bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P828: Reducing and Sustaining "Door-To-Monitored Bed" Times in Patients Receiving Alteplase for Acute Stroke Symptoms
Authors: Leatherwood Janet , Lall Maureen , McGraw Diane , Richards Rita , Smith Fiona
Published: March 2021

Background and Issues:
Acute strokes are medical emergencies that require rapid assessment and treatment. Following treatments, focused and frequent monitoring is essential to quickly identify and mitigate any physiological deterioration. However, hospital capacity and decreased availability of monitored beds often causes delay in admission and prolonged stays in the emergency department and the potential increase in morbidity and mortality.

Purpose:
The purpose of this quality improvement initiative is to reduce the length of time from a patient presenting to the emergency department with acute stroke symptoms and treated with alteplase, to the time that the patient is being monitored utilizing “comprehensive specialized stroke care” level monitoring. This level of monitoring allows for the patient to be assessed closely and frequently to ensure the absence of physiological or neurological deterioration as well as for any adverse thrombolytic reaction.

Methods:
To improve the process of patient progression within the hospital, the care team utilized the ADKAR® Change Management Model. This model focuses on sponsoring awareness, promoting desire, providing knowledge, ensuring ability, and reinforcing changes. Each of these five components is critical to implement the proposed changes and ensure the longevity of the process changes.

Results:
Since the implementation of the process change, the Primary Stroke Center has experienced twenty-four months of mean “door-to-monitored bed” times below the 180 minute benchmark. In addition, the mean “door to monitored bed” time has decreased from 210 minutes in the three months preceding the process change (n=20), to 113 minutes during the twenty-four months following the change (n=150).

Conclusions:
During this process change, the Stroke Center successfully reduced the time between patient arrival and being in a monitored bed. The use of the ADKAR® Change Management Model is particularly advantageous in implementing a process change that is expected to be sustained into the future.
Abstract P833: Standardized Protocols Reduce Response Times for LVO Strokes
Authors: Vanderhye Vanesa K , Christel Lynda , Turkmani Ali , Sands Kara A
Published: March 2021

Introduction:
Acute ischemic stroke treatment is time sensitive especially for large vessel occlusion (LVO) strokes with the goal to achieve early cerebral reperfusion. Research suggests standardized protocols incorporate early notification to reduce time from arrival to mechanical thrombectomy (MT). The MT workflow at a certified stroke center required multiple phone calls to mobilize staff and resources resulting in treatment delays. The average time from neurosurgery notification (NN) to case start (CST) was 60.4 minutes (min) resulting in average door-to-puncture (DTP) time of 124.8 min further delaying early reperfusion.

Purpose:
Standardize MT workflows and incorporate a 1-step notification system to reduce average NN to CST by 20% to 45 min to achieve 90 min average DTP time by 90 days post implementation.

Methods:
Baseline data for MT cases admitted 1/1/18 - 9/2/19 arriving in the emergency room (ER) and occurring inpatient were abstracted from stroke alert logs and the electronic health record. MT transfers were excluded. A multidisciplinary group of key stakeholders completed both high level process and workflow analysis maps and mock simulations to identify gaps. Both an analysis of variance and Tukey-Kramer’s T Test were performed revealing NN to CST was most statistically significant (p<.0001) and largest root cause for overall increased DTP times. New service-specific workflows were developed including 1-step notification activated via an existing group paging system used for other purposes. Activation notified on call staff of the MT case and patient location. Data points collected were NN to CST (ED and inpatient) and DTP (ED only).

Results:
Average NN to CST time was 26.7 min (33.3 min decrease or 55.1%; p<.0001, n=12) resulting in DTP average of 83.4 min (41.4 min decrease or 35.3%, n=10) 90 days post-implementation. The paging system was cost-neutral due to existing licensing agreements.

Conclusion:
In conclusion, streamlined workflows incorporating 1-step notification reduced time from notification to staff response so MT procedures could start sooner. A multidisciplinary approach along with key stakeholder buy-in was instrumental in successful project implementation.
Abstract P838: Stroke Center Certification of a Community Hospital Results in Six Fold Increase in Thrombolytic Treatment for Stroke
Authors: Shurina Christy A , Hackett Christopher T , Noah Patty , Cerejo Russell , Tayal Ashis H
Published: March 2021

Introduction:
Prior studies that have demonstrated improved quality metrics after stroke certification often have added new neurological services to become certified. We aimed to evaluate the changes in volume of acute stroke/TIA and thrombolytic treatments in a hospital that underwent Primary Stroke Certification after seven years of established inpatient neurology and telestroke support.

Methods:
A retrospective analysis of prospectively collected data was completed from a community hospital. Data included 20 months prior to stroke certification (including 12 months with a stroke coordinator) and 17 months after certification. Annualized thrombolytic treatment and total stroke/TIA admissions were reviewed. Mann Whitney tests were used to determine if thrombolytic treatment, patients identified for mechanical stroke thrombectomy (MST), or both [total acute ischemic stroke (AIS) treatment] and total stroke/TIA volume per month differed before and after stroke certification. A subgroup analysis used a Mann Whitney to determine if the addition of a stroke coordinator during preparation for certification affected outcome metrics.

Results:
The hospital admitted 677 stroke/TIA patients during the study period, 230 before (82 without a stroke coordinator, 148 with a stroke coordinator) and 447 after stroke certification. Thrombolytic treatment increased from 2.4 patients per year prior to certification and 14.8 patients per year after stroke certification. The following outcome variables were increased after certification: thrombolytic treatments (1 vs. 0, p<0.001), patients identified for MST (1 vs. 0, p=0.001), total AIS treatments (1 vs. 0, p<0.001) and total stroke/TIA volume (27 vs. 11, p<0.001). Subgroup analysis suggested that preparation with a stroke coordinator was associated with increases in total AIS treatments (p=0.04) and telestroke requests (p=0.04); however, no differences in total stroke/TIA volume (p=0.18), thrombolytic treatments (p=0.08) or MST (p=0.41) were appreciated in absence of stroke coordinator.

Conclusions:
We found significantly increased rates of thrombolytic treatments, total stroke/TIA volume and patients identified for MST in a community hospital after primary stroke certification.
Abstract P846: The Collateral Damage of COVID-19 Pandemic on Stroke Care: Data From a State Stroke Registry
Authors: Balucani Clotilde , Carhuapoma Juan R , Faigle Romanus R , Johnson Brenda J , Aycock Anna C , Phipps Michael S , Goldszmidt Adrian J , Schrier Chad , yarbrough karen l , Toral Linda , Groman Susan , Lawrence Erin , Aldrich Eric M , Elizabeth Marsh , Urrutia Victor C
Published: March 2021

Introduction:
During the Coronavirus Disease-2019 (COVID-19) pandemic the “stay-home” public campaign implemented to contain the spread of the virus and the reorganization of hospitals to manage the overwhelming volume of affected patients, may have had unintended consequences. Prior studies reported a decrease in the number of stroke and TIAs admissions. Most reports have been from single hospitals, there is no data available on the impact on a statewide level.

Methods:
A retrospective analysis of stroke quality improvement data reported to the State of Maryland. These data are from Primary, Thrombectomy-Capable, and Comprehensive Stroke Centers. The number of admissions for stroke overall and by stroke subtype are reported and compared for March-June 2020 vs. March-June 2019. Last known well (LKW) to hospital arrival, intravenous tPA (IV tPA) and thrombectomy rates were analyzed.

Results:
The overall number of stroke admissions from March-June 2020 compared to March-June 2019 was 1,001 vs. 1,203 in March, 809 vs. 1,112 in April, 950 vs. 1206 in May, and 937 vs. 1,261 in June. There was an average 21% decrease for the 4-month period in 2020 compared to 2019. For ischemic stroke, there was a decrease in hospital admission for each month in 2020 vs. 2019: 740 vs. 922 in March, 606 vs. 866 in April, 721 vs. 906 in May, and 698 vs. 880 in June. TIAs admission rates were similarly decreased in 2020 vs. 2019: 116 vs. 136, 74 vs. 97, 111 vs. 137, and 107 vs. 111. The number of ICH admissions in 2020 vs. 2019 was 100 vs. 107 in March, 90 vs. 112 in April, 96 vs. 116 in May, and 103 vs. 121 in June. Median LKW well to hospital arrival was 292 vs. 254 min in March, 383 vs. 293 min in April, 291.5 vs. 247 min in May, and 320 vs. 292 min in June. There was about 1% decrease in thrombectomy rates in the 4-month period in 2020 compared to 2019.

Conclusions:
During the COVID-19 pandemic in the State of Maryland there was a consistent decrease in the volume of stroke admissions. Median LKW to hospital arrival was also increased, supporting evidence for of a delay in stroke care. While reasons for these changes need to be further explored, our findings suggest that public health campaigns for the pandemic should take into account and not adversely affect the acute care of unrelated medical emergencies.
Abstract P85: Impact of Covid-19 Pandemic on Hospitalizations and Outcomes of Acute Ischemic Stroke Patients, Paul Coverdell National Acute Stroke Program (pcnasp)
Authors: Tong Xin , Coleman King Sallyann , Odom Erika , Yang Quanhe
Published: March 2021

Introduction:
Studies suggest a significant reduction in emergency department visits and hospitalizations for acute ischemic stroke (AIS) during the COVID-19 pandemic in the United States. Few studies have examined AIS hospitalizations, treatments, and outcomes during the pandemic period. The present study compared the demographic and clinical characteristics of patients hospitalized with AIS before and during the COVID-19 pandemic (weeks 11-24 in 2019 vs. 2020).

Method:
We identified 42,371 admissions with a clinical diagnosis of AIS, from 370 participating hospitals who contributed data during weeks 11-24 in both 2019 and 2020 to the Paul Coverdell National Acute Stroke Program (PCNASP).

Results:
During weeks 11-24 of the COVID-19 period, AIS hospitalizations declined by 24.5% compared to the same period in 2019 (18,233 in 2020 vs. 24,138 in 2019). In 2020, the percentage of individuals aged <65 years who were hospitalized with AIS was higher compared with the same period in 2019 (34.6% vs. 32.7%, p<0.001); arriving by EMS were higher in 2020 compared with 2019 (47.7% vs. 44.8%, p<0.001). Individuals admitted with AIS in 2020 had a higher mean National Institutes of Health Stroke Scale (NIHSS) score compared with 2019 (6.7 vs. 6.3, p<0.001). In 2020, the in-hospital death rates increased by 16% compared to 2019 (5.0% vs. 4.3%, p<0.001). However, there were no differences in rates of alteplase use, achievement of door to needle in 60 minutes, or complications from reperfusion therapy between the two time periods.

Conclusion:
A higher percentage of younger (<65 years) individuals and more severe AIS cases were admitted to the participating hospitals during weeks 11 to 24 of the COVID-19 pandemic in 2020 compared to the same period in 2019. The AIS in-hospital death rate increased 16% during the pandemic weeks as compared to the same weeks in 2019. Additional studies are needed to examine the impacts of the COVID-19 pandemic on stroke treatment and outcomes.
Abstract P850: Four C’s Are Vital in Improving Door to Thrombolytic Administration
Authors: McGee Betty A , Stephenson Melissa
Published: March 2021

Background and Purpose:
Thrombolytic therapy is a key link in the stroke chain of survival. Data suggests that four components are vital in decreasing door to thrombolytic administration in acute stroke patients eligible for treatment. Analysis of system data, pre and post implementation of a Door to Needle Project, afforded the opportunity to assess.

Hypothesis:
We assessed the hypothesis that commitment, collaboration, communication, and consistency (referred to as Four C’s) are vital in improving door to thrombolytic administration time in ischemic stroke patients.

Methods:
In this quantitative study, we utilized case data collected by a quality improvement team serving five emergency departments within a healthcare system. We retrospectively reviewed times of thrombolytic administration from admission to the emergency department in acute ischemic stroke patients. Cases were included based on eligibility criteria from American Heart Association’s Get With the Guidelines. Times from 2019 were compared with times through April 2020, before and after implementation of the project, which had multidisciplinary process interventions that reinforced the Four C’s.

Results:
The data revealed a 13.5 % reduction in median administration time. Cases assessed from 2019 had a median time of 52 minutes from door to thrombolytic administration, 95% CI [47.0, 59.0], n = 52. Cases assessed through April 2020 had a median time of 45 minutes from door to thrombolytic administration, 95% CI [39.0, 57.5], n = 18. Comparing cases through April 2020 to those of 2019, there were improvements of 38.1% fewer cases for administration in greater than 60 minutes and 27.8% fewer cases for administration in greater than 45 minutes.

Conclusion:
The hypothesis that Four C’s are vital in improving door to thrombolytic administration was validated by a decrease in median administration time as well as a reduction in cases exceeding targeted administration times. The impact to clinical outcomes is significant as improving administration time directly impacts the amount of tissue saved. Ongoing initiatives encompassing the Four C’s, within a Cerebrovascular System of Care, are essential in optimizing outcomes in acute stroke patients.
Abstract P857: Rapid Cycle Process Improvement During a Pandemic: Changing How Patients at Low Risk for Complications Are Monitored Post Intravenous Thrombolysis
Authors: Whaley Michelle , van Vliet Rebecca , Farrell Leah , Welcom David
Published: March 2021

Background:
During the initial emergence of the 2019 novel coronavirus (COVID-19) and the subsequent surge of patients requiring critical care, our Joint Commission certified thrombectomy-capable stroke center sought to utilize a low-intensity monitoring protocol in stable, post intravenous (IV) thrombolysis patients in our intensive care unit (ICU). The acuity level in our ICU jumped to an all-time high, with many critically ill COVID-19 patients. Our goal was simple, provide safe patient care, free up precious nursing time, and preserve the personal protective equipment supply.

Purpose:
The purpose of this study was to use a rapid cycle process improvement project to implement a low-intensity monitoring (LIM) protocol in stable, suspected stroke patients, who are deemed at low risk for complications, in the first twenty-four hours following IV thrombolysis.

Methods:
We utilized the Plan-Do-Study-Act (PDSA) model to implement this project. Collaboration between physician, nursing, and stroke program leaders occurred during the month of April 2020. Our new process utilized the
O
ptimal
P
ost
T
-pa
I
v
M
onitoring in
I
schemic
ST
roke (OPTIMIST) protocol. We continued to admit our post IV alteplase patients to the ICU, rather than a step-down unit, in order to accommodate the 3:1 patient to nurse ratio, ensure protocol adherence, and maximize patient safety with this high-risk medication. We used change of shift huddles to educate the ICU nursing staff over a two-week period. Stroke program advanced practice nurses were on-site to ensure compliance.

Results:
Since implementation of the new protocol, two IV alteplase patients have met protocol criteria; both remained stable throughout the twenty-four-hour LIM period. The protocol’s nursing ratio changes allowed the other, critically ill patients, to be staffed with traditional ICU ratios.

Conclusion:
Rapid cycle PI projects can be accomplished during times of extreme challenge, as evidenced during the COVID-19 pandemic. Nursing staff was able to adapt and even welcomed the change, while maintaining patient safety. Further study is needed to document the ongoing effect of this protocol.
Abstract P864: Use of the American Stroke Association Patient Time Tracker Tool to Reduce DTN Times in Stroke
Authors: Sarafin Jo-Ann M , Harmon Melissa
Published: March 2021

Introduction:
More expedient door-to-needle (DTN) times with IV Alteplase in stroke have proven to result in better patient outcomes. Despite multiple bodies of evidence that support this conclusion, there remains challenges in accomplishing rapid times to treatment. The American Stroke Association (ASA) has developed in Target Stroke Phase III, criteria that requires DTN times within 45 minutes for at least 75% of applicable patients and DTN times within 30 minutes for at least 50 % of applicable patients. Despite various quality improvement projects many hospitals still struggle to shorten DTN times.

Objective:
An internal review of data from January 2019 to December 2019 revealed that despite more experience in acute stroke thrombolytic therapy, treatment times were prolonged. In order to shorten DTN times, a method to highlight time targets in evaluation and treatment was instituted. The ASA Time Tracker Tool was utilized to provide feedback on all stroke patients receiving IV Alteplase with the goal of better exploring reasons for delay in a timely manner that included input from the treatment team.

Methods:
In March 2020 the utilization of the ASA Time Tracker Tool was introduced. The tool was completed for every stroke patient receiving IV t-PA within 48-72 hours of thrombolytic administration. Each case included reasons for delay that was documented in the EMR. Professional staff including nursing and medicine were provided each case and asked for input regarding perceived delays to treatment to better discern obstacles to care.

Results:
Prior to institution of the ASA Time Tracker Tool the median DTN time was 41.7 minutes for 2019. After the tool was instituted the DTN times fell in Quarter 2 2020 to 38 minutes. Residents and nurses alike verbalized positively about receiving the tool as a mechanism for valuable feedback as well as an opportunity to provide their own input on potentially correctable areas to reduce DTN times.

Conclusion:
The use of the ASA Time Tracker Tool to share crucial time sensitive targets in the acute treatment of ischemic stroke is one method to reduce DTN times. Further study is needed to determine frequently occurring obstacles from the treatment team’s point of view with attention to correcting those barriers that prolong DTN times.
Abstract P866: Care Coordination, Bringing It All Together
Authors: Davis Cecile , Erickson Sheila , Royer Diane , Rutherford Wendy , DuBose Briony , Herrera Toni , Plume Tracy , Cummings Maira , Black Kathleen
Published: March 2021

Background:
It is challenging to quantify the soft elements of care, that often make the most difference in the long-term success of the patients’ recovery such as stroke knowledge, readiness for discharge, family involvement and patient support resources. The interdisciplinary team members document their specialty notes, however they are saved individually and in different sections of the EMR. The stroke team was challenged to create a process that pulls this data together.

Hypothesis:
We hypothesized that combining interdisciplinary team documentation into a Stroke Care Coordination Note in the EMR, would empower the care team to modify the acute care plan and simultaneously communicate post-hospital needs in order to maximize patients’ transition and outcomes.

Methods:
Through the engagement of Lean Six Sigma resources, the multidisciplinary team evaluated current processes and documentation to identify gaps. Tools utilized in facilitated meetings include; scope and critical success factors, SIPOC, process mapping, PARMI analysis, and brainstorming. Additionally, sensing sessions and GEMBA observations provided key insights into current state and engaged stakeholders.

Results:
The team created a Stroke Care Coordination Note in the EMR that consolidates interdisciplinary notes, demonstrates the stroke patients’ individualized plan of care and communicates post hospital needs. Post implementation, additional benefits have been realized such as: ease of use (one touch click), improved nursing communication during transitions of care, and improved communication with ancillary teams such as therapy and discharge planners.

Conclusion:
A thorough assessment of the current state and gaps, Joint Commission requirements and engagement of interdisciplinary team members, led to the development of a Stroke Care Coordination Note. At any given time, this note can be activated, convey the patients individualized stroke plan of care in the EMR, and be accessed by the interdisciplinary team. The care team stated improved overall patient care and communication during transitions of care. The ease of the use of the note and additional realized benefits support future systemic implementation among additional disease processes and entities.
Abstract P868: Clinical Challenges of the ICU Complex Stroke Patient
Authors: Amatangelo Mary P
Published: March 2021

Ischemic stroke accounts for approximately 85% of all strokes. Reperfusion therapy with intravenous Alteplase and/or endovascular thrombectomy is mainstay of acute stroke management. Approximately 30% of ischemic stroke patients will deteriorate in the first 24 hours regardless of pharmacologic and/or mechanical intervention. 15%-20%
will
require care in an intensive care unit (ICU). Severe strokes constitute a minority of cases though are associated with a majority of subsequent disability and death. The complex stroke patient presents many clinical challenges for the ICU nurse.

This presentation will review nursing clinical challenges of the complex stroke patient in the ICU.

The ICU Nurse is challenged with a variety of complex interventions caring for the ICU stroke patient. There is a significant subset of ischemic stroke patients at risk for secondary brain injury who may benefit from critical care monitoring and intervention. Nursing assessment, treatments, goals of care, and collaboration with the interdisciplinary ICU team will be addressed.

There is evidence that care in a neuroscience-specific ICU leads to improved outcomes in traumatic brain injury, intraparenchymal hemorrhage, and subarachnoid hemorrhage and reduced cost of care for neurosurgical patients. There is less direct evidence to support benefit of ICU care in ischemic stroke, but the association between care at a specialized stroke center and outcome is well established.

Recognizing nursing’s role in the care of the ICU stroke patient is key. The assessment and identification of subtle changes are imperative. Intervening with a variety of timely treatment options to eliminate complications must occur. Implementing current evidence-based practice allows for the best patient outcomes.

The ICU nurse is challenged with the early recognition and appropriate management of neurological and non-neurological complications of the stroke patient in the ICU. This can be a significant factor in reducing mortality during the acute hospitalization. Standardized care implemented by the collaboration of nursing, neurointensivist and a critical care team, can not only decrease the length of stay, though also offer a greater chance of being discharged to home.
Abstract P87: Time of Stroke Onset in Coronavirus Disease 2019 Patients Around the Globe: A Systematic Review and Analysis
Authors: Valencia-Enciso Natalia , Ortiz-Pereira Monica , Zafra-Sierra Maria P , Espinel Gomez Laura Alejandra , Bayona Hernan F
Published: March 2021

Introduction:
Coronavirus disease 2019 (COVID-19) has been associated with stroke, particular characteristics of these patients are not fully understood. The adequate management of these patients depends on the comprehension of factors such as temporality, clinical presentation and etiology. We hypothesize there is a differential temporal relationship between COVID-19 severity and stroke onset.

Methods:
Considering PRISMA guidelines, a systematic review of the literature as of July 2020 was conducted and registered on PROSPERO. Pubmed and Scopus studies reporting patients with COVID-19 and stroke were included. Clinical, sociodemographic and laboratory characteristics of patients were extracted and analyzed.

Results:
Forty-seven studies and 176 patients were included, with a mean age of 63.1 years (SD= 16 n=122), most of them were males (63.2% n=171). The most frequent etiology was cryptogenic (40.9% n=66), and a mean National Institute of Health Stroke Scale of 14.4 points was found (SD= 8.6 n=73). Large vessel occlusion (LVO) was reported in 65.9% patients (n=91) and these patients were younger with greater stroke severity. D-dimer, C-reactive protein, fibrinogen, ferritin and lactate dehydrogenase were elevated in most patients with reported findings. Most patients had severe COVID-19. The mean time from onset of respiratory symptoms to stroke was 9 days (SD=9.9), a shorter time was noted in those with mild and moderate disease compared with the longest time in severe disease, this difference was statistically significant (p< 0.001).

Conclusions:
There is a trend between the severity of COVID-19 and time to stroke onset, in which mild disease is associated with earlier stroke than severe disease. Age and stroke severity are related to the development of LVO. Inflammation and hypercoagulability markers are elevated in this disease, we propose to consider hypercoagulability secondary to COVID-19 as an underlying cause of stroke in these patients.
Abstract P874: Trends in Racial and Ethnic Diversity in Vascular Neurology Fellowships From 2006 to 2018
Authors: Das Saurav , Padalia Arjun , Wang Yan , Akca Ozan , Ford Andria L , Zazulia Allyson R
Published: March 2021

Introduction:
The need for recruitment of neurologists from underrepresented communities has been emphasized to maintain workforce diversity in academic neurology practice. The objective of the study is to describe the racial and ethnic diversity of neurology residents (NR) pursuing vascular neurology (VN) fellowship.

Methods:
Cross-sectional study of race/ethnicity of NR and VN fellows using published Graduate Medical Education (GME) census reports from 2006, when race/ethnicity data were first included, to 2018. Proportions were compared using chi-square test. Non-Accreditation Council of GME fellowship data was unavailable for analysis.

Results:
A total of 24450 NR were included in the sample of which 12718 (52%) were White, 993 (4.1%) Black, 1973(8%) Hispanics, 8232(33%) Asians. Of 910 NR who pursued VN fellowship, 413 (49.2%, SD 12.5%) were White, 27 Black (3%, SD 2.1%), 333 Asians (34%, SD 10.7%) and 78 Hispanics (10%, SD 5%). When comparing periods 2006-10 vs 2016-18, the proportion of White NR has increased by 2% (p=0.014), however, the increase in Black NR is 0.1% and not statistically significant. The proportion of Asian VN fellows significantly increased to 43% in 2016-20 compared to 24% over the entire period (p=0.039).

Conclusion:
There are racial disparities among NR and fellowship trainees. Even though there is diversity among VN fellows, continued efforts should be made to promote underrepresented ethnic groups.
Abstract P875: Disparities in Delivery of Endovascular Therapy: Data From the Florida State Registry
Authors: Krementz Nastajjia , Wang Kefeng , Gutierrez Carolina M , Bustillo Antonio , Mueller Nils H , Yavagal Dileep R , Bhatt Nirav , Gardener Hannah , Dong Chuanhui , Marulanda-londono Erika T , Hanel Ricardo , Mehta Brijesh , Rose David , Rundek Tatjana , Romano Jose G , Sacco Ralph L , Asdaghi Negar
Published: March 2021

Background:
Access to endovascular therapy (EVT) should be equitable to all eligible ischemic stroke patients presenting within the treatment time window. In the Florida Stroke Registry (FSR) we sought to determine sex, race/ethnic, hospital and regional disparities in the delivery of EVT.

Methods:
From January 2010 to January 2020, a total of 99,088 ischemic stroke cases within 24 hours of symptom onset were enrolled. Multivariable logistic regression with generalized estimating equations evaluated independent predictors of EVT utilization.

Results:
A total of 7,812 patients received EVT (51.2% female, mean age 71.3 ± SD 14.6 years, 61.4% white, 17.4% black, 21.2% Hispanic). Compared to those not treated, EVT treated patients were more likely Hispanic (21.2% vs. 14.6%), arrived earlier to the hospital (median 120 min (IQR 292) vs. 170 min (IQR 446)), via EMS (94% vs. 66%), with more severe strokes (median NIHSS 15 (IQR11) vs. 5 (IQR 9)), to large hospitals (≥ 680 beds) (73.4% vs. 47.7%), in South Florida (50.8% vs. 38.2%). In multivariable analysis, female sex (OR 1.05, 95% CI 1-1.11), atrial fibrillation (OR 1.57, 95% CI 1.45-1.7), higher NIHSS (> 6) (OR 6.19, 95% CI 5.11-7.51) and presenting to a high-volume hospital (OR 3.47, 95% CI 2.25-5.36) positively predicted EVT utilization, whereas older age (>80 years) (OR 0.88, 95% CI 0.80-0.96), and black race (vs. white OR 0.87, 95% CI 0.76-1), were independently associated with lower use of EVT.

Conclusions:
In this large state-wide registry study, we found significant race-ethic and geographical disparities in delivery of EVT. Systems of care should address disparities in stroke treatment to improve access to EVT for all eligible stroke patients.
Abstract P876: Allostatic Load Predicts Racial Disparities in Intracerebral Hemorrhage Outcomes
Authors: Harris Jennifer , Boehme Amelia , Chan Luisa , Moats Harmon , Dugue Rachelle , Izeogu Chigozirim , Pavol Marykay , Williams Olajide A , Marshall Randolph S
Published: March 2021

Introduction:
A large portion of stroke disparities remains unexplained, even after controlling for an array of demographic, comorbidity, and health care access variables. There is a need to close this knowledge gap by investigating novel factors that may contribute to stroke disparities. Allostatic load (AL) is the lifetime adverse physiologic impact of needing to adjust to socially structured stressors such as racism. AL has been shown to increase health vulnerability and worsen outcomes in marginalized populations. We sought to assess the differential impact of AL on cognitive outcomes post intracerebral hemorrhage (ICH) across race-ethnicity.

Methods:
The Columbia University Intracerebral Hemorrhage Outcomes Project (ICHOP) prospectively collected data from patients presenting to Columbia University Medical Center with a diagnosis of ICH from March 2009 to May 2016. Data included demographics, stroke scores, labs, neurological deterioration, hospital complications, neuroimaging, medical history, and discharge data. Ten markers of AL (BMI, A1c, SBP, triglycerides, CRP, HDL, LDL, HGB, HR, albumin) were obtained. An AL score was generated by summing the elements in each patient that fell outside normal clinical ranges, with an AL score range from 0-10. We used linear regression models to evaluate the relationship between AL and Telephone Interview for Cognitive Status (TICS) at discharge in the entire population, and then stratified by race-ethnicity.

Results:
Among 248 White, 195 Black, and 261 Hispanic ICH patients, neither mean AL nor mean TICS differed by race/ethnicity (p=0.55, p=0.21 respectively). In the overall ICHOP cohort AL was associated with TICS at discharge (Beta -0.939, SE 0.46, p=0.043). In Whites and Hispanics AL was not associated with TICS at discharge (beta 0.267, SE 0.75, p=0.725, beta -0.71, SE 0.73, p=0.33 respectively). In Black patients, higher AL was associated with a decrease in TICS at discharge (beta -2.24, SE 0.90, p=0.016).

Conclusion:
AL was associated with cognitive scores at discharge for Black patients but not Hispanics or Whites, suggesting that AL is an important determinant of post ICH outcomes for certain minority populations. AL may explain some of the unexplained health disparities in stroke populations.
Abstract P879: Differences in Statistical Performance of Polygenic Risk Scores for Cardiovascular Disease Across Different Race/Ethnicities
Authors: Acosta Julian N , Both Cameron , Szejko Natalia , Brown Stacy , Sheth Kevin N , Falcone Guido J
Published: March 2021

Introduction:
Genome-wide association studies have identified numerous genetic risk variants for stroke and myocardial infarction (MI) in Europeans. However, the limited applicability of these results to non-Europeans due to racial/ethnic differences in the genetic architecture of cardiovascular disease (CVD), coupled with the limited availability of genomic data in non-Europeans, may create significant health disparities now that genomic-based precision medicine is a reality. We tested the hypothesis that the performance of polygenic risk scores (PRS) for CVD differ in Europeans versus non-Europeans.

Methods:
We conducted a nested study within the UK Biobank, a prospective, population-based study that enrolled ~500,000 participants across the UK. For this study, we identified self-reported black participants and randomly matched them 1:1 by age and sex with white participants. We created a PRS using previously discovered loci for stroke and MI. We then tested whether this PRS representing the aggregate polygenic susceptibility to CVD yielded similar precision in black versus white participants in logistic regression models.

Results:
Of the 502,536 participants enrolled in the UK Biobank, 8,061 were self-reported blacks, with 7,644 having available data for our analyses. We randomly matched these participants with white individuals, leading to a total sample size of 15,288 (mean age 51.9 [SD 8.1], female 8,722 [57%]). The total number of events was 741 overall, with 363 happening in blacks and 378 happening in whites. In logistic regression models including age, sex, and 5 principal components, the statistical precision (e.g. narrower confidence intervals) for the PRS was substantially higher for whites (OR 1.22, 95%CI 1.08 - 1.37; p<0.0001) compared to blacks (OR 1.24, 95%CI 1.05-1.47; p=0.01). Secondary analyses using genetically-determined ancestry yielded similar results.

Conclusion:
Because CVD-related PRSs are derived mainly using genetic risk factors identified in populations of European ancestry, their statistical performance is lower in non-European populations. This asymmetry can lead to significant health disparities now that these tools are being evaluated in multiple precision medicine approaches.
Abstract P884: Differences in Stroke Type and Stroke Risk Factors Between African Americans and Ghanaian Stroke Patients
Authors: Olasoji Esther , SARFO FRED S , Simpkins Alexis
Published: March 2021

Introduction:
Ancestral lineage of many African Americans (AA) includes West African descent. Previous research has shown a higher prevalence of cardiovascular risk factors such as hypertension and diabetes mellitus (DM) in AA compared to other racial groups in the United States (US). Some have attributed these differences in the US population to ancestral lineage of the AA population. We sought to compare the stroke type and stroke risk factors between AA and Ghana, a country in West Africa.

Methods:
Data from the UFHealth institutional stroke database and the Kumasi, Ghana Stroke Survivors Registry between 01/2014 and 11/2019 provided a dataset of adult patients diagnosed with stroke from both locations. Multivariate regression analysis identified differences between country of origin, race, stroke type and clinical factors.

Results:
Among the 5519 patients, the median age was 66 (IQR 45 - 87), 49% woman, 16% AA, 19% Ghanaian, and 66% non-Hispanic white. In the total population, 22% had an intracerebral hemorrhage, 69% ischemic stroke, and 9% subarachnoid hemorrhage. Compared to patients in the U.S., patients from Ghana were younger (OR 1.06, 1.05-1.06 95% CI); more likely female (OR 1.66, 1.0-1.97 95% CI), hypertensive (OR 8.87, 6.46-12.17 95%CI), and more likely to consume alcohol (OR 4.25, 3.32-5.44 95% CI). Ghanaians were less likely to have DM (OR 0.81, 0.66-0.99 95% CI), smoke (OR 0.10, 0.07-0.13 95% CI), and live in an urban vs rural setting (OR 0.84, 0.71-0.99 95% CI). Compared to AA specifically, Ghanaians were younger (OR 1.02, 1.01-1.03 95% CI); more likely female (OR 1.45, 1.15-1.81 95% CI), hypertensive (OR 4.66, 3.25-6.68 95%CI), more likely to consume alcohol (OR 3.68, 2.62-5.18 95% CI); less likely to have DM (OR 0.55, 0.43-0.71 95% CI), smoke (OR 0.13, 0.08-0.19 95% CI), and less likely live in an urban vs rural setting (OR 0.66, 0.53-0.82 95% CI).

Conclusion:
Significant differences were found between stroke risk factors (hypertension, DM, alcohol consumption, and smoking) and race as well as country of origin. Further study of social and environmental differences between groups may elucidate the differences in stroke risk factors between AA’s and West Africans.
Abstract P887: Lack of Racial, Ethnic, and Sex Disparities in Ischemic Stroke Care Metrics Within a Telestroke Network
Authors: Reddy Sujan T , Wu Tzu-Ching , Zhang Jing , Rahbar Mohammad H , Ankrom Christy , Zha Alicia , Cossey TC , Aertker Benjamin M , Vahidy Farhaan S , Parsha Kaushik N , Jones Erica , Sharrief Anjail Z , Savitz Sean I , Jagolino-cole Amanda L
Published: March 2021

Introduction:
Little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care.

Methods:
We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. Single imputation using fully conditional specification was conducted to impute missing values in NIHSS (N=103). We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke.

Results:
Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients) (Table 1), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration or incidence of MT utilization (Table 1 & 2).

Conclusion:
There was a lack of racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care beyond our single-network review, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.
Abstract P890: Associating Cryptogenic Ischemic Stroke In The Young With Cardiovascular Risk Factor Phenotypes In A Diverse Urban Community
Authors: Dardick Joseph , Flomenbaum David , Labovitz Daniel L , Cheng Natalie , Liberman Ava L , Esenwa Charles
Published: March 2021

Introduction:
Acute Ischemic Stroke (AIS) in the young is increasing in prevalence and the largest sub-type within this cohort is cryptogenic. The risk factors and etiologies for these strokes likely differ by socioeconomic, racial, and ethnic background. To curb this trend, new ways of defining cryptogenic stroke and its risk factors are needed that can be applied to different populations. We aimed to create such a framework using patients in one of the poorest and most diverse urban counties in the country: Bronx, NY.

Methods:
We conducted a retrospective cohort study of AIS patients aged 18-49 who presented to an urban tertiary care center. Stroke risk factor phenotypes were determined by multivariate analysis and resultant models were applied to cryptogenic stroke cases.

Results:
A total 449 patients met inclusion criteria. The mean age was 41, 49% were women, 39% were Black, and 32% were Hispanic. 133 patients had strokes due to small and large vessel disease (vascular phenotype); these patients had higher rates of hypertension, intracranial atherosclerosis, and diabetes mellitus, and higher admission glucose, HbA1c, admission blood pressure, and cholesterol compared to the patients with cardioembolic AIS. The 69 patients with strokes due to cardioembolism (cardiac phenotype) had significantly higher rates of congestive heart failure (CHF), rheumatic heart disease, atrial fibrillation, clotting disorders, left ventricular hypertrophy, larger left atrial sizes, lower ejection fractions, and higher B-type natriuretic peptide and troponin levels. There were no differences in stroke subtype by race or ethnicity. Adjusted multivariate analysis produced 6 variables independently associated with the vascular phenotype (age, male sex, hemoglobin A1c, EF, LDL cholesterol, and family history of AIS) and 5 independently associated with the cardiac phenotype (age, female sex, decreased EF, CHF, and absence of intracranial atherosclerosis). Applying these models to 97 cryptogenic stroke cases yielded that 51.5% fit the vascular phenotype and 3.1% fit the cardiac phenotype.

Conclusion:
In our cohort of young patients in a low-resource, diverse urban community, half of cryptogenic cases fit the risk factor phenotype of small and large vessel strokes.
Predictors of Daily Steps at 1-Year Poststroke
Authors: Handlery Reed , Regan Elizabeth W. , Stewart Jill C. , Pellegrini Christine , Monroe Courtney , Hainline Garrett , Handlery Kaci , Fritz Stacy L.
Published: March 2021

Background and Purpose:

Walking has the potential to improve endurance and community participation after stroke. Obtaining ≥6000 daily steps can decrease subsequent stroke risk. Early identification of those prone to low daily steps could facilitate interventions that lead to increased walking and improved health. The purpose of this study was to (1) determine which factors at 2 months poststroke can predict daily step counts at 1 year and (2) determine what step count at 2 months corresponds to obtaining ≥6000 daily steps at 1-year poststroke.

Methods:

This was a secondary analysis of data from the Locomotor Experience Applied Post Stroke trial, which enrolled participants with walking speeds <0.80 m/second at 2 months poststroke. Daily steps were assessed at 2 months and 1-year poststroke. Linear regression was used to predict daily step counts at 1 year based on factors including age, sex, race and/or ethnicity, stroke severity, walking speed, endurance, fitness, motor function, balance, and balance confidence. A receiver operating characteristic curve determined which step count corresponded to reaching ≥6000 steps at 1 year.

Results:

Data from 206 participants, mean age=63 (13) years, 43% female, mean baseline daily step count=2922 (2749) steps, were analyzed. The final model to predict daily steps at 1 year poststroke contained daily steps at 2 months and balance (Berg Balance Scale score); these factors explained 38% of the variability in daily steps at 1 year (
P
≤0.001). Participants obtaining ≥1632 daily steps at 2 months were 1.86 (95% CI, 1.52–2.27) times more likely to reach ≥6000 daily steps at 1-year poststroke.

Conclusions:

Daily steps and balance at 2 months poststroke were the strongest predictors of future daily steps. Improving daily physical activity and targeting balance early after stroke may be necessary to increase physical activity at 1-year poststroke.
“Dressed as a Harlot and Cunning of Heart”? A New Look at the Heart of the Strange Woman in the Book of Proverbs
Authors: Kozlova Ekaterina E.
Published: March 2021

The collocation נצרת לב in the profile of the strange woman in Proverbs is a well- known exegetical crux (Prov 7:10). Since in Prov 4 guarding one’s heart has a positive meaning, the phrase “guarded of heart” in the portrait of a negative character seems out of place. Traditionally scholars approached this difficulty (1) by emending the MT to לוט נצרת, i.e., picturing the woman covered with a veil; (2) by positing נצר II and reading the phrase as “tumultuous mind”; and (3) by arguing that the root in question may have the unique connotation of “cunning” or “wily” in Prov 7:10. Given the dominant death-related symbolism in the depiction of this anti-heroine, this discussion links the verb “to guard’ in Prov 7 to its usage in Isa 65:4, arguing that the strange woman is thought of as possessing a tomb-chamber for a heart and styled as the ultimate femme fatale.
Redescription of a predatory and cannibalistic nematode, Butlerius butleri Goodey, 1929 (Rhabditida: Diplogastridae), from South Africa, including its first SEM study
Authors: Shokoohi Ebrahim , Abolafia Joaquín
Published: March 2021

Butlerius butleri was isolated during a survey on free-living soil nematodes from South Africa. The South African population of B. butleri is characterised by having a large stoma divided into two chambers and bearing a thorn-like dorsal tooth, spicules 44 (41-49) μm long, gubernaculum 29 (28-30) μm long, three pairs of precloacal papillae and five pairs of postcloacal papillae, and a filiform tail 280 (204-332) μm long in females, 310 (256-356) μm long in males. The SEM observation showed the cheilostom is divided into six conical plates 2.1-2.3 μm long. Nblast of 18S rDNA revealed 99% similarity and 6-7 bp differences with the B. butleri (KP453998) from Iran. Molecular analysis of B. butleri based on the sequence of the 18S and 28S rDNA placed it together with Butlerius and close to Pseudodiplogasteroides and Diplogasteroides. This species showed predatory and cannibalistic behaviours, feeding on other B. butleri in the substrate. SEM photographs of the species are presented for the first time.
The Muslim Brotherhood: Libya as the Last Resort for the Continued Existence of the Global Movement
Authors: Hweio Haala
Published: March 2021

The fall of the first Muslim Brotherhood government in Egypt and the ban of the movement in Egypt in 2013 increased the pressure on the Brotherhood’s branch in Libya to fulfill the group’s dreams of power. Libya now remains a potential chance for the group to realize its political ambitions of control and power. The desperation of the group pushed it to take extreme measures that contradict, on many occasions, the group’s declared principles of peaceful and gradual bottom-up change. The group uses all possible means to gain complete political control over Libya, which contributes to prolonging the conflict in the country.
Remembering Our Heroes: Global Jihad’s Militancy in a Comparative Perspective
Authors: Hatina Meir
Published: March 2021

Many studies have been devoted to the features of global jihad (also known as Salafi jihadism), its historical development, its difference from other Salafi groups, or its struggles with ideological rivals. Little emphasis, however, has been given to global jihadists’ ideological genealogy, and hence to locating them in a comparative perspective. How did they commemorate their formative heroes, such as the medieval jurist Ibn Taymiyya and mid-twentieth century ideologues, such as Sayyid Qutb, Abu al-Aʿla al-Mawdudi, ʿAbd al-Salam Faraj, Shukri Mustafaʾ, Marwan Hadid or Saʿid Hawwa? Were these figures still perceived as cultural heroes, or were they shunned? Did their writings continue to provide sources of inspiration, or were they replaced by new manifestos? An in-depth discussion of these questions, based on a textual analysis of jihadi sources, may shed further light on global jihadists’ ideological evolution and self-perceptions. It will provide an additional prism for analyzing modern Sunni militancy, and scrutinize the extent its protagonists’ treatises match past traditions or, alternatively, deviate from them in favor of cultivated traditions, thus advancing a dissident agenda.