bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 430: Variation of Post Arrest Survival to Discharge and Cerebral Performance Category 1/2 in State of Michigan
Authors: Berger David A , Chen Nai-Wei , Miller Joseph B , Welch Robert D , Reynolds Joshua C , PRIBBLE James M , Swor Robert A
Published: June 2021

Introduction:
Resuscitation from out-of-hospital cardiac arrest (OHCA) requires success in the entire chain of survival. Our prior work demonstrated substantial variation in provision of left heart catheterization (LHC) and TTM within Michigan (MI) hospitals but did not evaluate impact on survival. The objective of this study is to characterize the variation in post arrest survival to discharge and CPC-1/2 in MI Hospitals.

Methods:
We used the MI Cardiac Arrest to Enhance Survival (CARES) registry, to analyze all adult OHCA patients with ROSC from 2014 - 2017 that survived to hospital admission. Hospitals (N=40) were included if they managed > 30 cases/4-years for all rhythms and > 20 cases/4-years for shockable patients. We excluded transferred patients; those resuscitated with bystander CPR only and patients < 18 years old. We assessed provision of LHC and TTM by hospital, survival to hospital discharge and survival with good neurologic outcome (CPC 1 or 2). We report crude and adjusted survival rates by hospital with median and range. To account for variations between hospitals, the adjusted survival rates were estimated using multilevel multi-variable regression analyses, adjusting for OHCA variables predictive of survival.

Results:
There were 5486 patients included CARES patients, 4,715 ultimately included for analyses of survival to discharge and survival with good neurological outcome. Of included hospitals (N=40), the median of crude rate was 31.4% [Range: 12.5%, 51.9%] for survival at discharge and 25.1% [Range: 5.2%, 42.2%] for survival rate with CPC-1/2. In the multivariable analyses, adjusting for patient characteristics, the median of adjusted rate was 27.6% [Range: 18.1%, 42.0%] for survival and 21.3% [Range: 9.7%, 32.8%] for survival to discharge with CPC-1/2.

Conclusion:
We observed substantial disparities in inter-hospital rates of survival at discharge, with a 4-fold range of survival and 8-fold range of survival with CPC-1/2. This survival variation was ameliorated but still persisted in the adjusted modeling analysis. Variation in post arrest survival by hospital is not explained by patient and arrest characteristics, and identifies a need for hospital quality improvement activities to improve post arrest patient survival.
Abstract 435: Controlled Sequential Elevation of the Head and Thorax Rapidly Achieves 50% of Baseline Cerebral Perfusion Pressure During Active Compression-Decompression Cardiopulmonary Resuscitation With an Impedance Threshold Device in a Swine Model of Cardiac Arrest
Authors: Rojas-Salvador Carolina , Salverda Bayert , Moore Johanna C , Lick Michael C , Debaty Guillaume P , Lurie Keith G
Published: June 2021

Introduction:
Controlled sequential elevation of the head and thorax (CSE) during active compression-decompression (ACD) CPR with an impedance threshold device (ITD) has previously resulted in sustained nearly normal cerebral perfusion pressures (CerPP) of 75 mmHg. However, the optimal speed of CSE remains unknown. It is also unknown if some CPR is needed to ‘prime the system’ prior to maximal CSE.

Hypothesis:
An optimized CSE will achieve 50% of baseline (50% BL) CerPP in <3 minutes from the start of CPR.

Methods:
Female farm pigs were intubated and anesthetized. Central vascular and intracranial access were obtained. After 8 min of untreated ventricular fibrillation, pigs were placed in a customized elevation device (CED). After 2 min of ACD+ITD CPR at the lowest CED level to prime the circulation, pigs were randomized to CSE over 1) 4-min or 2) 10-min until the CED reached its highest level. ACD ITD CPR was performed for a total of 19 minutes. Based upon initial results, two additional groups of pigs were studied: one with a CSE over 2-min after the 2 min ‘priming’ step, and the other with CSE over 24-sec without priming. The primary outcome was time in minutes to achieve 50% BL of CerPP values.

Results:
There were six pigs per study group (4-min, 10-min, 2-min and 24-sec). The 4-min CSE group achieved 50% BL CerPP faster (min ± SD) than the 10-min CSE group (2.53 ± 1.26 vs 5.98 ± 3.16 , p=0.04, Figure 1). The 2-min CSE group CerPP was similar to the 4-min group (2.36 ± 2.18, p=0.92). The time to 50% BL CerPP trended 4 min faster in the 2-min CSE group versus the 24-sec CSE group (6.6 ± 6.73, p=0.16), as shown in the figure. With CSE, CerPPs increased over time in all groups. All pigs were resuscitated.

Conclusions:
A 50% BL CerPP value was achieved in <3 minutes by combining a priming step and 2-min CSE time together with ACD+ITD CPR. This optimized approach is more advantageous than the 24-sec or 10-min elevation times.
Abstract 436: Ventilation Rate Impact on End-Tidal Carbon Dioxide Levels During Manual Cardiopulmonary Resuscitation
Authors: Ruiz Jesus M , Gutierrez Jose J , Ruiz de Gauna Sofia , Leturiondo Mikel , Leturiondo Luis A , Corcuera Carlos , Russell James K , DAYA Mohamud R
Published: June 2021

Introduction:
End-tidal carbon dioxide (ETCO2) levels during cardiopulmonary resuscitation (CPR) depend primarily on the blood flow generated by chest compressions, on the ventilation rate and on the metabolic activity of the patient tissues. A better characterization of the influence of each factor is warranted.

Objective:
To assess the quantitative relation between ETCO2 and ventilation rate from retrospective analysis of adult out-of-hospital resuscitations.

Methods:
Monitor recordings of 163 adult out-of-hospital cardiac arrest cases treated by Tualatin Valley Fire & Rescue (Tigard, OR) from 2012 through 2017. Recordings contained concurrent capnogram, ECG, transthoracic impedance (TI) and compression depth. Episodes were manually inspected to identify pairs of segments with different ventilation rates (
vr
1,
vr
2) and meeting the following criteria: 1) Reliable capnogram to annotate the ETCO2 value of each segment (
ET
1,
ET
2). 2) A maximum of 2 min separation between segments so that similar metabolic activity could be assumed. 3) Absence of circulation, by inspecting the ECG and the TI signal. 4) Compression depth and rate variation between segments < 4 mm and 8 compressions per minute, respectively.

We applied curve fitting to the data with a custom equation (see figure) and non-linear least squares as fit option.

Results:
Forty pairs of segments were included. The figure shows the measurements and the resulting fitting curve normalized to
vr
1 = 10 ventilations per minute (vpm). Factor
K
was 0.93, and the coefficient of determination R
2
was 0.90. Thus, for instance, the ETCO2 at 5 vpm would be 1.64 times the ETCO2 at 10 vpm. Similarly, the ETCO2 at 15 vpm would be 0.80 times the ETCO2 at 10 vpm.

Conclusions:
The obtained curve may help to eliminate the influence of ventilation rate on ETCO2 during cardiopulmonary resuscitation. This finding is a step forward to a better understanding of ETCO2 variation during the course of resuscitation.
Abstract 439: Using the Time Interval Between R-Wave Detection and Maximum Compression Pressure to Target and Validate Delivery of Synchronized Chest Compressions During Pseudo Electro-Mechanical Dissociation
Authors: Lampe Joshua W , Gould Jeff R , Moodie Karen L , Soucy Zachary P , Burrage Peter S , Paradis Norman A
Published: June 2021

Introduction:
The treatment of pseudo electro-mechanical dissociation (P-EMD) with standard chest compressions leads to some compressions that interfere with blood flow created by ventricular contraction and others that are synergistic. We have previously reported that the hemodynamics generated by standard chest compressions (StdCPR) depended on the time interval between the R-wave and the maximum compression pressure (t_int). Our goal was to use the t_int to identify the optimal timing for compression synchronization and to validate the delivery of synchronized chest compressions.

Methods:
Eight animals underwent surgical preparation and were exposed to hypoxia to induce P-EMD. The treatment period was divided into eight 45 sec epochs during which the P-EMD was left untreated or was treated with StdCPR or chest compressions synchronized to the R-wave in the ECG (SyncCPR). For each heart beat t_int was calculated as t
peak AOP
- t
Rwave
, blood pressures were averaged, and blood flows were integrated. 1,598 chest compressions were analyzed. The location of local extrema in hemodynamic parameters as a function of positive t_int values were identified recursively by dividing the range of t_int values into increasing numbers of bins and determining which bin had the highest mean value.

Results:
Blood flows and pressures exhibited a non-linear dependence on t_int. The maximum CPP occurred at t_int = 90 ±2.3 ms. The maximum aortic pressure occurred at t_int = 70 ±2.3 ms. The minimum right atrial pressure occurred at t_int = 280 ±2.3 ms. The maximum carotid blood flow occurred at t_int = 100 ±2.3 ms. The maximum jugular blood flow occurred at t_int = 400 ±2.3 ms. Unsynchronized chest compressions resulted in a t_int of -21 ± 170 ms. Synchronized chest compressions resulted in a t_int of 119 ± 13 ms.

Conclusions:
Local maxima and minima during StdCPR were identified in several hemodynamic parameters, but the extrema were not perfectly co-located. It appears that a t_int of 90-100 ms could be optimal. SyncCPR were delivered at 119 ms, which is not far from the local maxima observed for CPP and carotid blood flow.
Abstract 445: Cardiopulmonary Resuscitation Training for Families of Cardiac Patients Before Hospital Discharge Using a Mobile Application
Authors: Blewer Audrey L , McGovern Shaun K , Murray Andrew D , Leary Marion , Putt Mary , Riegel Barbara , Shea Judy A , Berg Robert , David Asch A , Merchant Raina , Nadkarni Vinay , Viera Anthony , Abella Benjamin
Published: June 2021

Introduction:
Since over 75% of sudden cardiac arrest events occur in the home where family members may be first responders, broad cardiopulmonary resuscitation (CPR) training for family members of high-risk cardiac patients represents a promising intervention. The use of mobile application-based (mApp) CPR training may facilitate this, but data on the approach are limited.

Objectives:
We compared CPR skill retention among those trained with an mApp and hypothesized that training with the mApp would be non-inferior to training with a well-established video self-instruction (VSI) kit. As a secondary analysis, we examined dissemination via the “multiplier rate” (i.e., those additionally trained by primary trainees) by intervention.

Methods:
We conducted a multicenter pragmatic, randomized control trial assessing non-inferiority of training family members of cardiac patients in CPR with an mApp (video, but no practice manikin) to training with an established VSI method (video and manikin). Subject’s CPR skills were tested 6-months post-training. We hypothesized that mApp training would be non-inferior to VSI training, with a non-inferiority margin set at 5 chest compressions (cc) per min.

Results:
From 01/2016-01/2018, 1446 subjects were enrolled at 8 hospitals with 685 trained with VSI, and 761 trained with the mApp. Of those, 541 were included in the skills analysis (275 VSI, 266 App). The mean age was 52±16 years and 69% were female. Mean cc rate was 85±34 per min; mean cc depth was 40±14 mm. When stratified by intervention arm, those trained with VSI had a mean rate of 86 per min (83, 90), compared to 88 per min (84, 92) with the mApp; those trained with VSI had a mean depth of 42 mm (41, 44), compared to 39 mm (38, 41) with the mApp. Findings were similar when accounting for loss to follow-up. We concluded non-inferiority of the mApp with a mean difference of 1 (-5, 7) cc per min for rate. Subjects trained with VSI shared with an additional 2±4 individuals compared to 1±2 (p<0.01) of those trained with the mApp.

Conclusion:
In this large prospective trial of CPR skill retention, the mApp CPR training approach was non-inferior to VSI training for family members of cardiac patients. Future work may include evaluating additional means for adoption and dissemination of the mApp.
Abstract 447: Longitudinal Improvement in CPR Quality Following RQI Implementation in a Pediatric Emergency Department
Authors: Donoghue Aaron , Abbadessa Mary Kate , Gaines Shannon , Heard Debra , Myers Sage , Niles Dana E , Nadkarni Vinay M , Griffin Russell E
Published: June 2021

Introduction and Objective:
The optimal retraining interval in CPR for healthcare providers is unknown. The Resuscitation Quality Improvement Program (RQI
®
) is a competency based, low-dose high-frequency quality improvement solution CPR psychomotor skills. We sought to describe the longitudinal change in skill performance during simulated CPR over a one year period following the implementation of RQI in a tertiary pediatric ED.

Methods:
Observational study in a single pediatric ED. All healthcare providers involved in resuscitative care in the ED were enrolled in RQI in October 2017. Once per 3-month period, each provider completed a feedback-guided skills session for 4 basic BLS skills (Infant compressions, infant ventilation, adult compressions, adult ventilation). A weighted scoring algorithm (range 0-100%) was used to score each subject’s performance. In the event of a score of less than 75%, repeated attempt(s) were required until a passing score was achieved. Q4 2017 median overall scores and first daily scores were compared to Q3 2018 median overall scores and first daily scores using a Wilcoxon Signed-Rank Test.

Results:
159 providers completed all four quarterly training sessions in the 12-month study period. Median scores stratified by quarter and difference scores between the first and last quarter for each task are shown in Table 1. Overall scores and first daily scores for all four psychomotor CPR skills improved significantly for all tasks between Q4 2017 and Q3 2018.

Conclusions:
Pediatric ED providers enrolled in RQI showed improved CPR skill performance over a one year period. Future research should link RQI training and skill performance with CPR performance during actual patient care.
Abstract 461: Evaluation of the Impact of Additional Structured Cardiac Arrest Training on Internal Medicine Residents in a Community Hospital
Authors: Azhar Abdullah Zoheb , Majmundar Monil , Golfeyz Shmuel , Kansara Tikal , Mercado Jonna , Mushiyev Savi
Published: June 2021

Introduction:
There are approximately 200,000 cases of in-hospital cardiac arrest (IHCA) annually in the United States. Of these cases, only 40-50% achieve return of spontaneous circulation (ROSC) and only 20-30% are discharged. Though most hospital staff are trained in cardiac arrest resuscitation, a significant disparity in resuscitation has been noted between different hospital settings. We thus instituted additional structured cardiac arrest training in an Internal Medicine residency program, to supplement the biennial advanced cardiac life support (ACLS) training.

Hypothesis:
We hypothesized that institution of a dedicated structured cardiac arrest team (code team) in addition to monthly training for those on the team, would improve the confidence, skills, and leadership level, of residents at managing an IHCA situation.

Methods:
A structured code team with specific roles for each resident was instituted in a New York City-based community hospital. Training was guided by audio-visual lectures and then reinforced by performing mock cardiac arrest drills. Resident assessments were done pre and post-training through an anonymous standardized questionnaire. Summative measures of mean confidence, mean ACLS skills, and leadership were evaluated. Uni and bivariate analysis, and T-tests for statistical significance were performed using STATA 15 software.

Results:
Our sample of 32 residents showed an increase in mean learning scores across all the three domains. Confidence scores increased from 7.23 to 8.44, ACLS skills increased from 7.40 to 8.57 and leadership scores increased from 6.56 to 7.88. Paired T-tests demonstrated high significance (P<0.000).

Conclusion:
This study demonstrates the effectiveness of additional structured cardiac arrest training on confidence, skills, and leadership of resident physicians in an Internal Medicine program. The next phase of this study will be to re-evaluate knowledge and confidence at 3 and 6 months after training.
Abstract 463: Communicating Through Chaos: A Hybrid Educational Initiative for Urgent Care Oncology Nurses
Authors: Moore Julie , Dilling Maggie
Published: June 2021

Introduction:
Cancer and cardiovascular disease are two leading causes of death in North America and can occur concurrently in oncology patients. Novel cancer treatments can cause direct cardiovascular side effects, increasing patient mortality. We aimed to educate oncology nurses of ST-Elevated Myocardial Infarction (STEMI) recognition and treatment using a hybrid educational model of didactic and simulation methods with contextual learning.

Hypothesis:
We hypothesize that a hybrid model including didactic and simulation methodology would result in increased knowledge, skills, and attitudes in the management of patients with STEMI. This would lead to decreased STEMI-related morbidity and improve interprofessional care co-ordination.

Methods:
Education was provided to 71% (5/7) of Registered Nurses in the Urgent Care Centre of Princess Margaret Hospital in Toronto, Canada. From a unit-wide needs assessment, RNs determined that patient management, care co-ordination and communication skills were areas of educational need, and simulation and lectures were preferred education methods. Current evidence, treatment, and policies for STEMI were incorporated into a short lecture, followed immediately by in situ high fidelity simulation scenarios. All education incorporated the AHA principle of contextual learning to support clinically-relevant knowledge acquisition. Educational gain was assessed using pre- and post-education testing.

Results:
Following the educational intervention, all learners had an increase in post-test scores. Recognition of the need for an ECG improved by 60% (3/5) and nurses felt more confident in caring for STEMI patients (3.6/4 average score). Learners found the education beneficial and relevant to their practice (100% of respondents). Nurses emphasized the value of didactic education followed by skills application in simulated cases as valuable to their learning from qualitative survey feedback.

Conclusion:
We developed and implemented a highly-relevant hybrid STEMI educational initiative following a needs assessment. Learners exhibited knowledge acquisition through pre and post-test results. Data collection regarding door-to-ECG and door-to-diagnosis times post-education is ongoing.
Abstract 480: Feasibility of an Augmented Reality Cardiopulmonary Resuscitation Training System for Health Care Providers
Authors: Balian Steve , McGovern Shaun , Abella Benjamin , Blewer Audrey , Leary Marion
Published: June 2021

Introduction:
Augmented reality (AR) has the potential to offer a novel approach to CPR training that supplements conventional training methods with gamification and a more interactive learning experience. This is done through computer-generated imagery superimposed on users’ view of the real environment to simulate interactive training scenarios.

Objective:
We sought to test the feasibility of an AR CPR training system (CPReality) for health care providers (HCPs).

Methods:
In this feasibility trial, a CPR training manikin was integrated with a commercial AR device (Microsoft HoloLens) to provide participants with real-time audio-visual feedback via a holographic overlay of blood flow to vital organs dependent on CC quality. In this system, higher quality CC visually improved virtual blood circulation. HCPs performed a 2-minute cycle of hands-only CPR using only the AR system, and CC parameters were recorded. Descriptive data on participants’ demographics, CC quality, and satisfaction with the training environment were reported.

Results:
Between 10/2019-11/2019, we enrolled a convenience sample of 51 HCPs. The median age of participants was 31 years (IQR 27-41), 71% (36/51) were female, and 67% (34/51) were registered nurses. CC rates (mean 126 ± 12.9 cpm), depths (median 53 mm, IQR 46-58), and percent with complete recoil (median 80%, IQR 12-100) were consistent with guideline recommendations for good quality CPR. Participants were predominantly satisfied with the system, with 82% perceiving the experience as realistic, 98% recognizing the visualizations as helpful for training, and 94% willing to use the application in future CPR training.

Conclusions:
As AR is increasingly applied in the healthcare setting, integration in CPR training offers a novel and promising educational approach. In this convenience sample of trained HCPs, high quality CC delivery was feasible using the AR CPR training system which was received favorably by most participants.
Abstract 481: Cardiopulmonary Resuscitation: The Effect of Fatigue on Professional Rescuers During Continuous Chest Compressions
Authors: McAlister Olibhear , Harvey Adam , Torney Hannah , McCartney Ben , Davis Laura , Owens Pamela , Idris Ahamed H
Published: June 2021

Introduction:
It is reported that quality of chest compressions (CC) during cardiopulmonary resuscitation (CPR) for both professional and non-professional rescuers often do not meet guideline requirements. Devices which provide feedback on the quality of CCs are designed to reduce the incidence of suboptimal compressions and promote the administration of effective CCs.

Objective:
This analysis investigates the effect of CPR duration on the performance of continuous CCs delivered by professional rescuers.

Methods:
Data were collected from a first responder group based in Texas, USA. Responders were instructed to use a CPR depth feedback device (Laerdal CPRmeter) and an automatic external defibrillator (AED; HeartSine SAM 350P) when attending sudden cardiac arrest events. The AED was configured with a shock protocol separated by 2-minute episodes of CPR and rescuer CC depth and rate were guided by the CPR depth feedback device. CC depth and rate data were processed for 174 patient events. Each CPR episode was divided into 4-analysis windows, 30-seconds in duration. Mean CC depth and rate data was calculated for each window. There were 1433 observations of CC depth and rate available for analysis across 414 CPR episodes. The data was fitted by a multiple linear regression model to assess the effect of CPR duration on CC performance.

Results:
The mean CC depth at the beginning of an event was 49.01 +/-0.51 mm. CC depth decreased by 0.82 mm, for each passing 30-second interval (p < 0.001). The mean CC rate at the beginning of an event was 111.17 +/- 0.33 compression per minute (CPM). No significant difference was observed between CC rate and duration of continuous CCs (p = 0.896) however there was a significant increase in CC rate observed of 0.408 CPM for each elapsed 2-minute CPR episode (p = 0.011).

Conclusion:
A reduction in CC depth was observed within each CPR episode, which may be indicative of fatigue during continuous CCs. Although a reduction of 3.28 mm throughout a 2-minute period of CPR may be clinically insignificant, this effect was observed within a trained rescuer group with CPR feedback. Further research is required to assess the effect of fatigue in non-professional responders.
Abstract 482: Differences in Ground Reaction Forces and Chest Compression Release Velocity in Professional and Lay Rescuers With and Without the Use of Real-Time CPR Feedback
Authors: Clark Lyra , Senderling Ben , Gould Jeff R , Kaufman Chris , Stergiou Nick
Published: June 2021

Purpose:
Chest compression release velocity (CCRV) has been associated with survival and favorable neurological outcome after cardiac resuscitation. Both complete chest release and high CCRV contribute to improved venous return during CPR. Differences in compression forces delivered by professional and lay rescuers are reported, which may contribute to differences in CCRV. The aim of this pilot study was to investigate differences in ground reaction force (GRF) and CCRV between professional and lay rescuers during CPR performed on a manikin with and without real-time feedback.

Methods:
Professional (n = 5) and lay rescuers (n = 11) performed two minutes of continuous compressions on a manikin positioned over a force plate for two trials. CPR feedback provided by a defibrillator was disabled in the first trial and enabled in the second. CPR pads containing an accelerometer were used to calculate individual compression characteristics. Relative maximum and minimum GRFs were calculated for each compression cycle and averaged over each trial. Paired and independent sample t tests and Pearson correlations were conducted in STATA 15.1.

Results:
CCRV was higher in professionals vs. lay rescuers with feedback disabled and enabled (
p
<0.05). Professionals had greater maximal and lower minimum forces than lay rescuers without feedback (
p
<0.05), though there were no differences between groups with feedback enabled (Table 1). CCRV was associated with minimum force (r = -0.63,
p
<0.01) and force range (r = 0.78,
p
<0.01) in all rescuers. Analysis of GRFs by CCRV for all rescuers indicated lower force minimum (9.71
+
3.16 N,
p
<0.05) with CCRV >400 mm/s in comparison to CCRV 300-400 mm/s (39.73
+
8.91 N) and CCRV 200-300 mm/s (63.82
+
16.98 N).

Conclusions:
CPR feedback attenuated differences in GRF between professional and lay rescuers. CCRV was greater in professionals and was associated with measures of GRF, and thus may serve as an indicator of both velocity and amount of chest release.
Abstract 099: Prevalence of Headaches in Patients with Fibromuscular Dysplasia: A Report from the US Registry for FMD
Authors: Swan Kirby , Gu Xiaokui , Kline-Rogers Eva , Wells Bryan J , Repack Adrienne , Krallman Rachel , Kim Esther S , Olin Jeffrey W , Gornik Heather L , Mace Pamela D , Froehlich James B , Bumpus Sherry M
Published: June 2021

Introduction:
Fibromuscular dysplasia (FMD) is a polyvasculopathy that may result in aneurysm or dissection in affected arterial beds. A common symptom of FMD is headache (HA). The purpose of this study is to describe and compare characteristics of FMD patients with (w/HA) and without headaches (wo/HA) in the current US Registry for FMD.

Method:
Data regarding demographics, family history, medical history, and vascular beds affected in patients with FMD were collected from the US Registry for FMD between 2009 and 2016. Patients with complete HA data were included, and data were compared between patients w/HA and wo/HA as reported at time of registry enrollment.

Results:
Of the 1,433 patients in the registry, 1,251 (87.3%) had complete HA data. Most were female (94.1%), with a mean age of 56.0±12.4. A history of HA was reported in 844 (67.5%) patients and 54.2% reported a HA at least weekly. No difference in gender distribution was seen between HA groups. Patients w/HA were younger at the time of FMD diagnosis (50.6±11.8 years v 58.0±13.8 years, p<0.001) and were less likely to have a history of HTN (66.8% v 74.8%, p=0.004), hyperlipidemia (36.9% v 47.2%, p=0.004), or renal failure (2.6% v 5.7%, p=0.009). Patients w/HA were more likely to have a history of aneurysm or dissection in the extracranial carotid, intracranial, or vertebral arteries (aneurysm: 13.0% v 7.2% p=0.003; dissection: 25.1% v 8.3%, p<0.001). No differences in extracranial carotid, intracranial, or vertebral FMD involvement between patients w/ and w/o HA were seen when those with history of aneurysm or dissection of those arteries were excluded (71.2% v 66.8%, p=0.20). Headache patients more often reported a history of depression (25.1% v 16.5%, p=0.01) and anxiety (28.3% v 18.0%, p=0.003).

Conclusion:
More than half of FMD patients experience HAs, most on an at least weekly basis. FMD patients with HA tended to be younger, and more likely to have extracranial carotid, intracranial, or vertebral disease as well as aneurysm and dissection. Depression and anxiety was also more common in FMD patients with HA. Further research is needed to classify the types of headaches being experienced as well as effective management strategies.
Abstract 181: What’s in the Black Box?: Describing Current Practice, Challenges, and Barriers of Cardiology and Palliative Care Collaboration
Authors: Wells Rachel , Mancarella Gisella , Dionne-Odom J. Nicholas , McIlvennan Colleen K , Wordingham Sara E , Goodlin Sara , Blume Elizabeth , Cooper Stephanie , Josephson Richard , Alexander Karen , Cestoni Abby , Maurer Matthew , Hauptman Paul , Kirkpatrick James , Bakitas Marie , Swetz Keith M ,   American College of Cardiology- Palliative Care Working Group of the Geriatrics Section
Published: June 2021

Background:
Guidelines recommend involvement of palliative care (PC) for patients with cardiovascular (CV) disease and their families. Little is known about the current integration of PC and CV services.

Research Objectives:
Our national survey aimed to describe current practices and to identify benefits, challenges, and barriers with collaboration.

Methods:
Qualitative content analysis of open-response questions in an investigator-developed electronic survey study of CV and PC providers (MDs, NPs, PAs, and other allied health) using email listservs, social media, and crowdsourcing. Frequencies were tabulated using SAS statistical software.

Results:
Of 134 respondents, most were physicians (n=56, 57%) or advanced practice RNs or PAs (n=37, 28%), from 52 U.S. institutions, representing 33 states. The most common care for which PC was integrated were mechanical circulatory support, advanced heart failure, and heart transplantation; the least common care for which PC was integrated were TAVR, ECMO, and pulmonary hypertension. Integrated practice (n=80, 61%), PC identification of goals of care (n=20, 15%) and PC aid in patient/family communication (n=15, 11%) were the most commonly identified as positives in current practice. PC provider workforce (n=22, 16%), underutilization of PC referrals (n=20, 15%), late disease PC referral (n=19, 14%), and fundamental knowledge deficit of specialty scope (n=18, 14%) were most frequently identified as challenges. Other barriers specifically noted were underdeveloped health infrastructure and limited allocated resources (n=23,17%) and mis-/negative perception of services (n=15, 11%).

Conclusion:
PC and CV collaboration occurs for a high proportion of CV patients and is viewed as overwhelming positive, despite the challenges of limited PC specialists availability, underdeveloped healthcare infrastructure, limited understanding of specialty practice, and late referrals. Priorities includes increasing PC provider availability, expanding knowledge of PC services, educating providers on models of collaboration, and improving institutional support.
Abstract 215: The Treatment Quality of Patients With Non-ST Elevation Acute Coronary Syndrome: Association With In-hospital Outcomes, Predictors of Nonconformity With Guidelines
Authors: Erlikh Alexey D , Kashtalap Vassily , Barbarash Olga , Gratsiansky Nikolay ,   all participants of RECORD-3 registry
Published: June 2021

Background:
It is known that closer adherence to clinical guidelines for management of acute coronary syndrome (ACS) is associated with better outcomes. Despite financial and organizational efforts only a small reduction of ACS mortality has been achieved in Russia during recent years. Official statistic data does not allow to evaluate the association of outcomes with quality of ACS treatment. AIM of the analysis was to assess quality of treatment (determined as conformity with guidelines) in patients with non-ST elevation ACS (NSTEACS) in Russian hospitals based on the data of the RECORD-3 registry.

Methods:
The ACS registry RECORD-3 was prospective observational study in which consecutive patients with ACS admitted to 47 hospitals from 37 cities were included within 1 month (Mar-Apr 2015). Recommendations of IA and IB classes from 2015 European society of cardiology guidelines (n=15) were used for evaluation of quality of treatment. The number of applicable recommendations (from 8 to 15) and the rate of their implementation were calculated for each patient. The 3-rd-4-th quartiles of implementation were named “guideline conforming treatment” (GCT), and 1-st and 2-nd quartiles - “guideline non-conforming treatment” (GNT).

Results:
Among 2370 included patients, 1502 (63.4%) had NSTEACS. The median of implementation of recommendations was 63.6% (1-3 quartiles 54.5% - 72.7%). Portions of patients with 100%, >75% and <50% implementation of recommendations were 1.4%, 19.0%, and 14.6%, respectively. During hospitalization (median 10 days) 7 patients (1.0%) receiving “GCT” and 30 patients (3.7%) receiving “GNT” died (relative risk 3.65, 95% confidence interval 1.61-8.26; p=0.0015). At multifactorial regression analysis, independent predictors of “GNT” were: Killip class IV, hospitalization without an ambulance assistance and admission to “noninvasive” hospital, previous atrial fibrillation, absence of ST-depression on first ECG, normal troponin level, first glucose level ≤6.0 mmol/l, not using aspirin or ACE-inhibitor regularly before ACS.

Conclusions:
The analysis of Russian registry RECORD-3 data showed that in participating hospitals >75% of recommendations of IA and IB classes were implemented only in 19% of NSTEACS patients. Hospital mortality was significantly higher in patients with “GNT”. Independent predictors of “GNT” were Killip class IV, hospitalization without an ambulance assistance and admission to “noninvasive” hospital, previous atrial fibrillation, absence of ST-depression, normal troponin or glucose levels, lack of aspirin or ACE-inhibitor regular use before ACS.
Epidemiology of Cardiopulmonary Resuscitation in Critically Ill Children Admitted to Pediatric Intensive Care Units Across England: A Multicenter Retrospective Cohort Study
Authors: Mustafa Khurram , Buckley Hannah , Feltbower Richard , Kumar Ramesh , Scholefield Barnaby R.
Published: June 2021

Background

Cardiopulmonary arrests are a major contributor to mortality and morbidity in pediatric intensive care units (PICUs). Understanding the epidemiology and risk factors for CPR may inform national quality improvement initiatives.

Methods and Results

A retrospective cohort analysis using prospectively collected data from the Paediatric Intensive Care Audit Network database. The Paediatric Intensive Care Audit Network contains data on all PICU admissions in the United Kingdom. We identified children who received cardiopulmonary resuscitation (CPR) in 23 PICUs in England (2013–2017). Incidence rates of CPR and associated factors were analyzed. Logistic regression was used to estimate the size and precision of associations. Cumulative incidence of CPR was 2.2% for 68 114 admissions over 5 years with an incidence rate of 4.9 episodes/1000 bed days. Cardiovascular diagnosis (odds ratio [OR], 2.30; 95% CI, 2.02–2.61), age <1 year (OR, 1.84; 95% CI, 1.65–2.04), the Paediatric Index of Mortality 2 score on admission (OR, 1.045; 95% CI, 1.042–1.047) and longer length of stay (OR, 1.013; 95% CI, 1.012–1.014) were associated with increased odds of receiving CPR. We also found a higher risk of CPR associated with a history of preadmission cardiac arrest (OR, 20.69; [95% CI, 18.16–23.58) and for children with a cardiac condition admitted to a noncardiac PICU (OR, 2.75; 95% CI, 1.91–3.98). Children from Black (OR, 1.68; 95% CI, 1.36–2.07) and Asian (OR, 1.49; 95% CI, 1.28–1.74) racial/ethnic backgrounds were at higher risk of receiving CPR in PICU than White children.

Conclusions

Data from this first multicenter study from England provides a foundation for further research and evidence for benchmarking and quality improvement for prevention of cardiac arrests in PICU.
Abstract 169: Clinical and Imaging Biomarkers of Childhood Arteriopathy: Results of the Vascular effects of Infection in Pediatric Stroke (VIPS) Study
Authors: Wintermark Max , Hills Nancy K , Barkovich A. James , Zhu Guangming , Leiva-Salinas Carlos , Hou Qinghua , Dowling Michael M , Bernard Timothy J , Friedman Neil R , Mackay Mark , Kirton Adam , Ichord Rebecca N , Fullerton Heather J ,   The VIPS Investigators
Published: June 2021

Introduction:
Childhood cerebral arteriopathies are heterogeneous and difficult to classify. Our goal was to identify clinical and imaging biomarkers associated with subtypes of childhood arteriopathy in order to facilitate their diagnosis and classification in both research and clinical settings.

Methods:
From 2009-2014, the VIPS study enrolled 355 children (age 29d-18y) with arterial ischemic stroke. A neuroradiologist and pediatric vascular neurologist independently reviewed vascular imaging and clinical data to diagnose arteriopathy (none, possible, definite), and then classify arteriopathy subtype: arterial dissection, transient cerebral arteriopathy (TCA), moyamoya, and secondary vasculitis. Disagreements were resolved through discussion by a panel of two neuroradiologists and two pediatric vascular neurologists. We constructed multivariable logistic regression models to identify characteristics independently associated with each subtype.

Results:
Of 127 cases with definite arteriopathy, 109 received a single arteriopathy subtype diagnosis (26 dissection, 25 TCA, 34 moyamoya, 15 secondary vasculitis, and 9 “other”), while 18 were of indeterminate subtype. There were no cases of primary vasculitis. Independent predictors of arteriopathy subtype are shown (Table). The association between black race and moyamoya is explained by sickle cell anemia. A banding pattern on the vascular imaging was pathognomonic of TCA. Moyamoya and vasculitis secondary to meningitis had similar distal internal carotid artery abnormalities, but lenticulostriate collaterals suggested moyamoya, and a decreased level of consciousness predicted secondary vasculitis.

Conclusions:
The different subtypes of childhood arteriopathies are associated with typical clinical, parenchymal and vascular imaging features that can help narrow the differential diagnosis in pediatric stroke patients with vascular abnormalities.
Abstract 186: IV tPA Recanalization Rates by Site of Occlusion and Time After tPA Bolus- Main Results Of The Interrsect Multinational Multicenter Prospective Cohort Study
Authors: Menon Bijoy K , Najm Mohamed , Al-Ajlan Fahad , Puig Alcantara Josep , Dowlatshahi Dar , Calleja Ana , Sohn Sung-Il , Ahn Seong H , Poppe Alexandre , Mikulik Robert , Asdaghi Negar , Field Thalia S , Jin Albert , Asil Talip , Boulanger Jean-Martin , Smith Eric E , Coutts Shelagh B , Barber Phil A , Bal Simer , Mishra Sachin , Trivedi Anurag , Dey Sadanand , Goyal Mayank , Hill Michael D , Demchuk Andrew M ,   INTERRSeCT Study Investigators
Published: June 2021

Introduction:
Decisions to transport patients from primary to comprehensive stroke centre would be influenced by info on likelihood/timing of spontaneous or IV tPA recanalization (recan). We examined recan rates by time for a wide range of occlusion sites in the INTERRSeCT multicenter prospective cohort study.

Methods:
Acute stroke patients consented/enrolled at 12 centers/5 countries if intracranial occlusion present on baseline CTA; eGFR≥60 ml/min. CTA was repeated 2-6 hrs later for recan unless patient taken for EVT (first run of angio used instead). Primary outcome was successful recan (rAOL scale score 2b/3) interpreted by central core lab.

Results:
619 patients enrolled, 81.6% received IV tPA. 59.9% recan by follow-up CTA and 40.1% by first run angio. Median baseline NIHSS 14 (IQR 11); mean age 70.1 yrs (SD 13); median onset to baseline CTA 115 mins (IQR 108). Recan assessment imaging median 162 mins (IQR 198) from IV tPA bolus or baseline CTA (if no IV tPA). Successful recan (rAOL 2b-3) rates comparing baseline to repeat imaging shown in Figure 1a (IV tPA red; no IV tPA blue). IV tPA had much higher recan than non-IV tPA group (30.5% vs 11%, p<0.0001). Successful recan rates by occlusion site and by time from IV tPA bolus shown in Figure 1b. Site of occlusion, tPA administration, time from tPA to recan assessment and baseline residual flow were the only independent predictors of recan (all p<0.0001). Distal M1 MCA had highest recan [RR 4.12; 95% CI 1.91-8.86 vs. ICA].

Conclusions:
Early recan rates were low across all occlusion sites. Beyond 6 hrs post tPA, recan rates approached EVT levels except for ICA. Imaging factors such as residual flow may further refine transport/triage decisions.
Abstract 88: No Disparities in Acute Stroke Treatment in Kaiser Stroke EXPRESS Program
Authors: Klingman Jeffrey G , Hatfield Meghan , Klingman Lauren , Wilson Benjamin , Nguyen-Huynh Mai N ,   on behalf of KPNC Stroke FORCE team
Published: June 2021

Background:
Prior published studies reported disparities in timely treatment with tPA for stroke patients who were older, African American or female. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for the entire region, which included immediate evaluation by a stroke neurologist via video, an expedited IV tPA treatment program, rapid CT angiographic investigation, and expedited transfer of appropriate patients with large vessel occlusion (LVO) for endovascular stroke treatment (EST). We sought to evaluate whether disparities exist in acute stroke treatment within the redesigned process.

Methods:
KPNC is an integrated health care system with 21 certified stroke centers serving 3.9+ millions members. All centers implemented the new program by January 2016. Using clinical data from 1/1/16 to 7/10/16, we evaluated the frequency of IV tPA administration by gender, race, and age groups after implementation of the new process. We performed multivariate analysis with age, gender, race-ethnicity, Kaiser membership, mode of ED arrival (by ambulance vs. private transportation) to assess for any disparities in achieving DTN time.

Results:
Post implementation, we found no significant differences in the rates of IV t-pa administration in eligible patients based on race, gender, age category (<40 years, 40-64, 65-79, ≥80), Kaiser membership, or mode of ED arrival. In multivariate analysis for factors influencing DTN time, no differences were seen for DTN time <60 minutes. Age (OR=1.02, 95% CI 1.00-1.03, p=0.03) and arrival by ambulance (OR=5.01, 95% CI 3.01-8.60, p<0.001) were associated with a faster DTN time of <30 minutes.

Conclusions:
Thus far, we have found no disparities in the use of IV tPA or DTN time for a large integrated healthcare system after implementation of the Stroke EXPRESS program. A consistent standardized approach to acute stroke care may help to reduce disparities on the basis of race, gender, age, or even membership in healthcare system.
Abstract TMP89: Collaterals and Reperfusion Mediate Blood Pressure Changes in Acute Ischemic Stroke
Authors: Liebeskind David S , Woolf Graham W , Sanossian Nerses , Hinman Jason D , Raychev Radoslav , Sharma Latisha K , Kim Doojin , Rao Neal M , Starkman Sidney , Jahan Reza , Szeder Viktor , Tateshima Satoshi , Duckwiler Gary R , Saver Jeffrey L , Scalzo Fabien ,   for the UCLA Stroke Investigators
Published: June 2021

Background:
The pathophysiology and optimal management of blood pressure changes in acute ischemic stroke remain unknown. Blood pressure guidelines do not consider patient-specific or serial data on dynamic blood pressure readings. We investigated continuous blood pressure data during endovascular therapy for acute stroke to discern changes associated with collaterals, recanalization and reperfusion.

Methods:
Continuous monitoring blood pressure data was collected in consecutive cases of endovascular therapy for acute ischemic stroke due to ICA or proximal MCA occlusion. Angiography details were independently analyzed to document site of arterial occlusion, baseline collateral grade, time of device deployments, time of recanalization, time of final reperfusion, final AOL recanalization and final TICI reperfusion. Statistical analyses correlated instantaneous and serial blood pressure changes with these angiographic parameters.

Results:
80 patients (median age 73 years; 33 women) were studied. Arterial lesions included 37 ICA and 41 proximal M1 MCA occlusions. Collateral grade prior to intervention included 2 ASITN grade 4, 26 grade 3, 23 grade 2, 6 grade 1 and 0 grade 0. oTICI2C reperfusion scores after thrombectomy included 2 TICI 3 (100%), 22 TICI 2C (90-99%), 25 TICI o2B (67-89%), 9 TICI m2B (50-66%), 19 TICI 2A (<50%) and 3 TICI 0/1. More robust collateral grade was associated with greater reperfusion scores (r=0.32, p=0.028). The change in blood pressure (ΔBP) from earliest BP to time of recanalization was mean 59% of ΔBP during the entire procedure. Better collaterals were associated with lower BP prior to recanalization (r=-0.377, p=0.012). Lower BP prior to recanalization was linked with greater TICI reperfusion (r=-0.242, p=0.050). Higher TICI reperfusion scores were also associated with a greater drop or ΔBP at the time of recanalization (r=0.269, p=0.031). AOL recanalization was not related to ΔBP.

Conclusions:
Collaterals and reperfusion, but not recanalization, mediate blood pressure changes in acute ischemic stroke. Prospective, precision medicine stroke studies should leverage patient-specific, real-time data on continuous blood pressure with imaging correlates to define BP goals of future in-hospital management.
Abstract TP224: Interleukin-37 Level is Elevated in Acute Ischemic Stroke
Authors: Bushnaq Saif , Zafar Atif , Duraisamy Kempuraj , Tasneem Nudrat , Khan Mohammad M , Leira Enrique , Zaheer Asgar Zaheer
Published: June 2021

Background:
Interleukin-37 (IL-37) is a new member of IL-1 cytokine family with a defined role as a negative feedback inhibitor of pro-inflammatory responses. IL-37 has yet to be evaluated in non-immune neurological diseases like ischemic or hemorrhagic stroke. This study aimed to measure the urine and serum IL-37 levels in patients with acute ischemic stroke.

Method:
Twelve patients consented for the study. Two sets of serum and urine samples were obtained and analyzed; one upon admission to the hospital, and the second the next morning after overnight fasting. The trends in serum level of IL-37 in 5 stroke patients, while trends in urine level of 6 patients were available, measured by real-time polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). Prior studies with healthy volunteers as control group have consistently showed IL-37 plasma level around or less than 65 pg/ml with maximum normal levels on ELISA approximated at 130 pg/ml.

Results:
IL-37 level in urine in stroke patients ranged from 297 - 4467. IL-37 levels were in the range of 300s to 1000s in patients with ischemic stroke compared with reported healthy controls in literature where the level was always less than 90. Three of these 10 patients presented within 3 hours of stroke onset with IL-37 serum levels being 2655 pg/ml, 3517 pg/ml and 5235 pg/ml. In all others, it ranged much less than that, with the trend of delayed presentation giving less IL-37 levels, both in urine and serum. There were no clear differences found in patients with or without tPA, diabetes, hyperlipidemia and high blood pressure in our small study.

Conclusion:
The study shows a rather stable elevation of IL-37 levels post-ischemic stroke, which if compared to available data from other studies, is 3-10 times elevated after acute ischemic stroke with an uptrend in the first few days. IL-37 plays some role in mediating post-stroke inflammation with significant rise in serum and urine IL-37 levels suggesting a key role of this novel cytokine in post-stroke pathology. This is the first ever reported study measuring and trending IL-37 levels in human plasma after an acute ischemic stroke.