Patients' experiences of a suppoRted self-manAGeMent pAThway In breast Cancer (PRAGMATIC): quality of life and service use results

PURPOSE

To describe trends and explore factors associated with quality of life (QoL) and psychological morbidity and assess breast cancer (BC) health service use over a 12-month period for patients joining the supported self-management (SSM)/patient-initiated follow-up (PIFU) pathway.

METHODS

Participants completed questionnaires at baseline, 3, 6, 9 and 12 months that measured QoL (FACT-B, EQ 5D-5L), self-efficacy (GSE), psychological morbidity (GHQ-12), roles and responsibilities (PRRS) and service use (cost diary).

RESULTS

99/110 patients completed all timepoints; 32% (35/110) had received chemotherapy. The chemotherapy group had poorer QoL; FACT-B total score mean differences were 8.53 (95% CI: 3.42 to 13.64), 5.38 (95% CI: 0.17 to 10.58) and 8.00 (95% CI: 2.76 to 13.24) at 6, 9 and 12 months, respectively. The odds of psychological morbidity (GHQ12 >4) were 5.5-fold greater for those treated with chemotherapy. Financial and caring burdens (PRRS) were worse for this group (mean difference in change at 9 months 3.25 (95% CI: 0.42 to 6.07)). GSE and GHQ-12 scores impacted FACT-B total scores, indicating QoL decline for those with high baseline psychological morbidity. Chemotherapy patients or those with high psychological morbidity or were unable to carry out normal activities had the highest service costs. Over the 12 months, 68.2% participants phoned/emailed breast care nurses, and 53.3% visited a hospital breast clinician.

CONCLUSION

The data suggest that chemotherapy patients and/or those with heightened psychological morbidity might benefit from closer monitoring and/or supportive interventions whilst on the SSM/PIFU pathway. Reduced access due to COVID-19 could have affected service use.

Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group

Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.

Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations

BACKGROUND

Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed.

OBJECTIVE

To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion.

METHODS

We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression.

RESULTS

Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations.

CONCLUSION

Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.

The Impact of COVID-19 on Hospitalised COPD Exacerbations in Malta

METHOD

Data was collected retrospectively from electronic hospital records during the periods 1st March until 10th May in 2019 and 2020.

RESULTS

There was a marked decrease in AECOPD admissions in 2020, with a 54.2% drop in admissions (n = 119 in 2020 vs. n = 259 in 2019). There was no significant difference in patient demographics or medical comorbidities. In 2020, there was a significantly lower number of patients with AECOPD who received nebulised medications during admission (60.4% in 2020 vs. 84.9% in 2019; p ≤ 0.001). There were also significantly lower numbers of AECOPD patients admitted in 2020 who received controlled oxygen via venturi masks (69.0% in 2020 vs. 84.5% in 2019; p = 0.006). There was a significant increase in inpatient mortality in 2020 (19.3% [n = 23] and 8.4% [n = 22] for 2020 and 2019, respectively, p = 0.003). Year was found to be the best predictor of mortality outcome (p = 0.001). The lack of use of SABA pre-admission treatment (p = 0.002), active malignancy (p = 0.003), and increased length of hospital stay (p = 0.046) were also found to be predictors of mortality for AECOPD patients; however, these parameters were unchanged between 2019 and 2020 and therefore could not account for the increase in mortality.

CONCLUSIONS

There was a decrease in the number of admissions with AECOPD in 2020 during the COVID-19 pandemic, when compared to 2019. The year 2020 proved to be a significant predictor for inpatient mortality, with a significant increase in mortality in 2020. The decrease in nebuliser and controlled oxygen treatment noted in the study period did not prove to be a significant predictor of mortality when corrected for other variables. Therefore, the difference in mortality cannot be explained with certainty in this retrospective cohort study.

Coagulation Differences Detectable in Deep and Lobar Primary Intracerebral Hemorrhage Using Thromboelastography

BACKGROUND

There are radiographic and clinical outcome differences between patients with deep and lobar intracerebral hemorrhage (ICH) locations. Pilot studies suggest that there may be functional coagulation differences between these locations detectable using whole blood coagulation testing.

OBJECTIVE

To confirm the presence of interlocation functional coagulation differences using a larger cohort of deep and lobar ICH patients receiving whole blood coagulation testing: thromboelastography (TEG; Haemonetics).

METHODS

Clinical and laboratory data were prospectively collected between 2009 and 2018 for primary ICH patients admitted to a tertiary referral medical center. Deep and lobar ICH patients receiving admission TEG were analyzed. Patients with preceding anticoagulant use and/or admission coagulopathy (using prothrombin time/partial thromboplastin time/platelet count) were excluded. Linear regression models assessed the association of ICH location (independent variable) with TEG and traditional plasma coagulation test results (dependent variable) after adjusting for baseline hematoma size, age, sex, and stroke severity.

RESULTS

We identified 154 deep and 53 lobar ICH patients who received TEG. Deep ICH patients were younger and had smaller admission hematoma volumes (median: 16 vs 29 mL). Adjusted multivariable linear regression analysis revealed longer TEG R times (0.57 min; 95% CI: 0.02-1.11; P = .04), indicating longer clot formation times, in deep compared to lobar ICH. No other TEG parameter or plasma-based coagulation differences were seen.

CONCLUSION

We identified longer clot formation times, suggesting relative coagulopathy in deep compared to lobar ICH confirming results from prior work. Further work is required to elucidate mechanisms for these differences and whether ICH location should be considered in future coagulopathy treatment paradigms for ICH.

Functional Coagulation Differences Between Lobar and Deep Intracerebral Hemorrhage Detected by Rotational Thromboelastometry: A Pilot Study

BACKGROUND

Lobar intracerebral hemorrhage (ICH) is known to have better clinical outcomes and preliminary evidence of less hematoma expansion compared to deep ICH. No functional coagulation differences between lobar and deep ICH have been identified using traditional plasma-based coagulation tests. We investigated for coagulation differences between lobar and deep ICH using whole-blood coagulation testing (Rotational Thromboelastometry: [ROTEM]).

METHODS

Clinical, radiographic, and laboratory data were prospectively collected for primary ICH patients enrolled in a single-center ICH study. Patients with preceding anticoagulant use or admission coagulopathy on traditional laboratory testing were excluded. Lobar and deep ICH patients receiving admission ROTEM were analyzed. Linear regression was used to assess the association of ICH location with coagulation test results after adjusting for potential confounders.

RESULTS

There were 12 lobar and 19 deep ICH patients meeting inclusion criteria. Lobar ICH patients were significantly older and predominantly female. Lobar ICH had faster intrinsic pathway coagulation times (139.8 vs 203.2 s; 95% CI - 179.91 to - 45.96; p = 0.002) on ROTEM testing compared to deep ICH after adjusting for age, sex, and hematoma volume. This revealed functional coagulation differences, specifically quicker clot formation in lobar compared to deep ICH. No differences were noted using traditional coagulation testing (prothrombin time/partial thromboplastin time/platelet count).

CONCLUSIONS

Our pilot data may suggest that there are functional coagulation differences between lobar and deep ICH identified using ROTEM. Whole-blood coagulation testing may be useful in assessing coagulopathy in ICH patients and in determining reversal treatment paradigms, though further work is needed.

Abstract TP265: Far-Forward Stroke Care: Parallel Processing in the Prehospital Environment May Achieve Door-to-Needle Times of Less Than 15 Minutes on a Mobile Stroke Treatment Unit

Introduction: The time from 911 activation (i.e. alarm) to administration of intravenous (IV) alteplase in acute ischemic stroke is associated with functional, patient centered-outcomes. Mobile stroke treatment units (MSTUs) have emerged as a stroke system tool that may hasten treatment times. Optimal workflows on MSTUs remain to fully elucidated.

Methods: Retrospective review of a QA database of patients treated on a MSTU with door-to-needle-times (DTN) of </= 15 minutes to describe workflows and team dynamics that were associated with expeditious treatment.

Results: In October of 2018 the University of Rochester Medical Center launched a MSTU, initially operating on Monday through Friday in the city of Rochester from 8am until 4 pm. Over the initial 3 months, there were 96 MSTU responses leading to 54 transported patients, 3 of which were treated with IV alteplase. One patient with an initial NIHSS of 17 was treated with IV alteplase within 9 minutes of reaching the MSTU door. Workflow elements felt to hasten treatment included registration of the patient in the electronic health record (EHR) prior to the patient reaching the MSTU and enabling the telestroke provider to listen to the initial history and physical being performed by the MSTU RN at the scene. The later is accomplished by using a telestroke iPhone application that allows for a “3-way-call” between the MSTU RN, the MSTU, and the telestroke provider. The MSTU RN wears a Bluetooth earpiece that captures the conversation with the patient, witnesses on scene, and initial EMS responders and enables the MSTU RN to summarizes key history and exam findings, vitals, and blood glucose results while keeping their hands available for patient care. Simultaneously, the telestroke provider reviews the patient’s chart in the EHR for alteplase contraindications, prior imaging results, and pertinent medical history.

Conclusion: Registering the patient in the EHR and integrating the telestroke provider into the initial patient assessment at the scene in the prehospital setting may allow for consistent door to needle times of < 15 minutes on MSTUs, which may further improve patient outcomes.

Abstract TMP72: Auto-Launching of Interfacility Transport for Presumed Emergent Large Vessel Occlusion Strokes Decreases Door-In-Door-Out (DIDO) Times and May Improve Outcomes

Introduction: Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care.

Methods: Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC), Cayuga Medical Center (CMC), and Geneva General Hospital (GGH) are NYS-DSCs located 115, 91, and 50 miles from SMH, respectively. Clinical leaders at each site collaborated to implement an integrated regional system of care for LVO-AIS, dubbed “Code LVO”, which includes the auto-launching of an interfacility transport to the referring hospital for presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of </=24 hours. We retrospectively reviewed a QA database for transfer patients with an ASPECTS of >/= 6 and proximal anterior circulation LVO on a CTA at the referring hospital to identify the door-in-door-out (DIDO) times, thrombectomy attempt rate, and mortality of patients before and after Code LVO implementation. Wilcoxon Rank-Sum was used to analyze median DIDO times and Fisher’s exact was used to analyze the proportion of DIDO times of < 90 minutes, < 60 minutes, thrombectomy attempt rate, and mortality.

Results: There were 51 pre- Code LVO versus 12 post Code-LVO transfers. The median DIDO times were significantly reduced post-Code LVO (80 vs 127 minutes, p=0.001). The proportion of DIDO times < 90 minutes and < 60 minutes were significantly improved (58% vs 16%, p=0.005 and 17% vs 0%, p=0.034, respectively). Mortality was numerically, but not significantly, reduced (17% vs 22%). Median DIDO times were significantly shorter in those undergoing thrombectomy (97 vs 136 minutes, p=0.008) and numerically longer in those who died (138 vs 112 minutes, p=0.24).

Conclusions: Auto-launching of interfacility transport within an integrated regional system care for LVO-AIS decreases DIDO times and may improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.

A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Background

Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place.

Methods

Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting.

Results

We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms.

Conclusions

These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05900-x) contains supplementary material, which is available to authorized users.

Kounis syndrome uncovers severe coronary disease: an unusual case of acute coronary syndrome secondary to allergic coronary vasospasm

Acute coronary syndrome occurring during the course of a type I hypersensitivity reaction constitutes Kounis syndrome. We report a case of a 64-year-old man who presented with a non-ST elevation myocardial infarction and peripheral blood eosinophilia. He had rhinitis and constitutional symptoms for several days prior to presentation. Blood investigations revealed moderate eosinophilia and elevated IgE levels. A cardiac MRI showed generalised oedema with a subtle wall motion abnormality in basal inferior/inferolateral wall, and subendocardial high signal on late gadolinium enhancement suggesting a localised myocardial infarction. A coronary angiogram then revealed triple vessel disease. A diagnosis of Kounis syndrome was made. Within days of starting appropriate treatment, the patient’s eosinophil count returned to normal with improvement of clinical picture.

A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Background

Management algorithms for adult severe traumatic brain injury (sTBI) were omitted in later editions of the Brain Trauma Foundation’s sTBI Management Guidelines, as they were not evidence-based.

Methods

We used a Delphi-method-based consensus approach to address management of sTBI patients undergoing intracranial pressure (ICP) monitoring. Forty-two experienced, clinically active sTBI specialists from six continents comprised the panel. Eight surveys iterated queries and comments. An in-person meeting included whole- and small-group discussions and blinded voting. Consensus required 80% agreement. We developed heatmaps based on a traffic-light model where panelists’ decision tendencies were the focus of recommendations.

Results

We provide comprehensive algorithms for ICP-monitor-based adult sTBI management. Consensus established 18 interventions as fundamental and ten treatments not to be used. We provide a three-tier algorithm for treating elevated ICP. Treatments within a tier are considered empirically equivalent. Higher tiers involve higher risk therapies. Tiers 1, 2, and 3 include 10, 4, and 3 interventions, respectively. We include inter-tier considerations, and recommendations for critical neuroworsening to assist the recognition and treatment of declining patients. Novel elements include guidance for autoregulation-based ICP treatment based on MAP Challenge results, and two heatmaps to guide (1) ICP-monitor removal and (2) consideration of sedation holidays for neurological examination.

Conclusions

Our modern and comprehensive sTBI-management protocol is designed to assist clinicians managing sTBI patients monitored with ICP-monitors alone. Consensus-based (class III evidence), it provides management recommendations based on combined expert opinion. It reflects neither a standard-of-care nor a substitute for thoughtful individualized management.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05805-9) contains supplementary material, which is available to authorized users.

Comparison of aeroallergen sensitisation patterns in the United States and Europe

The global prevalence of allergic diseases have increased considerably and are a major socio-economic burden. Asthma is a complex disease and understanding asthma phenotypes and endotypes could eventually lead to individualised management, and offer better symptom control and quality of life. In this review, we first summarise the pathogenesis of atopic asthma and delve into the assessment of sensitisation to aeroallergens through skin prick testing and serological testing with total and specific immunoglobulin E testing. We will then analyse the distribution of aeroallergen sensitisation patterns in the United States and Europe and its effect on the population. This review gives a comprehensive overview on atopy and it compares the prevalence and effect of atopy within various regions of both continents using data from large multicentre studies. We will conclude this review by discussing the efficacy of add-on treatments in the most prevalent severe asthma phenotypes and endotypes.

[Primary prophylaxis of venous thromboembolism in ambulatory cancer patients treated with antineoplastic agents]

Apart from myeloma, primary prophylaxis of venous thromboembolism (VTE) in ambulatory cancer patients treated with chemotherapy is underused, despite its proven benefit for pancreatic cancer and to a lesser extent for lung cancer. This prophylaxis has been showed to be effective for myeloma, pancreas but in absolute numbers these cancers lead to a few venous thromboembolic events. Up to date, VTE risk scores cannot be used as a discriminatory criterion to select a high-risk population that could really benefit from this prevention. VTE depends in part on oncogenic mutations of tumor cells that result in an imbalance between activation and inhibition pathways that are involved in venous thrombus formation. So, stratification of risk of VTE in cancer patients could be considered from a clinical and molecular point of view and result in a tailored prophylaxis. This "personalized medicine" that is currently used for the anti-tumor treatment of many cancers and hematological malignancies, could lead to a more effective prophylaxis of VTE in cancer patients.

Abstract WP320: Coaching Stroke Quarterbacks in an Academic Medical Center to Improve Door to Treatment Times

Background: Rapid treatment for acute ischemic stroke (AIS) improves patient outcomes. In an academic medical center AIS treatment often involves a large team including trainees. A clear process allowing for rotating team members and varied experience in AIS care across disciplines is key for timely intervention.

Purpose: To improve the percentage of patients with door to needle (DTN) and door to puncture (DTP) times within 45 and 90 minutes.

Methods: A multidisciplinary team including EMS, Emergency Medicine (EM), Nursing, Radiology, Neurology, Neurosurgery, Pharmacy, Surgical Services, and Operations Excellence, along with residents from each specialty, convened for a Lean initiative to reduce door to treatment (DTT) times in an academic Comprehensive Stroke Center. An extensive process map was generated that identified 1) unclear role delineation for EM, Neurology, and Neurosurgery residents, and 2) uncertainty in optimizing the simultaneous processes of history-taking, NIHSS assessment and imaging determination. A model clarifying CT decision–making guidelines and designating a team leader or “Stroke Quarterback” was developed. A three month test of the process was conducted.

Results: There was a 42% improvement in DTN within 45 minutes and 33.4% improvement in DTP within 90 minutes when compared to the same 3 month period one year prior to the test of change (figure 1). The rate of DTT within goal varied from month to month.

Conclusions: Despite the varied levels of experience and training of providers at an academic hospital, the acute stroke response team must provide consistent and expeditious care in every instance. Identifying a team leader as a “stroke quarterback” allows for real-time decision-making (audibles), clear delegation of responsibilities (player assignments) based on experience, and utilization of structured processes (playbook). Our model is well-suited for the academic medical center environment and appears to reduce time to treatment.

Abstract WP286: Auto-launching of Interfacility Transport to Referring Hospitals for Presumed Emergent Large Vessel Occlusion Strokes May Decrease Time to Mechanical Thrombectomy and Improve Outcomes

Introduction: Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care.

Methods: Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC) is NYS-DSC located in Elmira, NY, 115 miles from SMH. Clinical leaders at SMH and AOMC collaborated to engineer a system of care to expeditiously transfer qualifying MT candidates. The system of care, dubbed Code LVO, included the auto-launching of an interfacility transport team (preferable a medical helicopter) to AOMC and notification to the SMH Vascular Neurologist (VN) on ED arrival for any presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of </=24 hours to review the non-contrast Head CT (NCCT) and CTA of the head and neck for an ASPECTS Score >/=6 and an LVO via a cloud-based image sharing platform. We retrospectively reviewed the records of LVO-AIS transfers in a QA database to identify the door-in-door-out (DIDO) time, AOMC door to SMH door (D2D) time, and AOMC door to SMH skin puncture (D2S) time, and the outcomes of patients before and after Code LVO implementation.

Results: Over an 18-month period pre- Code LVO, there were seven AOMC to SMH LVO-AIS transfers. None underwent MT due to large or completed infarcts on SMH arrival. Seventy-one percent died or went to hospice. The median DIDO time was 93 minutes (range 66-273) and D2D was 239 minutes (range 112-392). Post- Code LVO, six Code LVO evaluations were requested, and three were transferred. All LVO-AIS underwent successful MT, with a median DIDO time of 45 minutes (range 44-60), D2D time of 95 minutes (range 85-102), and DTS time of 141 minutes (124-158) and went to nursing home or acute rehab.

Conclusions: Auto-launching of interfacility transport to referring hospitals for select presumed LVO-AIS may decrease time to MT and improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.

Abstract TP447: Coagulation Differences Between Deep and Lobar Intracerebral Hemorrhage Detected by Thromboelastography

Introduction: Despite smaller baseline hematoma volumes, deep primary intracerebral hemorrhage (ICH) is known to have worse clinical outcomes and preliminary evidence of more hematoma expansion compared to lobar ICH. This is not thought to be related to differences in functional coagulation as prior studies have not identified differences in traditional, plasma-based coagulation tests between these locations. We investigated for clotting differences between deep and lobar ICH using Thromboelastography (TEG: whole-blood coagulation assessment).

Methods: Clinical, radiographic and laboratory data was prospectively collected between 2009-2018 for primary ICH patients admitted to University of Texas Health Sciences Center at Houston. Deep and lobar ICH patients, without preceding history of anticoagulation use or coagulopathy on admission testing, who received admission TEG and traditional plasma coagulation tests were included for analysis. Patients receiving hemorrhage reversal transfusions prior to TEG were excluded. Multivariable linear regression assessed the association of ICH location with functional coagulation tests after adjusting for age, sex, NIHSS, and baseline hematoma volume.

Results: Of 207 ICH patients included for analysis, there were 154 (74%) deep and 53 (26%) lobar ICH. Deep ICH patients were significantly younger (mean: 56 vs 68 years), had higher admission systolic blood pressures (mean: 200 vs 182mmHg) and smaller admission hematoma volumes (median: 16.2 vs 28.7mL) than lobar ICH patients. Deep ICH had longer TEG R times (mean: 5.1 vs 4.4 minutes) indicating a slower and less optimal time to clot formation compared to lobar ICH. After controlling for potential confounders, the adjusted mean R times continued to be longer in deep compared to lobar ICH by 0.57 minutes (95% CI 0.02-1.11, p=0.04).

Conclusions: Our findings suggest that there may be functional coagulation differences detected with whole blood coagulation testing between deep and lobar ICH. Further work is needed to determine whether whole blood coagulation testing to assess coagulopathy after ICH should play a role in hemorrhage reversal treatment paradigms.

Regional Cerebral Oximetry as an Indicator of Acute Brain Injury in Adults Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation-A Prospective Pilot Study

Background: Regional cerebral oxygen saturation (rScO2) measured by near-infrared spectroscopy (NIRS) can be used to monitor brain oxygenation in extracorporeal membrane oxygenation (ECMO). ECMO patients that develop acute brain injuries (ABIs) are observed to have worse outcomes. We evaluated the association between rScO2 and ABI in venoarterial (VA) ECMO patients. Methods: We retrospectively reviewed prospectively-collected NIRS data from patients undergoing VA ECMO from April 2016 to October 2016. Baseline demographics, ECMO and clinical characteristics, cerebral oximetry data, neuroradiographic images, and functional outcomes were reviewed for each patient. rScO2 desaturations were defined as a >25% decline from baseline or an absolute value < 40% and quantified by frequency, duration, and area under the curve per hour of NIRS monitoring (AUC rate, rScO2^*min/h). The primary outcome was ABI, defined as abnormalities noted on brain computerized tomography (CT) or magnetic resonance imaging (MRI) obtained during or after ECMO therapy. Results: Eighteen of Twenty patients who underwent NIRS monitoring while on VA ECMO were included in analysis. Eleven patients (61%) experienced rScO2 desaturations. Patients with desaturations were more frequently female (73 vs. 14%, p = 0.05), had acute liver dysfunction (64 vs. 14%, p = 0.05), and higher peak total bilirubin (5.2 mg/dL vs. 1.4 mg/dL, p = 0.02). Six (33%) patients exhibited ABI, and had lower pre-ECMO Glasgow Coma Scale (GCS) scores (5 vs. 10, p = 0.03) and higher peak total bilirubin levels (7.3 vs. 1.4, p = 0.009). All ABI patients experienced rScO2 desaturation while 42% of patients without ABI experienced desaturation (p = 0.04). ABI patients had higher AUC rates than non-ABI patients (right hemisphere: 5.7 vs. 0, p = 0.01, left hemisphere: 119 vs. 0, p = 0.06), more desaturation events (13 vs. 0, p = 0.05), longer desaturation duration (2:33 vs. 0, p = 0.002), and more severe desaturation events with rScO2 < 40 (9 vs. 0, p = 0.05). Patients with ABI had lower GCS scores (post-ECMO initiation) before care withdrawal or discharge than those without ABI (10 vs. 15, p = 0.02). Conclusions: The presence and burden of cerebral desaturations noted on NIRS cerebral oximetry are associated with secondary neurologic injury in adults undergoing VA ECMO.

Relationship between domestic smoking and metals and rare earth elements concentration in indoor PM2.5

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM_2.5 and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 "cases" and 32 "controls" (children with and without respiratory symptoms, respectively) were evaluated by 48-h PM_2.5 indoor/outdoor monitoring. PM_2.5 mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP-MS. PM_2.5 and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM_2.5, Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM_2.5, Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children.

Abstract TP43: Trends in Interhospital Transfers and Mechanical Thrombectomy for Acute Ischemic Stroke

Introduction: Stroke care in the US is becoming increasingly regionalized. Many patients undergo interhospital transfer to obtain access to specialized, time-sensitive interventions such as mechanical thrombectomy.

Methods: We used the stratified survey design of the US Nationwide Inpatient Sample, 2009-2014, to examine nationwide trends in interhospital transfers for ischemic stroke and the relationship between transfers and thrombectomy. International Classification of Disease—Ninth Revision diagnosis and procedure codes were used to identify acute stroke admissions and inpatient procedures (tissue plasminogen activator [tPA] administration and thrombectomy), respectively. The analysis was restricted to hospitals with the capabilities to perform thrombectomy. Trends were assessed using a Cochran-Armitage test.

Results: From 2009 to 2014, an estimated 759,648 ischemic stroke admissions were identified within hospitals offering thrombectomy (102,674 in 2009; 154,280 in 2014). The proportion of stroke admissions to these hospitals that underwent interhospital transfer prior to arrival increased from 13.5% (n=13,811) in 2009 to 18.9% (n=19,175) in 2014 ( P trend<0.001). Compared to “front door” patients, transfers were more likely to receive tPA (10.7% vs. 26.5%; P <0.001) and thrombectomy (2.7% vs. 5.7%; P <0.001). The proportion of transfers that received thrombectomy increased from 4.5% (n=625) to 6.0% (n=1,745) from 2009 to 2014 ( P trend=0.016). Approximately 30% of patients receiving thrombectomy for ischemic stroke were transferred from another acute care facility (n=7,328). Among patients receiving tPA, transferred patients were slightly less likely to receive thrombectomy compared to those arriving by “front door” at thrombectomy performing centers (13.9% vs. 15.4%; P =0.004).

Conclusions: From 2009 to 2014, interhospital stroke transfers to thrombectomy performing hospitals more than doubled. For every ~5 additional stroke transfers over the time period examined, one additional transferred patient received thrombectomy. As stroke systems of care continue to evolve across the US, the optimization of stroke transfers presents an opportunity to increase access to meaningful interventions such as thrombectomy.