Background and Purpose — Only a small minority of acute stroke patients receive approved acute stroke therapy. We performed a community and professional behavioral intervention project to increase the proportion of stroke patients treated with approved acute stroke therapy. Methods — This study used a quasi-experimental design. Intervention and comparison communities were compared at baseline and during educational intervention. The communities were based in 5 nonurban East Texas counties. The multilevel intervention worked with hospitals and community physicians while changing the stroke identification skills, outcome expectations, and social norms of community residents. The primary goal was to increase the proportion of patients treated with intravenous recombinant tissue plasminogen activator (rTPA) from 1% to 6% of all cerebrovascular events in the intervention community. Results — We prospectively evaluated 1733 patients and validated 1189 cerebrovascular events. Intravenous rTPA treatment increased from 1.38% to 5.75% among all cerebrovascular event patients in the intervention community ( P =0.01) compared with a change from 0.49% to 0.55% in the comparison community ( P =1.00). Among the ischemic stroke patients, an increase from 2.21% to 8.65% was noted in the intervention community ( P =0.02). The comparison group did not appreciably change (0.71% to 0.86%, P =1.00). Of eligible intravenous rTPA candidates, treatment increased in the intervention community from 14% to 52% ( P =0.003) and was unchanged in the comparison community (7% to 6%, P =1.00). Conclusions — An aggressive, multilevel stroke educational intervention program can increase delivery of acute stroke therapy. This may have important public health implications for reducing disability on a national level.

Background and Purpose —Activating emergency medical services (EMS) is the most important factor in reducing delay times to hospital arrival for stroke patients. Determining who calls 911 for stroke would allow more efficient targeting of public health initiatives. Methods —The T.L.L. Temple Foundation Stroke Project is an acute stroke surveillance and intervention project in nonurban East Texas. Prospective case ascertainment allowed chart abstraction and structured interviews for all hospitalized stroke patients to determine if EMS was activated, and if so, by whom. Results —Of 429 validated strokes, 38.0% activated EMS by calling 911. Logistic regression analysis comparing those who called 911 with those who did not activate EMS found that individuals who were employed were 81% less likely to have EMS activated (OR 0.19, 95% CI 0.04 to 0.63). Of the 163 cases in which 911 was called, the person activating EMS was: self (patient), 4.3%; family member of significant other, 60.1%; paid caregiver, 18.4%; and coworker or other, 12.9%. Significant associations between the variables age group ( P =0.02), insurance status ( P =0.007), and living alone ( P =0.05) with who called 911 was found on χ ² analysis. Conclusions —Educational efforts directed at patients themselves at risk for stroke may be of low yield. To increase the use of time dependent acute stroke therapy, interventions may wish to concentrate on family, caregivers, and coworkers of high-risk patients. Large employers may be good targets to increase utilization of EMS services for acute stroke.

Summary: Background  The burden of functional GI disorders and their associations with psychological distress in women veterans is unclear.Aim  To examine 1‐year prevalence of irritable bowel syndrome (IBS) and dyspepsia symptoms and their associations with anxiety, depression and post‐traumatic stress disorder (PTSD) among women veterans receiving primary care at a Veteran Affairs Medical Center Women’s Clinic.Methods  Irritable bowel syndrome, dyspepsia and psychological distress were assessed using the validated self‐administered Bowel Disorder Questionnaire, the Beck Depression and Anxiety Inventories, as well as the Mississippi Scale for Combat‐Related Post‐Traumatic Stress Disorder Questionnaire.Results  We enrolled 248 women (84% participation rate). Ninety‐three (38%) reported IBS and 51 (21%) dyspepsia symptoms. Women with IBS and dyspepsia reported higher mean scores of anxiety (IBS: 24 vs. 12, P < 0.0005 and dyspepsia: 26 vs. 12, P < 0.0005), depression (IBS: 22 vs. 11, P = 0.0005 and dyspepsia: 23 vs. 11, P < 0.0005) and PTSD (IBS: 87 vs. 69, P < 0.001 and dyspepsia: 86 vs. 69, P < 0.0005). Age‐ and ethnicity‐adjusted logistic regression analyses showed a 3‐ to 46‐fold increase in odds of IBS and dyspepsia among women with anxiety, depression or PTSD.Conclusion  Women veterans have high prevalence of IBS and dyspepsia symptoms, both of which are highly associated with presence of depression, anxiety and PTSD.

Aliment Pharmacol Ther 2010; 32: 551–561 Summary Background Over 1.8 million women in the U.S. are veterans of the armed services. They are at increased risk of occupational traumas, including military sexual trauma. Aim To evaluate the association between major traumas and irritable bowel syndrome among women veterans accessing Veteran Affairs (VA) healthcare. Methods We administered questionnaires to assess trauma history as well as IBS, post‐traumatic stress disorder (PTSD) and depression symptoms to 337 women veterans seen for primary care at VA Women’s Clinic between 2006 and 2007. Logistic regression was used to evaluate the association between individual traumas and IBS risk after adjustment for age, ethnicity, PTSD and depression. Results Irritable bowel syndrome prevalence was 33.5%. The most frequently reported trauma was sexual assault (38.9%). Seventeen of eighteen traumas were associated with increased IBS risk after adjusting for age, ethnicity, PTSD and depression, with six statistically significant [range of adjusted odds ratios (OR) between 1.85 (95% CI, 1.08–3.16) and 2.6 (95% CI, 1.28–3.67)]. Depression and PTSD were significantly more common in IBS cases than controls, but neither substantially explained the association between trauma and increased IBS risk. Conclusions Women veterans report high frequency of physical and sexual traumas. A lifetime history of a broad range of traumas is independently associated with an elevated risk of the irritable bowel syndrome.

Objective: To evaluate the practice patterns for stroke care in rural emergency departments (ED). Methods: The authors prospectively evaluated clinical practice decisions for all ED patients in two non-urban East Texas communities using active and passive surveillance methods. Data collected included demographics, risk factors, symptoms, and treatment. Data analysis consisted of descriptive statistics and logistic regression analysis. Results: During the study period, 429 patients presented with validated strokes. Risk factors included hypertension (65%), previous stroke (41%), coronary artery disease (33%), diabetes (25%), current smoking (17%), and atrial fibrillation (11%). In the ED, neurology consultation occurred in 32%, head CT in 88%, and ECG in 85%. Heparin was used in 9%, and 5% received aspirin. Blood pressure was lowered in 19% from a mean high of 189(±38)/97(±26), average reduction 34 points (18%) systolic. Motor symptoms were more likely to prompt a neurology consultation (OR = 2.47). Heparin was used more commonly for patients with atrial fibrillation (OR = 2.93). Socioeconomic factors did not alter care. IV recombinant tissue plasminogen activator was used in 1.4% of ischemic stroke cases. Conclusions: Acute stroke care in this representative non-urban community frequently does not follow published guidelines or clinical trial results. Whereas a high percentage of patients receive CT, aggressive blood pressure treatment occurs commonly and at pressures below current recommendations. The use of heparin is common, more so than aspirin treatment. These facts argue for educational interventions aimed at non-urban physicians to improve evidence-based medical practice.