bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP314: Comparison of Patient-centered Outcome Measures of the International Consortium for Health Outcomes Measurements (ICHOM) Between Private and Public Healthcare System in Brazil
Authors: Martins Sheila C , Souza Ana C , Carbonera Leonardo A , Martins Magda C , Martin Kelin , Portal Marcelle , Parrini Mohamed , Almeida Andrea G , Brondani Rosane , Weiss Gustavo , Nasi Luiz A
Published: October 2018

Introduction:
An international experts panel was assembled to create a standard set of outcome measures for use in both low and high-income countries. Additionally, the panel intended to represent the most relevant outcomes for subsequent cost-effectiveness analysis. For implementing the tool, it was necessary to make it feasible in different healthcare systems. The objective of this study was to implement and compare the ICHOM outcome measures between two different stroke centers: a university public hospital and a private hospital.

Methods:
the medical data of all patients with stroke diagnosis consecutively admitted in the two hospitals were registered. ICHOM outcomes in the 3-month follow-up were measured by interviews in person, by phone or by e-mail, and the results were compared between the hospitals.

Results:
90-day outcome measurements were available for 328 patients (169 in the private hospital and 159 in the public), corresponding to 87% of the patients admitted with stroke diagnosis in these hospitals. The mean age was 68 years in the private vs. 65 in the public, with a mean NIHSS of 7, and 90% had ischemic strokes (18% received IV thrombolysis in the private setting vs. 16% in the public). Public hospital inpatients had a greater number of comorbidities. The mortality rate was 14% in both hospitals, and functional independence (mRS 0-2) occurred in 51% of private setting patients and 39% of the public. The greater proportion of patients needing help for dressing or toileting, as well as having language issues, was in the public setting. Better outcomes were measured in the private hospital regarding the resumption of the social role (64% vs 40%), satisfaction with social activities (65% vs 57%) and good quality of life (66% vs 57%). In both hospitals, 34% had access to physiotherapy after hospital discharge.

Conclusions:
In patients with acute stroke from private and public hospitals the thrombolysis eligibility are similar, without increasing the mortality rates in the public setting. However, better functional outcomes were found in private patients, probably due to less comorbidities, better prevention and post-discharge rehabilitation care.
Abstract TP320: A Randomized, Double-blind, Placebo-controlled, Phase I / IIa Clinical Trial for Evaluation of the Safety and Potential Therapeutic Effects After Intravenous Transplantation of Human Umbilical Cord-derived Mesenchymal Stem Cells in Patients With Cerebral Infarction
Authors: Kim Ok Joon
Published: October 2018

Hypothesis:
Cord has tremendous amount of stem cells that are easier and safer to obtain. The purpose of this study is to investigate the safety and the potential therapeutic effects per dose of human umbilical cord-derived mesenchymal stem cells(Cordstem-ST) IV transplantation in acute cerebral infarction.

Methods:
This study consist two treatment cohorts: Cohort 1 is one episode of IV Cordstem-ST 2.0 x 10^8 cells or placebo injection on day 0. Cohort 2 is two episodes of IV Cordstem-ST 2.0 x 10^8 cells or placebo injections on day 0 and day 7. Total 18 patients were enrolled and nine patients were allocated in each Cohort. Initially, we non-randomly non-blindly injected Cordstem-ST in initial 3 patients among 2 cohorts to investigate safety evaluation for KFDA requirement. And then we processed randomized, double-blind, placebo-controlled study in remaining 12 patients. Among 12 patients, the ratio of placebo and Cordstem-ST is 1:2 in each cohort. Patients were eligible for acute ischemic stroke patients within 7 days of stroke onset involving anterior circulation territory confirmed by the diffusion weighted MRI and NIHSS score between 5 and 20. Primary outcome measured by number of treatment related-adverse events during 6 months period. Secondary outcome measured improvement in clinical function as assessed by NIHSS, mRS, and BI compared to baseline at 6 months. Other studies including brain imaging (MR volumetry, tractogram, PET), immunochemistry (including biochemical markers), neuropsychological, and genetic studies were performed.

Results:
We finished this study for 18 patients. All patients had no serious adverse effects. Now, we are processing for rechecking final data and constructing about statistical analyzing methods before opening data randomization. Within 1-2 weeks, all data will be locked for blocking data correction. And then, randomization of data will be opening and we will evaluate primary and secondary outcomes according to schedule of pre-planned statistical analysis. We will present final results in 2018 ISC.

Conclusions:
We processed this study without any significant problems. Although, up to now, opening process of randomization has not been arrived, we are anticipating announcement of good results in 2018 ISC.
Abstract TP325: Utilizing Data to Drive Stroke Program Management
Authors: Shah Ruchir , Catalano Peter , Heck Susan , Jennings Traci , Butler Jennifer , Devlin Thomas
Published: October 2018

Introduction:
There continues to be a lack of standard data management tools for neurovascular service lines and stroke programs. Many hospitals use “home grown” spreadsheets or upload to various registries which are designed more toward research initiatives than daily operations.

Hypothesis:
Installation of a dedicated Neurovascular Information System (NVIS) will result in improved efficiency, quality, and financial performance in operating a stroke program and/or neurovascular service line.

Methods:
A large health system in Tennessee installed an NVIS for daily use within its Comprehensive Stroke Center. The NVIS was designed to support automated data entry by front line care givers and capture clinical data for initial patient evaluation. This standardized data set is used to create an auto-generated neurologic consult report that posts to the patient record. The system is utilized through mobile technology, such as tablets and static monitoring units in identified key locations.

Data related to post discharge follow up referrals and visits to the neurology clinic, sleep lab, and cardiology clinic are also captured. Personnel from post-discharge clinics query the data base to assure patients receive appropriate follow up testing and care across the broader care delivery system. The staff is matching financial and post-discharge results with clinical markers to derive cost-benefit benchmarks.

Results:
Data collection and reporting systems have provided efficiencies for neurology caregivers. Neuroconsults are auto generated by the NVIS while the patient is on the table in the CT scanner and discrete data fields are then uploaded to national databases. The health system increased its capture of downstream testing for the stroke population. Stroke patient visits to these follow up clinics/services have increased by at least 50% from last year. Referral information recorded in NVIS documents indications for follow up and guides the post discharge clinician in scheduling appropriate tests in the right timeframe.

Conclusion:
Utilization of a dedicated NVIS reversed the narrative related to stroke program management and allowed program leaders to use data to drive programmatic decisions and development to support care delivery processes.
Abstract TP328: Cost-Utility of Intravenous Recombinant Tissue Plasminogen Activator in the Treatment of Acute Ischemic Stroke: a Systematic Review
Authors: Niknam Kian , Dollar Krista , Pellegrini Eric , Kim Anthony
Published: October 2018

Background:
Intravenous recombinant tissue plasminogen activator (IV rtPA) is a recommended thrombolytic for the treatment of acute ischemic stroke that has shown to improve outcomes in various trials, but its cost-utility within varying time windows has not been systematically reviewed.

Method:
A systematic review was conducted using 2 reviewers and 1 adjudicator. Search strategies were implemented in PUBMED/MEDLINE, EMBASE, Web of Science, and Cochrane Review. Forms and data were managed through RedCap. Studies that met specific inclusion criteria, such as authors citing the time window and analytic horizon they investigated, and specifying the type of model they implemented, were further assessed for cost-utility benefit.

Results:
Of the 385 results from the implemented search strategy, 18 studies met inclusion criteria, with 94% agreement between reviewers. Eleven studies looked at the time window within 3 hours of stroke symptom onset, 3 looked between 3 to 4.5 hours, 3 looked within 4.5 hours of onset, and 1 looked within 6 hours of onset. All but 1 study with an analytic horizon of 1 year looking at a 0-3 hour time window showed that that IV rtPA was either dominant or cost-effective at a willingness to pay of $50,000/QALY.

Conclusion:
IV rtPA shows to be cost-effective across a variety of assumptions, both at a national and international level. The analytic horizon and time window do significantly impact the cost-effectiveness of IV rtPA, but even at later time windows, the IV rtPA shows to be cost-effective relative to standard treatment and care.
Abstract TP330: Lacune Distribution in Asians With Primary Intracerebral Hemorrhage: An MRI and Amyloid PET Study
Authors: Tsai Hsin-Hsi , Pasi Marco , Tsai Li-Kai , Chen Ya-Fang , Lee Bo-Ching , Tang Sung-Chun , Yen Ruoh-Fang , Gurol M. Edip , Jeng Jiann-Shing
Published: October 2018

Background:
Lacunar infarcts located in centrum-semiovale and lobar regions were more frequent in Caucasians with intracerebral hemorrhage related to cerebral amyloid angiopathy (CAA-ICH) while deep-seated lacunes in ICH related to hypertension (HTN-ICH), but these associations have never been validated in Asian patients. In the present study, we evaluated whether lobar lacunes were associated with core CAA markers such as lobar microbleeds (CMB) and higher amyloid load on
11
C-Pittsburgh Compund B (PiB) PET in an Asian ICH population.

Methods:
One hundred and ten patients of primary ICH who received MRI scans were classified as CAA-ICH or HTN-ICH according with the presence of strictly lobar or strictly deep bleeds (both ICH and CMBs), respectively. Lacunes were evaluated in the supratentorial area and classified as lobar (when located in CSO, frontal, parietal, insular/subinsular, temporal, and occipital lobes) or deep (when located in thalamus, basal ganglion, internal and external capsule) based on the location. A subgroup of 36 patients also underwent PiB-PET and global standardized uptake value ratio (SUVR) were calculated.

Results:
There were 24 CAA-ICH (mean age 70.9 ± 13.9) and 86 HTN-ICH (mean age 59.3 ± 13.0). Lobar lacunes were more frequent in CAA-ICH than HTN-ICH (29.2 vs 11.6%, p=0.036). In univariate analysis, lobar lacunes were significantly related to lobar CMB (p<0.001) and white matter hyperintensity (WMH) severity (p=0.001). In multivariable models, lobar lacunes were again associated with lobar CMB (Odds ratio 6.9, 95 % confidence interval 1.5-31.3, p=0.011) after adjustment for age, sex, hypertension and WMH. In 15 CAA-ICH and 21 HTN-ICH patients with PiB PET, correlation analyses between lobar lacune counts and global SUVR was high (r=0.40, p=0.02) and remained significant after adjustment for age (
r
=0.34, p=0.04).

Conclusion:
Lobar lacunes were more frequent in Asian patients with CAA-related strictly lobar hemorrhages. Their independent association with lobar CMB and brain amyloid deposition suggests a strong relationship with CAA even in an Asian cohort with overall higher hypertensive load.
Abstract TP332: Etiology, Imaging Characteristics and Outcome of Intracerebral Hemorrhage In Patients Treated With Direct Oral Anticoagulants vs. Vitamin K Antagonists: A Single Centre Experience
Authors: Charidimou Andreas , Pasi Marco , Biffi Alessandro , Lee Myung Joo , Schwab Kristin M , Viswanathan Anand , Schwamm Lee , Greenberg Steven M , Rosand Jonathan , Goldstein Joshua N , Gurol Mahmut E
Published: October 2018

Introduction:
Intracerebral hemorrhage (ICH) is the most feared complication of anticoagulation. Risk markers, causes, characteristics, and outcome of acute direct oral anticoagulants (DOAC) ICH are an active field of investigation. We assessed these characteristics in patients with acute DOAC-ICH vs. vitamin K antagonist-associated ICH (VKA-ICH) and non-anticoagulant ICH.

Methods:
Consecutive patients admitted to our Stroke centre with acute ICH (September 2013-May 2017) were screened. Outcomes were mortality and poor functional outcome (defined as mRS≥4) at discharge. Baseline clinical/imaging variables and outcome were compared between DOAC-ICH and VKA-ICH groups. We also compared these groups to spontaneous ICH (n=395). In DOAC-ICH we reviewed the presence of potential imaging markers of high ICH risk.

Results:
We included 124 patients: 20 DOAC-ICH and 104 VKA-ICH. The two groups were similar in baseline demographics and vascular risk factors. There was no difference in median baseline ICH volume in DOAC-ICH vs. VKA-ICH (median: 16.5 ml, IQR: 4.4-40.1 vs. 18.6 ml, IQR: 3.6-46.5; p=0.877). Hematoma location was more often deep/brainstem in DOAC-ICH vs. VKA-ICH (80% vs. 45% respectively; p<0.001). The discharge mortality was higher (but not significant) for DOAC-ICH vs. VKA-ICH group (50% vs. 37.5%; p=0.295). The two groups had similar rates of poor functional outcome at discharge (90% vs. 92.3%; p=0.729). Compared to spontaneous ICH, DOAC-ICH and VKN-ICH had higher mortality at discharge (27% vs. 55%; p=0.022 and 27% vs. 37%; p=0.029 respectively). Eight DOAC-ICH had brain MRIs available. 7/8 patients showed evidence of microbleeds: multiple in a mixed distribution (i.e. both deep and lobar) in 4, strictly deep in 2 and strictly lobar in one patient. Two patients had evidence of cortical superficial siderosis. All DOAC-ICH patients had white matter hyperintensities on MRI or CT, with moderate-to-severe lesions in 71%.

Conclusion:
ICH volume, mortality and functional outcome are similar for DOAC-ICH and VKA-ICH, but their outcomes are worse than non-anticoagulant ICH. High ICH risk markers seem to be common on imaging in the majority of DOAC-ICH, and tend to occur in deep brain regions, a clinically relevant hypothesis-generating finding.
Abstract TP337: Did Pre-Randomization Use of Intravenous Nicardipine Adversely Affect the Results of Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 Trial?
Authors: Qureshi Adnan , Palesch Yuko , Foster Lydia , Qureshi Mushtaq , Suarez Jose
Published: October 2018

Background:
The design of the ATACH-2 trial permitted use of intravenous (IV) nicardipine to maintain systolic blood pressure (SBP) <180 mm Hg prior to randomization. We performed an analysis to determine if pre-randomization use of IV nicardipine modified the treatment effect of intensive SBP reduction (compared with standard SBP reduction) in patients with intracerebral hemorrhage (ICH).

Methods:
ATACH-2 evaluated the treatment effect of intensive (goal 110-139 mmHg) over standard (goal 140-179 mmHg) SBP reduction using IV nicardipine within 4.5 hours of symptom onset in subjects with ICH in a generalized linear (GLM) model. The outcome was death or disability (modified Rankin scale 4-6) at 3-months post-randomization ascertained by a blinded investigator. The interaction between pre-randomization use of IV nicardipine and treatment was tested in the model at p<0.15 level. Additional variables included were age, Glasgow coma scale score category (3-11, 12-14, and 15), and presence of intraventricular hemorrhage.

Results:
Pre-randomization IV nicardipine was used in 517 of 1000 subjects who were randomized. The baseline SBP of those who did and did not receive pre-randomization nicardipine were similar. The interaction term in the GLM was significant (p=0.133). The outcome for each subgroup (with or without pre-randomization nicardipine) is given below.

Conclusions:
A small modifying effect of treatments effect with pre-randomization use of IV nicardipine was observed in ATACH-2 trial which may have implications for future clinical trial design.
Abstract TP339: Utilization of Comprehensive Stroke Center Services for Patients With Primary Intracerebral Hemorrhage
Authors: Meyer Ellie G , Meeks Jennifer R , Bambhroliya Arvind B , Slaughter Kristen B , Fraher Christopher J , Sheth Sunil A , Savitz Sean I , Vahidy Farhaan S
Published: October 2018

Introduction:
Intracerebral hemorrhage (ICH) patients are routinely transferred to comprehensive stroke centers (CSCs) for neurosurgical and neurocritical care. We compared transferred (TP) and directly presenting (DP) ICH patients at our CSC, and explore the factors associated with non-utilization of CSC Services (NCS).

Methods:
We identified primary ICH patients, admitted between 01/01/2016 and 03/31/2017, from our Stroke Registry. We used logistic regression to compare demographics, disease severity, and outcomes between TP and DP, and report odds ratios (OR) and 95% confidence intervals (CI). We categorized patients who did not stay in the neurocritical care unit and did not undergo neurosurgical procedures (including extra-ventricular drain) as NCS patients. We used receiver operative curve (ROC) analyses to determine the discriminatory potential of routinely used severity scales in identifying NCS patients and report area under the curve (AUC).

Results:
We included 958 patients in our analyses. TP had significantly lower disease severity and shorter length of stay. Overall, 33.7% of patients were NCS, and NCS patients were more likely to be TP as compared to DP [OR (CI): 1.60 (1.18-2.16)]. NCS patients also had a significantly lower median National Institutes of Health Stroke Scale (NIHSS) and ICH scores, and higher median Glasgow Coma Scale (GCS) score on presentation (Table 1). All three scales had a fair-good individual discrimination for classifying NCS patients (AUC for GCS, NIHSS, ICH Score: 0.71, 0.77, and 0.80 respectively). After dichotomizing GCS at 10 and categorizing NIHSS at 0-5 / 6-15 / 16+, the combined AUC for all three scales was 0.84 (Figure 1).

Conclusion:
A third of ICH patients presenting at CSC do not utilize neurosurgical / neurocritical care. Identification and triage of these patients may help optimize ICH care. Disease severity scales may be helpful in classification of these patients. Further validation studies are warranted.
Abstract TP345: Early Versus Delayed Blood Cultures in Intracerebral Hemorrhage
Authors: Stretz Christoph , Brown Robert J
Published: October 2018

Introduction:
Fever commonly occurs in patients with spontaneous intracerebral hemorrhage (sICH). However, it is non-infectious in the majority of cases. Blood cultures (BCx) are often obtained as part of a fever work-up, yet their utility may be limited and false-positive results may potentially compromise patient care. We hypothesized blood cultures in the first 48 hours would more likely be false-positive.

Methods:
We performed a retrospective chart review of patients admitted to a tertiary medical center with a diagnosis of spontaneous intracerebral hemorrhage. Patients with secondary causes of ICH as well as institution of comfort measures only were excluded. Data obtained included demographics, clinical parameters of ICH and blood culture results. Blood culture results and charts were reviewed for adjudication of false-positive and true-positive cultures.

Results:
Of 654 included patients with sICH, 226 patients (34%) had 1065 blood cultures obtained. 52 cultures were positive, of which 23 were classified as false-positive and 29 as true positive. False positive results were more common in the first 2 days (17 vs. 6), while true positive results were more common after the first 48 hours (12 vs. 17) (p= 0.018).

Conclusion:
Early blood cultures in patients with sICH are more commonly non-infectious. In line with prior published data, our results demonstrate the high cost and limited yield for blood cultures within the first 48 hours.
Abstract TP35: Asymptomatic Hemorrhagic Transformation in Acute Ischemic Stroke Patients Treated With Endovascular Thrombectomy is Associated With Poor Outcome
Authors: Jiang Fang , Zhao Wenbo , Che Ruiwen , Li Ming , Ji Xunming
Published: October 2018

Introduction:
Asymptomatic hemorrhagic transformation (AHT) is a common complication in acute ischemic stroke (AIS) patients treated with endovascular therapy. However, whether AHT has impact on the functional outcome of this patient’s populations is unclear, especially in patients treated with endovascular thrombectomy (ET). In this study, we aim to evaluate the influence of AHT on the functional outcome of AIS patients treated with ET.

Methods:
This observational study based on a prospective registry study. AIS patients with anterior circulation large artery occlusion and underwent ET with second-generation stent retrievers (i.e., Solitaire FR and Trevo) were recruited. AHT was diagnosed by CT according to the Heidelberg Bleeding Clarification. Head CT was performed 12-24 hours and 5-7 days post-treatment. The primary outcome was functional outcome at 3 months post-treatment assessed by modified Rankin Scale (mRS).

Results:
One hundred and two consecutive AIS patients (aged 61.1 years old) were recruited. 39 patients (38.2%) had AHT on post-treatment CT. Patients with AHT were more likely to receive post-procedures sedation (69.2% vs. 23.8%,
p
<0.001). Less patients with AHT achieved favorable outcome (mRS<3) at 3 months follow up (35.9% vs. 61.9%,
p
=0.011). Compared with 7 of 63 subjects (11.1%) died in no AHT group, 14 of 39 subjects (35.9%) died in AHT group, which was significantly higher (
p
=0.003). The median length of follow-up was 19 (IQR 3.5-32) months. In long-term follow up, less patients with AHT achieved favorable outcome (30.8% vs. 66.7%,
p
<0.001). 15 of 26 subjects (57.7%) died in AHT group, as compared with 8 of 50 subjects (16.0%) died in no AHT group, which was significant higher (
p
<0.001). On multivariate analysis, AHT was an independent predictor for both short- and long-term functional outcome and mortality.

Conclusions:
In AIS patients undergoing ET with second-generation stent retrievers, AHT is associated with increased risk of poor outcome.
Abstract TP350: Extension of tPA Treatment Window With Granulocyte-colony Stimulating Factor in a Thromboembolic Rat Model of Stroke
Authors: dela Peña Ike , Shen Guofang , Knecht Talia , Liu Jeffrey , Liang Hsiao Fang , Solak Sarah , Davis Willie
Published: October 2018

Background:
When given beyond 4.5 hours of stroke onset, tissue plasminogen activator (tPA) produces deleterious side effects in the ischemic brain, notably, hemorrhagic transformation (HT). Extending the narrow time window of tPA will benefit a significant number of stroke patients. We previously showed that granulocyte-colony stimulating factor (G-CSF) attenuated delayed tPA (6 h post stroke)-induced HT in rats subjected to stroke via intraluminal filament occlusion of the middle cerebral artery. Here, we examined whether the drug reduces delayed tPA induced-HT, cerebral infarction and neurological deficits in rats subjected to a thromboembolic (TE) stroke, and whether efficacy of G-CSF treatment extends at longer periods of recovery. Stroke Therapy Academic Industry Roundtable (STAIR) guidelines indicate necessity of testing effects of a drug candidate in multiple ischemia models before it progresses to clinical development.

Methods and Results:
After stroke induction through the TE method, rats were given intravenous saline (control), tPA (10 mg/kg), or G-CSF (300 μg/kg) and tPA at 6 h post-stroke. Treatment with G-CSF decreased delayed tPA-associated HT in stroked rats as measured by the spectrophotometric hemoglobin assay. Reduction in HT was accompanied by a decrease in infarct volume and improvement in stroke-induced motor and neurological deficits at 7 days after stroke. Moreover, G-CSF treatment also reduced the mortality rate due to delayed tPA therapy by almost 50%. Flow cytometry showed significant increase in the population of CD34+/VEGFR2+ bone marrow stem cells in the blood of stroked rats subjected to the combination treatment compared with rats given saline alone or tPA. Double labeling of CD34+ and VEGFR2 revealed enrichment of CD34+/VEGFR2 expression in the ischemic cortex and striatum of rats subjected to G-CSF treatment, indicating involvement of endothelial progenitor cells in the therapeutic effects of G-CSF.

Conclusion:
These results further corroborate efficacy of G-CSF to reduce delayed tPA-induced HT and neurological deficits in experimental stroke models, and suggest potentiality of the drug to extend the therapeutic time window of tPA therapy for stroke.
Abstract TP352: Dysphagia Screening: The Quest for a Validated Tool
Authors: Seitz Cooley Amy E , Hunter Susan , Tillet Katherine
Published: October 2018

Background:
Patients with stroke and other comorbidities are at risk for dysphagia and aspiration. Aspiration pneumonia is associated with high morbidity and mortality rates. Get with the Guidelines-Stroke recommends that stroke patients undergo dysphagia screening with a validated, evidence-based bedside testing protocol, approved by the hospital, prior to any oral intake. Dysphagia screening is also mandatory for any patient presenting with a stroke or transient ischemic attack per The Joint Commission guidelines, and may increase early identification in other populations. The dysphagia screen used within the health system’s acute care hospitals was not a validated tool.

Purpose:
The purpose of this evidence-based practice project was to determine which validated dysphagia screening tool best identifies hospitalized adult patients at risk for dysphagia and aspiration?

Methods:
The Johns Hopkins Nursing Evidence Based Practice Model was used for the evidence appraisal and synthesis. A thorough review of the evidence was conducted in multiple databases using keywords dysphagia, dysphagia screen*, and aspiration pneumonia. The evidence was reviewed by a system-wide interprofessional team. Articles were excluded if the screen was not validated in multiple populations or was not administered by nurses.

Results:
Sixteen articles were included in the evidence synthesis. Sources of evidence with consistently good quality were found. The 3-ounce water test was most frequently used in the published studies. The Yale Swallow protocol incorporating the 3-oz water study was widely researched for the stroke and general patient populations and is administered by multiple disciplines including nurses. The Yale swallow protocol is pass or fail with 96.5 sensitivity and 97.9 specificity if passed.

Conclusions:
Based on evidence synthesis, the Yale Swallow Protocol was determined to be a valid and reliable tool that met the test of applicability and feasibility for implementation throughout the health system. A recommendation for change was presented and fully endorsed by the health system’s stroke and pneumonia clinical effectiveness teams and nursing practice council. The tool was implemented after staff education and training was completed.
Abstract TP36: Medical Specialty and Training of Physicians Performing Mechanical Thrombectomy for Acute Ischemic Stroke in the U.S
Authors: Kamel Hooman , Chung Caroline , Kone Gbambele , Gupta Ajay , Morris Nicholas , Fink Matthew , Navi Babak
Published: October 2018

Introduction:
We sought to determine the medical specialty and training of U.S. physicians who perform mechanical thrombectomy for stroke.

Methods:
We analyzed claims between 2009-2015 from a 5% nationally representative sample of Medicare beneficiaries ≥65 years of age. Validated
ICD-9-CM
diagnosis codes were used to identify hospitalizations for acute ischemic stroke. Mechanical thrombectomy was defined as a physician claim with
CPT
code 37184 and an accompanying diagnosis of cerebrovascular disease. Medical specialty was identified using the claim’s Medicare provider specialty code. We reviewed public online profiles to ascertain providers’ residency and fellowship training. Statistical analysis involved chi-square tests and kappa statistics.

Results:
During 77,774 stroke hospitalizations, we identified 555 thrombectomies, of which 341 (61.4%; 95% CI, 57.2-65.5%) were performed by radiologists, 110 (19.8%; 95% CI, 16.6-23.4%) by neurologists, 91 (16.4%; 95% CI, 13.4-19.7%) by neurosurgeons, and 13 (2.3%; 95% CI, 1.3-4.0%) by others such as cardiologists and vascular surgeons. Of the 555 procedures, 367 (66.1%; 95% CI, 62.0-70.1%) were performed by a physician who had completed a dedicated neurointerventional fellowship. There was excellent agreement (91.4%; kappa, 0.86) between Medicare specialty designations and the online profiles of the 350 physicians who performed these 555 procedures. The rate of mechanical thrombectomy rose from 0.62% (95% CI, 0.56-0.68%) before publication of the MR CLEAN trial to 1.45% (95% CI, 1.21-1.72%) after, but there was no significant change after its publication in the distribution of providers’ specialties or the proportion of procedures performed by those with neurointerventional fellowship training (Figure).

Conclusions:
Most mechanical thrombectomies for stroke in the U.S. are performed by radiologists, neurologists, and neurosurgeons with dedicated neurointerventional fellowship training.
Abstract TP369: Rapid Evaluation of Acute Ischemic Stroke Patients for Intervention
Authors: Henderson Kathleen A
Published: October 2018

Background:
Only Primary Stroke Center (PSC) in large metropolitan area implementing RAPID CT-Perfusion (CT-P) software to quickly determine if patients may benefit from endovascular therapy (E.T.) and transfer to a Comprehensive Stroke Center (CSC).

Purpose:
To rapidly evaluate potential candidates for E.T. utilizing objective criteria via a standardized algorithm and CT-P technology. The goal was to improve assessment of large vessel occlusions and “wake up strokes” increasing practitioner’s confidence in transferring only those patients who may benefit from E.T. Patients who would not benefit from E.T. are confirmed, allowing the PSC to retain those patients, avoiding over-burdening of the CSC, and increasing patient and staff satisfaction.

Method:
Algorithm developed addressed the eligibility of acute ischemic stroke patients for potential E.T. based on objective criteria. Stroke patients receive CT scan on arrival, are screened for and administered IV Alteplase immediately if eligible. Algorithm is applied and if criteria met, RAPID CT-P study is performed and transmitted to CSC. This software quickly determines the presence of any salvageable penumbra from a large vessel occlusion. The software decreased the decision time from over 60 minutes to less than 8 minutes. At the time the CT-P is done, it transmits the images to the PSC neurologists and the CSC neuro-interventionalists via cellphone or iPad.

Results:
Objective tools to select appropriate patients for transfer for E.T. From October 2016 to June 2017, 64 patients had the RAPID CT-P. Of 64; 20 were transferred, 19 had intervention, and 44 remained at the PSC. The one transfer that did not receive E.T. had received IV tPA and re-perfused by the time of arrival to the CSC. In conclusion, this process made a significant positive impact on the outcomes of transferred patients receiving E.T. Physicians feel more confident in transferring appropriate patients and offering them E.T. Patients that are not eligible for this therapy are admitted, whereas before they could have been transferred to the CSC and not found not eligible for E.T. This has also led to increased collaboration, satisfaction, and collegiality between the two centers.
Abstract TP38: Drip and Ship versus Direct Transfer to Comprehensive Stroke Center: A Modelling Based Analysis
Authors: Malhotra Ajay , Wu Xiao , Matouk Charles , Schindler Joseph
Published: October 2018

Introduction:
The success of thrombectomy trials for acute ischemic stroke create 2 options for prehospital decision-making-(1) transport the patient to the nearest endovascular capable center (ECC) even though this may mean bypassing a closer non-ECC (mothership model): or (2) transport to nECC for intravenous thrombolysis and then transfer the patient to the nearest ECC for endovascular therapy (drip and ship model).

Methods:
A decision- analytical modelling study was constructed to simulate a 50-year old man with acute stroke. Input probabilities were derived from recent literature with thrombectomy data and outcomes from the HERMES. We include extensive subgroup analysis by varying each possible time interval and evaluate the two strategies under different circumstances. Multiple sensitivity analysis were performed to give the threshold values.

Results:
In the base case calculation , we found Mothership to be the better strategy. The results shows when time to nECC is 30 min, Mothership is the better strategy until the time to ECC exceeds 93 min, or when it takes less than 126 min to transfer patients from nECC to ECC. When the time to nECC is 90 min, Drip and Ship becomes the better strategy regardless of the additional time to ECC and the transfer time. Subsequently we assigned the time to perform IA in transferred patients as 1.5 longer than patients who are directly sent to ECC and performed further sensitivity analyses. When nECC is within 30 min away, Drip and Ship is the better strategy when it takes more than 78 min to get to ECC, regardless of the transfer time.

Conclusion:
We have used decision analysis, modelling based technique to address the problem of acute stroke triage from a population-based perspective. By feeding in the time to the nearest ECC and nECC, the EMS and stroke team can make the most appropriate decision on where to transfer the patient for the best outcomes based on the currently available data.
Abstract TP380: Highlighting Your Hospitalization: An Improvement In Post Stroke Care Education
Authors: Ruhs Anna
Published: October 2018

Background:
Post stroke care can be complex and overwhelming for patients and their caregivers. As recommended by the American Stroke Association, discharge planning including appropriate referrals and stroke follow-up appointments can optimize the immediate recovery period for patients and their caregivers. The 2016 trend in our primary stroke center certified community hospital (with a 6 bed stroke unit) was lack of understanding regarding post stroke care and stroke clinic follow-up appointments. By increasing inpatient nursing focus on the key topics on the discharge instructions, our objective was to increase understanding of post stroke follow up planning.

Methods:
Our approach for increased understanding of post stroke care included: the inpatient discharging nurse highlighting in yellow follow up appointments and referrals on the printed discharge instructions, and the placement of post-discharge phone calls by the stroke coordinator to patients discharged home. The stroke coordinator documented the level of understanding of follow up appointments, medications, and therapy needs defined by the patient and answered remaining questions.

Results:
Pre-intervention (August - December 2016): 44% of 7-10 day post hospitalization calls resulted in concerns related to post stroke care. 31% of these concerns were related to lack of understanding of follow up appointments. Post-intervention (January - June 2017): only 19% of calls demonstrated post stroke care questions (56.8 % improvement). The lack of understanding of follow up appointments decreased to 25% (19.3% improvement). The 30 day stroke related readmission rate for the Medicare population has decreased in 2017 (1.9% compared to 3.6% in 2016), supporting an improvement in the understanding and implementation of post stroke care.

Conclusions:
Inpatient nursing interventions can impact the patient and caregiver’s understanding of post stroke care needs. As the burden of this disease is felt beyond hospitalization, the increased focus on discharge planning/post stroke care should start in the acute phase of the stroke care continuum. Future work in this area may include more detailed discharge instructions to improve further patient understanding.
Abstract TP382: Post Stroke Depression: Value of Patient Health Questionnaires in Outpatient Setting
Authors: Rieman Abigail , Schiano Stacey
Published: October 2018

Background:
Thirty percent of all stroke patients suffer from post-stroke depression (PSD). Unrecognized and untreated PSD can lead to improper medication adherence, hospital readmission and death. During hospitalization following acute stroke, identification of PSD is challenging due to immediate health issues, and short hospital stay. Screening patients for PSD is essential throughout the care continuum.

Purpose:
Identify and manage patients who screen positive for PSD in the outpatient setting.

Methods:
Priority to address all facets of our patients’ care in all phases of treatment. Our Stroke Center has a large catchment area, and identifies the primary care providers (PCP) in the community as the best resources for treatment of PSD. Patients are screened for PSD while hospitalized. If determined to be at risk, treatment is initiated and communicated to the outpatient Stroke Registered Nurse Care Coordinator (RNCC). All stroke patients are rescreened for PSD in the outpatient stroke clinic. The Patient Health Questionnaire-9 (PHQ-9) is the chosen validated tool. If the PHQ-9 is 15 or greater on a scale of 1-27 it is identified as a positive screen for PSD. Patients are given a written PHQ-9, medication list, and history form to complete in clinic. The completed PHQ-9 is given to the RNCC and results are reviewed with the provider. The RNCC contacts the patient’s PCP and notifies them of the positive screen for PSD. With this information appointments and medication dosing can be modified. The results of the PHQ-9 are entered into the electronic medical record with any prescribed intervention.

Results:
Patients are unaware that PSD can be a common finding and have expressed a sense of relief knowing there is recognition and support. Screening enhances communication and coordination between the stroke providers and the regional PCPs. It provides an opportunity for patients to communicate their psychosocial needs to help identify resources available.

Conclusions:
It is feasible to screen stroke patients for PSD in the outpatient setting. This screening allows for identification of risk, modification of treatment, and collaboration with providers in the community.
Abstract TP384: Safety of Rapid Therapy Evaluation for Tissue Plasminogen Activator Treated Patients
Authors: Speirs Lauri , Graves David
Published: October 2018

Background:
Many patients who receive tissue plasminogen activator (t-PA) are medically stable, yet current practice is to keep all patients on bedrest for a minimum of 24 hours.

Purpose:
The purpose of this research project was to compare the current practice of bedrest for 24 hours after patients received t-PA with a physical therapy evaluation and treatment plan initiated between 6 and 24 hours of the patients receiving t-PA. Our goal was to assure safety by proving non-inferiority with rapid evaluation.

Methods:
All patients receiving t-PA were considered for this study. Consent was obtained for 30 patients by study investigators. Patient were deemed medically stable by the attending physician. Control group consisted of 51 suspected stroke patients who received t-PA from January through August 2015. Comparison data for primary endpoints was falls, mortality, and length of stay to measure non-inferiority. Comparison data for secondary endpoints was initial and last documented National Institutes of Health Stroke Score (NIHSS) to measure patient outcomes after intervention.

Results:
Our study showed no significant difference in falls, mortality or length of stay. The improvement in the NIHSS at discharge was also not statistically significant.

Conclusion:
In conclusion, Physical Therapists evaluating patients within 24 hours of receiving t-PA, while not decreasing length of stay or statistically improving outcomes at discharge; we found early therapy is safe for most of our stroke population.
Abstract TP385: A Mobile-Friendly Website to Reduce Stroke Caregiver Burden: A Qualitative and Pilot Study
Authors: Caunca Michelle R , Simonetto Marialaura , Rice Jordyn , De Leon-Benedetti Andres , Hartley Gregory , Czaja Sara J
Published: October 2018

Background:
Researchers estimate the prevalence of stroke caregiver burden to be 25-50%. Currently, there are no feasible, user-centered interventions in practice to improve stroke caregiver burden.

Objectives:
To refine the Stroke Caregiver Support System, a mobile-friendly website, with feedback from structured interviews, and to test the feasibility of the Stroke Caregiver Support System with a small pilot study.

Methods:
We employed a user-centered design framework for the development of our intervention, which includes 9 topical modules with brief introductory videos and curated resources from publically available sources. To refine the intervention, we used feedback from structured qualitative interviews with stroke caregivers for each aspect of the intervention. We then enrolled 8 stroke caregivers in a pilot study to measure baseline caregiver burden and depressive symptoms and test the feasibility of the intervention. All descriptive statistics were computed using SAS 9.4.

Results:
In structured qualitative interviews (N=4), stroke caregivers were aged 53-59 years; 3 of these caregivers were daughters of stroke survivors, and 2 identified as Hispanic/Latino. The main criticisms of the website included: a) low volume on videos, b) the need for more specific information for the physical challenges of caregiving, and c) the need to improve the language to make it less “scientific.” Generally, caregivers found the modules relevant and the content useful. The pilot study included 8 caregivers (mean [SD] age = 45 [17]), including 7 females, 5 who identified as Hispanic/Latino, and 6 who had a college education or greater. These caregivers had a mean (SD) Zarit burden score of 17 (8) and mean (SD) 10-item CES-D score of 14 (5). In general, caregivers found the website content and organization helpful, but the design and layout needed improvement. Caregivers emphasized that each “caregiver journey” was different, so tailored intervention is needed.

Conclusions:
Caregivers provided important feedback for the design of this mobile-friendly, educational intervention. Post-intervention measures will give insight into the feasibility and potential efficacy of the Stroke Caregiver Support System to attenuate caregiver burden.
Abstract TP387: Hospital-Acquired Pneumonia Prevention Program to Minimize the Risk for Aspiration Pneumonia in Stroke Survivors
Authors: Shah Shakeela , Diep Elizabeth , Dini Saeed , Arbuckle Robert , Sangha Navdeep
Published: October 2018

Background:
Aspiration pneumonia is one of the leading causes of post stroke morbidity. It increases length of stay, rehabilitation period, readmission rates and mortality. Retrospective chart review at Kaiser Permanente, Woodland Hills indicated that hospital-acquired infections were the leading cause of harm in patient deaths. Of these deaths, hospital-acquired pneumonia (HAP) was the leading contributor. HAPs account for 5% of our hospital’s total pneumonia admissions.

Objective:
We aimed to implement a simple, multidisciplinary Hospital-Acquired Pneumonia Prevention (HAPP) program in one of our stroke units, which had the highest incidence of HAPs, thus improving our stroke recovery and outcome.

Method:
We analyzed data in a 15-month period, from January 2015 - April 2016, and determined our baseline data for HAP incidence. Data were separated based on nursing units. The stroke units had the highest incidences of HAPs, accounting for 50% of cases (53 out of 102 cases) in the hospital. We selected the stroke unit with the highest incidence to implement the HAPP program. Patients who were at risk for HAPs were identified using the following: Age ≥ 65, history of or actual aspiration, malnutrition, parenteral tube presence, chronic obstructive pulmonary disease, smoking, ventilator use and post-surgery. Once the patient had been identified as at risk for HAP, the HAPP bundle was implemented. The HAPP bundle included head of bed > 30
°
at all times, up and out of bed for all meals, oral care using chlorhexidine rinse, ambulate at least twice per day, bedside incentive spirometry use and patient/family education.

Results:
After 3 months of HAPP program implementation there was a significant reduction of HAPs when compared to the same time period the previous year. In 4thQtr 2015, we had 8 HAPs, in 4thQtr 2016 after HAPP program implementation, we had 0 HAP on our targeted stroke unit.

Conclusion:
Based on our 3 month data, the HAPP program is effective in preventing HAPs. However, we would need to further look at data over a longer period to determine the success of the bundle in preventing HAPs. We also would be spreading this practice throughout all the nursing units within our hospital and eventually to the rest of our hospital system within the Southern California Region.
Abstract TP389: Achievement of Healthy Weight Loss Among Patients With Recent Ischemic Stroke or TIA and Obesity
Authors: Dearborn Jennifer L , Viscoli Catherine M , Kernan Walter N
Published: October 2018

Introduction:
Approximately 30% of patients with a recent ischemic stroke or TIA are obese as defined by a body mass index (BMI) ≥30 kgs/m
2
. Guidelines from professional and governmental organizations recommend that patients with obesity lose weight to improve cardiovascular risk factors including glucose control, diabetes risk, blood pressure, and lipid metabolism. In this study, we examined the proportion of patients with a recent ischemic stroke or TIA who achieve these recommendations and meet two common goals for weight reduction within two years: 1) reduction of weight by 5% from baseline and reduction to a BMI <27 kgs/m
2
.

Methods:
Participants were men and women assigned to placebo treatment in the Insulin Resistance Intervention after Stroke (IRIS) Trial who were obese at the time of enrollment. The IRIS trial was a randomized trial that examined the effectiveness of pioglitazone compared with placebo for prevention of stroke or MI among non-diabetic patients with a recent ischemic stroke or TIA and insulin resistance. The trial enrolled participants from 2005 to 2012. Participants were followed for a minimum of 28 months and were seen in-person and weighed annually.

Results:
Of the 1937 participants in the placebo arm of IRIS, 855 (44%) had BMI≥30 kgs/m
2
at entry. Mean age was 61 years (standard deviation, 10) and 59% were male. At one year, 788 patients with obesity at baseline remained in the trial with weight measured (10 died, 14 dropped-out, and 43 were missing weight). Among these patients, 133 (17%) had lost 5% of their body weight and 12 (2%) had achieved a BMI < 27 kgs/m
2
at 12 months. Two years from randomization, 22% had lost 5% of their body weight and 3% had achieved a BMI <27 kgs/m
2
.

Conclusion:
In this cohort of patients with ischemic stroke or TIA and obesity, less than a quarter achieved even modest goals for weight loss after one or two years. Clinical trials will be required to determine if failure to lose weight represents a lost opportunity for secondary stroke prevention. Trials can determine 1) if weight loss is effective for preventing recurrent stroke, cardiovascular disease and diabetes and for improving function after ischemic stroke or TIA and 2) the amount of weight loss that must be achieved to realize meaningful benefit.