3.33 for >60 days; P=0.89). For carotid artery stenting, risk of periprocedural stroke or death was also not significantly different for later time periods relative to the earliest time period (hazard ratio, 1.12; 95% confidence interval, 0.53-2.40 for 15-60 days and hazard ratio, 1.15; 95% confidence interval, 0.48-2.75 for >60 days; P=0.93). Conclusions: Time from symptoms to carotid endarterectomy or carotid artery stenting did not alter periprocedural safety, supporting early revascularization regardless of modality. Clinical trial registration: URL: Unique identifier: NCT00004732.
    No preview · Article · Oct 2015 · Stroke

  • No preview · Conference Paper · Oct 2015
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    ABSTRACT: Hypercoagulability in sickle cell disease (SCD) is associated with multiple SCD phenotypes, association with stroke risk has not been well described. We hypothesized that serum levels of biomarkers of coagulation activation correlate with high transcranial Doppler ultrasound velocity and decreases with blood transfusion therapy in SCD patients. Stored serum samples from subjects in the Stroke Prevention in Sickle Cell Anemia (STOP) trial were analyzed using ELISA and protein multiplexing techniques. 40 subjects from each treatment arm (Standard Care [SC] and Transfusion [Tx]) at three time points—baseline, study exit and one year post-trial and 10 each of age matched children with SCD but normal TCD (SNTCD) and with normal hemoglobin (HbAA) were analyzed. At baseline, median vWF, TAT and D-dimer levels were significantly higher among STOP subjects than either HbAA or SNTCD. At study exit, median hemoglobin level was significantly higher while median TCD velocity was significantly lower in Tx compared to SC subjects. Median vWF (409.6 vs. 542.9 μg/ml), TAT (24.8 vs. 40.0 ng/ml) and D-dimer (9.2 vs. 19.1 μg/ml) levels were also significantly lower in the Tx compared to the SC group at study exit. Blood levels of biomark-ers coagulation activation/thrombin generation correlated positively with TCD velocity and negatively with number of blood transfusions. Biomarkers of coagulation activation/throm-bin generation were significantly elevated in children with SCD, at high risk for stroke. Reduction in levels of these biomarkers correlated with reduction in stroke risk (lower TCD velocity), indicating a possible role for hypercoagulation in SCD associated stroke.
    Full-text · Article · Sep 2015 · PLoS ONE
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    ABSTRACT: Background and purpose: There is higher combined risk of stroke or death (S+D) at older ages with carotid stenting. We assess whether this can be attributed to patient or arterial characteristics that are in the pathway between older age and higher risk. Methods: Mediation analysis of selected patient (hypertension, diabetes mellitus, and dyslipidemia) and arterial characteristics assessed at the clinical sites and the core laboratory (plaque length, eccentric plaque, ulcerated plaque, percent stenosis, peak systolic velocity, and location) was performed in 1123 carotid artery stenting-treated patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). We assessed the association of age with these characteristics, the association of these characteristics with stroke risk, and the amount of mediation of the association of age on the combined risk of periprocedural S+D with adjustment for these factors. Results: Only plaque length as measured at the sites increased with age, was associated with increased S+D risk and significantly mediated the association of age on S+D risk. However, adjustment for plaque length attenuated the increased risk per 10 years of age from 1.72 (95% confidence interval, 1.26-2.37) to 1.66 (95% confidence interval, 1.20-2.29), accounting for only 8% of the increased risk. Conclusions: Plaque length seems to be in the pathway between older age and higher risk of S+D among carotid artery stenting-treated patients, but it mediated only 8% of the age effect excess risk of carotid artery stenting in CREST. Other factors and mechanisms underlying the age effect need to be identified as plaque length will not identify elderly patients for whom stenting is safe relative to endarterectomy. Clinical trial registration: URL: Unique Identifier: NCT00004732.
    No preview · Article · Sep 2015 · Stroke

  • No preview · Article · Aug 2015 · Journal of Vascular Surgery
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    ABSTRACT: Post-hoc, we hypothesized that over the recruitment period of the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), increasing experience and improved patient selection with carotid stenting, and to a lesser extent, carotid endarterectomy would contribute to lower periprocedural event rates. Three study periods with approximately the same number of patients were defined to span recruitment. Composite and individual rates of periprocedural stroke, myocardial infarction, and death rate were calculated separately by treatment assignment (carotid stenting/carotid endarterectomy). Temporal changes in unadjusted event rates, and rates after adjustment for temporal changes in patient characteristics, were assessed. For patients randomized to carotid stenting, there was no significant temporal change in the unadjusted composite rates that declined from 6.2% in the first period, to 4.9% in the second, and 4.6% in the third (P=0.28). Adjustment for patient characteristics attenuated the rates to 6.0%, 5.9%, and 5.6% (P=0.85). For carotid endarterectomy-randomized patients, both the composite and the combined stroke and death outcome decreased between periods 1 and 2 and then increased in period 3. The hypothesized temporal reduction of stroke+death events for carotid stenting-treated patients was not observed. Further adjustment for changes in patient characteristics between periods, including the addition of asymptomatic patients and a >50% decrease in proportion of octogenarians enrolled, resulted in practically identical rates. URL: Unique identifier: NCT00004732. © 2015 American Heart Association, Inc.
    No preview · Article · Jul 2015 · Stroke
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    ABSTRACT: With patients living a decade or longer post-procedure, long-term data are needed to assess the durability of carotid artery stenting versus carotid endarterectomy. Identifying characteristics of those consenting or declining to continue in long-term follow-up may suggest strategies to improve retention in clinical trials. This report describes differences between patients choosing or declining to continue follow-up for up to 10 years in the Carotid Revascularization Endarterectomy versus Stenting Trial. Following completion of the primary outcome, patients who were in active Carotid Revascularization Endarterectomy versus Stenting Trial follow-up were asked to continue beyond their original 4-year commitment for a maximum of 10 years. The characteristics of those who consented were compared with those who declined. Univariate and multivariable logistic regression were used for analysis, and backwards stepwise logistic regression (the most parsimonious model) was used to determine the factors associated with continuation. Of the 1921 active Carotid Revascularization Endarterectomy versus Stenting Trial participants for whom consent to extend follow-up was requested, 1695 (88%; mean age: 68.4) consented; 226 (12%; mean age: 69.6) declined. Of those who did not consent versus those who consented, 66% versus 48% were symptomatic at baseline (p < 0.0001), at follow-up 28% versus 20% were smokers (p = 0.009), 85% versus 90% were hypertensive (p = 0.01), and 84% versus 94% were dyslipidemic (p < 0.0001). Additional factors that differed between those who did not consent and those who consented included the mean number of years in the study at time of consent (4.8 years vs 3.7 years (p = <0.0001)) and patients from sites that enrolled ≤30 patients compared to sites randomizing 30 or more (70% vs 52% (p < 0.0001)). Multivariable logistic regression indicated that those with lesser odds of consenting to the extended follow-up were older (odds ratio: 0.80; 95% confidence interval: 0.67, 0.96), more likely to be symptomatic (odds ratio: 0.58; 95% confidence interval: 0.42, 0.80), smokers (odds ratio: 0.48; 95% confidence interval: 0.34, 0.70), were in the study 5+ years versus <3 (odds ratio: 0.21; 95% confidence interval: 0.13, 0.34), and at a site that randomized <30 patients (odds ratio: 0.46; 95% confidence interval: 0.33, 0.63), while patients with dyslipidemia at follow-up had increased odds of consenting (odds ratio: 2.28 (1.47, 3.54)). Symptomatic status, increasing age, randomized at lower volume centers, and longer time in follow-up were associated with reduced odds of consenting to long-term follow-up. Identifying factors associated with reduced willingness to extend participation long-term can suggest targeted strategies to improve retention in future clinical trials. © The Author(s) 2015.
    Full-text · Article · Jun 2015 · Clinical Trials
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    ABSTRACT: Sepsis is the syndrome of body-wide inflammation triggered by infection and is a major public health problem. Diet plays a vital role in immune health but its association with sepsis in humans is unclear. We examined 21,404 participants with available dietary data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a national cohort of 30,239 black and white adults ≥45 years of age living in the US. The primary exposures of interest were five empirically derived diet patterns identified via factor analysis within REGARDS participants: "Convenience" (Chinese and Mexican foods, pasta, pizza, other mixed dishes), "Plant-based" (fruits, vegetables), "Southern" (added fats, fried foods, organ meats, sugar-sweetened beverages), "Sweets/Fats" (sugary foods) and "Alcohol/Salads" (alcohol, green-leafy vegetables, salad dressing). The main outcome of interest was investigator-adjudicated first hospitalized sepsis events. A total of 970 first sepsis events were observed over ~6 years of follow-up. In unadjusted analyses, greater adherence to Sweets/Fats and Southern patterns was associated with higher cumulative incidence of sepsis, whereas greater adherence to the Plant-based pattern was associated with lower incidence. After adjustment for sociodemographic, lifestyle and clinical factors, greater adherence to the Southern pattern remained associated with higher risk of sepsis (hazard ratio [HR] comparing the fourth to first quartile, HR 1.39, 95 % CI 1.11,1.73). Race modified the association of the Southern diet pattern with sepsis (P interaction = 0.01), with the Southern pattern being associated with modestly higher adjusted risk of sepsis in black as compared to white participants (HR comparing fourth vs. first quartile HR 1.42, 95 % CI 0.75,2.67 vs. 1.21, 95 % CI 0.93,1.57, respectively). A Southern pattern of eating was associated with higher risk of sepsis, particularly among black participants. Determining reasons for these findings may help to devise strategies to reduce sepsis risk.
    Preview · Article · Jun 2015 · BMC Infectious Diseases

  • No preview · Article · Jun 2015 · Journal of Vascular Surgery
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    Full-text · Dataset · May 2015
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    ABSTRACT: Cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy (CEA) and can cause significant chronic disability. Data from prior randomized trials are limited and provide no health-related quality of life (HRQOL) outcomes specific to CNI. Incidence of CNIs and their outcomes for patients in the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) were examined to identify factors predictive of CNI and their impact on HRQOL. Incidence of CNIs, baseline and procedural characteristics, outcomes, and HRQOL scores were evaluated in the 1151 patients randomized to CEA and undergoing surgery ≤30 days. Patients with CNI were identified and classified using case report forms, adverse event data, and clinical notes. Baseline and procedural characteristics were compared using descriptive statistics. Clinical outcomes at 1 and 12 months were analyzed. All data were adjudicated by two neurologists and a vascular surgeon. HRQOL was evaluated using the Medical Outcomes Short-Form 36 (SF-36) Health Survey to assess general health and Likert scales for disease-specific outcomes at 2 weeks, 4 weeks, and 12 months after CEA. The effect of CNI on SF-36 subscales was evaluated using random effects growth curve models, and Likert scale data were compared by ordinal logistic regression. CNI was identified in 53 patients (4.6%). Cranial nerves injured were VII (30.2%), XII (24.5%), and IX/X (41.5%), and 3.8% had Horner syndrome. CNI occurred in 52 of 1040 patients (5.0%) receiving general anesthesia and in one of 111 patients (0.9%) operated on under local anesthesia (P = .05). No other predictive baseline or procedural factors were identified. Deficits resolved in 18 patients (34%) at 1 month and in 42 of 52 patients (80.8%) by 1 year. One patient died before the 1-year follow-up visit. The HRQOL evaluation showed no statistical difference between groups with and without CNI at any interval. By Likert scale analysis, the group with CNI showed a significant difference in the difficulty eating/swallowing parameter at 2 and 4 weeks (P < .001) but not at 1 year. In CREST, CNI occurred in 4.6% of patients undergoing CEA, with 34% resolution at 30 days and 80.8% at 1 year. The incidence of CNI was significantly higher in patients undergoing general anesthesia. CNI had a small and transient effect on HRQOL, negatively affecting only difficulty eating/swallowing at 2 and 4 weeks but not at 1 year. On the basis of these findings, we conclude that CNI is not a trivial consequence of CEA but rarely results in significant long-term disability. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Mar 2015 · Journal of Vascular Surgery
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    ABSTRACT: The purpose is to determine whether patching during carotid endarterectomy (CEA) affects the perioperative and long-term risks of restenosis, stroke, death, and myocardial infarction as compared with primary closure. We identified all patients who were randomized and underwent CEA in Carotid Revascularization Endarterectomy versus Stenting Trial. CEA patients who received a patch were compared with patients who underwent CEA with primary closure without a patch. We compared periprocedural and 4-year event rates, 2-year restenosis rates, and rates of reoperation between the 2 groups. We further analyzed results by surgeon specialty. There were 1151 patients who underwent CEA (753 [65%] with patch and 329 [29%] with primary closure). We excluded 44 patients who underwent eversion CEA and 25 patients missing CEA data (5%). Patch use differed by surgeon specialty: 89% of vascular surgeons, 6% of neurosurgeons, and 76% of thoracic surgeons patched. Comparing patients who received a patch versus those who did not, there was a significant reduction in the 2-year risk of restenosis, and this persisted after adjustment by surgeon specialty (hazard ratio, 0.35; 95% confidence interval, 0.16-0.74; P=0.006). There were no significant differences in the rates of periprocedural stroke and death (hazard ratio, 1.58; 95% confidence interval, 0.33-7.58; P=0.57), in immediate reoperation (hazard ratio, 0.6; 95% confidence interval, 0.16-2.27; P=0.45), or in the 4-year risk of ipsilateral stroke (hazard ratio, 1.23; 95% confidence interval, 0.42-3.63; P=0.71). Patch closure in CEA is associated with reduction in restenosis although it is not associated with improved clinical outcomes. Thus, more widespread use of patching should be considered to improve long-term durability. Unique identifier: NCT00004732. © 2015 American Heart Association, Inc.
    Full-text · Article · Jan 2015 · Stroke
  • G. Howard · T. G. Brott · J. Meschia · J. H. Voeks

    No preview · Conference Paper · Dec 2014
  • Daniel T Lackland · Jenifer H Voeks
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    ABSTRACT: The incorporation of physical activity and exercise represents a clinically important aspect in the management of metabolic syndrome, hypertension, and diabetes. While the benefit of exercise and active lifestyles is well documented for prevention and risk reduction of cardiovascular and stroke outcomes, the detailed regiment and recommendations are less clear. The components of a prescribed physical activity include consideration of activity type, frequency of an activity, activity duration, and intensity of a specific physical movement. The exercise parameters prescribed as part of the management of metabolic syndrome, diabetes, and elevated blood pressure are most often proposed as separate documents while the general recommendations are similar. The evidence is strong such that physical activity and exercise recommendations in disease management guidelines are considered high quality. The general recommendations for both blood pressure and glycemic management include a regiment of physical activity with moderate- to high-intensity exercise of 30-min bouts on multiple days with a desired goal of a total of 150 min of exercise per week. While additional research is needed to identify the specific exercise/activity mode, frequencies for exercise training, intensity levels, and duration of exercise that achieve maximal blood pressure and glycemic lowering, this general recommendation showed a consistent and significant benefit in risk reduction. Similarly, the current available evidence also indicates that aerobic exercise, dynamic resistance exercise, and isometric exercises can lower blood pressure and improve glycemic control.
    No preview · Article · Nov 2014 · Current Hypertension Reports
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    ABSTRACT: The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) is a multicenter randomized trial of stenting versus endarterectomy in patients with symptomatic and asymptomatic carotid disease. This study assesses management of vascular risk factors. Management was provided by the patient's physician, with biannual monitoring results collected by the local site. Therapeutic targets were low-density lipoprotein, cholesterol <100 mg/dL, systolic blood pressure <140 mm Hg, fasting blood glucose <126 mg/dL, and nonsmoking status. Optimal control was defined as achieving all 4 goals concurrently. Generalized estimating equations were used to compare risk factors at baseline with those observed in scheduled follow-up visits for up to 48 months. In the analysis cohort of 2210, significant improvements in risk-factor control were observed across risk factors for all follow-up visits compared with baseline. At 48 months, achievement of the low-density lipoprotein cholesterol goal improved from 59.1% to 73.6% (P<0.001), achievement of the systolic blood pressure goal improved from 51.6% to 65.1% (P<0.001), achievement of the glucose goal improved from 74.9% to 80.7% (P=0.0101), and nonsmoking improved from 74.4% to 80.9% (P<0.0001). The percentage with optimal risk-factor control also improved significantly, from 16.7% to 36.2% (P<0.001), but nearly 2 of 3 study participants did not achieve optimal control during the study. Site-based risk-factor control improved significantly in the first 6 months and over the long term in CREST but was often suboptimal. Intensive medical management should be considered for future trials of carotid revascularization. Unique identifier: NCT00004732. © 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
    Full-text · Article · Oct 2014 · Journal of the American Heart Association
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    ABSTRACT: Background Response to stroke symptoms and the use of 911 can vary by race/ethnicity. The quickness with which a patient responds to such symptoms has implications for the outcome and treatment. We sought to examine a sample of patients receiving a Remote Evaluation of Acute isCHemic stroke (REACH) telestroke consult in South Carolina regarding their awareness and perception of stroke symptoms related to the use of 911 and to assess possible racial/ethnic disparities. Methods As of September 2013, 2325 REACH telestroke consults were conducted in 13 centers throughout South Carolina. Telephone surveys assessing use of 911 were administered from March 2012-January 2013 among 197 patients receiving REACH consults. Univariate and multivariate logistic regression was performed to assess factors associated with use of 911. Results Most participants (73%) were Caucasian (27% were African–American) and male (54%). The mean age was 66 ± 14.3 years. Factors associated with use of 911 included National Institutes of Health Stroke Scale scores >4 (odds ratio [OR], 5.4; 95% confidence interval [CI], 2.63-11.25), unknown insurance which includes self-pay or not charged (OR, 2.90; 95% CI, 1.15-7.28), and perception of stroke-like symptoms as an emergency (OR, 4.58; 95% CI, 1.65-12.67). African–Americans were significantly more likely than Caucasians to call 911 (62% vs. 43%, P = .02). Conclusions African–Americans used 911 at a significantly higher rate. Use of 911 may be related to access to transportation, lack of insurance, or proximity to the hospital although this information was not available. Interventions are needed to improve patient arrival times to telemedicine equipped emergency departments after stroke.
    Full-text · Article · Oct 2014 · Journal of Stroke and Cerebrovascular Diseases
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    ABSTRACT: Background and Purpose Evidence indicates that center volume of cases affects outcomes for both carotid endarterectomy and stenting. We evaluated the effect of enrollment volume by site on complication rates in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Methods The primary composite end point was any stroke, myocardial infarction, or death within 30 days or ipsilateral stroke in follow-up. The 477 approved surgeons performed >12 procedures per year with complication rates <3% for asymptomatic patients and <5% for symptomatic patients; 224 interventionists were certified after a rigorous 2 step credentialing process. CREST centers were divided into tertiles based on the number of patients enrolled into the study, with Group 1 sites enrolling <25 patients, Group 2 sites enrolling 25 to 51 patients, and Group 3 sites enrolling >51 patients. Differences in periprocedural event rates for the primary composite end point and its components were compared using logistic regression adjusting for age, sex, and symptomatic status within site-volume level. Results The safety of carotid angioplasty and stenting and carotid endarterectomy did not vary by site-volume during the periprocedural period as indicated by occurrence of the primary end point (P=0.54) or by stroke and death (P=0.87). A trend toward an inverse relationship between center enrollment volume and complications was mitigated by adjustment for known risk factors. Conclusions Complication rates were low in CREST and were not associated with center enrollment volume. The data are consistent with the value of rigorous training and credentialing in trials evaluating endovascular devices and surgical procedures. Clinical Trial Registration URL: Unique identifier: NCT00004732.
    No preview · Article · Sep 2014 · Stroke
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    ABSTRACT: Background: The use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) diagnostic codes can identify racial disparities in ischemic stroke hospitalizations; however, inclusion of revascularization procedure codes as acute stroke events may affect the magnitude of the risk difference. This study assesses the impact of excluding revascularization procedure codes in the ICD-9 definition of ischemic stroke, compared with the traditional inclusive definition, on racial disparity estimates for stroke incidence and recurrence. Methods: Patients discharged with a diagnosis of ischemic stroke (ICD-9 codes 433.00-434.91 and 436) were identified from a statewide inpatient discharge database from 2010 to 2012. Race-age specific disparity estimates of stroke incidence and recurrence and 1-year cumulative recurrent stroke rates were compared between the routinely used traditional classification and a modified classification of stroke that excluded primary ICD-9 cerebral revascularization procedures codes (38.12, 00.61, and 00.63). Results: The traditional classification identified 7878 stroke hospitalizations, whereas the modified classification resulted in 18% fewer hospitalizations (n = 6444). The age-specific black to white rate ratios were significantly higher in the modified than in the traditional classification for stroke incidence (rate ratio, 1.50; 95% confidence interval [CI], 1.43-1.58 vs. rate ratio, 1.24; 95% CI, 1.18-1.30, respectively). In whites, the 1-year cumulative recurrence rate was significantly reduced by 46% (45-64 years) and 49% (≥ 65 years) in the modified classification, largely explained by a higher rate of cerebral revascularization procedures among whites. There were nonsignificant reductions of 14% (45-64 years) and 19% (≥ 65 years) among blacks. Conclusions: Including cerebral revascularization procedure codes overestimates hospitalization rates for ischemic stroke and significantly underestimates the racial disparity estimates in stroke incidence and recurrence.
    No preview · Article · Sep 2014 · Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association

Publication Stats

2k Citations
383.77 Total Impact Points


  • 2012-2016
    • Medical University of South Carolina
      • Division of Neuroradiology
      Charleston, South Carolina, United States
  • 2007-2014
    • University of Alabama at Birmingham
      • • School of Public Health
      • • Department of Epidemiology
      Birmingham, Alabama, United States