The Kentucky Appalachian Stroke Registry (KApSR)

BACKGROUND

The population of rural Kentucky and West Virginia has a disproportionately high incidence of stroke and stroke risk factors. The Kentucky Appalachian Stroke Registry (KApSR) is a novel registry of stroke patients developed to collect demographic and clinical data in real time from these patients' electronic health records.

OBJECTIVE

We describe the development of this novel registry and test it for ability to provide the information necessary to identify care gaps and direct clinical management.

METHODS

The KApSR was developed as described in this article. To assess utility in patient care, we developed a "Diabetes Quality Assurance Dashboard" by cross-referencing patients in the registry with a diagnosis of ischemic cerebrovascular disease with patients that were tested for hemoglobin A1c (HbA1c) levels, patients with HbA1c levels diagnostic for diabetes mellitus (DM), and patients with an elevated HbA1c that were formally diagnosed with DM.

RESULTS

For the 1008 patients treated for ischemic cerebrovascular disease in the year studied, 859 (85%) had their HbA1c tested. Of those, 281 had levels of 6.5 or greater, although only 261 (93%) were discharged with a formal diagnosis of DM.

CONCLUSIONS

The KApSR has practical value as a tool to assess a large population of patients quickly for care quality and for research purposes.

Uncovering the Rosetta Stone: Report from the First Annual Conference on Key Elements in Translating Stroke Therapeutics from Pre-Clinical to Clinical

The first annual Stroke Translational Research Advancement Workshop (STRAW), entitled “Uncovering the Rosetta Stone: Key Elements in Translating Stroke Therapeutics from Pre-Clinical to Clinical” was held at the University of Kentucky on October 4–5, 2017. This workshop was organized by the Center for Advanced Translational Stroke Science. The workshop consisted of 2 days of activities. These included three presentations establishing the areas of research in stroke therapeutics, discussing the routes for translation from bench to bedside, and identifying successes and failures in the field. On day 2, grant funding opportunities and goals for the National Institute for Neurological Diseases and Stroke were presented. In addition, the meeting also included break-out sessions designed to connect researchers in areas of stroke, and to foster potential collaborations. Finally, the meeting concluded with an open discussion among attendees led by a panel of experts.

Abstract TP6: Evaluation of Patients With High NIH Stroke Scale as Thrombectomy Candidates Using the Kentucky Appalachian Stroke Registry (KApSR)

Background: Mechanical thrombectomy has become standard of care for emergent large vessel occlusive (ELVO) stroke. Estimates of incidence for thrombectomy eligibility vary significantly. NIH Stroke Scale (NIHSS) of 9 or greater is highly predictive of large vessel occlusion. Using our Kentucky Appalachian Stroke Registry (KApSR), we evaluated regional trends in stroke admissions with NIHSS of 10 or more to determine effects and needs in thrombectomy utilization.

Methods: Using the KApSR database that captures patients throughout the Appalachian region in our stroke network, we evaluated patients admitted with ischemic stroke with NIHSS > 9 anytime during admission. We recorded demographics, comorbidities, treatment (thrombectomy, decompressive craniectomy), and county of origin. Change in NIHSS from admission to discharge was measured as an indicator of inpatient outcome. Summary statistics and analyses were performed on SPSS; p<0.05 was significant.

Results: From 2010 to 2016, 2250 patients were included; 132 (5.9%) underwent thrombectomy. 66.8% were admitted with NIHSS > 9. Annual utilization of thrombectomy increased over time from 0.8% in 2010 to 10.6% in 2016. When thrombectomy was considered, median change in NIHSS was -2 (IQR 8) in patients without thrombectomy versus -5 (IQR 12) in patients who underwent thrombectomy; the difference was significant (p<0.001). Furthermore, while the median change in NIHSS remained stable for non-thrombectomy patients, it improved over time for thrombectomy patients (Figure 1).

Conclusion: Among patients with significant inpatient ischemic stroke, a majority present with NIHSS greater than 9. While thrombectomy has become more common, it was only utilized in 10.6% of patients in 2016. Furthermore, patients who underwent thrombectomy has significant inpatient clinical improvement compared to those that did not. Thus, further efforts are necessary to maximize the use of thrombectomy when appropriate.

Abstract TP95: Intra-arterial Interleukin-1 alpha is Well Tolerated and Neuroprotective After Experimental Ischemic Stroke

Endovascular thrombectomy combined with t-PA is the current standard of care for emergent large vessel occlusion (ELVO) stroke. Unfortunately, despite rising recanalization rates, stroke remains the leading cause of long-term disability worldwide suggesting that additional therapies are needed. Severe stroke morbidity may be due, partially, to the acute and sustained inflammatory stroke response. Preclinical research has shown some promise with anti-inflammatory agents in limiting brain injury and improving functional outcome; however, the post-stroke inflammatory cascade appears to have both beneficial and deleterious effects making the translation of such anti-inflammatory approaches perilous. We aim to show that the inflammatory cytokine interleukin-1alpha (IL-1α) is well-tolerated, neuroprotective, and conveys functional benefit after ischemic stroke. 3-month-old C57/BL6 mice were subjected to MCAo and given IL-1α via IV injection or IA infusion upon recanalization. Mice were allowed to recover for 7 days before sacrifice. Brains were flash frozen for IHC and serum for high sensitivity ELISA. We noted that IV IL-1α (1 ng) is neuroprotective (as measured by cresyl violet stained infarct volumes) and significantly improved functional recovery in open field behavioral tests. When given IV, IL-1α showed transient hemodynamic side effects that are typical of IL-1α’s known physiologic functions (fever, sterile inflammation, etc.) These effects are short lived with systemic (IV) administration and IA IL-1α (0.1 ng) administration showed neuroprotection without the side effects seen with IV treatment. Additionally, we noted that IL-1α is directly neuroprotective of primary mouse cortical neurons exposed to oxygen and glucose deprivation conditions in vitro . IL-1α’s profound, direct neuroprotective effects and its functional benefit, make IL-1α an attractive target for future study in ischemic stroke.

Abstract TMP107: Blood and Clot Thrombectomy Registry and Collaboration (BACTRAC) Protocol: Novel Method for Evaluating Human Stroke

Background: Research in ischemic stroke struggles from failures to translate stroke conditions between animal models and human patients. With mechanical thrombectomy, we have for the first time developed a protocol to facilitate tissue banking of intracranial thrombi as well as the blood immediately proximal and distal to it. These tissues provide a unique resource to correlate changes in the human condition to animal models. Our aim was to develop a reproducible protocol to bank these specimens for future gene expression and proteomic analysis.

Methods: We developed an IRB-approved protocol for tissue processing during thrombectomy (www.clinicaltrials.gov NCT03153683). The protocol was a joint clinical/basic science effort among multiple laboratories and the Neurointerventional Radiology Service Line. We placed laboratory supplies in the angio suite, and developed a step-by-step protocol for specimen retrieval and processing.

Results: Our protocol successfully yielded samples for analysis in all but one case. In our preliminary dataset, the protocol yielded adequate amounts of tissue for distal blood, proximal blood, and thrombus. We present the tissue banking protocol for dissemination, and highlight the training protocol and mechanics of on-call research staffing for 24/7 tissue processing. In addition, preliminary integrity analyses demonstrated high quality yields for RNA and protein.

Conclusion: We have developed a novel tissue banking protocol to capture thrombus, and both proximal and distal blood to the intracranial thrombus in human stroke patients. The specimens are captured during the thrombectomy procedure, and allow us to study the initial molecular response to ischemic stroke in the human condition in ways previously unavailable.

Abstract WMP113: Translational Evaluation of Acid/Base and Electrolyte Alterations in Acute Large Vessel Stroke

Background and Purpose: Monitoring for hypotension, hyperglycemia, hypoxia, and dehydration is key to reducing early death in stroke patients. Evaluation of physiological predictors of infarct volume and mortality may provide opportunities for effective interventions to improve outcomes. The purpose of this study is: 1) to describe and compare the predictive effects of venous blood gas (VBG) on infarct volume and mortality in acute stroke in rats; 2) and we have begun to collect arterial blood gas (ABG) to compare differences obtained proximal and distal to the occluded intracranial thrombi in acute ischemic stroke patients.

Methods: 3-month old Sprague-Dawey rats (n = 9) underwent permanent or transient middle cerebral artery occlusion (MCAO). Pre- and post-MCAO venous samples provided pH, pCO 2 , pO 2 , and electrolyte values (iCa 2+ , K + , and Na + ). Linear regression determined predictors of infarct volume from these values, and Cox regression analyzed VBG changes between tMCAO (n = 28) and pMCAO (n = 29) to determine predictors of mortality. We compared mean proximal and distal pH, pCO 2 , pO 2 , and electrolytes (iCa 2+ , K + , and Na + ) in stroke patients (n = 7) arterial samples using Wilcoxon Signed Ranks test.

Results: Animal studies demonstrated pH and iCa 2+ are predictors of infarct volume, but not mortality. After pMCAO (n = 9), change in pH or iCa 2+ significantly predicted infarct volume [F(1,7) = 7.351, β = -0.716, p = 0.03] and [F(1, 7) = 6.782, β = -0.701, p = 0.035]; as pH and calcium decreased, infarct volume increased. These variables explained 44% and 42% of the total variance in these models. In human patients (n = 7), there were significant differences in blood samples proximal and distal to the intracranial thrombus for pCO 2 (p = 0.018), HCO 3- (p = 0.028), iCa 2+ (p = 0.043), K + (p = 0.028), and Na + (p = 0.044).

Conclusions: In conclusion, there are acute changes in acid/base balance and electrolytes during stroke in rodent models and humans. In cross-species comparison ionized calcium changes were significant in both, with iCa 2+ changes predicting stroke volume in the rat model. These preliminary findings are novel, and warrant further exploration in human patients.

Abstract TMP28: Inhibition of Integrin α 5 β 1 With the Small Peptide Atn-161 Reduces Infarct Volume and Improves Functional Recovery Through Reduction of Blood-brain Barrier Permeability

Reperfusion-induced injury after recanalization is exacerbated by blood-brain barrier (BBB) dysfunction after ischemic stroke. Endothelial cell integrin receptors, specifically the β 1 subtype, play a direct role in BBB dysfunction through regulation of barrier-forming tight junction (TJ) proteins. We hypothesize that inhibition of an endothelial specific β 1 integrin, α 5 β 1 , after oxygen-glucose deprivation (OGD) in vitro and also after experimental stroke in vivo will stabilize the BBB through the TJ claudin-5, reducing infarct volumes and improving functional recovery. First, stroke was simulated in vitro by OGD or TNF- α treatment of brain endothelial cell monolayers. Treatment with the small peptide α 5 β 1 inhibitor ATN-161 (10 μM) resulted in decreased barrier permeability as measured by trans-endothelial cell electrical resistance and FITC-dextran permeability. Immunocytochemistry showed extracellular localization and upregulation of claudin-5 with ATN-161 treatment. Next, transient tandem middle cerebral artery occlusion was performed on 12-week-old male mice for 1 hour. On confocal and SEM imaging, post-stroke α 5 β 1 expression was upregulated primarily in the luminal vascular surface by post-stroke day (PSD) 2 rather than at the basement membrane (next to its extracellular matrix ligands). IP injection of ATN-161 (1 mg/kg) immediately after reperfusion and on PSD 1, and PSD2 caused a significant, but transient and acute (after the initial dose only) change in animal pulse distension, but no change in body temperature or heart rate. Infarct volumes, measured by TTC stain, were significantly reduced in ATN-161 treated animals. Furthermore, BBB integrity was improved by ATN-161 as determined by IgG staining and FITC-Dextran injection. Functional recovery, assessed by a 5-item Neuroscore, was also significantly improved. In conclusion, inhibition of α 5 β 1 by ATN-161 was well tolerated, reduced infarct volume, and improved behavioral recovery. Additional studies showed this result was likely due to reduced BBB permeability through the TJ claudin-5. Therefore, inhibition of α 5 β 1 with ATN-161 could represent a novel therapeutic approach for stroke worthy of further investigation.

Internal carotid artery stenosis: A novel surgical model for moyamoya syndrome

Moyamoya is a cerebrovascular disorder characterized by progressive stenosis of the intracranial internal carotid arteries. There are two forms: Disease and Syndrome, with each characterized by the sub-population it affects. Moyamoya syndrome (MMS) is more prominent in adults in their 20's-40's, and is often associated with autoimmune diseases. Currently, there are no surgical models for inducing moyamoya syndrome, so our aim was to develop a new animal model to study this relatively unknown cerebrovascular disease. Here, we demonstrate a new surgical technique termed internal carotid artery stenosis (ICAS), to mimic MMS using micro-coils on the proximal ICA. We tested for Moyamoya-like vasculopathies by fluorescently labelling the mouse cerebrovasculature with Di I for visualization and analysis of vessel diameter at the distal ICA and anastomoses on the cortical surface. Results show a significant narrowing of the distal ICA and anterior cerebral artery (ACA) in the Circle of Willis, as observed in humans. There is also a significant decrease in the number of anastomoses between the middle cerebral artery (MCA) and the ACA in the watershed region of the cortex. While further characterization is needed, this ICAS model can be applied to transgenic mice displaying co-morbidities as observed within the Moyamoya syndrome population, allowing a better understanding of the disease and development of novel treatments.

Intra-arterial verapamil post-thrombectomy is feasible, safe, and neuroprotective in stroke

Large vessel ischemic stroke represents the most disabling subtype. While t-PA and endovascular thrombectomy can recanalize the occluded vessel, good clinical outcomes are not uniformly achieved. We propose that supplementing endovascular thrombectomy with superselective intra-arterial (IA) verapamil immediately following recanalization could be safe and effective. Verapamil, a calcium channel blocker, has been shown to be an effective IA adjunct in a pre-clinical mouse focal ischemia model. To demonstrate translational efficacy, mechanism, feasibility, and safety, we conducted a group of translational experiments. We performed in vivo IA dose-response evaluation in our animal stroke model with C57/Bl6 mice. We evaluated neuroprotective mechanism through in vitro primary cortical neuron (PCN) cultures. Finally, we performed a Phase I trial, SAVER-I, to evaluate feasibility and safety of administration in the human condition. IA verapamil has a likely plateau or inverted-U dose-response with a defined toxicity level in mice (LD₅₀ 16-17.5 mg/kg). Verapamil significantly prevented PCN death and deleterious ischemic effects. Finally, the SAVER-I clinical trial showed no evidence that IA verapamil increased the risk of intracranial hemorrhage or other adverse effect/procedural complication in human subjects. We conclude that superselective IA verapamil administration immediately following thrombectomy is safe and feasible, and has direct, dose-response-related benefits in ischemia.

Acquired von Willebrand syndrome in respiratory extracorporeal life support: a systematic review of the literature

BACKGROUND AND OBJECTIVE

Venovenous extracorporeal membrane oxygenation (VV ECMO) and extracorporeal CO2 removal (ECCO2R) are increasingly used in the management of severe respiratory failure. With bleeding complications being one of the major risks of these techniques, our aim in this systematic review was to assess the available literature on acquired von Willebrand syndrome (AvWS) and extracorporeal support. AvWS has previously been associated with bleeding and shear stress.

DESIGN AND DATA SOURCES

A systematic review, using Medline via PubMed, was performed to identify eligible studies up to January 2017.

RESULTS AND CONCLUSION

The prevalence of AvWF among patients on VV ECMO or ECCO2R is high, but only a limited number of studies are reported in the literature. AvWS testing should be performed, including vWF multimer analysis, vWF activity and vWF antigen concentration. The extent to which vWF contributes to bleeding during ECMO, or how much changes in ECMO management can influence high molecular weight vWF multimer levels, cannot be answered from the currently available evidence and there remains a need for future studies.

Global tidal variations, regional distribution of ventilation, and the regional onset of filling determined by electrical impedance tomography: reproducibility

The reproducibility of the regional distribution of ventilation and the timing of onset of regional filling as measured by electrical impedance tomography lacks evidence. This study investigated whether electrical impedance tomography measurements in healthy males were reproducible when electrodes were replaced between measurements. Part 1: Recordings of five volunteers lying supine were made using electrical impedance tomography and a pneumotachometer. Measurements were repeated at least three hours later. Skin marking ensured accurate replacement of electrodes. No stabilisation period was allowed. Part 2: Electrical impedance tomography recordings of ten volunteers; a 15 minute stabilisation period, extra skin markings, and time-averaging were incorporated to improve the reproducibility. Reproducibility was determined using the Bland-Altman method. To judge the transferability of the limits of agreement, a Pearson correlation was used for electrical impedance tomography tidal variation and tidal volume. Tidal variation was judged to be reproducible due to the significant correlation between tidal variation and tidal volume (r² = 0.93). The ventilation distribution was not reproducible. A stabilisation period, extra skin markings and time-averaging did not improve the outcome. The timing of regional onset of filling was reproducible and could prove clinically valuable. The reproducibility of the tidal variation indicates that non-reproducibility of the ventilation distribution was probably a biological difference and not measurement error. Other causes of variability such as electrode placement variability or lack of stabilisation when accounted for did not improve the reproducibility of the ventilation distribution.

Abstract TP101: Intra-arterial IL-1α is Well Tolerated and Neuroprotective After Experimental Ischemic Stroke

Endovascular thrombectomy and t-PA are the only current standard of care treatments for emergent large vessel occlusion (ELVO) stroke. Despite rising recanalization rates, stroke remains the leading cause of long-term disability worldwide suggesting that additional therapies are needed. Severe stroke morbidity may be due, in part, to the acute and sustained inflammatory stroke response. Preclinical research has supported anti-inflammatory agents in limiting brain injury and improving functional outcome; however, the post-stroke inflammatory cascade appears to have both beneficial and deleterious effects, necessitating careful therapeutic translation. We have recently demonstrated that delayed (3 day) post-stroke intravenous (IV) administration of the interleukin (IL)-1α (one of the two major isoforms of the pro-inflammatory family of cytokine IL-1), promoted, rather than suppressed, post-stroke angiogenesis in the transient middle cerebral artery occlusion (MCAo) mouse model. In this study, we aimed to show a therapeutic efficacy of IL-1α in neuroprotection. We investigated the potential for IL-1α, administered acutely IV or intra-arterial (IA) (n=5) after mouse MCAo, to also be neuroprotective. We noted that IV IL-1α (1 ng) is neuroprotective (as measured by cresyl violet stained infarct volumes) with mild, transient side effects (blunted hypertension and bradycardia) that were well tolerated, and with better functional recovery in free motion behavioral tests. IA IL-1α (0.1 ng) administration was even more neuroprotective without the systemic changes seen with IV treatment. Additionally, we noted that IL-1α is directly neuroprotective of primary mouse cortical neurons exposed to oxygen and glucose deprivation conditions in vitro . Taken together, these results suggest that IL-1α could be therapeutic after stroke when administered IV or IA, and the latter may eliminate potentially harmful hemodynamic side effects.

Abstract TP301: Outlier Analysis of NIHSS Change in a Regional Database of Acute Ischemic Stroke

Introduction: Change in NIH Stroke Scale from admission to discharge has been proposed as an outcome-based method of assessing quality of care in the inpatient setting. Using the Kentucky Appalachian Stroke Registry database, statistical outliers were identified as potential targets for investigation. We aimed to use the analysis of this subset of patients to identify characteristics favoring exceptionally good or poor outcome.

Methods: De-identified patient data was obtained from the Kentucky Appalachian Stroke Registry for all acute ischemic stroke patients from January 1, 2013 to December 31, 2014 using discharge diagnoses. Statistical process control methodology was used to identify hospitalizations with positive or negative NIHSS change more than three standard deviations from the mean. The statistical outliers underwent manual chart review to validate the data obtained from the registry and supplement it qualitatively to identify common characteristics. Chi-square tests were conducted to assess the association between patient characteristics and being a positive or negative outlier.

Results: Positive outliers were less likely to have hypertension and more likely to have received intravenous thrombolysis. Negative outliers were more likely to have carotid stenosis. Both groups were more likely to have a diagnosis of cardiac arrhythmia and to have received mechanical thrombectomy.

Conclusions: Gathering registry data regarding NIHSS outliers is a feasible and potentially useful tool in understanding and improving care. The absence of hypertension may represent positive predictive recovery potential in severe stroke. Patients with significant carotid disease on presentation may be at risk of neurological decline. Furthermore, patients with large vessel occlusions undergoing thrombectomy represent a high-variance population with the greatest improvements and greatest deteriorations during inpatient hospitalization.

Abstract 43: Neuroprotective Effects of Inhibition of α5β1 Integrin Following Experimental Stroke: A Dual Center Pre-Clinical Study

Blood-brain barrier (BBB) dysfunction after ischemic stroke exacerbates brain damage by contributing to edema and inflammation. The β1 integrin receptor family may contribute to this dysfunction via alteration of BBB-forming tight junction proteins. We hypothesize that inhibition of the β1 integrin receptor subtype α5β1, which is acutely expressed in infarct and peri-infarct vasculature after experimental stroke, reduces BBB permeability, reduces infarct volume, and improves functional recovery. A randomized and blinded trial was conducted using transient middle cerebral artery occlusion (MCAO) in mice (60 min; n=8) and rats (90 min; n=15) in two independent laboratories. ATN-161 (α5β1 inhibitor; 1 mg/kg) was administered IV immediately upon reperfusion and on post-stroke day 1 and 2. Infarct volume was determined by cresyl violet (mice) and T 2 weighted MRI (rat) at day 3 post MCAO. Steady state contrast enhanced MRI was used to assess BBB breakdown in rats at day 3. ATN-161 resulted in a significant reduction in infarct volume in both mice and rats when measured at post-stroke day 3 (p<0.001). BBB permeability was decreased upon ATN-161 treatment in vivo as determined by reduced IgG and claudin-5 immunostaining in mice and reduced extent of Gadolinium enhanced MRI signal change in rats. Behavioral tests (open field, rotorod, sticky label and 28 point neuroscore), demonstrated significantly improved functional recovery in both mice and rats following treatment with ATN-161. Finally, in vitro studies where stroke was simulated using oxygen and glucose deprivation or TNF-α, ATN-161 (10 μM) treatment demonstrated decreased barrier permeability as measured by trans-endothelial cell electrical resistance, FITC-dextran permeability, and claudin-5 immunocytochemistry. Collectively, our results demonstrate that post-stroke inhibition of α5β1 integrin with the small peptide ATN-161 profoundly reduces infarct volume, improves functional outcome and decreases BBB permeability in both mice and rats using two different ischemic stroke models. Therefore, inhibition of α5β1 by ATN-161 could represent a novel stroke therapeutic target worthy of further investigation.

Intra-arterial nitroglycerin as directed acute treatment in experimental ischemic stroke

BACKGROUND

Nitroglycerin (also known as glyceryl trinitrate (GTN)), a vasodilator best known for treatment of ischemic heart disease, has also been investigated for its potential therapeutic benefit in ischemic stroke. The completed Efficacy of Nitric Oxide in Stroke trial suggested that GTN has therapeutic benefit with acute (within 6 hours) transdermal systemic sustained release therapy.

OBJECTIVE

To examine an alternative use of GTN as an acute therapy for ischemic stroke following successful recanalization.

METHODS

We administered GTN IA following transient middle cerebral artery occlusion in mice. Because no standard dose of GTN is available following emergent large vessel occlusion, we performed a dose-response (3.12, 6.25, 12.5, and 25 µg/µL) analysis. Next, we looked at blood perfusion (flow) through the middle cerebral artery using laser Doppler flowmetry. Functional outcomes, including forced motor movement rotor rod, were assessed in the 3.12, 6.25, and 12.5 µg/µL groups. Histological analysis was performed using cresyl violet for infarct volume, and glial fibrillary activating protein (GFAP) and NeuN immunohistochemistry for astrocyte activation and mature neuron survival, respectively.

RESULTS

Overall, we found that acute post-stroke IA GTN had little effect on vessel dilatation after 15 min. Functional analysis showed a significant difference between GTN (3.12 and 6.25 µg/µL) and control at post-stroke day 1. Histological measures showed a significant reduction in infarct volume and GFAP immunoreactivity and a significant increase in NeuN.

CONCLUSIONS

These results demonstrate that acute IA GTN is neuroprotective in experimental ischemic stroke and warrants further study as a potentially new stroke therapy.

A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients

PURPOSE

To improve jugular central venous access device (CVAD) securement, prevent CVAD failure (composite: dislodgement, occlusion, breakage, local or bloodstream infection), and assess subsequent trial feasibility.

MATERIALS AND METHODS

Study design was a 4-arm, parallel, randomized, controlled, nonblinded, pilot trial. Patients received CVAD securement with (i) suture+bordered polyurethane (suture + BPU; control), (ii) suture+absorbent dressing (suture + AD), (iii) sutureless securement device+simple polyurethane (SSD+SPU), or (iv) tissue adhesive+simple polyurethane (TA+SPU). Midtrial, due to safety, the TA+SPU intervention was replaced with a suture + TA+SPU group.

RESULTS

A total of 221 patients were randomized with 2 postrandomization exclusions. Central venous access device failure was as follows: suture + BPU controls, 2 (4%) of 55 (0.52/1000 hours); suture + AD, 1 (2%) of 56 (0.26/1000 hours, P=.560); SSD+SPU, 4 (7%) of 55 (1.04/1000 hours, P=.417); TA+SPU, 4 (17%) of 23 (2.53/1000 hours, P=.049); and suture + TA+SPU, 0 (0%) of 30 (P=.263; intention-to-treat, log-rank tests). Central venous access device failure was predicted (P<.05) by baseline poor/fair skin integrity (hazard ratio, 9.8; 95% confidence interval, 1.2-79.9) or impaired mental state at CVAD removal (hazard ratio, 14.2; 95% confidence interval, 3.0-68.4).

CONCLUSIONS

Jugular CVAD securement is challenging in postcardiac surgical patients who are coagulopathic and mobilized early. TA+SPU was ineffective for CVAD securement and is not recommended. Suture + TA+SPU appeared promising, with zero CVAD failure observed. Future trials should resolve uncertainty about the comparative effect of suture + TA+SPU, suture + AD, and SSD+SPU vs suture + BPU.

Nursing team leader handover in the intensive care unit contains diverse and inconsistent content: An observational study

BACKGROUND

Despite a proliferation of evidence and the development of standardised tools to improve communication at handover, evidence to guide the handover of critical patient information between nursing team leaders in the intensive care unit is limited.

OBJECTIVE

The study aim was to determine the content of information handed over during intensive care nursing team leader shift-to-shift handover.

DESIGN

A prospective observational study.

SETTING

A 21-bed medical/surgical adult intensive care unit specialising in cardiothoracic surgery at a tertiary referral hospital in Queensland, Australia.

PARTICIPANTS

Senior nurses (Grade 5 and 6 Registered nurses) working in team leader roles, employed in the intensive care unit were sampled.

METHOD

After obtaining consent from nursing staff, team leader handovers were audiotaped over 20 days. Audio recordings were transcribed and analysed using deductive and inductive content analysis. The frequency of content discussed at handover that fell within the a priori categories of the ISBAR schema (Identify-Situation-Background-Assessment-Recommendation) was calculated.

RESULTS

Forty nursing team leader handovers were recorded resulting in 277 patient handovers and a median of 7 (IQR 2) patients discussed at each handover. The majority of nurses discussed the Identity (99%), Situation (96%) and Background (88%) of the patient, however Assessment (69%) content was varied and patient Recommendations (60%) were discussed less frequently. A diverse range of additional information was discussed that did not fit into the ISBAR schema.

CONCLUSIONS

Despite universal acknowledgement of the importance of nursing team leader handover, there are no previous studies assessing its content. Study findings indicate that nursing team leader handovers contain diverse and inconsistent content, which could lead to inadequate handovers that compromise patient safety. Further work is required to develop structured handover processes for nursing team leader handovers.

Stroke neuroprotection revisited: Intra-arterial verapamil is profoundly neuroprotective in experimental acute ischemic stroke

While clinical trials have now solidified the role of thrombectomy in emergent large vessel occlusive stroke, additional therapies are needed to optimize patient outcome. Using our previously described experimental ischemic stroke model for evaluating adjunctive intra-arterial drug therapy after vessel recanalization, we studied the potential neuroprotective effects of verapamil. A calcium channel blocker, verapamil is often infused intra-arterially by neurointerventionalists to treat cerebral vasospasm. Such a direct route of administration allows for both focused targeting of stroke-impacted brain tissue and minimizes potential systemic side effects. Intra-arterial administration of verapamil at a flow rate of 2.5 µl/min and injection volume of 10 µl immediately after middle cerebral artery recanalization in C57/Bl6 mice was shown to be profoundly neuroprotective as compared to intra-arterial vehicle-treated stroke controls. Specifically, we noted a significant (P ≤ 0.05) decrease in infarct volume, astrogliosis, and cellular apoptosis as well as a significant increase in neuronal survival and functional outcome over seven days. Furthermore, intra-arterial administration of verapamil was well tolerated with no hemorrhage, systemic side effects, or increased mortality. Thus, verapamil administered intra-arterially immediately following recanalization in experimental ischemic stroke is both safe and neuroprotective and merits further study as a potential therapeutic adjunct to thrombectomy.