Among critically ill stroke patients, ED-LOS > or =5 h before transfer to the NICU is independently associated with poor outcome at hospital discharge.

To determine whether warfarin-treated patients with an international normalized ratio less than 1.7 who receive intravenous tissue plasminogen activator for acute ischemic stroke are at increased risk for symptomatic intracerebral hemorrhage.

Background and Purpose-Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. Stroke Warning Information and Faster Treatment (SWIFT) compared an interactive intervention (II) with enhanced educational (EE) materials on recurrent stroke arrival times in a prospective cohort of multiethnic stroke/ transient ischemic attack survivors. Methods-A single-center randomized controlled trial (2005)(2006)(2007)(2008)(2009)(2010)(2011) randomized participants to EE (bilingual stroke preparedness materials) or II (EE plus in-hospital sessions). We assessed differences by randomization in the proportion arriving to emergency department <3 hours, prepost intervention arrival <3 hours, incidence rate ratio for total events, and stroke knowledge and preparedness capacity. Results-SWIFT randomized 1193 participants (592 EE, 601 II): mean age 63 years; 50% female, 17% black, 51%Hispanic, 26% white. At baseline, 28% arrived to emergency department <3 hours. Over 5 years, first recurrent stroke (n=133), transient ischemic attacks (n=54), or stroke mimics (n=37) were documented in 224 participants. Incidence rate ratio=1.31 (95% confidence interval=1.05-1.63; II to EE). Among II, 40% arrived <3 hours versus 46% EE (P=0.33). In prepost analysis, there was a 49% increase in the proportion arriving <3 hours (P=0.001), greatest among Hispanics (63%, P<0.003). II had greater stroke knowledge at 1 month (odds ratio=1.63; 1.23-2.15). II had higher preparedness capacity at 1 month (odds ratio=3.36; 1.86, 6.10) and 12 months (odds ratio=7.64; 2.49, 23.49). Conclusions-There was no difference in arrival <3 hours overall between II and EE; the proportion arriving <3 hours increased in both groups and in race-ethnic minorities. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00415389.

Background: Hydroxymethylglutaryl coenzyme A reductase inhibitors (‘statins’) reduce the neuronal injury in dose-dependent fashion in rodent stroke models. We sought to determine whether lovastatin at doses above those currently approved can be administered safely within 24 h after an acute ischemic stroke. Methods: We conducted a phase 1B dose-finding study using an adaptive design novel to stroke trials, the continual reassessment method, to find the highest tolerated dose of lovastatin. Planned doses were 1, 3, 6, 8 and 10 mg/kg/day for 3 days. The primary safety outcomes were myotoxicity and hepatotoxicity. The model was calibrated to select a dose causing 7–13% toxicity. Results: We enrolled 33 patients (16 men/17 women, age range 23–82 years). Three patients were treated at 1 mg/kg, 10 at 3 mg/kg, 12 at 6 mg/kg, and 8 at 8 mg/kg. Thirty of the 33 patients (90.9%) completed at least 11 of 12 doses. Two patients at the 6-mg/kg dose level experienced transient mild elevations in transaminases without clinical sequelae. After an initial dose reduction, the dose was re-escalated to 8 mg/kg, and no further patients reached safety outcomes. No clinical liver disease, myopathy, or creatine phosphokinase elevations occurred. The final model-based toxicity at 8 mg/kg was 13%; no patient was treated at 10 mg/kg. Conclusions: Lovastatin at doses above those currently approved by the Food and Drug Administration is feasible for 3 days after an acute ischemic stroke and the maximum tolerated dose is estimated to be 8 mg/kg/day. Further randomized studies are warranted to confirm its safety and to demonstrate its efficacy in improving functional outcomes after stroke.

Storm preparation should include disseminating information regarding carbon monoxide and proper generator use, considerations for prescription refills, neighborhood security, and location of food distribution centers. Lower-income individuals may have greater difficulty meeting their needs following a natural disaster, and recovery efforts may include prioritization of these households.