Temporal trends in reperfusion therapy for patients with acute ischemic stroke.

OBJECTIVES: To analyze the temporal trends in thrombolysis rates after implementation of a regional emergency network for acute ischemic stroke (AIS). METHODS: We conducted a retrospective study based on a prospective multicenter observational registry. The AIS benefited from reperfusion therapy included in 1 of the 5 primary stroke units or 1 comprehensive stroke center and 37 emergency departments were included using a standardized case report form. The population covers 3 million inhabitants. RESULTS: In total, 32,319 AIS was reported in the regional hospitalization database of which 2215 thrombolyzed AIS patients were included in the registry and enrolled in this study. The annual incidence rate of thrombolysis continuously and significantly increased from 2010 to 2018 (10.2% to 17.3%, P-trend = 0.0013). The follow-up of the onset-to-door and the door-to-needle delays over the study period showed stable rates, as did the all-cause mortality rate at 3-months (13.2%). CONCLUSION: Although access to stroke thrombolysis has increased linearly since 2010, the 3-month functional outcome has not evolved as favorably. Further efforts must focus on reducing hospital delays.

Associations between Thyroid Stimulating Hormone Levels and Both Severity and Early Outcome of Patients with Ischemic Stroke.

We aimed to investigate associations between serum thyroid stimulating hormone (TSH) levels and both severity and outcome after ischemic stroke (IS). A total of 731 patients consecutive IS patients were enrolled (mean age 69.4 ± 15.4, 61.6% men), and serum TSH levels were measured at admission and analyzed according to the tertiles of their distribution (<0.822 vs. 0.822-1.6 vs. >1.6 mUI/l). Associations between TSH and both severity at admission (National Institutes of Health Stroke Scale (NIHSS) scores <5 vs. ≥5) and functional outcome at discharge assessed by the modified Rankin Scale were analyzed using logistic regression and ordinal logistic regression models, respectively. High TSH levels were independently associated with both a decreased risk of NIHSS score ≥5 at admission (prevalence proportion ratio = 0.62; 95% CI 0.41-0.94, p = 0.024 for tertile 3 vs. tertile 1). In addition, patients with high TSH levels had a better functional outcome at discharge (OR 0.43; 95% CI 0.30-0.60, p < 0.001 for tertile 2 vs. tertile 1; OR 0.39; 95% CI 0.27-0.56, p < 0.001 for tertile 3 vs. tertile 1). The mechanisms underlying these associations and their potential exploitation in terms of therapeutic strategies need to be explored.

Influence of the type of cerebral infarct and timing of intervention in the early outcomes after carotid endarterectomy for symptomatic stenosis.

OBJECTIVE: Our objectives were to compare early postoperative outcomes after carotid endarterectomy for symptomatic carotid stenosis and to analyze the impact of time to treatment between patients with a territorial or a border-zone infarct. METHODS: This is a single-center, retrospective study carried out on data from a single-center, prospective database. Patients undergoing carotid endarterectomy for symptomatic carotid stenosis after an ipsilateral acute ischemic stroke were included between January 1, 2009 and December 31, 2013. The only exclusion criterion was a mixed-topography stroke. We included 114 patients who were retrospectively divided into groups according to the location of the infarct: group TI for territorial infarction and group BZ for border-zone infarction. The primary end point was the 30-day death or stroke rate. RESULTS: Ninety patients were included in the TI group (79%) and 24 in the BZ group (21%) with a mean age of 73 ± 11 years. All demographic data were similar between the two groups except for dyslipidemia, which was greater in the BZ group (72% vs 47%, P = .03) and the subocclusive feature of carotid stenosis (14% in the TI group vs 33% in the BZ group, P .04). There was one death and one stroke in each group, with a 30-day death and stroke rate of 2% in the TI group and 8% in the BZ group (P = .18). Multivariate analysis showed that the National Institute of Health Stroke Score (NIHSS) score was the only independent predictive factor of complications with an increase of 36% per additional point in this score. Sixty-eight patients (76%) in the TI group and 14 (58%) in the BZ group were operated on during the first 2 weeks after the neurological event. In this subgroup, the 30-day death or stroke rate was 2% in the TI group (one stroke) vs 14% in the BZ group (one stroke and one death; P = .06). The preoperative NIHSS score was again the only factor significantly associated with the postoperative complication rate (P = .03). CONCLUSIONS: In our series, surgery for patients with symptomatic carotid stenosis after border-zone infarction resulted in more complications than after territorial infarction, although no significant differences were found. This study nonetheless raised questions concerning the optimal timing of carotid surgery depending on the type of the original stroke. Other larger-scale studies are necessary to determine whether the type of cerebral infarction needs to be taken into account in decisions whether to operate on the diseased carotid as early as possible.

A time estimation task as a possible measure of emotions: difference depending on the nature of the stimulus used.

OBJECTIVE: Time perception is fundamental for human experience. A topic which has attracted the attention of researchers for long time is how the stimulus sensory modality (e.g., images vs. sounds) affects time judgments. However, so far, no study has directly compared the effect of two sensory modalities using emotional stimuli on time judgments. METHODS: In the present two studies, healthy participants were asked to estimate the duration of a pure sound preceded by the presentation of odors vs. emotional videos as priming stimuli (implicit emotion-eliciting task). During the task, skin conductance (SC) was measured as an index of arousal. RESULTS: Olfactory stimuli resulted in an increase in SC and in a constant time overestimation. Video stimuli resulted in an increase in SC (emotional arousal), which decreased linearly overtime. Critically, video stimuli resulted in an initial time underestimation, which shifted progressively towards a time overestimation. These results suggest that video stimuli recruited both arousal-related and attention-related mechanisms, and that the role played by these mechanisms changed overtime. CONCLUSIONS: These pilot studies highlight the importance of comparing the effect of different kinds on temporal estimation tasks, and suggests that odors are well suited to investigate arousal-related temporal distortions, while videos are ideal to investigate both arousal-related and attention-related mechanisms.

Diagnostic procedures in ischaemic stroke patients with dementia. a population-based study.

BACKGROUND: Dementia is a frequent condition in stroke patients. AIMS: To investigate the effect of dementia on access to diagnostic procedures in ischaemic stroke patients. METHODS: All cases of ischaemic stroke from 2006 to 2010 were identified from the population-based Stroke Registry of Dijon, France. Patients' characteristics were recorded, as was the use of brain computed tomography scans, brain magnetic resonance imaging, electrocardiogram, echocardiography, and Doppler ultrasonography of the cervical arteries. Dementia was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Logistic regression models were used to evaluate the associations between dementia and the use of the diagnostic procedures. RESULTS: Of the 907 patients recorded, 104 were excluded because of death and inability to test cognition. Among the remaining 803 patients, 149 (18·5%) had dementia. Almost all of the patients underwent a brain computed tomography scan and an electrocardiogram during their stay. In contrast, the use of both Doppler ultrasonography of the cervical arteries (79·2% versus 90·2%, P < 0·001), echocardiography (32·9% versus 43·6%, P = 0·02), and brain magnetic resonance imaging (21·5% versus 34·4%, P < 0·001) were significantly lower in stroke patients with dementia than in those without. In multivariate logistic regression, dementia was associated with a lower use of both Doppler ultrasonography (odds ratio = 0·49; 95% confidence interval: 0·29-0·81, P = 0·005), echocardiography (odds ratio = 0·57; 95% confidence interval: 0·37-0·89, P = 0·012), brain magnetic resonance imaging (odds ratio = 0·55; 95% confidence interval: 0·34-0·89, P = 0·015), and a comprehensive assessment (odds ratio = 0·62; 95% confidence interval: 0·40-0·96, P = 0·033). CONCLUSION: Demented patients were less likely to undergo diagnostic procedures after ischaemic stroke. Further studies are needed to determine whether this lower utilization could account for the reported excess in recurrent events in these patients.

Association between serum concentration of vitamin D and 1-year mortality in stroke patients.

BACKGROUND: The prevalence of 25-hydroxyvitamin D [25(OH)D] deficiency is high in patients presenting with an acute stroke, and it may be associated with greater clinical severity and a poor early functional prognosis. However, no data about its impact on long-term prognosis is available. In this study, we aimed to assess the association between 25(OH)D levels and 1-year mortality in stroke patients. METHODS: From February to December 2010, 382 Caucasian stroke patients admitted to the Department of Neurology of the University Hospital of Dijon, France, were enrolled prospectively. Demographics and clinical information including stroke severity assessed using the National Institutes of Health Stroke Scale score were collected. The serum concentration of 25(OH)D was measured at baseline. Multivariable Cox regression models were used to evaluate the association between 1-year all-cause mortality and serum 25(OH)D levels treated as either a log-transformed continuous variable or dichotomized (<25.7 and ≥25.7 nmol/l) at the first tertile of their distribution. RESULTS: Of the 382 stroke patients included, 63 (16.5%) had died at 1 year. The mean 25(OH)D level was lower in these patients (32.3 ± 22.0 vs. 44.6 ± 28.7 nmol/l, p < 0.001), and survival at 1 year was worse in patients in the lowest tertile of 25(OH)D levels (defined as <25.7 nmol/l); log-transformed 25(OH)D levels were inversely associated with 1-year mortality (hazard ratio, HR = 0.62; 95% confidence interval, 95% CI: 0.44-0.87; p = 0.007), and patients with 25(OH)D levels <25.7 nmol/l were at a higher risk of death at 1 year (HR = 1.95; 95% CI: 1.14-3.32; p = 0.014). In multivariable analyses, the association was no longer significant but a significant interaction was found for age, and stratified analyses by age groups showed an inverse relationship between 25(OH)D levels and 1-year mortality in patients aged <75 years [HR = 0.38; 95% CI: 0.17-0.83; p = 0.015 for log-transformed 25(OH)D levels, and HR = 3.12; 95% CI: 0.98-9.93; p = 0.054 for 25(OH)D levels <25.7 vs. >25.7 nmol/l]. CONCLUSION: A low serum 25(OH)D level at stroke onset may be associated with higher mortality at 1 year in patients <75 years old. Further studies are needed to confirm these findings and to determine whether vitamin D supplementation could improve survival in stroke patients.

The impact of World and European Football Cups on stroke in the population of Dijon, France: a longitudinal study from 1986 to 2006.

BACKGROUND: Acute stress may trigger vascular events. We aimed to investigate whether important football competitions involving the French football team increased the occurrence of stroke. METHODS: We retrospectively retrieved data of fatal and nonfatal stroke during 4 World Football Cups (1986, 1998, 2002, and 2006) and 4 European Championships (1992, 1996, 2000, and 2004), based on data from the population-based Stroke Registry of Dijon, France. One period of exposure was analyzed: the period of competition extended to 15 days before and after the competitions. The number of strokes was compared between exposed and unexposed corresponding periods of preceding and following years using Poisson regression. RESULTS: A total of 175 strokes were observed during the exposed periods compared with 192 and 217 strokes in the unexposed preceding and following periods. Multivariate regression analyses showed an overall 30% significant decrease in stroke numbers between periods of competition and unexposed periods of following year (risk ratio (RR) = 1.3; 95% confidence interval [CI] = 1.0-1.6; P = .029) but not with that of preceding year (RR = 1.1; 95% CI = .9-1.3; P = .367). This was mostly explained by a 40% decrease in stroke numbers during European Championships, compared with the unexposed following periods (RR = 1.4; 95% CI = 1.0-1.9; P = .044) in stratified analyses by football competitions. CONCLUSIONS: Watching European football competitions had a positive impact in the city of Dijon with a decrease of stroke numbers. European championship is possibly associated with higher television audience and long-lasting euphoria although other factors may be involved. Further studies using nationwide data are recommended to validate these findings.

Smoking status and severity of ischemic stroke. A population-based study.

We aimed to investigate the impact of smoking status on clinical severity in patients with ischemic stroke event (IS). Patients were prospectively identified among residents of the city of Dijon, France (ca. 151,000 inhabitants), using a population-based registry, between 2006 and 2011. Demographic and clinical data were recorded. The initial clinical severity was quantified by the means of the National Institutes of Health Stroke Scale (NIHSS). Multivariable ordinal logistic regression was used to assess the effect of smoking status on severity. Among the 1,056 recorded patients with IS, data about smoking status were available for 973 (92.1%), of whom 658 (67.3%) were non-smokers, 187 (19.2%) were current smokers, and 128 (13.2%) were former smokers. Compared with non-smoking, former smoking was associated with less severe IS (OR 0.55; 95% CI 0.38-0.82, p = 0.003), whereas this association was not found for current smokers (OR 0.97; 95% CI 0.69-1.36, p = 0.856). Further work is needed to understand the underlying mechanisms of this finding.

Characteristics and outcomes of patients with multiple cervical artery dissection.

BACKGROUND AND PURPOSE: Little is known about factors contributing to multiple rather than single cervical artery dissections (CeAD) and their associated prognosis. METHODS: We compared the baseline characteristics and short-term outcome of patients with multiple to single CeAD included in the multicenter Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) study. RESULTS: Among the 983 patients with CeAD, 149 (15.2%) presented with multiple CeAD. Multiple CeADs were more often associated with cervical pain at admission (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.10-2.30), a remote history of head or neck surgery (OR, 1.87; 95% CI, 1.16-3.00), a recent infection (OR, 1.71; 95% CI, 1.12-2.61), and cervical manipulation (OR, 2.23; 95% CI, 1.26-3.95). On imaging, cervical fibromuscular dysplasia (OR, 3.97; 95% CI, 2.04-7.74) and the presence of a pseudoaneurysm (OR, 2.91; 95% CI, 1.86-4.57) were more often seen in patients with multiple CeAD. The presence of multiple rather than single CeAD had no effect on functional 3-month outcome (modified Rankin Scale score, ≥3; 12% in multiple CeAD versus 11.9% in single CeAD; OR, 1.20; 95% CI, 0.60-2.41). CONCLUSIONS: In the largest published series of patients with CeAD, we highlighted significant differences between multiple and single artery involvement. Features suggestive of an underlying vasculopathy (fibromuscular dysplasia) and environmental triggers (recent infection, cervical manipulation, and a remote history of head or neck surgery) were preferentially associated with multiple CeAD.

Intracerebral haemorrhage profiles are changing: results from the Dijon population-based study.

Incidence of intracerebral haemorrhage over the past three decades is reported as stable. This disappointing finding is questionable and suggests that any reduction in intracerebral haemorrhage incidence associated with improvements in primary prevention, namely, better control of blood pressure, might have been offset by an increase in cases of intracerebral haemorrhage owing to other factors, including the use of antithrombotic drugs in the ageing population. Therefore, we aimed to analyse trends in intracerebral haemorrhage incidence from 1985 to 2008 in the population-based registry of Dijon, France, taking into consideration the intracerebral haemorrhage location, the effect of age and the changes in the distribution of risk factors and premorbid treatments. Incidence rates were calculated and temporal trends were analysed by age groups (<60, 60-74 and ≥75 years) and intracerebral haemorrhage location (lobar or deep) according to study periods 1985-92, 1993-2000 and 2001-08. Over the 24 years of the study, 3948 patients with first-ever stroke were recorded. Among these, 441 had intracerebral haemorrhage (48.3% male), including 49% lobar, 37% deep, 9% infratentorial and 5% of undetermined location. Mean age at onset increased from 67.3 ± 15.9 years to 74.7 ± 16.7 years over the study period (P < 0.001). Overall crude incidence was 12.4/100,000/year (95% confidence interval: 11.2-13.6) and remained stable over time. However, an ∼80% increase in intracerebral haemorrhage incidence among people aged ≥75 years was observed between the first and both second and third study periods, contrasting with a 50% decrease in that in individuals aged <60 years, and stable incidence in those aged 60-74 years. This result was attributed to a 2-fold increase in lobar intracerebral haemorrhage in the elderly, concomitantly with an observed rise in the premorbid use of antithrombotics at this age, whatever the intracerebral haemorrhage location considered. In conclusion, intracerebral haemorrhage profiles have changed in the past 20 years, suggesting that some bleeding-prone vasculopathies in the elderly are more likely to bleed when antithrombotic drugs are used, as illustrated by the rise in the incidence of lobar intracerebral haemorrhage in the elderly, in which cerebral amyloid angiopathy may be strongly implicated. Future research should focus on the impact and management of antithrombotics in patients with intracerebral haemorrhage, which may differ according to the underlying vessel disease.

How accurate is the reporting of stroke in hospital discharge data? A pilot validation study using a population-based stroke registry as control.

Population-based stroke registries can provide valid stroke incidence because they ensure exhaustiveness of case ascertainment. However, their results are difficult to extrapolate because they cover a small population. The French Hospital Discharge Database (FHDDB), which routinely collects administrative data, could be a useful tool for providing data on the nationwide burden of stroke. The aim of our pilot study was to assess the validity of stroke diagnosis reported in the FHDDB. All records of patients with a diagnosis of stroke between 2004 and 2008 were retrieved from the FHDDB of Dijon Teaching Hospital. The Dijon Stroke Registry was considered as the gold standard. The sensitivity, positive predictive value (PPV), and weighted kappa were calculated. The Dijon Stroke Registry identified 811 patients with a stroke, among whom 186 were missed by the FHDDB and thus considered false-negatives. The FHDDB identified 903 patients discharged following a stroke including 625 true-positives confirmed by the registry and 278 false-positives. The overall sensitivity and PPV of the FHDDB for the diagnosis of stroke were, respectively, 77.1 % (95 % CI 74.2-80) and 69.2 % (95 % CI 66.1-72.2). For cardioembolic and lacunar strokes, the FHDDB yielded higher PPVs (respectively 86.7 and 84.6 %; p < 0.0001) than those of other stroke subtypes. The PPV but not sensitivity significantly increased over the years (p < 0.0001). Agreement with the stroke registry was moderate (kappa 52.8; 95 % CI 46.8-58.9). The FHDDB-based stroke diagnosis showed moderate validity compared with the Dijon Stroke Registry as the gold standard. However, its accuracy (PPV) increased with time and was higher for some stroke subtypes.

Prognostic value of early epileptic seizures on mortality and functional disability in acute stroke: the Dijon Stroke Registry (1985-2010).

We aimed to evaluate the prognostic value of early epileptic seizures after stroke. All consecutive patients with a first-ever stroke were prospectively identified within the population of Dijon, France, thanks to a population-based registry, from 1985 to 2010. Early epileptic seizures were defined as seizures occurring within 14 days after stroke onset. Outcomes were 1-month and 1-year mortality, and severe functional handicap at discharge. Of the 4,411 stroke patients included, data about seizures were available in 4,358 (98.8, 53.5 % women, mean age, 74.1 ± 14.8 years). Among these patients, 134 (3.1 %) had early seizures. Stroke patients with early seizures differed from those without seizures, as there was a higher proportion of hemorrhagic stroke, higher blood glucose level at admission, smoking status, and more frequent impaired. Higher risks of 1-month and 1-year mortality in patients with early seizures (unadjusted HR 1.45, 95 % CI 1.00-2.10; HR = 1.59, 95 % CI 1.21-2.09, respectively) disappeared (HR 0.71, 95 % CI 0.49-1.08 and HR 0.85, 95 % CI 0.64-1.17) after adjustment for stroke severity and other confounding factors. Early seizures were associated with severe handicap in unadjusted analyses (OR 2.07, 95 % CI 1.46-2.95) but the association was no longer significant after multivariable adjustment (OR 1.12, 95 % CI 0.69-1.83). Early epileptic seizures were not associated with higher risks of mortality at 1 month and 1 year or with unfavorable functional outcome after acute stroke. The adverse effects of epileptic seizures may not be distinguishable from stroke severity, which is strongly related to epileptic seizures.

Secondary prevention in patients with vascular disease. A population based study on the underuse of recommended medications.

OBJECTIVES: To investigate the premorbid use of secondary prevention medications in patients with recurrent vascular events. DESIGN: Prospective, observational, population based study. SETTING: The Dijon Stroke Registry and the registry of myocardial infarction of Dijon and Côte d'Or, France. PATIENTS: All patients with cerebral ischaemia (ischaemic stroke or transient ischaemic attacks) or coronary artery disease (CAD) and a history of vascular disease (cerebral ischaemia, CAD or peripheral arterial disease (PAD)) in Dijon, France from 2006 to 2010. MAIN OUTCOME MEASURES: Data on medical history and prior use of treatments were collected. Mutivariate analyses were performed to identify predictors of the use of medications. RESULTS: 867 patients (614 cerebral ischaemia and 253 CAD) were recorded including 448 (51.7%) with a history of cerebral ischaemia only, 191 (22.0%) with a history of CAD only, 68 (7.8%) with a history of PAD only and 160 (18.5%) with a history of polyvascular disease. In these 867 patients, 57.3% were on antithrombotic therapy, 61.2% were treated with antihypertensive drugs, 32.9% received statins and only 23.6% were on an optimal regimen, defined as a combination of the three therapies. Compared with patients with previous CAD only, those with previous cerebral ischaemia only were less likely to be receiving each of these treatments or to receive an optimal regimen (OR=0.17, 95% CI 0.14 to 0.26, p<0.001). CONCLUSIONS: Our findings underline the fact that the underuse of secondary preventive therapies is common in patients with recurrent vascular events, especially those with previous cerebral ischaemia. This underuse could be targeted to reduce recurrent vascular events.

Effect of previous statin therapy on severity and outcome in ischemic stroke patients: a population-based study.

Although statin therapy has been shown to be effective in the prevention of ischemic stroke, its effect on stroke severity and early outcome is still controversial. We aimed to evaluate the association between statin use before onset and both initial severity and functional outcome in ischemic stroke patients. All cases of first-ever ischemic stroke that occurred in Dijon, France (151,000 inhabitants) between 2006 and 2011 were prospectively identified from the Dijon Stroke Registry. Vascular risk factors, clinical severity at onset assessed by the NIHSS score, stroke subtypes, prestroke statin use, and lipid profile were collected. Functional outcome was defined by a six-level categorical outcome using the modified Rankin scale. Analyses were performed using ordinal logistic regression models. Among the 953 patients with first-ever ischemic stroke, 127 (13.3 %) had previously been treated with statins. Initial stroke severity did not differ between statin users and non-users [median NIHSS score (interquartile range) 4.0 (7.0) versus 4.0 (9.0) p = 0.104]. In unadjusted analysis, statin use was associated with a lower risk of an unfavorable functional outcome at discharge (OR 0.69; 95 % CI 0.49-0.96; p = 0.026) that was no longer significant in multivariate analyses (OR 0.76; 95 % CI 0.53-1.09; p = 0.134). After adjustment for admission plasma LDL cholesterol levels, the non-significant association was still observed (OR 0.76; 95 % CI 0.49-1.18; p = 0.221). This population-based study showed that prestroke statin therapy did not affect initial clinical severity but was associated with a non-significant better early functional outcome after ischemic stroke.

Poststroke disposition and associated factors in a population-based study: the Dijon Stroke Registry.

BACKGROUND AND PURPOSE: The organization of poststroke care will be a major challenge in coming years. We aimed to assess hospital disposition after stroke and its associated factors in clinical practice. METHODS: All cases of stroke from 2006 to 2010 were identified from the population-based Stroke Registry of Dijon, France. Demographic features, risk factors, and prestroke treatments were recorded. Admission stroke severity was assessed using the National Institutes of Health Stroke Scale score. At discharge, we collected dementia, disability using the modified Rankin Scale, length of stay, and hospital disposition (home, rehabilitation, convalescent home, and nursing home). Multivariate analyses were performed using logistic regression models to identify associated factors of postdischarge disposition. RESULTS: Of the patients with 1069 stroke included, 913 survived acute care. Among them, 433 (47.4%) returned home, whereas 206 (22.6%) were discharged to rehabilitation, 134 (14.7%) were admitted to a convalescent home, and 140 (15.3%) to a nursing home. Old patients, those under anticoagulants before stroke, those with severe stroke on admission, severe disability at discharge, dementia, or prolonged length of stay were less likely to return home. Moreover, advanced age, severe initial stroke, severe disability at discharge, and dementia were associated with admission to convalescent and nursing homes rather than rehabilitation centers. CONCLUSION: This population-based study demonstrated that postdischarge destinations are associated with several factors. Our findings may be useful to establish health policy concerning the organization of poststroke care.

The deleterious effect of admission hyperglycemia on survival and functional outcome in patients with intracerebral hemorrhage.

BACKGROUND AND PURPOSE: We aimed to evaluate the association between blood glucose (BG) levels at admission and both functional outcome at discharge and 1-month mortality after intracerebral hemorrhage (ICH). METHODS: All cases of first-ever ICH were identified from the population-based Stroke Registry of Dijon, France from 1985 to 2009. Clinical and radiological information was recorded. BG was measured at admission. Multivariate analyses were performed using logistic and Cox regression models. Multiple imputation was used as a sensitivity analysis. RESULTS: We recorded 465 first-ever ICH. BG at admission was obtained in 416 patients (89.5%) with a median value of 6.92 mmol/L. In multivariate analyses, BG in the highest tertile (≥8.6 mmol/L) was an independent predictor of functional handicap (odds ratio, 2.51; 95% CI, 1.43-4.40; P=0.01) and 1-month mortality (hazard ratio, 2.51; 95% CI, 1.23-2.43; P=0.002). The results were consistent with those obtained from multiple imputation analyses. CONCLUSIONS: Admission hyperglycemia is associated with poor functional recovery at discharge and 1-month mortality after ICH. These results suggest a need for trials that evaluate strategies to lower BG in acute ICH.

Prior transient ischemic attack and dementia after subsequent ischemic stroke.

Although functional recovery and survival after ischemic stroke seem to improve in patients with prior transient ischemic attack (TIA), little is known about the effect of prior TIA on poststroke cognition. To evaluate the impact of prior TIA on dementia, 1697 nonaphasic patients who survived the first month after their first-ever ischemic stroke were identified from the population-based registry of Dijon, France, from 1985 to 2007 and divided into 3 groups according to the time interval between prior TIA and stroke (<4 wk, ≥4 wk, no TIA). Outcome was dementia diagnosed by neurologists using Diagnostic and Statistical Manual of mental disorders-III or IV criteria over the first month after stroke. Multivariate analyses were performed using logistic regression models. The prevalence of dementia after stroke was 20.6% [95% confidence interval (CI), 18.5-22.7], 26.8% (95% CI, 13.3-40.4), and 33.1% (95% CI, 27.3-38.9) among patients without TIA, with a prestroke TIA≥4 weeks, and with a prestroke TIA<4 weeks, respectively. Patients with prestroke TIA<4 weeks (adjusted odds ratio: 1.83; 95% CI, 1.32-2.52; P=0.0003) had a higher risk of dementia than those without TIA.

Effort-reward imbalance at work and recurrent coronary heart disease events: a 4-year prospective study of post-myocardial infarction patients.

OBJECTIVE: Prospective studies have shown that effort-reward imbalance (ERI) at work is associated with the incidence of a first coronary heart disease (CHD) event. However, it is unknown whether ERI at work increases the risk of recurrent CHD events. The objective of this study was to determine whether ERI at work and its components (effort and reward) increase the risk of recurrent CHD in post-myocardial infarction (post-MI) workers. METHODS: We carried out a prospective cohort study of 669 men and 69 women who returned to work after a first MI. ERI at work was assessed by telephone interview using validated scales of reward and psychological demands. The outcome was a composite of fatal CHD, nonfatal MI, and unstable angina. CHD risk factors were documented in medical files and by interview. The participants were followed up for a mean period of 4.0 years (1998-2005). RESULTS: During the follow-up, 96 CHD events were documented. High ERI and low reward were associated with recurrent CHD (respective adjusted hazard ratios [HRs] = 1.75, 95% confidence interval [CI] = 0.99-3.08, and HR = 1.77, 95% CI = 1.16-2.71). There was a gender interaction showing stronger effects among women (respective adjusted HRs for high ERI and low reward: HR = 3.95, 95% CI = 0.93-16.79, and HR = 9.53, 95% CI = 1.15-78.68). CONCLUSIONS: Post-MI workers holding jobs that involved ERI or low reward had increased risk of recurrent CHD.

Effort-reward imbalance at work and psychological distress: a validation study of post-myocardial infarction patients.

OBJECTIVES: To examine whether the psychometric properties of the effort-reward imbalance (ERI) at work scales could be replicated with post-myocardial infarction (post-MI) patients and to measure the criterion validity through its association with psychological distress. METHODS: A cross-sectional survey was conducted among 814 patients (739 men and 75 women) who had returned to work after their first MI and who were followed up by telephone at an average of 2.2 years after their baseline interview (1998-2000). The psychological demands scale of the Karasek Job Content Questionnaire was used to measure effort. Reward was measured with nine items from the original reward scale by Siegrist plus two proxy items. Exploratory and confirmatory factor analyses were used to test the theoretical structure of ERI. Using log-binomial regression models, we evaluated the association between ERI scales and psychological distress measured with the 14-item Psychiatric Symptom Index. RESULTS: ERI scales and subscales demonstrated adequate internal consistencies. Exploratory factor analysis using oblique (promax) rotation yielded a three-factor solution with items representative of extrinsic effort (Factor 1) and reward subscales (Factors 2 and 3). Confirmatory factor analysis demonstrated a good fit with the data. The internal consistencies and discriminant validities of the ERI scales were satisfactory. Furthermore, effort, reward, and ERI ratio were significantly associated with psychological distress (adjusted prevalence ratio [PR] = 1.71, 95% confidence interval [CI] = 1.26-2.31; PR = 1.63, 95% CI = 1.16-2.29; and PR = 1.70, 95% CI = 1.17-2.47, respectively). CONCLUSIONS: The psychometric properties of the ERI scales were generally reproduced among post-MI patients. The associations with psychological distress supported the criterion validity of the ERI scales in this population.