Experiences of health care services among people with cognitive disabilities and mental health conditions

BACKGROUND

People with cognitive disabilities such as intellectual and developmental disabilities face significant barriers to accessing high-quality health care services. Barriers may be exacerbated for those with co-occurring mental health conditions.

OBJECTIVE

This study compares patient experiences of health care services between adults with and without cognitive disabilities and, among people with a cognitive disability, those with and without co-occurring mental health conditions.

METHODS

Cross-sectional analyses were conducted using 2021 Medical Expenditure Panel Survey data, a national U.S. survey, to examine differences in Consumer Assessment of Healthcare Providers and Systems measures.

RESULTS

Adults with cognitive disabilities reported lower satisfaction with health care services compared to the general population (7.62 (95% confidence interval (CI): 7.41-7.83) vs. 8.33 (95% CI: 8.29-8.38) on scale from 0 to 10). Adults with cognitive disabilities were less likely to report that providers listened carefully to them (odds ratio (OR): 0.55, 95% CI: 0.42-0.71), explained things in a way that was easy to understand (OR: 0.48, 95% CI: 0.35-0.66), showed respect for what they had to say (OR: 0.38, 95% CI: 0.29-0.51), spent enough time with them (OR: 0.52, 95% CI: 0.40-0.69), or gave advice that was easy to understand (OR: 0.40, 95% CI: 0.28-0.58) compared to the general population. Among adults with cognitive disabilities, there were no differences based on co-occurring mental health conditions.

CONCLUSIONS

Adults with cognitive disabilities report lower satisfaction with health care services driven by worse experiences with the health care system. Policies to increase provider capacity to support this population should be prioritized.

Psychiatric Presentations and Medication Use in Older Adults With Intellectual and Developmental Disabilities

OBJECTIVE

Adults with intellectual and developmental disabilities (IDD) are living longer, yet research about the medical and psychiatric needs of older adults still lags behind that of younger individuals with IDD. The aim of this study was to assess age-related differences in the mental health presentations of adults with IDD.

METHODS

Fully deidentified data for adults 30 years and older were extracted from the START (Systemic, Therapeutic, Assessment, Resources, and Treatment) Information Reporting System, a deidentified database housed at the Center for START Services. Caregivers and START team documents reported psychiatric diagnoses, service use, recent stressors, and challenging behaviors. t Tests, Mann Whitney U tests, χ² tests, and multinominal logistic regression models were used to compare the two age groups, 30-49 years (n = 1,188) versus 50 years and older (n = 464).

RESULTS

Older adults had more medical conditions, fewer reported psychiatric conditions, and were more likely to be taking more psychiatric medications compared to younger adults, after adjusting for demographic variables, disability level, and number of recent stressors.

CONCLUSION

Although older individuals reported fewer psychiatric diagnoses, they were more likely to take higher numbers of psychiatric medications and have more medical conditions. Clinicians and researchers ought to devote more attention to the healthcare needs of older adults with IDD, a vulnerable group exposed to polypharmacy and at risk of adverse events.

Abstract 97: Cerebrovascular Trained Advance Practice Nurse Practitioners Can Safely and Accurately Administer Alteplase as Well as Their Neurology Physician Colleagues via Telemedicine

Background: Acute Ischemic Stroke (AIS) treatment is time sensitive. Many hospitals lack neurology expertise on site to assess patients and assist emergency medicine colleagues with administration of thrombolytic therapy. Telestroke services have been shown to be as safe for administering thrombolytic therapy as on-site neurological expertise. Neurologists covering acute stroke services on-site and via telemedicine are in short supply. Advance Practice Registered Nurses (APRNs) specializing in stroke and cerebrovascular disease have helped fill the gap, however, data are lacking on APRN acute telestroke coverage, thrombolytic administration, and patient outcomes.

Purpose: The aim was to determine whether cerebrovascular trained APRNs covering our 24/7/365 CSC telestroke service could accurately and safely administer alteplase as well as our neurology physician colleagues.

Methods: All consecutive AIS telestroke consults were reviewed at 2 rural community hospital spoke sites from 1/1/17-7/1/19. Telestroke call was shared among neurologists and 2 APRNs. Both APRNs have > 10 years of cerebrovascular disease experience. Nationally accepted AHA guidelines for inclusion/exclusion for alteplase (tPA) administration were followed and documented accordingly up to 4.5 hours from onset.

Results: A total of 1,515 telestroke consults were performed (427 MD, 1088 APRN). Of those, 121 were diagnosed with suspected AIS, met criteria for tPA, and it was administered.

Conclusions: APRNs at our CSC providing telestroke coverage at 2 rural community hospitals resulted in no statistical difference in stroke care delivery and patient outcomes compared to our physician colleagues. Incorporating APRNs into telestroke call coverage needs further study to better define necessary telehealth training, curriculum, standardized professional competencies, and consideration of state laws.

Abstract WP477: ICH in a Mid-South Mobile Stroke Unit Sample: Demographics, Clinical Findings, and Geospatial Distribution

Background: Clinical and geospatial differences in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) patients within stroke belt region mobile stroke units (MSU) have not been described. We sought to understand presentation differences in the Mid-South.

Methods: Consecutive MSU patients were analyzed for demographic, call, and clinical characteristics. Cases were geocoded, spatially joined to zip code shapefile with raw counts normalized to population; incidence rates were calculated and symbolized by mathematical natural breaks.

Results: 292 AIS and 29 ICHs were transported in 52 weeks; age was similar (ICH 63 + 15 vs. AIS 64 + 15), cases were mostly female (ICH 64%; AIS 60%), with African Americans (AA) significantly more likely to have AIS (74%) compared to ICH (64%; p=0.023). Median ICH NIHSS was significantly higher (median 9.5, IQR 5.5-17) then AIS NIHSS (median 5, IQR 2-9; p<0.001), as were SBP (ICH 184 + 37mmHg vs. AIS 159 + 35mmHg; p<0.001) and DBP (ICH 104 + 21mmHg vs. AIS 91 + 21mmHg; p=0.003). ICH patients were significantly more likely to be treated within the first 60 minutes of symptom onset (p<0.001) then AIS. High incidence ICH territories were geospatially defined.

Conclusions: Mid-South ICH MSU patients have surprisingly different demographics than National data, and were most commonly female, but less likely to be of AA. A discreet geospatial ICH pattern was identified for high ICH risk.

2136. Systematic Review of Surgical Wound Class Reveals Marked Service-Related Discrepancies and Can Improve Appropriateness of Classification Impacting the Expected Number of Infections and the Standardized Infection Ratio (SIR)

Background

During surgical operations, surgical wounds are classified according to the wound classification system (I—clean; II—clean/contaminated; III—contaminated; and IV—dirty). Accuracy in assessing the degree of wound contamination is crucial since it greatly impacts the risk of a surgical site infection (SSI). Thus, wound classifications (WC) are determinant in calculating the expected number of SSIs. At our institution we suspected that surgical wounds were not always accurately classified, and were skewed toward under-classifying wound class. This contributed to incorrect and reduced expected SSIs and an inflated SSI Standardized Infection Ratio (SIR).

Methods

An independent team reviewed 273 surgical cases from our top priority SSI reduction areas: Prosthetic knees (KPRO), coronary artery bypass grafts (CABG), abdominal hysterectomies (HYST) and colorectal surgery (COLO). Whenever there was discordance in surgeon vs. review team WC, an arbitrator reviewed the case with the surgeon and corrected misclassified cases as appropriate. Reclassifications were documented in the medical record as well as in the National Healthcare Safety Network (NHSN) system.

Results

Figure 1 shows all WC reviews. Overall, 14% of all surgeries were misclassified and 95% of misclassifications were under-classifications. Appropriateness of WC varied widely by surgical service, with 100% concordant WC for KPRO, while 9% of HYST and CABG were misclassified, and fully 38% of COLOs were misclassified (Figure 1). These errors led to under predicting expected SSIs and, if not corrected, would have a measurable impact on our SSI SIR.

Conclusion

The inaccurate classifications vary by service/surgery, but in COLO we found them to be common and overwhelmingly skewed toward under-classification, which had a measurable impact on the number of expected SSIs and on SSI SIR. Focusing efforts on surgeries more prone to misclassification (such as COLO rather than KPRO) may be a worthwhile focused quality improvement effort.

Disclosures

J. P. Parada, Merck: Speaker’s Bureau, Speaker honorarium.

Abstract 4285: Genomics-driven clustering of disease-related biomarkers identifies therapeutic options in myelodysplastic syndromes (MDS)

Hypomethylating agents (HMA) and lenalidomide (LEN) are approved and used in the treatment of patients (pts) with MDS, though these drugs fail in most pts. No method exists to predict drug response beyond associating single actionable mutations with a single drug's response. We hypothesized that MDS pts can be clustered by similarities in genomic/molecular profiles, & that each cluster may be assigned combos of FDA-approved drugs to target their unique biomarker profile. Bone marrow cells from 88 MDS pts & the MDS-L cell line were analyzed by cytogenetics & for mutations in 14 myeloid genes using NGS. 31 pts had sufficient data for analysis. 20 profiles had similar aberrations & were grouped. Genomic data from pts and MDS-L were entered into a computational biology modeling (CBM) software, which generates a disease-specific protein network map using PubMed to create digital models and identify characteristic biomarkers unique to each pt. An algorithm was created to cluster the models based on overlapping disease-specific biomarkers. Digital drug simulations (DDS) were conducted both on MDS-L & pt simulation models by quantitatively measuring drug effect on a cell growth score (CGS), a composite of cell proliferation, viability & apoptosis. DDS identified drugs by assessing their impact on disease-specific biomarkers and calculated CGSs. Predictions were validated using MTT. 14/31 MDS pt profiles, including the MDS-L cell line, clustered into 4 groups based on biomarker characteristics.MDS-L cells harbor NRAS (G12A) mutation,-7,-12,+1,+8,+19,+20 and +21. Genes associated with increased copy number (CN) include AURKA, IGFR, PAR5, MTOR, IL6, JAK3, MDM4, MYC, MCL1, COX2, PDE4A, and RCE1; genes associated with decreased CN include DUSP1, RASA1, NR3C1, IRF1, ETV6, and SHH. CBM identified active biomarkers in MDS-L cells (90RSK, MAPK7, AKT and BTK), validated by western blot. DDS predicted nelfinavir+celecoxib to be effective in MDS-L. MDS-L cells were treated with nelfinavir, celecoxib, and nelfinavir+celecoxib with increasing doses. Nelfinavir & celecoxib reduced MDS-L viability in a dose-dependent manner, while nelfinavir+celecoxib showed additive reduction of MDS-L viability. DDS was performed on each pt to predict response to HMA and LEN. Two of the clusters (n=2/cluster) were predicted to be non-responders to any SOC therapy. A third cluster (n=3) was predicted to respond to HMA, but not LEN, and the fourth cluster (n=6) showed varying or no response to either HMA/LEN. These results use a novel concept of using genomics & CBM to cluster profiles with overlapping disease-relevant biomarkers & similar drug response predictions. CBM can identify pt populations who may benefit from certain therapeutic regimens, improving response rates, & give insights into the mechanisms by which each drug impacts the MDS-specific biomarkers

Citation Format: Leylah M. Drusbosky, Kimberly E. Hawkins, Amy Meacham, Elizabeth Wise, Neeraj Kumar Singh, Chandan Kumar, Sumanth M. Vasista, Rakhi P. Suseela, Taher Abbasi, Shireen Vali, Kaoru Tohyama, Maher Albitar, Peter P. Sayeski, Christopher R. Cogle. Genomics-driven clustering of disease-related biomarkers identifies therapeutic options in myelodysplastic syndromes (MDS) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4285.

Abstract TP66: IV Thrombolysis May be Safe in Patients With Lower Platelet Counts

Background & Purpose: It has been well established that intravenous alteplase (IVa) administration for treatment of acute ischemic stroke (AIS) improves clinical outcome at 3 months, and earlier treatment is more likely to result in a favorable outcome with reduced symptomatic intracranial hemorrhage (sICH). A platelet count (PC) of <100,000/mm3 remains a contraindication IVa, but the incidence is low. With the limited time to diagnose an AIS and candidacy for IVa, often lab results are received after drug initiation. Research indicates that IVa for AIS may be safe and the risk of developing sICH is low if IVa is given before PC is resulted. According to AHA/ASA guidelines, treatment is not delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test. The purpose of this study is to evaluate the incidence of asymptomatic hemorrhage (aICH), functional outcome, and safety of IVa in AIS patients with PC <100,000/mm3 prior to PC results.

Methods: We retrospectively reviewed charts of patients who received IVa from January, 2009 to July, 2017 at our facility. Patients were identified and treated based on standard FDA approved guidelines. We identified patients with admission PC <100,000/mm3. We compared admission and discharge PC and NIHSS, baseline and discharge mRS, and discharge disposition. We evaluated their medical and social history and antiplatelet use prior to admission. Brain MRI and 24 hour noncontrast CT head were reviewed.

Results: 511 patients received IVa for treatment of AIS at our facility during the study period. Four patients (0.97%) with a PC of <100,000/mm3 (70,000/mm3 – 97,000/mm3) received full dose IVa. None of the 4 subjects had a hemorrhagic complication on 24 hour CT. Upon discharge, all 4 patients had an improvement in the NIHSS (mean 3.7 points) and were functionally independent at discharge (mRS 0-1). All 4 patients were discharged home.

Conclusion: IVa treatment in AIS with PC <100,000/mm3 did not result in aICH in this group of patients. Our study supports the claim that lower PC is rare in AIS patients and there is no need to wait for PC results before starting IVa. Full dose IVa in lower PCs may be safe, but a larger sample size should be studied to further evaluate safety.

Abstract 5118: A novel polyamine sulfonamide with anti-leukemic activity

The greatest challenge in treating Acute Myeloid Leukemia (AML) is refractory disease. Although 60-80% of AML patients achieve complete remission after induction chemotherapy, majority of these patients relapse and die of progressive disease. New treatment options targeting the vulnerabilities of AML biology are highly critical for disease regression, in particular the chemo-resistant leukemia-initiating population, to ensure relapse-free survival in patients. Identifying novel druggable targets that are selective to AML despite their location in the vascular niche is thus highly warranted. We developed an in vitro co-culture model consisting of AML cells and Bone Marrow- derived Endothelial Cells (BMECs), mimicking the protective effect of the vascular niche in the bone marrow microenvironment. Using this unique model, and taking advantage of combinatorial chemistry, we performed high-throughput chemical-phenotypic screening of approximately 30 million novel compounds and identified a novel polyamine sulfonamide 2470-51 that can selectively kill AML cells by overcoming the protective effect of the BMECs. In addition to AML blasts, 2470-51 also exhibited highly selective activity against the leukemic stem and progenitor cell population while sparing normal hematopoietic stem and progenitor cells. In vivo studies using patient-derived xenograft models indicated significant regression in AML engraftment post 2470-51 treatment. Target identification experiments involving unbiased label-free shotgun proteomic analysis in combination with targeted Selected Ion Monitoring (SIM) revealed covalent drug binding targets of 2470-51. By performing differential protein expression analysis using ITRAQ analysis, we identified downstream mechanisms that led to mitotic cell cycle arrest and cell death. Collectively, our findings display the in vitro as well as in vivo efficacy of a novel polyamine sulfonamide in eliminating AML, including the leukemia initiating compartment. We also uncover a novel mechanism in AML that can be taken advantage of for selective toxicity. Furthermore, we establish the role of 2470-51 as a potential therapeutic agent in treating AML.

Citation Format: Vindhya Vijay, Amy Meacham, Leylah Drusbosky, Elizabeth Wise, Christopher Cogle. A novel polyamine sulfonamide with anti-leukemic activity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5118. doi:10.1158/1538-7445.AM2017-5118

Peripheral Blood Cytokine Levels After Acute Myocardial Infarction: IL-1β- and IL-6-Related Impairment of Bone Marrow Function

RATIONALE

Intracoronary infusion of bone marrow (BM) mononuclear cells after acute myocardial infarction (AMI) has led to limited improvement in left ventricular function. Although experimental AMI models have implicated cytokine-related impairment of progenitor cell function, this response has not been investigated in humans.

OBJECTIVE

To test the hypothesis that peripheral blood (PB) cytokines predict BM endothelial progenitor cell colony outgrowth and cardiac function after AMI.

METHODS AND RESULTS

BM and PB samples were collected from 87 participants 14 to 21 days after AMI and BM from healthy donors was used as a reference. Correlations between cytokine concentrations and cell phenotypes, cell functions, and post-AMI cardiac function were determined. PB interleukin-6 (IL-6) negatively correlated with endothelial colony-forming cell colony maximum in the BM of patients with AMI (estimate±SE, -0.13±0.05; P=0.007). BM from healthy individuals showed a dose-dependent decrease in endothelial colony-forming cell colony outgrowth in the presence of exogenous IL-1β or IL-6 (P<0.05). Blocking the IL-1R or IL-6R reversed cytokine impairment. In AMI study participants, the angiogenic cytokine platelet-derived growth factor BB glycoprotein correlated positively with BM-derived colony-forming unit-endothelial colony maximum (estimate±SE, 0.01±0.002; P<0.001), multipotent mesenchymal stromal cell colony maximum (estimate±SE, 0.01±0.002; P=0.002) in BM, and mesenchymal stromal cell colony maximum in PB (estimate±SE, 0.02±0.005; P<0.001).

CONCLUSIONS

Two weeks after AMI, increased PB platelet-derived growth factor BB glycoprotein was associated with increased BM function, whereas increased IL-6 was associated with BM impairment. Validation studies confirmed inflammatory cytokine impairment of BM that could be reversed by blocking IL-1R or IL-6R. Together, these studies suggest that blocking IL-1 or IL-6 receptors may improve the regenerative capacity of BM cells after AMI.

CLINICAL TRIAL REGISTRATIONS

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00684060.

Abstract WP405: Age, Race, and Gender Disparities in Door to Needle Time: A Single Center Joint Commission Certified Comprehensive Stroke Center Experience

Introduction: Functional outcomes and quality of life are known benefits of Activase treatment in acute ischemic stroke (AIS), however, benefit is highly time dependent. Prior studies demonstrate that women and black patients with AIS are less likely to be treated with Activase in < 60 minutes. Utilization of best practice strategies identified in Target Stroke I & II has been an ongoing process improvement initiative at our facility since 2009.

Purpose: Our goal was to understand if disparities in Door to Needle Time (DTNT) exist by age, race, or gender at our Joint Commission certified CSC with utilization of best practice strategies.

Methods: A retrospective chart analysis with comparison of average DTNT by age, race and gender was performed on all AIS patients receiving Activase in our CSC from 2009-2015 (n=297). Differences in DTNT were analyzed using Student’s t-tests, ANOVA, and linear regression.

Results: Median DTNT for all patients was 56 minutes (Male 58, Female 56, Black 61, and White 56). Average DTNT by age did not show any significant correlation with a R 2 =0.003 (F:0.98 p=0.322). Additionally, there were no significant differences among classified age categories (18-55, 56-80, 81-90, 91+; p=0.50). Average DTNT for females and males were observed to be 62.6 (95% CI 58.6-66.7) and 61.0 (95% CI 57.1-65.0), (p=0.57). Average DTNT for Blacks and Whites were observed to be 64.9 (95% CI 56.8-73.0) and 61.1 (95% CI 58.1-64.2), (p=0.35). Further analysis of gender by race classification demonstrated no significant differences in average DTNT (Black-Female 66.7, Black-Male 64.0, White-Female 62.1, White-Male 60.4 - F:0.44 p=0.73).

Conclusion: No disparities in DTNT were found for age, race or gender at our CSC from 2009-2015. Target Stroke may have contributed to the absence of disparities. Comparison of DTNTs by age, race and gender before and after instituting Target Stroke at our CSC, other certified centers, and non-certified centers, is planned for our region. Further analyses will include arrival mode, payer source, stroke severity on arrival, off hour presentation, symptomatic hemorrhagic transformation rates, functional outcomes, and discharge disposition.

Ex vivo virotherapy with myxoma virus does not impair hematopoietic stem and progenitor cells

BACKGROUND

Relapsing disease is a major challenge after hematopoietic cell transplantation for hematological malignancies. Myxoma virus (MYXV) is an oncolytic virus that can target and eliminate contaminating cancer cells from auto-transplant grafts. The aims of this study were to examine the impact of MYXV on normal hematopoietic stem and progenitor cells and define the optimal treatment conditions for ex vivo virotherapy.

METHODS

Bone marrow (BM) and mobilized peripheral blood stem cells (mPBSCs) from patients with hematologic malignancies were treated with MYXV at various time, temperature and incubation media conditions. Treated BM cells from healthy normal donors were evaluated using flow cytometry for MYXV infection, long-term culture-initiating cell (LTC-IC) assay and colony-forming cell (CFC) assay.

RESULTS

MYXV initiated infection in up to 45% of antigen-presenting monocytes, B cells and natural killer cells; however, these infections were uniformly aborted in >95% of all cells. Fresh graft sources showed higher levels of MYXV infection initiation than cryopreserved specimens, but in all cases less than 10% of CD34(+) cells could be infected after ex vivo MYXV treatment. MYXV did not impair LTC-IC colony numbers compared with mock treatment. CFC colony types and numbers were also not impaired by MYXV treatment. MYXV incubation time, temperature or culture media did not significantly change the percentage of infected cells, LTC-IC colony formation or CFC colony formation.

CONCLUSIONS

Human hematopoietic cells are non-permissive for MYXV. Human hematopoietic stem and progenitor cells were not infected and thus unaffected by MYXV ex vivo treatment.

Chemosensitizing AML cells by targeting bone marrow endothelial cells

Refractory disease is the greatest challenge in treating patients with acute myeloid leukemia (AML). Blood vessels may serve as sanctuary sites for AML. When AML cells were co-cultured with bone marrow endothelial cells (BMECs), a greater proportion of leukemia cells were in G0/G1. This led us to a strategy of targeting BMECs with tubulin-binding combretastatins, causing BMECs to lose their flat phenotype, degrade their cytoskeleton, cease growth, and impair migration despite unchanged BMEC viability and metabolism. Combretastatins also caused downregulation of BMEC adhesion molecules known to tether AML cells, including vascular cell adhesion molecule (VCAM)-1 and vascular endothelial (VE)-cadherin. When AML-BMEC co-cultures were treated with combretastatins, a significantly greater proportion of AML cells dislodged from BMECs and entered the G2/M cell cycle, suggesting enhanced susceptibility to cell cycle agents. Indeed, the combination of combretastatins and cytotoxic chemotherapy enhanced additive AML cell death. In vivo mice xenograft studies confirmed this finding by revealing complete AML regression after treatment with combretastatins and cytotoxic chemotherapy. Beyond highlighting the pathologic role of BMECs in the leukemia microenvironment as a protective reservoir of disease, these results support a new strategy for using vascular-targeting combretastatins in combination with cytotoxic chemotherapy to treat AML.

Abstract WP84: Thrombolysis is Safe in the Nonagenarians With Acute Ischemic Stroke

Introduction: People aged 90 years or older are the fastest growing group in North America. This group was excluded from traditional clinical trials of intravenous tissue plasminogen activator (iv tPA) thrombolysis. IV tPA is the most beneficial emergent therapy in acute ischemic stroke (AIS). We have compassionately treated AIS patients in this age group with iv tPA in recent years.

Hypothesis: Our aim is to evaluate the safety and outcome of iv tPA use in nonagenarian patients with AIS

Methods: Consecutively iv tPA-treated AIS patients who were older than 90 years and were admitted at our institution from January 2004-June 2015 were included. The administration of iv tPA was within 3 hours after the stroke onset. We reviewed the clinical features of the patients at presentation, complications, and outcomes. Outcome measures at discharge included improvement of NIHSS, mRS, symptomatic intracranial hemorrhage (sICH), and discharge disposition. We also assessed the rate of complications of iv tPA. Multiple logistic regression analysis was used to evaluate association between the outcome versus the severity of stroke, or versus pre-stroke dependence.

Results: A total of 35 AIS patients who were 90 years or older (female 80%; and median age 93 years old) were treated with iv tPA. At baseline twenty-two patients (62.9%) had a history of atrial fibrillation without anticoagulation, and more than half (20/35) patients needed assistance for gait instability, but they were otherwise functional. Median NIHSS on admission was 16 (IQR 9-22). Two patients (5.7%) had symptomatic intracerebral hemorrhage. At discharge the median NIHSS was 10 (IQR 1-19). Ten patients (28.6%) had favorable outcome (mRS ≤ 2) while sixteen patients (45.7%) had good outcome (mRS ≤ 3). Four patients were discharged home and 16 patients went to rehabilitation facility. Fifteen patients (42.9%) succumbed to cardio-pulmonary failure or were discharged to hospice. Mild AIS patients (NIHSS <7) had better outcomes (p < 0.05). The pre-existing dependence (mRS ≥3) did not predict poor outcome.

Conclusion: It is safe to administer iv tPA to AIS patients who are 90 years or older although the benefits are less robust compared to younger patients. Patients with milder deficits had more favorable outcomes.

Abstract 180: Stroke Mimics in Drip and Ship Thrombolytic Therapy

Introduction: Drip and ship (DS) thrombolysis provides immediate acute ischemic stroke treatment and follow-up tertiary stroke care at a certified Comprehensive Stroke Center (CSC) for one quarter of the US population living in rural areas. Studies reveal that patients with stroke mimic (SM) inadvertently receive treatment due to lack of immediate access to specialists and the limited treatment time window.

Hypothesis: We hypothesized that a higher percentage of SM would receive thrombolysis via the DS paradigm than those directly presenting to the CSC.

Methods: We reviewed consecutive DS tPA cases transferred to the University of Louisville Hospital (ULH) and tPA cases originating at ULH from January, 2013 to June, 2015. ULH is a CSC that provides rural Kentucky and Southern Indiana hospitals with 24-hour telephone access to stroke specialists. We compared the percentage of SMs via a DS paradigm to those originating at ULH. SM data collected included demographics, medical history, NIHSS, complications, discharge diagnosis, discharge disposition, and the length of hospitalization. Etiology of SM was evaluated in the Old (≥ 65 years old) and the Young (<65 years old) group, respectively. Comparative analyses with t-tests and Fisher Exact tests were performed.

Results: Total numbers of tPA cases were similar between the DS (201) and the ULH (200) groups, but the percentage of SM in the DS group was double the ULH group (27.4% vs 13.5%). Clinical features, NIHSS on admission, and percentage of SM patients who were 65 years or older were similar in both groups. None of SM had intracranial hemorrhage or severe adverse events. One patient in the DS had minor hematemesis without transfusion. All except one patient returned home or to an assisted living facility. One patient who was from home was discharged to a nursing home due to Parkinson’s disease. Psychiatric disease was more common in the Young SM than the old (45.3% vs 7.4%, p < 0.05). Encephalopathy for various reasons (25.9%) and seizures (22.2%) were the two most common causes in the Old SM.

Conclusions: SMs are treated with tPA more often in the DS paradigm than when presenting to a CSC. Although the thrombolysis caused no harm, adequate access to specialists (i.e telestroke) may decrease unnecessary treatment with tPA.

Abstract WP323: Bridging The Gap Between Acute Care and Public Health

Background: The WHO estimates that only 50% of patients with chronic illness adhere to treatment recommendations. The Affordable Care Act targets hospital readmission rates as cost savings opportunities. Readmission rates reported in the literature range from 6-33%. Transitional care programs have been shown to improve patient outcomes.

Purpose: To reduce readmission and recurrent stroke, the Stroke Patient Education and Navigation (SPEN) Project sought to enhance the continuum of care post discharge by forming collaboration between the University of Louisville Stroke Center (UL), Taylor Regional Hospital (TRH) and the Department for Public Health. Primary outcomes of this three-year project were hospital readmission, medication adherence, utilization of community resources, and National Quality Forum (NQF) 18: blood pressure less than 140/90.

Methods: Stroke patients transferred from TRH to UL discharged home from October 2013 to January 2015 were invited to participate. After discharge nurses made 3 home visits at 2 weeks, 3 months, and 6 months to assess outcomes, biometrics, and blood pressure self-management. A follow up phone call was made at one year.

Results: 44 patients participated (mean age 70, 28 male, 16 female). 32/44 (73%) completed all 3 visits. 36/44 (82%) with medication adherence. 2/44 (5%) readmitted within 30 days (1 with TIA and 1 with pneumonia). 2/24 (8%) participated in a community resource (smoking cessation program and diabetes classes). Reasons for not using community resources were lack of transportation and “not needed”. Results of NQF 18 goals achieved: 29/44 (66%) at visit 1 and 12/28 (43%) for all 3 visits. At one-year post discharge 10 patients had been readmitted, 3 for vascular events (1 TIA, 1 MI, 1 HTN). Cost of project per patient was $306.62.

Conclusions: the SPEN project achieved low 30-day readmission rate and positive medication compliance, but did not achieve utilization of community resources or satisfactory NQF 18 results. Future projects should consider methods to improve resource utilization and cost effective methods of follow-up, such as multiple telephone or telehealth interactions.

Identification of Bone Marrow Cell Subpopulations Associated With Improved Functional Outcomes in Patients With Chronic Left Ventricular Dysfunction: An Embedded Cohort Evaluation of the FOCUS-CCTRN Trial

In the current study, we sought to identify bone marrow-derived mononuclear cell (BM-MNC) subpopulations associated with a combined improvement in left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), and maximal oxygen consumption (VO₂ max) in patients with chronic ischemic cardiomyopathy 6 months after receiving transendocardial injections of autologous BM-MNCs or placebo. For this prospectively planned analysis, we conducted an embedded cohort study comprising 78 patients from the FOCUS-Cardiovascular Cell Therapy Research Network (CCTRN) trial. Baseline BM-MNC immunophenotypes and progenitor cell activity were determined by flow cytometry and colony-forming assays, respectively. Previously stable patients who demonstrated improvement in LVEF, LVESV, and VO₂ max during the 6-month course of the FOCUS-CCTRN study (group 1, n = 17) were compared to those who showed no change or worsened in one to three of these endpoints (group 2, n = 61) and to a subset of patients from group 2 who declined in all three functional endpoints (group 2A, n = 11). Group 1 had higher frequencies of B-cell and CXCR4⁺ BM-MNC subpopulations at study baseline than group 2 or 2A. Furthermore, patients in group 1 had fewer endothelial colony-forming cells and monocytes/macrophages in their bone marrow than those in group 2A. To our knowledge, this is the first study to show that in patients with ischemic cardiomyopathy, certain bone marrow-derived cell subsets are associated with improvement in LVEF, LVESV, and VO₂ max at 6 months. These results suggest that the presence of both progenitor and immune cell populations in the bone marrow may influence the natural history of chronic ischemic cardiomyopathy-even in stable patients. Thus, it may be important to consider the bone marrow composition and associated regenerative capacity of patients when assigning them to treatment groups and evaluating the results of cell therapy trials.

Abstract T P350: Bridging The Gap Between Acute Care and Public Health

Background: The WHO estimates that only 50% of patients with chronic illness adhere to treatment recommendations. The Affordable Care Act targets hospital readmission rates as cost savings opportunities. Transitional care programs have been shown to improve patient outcomes.

Purpose: To reduce readmission and recurrent stroke, the Stroke Patient Education and Navigation (SPEN) Pilot Project sought to enhance the continuum of care post discharge by forming collaboration between the University of Louisville Stroke Center (ULSC), Taylor Regional Hospital (TRH) and the Department for Public Health. Primary outcomes of this one-year pilot were hospital readmission rate, medication compliance, and utilization of community resources.

Methods: Stroke patients transferred from TRH to ULSC discharged home were invited to participate. Upon d/c home nurses made three home visits (2 weeks, 3 months, and 6 months post discharge) to assess outcomes and to obtain demographics, PCP, whether patient was receiving rehab, mRS score, BMI, vital signs, labs, vascular risk factors, patient/caregivers’ ability to measure their own blood pressure, verbalize stroke symptoms, behavioral modifications since hospital discharge, and self assessment of perceived health status.

Results: 21 patients agreed to participate in SPEN, 3 of whom did not complete the study. The average time per 1 st , 2 nd , and 3 rd nurses’ visits were 4 hours, 3.2 hours, and 2.9 hours respectively. The total cost of 56 health department home visits, including travel and expenses was $12,219.02, a cost per home visit of $218.20. The cost per patient for the project was $581.86. 95.2% adhered to their medications as prescribed. No patients were readmitted to the hospital within 30 days. Only one person (4.8%) participated in a community resource, a smoking cessation program at the health department. Most sited that they did not utilize community resources due to lack of transportation.

Conclusions: SPEN results revealed excellent medication compliance, no hospital readmissions within 30 days, but low community resource utilization. The sample size was small and limited to six -month follow up. Further outcomes and cost analyses can be obtained with a larger sample size and extended follow up.

Detailed analysis of bone marrow from patients with ischemic heart disease and left ventricular dysfunction: BM CD34, CD11b, and clonogenic capacity as biomarkers for clinical outcomes

RATIONALE

Bone marrow (BM) cell therapy for ischemic heart disease (IHD) has shown mixed results. Before the full potency of BM cell therapy can be realized, it is essential to understand the BM niche after acute myocardial infarction (AMI).

OBJECTIVE

To study the BM composition in patients with IHD and severe left ventricular (LV) dysfunction.

METHODS AND RESULTS

BM from 280 patients with IHD and LV dysfunction were analyzed for cell subsets by flow cytometry and colony assays. BM CD34(+) cell percentage was decreased 7 days after AMI (mean of 1.9% versus 2.3%-2.7% in other cohorts; P<0.05). BM-derived endothelial colonies were significantly decreased (P<0.05). Increased BM CD11b(+) cells associated with worse LV ejection fraction (LVEF) after AMI (P<0.05). Increased BM CD34(+) percentage associated with greater improvement in LVEF (+9.9% versus +2.3%; P=0.03, for patients with AMI and +6.6% versus -0.02%; P=0.021 for patients with chronic IHD). In addition, decreased BM CD34(+) percentage in patients with chronic IHD correlated with decrement in LVEF (-2.9% versus +0.7%; P=0.0355).

CONCLUSIONS

In this study, we show a heterogeneous mixture of BM cell subsets, decreased endothelial colony capacity, a CD34+ cell nadir 7 days after AMI, a negative correlation between CD11b percentage and postinfarct LVEF, and positive correlation of CD34 percentage with change in LVEF after cell therapy. These results serve as a possible basis for the small clinical improvement seen in autologous BM cell therapy trials and support selection of potent cell subsets and reversal of comorbid BM impairment.

CLINICAL TRIAL REGISTRATIONS URL

http://www.clinicaltrials.gov. Unique identifiers: NCT00684021, NCT00684060, and NCT00824005.

Epidemiological characteristics of human and animal rabies in Azerbaijan

The Caucasus is a region of geopolitical importance, in the gateway between Europe and Asia. This geographical location makes the region equally important in the epidemiology and control of transboundary infectious diseases such as rabies. Azerbaijan is the largest country in the Caucasus, and although rabies is notifiable and considered endemic, there is little information on the burden of human and animal rabies. Here, we describe a cross-disciplinary international collaboration aimed at improving rabies control in Azerbaijan. Partial nucleoprotein gene sequences were obtained from animal rabies cases for comparison with those from surrounding areas. Reported human and animal rabies cases between 2000 and 2010 were also reviewed and analysed by region and year. Comparison of rabies virus strains circulating in Azerbaijan demonstrates more than one lineage of rabies virus circulating concurrently in Azerbaijan and illustrates the need for further sample collection and characterization. Officially reported rabies data showed an increase in human and animal rabies cases, and an increase in animal bites requiring provision of post-exposure prophylaxis, since 2006. This is despite apparently consistent levels of dog vaccination and culling of stray dogs.

Abstract WP355: Impact of Target Stroke on Reducing Door-to-Needle Times

Background: Intravenous tissue plasminogen activator (IV-tPA) is the only FDA approved drug treatment for Acute Ischemic Stroke (AIS) within 3 hours or less from onset of stroke symptoms. The guidelines also recommend that stroke centers be able to administer IV-tPA in less than 60 minutes from the time the patients arrive, door-to-needle (DTN) time. Since less than one third of hospitals achieve this DTN goal, the American Stroke Association developed a national initiative to reduce the door to needle time called “Target Stroke” (TS).

Methods: A retrospective analysis was conducted of DTN times on 59 consecutive patients receiving IV-tPA at the University of Louisville Hospital from January 2009 to July, 2012. TS was instituted the fourth quarter of 2011. The percentage of patients meeting the target DTN time of less than 60 minutes was compared before and after TS was instituted (Quarter 1 and 2, 2011 vs Q1-2, 2012). Q1-2, 2010 and Q1-2, 2009 were also compared to Q1-2, 2012. Data were analyzed using 2X2 Fisher’s exact test. A two-tailed probability value of p <0.05 was considered significant.

Results: The data show a statistically significant association between DTN time in less than 60 minutes and target stroke implementation ( p <0.001, Q1-2, 2011 vs Q1-2, 2012; p <0.001, Q1-2, 2010 vs Q1-2, 2012 and p <0.020 Q1-2, 2009 vs Q1-2, 2012).

Conclusions/Discussion: More patients received IV-tPA in less than 60 minutes after implementation of TS than before. Utilization of TS significantly improved DTN times at University of Louisville Hospital. Our next step will be to compare outcomes for the same data set using discharge modified Rankin Scale and discharge disposition.

Virotherapy using myxoma virus prevents lethal graft-versus-host disease following xeno-transplantation with primary human hematopoietic stem cells

Graft-versus-host disease (GVHD) is a potentially lethal clinical complication arising from the transfer of alloreactive T lymphocytes into immunocompromised recipients. Despite conventional methods of T cell depletion, GVHD remains a major challenge in allogeneic hematopoietic cell transplant. Here, we demonstrate a novel method of preventing GVHD by ex vivo treatment of primary human hematopoietic cell sources with myxoma virus, a rabbit specific poxvirus currently under development for oncolytic virotherapy. This pretreatment dramatically increases post-transplant survival of immunocompromised mice injected with primary human bone marrow or peripheral blood cells and prevents the expansion of human CD3(+) lymphocytes in major recipient organs. Similar viral treatment also prevents human-human mixed alloreactive T lymphocyte reactions in vitro. Our data suggest that ex vivo virotherapy with myxoma virus can be a simple and effective method for preventing GVHD following infusion of hematopoietic products containing alloreactive T lymphocytes such as: allogeneic hematopoietic stem and progenitor cells, donor leukocyte infusions and blood transfusions.

Unravelling the mechanisms underpinning chemokine receptor activation and blockade by small molecules: a fine line between agonism and antagonism?

Chemokines are a family of small basic proteins which induce the directed migration of cells, notably leucocytes, by binding to specific GPCRs (G-protein-coupled receptors). Both chemokines and their receptors have been implicated in a host of clinically important diseases, leading to the notion that antagonism of the chemokine–chemokine receptor network may be therapeutically advantageous. Consequently, considerable effort has been put into the development of small-molecule antagonists of chemokine receptors and several such compounds have been described in the literature. One curious by-product of this activity has been the description of several small-molecule agonists of the receptors, which are typically discovered following the optimization of lead antagonists. In this review we discuss these findings and conclude that these small-molecule agonists might be exploited to further our understanding of the molecular mechanisms by which chemokine receptors are activated.

4-Hydroxy-5,6-dihydropyrones as inhibitors of HIV protease: the effect of heterocyclic substituents at C-6 on antiviral potency and pharmacokinetic parameters

Due largely to the emergence of multi-drug-resistant HIV strains, the development of new HIV protease inhibitors remains a high priority for the pharmaceutical industry. Toward this end, we previously identified a 4-hydroxy-5,6-dihydropyrone lead compound (CI-1029, 1) which possesses excellent activity against the protease enzyme, good antiviral efficacy in cellular assays, and promising bioavailability in several animal species. The search for a suitable back-up candidate centered on the replacement of the aniline moiety at C-6 with an appropriately substituted heterocyle. In general, this series of heterocyclic inhibitors displayed good activity (in both enzymatic and cellular tests) and low cellular toxicity; furthermore, several analogues exhibited improved pharmacokinetic parameters in animal models. The compound with the best combination of high potency, low toxicity, and favorable bioavailabilty was (S)-3-(2-tert-butyl-4-hydroxymethyl-5-methyl-phenylsulfanyl)-4-hydroxy-6-isopropyl-6-(2-thiophen-3-yl-ethyl)-5,6-dihydro-pyran-2-one (13-(S)). This thiophene derivative also exhibited excellent antiviral efficacy against mutant HIV protease and resistant HIV strains. For these reasons, compound 13-(S) was chosen for further preclinical evaluation.

Health problems and service utilization in the homeless

This study examined the health problems and utilization patterns of homeless individuals (n = 292) seeking medical services in a small, southern community. Results showed that the medical problems for which the homeless sought treatment were often (72.6 percent) a reoccurring problem for which treatment had been previously received. The most prevalent medical problem was upper respiratory infection (47 percent), likely exacerbated by the high rate (73 percent) of cigarette smoking found among the sample. More than half (51.4 percent) of the participants had used other medical services in the past month. Despite these high rates of utilization, the homeless may, in fact, be underutilizing appropriate preventive medical services, waiting until the medical problem becomes serious before seeking treatment, and overutilizing emergency rooms for nonemergency care. Community-based services sensitive to the needs of the homeless are likely to cost communities less money while providing better services to the homeless.