Selective cytotoxicity and cell death induced by human amniotic membrane in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has a worldwide high incidence and mortality. For this reason, it is essential to invest in new therapies for this type of cancer. Our team already proved that human amniotic membrane (hAM) is able to inhibit the metabolic activity of several human cancer cell lines, including HCC cell lines. Taking into account the previously performed work, this experimental study aimed to investigate the pathways by which hAM protein extracts (hAMPEs) act on HCC. Our results showed that hAMPE reduce the metabolic activity, protein content and DNA content in a dose- and time-dependent manner in all HCC cell lines. This therapy presents selective cytotoxicity, since it was not able to inhibit a non-tumorigenic human cell line. In addition, hAMPE induced cell morphology alterations in all HCC cell lines, but death type is cell line dependent, as proved by in vitro and in vivo studies. In conclusion, hAMPE have a promising role in HCC therapy, since it is capable of inducing HCC cytotoxicity and cell death.

Are allergic multimorbidities and IgE polysensitization associated with the persistence or re-occurrence of foetal type 2 signalling? The MeDALL hypothesis

Allergic diseases [asthma, rhinitis and atopic dermatitis (AD)] are complex. They are associated with allergen-specific IgE and nonallergic mechanisms that may coexist in the same patient. In addition, these diseases tend to cluster and patients present concomitant or consecutive diseases (multimorbidity). IgE sensitization should be considered as a quantitative trait. Important clinical and immunological differences exist between mono- and polysensitized subjects. Multimorbidities of allergic diseases share common causal mechanisms that are only partly IgE-mediated. Persistence of allergic diseases over time is associated with multimorbidity and/or IgE polysensitization. The importance of the family history of allergy may decrease with age. This review puts forward the hypothesis that allergic multimorbidities and IgE polysensitization are associated and related to the persistence or re-occurrence of foetal type 2 signalling. Asthma, rhinitis and AD are manifestations of a common systemic immune imbalance (mesodermal origin) with specific patterns of remodelling (ectodermal or endodermal origin). This study proposes a new classification of IgE-mediated allergic diseases that allows the definition of novel phenotypes to (i) better understand genetic and epigenetic mechanisms, (ii) better stratify allergic preschool children for prognosis and (iii) propose novel strategies of treatment and prevention.

The locus C11orf30 increases susceptibility to poly-sensitization

A number of genetic variants have been associated with allergic sensitization, but whether these are allergen specific or increase susceptibility to poly-sensitization is unknown. Using data from the large multicentre population-based European Community Respiratory Health Survey, we assessed the association between 10 loci and specific IgE and skin prick tests to individual allergens and poly-sensitization. We found that the 10 loci associate with sensitization to different allergens in a nonspecific manner and that one in particular, C11orf30-rs2155219, doubles the risk of poly-sensitization (specific IgE/4 allergens: OR = 1.81, 95% CI 0.80-4.24; skin prick test/4+ allergens: OR = 2.27, 95% CI 1.34-3.95). The association of rs2155219 with higher levels of expression of C11orf30, which may be involved in transcription repression of interferon-stimulated genes, and its association with sensitization to multiple allergens suggest that this locus is highly relevant for atopy.

Abstract T P62: Safety Scans after Intravenous Thrombolytic Therapy Fail to Alter Course or Management

Introduction: The risk of intracranial hemorrhage (ICH) following IV-rtPA is 20%, and symptomatic ICH is 6%. Due to this concern, many practitioners obtain a 24-hour safety image after administration of t-PA for acute ischemic stroke (AIS). We sought to determine whether 24-hour safety imaging influenced clinical management or outcomes

Methods: We conducted a retrospective analysis of suspected AIS patients treated with IV t-PA at our medical center between January 2012 and February 2014. Medical records were reviewed for clinical decision-making, neurologic deterioration, and ICH. All patients were examined on admission by NIHSS-certified neurologists. Baseline characteristics were captured from a department database. A stepwise linear regression was used to identify variables predicting change in management and discharge modified Rankin scores (mRS).

Results: Our study included 172 patients who received IV t-PA. After exclusion for endovascular treatment, clinical research trials that required follow-up imaging, and missing demographics, 116 patients were included in the final analysis. Neurologic deterioration was seen in 20 (17.2%) patients, intracranial hemorrhage was seen in 19 (16.3%) patients, and clinical management changed in 11 (9.4%) patients. Clinical deterioration was the only variable that predicted a change in management (logistic regression p<0.05). After adjusting for deterioration, neither 24-hour imaging nor presence of ICH predicted a change in management. Using a linear regression model, baseline NIHSS and clinical deterioration predicted mRS at discharge, whereas 24-hour imaging and change in clinical management did not (r 2 =0.43, p<0.001).

Conclusion: Our data suggests frequent examination for neurologic deterioration is superior to 24-hour imaging in guiding clinical decision making. These findings should be investigated prospectively.

Abstract T P329: Coo-Coo For Compliance: Improving Compliance of Acute Stroke Patient Documentation

Introduction/Background: As a Joint Commission Comprehensive Stroke Center we are charged with the task of meticulous monitoring of vital signs and neurologic status after thrombolytic therapy to prevent complications. This can be difficult to document in real time. In accordance with best practices and the AHA guidelines and the American Association of Neuroscience Nurses, we sought to improve the documentation of vital signs and neurologic evaluations during and after t-PA. During our Joint Commission Comprehensive Stroke Survey we were cited for improving the documentation of vital signs and neurological checks after t-PA.

Background: We identified nurses were starting documentation at awkward times, i.e. 1538 and attempting to add 15min to this time over a 24 hour period. The nurses were educated about rounding up to the 15min mark, making it easier to add 15min each time. We auditied documentation of every patient who received Acute Stroke Treatment, and sent feed back to nurses in “real time”. We discovered transportation from one department to another caused missed documentation. A transport monitor was purchased that can easily take a full set of vital signs during transport, and nurses were instructed to “back time” the documentation. We found that intensive documentation required the nurse to sift through multiple screens to document findings. The entire neuro team collaborated to create a Stroke Navigator for EPIC. This navigator contains all pieces of expected documentation of the stroke patient in one area of EPIC.

Conclusion: From January to December 2013, our Stroke Team saw 970 patients. 82 were treated with IV tPA, 18 were sent for Interventional clot retrieval, 6 received both IV tPA and Interventional clot retrieval, and 4 received tPA at another facility and transported to Cedars Sinai for higher level of care. We found issues within the system, that increased the chances of having vital documentation missed, or delayed by the nursing staff. Prior to the implementation of these new strategies our compliance rate with documentation was 32%. The results after the implementation of our new strategies were staggering. Our nurses were 94% compliant with documentation.

Abstract T P356: Functional Outcomes of the Acute Ischemic Stroke Patient Population

Background: Stroke is the leading cause of long-term disability and affects 795,000 in the U.S. each year. This study is conducted to enhance knowledge ofoutcomes after an acute ischemic stroke (AIS).Comprehensive Stroke Certification tasks hospitals with expanding knowledge of functional and quality of life outcomes for AIS patients through the early acute and post-acute phase of recovery and examining the effects of stroke severity, functional impairment,discharge destinations, functional independence, and quality of life post discharge.

Researchable question: What are most common setbacks after AIS affetcing functional outcome & readmission?

Methods: Looked at AIS patients from 12/2012 -12/ 2013 at Cedars-Sina. Of total of 709 patients 318 were contacted by phone. Measures collected by MedTel Outcomes LLC on all AIS patients one month after discharge. This included the Functional Independence Measure and standardized quality of life and participation measures.The median age was 65 years at the time of the stroke.

Results: Most common setbacks were recurrent strokes, pneumonia, falls& heart failure.All caused re-hospitalization after stroke. Discharge destinations 30 days post stroke hospitalization were: home independent 144 (43.3%). No significant disability 49 (14.7%), Slight disability 21 (6.3%) Moderate disability 44 ( 13.2%), moderate to severe disability 43 ( 12.9%) and finally severe disability 31( 9.3%). 83.7 % were home without assistance and 1.3 % were in board and care, 15 patients, (4.7 %) had been readmitted for recurrent stroke, 48 patients had fallen since discharge

Conclusions: Over 83.7 % of AIS patients were back living in the community at home with over 60 % having slight disability.The long-term outcomes have implications for late secondary and tertiary prevention and creating a model for predictors of these At follow-up, in terms of physical functioning measures,mostpatients were independent in toileting and self-care activities,half were independent in mobility excluding stairs.Data from this study can be used to understand the functional trajectory of recovery based on severity of stroke, discharge destination and other factors. It is important to understand patients’ characteristics to help prevent readmissions.

Abstract T P330: Depression Cognition Screens

Introduction/Background: Evidence suggests that approximately 1/3 of stroke survivors suffer from post stroke depression (PSD) and changes to their cognition. Delay in identifying these patients can effect rehabilitation resulting in poorer functional outcomes, reduced cognitive performance and possibly increase mortality. PSD can occur in all phases of stroke recovery with a peak incidence at 3 - 6 months. Early diagnosis is essential so to apply effective treatment or interventions that can result in enhanced recovery. As a Comprehensive Stroke Center, we at Cedar Sinai hospital are charged with the task of efficiently indentifying patients that are at risk by administrating the Patient Health Questionnaire (PHQ 2) to those who can participate.

Research Question: Does administering the PHQ 2 during the acute phase of stroke/TIA adequately identify those at risk for Depression and cognitive decline?

Methods: Plan: As per Joint Commission standard, depression cognition screens are to be conducted prior to discharge.

Do: Chose a tool that efficiently and skillfully identifies patients at risk.

Study: Analyze the results.

Act: Administer the PHQ 2 to those patients who have the capacity. For those patients that have a positive screen, notify their primary care provider for further evaluation or possible intervention.

Conclusions: We retrospectively reviewed from September 2012 to September 2013 Stroke/TIA patients that had the capacity to participate in the PHQ 2 Depression Cognition screen. We identified that of 442 patients that completed the screen, 43 or 9.7% had depression screen of 3 or greater or demonstrated cognitive decline with score of 1 or less. If not for these evaluations these patient may have not been identified so to assure follow-up and/or treatment which could improve functional outcomes for this patient population. Furthermore it demonstrates the need for continued reevaluation since the incidence of this issue has not reached its peak.

Arterial blood pressure responses to short-term exposure to low and high traffic-related air pollution with and without moderate physical activity

BACKGROUND

Short-term exposure to traffic-related air pollution (TRAP) has been associated with adverse cardiovascular outcomes. Physical activity (PA) in polluted air may increase pollutant uptake and increase these effects.

METHODS

Crossover real-world exposure study in 28 healthy participants comparing systolic (SBP) and diastolic blood pressure (DBP) responses to four different exposure scenarios: 2 h exposure in high or low-TRAP environment, each at rest and combined with intermittent moderate PA consisting of 15 min intervals alternating rest and cycling on a stationary bicycle. Data was analyzed using mixed effect models for repeated measures.

RESULTS

Exposure to high TRAP was associated with higher DBP (1.1 mm/Hg, p = 0.002) post-exposure, irrespective of exercise status. Ultrafine particles (UFP) increased DBP post-exposure (0.9 mm/Hg, p = 0.004). Interquartile increases in black carbon (BC), fine particulate matter (PM10 and PMcoarse), UFP, and nitric oxides (NOx) were associated with statistically significantly higher SBP post-exposure (1.2, 1.0, 1.1, and 1.1 mm/Hg, respectively). Intermittent PA compared with rest was associated with lower SBP post-exposure (-2.4 mm/Hg, p < 0.001). PA lowered SBP more after exposure to the low-TRAP site (-2.3 mm/Hg) compared with the high-TRAP site (-1.6 mm/Hg). We only found evidence of an interaction between PA and both PM10 and PMcoarse, increasing SBP.

CONCLUSION

Both SBP and DBP increase after exposure to TRAP. Intermittent PA attenuates the TRAP-related increases in SBP, with the exception of PM10 and PMcoarse, which potentiate these increases. We showed that in low-TRAP environments intermittent PA has stronger beneficial effects on SBP than in high-TRAP environments.

Abstract NS13: Road to Recovery after Stroke: Understanding Predictors of Discharge Destination, Functional Independence, and Quality of Life after Hospital Discharge

Introduction: Stroke is the leading cause of long-term disability and affects 795,000 people in the U.S. each year. This study was conducted to enhance knowledge of outcomes during recovery and the options for participating in rehabilitation and preventive care during patients’ transitions to the community. Comprehensive Stroke Certification charges hospitals with the task of expanding knowledge of functional and quality of life outcomes for all stroke patients through the continuum examining effects of stroke severity, functional impairment, and patient characteristics on discharge destinations, functional independence, and quality of life after discharge.

Methods: Retrospective analysis of an acute stroke quality improvement database which includes measures collected by MedTel Outcomes LLC on all stroke patients one month after discharge. Included, is the Functional Independence Measure and standardized quality of life and participation measures. In the database are standardized measures from the medical record such stroke type, Modified Rankin score, and acute functional independence measure score for 719 patients with a 30-day follow-up phone assessment for functional and quality of life measures from January 1, 2011 to December 31, 2012.

Preliminary Findings: Over 75% of patients had hemiparesis, & over 90% survived 30-days post discharge and were living in the community. At follow-up, mostwere independent in self-care, and half were independent in mobility excluding stairs. Those with right brain involvement had a complicated, slower recovery. Those with left brain involvement,had lower functional scores and a higher percentage of them were not living in the community, rather, living in institutions.

Conclusions: All patients experiencing a stroke should have evidence-based information on their options & what to expect during their recovery during their transitions into the community. The data base is useful as a source of outcome data for comparative effectiveness and to build a regional collaborative outcomes database for Comparative Effectiveness Research and quality benchmarking. Findings can be used to understand the functional trajectory of recovery based on severity of stroke and other factors.

Abstract W P287: Does Comprehensive Stroke Certification Demonstrate a Significant Effect on Volume and Quality of Care?

Introduction/Background information: At the onset of acute stroke symptoms, speed, capability, safety and skill are essential-lost minutes can be the difference between full recoveries, poor outcome, or even death. The Joint Commission's Certificate of Distinction for Comprehensive Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. While many hospitals have been surveyed, Cedars Sinai was the 5 th hospital in the nation to receive this certification.

Researchable question: Does Comprehensive stroke certification (CSC) demonstrate a significant effect on volume and quality of care?

Methods: We assembled a cross-functional, multidisciplinary expert team representing all departments and skill sets involved in treating stroke patients. We carefully screened eligible patients with acute ischemic stroke We assessed the number of patients treated at Cedars-Sinai with IV-T-pa t 6 months before and then 6 months after CSC and the quality of their care including medical treatment and door to needle time.

Results: In the 6 months prior to Joint Commissions Stroke Certification we treated 20 of 395acute stroke patients with t-PA with an average CT turnaround time of 31±19minutes and an average Door to needle time (DTNT) of 68±32minutes. In the 6 months since Joint Commission Stroke Certification we have increased the number of acute stroke patients treated by almost double. There were 37 out of 489(P=0.02, Chi Square) patients treated with IV t-PA with an average CT turnaround time of 22±7minutes (p=0.08, t-test, compared to pre-CSC) and an average DTNT of 61± 23minutes (not different than pre-CSC).

Conclusion: We conclude that Joint Commission Certification for stroke was associated with an increased rate of treatment with IV rt-PA in acute ischemic stroke patients. We were not able to document an effect on quality of care. Further studies of the impact of CSC certification are warranted.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Respiratory health and endotoxin: associations and modification by CD14/-260 genotype

Exposure to endotoxin has been associated with increased respiratory symptoms and decrements in lung function in occupational settings but little is known about the health effects of domestic exposure in adults. Here, we describe the association of respiratory disease, immunoglobulin (Ig)E sensitisation, bronchial reactivity and lung function with mattress endotoxin levels in adults, and determine whether these associations are modified by polymorphisms in CD14. Endotoxin levels in mattress dust from a population-based sample of 972 adults were measured. Associations were examined using generalised linear mixed models, adjusting for individual and household confounders. Effect modification of these associations by CD14/-260 (rs2569190) was assessed. Mattress endotoxin levels varied from 0.1 to 402.6 EU · mg(-1). Although there was no overall association of lung function with endotoxin exposure, there was evidence that the association of forced expiratory volume in 1 s and forced vital capacity with endotoxin was modified by CD14/-260 genotype (p-value for interaction 0.005 and 0.013, respectively). There was no evidence that symptoms, IgE sensitisation or bronchial reactivity were associated with mattress endotoxin levels. In this large epidemiological study of adults, there was no evidence that mattress endotoxin level was associated with respiratory symptoms or IgE sensitisation but the association of lung function with endotoxin levels may be modified by CD14 genotype.

Abstract 2258: Ambulance Directed Care for Acute Stroke Patients at Cedars-Sinai Medical Center

Quality Improvement Study: Background: Advances over the last decade highlight the important role of Emergency Medical Services (EMS) agencies in optimizing stroke care. Los Angeles County’s Department of Health Services (LA County DHS) Stroke Patient Policy was instituted on November 16, 2009. As a result, ambulances now transport suspected stroke patients directly to approved Stroke Centers. In a single institution-TJC certified as a PSC since 2008, we studied the effect of the Stroke Patient Destination Policy and ambulance-directed care on the percentage of ischemic stroke patients receiving acute stroke treatments (IV tPA, intra-arterial thrombolysis or clot-retrieval, or bridge therapy).

Methods: 2, 156 patient charts were retrospectively reviewed from the 16 months prior to the implementation of ambulance-directed care compared to a 16-month period between after implementation of ambulance-directed stroke care.

Results: In the pre-policy period, 344 suspected stroke patients arrived by EMS versus 491 suspected stroke patients arriving by EMS in the post-policy period - a 30% increase. (Chi 2 p=0.07). Of 344 patients, 34 (9.9%) received acute stroke treatment in the pre-policy period, compared to 63 of 491 patients receiving acute stroke treatments in the post-policy period (12.8%, NS). The median age of patients pre and post policy change was 69.5 years old. The median gender distribution was 46% male and 54% female. Neither age nor gender differed before or after the policy change.

Conclusions: Implementation of the LA County DHS Stroke Patient Destination Policy appeared to cause a higher volume of acute stroke patients receiving treatment at one Joint Commission certified academic medical center. The data suggests that 29 additional patients were treated with acute stroke treatments due to ambulance directed care. Additional confirmatory data is needed from other centers.

Abstract 2191: A Multidiciplinary Team Approach To Improving The Quality Of Care In The Setting Of Tissue Plasminogen Activator

Background and Purpose: Monitoring of vital signs and neurolgic status is imperative after thrombolytic therapy to prevent complications but can be difficult to document in real time. We sought to improve the documentation of vital signs and neurologic evaluations during and after t-PA.

Methods: We retrospectively audited all acute ischemic strokes receiving t-PA March through June 2010. A total of 12 patients received t-PA. The average age was 68.4 years with 48% of this population being male. These patients did not have adequate and consistent vital sign and neurologic check documentation. Of the 12 patients receiving t-PA, only 27.5% of patients had proper documentation as defined by the NINDS. In June and July 2010, the stroke team held 7 meetings with the nursing staff, ED, Neuro ICU, pharmacy and physicians to gather ideas for methods to improve compliance. An aggressive education endeavor was developed with nursing, physicians and pharmacy staff. The stroke team reinforced and re-educated staff regarding the standard order sets, stroke competencies and stroke guidelines. The nursing staff developed signage to place above the patient’s bed when receiving t-PA, to remind the staff of the required time frames for documentation. The ED staff created a reminder ticket/ flyer that the pharmacist carries in the t-PA administration box to hand to the nurse when t-PA is about to be administered. We moved the vital sign frequency from the second page to the front page of the standard t-PA administration order set.

Result: Between July 2010 and February 2011, we gave t-PA to 39 patients, of whom the average age was 61.0 years with 47.4% of this population being male. Utilizing all of the methods and extraordinary collaboration, 91% were fully compliant for neurologic checks and vitals signs during and following t-PA administration.

Conclusion: We conclude that ongoing education and reinforement is effective for promoting change in adherence to documentation guidelines after thrombolytic therapy. When we have the occasional fallout, we reach out to that area immediately to talk with and educate the staff to determine the cause and most importantly what we can do to prevent this. Working together has greatly improved documentation compliance.