EMMPRIN/CD147 plays a detrimental role in clinical and experimental ischemic stroke

Background: Ischemic stroke is a devastating disease, often resulting in death or permanent neurological deficits. EMMPRIN/CD147 is a plasma membrane protein that induces the production of matrix metalloproteinases (MMPs), which contribute to secondary damage after stroke by disrupting the blood brain barrier (BBB) and facilitating peripheral leukocyte infiltration into the brain.

Results: CD147 surface expression increased significantly after stroke on infiltrating leukocytes, astrocytes and endothelial cells, but not on resident microglia. Inhibition of CD147 reduced MMP levels, decreased ischemic damage, and improved functional, cognitive and histological outcomes after experimental ischemic stroke in both young and aged mice. In stroke patients, high levels of serum CD147 24 hours after stroke predicted poor functional outcome at 12 months. Brain CD147 levels were correlated with MMP-9 and secondary hemorrhage in post-mortem samples from stroke patients.

Conclusions: Acute inhibition of CD147 decreases levels of MMP-9, limits tissue loss, and improves long-term cognitive outcomes following experimental stroke in aged mice. High serum CD147 correlates with poor outcomes in stroke patients. This study identifies CD147 as a novel, clinically relevant target in ischemic stroke.

Identifying Gaps and Missed Opportunities for Intravenous Thrombolytic Treatment of Inpatient Stroke

Background: Inpatient stroke-codes (ISC) have traditionally seen low treatment rates with IV-thrombolytic (IVT). The purpose of this study was to identify the predictors of true stroke, prevalent IVT-treatment gap and study the factors associated with such missed treatment opportunities (MTO).

Methods: A retrospective chart review identified ISC from March 2017 to March 2018. Clinical, radiographic and demographic data were collected. Primary analysis was performed between stroke vs. non-stroke diagnoses. Dichotomous variables were analyzed using Chi-Square test of proportions and continuous variables with Wilcoxon-Ranked-Sum test. Significant factors were then tested in a multivariate logistic regression model for independence.

Results: From 211 ISC, 36% (n = 76) had an acute stroke. Hemorrhagic stroke (HS) was present in 5.7% (n = 12). Of the remaining 199, 44% (n = 87) were IVT-eligible but only 3.4% (n = 3) were treated. Of the remaining 84 IVT-eligible-but-untreated patients, 69(82.1%) were mimics, while 15 (17.9%) had an ischemic stroke (IS), constituting a MTO of 1 in 6 IVT-eligible patients, with National Institutes of Health Stroke Scale (NIHSS) ≤4 being the commonest deterrent. Independent predictors of stroke were ejection fraction (EF) <30% (p = 0.030, OR = 3.06), post-operative status (p = 0.001, OR = 3.71), visual field-cut (p = 0.008, OR = 3.70), and facial droop (p = 0.010, OR = 2.59).

Conclusion: In our study, one in three ISC were true strokes. IVT treatment rates were low with a MTO of 1 in 6 IVT-eligible patients. The most common reason for not treating was NIHSS ≤4. Knowing predictors of true stroke and the common barriers to IVT treatment can help narrow this treatment gap.

Abstract TP310: Effect of an Extended Treatment Window on Transfer Times in Patients With Stroke

STK-OP-1 examines transfer times for patients going to a higher level of care. Known as door in, door out or DIDO, certified stroke centers are required to report times for both ischemic and hemorrhagic stroke patients transferred to a Primary or Comprehensive Stroke Center (CSC).

Purpose: Barriers to time-sensitive transfer and complex decision making are common. As a result, Hartford Healthcare (HHC) began a QI initiative to measure DIDO times while introducing advanced CTP imaging and treatment in the extended window, April 2018. This project evaluates the impact on DIDO.

Methods: This multi-center QI project evaluated data pre and post implementation for stroke transfers to the CSC. Pre-implementation was May 2017 to April 2018, post-implementation May 2018 to March 2019. Patient and process of care data abstracted from Epic was entered into Excel. The main analysis compared median DIDO times using Wilcoxon Ranked Sum.

Results: Data were collected on hospital, stroke type/severity and treatments administered; patient demographics, and key timing variables of door in/door out, EMS and CT. While there is no universal criterion for DIDO, 60 minutes is often the ultimate goal with 90 or 120 minutes as intermediate goals. Pre and post implementation median DIDO times for all hospitals were 117 and 139 minutes (p = 0.02), for HHC hospitals 115 and 137 minutes (p = 0.027) and for non-HHC hospitals 118 and 140.5 minutes (p = 0.423). Of the pre-implementation group, 7.8% had CTP imaging prior to transfer compared with 9.3% post. Extended times post-implementation include factors such as complex decision making, patient eligibility or hospital capacity issues. A new transfer algorithm was implemented April 2019. Future analyses will correlate DIDO with patient, stroke and treatment categories to better define delays and barriers.

Relevance: A JC directive to CSCs are to develop supportive relationships with referring hospitals to facilitate efficient care. As decision making becomes more complex, the process for transfer needs to improve. DIDO goals need to be realistic to prevent secondary imaging at the CSC, i.e. the tradeoff for an extra 15 or 20 minutes should translate into shorter door to puncture times. Reducing the time to treatment may help improve patient outcomes.

Abstract TP52: Endovascular Therapy in Patients Over 80 Years of Age With Acute Ischemic Stroke

Introduction: Acute ischemic stroke treatment has undergone a paradigm shift, with patients being treated in the extended time window (6-24 hours post symptom onset). The purpose of this study is to assess outcomes in stroke patients above 80 years of age undergoing endovascular treatment (EVT) in the extended time window.

Methods: Acute ischemic stroke patients presenting to Hartford Hospital between January 2017 to June 2019 were considered for the study. Stroke outcomes in patients above 80 years of age with anterior circulation ischemic strokes presenting in the extended time window (Group A, n=30) were compared to a younger cohort of patients below 80 years (Group B, n=31). Patients over 80 years treated in the traditional time window (within 6 hours of symptom onset) served as a second set of controls (Group C, n=40). Statistical analysis was performed with a significance level of 0.05

Results: For angiographic results, there were no statistically significant differences in terms of good outcomes (TICI 2b-3) among patients of Group A, when compared to Groups B or C (p>0.05). For the endovascular procedures, no significant differences were noted in the total fluoroscopy time (Median Group A 44.05, Group B 38.1, Group C 35.25 min), total intra-procedure time (Median Group A 144, Group B 143, Group C 126 min) or total radiation exposure (Median Group A 8308, Group B 8960, Group C 8318 uGy-m 2 ). For stroke outcomes, a good clinical outcome was defined as modified Rankin score of 0-2 at discharge. Significantly better outcomes were noted in the younger patients in Group B - 35.4%, when compared to 13.3% in Group A (p=0.03). Comparative outcomes differed in the elderly patients above 80 years, Group A -13.3% vs Group C - 25%, although not statistically significant (p=0.23). There was a significant difference in mortality in patients of Group A - 40% as compared to 12% in the younger cohort, Group B (p= 0.01).

Conclusions: In the extended time window, patients above 80 years of age were noted to have a higher mortality, morbidity compared to the younger cohort of patients. No significant differences were noted in the stroke outcomes in patients above 80 years of age when comparing the traditional and the extended time window for stroke treatment.

Abstract TP156: NIH Stroke Scale at Discharge as a Predictor for Return to Work Status After Mild Stroke

Background: A significant proportion of patients are unable to return to work (RTW) post stroke. While post-stroke depression and fatigue have been linked to patients’ RTW status, the role of discharge NIHSS has not been studied.

Objective: To evaluate role of stroke severity, depression, fatigue, and cognitive impairment on patients’ ability to RTW.

Methods: A retrospective study was conducted using a survey completed by a convenience sample of patients during follow-up in stroke clinic. The survey included PHQ-9, Fatigue Assessment Scale (FAS), and the Montreal Cognitive Assessment (MoCA). Demographic, work status, and clinical data (discharge NIHSS, mRS, medical history) were also collected. NIHSS was evaluated both continuously and dichotomized ( < 1, > 1). Patients who did and did not RTW were compared using chi square tests of proportions and Wilcox Ranked Sum tests; independence of factors was explored using logistic regression predicting RTW.

Results: Out of 135 patients surveyed, 41% (N=56) reported employment at the time of their stroke. Of those, a significant percentage of patients were unable to RTW post stroke (57.1%); 39.3% (N=22) were unable to RTW due to physical limitations. Further analysis revealed patients who did not RTW were more likely to suffer from fatigue (p=0.026), have higher rates of cognitive impairment (p=0.027) and a higher NIHSS at discharge (p<0.001). Very low NIHSS was a very strong RTW predictor as patients with an NIHSS ≤ 1 at discharge were 15 times more likely to RTW than patients with a higher NIHSS (p=.001). Patients who worked in professional, managerial, or artistic occupations pre-stroke were more likely to return to work than those in public service, skilled or unskilled labor occupations (p=0.023). In multivariate analyses, fatigue, cognitive impairment and depression were no longer significant when NIHSS at discharge was a covariate. Type of occupation was independent of NIHSS.

Conclusions: For patients with mild stroke, NIHSS at discharge indicating minimal to no disability is a strong independent predictor for RTW status. For patients with greater deficit, depression, fatigue and cognitive impairment could play a greater role; additional studies of patients with greater variety of stroke severity would be needed.

Abstract TP352: Safety and Efficacy of Andexanet Alfa in Patients With Life Threatening Intracerebral Hemorrhage: A Single Center Experience

Background: Intracerebral hemorrhage (ICH) is a devastating condition with high 30- day mortality. Up to a third of patients experience hematoma expansion within the first 24 hours; anticoagulation with factor Xa inhibitors may increase the risk of expansion and poor outcomes.

Objective: We assessed our experience using Andexanet alfa (Aα) by evaluating stabilization of the hematoma and ischemic complications.

Methods: We conducted a single center prospective observational study on all patients receiving Aα for reversal of anticoagulation in the setting of an ICH and use of Factor Xa inhibitors. The degree of hematoma expansion within 12 hours of drug administration on non-contrast head CT was categorized as 'excellent' (<20% increase in hematoma size), ‘good' ( > 20-<35%), and 'poor' ( > 35%). Secondary outcomes included dosage, median length of stay, mortality, modified Rankin score (mRS), discharge disposition, and ischemic complications.

Results: Fifteen patients received Aα (5=lobar, 5=deep, 5= multicompartment). One patient with a presumed deep hemorrhage was excluded because subsequent imaging showed chronic mineralization. The predominant etiologies were hypertension (40%), amyloid angiopathy (26.6%) and trauma (13.3%). The median age was 86 years (IQR 19) and median ICH score on arrival was 2 (IQR 2), and median hematoma size was 14.3 mL (IQR 34.5). Most patients (71.4%) received the low dose formulation. Based on hematoma expansion, 64.3%, 14.3% and 21.4% of patients achieved excellent, good and poor hemostasis, respectively. Reduction in hematoma size was seen in 20% (n=3) while 13.3% (n=2) patients had no expansion. Median ICU and hospital length of stays were 2.0 days (IQR 2.2) and 6.6 days (IQR 9.78) respectively. Mortality was 28.6% and median mRS upon discharge was 4 (IQR 2), with most patients discharged to rehabilitation facilities (60%). There were no ischemic complications.

Conclusion: Our experience is consistent with the results of the ANNEXA 4 study with 78.6% of patients showing excellent or good hemostasis. These results led to improved clinical outcomes, with 60% of patients being discharged to rehabilitation. These data support the efficacy of this treatment paradigm in a real-world setting.

Abstract TP161: Sexual Dysfunction in Mild Stroke

Background: Stroke impacts several aspects of patients’ lives and sexual dysfunction post stroke has been reported in 40%-50% of patients. Current investigations have revealed links to depression, however this has not been examined specifically in mild stroke.

Objective: To determine prevalence and factors associated with sexual dysfunction after mild stroke

Design/methods: A retrospective study was conducted on a self-report questionnaire completed by a convenience sample of patients during a hospital follow-up appointment in the stroke clinic. Patients were asked about sexual dysfunction after stroke and if yes, to specify the cause: safety concern, physical limitation, consequence or change in libido. In addition, patients completed a PHQ-9 to measure depression, Fatigue Assessment Scale (FAS), and the Montreal Cognitive Assessment (MoCA). A thorough review of clinical history including NIHSS, mRS and demographics was completed by researchers. Descriptive statistics were used to identify and understand the patient population. Mild stroke was defined as NIHSS ≤ 5.

Results: In our study of 135 patients, 21 (16%) did not respond to the sexual dysfunction question. Of the 114 who responded, only 11 (9.6%) reported sexual dysfunction and 9 (81%) attributed their sexual dysfunction to physical limitations. Descriptive statistics of the respondent subgroup indicate that the cohort was 59% male with a median (IQR) age of 64 (57,75) and that 52% were living with someone at the time. The mean NIHSS on discharge was 1 (IQR 0-3) and 77% were ischemic strokes. Few patients experienced post stroke depression (21.9%, N=25), and the cohort reported low levels of fatigue (median FAS=19). Low incidence and response rates precluded an analysis of specific predictors in this cohort.

Conclusion: Physical limitations are reported to be the main cause of post stroke sexual dysfunction. Roughly 1 in 10 patients with mild stroke reported experiencing sexual dysfunction, however twice as many did not respond to the question. Therefore, the true incidence is unclear, prompting the need for further investigation on post stroke sexual dysfunction in mild stroke.

Abstract TP250: Reducing Treatment Time in Acute Ischemic Stroke by Utilizing a Kaizen Model

Introduction: Treating patients suspect of acute stroke requires efficient multidisciplinary teamwork in order to provide appropriate care. Several “Lean Management” methods have been applied in a variety of healthcare settings. Kaizen, meaning “improvement” in Japanese is a tool which emphasizes empowerment of employees on creating value streams to identify and reduce wastes, synchronize work flow processes, manage variability, and devise communication and sustainability plans. We report on the use of this methodology to improve our acute stroke care metrics.

Objective: To optimize the management of the acute stroke patient flow process from the emergency department ED to destination therapy by applying the Kaizen methods.

Methodes: This is a quality improvement project designed to evaluate the efficiency of the new workflow model for acute stroke that was put into place June 2018 at Hartford Hospital. A 5 day event spent involving all stakeholders from patient registration to destination treatment (IV or mechanical thrombolytic therapy) were conducted. During this event, a time work flow process for the management of suspected stroke patients was identified and an appropriate plan was formulated to reduce times. The following parameters were utilized: Door to CT scanner time (DTCT), Door to drug (IV-tPA) (DTD), and Door to mechanical thrombectomy puncture time (DTP). We included all stroke patients presenting to the ED and treated at our institution 6 months prior and post implementation. A non-parametric analysis was utilized.

Results: A total of 135 patients were included in this analysis, 60 prior and 75 post Kaizen. Improvement across all parameters was observed post Kaizen with an average reduction time of DTCT 5 min, DTD 5min, and DTP 22min. The median times pre-Kaizen were; DCT 14min IQR 6-27, DTD 55min IQR 43.5-77.5, and DTP 128min IQR 88-151. The median times post-Kaizen were; DTCT 9min IQR 6-23, DTD 50.5min IQR 37-64, and DTP 106 min IQR 83.5-141.5.

Conclusion: By utilizing the Kaizen, we identified numerous opportunities to reduce variability, standardize workflow processes, and ultimately reduce all parameter times. As time is brain, reducing pretreatment times favorably impacts patients’ outcomes and reduces morbidity in stroke.

Abstract TP365: Stroke Nurse Navigator Improves Post-Acute Transition of Care

Background: Post stroke care is multifaceted and should not end at hospital discharge. Patients often lack understanding of the importance of outpatient care to prevent secondary stroke.

Objective: To demonstrate the positive impact of a stroke nurse navigator in improving the post-acute transition of care by promoting outpatient follow up after hospitalization.

Methods: We retrospectively reviewed all patients discharged from our comprehensive stroke center (excluding hospice) with a primary diagnosis of ischemic or hemorrhagic stroke from January -December 2018, yielding 685 patients. We evaluated whether or not our nurse navigator influenced three aspects of follow up: if stroke clinic appointment was made before discharge, if patient attended the appointment and if patient called the clinic after discharge. Four categories were used based on level of navigator contact with the patient: (SC) Seen in-house and called within 30 days after discharge, (S) Seen only, (C) Called only or (N) No navigator contact. Chi-square test of proportions was used to evaluate the statistical significance among all four groups.

Results: Out of the 685 patients, 77.5% (n=531) were scheduled for clinic follow-up before discharge, 60.7% (n=416) attended the appointment and 20% called after discharge (n=137). The distribution of navigator contact level was (SC) 26.7%, (S) 17.5%, (C) 19.3% and (N) 36.5%. Both seeing and calling the patient was proven to be the most effective in all three areas: appointment made prior to discharge (SC) 89.6%, (S) 82.5%, (C) 74.2%, (N) 68% ( p=<0.001 ); patient attended the appointment (SC) 68.9%, (S) 60%, (C ) 65.9%, (N) 52.4% ( p=0.001 ) and patient called the clinic after discharge (SC) 26.2%, (S) 15.8%, (C ) 23.5%, (N) 15.6% ( p=0.02 ). Of interest, patients who were only called but not seen were more likely to attend the appointment or call the clinic as compared to being seen alone.

Conclusion: Contact with our nurse navigator increased post-acute follow up in our stroke clinic. An increased number of patient calls associated with navigator interaction showed these patients had a better understanding of the need for continued care. The nurse navigator improves continuity of post-acute care.

Caprini score and surgical times linked to the risk for venous thromboembolism after robotic-assisted radical prostatectomy

OBJECTIVE

To evaluate the Caprini score as an independent predictor of venous thromboembolism (VTE) in patients undergoing robotic-assisted radical prostatectomy (RARP) and to identify appropriate cut-points for clinical use.

MATERIAL AND METHODS

We performed a retrospective review of patients who underwent RARP for prostate cancer between December 2003 and February 2016. VTE cases developed the condition within 90 days of discharge. The control group was comprised of patients whose RARP most closely preceded and followed each VTE case in time and who were matched on lymph node dissection and surgeon. The Caprini score was calculated for each patient, and the groups were compared on a number of clinical variables. Multiple logistic regression was used to evaluate whether the Caprini score was an independent predictor of VTE. Receiver operating characteristics (ROC) curves were used to establish appropriate clinical cutpoints.

RESULTS

A total of 3719 patients underwent RARP during the study period. A total of 52 (1.4%) of patients met the criteria for cases. Data were available for 97 patients who met the criteria for controls. Multiple logistic regression indicated that the Caprini score and operative time were independently both significant predictors of VTE (p=0.005 and p=0.044, respectively). ROC indicated that the Caprini score showed a significant but moderate relationship to VTE (area under curve [AOC]=0.64; p=0.004). A Caprini score >6 was the best arithmetic balance for sensitivity (61.5; 95% confidence interval [CI]: 47.0-74.7) and specificity (59.8; 95% CI: 49.3-69.6).

CONCLUSION

The Caprini score predicts postoperative VTE in patients undergoing RARP.

Impact of Preoperative Specialty Consults on Hospitalist Comanagement of Hip Fracture Patients

BACKGROUND

Hip fractures typically occur in frail elderly patients. Preoperative specialty consults, in addition to hospitalist comanagement, are often requested for preoperative risk assessment.

OBJECTIVE

Determine if preoperative specialty consults meaningfully influence management and outcomes in hip fracture patients, while being comanaged by hospitalists DESIGN: Retrospective cohort study SETTING: Tertiary care hospital in Connecticut PATIENTS: 491 patients aged 50 years and older who underwent surgery for an isolated fragility hip fracture, defined as one occurring from a fall of a height of standing or less.

INTERVENTION

Presence or absence of a preoperative specialty consult MEASUREMENTS: Time to surgery (TTS), length of hospital stay (LOS), and postoperative complications RESULTS: 177 patients had a preoperative specialty consult. Patients with consults were older and had more comorbidities. Most consult recommendations were minor (72.8%); there was a major recommendation only for eight patients (4.5%). Multivariate analysis demonstrates that consults are more likely to be associated with a TTS beyond 24 hours (Odds Ratio [OR] 4.28 [2.79-6.56]) and 48 hours (OR 2.59 [1.52-4.43]), an extended LOS (OR 2.67 [1.78-4.03]), and a higher 30-day readmission rate (OR 2.11 [1.09-4.08]). A similar 30-day mortality rate was noted in both consult and no-consult groups.

CONCLUSIONS

The majority of preoperative specialty consults did not meaningfully influence management and may have potentially increased morbidity by delaying surgery. Our data suggest that unless a hip fracture patient is unstable and likely to require active management by a consultant, such consults offer limited benefit when weighed against the negative impact of surgical delay.

Impact of Resilience on Outcomes of Total Knee Arthroplasty

BACKGROUND

Resilience, defined as the ability to bounce back from stress, has been suggested as a predictor of surgical outcomes. The purpose of this study is to examine the relationship between resilience and patient-reported outcomes following primary elective total knee arthroplasty (TKA). We hypothesized that patients exhibiting greater preoperative resilience would report better outcome scores.

METHODS

A prospective cohort of 153 patients (74 male, 79 female) undergoing primary elective TKA completed questionnaires preoperatively and at 3 and 12 months following their index procedure. The validated Brief Resilience Scale was used to evaluate resilience. Hierarchical multiple linear regression was used to analyze the effect of resilience on KOOS-JR (Knee Injury and Osteoarthritis Outcome Score JR) and PROMIS-10 (Patient-Reported Outcomes Measurement Information System) outcome scores.

RESULTS

At 12 months, the change in the coefficient of determination (R²) attributable to preoperative resilience was 0.101 (P < .001) and 0.204 (P < .001) for physical and mental health, respectively. Although there was expected improvement in KOOS-JR scores following TKA, the effect of baseline resilience for this outcome was not significant. When evaluating resilience measured concurrently, there was significant correlation with both 3-month and 12-month KOOS-JR and PROMIS-10 outcome scores.

CONCLUSION

Preoperative resilience is a significant predictor of overall physical and mental health outcomes at both 3 and 12 months. Greater concurrent resilience predicted better scores across all outcomes. These findings suggest that major elective surgery, like other traumatic events, can cause a change in resilience. Although functional improvements after TKA are expected, those patients who exhibit greater resilience at baseline are more likely to report an improved quality of life.

Migraine History: A Predictor of Negative Diffusion-Weighted Imaging in IV-tPA-Treated Stroke Mimics

BACKGROUND

Migraine, seizures, and psychiatric disorders are frequently reported as "stroke mimics" in patients with negative diffusion-weighted imaging (DWI) after IV-tPA. We sought to determine predictors of negative DWI in suspected stroke patients treated with IV-tPA.

METHOD

A retrospective case-control study encompassing all acute stroke patients treated with IV-tPA (at our hospital or "dripped and shipped") from January 2013 to December 2014 was con- ducted. A total of 275 patients were identified with 47 negative DWI cases and 228 positive DWI controls. Variables including demographic factors, stroke characteristics, and clinical comorbidities were analyzed for statistical significance. A multivariate logistic regression was performed (SPSS-24) to identify predictors of negative DWI.

RESULTS

Approximately 17% of patients had negative DWI after IV-tPA. Compared to controls, migraine history independently predicted negative DWI (odds ratio [OR] 5.0 95% confidence interval [CI] 1.03-24.6, P = .046). Increasing age (OR .97 95% CI .94-.99, P = .02) and atrial fibrillation (OR .25 95% CI .08-.77, P = .01) predicted lower probability of negative DWI. Gender, admission NIHSS, treatment location, preadmission modified Rankin scale, diabetes mellitus, hypertension, hyperlipidemia, symptom side, seizure history, and psychiatric history did not predict negative DWI status.

CONCLUSIONS

In our study, roughly 1 in 6 patients treated with IV-tPA were later found to be stroke mimics with negative DWI. Despite a high proportion of suspected stroke mimics in our study, only preexisting migraine history independently predicted negative DWI status after IV-tPA treatment in suspected stroke patients.

Impact of Urology Resident Involvement on intraoperative, Long-Term Oncologic and Functional Outcomes of Robotic Assisted Laparoscopic Radical Prostatectomy

OBJECTIVE

To evaluate the impact of resident involvement in robot assisted laparoscopic prostatectomy on oncologic, functional, and intraoperative outcomes, both short and long term.

METHODS

We queried our prospectively maintained database of prostate cancer patients who underwent robotic-assisted laparoscopic prostatectomy from November 20, 2007 to December 27, 2016. We analyzed cases performed by 1 surgeon on a specific day of the week when the morning case involved at least 1 resident (R) and the afternoon case involved the attending physician only (nonresident [NR]). We compared R versus NR on a number of clinical, perioperative, and oncological outcomes.

RESULTS

A total of 230 NR and 230 R cases met inclusion criteria and were included in the analysis. Over one third (36.7%) of the NR group was Gleason 4+3 (Grade Group 3) or higher, relative to 25.9% of the R group, P = .015. Median operative time (OT) was significantly longer for R versus NR (200 minutes versus 156 minutes, P<.001) as was robotic time (161 minutes versus119 minutes, P<.001). No significant differences were noted for any other measure. Median follow-up for oncological outcomes was 30 and 33.5 months for NR and R, respectively (P= .3). Median OT and median estimated blood loss were both significantly greater in later years relative to the earlier years for R (2012-2016 versus 2007-2011; P< .001 for OT; P= .041 for median estimated blood loss) but not for NR.

CONCLUSION

Neither safety nor quality is diminished by R involvement in robot assisted laparoscopic prostatectomy.

Prostate cancer genomics: comparing results from three molecular assays

INTRODUCTION

OncotypeDx, Prolaris, and Decipher have each been validated to predict outcomes and guide treatment for patients with clinically localized prostate cancer, but they have yet to be compared to one another. Here we assess the correspondence between the results of each.

MATERIALS AND METHODS

We performed a retrospective chart review to identify patients who underwent at least two of the three genomic tests at Hartford Hospital between 2014 and 2017. We used test-specific definitions of a favorable prediction for each to compare the percent agreement between each pair. Results were also compared to treatment recommendations based on current National Comprehensive Cancer Network (NCCN) guidelines. We compared pair-wise agreement using Cohen's kappa (K).

RESULTS

Twenty-two patients received at least two different genomic tests. For 12 patients who received both the Decipher and Prolaris, % agreement and K were 66.7 and 0.31 (p = .276), respectively. For 8 patients who received both Prolaris and Oncotype DX, % agreement and K were 75 and 0.39 (p = .168), respectively. Two patients received both Decipher and Oncotype DX, yielding 50% agreement and an incalculable K. For Prolaris versus NCCN, % agreement and K were 75 and .21, respectively (p = .117; n = 20). For Decipher versus NCCN, % agreement and K were 60 and .15, respectively (p = .268; n = 15). For Oncotype DX versus NCCN (n = 10), agreement was 50%, K was incalculable.

CONCLUSIONS

Notable differences exist in prognostic outcomes obtained from OncotypeDx, Prolaris, and Decipher.

Robot-assisted sleeve gastrectomy and Roux-en-y gastric bypass: results from the metabolic and bariatric surgery accreditation and quality improvement program data registry

BACKGROUND

A stronger evidence base is needed to more fully understand the precise role that robot-assisted (RA) approaches may play in bariatrics.

OBJECTIVE

To investigate the utilization and safety of RA-sleeve gastrectomy (RA-SG) and RA-Roux-en-Y gastric bypass (RA-RYGB) using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry.

SETTING

National Database.

METHODS

We queried the MBSAQIP 2015 through 2016 registry for patients who underwent primary conventional laparoscopic or RA-SG and RA-RYGB. We compared pre- and perioperative characteristics and 30-day outcomes using logistic regression where number of events met statistical guidelines.

RESULTS

We included 126,987 cases: conventional laparoscopic SG (n = 83,940), RA-SG (n = 6,780), conventional laparoscopic RYGB (n = 33,525), and RA-RYGB (n = 2,742). The RA significantly lengthened operation time by 24 and 23 minutes for SG and RYGB, respectively. Mortality and serious adverse events were similar for the 2 techniques. RA-SG was associated with higher rates of 30-day intervention (1.3% versus .8%, OR: 1.38, P < .05) and hospital stay >2 days (12.1% versus 9.3%, OR: 1.30, P < .001). RA-RYGB was associated with higher 30-day rates of reoperation (2.6% versus 2.0%, OR: 1.37, P < .05) and readmission (7.0% versus 5.8%, OR:1.21, P < .05) and lower rates of transfusion (0.62% versus 1.12%, OR: .54, P < .05) and hospital stay >2 days (15.7% versus 17%, OR: .89, P < .05).

CONCLUSION

RA is as safe as the conventional laparoscopic approach in terms of mortality and serious adverse events.

Return to work after robot-assisted laparoscopic prostatectomy versus radical retro-pubic prostatectomy

INTRODUCTION

We compared the return-to-work interval (RTWI) after radical retro-pubic prostatectomy (RRP) and robot-assisted laparoscopic prostatectomy (RALP) in men being treated for early-stage prostate cancer.

MATERIALS AND METHODS

We mailed a 28-item questionnaire to a random sample of 2,696 patients who either had RRP from 1995 to 2004 or RALP from 2004 to 2011.

RESULTS

We received analyzable questionnaires from 315 patients; 178 had RALP and 137 had RPP. The median RTWI was shorter in the RALP group than in the RRP group (3 versus 4 weeks, p = .016). The percent of subjects who had not returned to work 4 weeks after surgery was 23.6% for RALP and 38.2% for RRP (p = .010). In multivariate regression analysis, surgical approach was a significant predictor of RTWI independent of other social/clinical variables that were associated with either surgical approach or RTWI (p = .014).

CONCLUSION

Our data support a shortening of RTWI by RALP.

Three Territory Sign: An MRI marker of malignancy-related ischemic stroke (Trousseau syndrome)

Background

Multiple acute cerebral territory infarcts of undetermined origin are typically attributed to cardioembolism, most frequently atrial fibrillation. However, the importance of 3-territory involvement in association with malignancy is under-recognized. We sought to highlight the "Three Territory Sign" (TTS) (bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging [DWI] lesions), as a radiographic marker of stroke due to malignancy.

Methods

We conducted a single-center retrospective analysis of patients from January 2014 to January 2016, who suffered an acute ischemic stroke with MRI-DWI at our institution, yielding 64 patients with a known malignancy and 167 patients with atrial fibrillation, excluding patients with both to eliminate bias. All DWI images were reviewed for 3-, 2-, and 1-territory lesions. Chi-square test of proportion was used to test significance between the 2 groups.

Results

We found an association between the groups (malignancy vs atrial fibrillation) and the number of territory infarcts (p < 0.0001). Pairwise comparisons using the Holm p value adjustment showed no difference between 1- and 2-territory patterns (p = 0.465). However, the TTS was 6 times more likely observed within the malignancy cohort as compared to patients with atrial fibrillation (23.4% [n = 15] vs 3.5% [n = 6]) and was different from both 1-territory (p < 0.0001) and 2-territory patterns (p = 0.0032).

Conclusion

The TTS is a highly specific marker and 6 times more frequently observed in malignancy-related ischemic stroke than atrial fibrillation-related ischemic stroke. Evaluation for underlying malignancy in patients with the TTS is reasonable in patients with undetermined etiology.

Abstract TP72: Should Hypoperfusion Intensity Ratio Influence Patient Selection for Mechanical Thrombectomy?

Background: Current data utilizes clinical-radiographic mismatch (core and mismatch ratio) as patient selection criteria for mechanical thrombectomy in LVO. High HIR (Hypoperfusion Intensity Ratio) is known to correlate with core size, infarct growth and outcome though influence on patient selection has not been yet determined.

Hypothesis: Patients with High HIR and malignant profile (Tmax >10s greater than 50% of penumbra) indicative of fast growing infarct may influence final clinical outcome irrespective of reperfusion.

Methods: We retrospectively identified all AIS patients with LVO who underwent CTP imaging between January and June2018 within 24 hours from symptom onset. Demographics, CTP imaging variables, reperfusion status and outcomes (discharge NIHSS and mRS) were analyzed. HIR was dichotomized by proportion of greater and less than 0.5 into malignant vs favorable profile. Association with core size, infarct growth velocity, reperfusion (defined as TICI 2b or 3) and impact on outcomes was analyzed using Wilcoxon Ranked Sum tests for the (skewed) continuous and ordinal variables; chi-square test of proportion were used for categorical variables. The independent contribution of HIR and reperfusion predicting the major outcomes was assessed with logistic regression.

Results: A total of 67 patients with LVO were identified with a median age of 78 (IQR 62-87), NIHSS of 16 (IQR 11-21) and time from last seen normal to CT 404 minutes (IQR 113-734). Five patients were excluded due inadequate CTP data. Patients with high HIR (n=23) had a higher core size (median 39 cc; IQR 16-73) compared to 0 cc (IQR 0-12) than patients with low HIR (n=39; median 0; IQR 0-12) (p=<0.001) and faster Infarct growth rate 14.8 cc/hr (IQR 3.6-29.7) vs. 0 cc/hr (IQR 0-1.12) (p=<0.001). After adjusting for reperfusion, median discharge NIHSS was not significantly different (p=0.22) in groups with low vs high HIR, however in-hospital mortality differed (p=0.02).

Conclusion: Higher HIR and malignant profile is associated with larger index core size and faster growth rate. However, the influence of this profile on clinical outcomes after recanalization is yet to be established. Ongoing studies evaluating the utility of HIR on patient selection for thrombectomy are needed.

Abstract WP424: Identifying Gaps and Missed Opportunities for IV-Thrombolytic Treatment of Inpatient Stroke

Background: Inpatient stroke-codes have traditionally seen low treatment rates with IV-thrombolytic due do an abundance of stroke mimics and contraindications for treatment. However, data regarding missed treatment opportunities are lacking.

Objective: To identify the treatment gap and factors associated with missed treatment opportunities for inpatient strokes.

Methods: A retrospective chart review was performed identifying all inpatient stroke codes from March 2017 to March 2018. Clinical, radiographic and demographic patient data were collected. Primary analysis was performed between stroke vs. non-stroke final diagnosis. Dichotomous variables were analyzed using Chi-Square test of proportions and continuous variables with Wilcoxon Ranked Sum test. Significant factors were then tested in a multivariate logistic regression model for independence.

Results: Out of 211 codes, 36% (n=76) of patients had an acute stroke. An intracranial hemorrhage was present in 5.7% (n=12). Of the remaining 199 codes, 44% (n=87) were IV tPA eligible but only 3.4% (n=3) were treated. All treated patients had a confirmed stroke. Of the remaining 84 tPA-eligible patients, 44% (n=37) had >1 reason to hold treatment. The most frequent reason cited was NIHSS ≤4 in 40% (n=62), suspected metabolic encephalopathy in 23% (n=47) and abnormal blood pressure or blood sugar in 6.3% (n=13). From the eligible-but-untreated cohort, 82% (n=69) were stroke mimics while 18% (n=15) had strokes, constituting a missed treatment opportunity of 1 in 6 patients. Independent predictors of stroke were ejection fraction <30% (p=0.030, OR 3.06), post-operative status (p=0.003, OR 3.00), visual field cut (p=0.048, OR 2.61) and facial droop (p=0.048, OR 2.07). Sedative use (p=0.013, OR 0.33) and seizure at onset (p=0.015, OR 0.07) were inversely predictive of stroke.

Conclusion: In the inpatient setting, 1 in 3 codes are true strokes and treatment rates with IV thrombolytic are low with a missed treatment opportunity of 1 in every 6 eligible patients. The most frequent reasons for not treating include NIHSS ≤4 and suspicion of metabolic encephalopathy. Identifying patients with NIHSS ≤4 and knowing predictors of true stroke can help narrow this treatment gap.

Abstract TP409: Prevalence and Predictors of Stroke in Patients With Short-Term Mechanical Circulatory Support Devices: A Single-Center Study

Introduction: Short-term mechanical circulatory support devices (ST-MCS) include intra-aortic balloon-pump (IABP), extracorporeal membrane oxygenation (ECMO) and the CentriMag® and Impella® ventricular assist systems (VAS). Despite an exponential increase in their use, data regarding stroke prevalence and predictors are lacking.

Objective: To identify the prevalence and predictors of stroke in ST-MCS.

Methods: Data was collected prospectively into a database from January 2016 to June 2018 and retrospectively extracted and analyzed. Primary analysis was performed between acute-stroke vs. non-stroke diagnoses. Dichotomous and continuous variables were analyzed using Chi-Square test of proportions and Wilcoxon Ranked Sum test respectively.

Results: Out of 203 ST-MCS-patients [IABP 31.5% (n=64), Impella 24.6% (n=50), ECMO 31% (n=63) and CentriMag®VAS 12.8% (n=26)], 8.4% (n=17) had an acute stroke. Among them 6.4% (n=13) had ischemic stroke and 1% (n=2) had hemorrhagic stroke, with 1% (n=2) having both. CentriMag®VAS had a higher stroke rate than the other devices (23.1% [n=6] vs. 6.2% [n=11]; p=0.011, OR 4.53). Predictors of stroke in all patients were central cannulation (p=0.044, OR 3.08), duration >4 days (p=0.025, OR 3.21) and use of another ST-MCS device before primary device (p=0.043, OR 1.45). Flow-rate (p=0.86) and catheter size (p=0.15) did not predict stroke. Only 1 patient was eligible for thrombolytic therapy and received IV tPA, with the most common reasons to hold treatment being unknown last-seen-normal (n=8), coagulopathy (n=2) and established infarct on head CT (n=2). A large vessel occlusion was present in 20% (n=3), but none underwent a mechanical thrombectomy due of established infarction. All hemorrhagic strokes and 47% (n=7) ischemic strokes led to withdrawal of care.

Conclusion: About 1 in 12 patients placed on a ST-MCS device may have an acute stroke, but this can be as high as 1 in 5 with the use of the CentriMag®VAS. Factors such as central cannulation, duration >4 days and use of another ST-MCS device before the primary device may be predictive of acute stroke in these patients. Further research in the identification of such predictors, in conjunction with early symptom recognition could help improve treatment rates.

Abstract WP368: CT Perfusion and Radiation Exposure in Acute Ischemic Stroke: A Quality Improvement Study

Introduction: Treatment of acute ischemic stroke has undergone a paradigm shift after recently published trials DAWN & DEFUSE-3. Imaging techniques like CT perfusion (CTP) can identify eligible candidates who may benefit from intervention, however, this entails screening patients with CTP, resulting in higher radiation & contrast exposure.

Methods: Acute ischemic stroke patients admitted between Sept 2017 & Feb 2018, who underwent CTP screening at Hartford Hospital were considered for this study. Patients admitted between April & Sept 2017 who underwent CT Angiogram (CTA) Head alone for screening were considered for controls. A standard CTP algorithm was utilized, with image acquisition time initially set at 60 secs and later reduced to 45 secs. Imaging (CTP RAPID, CTA) related variables were analyzed. SPSS was used for statistical analysis.

Results: We assessed 50 patients who underwent CTP screening (CTP group) in the extended stroke window (6-24 hours) and 45 patients who served as controls. In the CTP group, 90% scans were of optimal quality, whereas 10% were deemed suboptimal. For CTP associated radiation exposure, the median dose length product (DLP) was 1420.3 mGy-cm (IQR 1420 to 1775.31 mGy-cm). The median DLP was 2401.89 mGy-cm in patients with 60 sec CTP acquisition time, significantly higher compared to 1420.3 mGy-cm in patients with 45 sec acquisition time (p<0.001). The median total radiation exposure (excluding endovascular intervention) during entire hospitalization for the CTP group was 5260 mGy-cm as compared to 3222.27 mGy-cm for controls, which was statistically significant (p<0.001). No radiation related adverse events were observed in the CTP group. In terms of contrast exposure, there was no significant difference in Sr creatinine obtained at day one or at discharge when compared to baseline (p=0.46). Amongst 50 patients screened with CT perfusion, 16 patients (32%) were deemed eligible for endovascular therapy.

Conclusions: Although CT perfusion screening may result in higher radiation exposure, the perfusion protocols may be optimized to reduce the amount of radiation imparted to patients without compromising on the scan quality. Despite additional contrast exposure, no significant effects were observed on the renal function.