Assessing Spns2-dependent S1P Transport as a Prospective Therapeutic Target

S1P (sphingosine 1-phosphate) receptor modulator (SRM) drugs interfere with lymphocyte trafficking by downregulating lymphocyte S1P receptors. While the immunosuppressive activity of SRM drugs has proved useful in treating autoimmune diseases such as multiple sclerosis, that drug class is beset by on-target liabilities such as initial dose bradycardia. The S1P that binds to cell surface lymphocyte S1P receptors is provided by S1P transporters. Mice born deficient in one of these, spinster homolog 2 (Spns2), are lymphocytopenic and have low lymph S1P concentrations. Such observations suggest that inhibition of Spns2-mediated S1P transport might provide another therapeutically beneficial method to modulate immune cell positioning. We report here results using a novel S1P transport blocker (STB), SLF80821178, to investigate the consequences of S1P transport inhibition in rodents. We found that SLF80821178 is efficacious in a multiple sclerosis model but - unlike the SRM fingolimod - neither decreases heart rate nor compromises lung endothelial barrier function. Notably, although Spns2 null mice have a sensorineural hearing defect, mice treated chronically with SLF80821178 have normal hearing acuity. STBs such as SLF80821178 evoke a dose-dependent decrease in peripheral blood lymphocyte counts, which affords a reliable pharmacodynamic marker of target engagement. However, the maximal reduction in circulating lymphocyte counts in response to SLF80821178 is substantially less than the response to SRMs such as fingolimod (50% vs. 90%) due to a lesser effect on T lymphocyte sub-populations by SLF80821178. Finally, in contrast to results obtained with Spns2 deficient mice, lymph S1P concentrations were not significantly changed in response to administration of STBs at doses that evoke maximal lymphopenia, which indicates that current understanding of the mechanism of action of S1P transport inhibitors is incomplete.

Determinants and Temporal Trends of Dual Antiplatelet Therapy After Mild Noncardioembolic Stroke

BACKGROUND

Short-term dual antiplatelet therapy (DAPT) reduces early stroke recurrence after mild noncardioembolic ischemic stroke (NCIS). We aim to evaluate temporal trends and determinants of DAPT prescription after mild NCIS in the Florida Stroke Registry, a statewide registry across Get With The Guidelines-Stroke participating hospitals.

METHODS

In this cross-sectional analysis of a cohort study, we included patients with mild NCIS (National Institutes of Health Stroke Scale score ≤3) who were potentially eligible for DAPT across 168 Florida Stroke Registry participating hospitals between January 2010 and September 2022. Using antiplatelet prescription as the dependent variable (DAPT versus single antiplatelet therapy), we fit logistic regression models adjusted for patient-related factors, hospital-related factors, clinical presentation, vascular risk factors, and ischemic stroke subtype, to obtain adjusted odds ratios (aORs) with 95% CIs.

RESULTS

From 283 264 Florida Stroke Registry ischemic stroke patients during the study period, 109 655 NCIS were considered eligible. Among these, 37 058 patients with National Institutes of Health Stroke Scale score >3 were excluded, resulting in a sample of 72 597 mild NCIS (mean age 68±14 years; female 47.3%). Overall, 24 693 (34.0%) patients with mild NCIS were discharged on DAPT and 47 904 (66.0%) on single antiplatelet therapy. DAPT prescription increased from 25.7% in 2010 to 52.8% in 2022 (β/year 2.5% [95% CI, 1.5%-3.4%]). Factors associated with DAPT prescription were premorbid antiplatelet therapy (aOR, 4.66 [95% CI, 2.20-9.88]), large-artery atherosclerosis (aOR, 1.68 [95% CI, 1.43-1.97]), diabetes (aOR, 1.29 [95% CI, 1.13-1.47]), and hyperlipidemia (aOR, 1.24 [95% CI, 1.10-1.39]), whereas female sex (aOR, 0.83 [95% CI, 0.75-0.93]), being non-Hispanic Black patients (compared with non-Hispanic White patients; aOR, 0.78 [95% CI, 0.68-0.90]), admission to a Thrombectomy-capable Stroke Center (compared with Comprehensive Stroke Center; aOR, 0.78 [95% CI, 0.66-0.92]), time-to-presentation 1 to 7 days from last seen well (compared with <24 h; aOR, 0.86 [95% CI, 0.76-0.96]), and small-vessel disease stroke (aOR, 0.81 [95% CI, 0.72-0.94]) were associated with not receiving DAPT at discharge.

CONCLUSIONS

Despite a temporal trend increase in DAPT prescription after mild NCIS, we found substantial underutilization of evidence-based DAPT associated with significant disparities in stroke care.

Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry

Temporal trends and factors associated with the withdrawal of life-sustaining therapy (WLST) after acute stroke are not well determined.

DESIGN

Observational study (2008-2021).

SETTING

Florida Stroke Registry (152 hospitals).

PATIENTS

Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Importance plots were performed to generate the most predictive factors of WLST. Area under the curve (AUC) for the receiver operating curve were generated for the performance of logistic regression (LR) and random forest (RF) models. Regression analysis was applied to evaluate temporal trends. Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST. Patients who had WLST were older (77 vs 70 yr), more women (57% vs 49%), White (76% vs 67%), with greater stroke severity on the National Institutes of Health Stroke Scale greater than or equal to 5 (29% vs 19%), more likely hospitalized in comprehensive stroke centers (52% vs 44%), had Medicare insurance (53% vs 44%), and more likely to have impaired level of consciousness (38% vs 12%). Most predictors associated with the decision to WLST in AIS were age, stroke severity, region, insurance status, center type, race, and level of consciousness (RF AUC of 0.93 and LR AUC of 0.85). Predictors in ICH included age, impaired level of consciousness, region, race, insurance status, center type, and prestroke ambulation status (RF AUC of 0.76 and LR AUC of 0.71). Factors in SAH included age, impaired level of consciousness, region, insurance status, race, and stroke center type (RF AUC of 0.82 and LR AUC of 0.72). Despite a decrease in the rates of early WLST (< 2 d) and mortality, the overall rates of WLST remained stable.

CONCLUSIONS

In acute hospitalized stroke patients in Florida, factors other than brain injury alone contribute to the decision to WLST. Potential predictors not measured in this study include education, culture, faith and beliefs, and patient/family and physician preferences. The overall rates of WLST have not changed in the last 2 decades.

Development of BNBSL: A β-ν spectra library for spectrometry applications

While modern nuclear decay data can provide many details of a given nuclides β-decay modes (branching ratios, decay heating etc.), knowledge of the emitted β-energy spectrum is often not included. This limitation hampers the use of decay data in some analysis, such as β-spectrometry of irradiated material, prediction of β-decay Bremsstrahlung or antineutrino, ν̄, detection. To address this deficiency, and for increased ease of β-spectrometry studies of complex samples, a library of β, ν and Bremsstrahlung-spectra, called BNBSL (Beta-Neutrino-Bremsstrahlung spectra library), has been produced. It has been found that the content compares favourably with experimental data and methodologies for its application to complex nuclear inventories have been developed. BNBSL contains spectra for over 1500 nuclides, which is hoped will benefit applied nuclear, radiation and materials science studies.

Preexisting Depression and Ambulatory Status After Stroke: Florida-Puerto Rico Collaboration to Reduce Stroke Disparities

OBJECTIVE

Stroke is a global public health burden, and therefore it is critical to identify modifiable risk factors to reduce stroke incidence and improve outcomes. Depression is such a risk factor; however, the association between preexisting depression and stroke outcomes, such as independent ambulation, is not well studied, especially among racial-ethnic minority groups. To address this gap in the literature, effects of preexisting depression on ambulatory status at hospital discharge after stroke were evaluated among individuals participating in the racially and ethnically diverse Florida-Puerto Rico Collaboration to Reduce Stroke Disparities project.

METHODS

Data were analyzed from a total of 42,031 ischemic stroke patients, who were independently ambulatory prior to their stroke, after discharge from 84 hospitals between 2014 and 2017. Preexisting depression was confirmed by medical history or antidepressant medication use. Multilevel multivariate logistic regression analyses were used to assess the association of preexisting depression with independent ambulation at hospital discharge. Effects of sex and race-ethnicity on this association were examined.

RESULTS

Of 42,031 participants (mean±SD age=70.4±14.2 years; 48% were female; race-ethnicity: 16% Black, 12% Hispanic living in Florida, and 7% Hispanic living in Puerto Rico), 6,379 (15%) had preexisting depression. Compared with participants without depression, those with preexisting depression were older, were more likely to be female and non-Hispanic White, and had a greater burden of vascular risk factors or comorbid conditions. Independent ambulation at hospital discharge was less frequent among women, Black participants, and individuals with vascular risk factors or comorbid conditions. In multivariate models, preexisting depression decreased the likelihood of independent ambulation at discharge (odds ratio=0.88, 95% CI=0.81, 0.97). No interactions were found between preexisting depression and race-ethnicity or sex.

CONCLUSIONS

Preexisting depression was independently associated with dependent ambulation at hospital discharge after stroke, regardless of sex and race-ethnicity. Treating depression may contribute to primary stroke prevention and could improve ambulatory status at discharge.

Nationally Certified Stroke Centers Outperform Self-Attested Stroke Centers in the Florida Stroke Registry

BACKGROUND

The Florida Stroke Act, signed into law in 2004, set criteria for Comprehensive Stroke Centers (CSC). For a set time period, Florida hospitals were permitted to either receive national certification (NC) or could self-attest (SA) as fulfilling CSC criteria. The aim of this project was to evaluate the quality of ischemic stroke care in NC versus SA stroke centers in Florida, using well-known, guideline-driven ischemic stroke outcome metrics.

METHODS

A total of 37 CSCs (74% of Florida CSCs) in the Florida Stroke Registry from January 2013 through December 2018 were analyzed, including 19 SA CSCs and 18 NC (13 CSCs and 5 Thrombectomy-Capable Stroke Center). Hospital- and patient-level characteristics and stroke metrics were evaluated, adjusting for demographics, medical comorbidities, and stroke severity.

RESULTS

A total of 78 424 acute ischemic stroke cases, 36 089 from SA CSCs and 42 335 from NC CSC/Thrombectomy-Capable Stroke Centers were analyzed. NC centers had older patients (73 [61-83] versus 71 [60-81]; P<0.001) with more severe strokes (median National Institutes of Health Stroke Scale score of 5 versus 4; P<0.001). NC had higher intravenous tissue-type plasminogen activator utilization (15% versus 13%; P<0.001), endovascular treatment (10% versus 7%; P<0.001) and faster median door-to-computed tomography (23 minutes [11-73] versus 31 [12-78]; P<0.001), door-to-needle (37 minutes [26-50] versus 45 [34-58]; P<0.001) and door-to-puncture times (77 minutes [50-113] versus 93 [62-140]; P<0.001). In adjusted analysis, patients arriving to NC hospitals by 3 hours were more likely to get intravenous tissue-type plasminogen activator in the 3- to 4.5-hour window (adjusted odds ratio, 1.87 [95% CI, 1.30-2.68]; P=0.001) and more likely to be treated with intravenous tissue-type plasminogen activator within 45 minutes (adjusted odds ratio, 1.61 [95% CI, 1.04-2.50]; P=0.04) compared with SA CSCs.

CONCLUSIONS

Among Florida-Stroke Registry CSCs, acute ischemic stroke performance and treatment measures at NC centers are superior to SA CSCs. These findings have implications for stroke systems of care in Florida and support legislation updates requiring NC and removal of SA claims.

A 10-year review of antihypertensive prescribing practices after stroke and the associated disparities from the Florida Stroke Registry

Background

Guideline based hypertension management is integral to the prevention of stroke. We examine trends in antihypertensive medications prescribed after stroke and assess how well a prescribers' blood pressure medication choice adheres to clinical practice guidelines (Prescribers'-Choice Adherence).

Methods

The Florida Stroke registry (FSR) utilizes statewide data prospectively collected for all acute stroke admissions. Based on established guidelines we defined optimal Prescribers'-Choice Adherence using the following hierarchy of rules: 1) use of an angiotensin inhibitor (ACEI) or angiotensin receptor blocker (ARB) as first-line antihypertensive among diabetics; 2) use of thiazide-type diuretics or calcium channel blockers (CCB) among African-American patients; 3) use of beta-adrenergic blockers (BB) among patients with compelling cardiac indication (CCI) 4) use of thiazide, ACEI/ARB or CCB class as first-line in all others; 5) BB should be avoided as first line unless CCI.

RESULTS

A total of 372,254 cases from January 2010 to March 2020 are in FSR with a diagnosis of acute ischemic, hemorrhagic stroke, transient ischemic attack or subarachnoid hemorrhage; 265,409 with complete data were included in the final analysis. Mean age 70 +/-14 years, 50% female, index stroke subtype of 74% acute ischemic stroke and 11% intracerebral hemorrhage. Prescribers'-Choice Adherence to each specific rule ranged from 48-74% which is below quality standards of 85%. There were race-ethnic disparities with only 49% Prescribers choice Adherence for African Americans patients.

Conclusion

This large dataset demonstrates consistently low rates of Prescribers'-Choice Adherence over 10 years. There is an opportunity for quality improvement in hypertensive management after stroke.

Acupuncture, Nutritional Augmentation, and Physical Rehabilitation: Improving Recovery Following Spinal Fusion

Spinal fusion is one of the most common procedures performed in spinal surgery. The increasing complexity and frequency with which this operation is performed has led to a rise in postoperative complications and delayed recovery. Perioperative care of patients with spinal conditions aims to adequately manage pain and accelerate the return to function following surgery. Traditional pharmaceutical interventions, especially opioid utilization, are associated with delayed recovery and significant adverse effects. As such, many studies are now evaluating the benefits and efficacy of non-pharmacological therapies for enhancing recovery after spinal fusion surgery. In this review, the mechanism of acupuncture relative to postoperative pain control and symptom reduction will be discussed. Additionally, this review examines the implications of malnutrition, current preclinical and clinical approaches for improving nutritional status, and various forms of physical rehabilitation that aim to combat postoperative complications and support recovery after spinal fusion surgery.

Abstract 14: Determinants Of Withdrawal Of Life-sustaining Therapy After Acute Stroke

Introduction: The decision to withhold or withdraw life-sustaining therapy (WLST) is common after acute stroke. Factors that may influence the decision are not well determined. We aimed to investigate factors associated with WLST in hospitalized acute stroke patients.

Methods: Patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) were included across 152 Florida hospitals participating in the prospective Florida Stroke Registry from 2008-2021. Importance plots were performed to generate the predictive factors associated with WLST. AUC-ROC curves were generated for the performance of logistic regression (LR) and random forest (RF) models. We used 75/15/15 for training/testing/validation.

Results: Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST during hospitalization. Patients who had WLST were older (77 vs. 69 years), more women (57% vs. 49%), more White (76% vs. 67%), greater stroke severity at presentation NIHSS ≥ 5 (29% vs.19%), more likely to be treated in comprehensive stroke centers (52% vs. 44%), more likely to have Medicare insurance (53% vs. 44%), less likely to be uninsured (8% vs. 13%), more likely to undergo surgical treatments (1.2% vs 0.3%), and more likely to have impaired level of consciousness (38% vs. 12%). The most predictive factors associated with the decision to WLST in AIS were age, stroke severity, state region, insurance status, stroke center type, race, and level of consciousness (RF AUC of .93 and LR AUC of .85). The most predictive factors in ICH were age, impaired level of consciousness, state region, race, insurance status, stroke center type, and ambulation status at baseline (RF AUC of .76 and LR AUC of .71). Most predictive factors in SAH were age, impaired level of consciousness, state region, insurance status, race, and stroke center type (RF AUC of .82 and LR AUC of .72).

Conclusion: Among acute hospitalized stroke patients; age, level of consciousness, state region, race, insurance status, ambulation status at baseline, and stroke center type could contribute to the decision to WLST.

Supporting safe and gradual reduction of long‐term benzodiazepine receptor agonist use: Development of the SAFEGUARDING‐BZRAs toolkit using a codesign approach

Introduction

Long‐term benzodiazepine receptor agonist (BZRA) use persists in healthcare settings worldwide and poses risks of patient harm.

Objective

This study aimed to develop an intervention to support discontinuation of long‐term BZRA use among willing individuals.

Methods

The intervention development process aligned with the UK Medical Research Council's complex intervention framework. This involved a previous systematic review of brief interventions targeting long‐term BZRA use in primary care and qualitative interviews based on the Theoretical Domains Framework that explored barriers and facilitators to discontinuing long‐term BZRA use. A codesign approach was used involving an active partnership between experts by experience, researchers and clinicians. Intervention content was specified in terms of behaviour change techniques (BCTs).

Results

The SAFEGUARDING‐BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG‐term BenZodiazepine Receptor Agonist uSe) toolkit comprises 24 BCTs and includes recommendations targeted at primary care‐based clinicians for operationalizing each BCT to support individuals with BZRA discontinuation.

Conclusion

The SAFEGUARDING‐BZRAs toolkit has been developed using a systematic and theory‐based approach that addresses identified limitations of previous research. Further research is needed to assess its usability and acceptability by service users and clinicians, as well as its potential to effectively support safe and gradual reduction of long‐term BZRA use.

Patient or Public Contribution

The qualitative interview phase included patients as participants. The codesign process included ‘experts by experience’ with either current or previous experience of long‐term BZRA use as collaborators.

Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care

BACKGROUND AND OBJECTIVES

Early consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment.

METHODS

We studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition.

RESULTS

Of 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score ≥5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98-2.51), had longer hospitalization (OR 1.37, 95% CI 1.33-1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52-0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57-0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217-314). In temporal trend analysis, we found a significant decrease in early WLST (<2 days) (R² 0.7, p = 0.002) and an increase in late WLST (≥2 days) (R² 0.7, p = 0.004).

DISCUSSION

In this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.

Supporting sAFE and GradUAl ReDuctIon of loNG-term BenzodiaZepine Receptor Agonist uSe: development of the SAFEGUARDING-BZRAs toolkit using a co-design approach

Introduction

Long-term benzodiazepine receptor agonist (BZRA) use (&gt;3 months) persists worldwide and poses risks of harm. Effective interventions are needed to address this issue.

Aim

To develop an intervention to support discontinuation of long-term benzodiazepine receptor agonist (BZRA) use.

Methods

The intervention development process built on previous qualitative work that used the Theoretical Domains Framework (TDF) to explore perceived barriers and facilitators to discontinuing long-term BZRA use (1). A co-design approach was used whereby lay individuals and professionals worked as equals during the research process based on principles of authentic participation and collaboration (2). The co-design team included five ‘experts by lived experience’ with experience of long-term BZRA use who previously provided input on other related work as patient and public involvement representatives or responded to an expression of interest call on social media. Two online co-design team meetings were held. During the first meeting, a summary of previous findings was presented together with a long-list of behaviour change techniques (BCTs) generated using established mapping matrices in which BCTs were reliably allocated to the TDF. Each team member independently documented their decision as to whether each BCT should be included in a short-list for potential inclusion in the final intervention using online polling software. The a priori decision rule was that 70% of team members had to agree regarding the inclusion/exclusion of a BCT. All other BCTs were then discussed at a follow-up meeting. A finalised list of BCTs for inclusion in the intervention was agreed at the second meeting using a consensus-based approach involving the same decision rule. Potential ways in which BCTs could be operationalised were then discussed.

Results

Thirty BCTs were discussed and six BCTs were excluded. For example, team members recommended avoiding ‘Social comparison’ as individual circumstances and experiences of discontinuation and associated withdrawal symptoms are unique and not directly comparable. Given the number of included BCTs, the co-design team recommended presenting them as a toolkit. The SAFEGUARDING-BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG-term BenzodiaZepine Receptor Agonist uSe) toolkit comprises 24 BCTs: ‘Goal setting (behaviour)’, ‘Review behaviour goal(s)’, ‘Review outcome goal(s)’, ‘Feedback on behaviour’, ‘Self-monitoring of behaviour’, ‘Social support (practical)’, ‘Social support (emotional)’, ‘Information about health consequences’, ‘Monitoring of emotional consequences’, ‘Information about emotional consequences’, ‘Prompts/cues’, ‘Habit reversal’, ‘Graded tasks’, ‘Pros and cons’, ‘Comparative imagining of future outcomes’, ‘Social reward’, ‘Self-reward’, ‘Reduce negative emotions’, ‘Distraction’, ‘Adding objects to the environment’, ‘Body changes’, ‘Verbal persuasion about capability’, ‘Focus on past success’ and ‘Credible source’. The toolkit includes recommendations targeted at primary care-based clinicians for operationalising each BCT to support BZRA discontinuation.

Conclusion

The SAFEGUARDING-BZRAs toolkit has been developed using a systematic, theory-based approach that addresses identified limitations of previous research (e.g. lack of detailed intervention description). In terms of limitations, it is possible that a different group of individuals may have developed a different type of intervention. To overcome this, a priori decision rules were used for decision making. Further research is needed to assess the toolkit’s usability and acceptability by service users and clinicians.

References

(1) Lynch et al. Health Expect. [in press] DOI: 10.1111/hex.13392.

(2) O’Donnell et al. BMC Health Serv Res. 2019;19(1):797

Abstract WP26: Covid Pandemic Versus Pre-pandemic Care Of Stroke Patients Within The Florida Stroke Registry

Background: The coronavirus 2019 (COVID-19) pandemic has affected all aspects of stroke care delivery and resource allocation. We sought to study this effect utilizing the Florida Stroke Registry (FSR), which collects data from hospitals in large metropolitan cities and small communities, each facing pandemic peaks at different timepoints and within various healthcare system organizations.

Methods: From March 2019 to March 2021, the FSR identified 82,899 patients with the final diagnosis of ischemic stroke and TIA. Stroke care metrics were compared in patients enrolled during the COVID-19 pandemic (March 2020 to February 2021) to those enrolled in the immediate pre-pandemic year. These metrics included utilization of intravenous thrombolytic (IVT), Endovascular therapy (EVT), Door-To-Needle time (DTN), Door-To-Puncture time (DTP), Door-To-Computed Tomography time (DTCT) and overall Defect-Free Care (DFC).

Results: Pre-pandemic patients (n= 41,929, 49.0% female, mean age 70.1 ± 14.6 years, 64.3% white, 20.4% black, 15.3% Hispanic) had similar demographics to pandemic patients (48.8% female, mean age 69.9 ± 14.4 years, 65.4% white, 19.9% black, 14.7% Hispanic). Pandemic stroke patients had more severe presentations (median NIHSS 3 [IQR 8] vs 3 [7], p < .0001), longer onset-to-arrival time (242 [677] vs 229 [654] minutes, p = 0.002), and were more likely to arrive via emergency medical services (62.3% vs. 60.8%, p < .0001) than pre-pandemic stroke patients. Although both groups received IVT equally (13.4% vs. 13.5%, p = 0.67), pandemic stroke patients were more likely to receive EVT (7.0% vs. 6.5%, p = 0.005) and had longer DTP (84 [60] vs. 81 [64] minutes, p = 0.01), shorter DTCT (22 [52] vs 23 [56] minutes, p = 0.01) and similar DTN (36 [22] vs. 37 [22] minutes, p = 0.05) times, with an increased DFC rate of 2.2% (86.6% vs. 84.4%, p < .0001).

Conclusions: In this large registry based study, we found that compared to pre-pandemic care, ischemic stroke patients treated during the COVID19 pandemic presented sicker and later to the hospital and were more likely to receive EVT, but had longer door-to-puncture times. Despite many healthcare delivery challenges imposed by COVID19, Florida hospitals within the FSR maintained high quality of stroke care overall.

Evidence of sheep and abattoir environment as important reservoirs of multidrug resistant Salmonella and extended-spectrum beta-lactamase Escherichia coli

The increase in antimicrobial-resistant (AMR) foodborne pathogens, including E. coli and Salmonella in animals, humans, and the environment, is a growing public health concern. Among animals, cattle, pigs, and chicken are reservoirs of these pathogens worldwide. There is a knowledge gap on the prevalence and AMR of foodborne pathogens in small ruminants (i.e., sheep and goats). This study investigates the prevalence and antimicrobial resistance of extended-spectrum beta-lactamase (ESBL) E. coli and Salmonella from sheep and their abattoir environment in North Carolina. We conducted a year-round serial cross-sectional study and collected a total of 1128 samples from sheep (n = 780) and their abattoir environment (n = 348). Sheep samples consisted of feces, cecal contents, carcass swabs, and abattoir resting area feces. Environmental samples consisted of soil samples, lairage swab, animal feed, and drinking water for animals. We used CHROMAgar EEC with 4 μg/ml of Cefotaxime for isolating ESBL E. coli, and ESBL production was confirmed by double-disk diffusion test. Salmonella was isolated and confirmed using standard methods. All of the confirmed isolates were tested against a panel of 14 antimicrobials to elucidate susceptibility profiles. The prevalence of ESBL E. coli and Salmonella was significantly higher in environmental samples (47.7% and 65.5%) compared to the sheep samples (19.5% and 17.9%), respectively (P < 0.0001). We recovered 318 ESBL E. coli and 368 Salmonella isolates from sheep and environmental samples. More than 97% (310/318) of ESBL E. coli were multidrug-resistant (MDR; resistant to ≥3 classes of antimicrobials). Most Salmonella isolates (77.2%, 284/368) were pansusceptible, and 10.1% (37/368) were MDR. We identified a total of 24 different Salmonella serotypes by whole genome sequencing (WGS). The most common serotypes were Agona (19.8%), Typhimurium (16.2%), Cannstatt (13.2%), Reading (13.2%), and Anatum (9.6%). Prevalence and percent resistance of ESBL E. coli and Salmonella isolates varied significantly by season and sample type (P < 0.0001). The co-existence of ESBL E. coli in the same sample was associated with increased percent resistance of Salmonella to Ampicillin, Chloramphenicol, Sulfisoxazole, Streptomycin, and Tetracycline. We presumed that the abattoir environment might have played a great role in the persistence and dissemination of resistant bacteria to sheep as they arrive at the abattoir. In conclusion, our study reaffirms that sheep and their abattoir environment act as important reservoirs of AMR ESBL E. coli and MDR Salmonella in the U.S. Further studies are required to determine associated public health risks.

Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness

BACKGROUND AND PURPOSE

Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST).

METHODS

Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition.

RESULTS

Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], P<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], P<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], P<0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate.

CONCLUSIONS

In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

Modelling the potential impact of mask use in schools and society on COVID-19 control in the UK

As the UK reopened after the first wave of the COVID-19 epidemic, crucial questions emerged around the role for ongoing interventions, including test-trace-isolate (TTI) strategies and mandatory masks. Here we assess the importance of masks in secondary schools by evaluating their impact over September 1-October 23, 2020. We show that, assuming TTI levels from August 2020 and no fundamental changes in the virus's transmissibility, adoption of masks in secondary schools would have reduced the predicted size of a second wave, but preventing it would have required 68% or 46% of those with symptoms to seek testing (assuming masks' effective coverage 15% or 30% respectively). With masks in community settings but not secondary schools, the required testing rates increase to 76% and 57%.

Sex and Race-Ethnic Disparities in Door-to-CT Time in Acute Ischemic Stroke: The Florida Stroke Registry

Background

Less than 40% of acute stroke patients have computed tomography (CT) imaging performed within 25 minutes of hospital arrival. We aimed to examine the race‐ethnic and sex differences in door‐to‐CT (DTCT) ≤25 minutes in the FSR (Florida Stroke Registry).

Methods and Results

Data were collected from 2010 to 2018 for 63 265 patients with acute ischemic stroke from the FSR and secondary analysis was performed on 15 877 patients with intravenous tissue plasminogen activator‐treated ischemic stroke. Generalized estimating equation models were used to determine predictors of DTCT ≤25. DTCT ≤25 was achieved in 56% of cases of suspected acute stroke, improving from 36% in 2010 to 72% in 2018. Women (odds ratio [OR], 0.90; 95% CI, 0.87–0.93) and Black (OR, 0.88; CI, 0.84–0.94) patients who had strokes were less likely, and Hispanic patients more likely (OR, 1.07; CI, 1.01–1.14), to achieve DTCT ≤25. In a secondary analysis among intravenous tissue plasminogen activator‐treated patients, 81% of patients achieved DTCT ≤25. In this subgroup, women were less likely to receive DTCT ≤25 (0.85, 0.77–0.94) whereas no significant differences were observed by race or ethnicity.

Conclusions

In the FSR, there was considerable improvement in acute stroke care metric DTCT ≤25 in 2018 in comparison to 2010. However, sex and race‐ethnic disparities persist and require further efforts to improve performance and reduce these disparities.

Abstract P870: Disparities in Timelines of Hospital Presentation in Patients With Ischemic Stroke: Florida Stroke Registry

Introduction: Characterizing the population of ischemic stroke (IS) patients presenting in the delayed reperfusion window is important to ensure equitable implementation of recently updated acute IS treatment guidelines.

Methods: Florida Stroke Registry (FSR) data from Jan 2010 - Jan 2020, provided a complete dataset of 98,372 IS cases presenting within 24 hrs of symptom onset. Generalized linear regression analysis was used to identify differences between delayed IS cases (>4.5 hours) versus those presenting within the early time window (≤ 4.5 hr).

Results: A total of 60,311 presented with 4.5 hr (median age 74 (interquartile range (IQR) 62-83), 49% women, 67% white, 15% Black, 18% Hispanic), and 38,061 presented in the delayed window (median age 72 (IQR 61- 82), 49% women, 63% white, 18% Black, 19% Hispanic). As compared to early presenters, delayed window patients were younger (OR 1.23, 95% confidence interval (CI) 1.17-1.29); more Black vs. White (OR 1.12, 95% CI 1.06-1.18), have higher NIHSS (OR 1.05, 95% 1.01-1.10), insured (OR 1.18, 95% 1.11-1.25), presenting to an academic hospital (OR 1.24, 95% CI 1.09-1.40) in South Florida (OR 1.23, 95% CI (1.08, 1.41)); less likely to arrive by EMS (OR 0.59, 95% CI 0.56-0.62) and less likely to receive reperfusion therapies (OR 0.86, 95% CI 0.79-0.94). In multivariable analysis adjusting for age, race, NIHSS, EMS, reperfusion therapies, hospital academic status and region, delayed window presentation was negatively associated with discharge home (OR 0.82, 95% CI 0.76-0.89), and ambulatory status at discharge (OR 0.89, 95% CI 0.84-0.93).

Conclusion: We found significant race, ethnic, socioeconomic and geographical disparities amongst those presenting in the delayed vs early reperfusion time windows with consequential effects on patient outcomes. Stroke education to younger minorities and adaptation of regional stroke systems of care are urgently needed.

Acidity, fluoride and silver ion concentrations in silver diamine fluoride solutions: a pilot study

BACKGROUND

There has been renewed interest in the use of silver diamine fluoride (SDF) for the management of carious lesions in high-risk groups. Previous studies have found a difference in clinical efficacy among different concentrations of SDF and discrepancies between ionic concentrations of fluoride (F) and silver (Ag) in SDF preparations. The aim of this study was to measure the free F, Ag ion concentrations and pH of a variety of commercially available SDF preparations.

METHODS

Seven SDF products used globally were evaluated for F and Ag ion concentrations using a calibrated ion-selective electrode and optical emission spectrometry respectively. Acidity was determined with a pH electrode.

RESULTS

The 30% SDF solution contained almost half the F concentration and a much higher Ag concentration than expected (16 343 ppmF and 246 000 ppmAg). Comparatively, the mean F concentration of the remaining six 38% solutions was 74 802 ppm (expected mean 44 800 ppm) ranging from 36 457 ppm to 120 760 ppm. The mean Ag concentration was 326 000 ppm (expected mean 253 870 ppm) and ranged from 246 000 ppm to 425 451 ppm. All solutions were found to be neutral or mildly alkaline in nature (pH 7-10.3).

CONCLUSIONS

Wide variations between claimed and measured F and Ag ion concentrations exist among the different brands of commercially available SDF products.

Equine cheek tooth extraction: Comparison of outcomes for five extraction methods

BACKGROUND

Post-operative complications are reported for all methods of equine cheek tooth extraction but not all methods carry the same risks. An outcome comparison for commonly used methods is needed so that clinicians can make informed treatment decisions.

OBJECTIVES

We conducted a side-by-side comparison of five cheek tooth extraction methods, comparing types and incidence of complications among oral extraction, tooth repulsion (three surgical approaches) and lateral buccotomy techniques.

STUDY DESIGN

Retrospective clinical study using hospital medical records.

METHODS

Medical records of all horses undergoing cheek tooth extraction between 1997 and 2013 were reviewed. Logistic regression was used to determine the likelihood of various post-operative complications, comparing oral extraction, tooth repulsion by maxillary and mandibular trephination or maxillary sinus bone flap, and lateral buccotomy.

RESULTS

The study included 137 horses and 162 cheek teeth extractions. Oral extraction was successful in 71% of patients in which it was attempted. Oral extraction (n = 55) had the lowest incidence of complications (20%) and repulsion by sinus bone flap (n = 20) the highest (80%). Complication rates for repulsion by maxillary (n = 19) and mandibular trephination (n = 28), and extraction by lateral buccotomy (n = 15) were 42, 54 and 53%, respectively. Cheek tooth repulsion by sinus bone flap significantly increased the odds of damage to adjacent teeth, post-operative sinusitis, damage to alveolar bone, delayed alveolar granulation and orosinus fistulation. Repulsion by maxillary trephination significantly increased the odds of superficial incisional surgical site infection; and extraction by lateral buccotomy significantly increased the odds of facial nerve neuropraxia. Post-operative pyrexia was more common in all repulsion methods.

MAIN LIMITATIONS

Some clinically relevant differences may have been missed due to small group numbers in several categories.

CONCLUSIONS

Oral extraction was associated with fewer post-operative complications than any other methods. Standing oral extraction remains the preferred choice, and recent surgical advances promise to further improve its success rate.

Polymyxin B hemoperfusion in endotoxemic septic shock patients without extreme endotoxemia: a post hoc analysis of the EUPHRATES trial

PURPOSE

The EUPHRATES trial examined the impact of polymyxin B hemoperfusion (PMX) on mortality in patients with septic shock and endotoxemia, defined as EAA ≥ 0.60. No difference was found in 28-day all-cause mortality. However, the trial showed that in some patients with septic shock the burden of endotoxin activity was extreme (EAA ≥ 0.9). In a post hoc analysis, we evaluated the impact of PMX use in patients with septic shock and endotoxin activity measured between 0.6-0.89.

METHODS

Post-hoc analysis of the EUPHRATES trial for the 194 patients with EAA ≥ 0.6-0.89 who completed two treatments (PMX or sham). The primary end point was mortality at 28 days adjusted for APACHE II score and baseline mean arterial pressure (MAP). Additional end points included changes in MAP, cumulative vasopressor index (CVI), median EAA reduction, ventilator-free days (VFD), dialysis-free days (DFD) and hospital length of stay. Subpopulations analyzed were site and type of infection and those with norepinephrine dose > 0.1 mcg/kg/min at baseline.

RESULTS

At 28 days, 23 patients of 88 (26.1%) in the PMX group died versus 39 of 106 (36.8%) in the sham group [risk difference 10.7%, OR 0.52, 95% CI (0.27, 0.99), P = 0.047]. When unadjusted for baseline variables, P = 0.11. The 28-day survival time in the PMX group was longer than for the sham group [HR 0.56 (95% CI 0.33, 0.95) P = 0.03]. PMX treatment compared with sham showed greater change in MAP [median (IQR) 8 mmHg (- 0.5, 19.5) vs. 4 mmHg (- 4.0, 11) P = 0.04] and VFD [median (IQR) 20 days (0.5, 23.5) vs. 6 days (0, 20), P = 0.004]. There were no significant differences in other end points. There was a significant difference in mortality in PMX-treated patients with no bacterial growth on culture [PMX, 6/30 (20%) vs. sham, 13/31 (41.9%), P = 0.005]. The median EAA change in the population was - 12.9% (range: increase 49.2%-reduction 86.3%). The mortality in the above median EAA change group was PMX: 6/38 (15.7%) vs. sham 15/49 (30.6%), P = 0.08.

CONCLUSIONS

These hypothesis-generating results, based on an exploratory post hoc analysis of the EUPHRATES trial, suggest measurable responses in patients with septic shock and an EAA ≥ 0.6 to 0.89 on changes in mean arterial pressure, ventilator-free days and mortality.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01046669. Funding Spectral Medical Incorporated.

Crossover between liquidlike and gaslike behavior in CH_{4} at 400 K

We report experimental evidence for a crossover between a liquidlike state and a gaslike state in fluid methane (CH_{4}). This crossover is observed in all of our experiments, up to a temperature of 397 K, 2.1 times the critical temperature of methane. The crossover has been characterized with both Raman spectroscopy and x-ray diffraction in a number of separate experiments, and confirmed to be reversible. We associate this crossover with the Frenkel line-a recently hypothesized crossover in dynamic properties of fluids extending to arbitrarily high pressure and temperature, dividing the phase diagram into separate regions where the fluid possesses liquidlike and gaslike properties. On the liquidlike side the Raman-active vibration increases in frequency linearly as pressure is increased, as expected due to the repulsive interaction between adjacent molecules. On the gaslike side this competes with the attractive van der Waals potential leading the vibration frequency to decrease as pressure is increased.

Abstract P119: Hypertension Trends in Florida Stroke Patients. The Florida Puerto Rico Collaboration to Reduce Stroke Disparities

Aim: To describe hypertension prevalence (HTN) in a race diverse stroke registry and investigate associated presentation in patients admitted for acute ischemic stroke (AIS) and hemorrhagic stroke in Florida hospitals participating in the Florida Collaboration to Reduce Stroke Disparities (CReSD).

Background: HTN affects about 30% of U.S. adults and this prevalence doubles among stroke survivors. HTN is a major risk factor for incident stoke and recurrent stroke. Quantifying the prevalence of HTN in stroke survivors is important to guide secondary stroke prevention.

Methods: 121,333 stroke cases were analyzed from 69 FL hospitals participating in the AHA Get With the Guidelines-Stroke Program and FL CReSD Stroke Registry. Hypertension was defined as systolic blood pressure >140mmHg. Demographics and CV risk factors were collected at admission. We investigated the differences in HTN prevalence between race groups: white (65%), black (20%) and Hispanic (15%) as well as between age groups: 18-60, 61-80 and >80 years old. Temporal trends of HTN prevalence were also analyzed from 2010 to 2016.

Results: In our stroke population, mean age was 70±15 and 60,667 were women (50%). HTN prevalence was 65% (78,553/121,333). Patients with HTN were significantly older (mean age 72±14 vs. 67±16 in non-HTN patients) and presented significantly higher prevalence of other CV risk factors such as diabetes, hyperlipidemia and had more previous stroke/TIAs. Women had greater prevalence of HTN (66% vs. 64% in males) in all age groups. Greater HTN prevalence was in blacks (70%) compared to white (64%) and Hispanics (58%) in all age groups. Interestingly, a significantly higher prevalence of HTN was found in AIS compared to hemorrhagic stroke but a higher SBP was observed in hemorrhagic strokes compared to AIS. Prevalence of HTN decreased of 8% from 2010 to 2016. Largest decline was observed among women (9%) and blacks (13%).

Conclusions: In our large Stroke Registry we observed higher prevalence of HTN in women, blacks and AIS. We also observe a decreasing trend over the past 7 years, especially among women and minorities (blacks and Hispanics). These findings provide an opportunity to design and implement interventions to reduce disparities in HTN and improve stroke outcome.

Disparities and Trends in Door-to-Needle Time: The FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities)

BACKGROUND AND PURPOSE

In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45.

METHODS

Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45.

RESULTS

DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72-0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57-0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%).

CONCLUSIONS

In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.

Knotted fields and explicit fibrations for lemniscate knots

We give an explicit construction of complex maps whose nodal lines have the form of lemniscate knots. We review the properties of lemniscate knots, defined as closures of braids where all strands follow the same transverse (1, ℓ) Lissajous figure, and are therefore a subfamily of spiral knots generalizing the torus knots. We then prove that such maps exist and are in fact fibrations with appropriate choices of parameters. We describe how this may be useful in physics for creating knotted fields, in quantum mechanics, optics and generalizing to rational maps with application to the Skyrme-Faddeev model. We also prove how this construction extends to maps with weakly isolated singularities.

Abstract TP2: Disparities in Delivery of Endovascular Therapy: Who Gets it and Where? The Florida Puerto Rico Collaboration to Reduce Stroke Disparities Study

Background and Purpose: Endovascular thrombectomy improves functional outcome in select ischemic stroke patients. In the NINDS-funded CReSD Registry we sought to determine the clinical, hospital and regional characteristics associated with use of this therapy in patients presenting with acute ischemic stroke.

Methods: Ischemic stroke patients within 24 hours of onset were prospectively included from 82 sites in Florida and Puerto Rico from January 2010 to April 2016. Independent predictors of endovascular therapy were evaluated using multivariable logistic regression with generalized estimating equations.

Results: Among 58,204 patients with acute ischemic stroke (50% male, 65% white, 15% black, 20% Hispanic, mean age±SD 71±14 yrs), 2105 (3.6%) received endovascular thrombectomy (50.9% men, 62.3% white, 13.7% black, 24% Hispanic, mean age±SD 70±15yrs) with (35.2%) or without intravenous thrombolysis. Patients who received endovascular therapy had a significantly lower risk of vascular risk factors except for Afib (33.7% vs 19.0%), more severe strokes (median NIHSS 15 vs. 5) and were more likely to arrive quickly (126 min vs. 210 min), via EMS (70.4% vs. 59.6%) or as a transfer from another hospital (20.8% vs 5.8%,) during working hours (47.7% vs. 45.6%), to large hospitals (≥ 680 beds) (48.3% vs 28.8%), and treated in South Florida (47.3% vs. 35.9%) as compared to those not receiving this treatment. In multivariable analysis; age (OR 0.97, 95% CI 0.96- 0.98), Blacks (OR 0.68, 95% CI 0.56-2.28) vs. White, off-hour presentation (OR 0.76, 95% CI 0.66- 0.96), to regions other than South Florida (North OR 0.40, 95% CI 0.17-0.93, Panhandle OR 0.12, 95% CI 0.04-0.36) remained independently associated with lower use of endovascular therapy. In contrast, Hispanics (OR 1.28, 95% CI 1.03- 1.69) vs. White and presenting to large hospital (OR 4.92, 95% CI 1.05- to 22.6) were associated with higher use of endovascular treatment.

Conclusions: There are significant race, regional and hospital disparities in delivery of endovascular care. Efforts should me made to improve access to endovascular treatment in patients presenting across the region to all stroke centers.

Abstract TMP81: Regional, Race-Ethnic and Sex Disparities in Lifestyle Interventions: Data from the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program

Background: As key components of the AHA Life’s Simple 7 campaign, lifestyle modifications play an integral role in the prevention of vascular disease. Little is known about the prevalence of lifestyle modification counseling in patients with acute ischemic stroke (AIS). We sought to investigate disparities in the delivery of lifestyle interventions to AIS patients in the large NINDS-funded FL-PR CReSD Registry of Get With The Guidelines-Stroke (GWTG-S) data.

Methods: GWTG-S collects data on the provision of several lifestyle interventions including counseling on exercise/weight loss, Therapeutic Lifestyle Changes (TLC) diet, diabetes (DM) education and antihypertensive (low sodium) diet. 80,598 AIS cases were prospectively included from 82 sites (69 FL; 13 PR) from 2010-2016. Multilevel logistic regression models adjusted for age, race, and aphasia were used to evaluate differences in the provision of lifestyle interventions as indicated for patients prior to hospital discharge.

Results: Among AIS cases, 51% were men, 62% non-Hispanic White (NHW), 18% NH-Black (NHB), 13% FL-Hispanic (FLH), and 6% PR-Hispanic (PRH). Mean age was 71±14 years. The highest mean BMI was in PRH (29±7 kg/m 2 ), with the lowest in NHW (27±6 kg/m 2 ) and FLH (28±6 kg/m 2 ). Despite this, PRH were less likely to receive exercise/weight loss counseling compared to NHW (OR 0.43, 95% CI 0.20-0.90) and FLH (OR 0.46, 95% CI 0.22-0.97). PRH also had lower odds of receiving TLC diet counseling compared to NHW and FLH (OR 0.32, 95% CI 0.15-0.68). Though NHB presented with higher rates of DM compared to NHW (38% vs. 25%), they were less likely to receive DM education (OR 0.95, 95% CI 0.91-0.99). Women were less likely to receive TLC diet counseling (OR 0.94, 95% CI 0.90-0.98) and DM education (OR 0.94, CI 0.92-0.97) compared to men. Despite higher HTN frequency in women and NHB (67% and 69%), both were less likely to receive low sodium diet recommendations as compared to men (OR 0.94, 95% CI 0.92-0.97) and NHW (OR 0.95, 95% CI 0.91-0.99).

Conclusion: Overall, disparities were identified in the provision of several lifestyle interventions in AIS patients. These interventions can benefit all and providers should continue counseling patients regarding modifiable risk factors to prevent future stroke.

Abstract 89: Differences in Acute Stroke Care in Primary and Comprehensive Stroke Centers in Florida: An Analysis of the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study- the NINDS Stroke Prevention Intervention Research Program

Introduction: Primary stroke center (PSC) and comprehensive stroke center (CSC) designation in Florida aims to improve delivery of care and outcomes for stroke patients. In line with the goals of the NINDS funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study, we sought to compare ischemic stroke performance metrics by stroke center designation in participating Florida hospitals.

Methods: We analyzed 74,623 cases with acute ischemic stroke from 26 CSC and 40 PSC from January 2010-April 2016. We described patient demographics, comorbidities and Get With The Guidelines-Stroke performance metrics of defect free care (compliance with 7 pre-defined performance core measures), door to CT time (DTCT) ≤25 mins and door to needle time (DTN) ≤60 mins.

Results: Compared with PSC patients, CSC patients were younger (70 ± 15 vs. 71 ± 14 years, p<.0001), more likely male (51% vs. 50%, p=.0008), more likely Hispanic (17% vs. 10%, p<.0001) and Black (21% vs. 17%, p<.0001), had more severe strokes (NIHSS median 5 (IQR 2-12) vs. 4 (IQR 1-9); NIHSS ≥16, 12% vs. 9%, p <.0001), were more likely to have atrial fibrillation (19% vs. 17%, p<.0001), and were more likely to arrive by EMS (55% vs. 46%, p<.0001). CSC cases were more likely to have faster DTCT (44 vs. 48 mins, p=.0124 ; < 25 mins 33% vs. 31%, p<.0001). More patients in CSC received thrombolysis (12% vs. 9%, p<.0001), with faster DTN (59 vs. 71 min, p <.0001; ≤60 minutes 53% vs. 37%, p <.0001). Patients in CSC had greater rates of defect free care (85% vs. 82.4%, p<.0001). Blacks had longer median DTCT than Whites and Hispanics in both CSC (56 mins Blacks vs. 41 mins Whites and Hispanics) and PSC (60 mins Blacks, 44 mins Whites, 57 mins Hispanics). Blacks in CSC had longer median DTN (63 mins) than Whites (60 mins) and Hispanics (53 mins). Hispanics had longer median DTN (73 mins) in PSC than Blacks (70 mins) and Whites (70 mins).

Conclusion: Patients treated in CSC, compared with those treated in PSC, received better defect-free care and had lower DTCT and DTN times. Race-ethnic disparities in performance metrics are still evident in both CSC and PSC. Identification of these disparities is important to design interventions to reduce disparities and improve stroke quality of care for all.

Readmissions - can they be predicted on admission?

This paper looks at the development of logistic regression models to predict readmissions for medical patients on their initial admission to hospital. The design of our study was a retrospective analysis of a large dataset drawn from a range of secondary sources - medical, nursing, therapy and social care records. Three northern hospitals and related community health districts and social care organizations in the UK participated. Records of 1,192 patients discharged from medical wards during the period April 1992-March 1995 were analysed. Readmission within six weeks of discharge was the main outcome measure.Four logistic regression equations were produced. Three individual site equations were calculated and classification levels for readmission of 17-22 per cent were achieved. Component factors that differed in importance were age, GP contact, social services contact, marital status and living status. The weakest equation was the equation that encompassed patients from all three sites, which classified 7 per cent of readmissions. It is possible to develop equations that will explain readmission for a fifth of medical patients on admission to individual hospitals. Further exploratory work needs to be undertaken to explore reasons for differences between districts and develop more generalizable predictive equations.