bluuebunny/crossref_metadata_2025_split huggingface dataset:
Abstract TMP84: Reducing Door to Needle and Door to Reperfusion Times: The Trim Effect
Authors: Rowell Marguerite 
Published: July 2021

Background and Purpose:
One minute of brain ischemia can kill 2 million nerve cells and 14 billion synapses. The more time that elapses before IV thrombolysis or mechanical reperfusion, the slimmer the odds of a successful outcome. Early in fiscal year 2015, the Door-To- Needle (DTN) and Door-To-Reperfusion (DTR) times at our comprehensive stroke center rose to 78 min and 165 min, respectively. Also, the rate of IV tPA administration within 60 min decreased to 17%. In January 2015, lean methodology, specifically, Teams Refocus Imagine Measure (TRIM) was used to reduce DTN and DTR times. The purpose was to achieve: DTN < 60 min, DTR < 120 min, and rate of IV tPA given within 60 min > 75%.

Methods:
The TRIM and the Plan-Do-Check-Act methods were used to improve outcomes. Components included value stream mapping, A3 problem solving, and real-time observations to identify barriers, duplications and wasted time. The team consisted of Neurology, Neurosurgery, Nursing, Emergency Medicine, Emergency Medical Systems (EMS), Interventional Services (IVS), Radiology, Pharmacy, Anesthesia, Laboratory, Registration, Social Work, Risk Management, Transfer Center, Research, and Performance Improvement. Median and average times and percent compliance were calculated for pre-TRIM and post-TRIM data. Some interventions included:

• Designated ED trauma room for all strokes
• Early entry of acute stroke orders
• Use glucose and EKG from EMS for acute evaluation
• One-call stroke alert
• Advance tPA mixing
• Advance CTA contrast preparation
• Notification of parking lot arrival by on-call IVS Team
• Advance anesthesia consent
• Early discussion with patient and family regarding tPA
• Timely communication of turnaround times for each stroke alert

Results:
In the first two weeks after implementing changes, 23 min was reduced from the stroke alert response. In five months, DTN decreased to 51 min and 63 min was eliminated from DTR.

Conclusion:
Through an organized multidisciplinary team approach using standardized process improvement methods, identified best practices, and out-of-the-box thinking, improved stroke turnaround times were achieved to provide quality patient care and improve patient outcomes.
Abstract TP107: Inhibition of Ras-related C3 Botulinum Toxin Substrate 1 (rac1) Signaling Worsens Neurite Regeneration After Stroke
Authors: Liu Lin , Yuan Hui , McCullough Louise , Li Jun 
Published: July 2021

Neurite plasticity is a critical aspect of functional recovery after stroke. Emerging data suggest that Rac1 plays a central role in neurite regeneration in the injured brain, specifically by stimulating neuronal intrinsic growth and counteracting the growth inhibitory signaling that leads to growth cone collapse. We assessed the hypothesis that Rac1 is an important stimulator of neurite regeneration after stroke.
Transient focal ischemia was induced by middle cerebral artery occlusion for 90 minutes in 7 to 8 week old male wild type mice. A specific Rac1 inhibitor, NSC 23766 (NSC) and a selective inhibitor (IPA 3) of PAK1, a downstream kinase of Rac1, were injected starting 7 days after stroke. Pellet reaching test (success rate) was used to assess the integrity of sensorimotor function.
Treatment with NSC worsened recovery assessed by pellet reaching test from day 14 to day 28 after stroke (Day 28: Vehicle 0.39 ±0.03 vs. NSC 0.18±0.03, n=7-9, p<0.05). It additionally reduced axonal density (neurofilament staining, NFL) in the peri-infarct zone (PIZ) assessed on 28 days after stroke (Vehicle 1.00±0.12 vs. NSC 0.50±0.04, n=4, p<0.05), with no effect on brain cavity size. Treatment with IPA 3 reduced the success rate in the pellet reaching test after ischemia (Day 28: Vehicle 0.40±0.03 vs. IPA 3 0.17 ±0.03, n=7-9, p<0.05) and NFL staining in PIZ 28 days after stroke (Vehicle 1.00±0.07 vs. IPA 3 0.52 ±0.10, n=4, p<0.05). LIM domain Kinase (LIMK1) is a key component of the intrinsic capacity of neurite regeneration. Interestingly, NSC reduced LIMK1 phosphorylation (Vehicle 1.47±0.09 vs. NSC 0.75±0.12, n=4, p<0.05) day 14 after stroke, while it increased levels of glial fibrillary acidic protein (GFAP), a signal of neurite growth inhibition (Day 14: Vehicle 1.00±0.24 vs. NSC 1.66±0.11, n=4, p<0.05).

Conclusions:
Inhibition of Rac1 signaling worsened functional recovery and reduced axonal density. This was associated with decreased activation of intrinsic pro-regenerative molecules and increased growth inhibitory signaling. Our data suggested that Rac1 signaling could enhance neurite regeneration and improve post-stroke functional recovery.
Abstract TP387: An Interdisciplinary Approach to Improving Acute Treatment- Implementation of the Rapid Acute Stroke Protocol
Authors: Wilson N , Gourdine K , Roche T , Nanlal L , Mascitelli J , Shoriah H , Shearer P , Paramasivam S , Mocco J , Mayer S , Fifi J T , Tuhrim S 
Published: July 2021

Background:
Recent emergence of evidence for the effectiveness of intra-arterial treatment (IAT) of acute ischemic stroke secondary to large vessel occlusion (LVO) has prompted hospitals to examine the efficiency of their initial evaluation process. Mount Sinai Hospital has taken an interdisciplinary approach to hyper acute stroke care. It streamlined its process focusing on rapid triage of stroke, stroke team assessment, IV tPA administration and detection of LVO.

Rapid Acute Stroke Protocol (RASP), including early stroke team activation by the triage nurse was implemented in December 2014. Triage nurses were trained in the identification of stroke and stroke team activation. Feedback was provided to nursing leadership and individual participants on every treated case. A ‘team member of the month’ was established to promote ongoing enthusiasm and team rapport.
We hypothesized that the combination of new evidence and the introduction of RASP would increase the number of patients treated, decrease time to stroke team assessment and door to puncture (DTP) time.

Method:
In this retrospective review of 51 consecutive patients with AIS treated with IAT from January 2014 until July 2015, the population was divided into two cohorts. Cohort 1 included patients treated from January 2014 through November 2014, prior to RASP initiation. Cohort 2 included patients treated from December 2014 through July 2015. Outcomes included number of patients treated, arrival to stroke team assessment, and DTP time.

Results:
In cohort 1, .9 cases per month were treated with IAT compared to 5.1 per month in cohort 2, a 5.2 fold increase. A greater percentage of these patients arrived in the ED via inter-hospital transfer 56% vs 30%. There was a decrease in arrival time to stroke team assessment for cohort 2 vs cohort 1 (3 vs 9 minutes) and a reduction of 46.6% from DTP time (79 minutes vs 148 minutes p=<.001).

Conclusion:
These findings demonstrate how an interdisciplinary approach to hyper acute care can have a dramatic effect on the stroke patient. Improved prenotification by EMS or the originating hospital contributed to immediate stroke team availability. However, key to RASP was empowering the triage nurse with the responsibility of stroke recognition and activation of the stroke code.
Abstract TP394: Stroke Education- Are you REaDy?
Authors: Wolber Nicole E , Paletz Laurie , Steiner Nili , Robertson Betty , Guerra Sonia 
Published: July 2021

Introduction/Background:
Patients stay healthier when informed, making communication the key to better outcomes. An informed and educated patient actively participates in their own treatment, improves outcomes, and reduces length of stay. We call and evaluate every patient 30 days post discharge. We found that many reported either not receiving stroke education, or could not recall if they had received it. The principle of Occam’s razor states: “The simplest idea is usually the best idea.” This principle was utilized to solve our problem.

Quality Questions:

1. How do we increase the likelihood that patients will remember that they have received stroke education?
2. How do we assure that patients recall health information provided to them.

Methods:
Stroke patients are given extensive, personalized stroke education during their admission, and reinforced daily by stroke team. Education materials were given to patients in white folders with a Cedars-Sinai logo. Stroke patients are phoned in 30 days and asked a series of 18 questions to assess well-being & assess patient’s experience during hospital stay, and after discharge. These calls revealed an unusual number of patients who were unable to recall being educated or receiving educational materials. We decided to simply change the stroke education folder from white to bright red. We instructed the call center to use the red folder as a prompt to help the patient recall receiving stroke education.

Conclusion:
A collaborative approach was used to ascertain an appropriate stimulus for the patient to recall their stroke specific education. Stroke education had to stand out amidst the myriad of information patients are bombarded with in the hospital. The team came up with the simple idea of using a bright red folder. When patients were called the call center would prompt the patient by saying “The stroke education was given to you in a bright red folder.” Prior to implementation of the red folders, only 81.5% of patients recalled receiving stroke education. After implementation of the red folders, 96.8% recalled receiving stroke education. The principle of Occam’s Razor proved to be correct in our study. A very simple idea such as changing the color of the folders to bright red proved to have very meaningful results.
Abstract WMP63: Outcomes After Regionalization of Acute Stroke Care: Time Trend Analysis From Multiple Counties in the State of California
Authors: Govindarajan Prasanthi , Shiboski Steve , Grimes Barbara , Cook Larry , Ghilarducci David , Johnston S.Claiborne 
Published: July 2021

Objective:
To determine if regionalization of acute stroke care is associated with IV t-PA use over a five year period.

Methods:
This is a before-after observational study of all ambulance transported patients with a discharge diagnosis of acute ischemic stroke (AIS). We excluded inter-facility transports and direct admissions. Our data sources were the patient discharge abstract file from the Office of Statewide Health Planning and Development and prehospital records. Probabilistic matching was used to link the records. Relative risk regression was performed to study the independent association of regionalization with IV t-PA use after controlling for patient, hospital demographics and stroke center status. Data analysis was performed using SAS 9.2

Results:
Number of ambulance transported AIS patients to 13 hospitals in both counties were 4282 in the “before-phase” and 15571 in the “after-phase” (County 1 “after-phase” n=11368 (73%), County 2 “after-phase” n= 4203 (27%). In the “after-phase”, 10189 (65.4%) were transported to primary stroke centers and 14981 (96.2%) were treated at community hospitals. In the “before-phase” IV t-PA was given to 79 patients (1.9%) and in the “after-phase” IV t-PA was given to 514 patients (3.3%). In the model, regionalization was independently associated with higher use of IV t-PA (Overall RR: 2.4 95% CI 1.4, 4.1)

aRR for County 1 - 1.2 95% CI 0.82, 1.65
aRR for County 2 - 2.4 95% CI 1.4, 4.1

Conclusions:
Regionalization was associated with higher rates of thrombolysis in AIS patients.

Figure 1:
IV t-PA rates before and after regionalization (County 1/County 2)

Table 1:
Independent association of regionalization with IV t-PA use
Abstract WP189: Trends in Comorbidities Among Stroke-related Hospitalizations in California, 2000-2013
Authors: Ratnasiri Anura W , Ratnasiri Buddhika M , DiLibero Ralph 
Published: July 2021

Background:
Preventive care for adults with hypertension and diabetes has improved over the recent decade. This study aims to identify trends of these and other comorbidities for patients with stroke-related hospitalizations in California from 2000 to 2013.

Methods:
This retrospective study is based on patient discharge information compiled by the California Office of Statewide Health and Planning Development from 2000 to 2013. The study population is comprised of residents, and represents over 31.68 million hospital events. Stroke hospitalizations were identified using the first listed diagnoses in the hospital records, ICD-9-CM codes 430 to 436.

Comorbidities were identified using ICD-9-CM codes in 24 other diagnostic fields in each stroke hospitalization, aided by AHRQ’s Clinical Classification Software.
Cochran Armitage trend test was employed to identify comorbidity trends from 2000 to 2013. Stroke hospitalizations were adjusted for sex, age, race/ethnicity and insurance type using multivariable logistic regression for each of the comorbidities analyzed.

Results:
Over 1 million hospitalizations and 77,908 in-hospital mortalities for stroke were identified from 2000 to 2013. Disorders of lipid metabolism among stroke-related hospitalizations rose by 230.5% from 16.7% in 2000 to 55.1% in 2013. Diabetes mellitus increased by 45.1% from 27.0% in 2000 to 39.2% in 2013. Cardiac dysrhythmia rose by 36.6% from 21.0% in 2000 to 28.7% in 2013 while hypertension rose by 22.0% from 67.7% in 2000 to 82.6% in 2013. The trend test showed significant upward trends (p <0.001) for these four comorbidities during the study period.

After adjusting for patient demographics and insurance type, all four comorbidities had a positive association with stroke-related hospitalizations: diabetes mellitus (AOR 1.247; 95% CI=1.228-1.267), hypertension (AOR 2.685;[95% CI=2.631-2.740), disorders of lipid metabolism (AOR 2.095; 95% CI=2.063-2.127) and cardiac dysrhythmias (AOR 1.193; 95% CI=1.172-1.213).

Conclusion:
Diabetes mellitus, hypertension, disorders of lipid metabolism and cardiac dysrhythmia are positively associated with stoke-related hospitalizations.
Strict Liability and Necessity in Grotius, Pufendorf, Smith, Kant, and Beyond
Authors: Wauters Bart 
Published: July 2021

Abstract
This article compares the views of Grotius and subsequent authors on the doctrines of necessity and strict liability. This comparison takes place at two levels. On the one hand, there is a comparison of the views of Grotius with those of Pufendorf, Smith, Kant and recent Kantian authors. On the other hand, there is a comparison between the doctrines of necessity and strict liability. This exercise leads to the conclusion that strict liability does not have to be a mere matter of choice opted for by positive law, but in some instances can also be thought of as a requirement of a private law framework expressing the fundamental moral equal freedom of man.
Functional Morphology of the Flight Apparatus of Ephemera vulgata (Ephemeroptera: Ephemeridae) and Implications for the Evolution of Flight in Insects
Authors: Pfau Hans Klaus 
Published: July 2021

Abstract
The mesothoracic flight apparatus of preserved and freshly killed specimens of Ephemera vulgata is examined in detail by means of functional morphological examinations. The basic drive mechanism of the forewing of Ephemera vulgata constitutes a four-bar kinematic chain, which encompasses the whole mesothorax. Based on this reassessment, the operating principles of the different subsystems of the flight apparatus of the mayfly were newly analysed. As in the Neoptera, the indirect dorsolongitudinal downstroke and dorsoventral upstroke muscles rotate the wing around an axis which runs through the main wing joint of the fulcrum. In contrast to the Neoptera, the wing is driven via the posterior notal wing process and fourth axillary. A strong direct subalar muscle is able to move the subalare (together with the pleural ridge) inwards and to affect the wingstroke via a bistable click mechanism in this unusual way. The axillary sclerites, two frontal first axillaries and one caudal fourth axillary, permit the radioanal plate to rotate forward–backward on the fulcrum. This motion system, which is superimposed on the kinematic chain mechanism, permits alterations of the wingstroke plane. A short muscle of the radioanal plate allows adjusting the passive pronation of the wing during the downstroke and achieving an increase of the aerodynamical angle of attack. The step-by-step derivability of basal flight mechanisms of the main groups of Pterygota indicates a paranotal origin of the wings. The possibility that the Ephemeroptera and Neoptera constitute sister groups is discussed.
Community pressure, regulatory pressure and corporate environmental performance
Authors: Zhou Yankun , Luo Le , Shen Hongtao 
Published: July 2021

This article analyses the relationship between community pressure, regulatory pressure and corporate environmental performance. Using a sample of 2192 firm-year observations in environmentally sensitive industries for the period 2007–2012, we find that increased community pressure is negatively associated with corporate pollution levels and thus positively associated with corporate environmental performance. Furthermore, intensified community pressure can strengthen regulatory enforcement, but it cannot increase the size of the government subsidy allotted to environmental issues. Finally, regulatory enforcement partly mediates the relationship between community pressure and environmental performance. This study contributes to the understanding of firms’ environmental management and the interaction of community and regulatory pressure. JEL Classification: G38, M41, Q53, Q56
Liquid biopsy as an option for predictive testing and prognosis in patients with lung cancer
Authors: Qvick Alvida , Stenmark Bianca , Carlsson Jessica , Isaksson Johan , Karlsson Christina , Helenius Gisela 
Published: July 2021

Abstract
Background
The aim of this study was to investigate the clinical value of liquid biopsy as a primary source for variant analysis in lung cancer. In addition, we sought to characterize liquid biopsy variants and to correlate mutational load to clinical data.

Methods
Circulating cell-free DNA was extracted from plasma from patients with lung cancer (n = 60) and controls with benign lung disease (n = 16). Variant analysis was performed using the AVENIO ctDNA Surveillance kit and the results were correlated to clinical and variant analysis data from tumor tissue or cytology retrieved from clinical routine diagnostics.

Results
There were significantly more variants detected in lung cancer cases compared to controls (p = 0.011), but no difference between the histological subgroups of lung cancer was found (p = 0.465). Furthermore, significantly more variants were detected in patients with stage IIIb–IV disease compared to patients with stage I–IIIa (median 7 vs 4, p = 0.017). Plasma cfDNA mutational load was significantly associated with overall survival (p = 0.010). The association persisted when adjusted for stage and ECOG performance status (HR: 3.64, 95% CI 1.37–9.67, p = 0.009). Agreement between tumor and plasma samples significantly differed with stage; patients with stage IIIb–IV disease showed agreement in 88.2% of the cases with clinically relevant variants, compared to zero cases in stage I–IIIa (p = 0.004). Furthermore, one variant in EGFR, two in KRAS, and one in BRAF were detected in plasma but not in tumor samples.

Conclusion
This study concludes that in the vast majority of advanced NSCLC patients a reliable variant analysis can be performed using liquid biopsy from plasma. Furthermore, we found that the number of variants in plasma is associated with prognosis, possibly indicating a strategy for closer follow up on this crucial patient group.
Pessimistic health and optimistic wealth distributions perceptions in Germany and the UK: evidence from an online-survey
Authors: Debbeler Luka J. , Schupp Harald T. , Renner Britta 
Published: July 2021

AbstractBackgroundInequalities in health and wealth distributions are becoming pressing societal problems in many countries. How these inequalities are perceived and to what degree perceptions are aligned with actual distributions, is important for trust in public health services, social and economic policies, and policymakers. This study aims to assess perceived and desired levels of inequality in health and wealth in Germany and the UK.MethodsThe online-survey was filled out by 769 volunteers (322 from Germany, 447 from the UK), recruited from an existing commercial panel (Prolific Academic) or via Facebook advertisements in 2019. Perceived and ideal national health and wealth distributions were assessed and compared to actual health indicators (i.e. days absent from work, number of visits to general practitioners (GPs) and self-rated health), and actual wealth distributions with t-tests.ResultsA pronounced gap emerged between the estimated, ideal and actual inequality. Both samples strikingly underestimated the proportion of (very) good health in the national distribution by a factor of ~ 2.3 (participants estimated that 34% of the German and 36% of the UK population respectively are very healthy or healthy, while the actual proportion in the population was 75% in Germany and 84% in the UK,P < 0.001 for all). Moreover, actual health distributions were much closer to the desired than the perceived health distributions (78% of German and 72% of UK participants ideally being very healthy or healthy). A reversed pattern of results emerged for wealth in both samples, with wealth inequality being strikingly worse than desired and inequality being underestimated by a factor ~ 1.7 (P < 0.001 for all). Results were consistent across demographic groups.ConclusionsRespondents in both Germany and the UK have profoundly negative misperceptions regarding the distribution of health, which contrasts with starkly positive misperceptions regarding the distribution of wealth, indicating that the public is healthier but poorer than they think. More importantly, from a public health perspective, a high level of consensus emerged, with both healthy and wealthy participants misperceiving health and wealth distributions.