Predicting mortality in moderate-severe TBI patients without early withdrawal of life-sustaining treatments including ICU complications: The MYSTIC-score

PURPOSE

To develop and internally validate the MortalitY in Moderate-Severe TBI plus ICU Complications (MYSTIC)-Score to predict in-hospital mortality of msTBI patients without early (<24 h) withdrawal-of-life-sustaining treatments.

METHODS

We analyzed data from a Neuro-Trauma Intensive Care Unit prospectively collected between 11/2009-5/2019. Consecutive adult msTBI patients were included if Glasgow Coma Scale≤12, and neither died nor had withdrawal-of-life-sustaining treatments within 24 h of admission (n = 485). Using univariate and multivariable logistic regression in a random-split cohort approach (2/3 derivation;1/3 validation), we identified independent predictors of in-hospital mortality while adjusting for validated predictors of mortality (IMPACT-variables). We constructed the MYSTIC-Score and examined discrimination and calibration.

RESULTS

The MYSTIC-Score included the ICU complications brain edema, herniation, systemic inflammatory response syndrome, sepsis, acute kidney injury, cardiac arrest, and urinary tract infection. In the derivation cohort(n = 324), discrimination and calibration were excellent (area-under-the-receiver-operating-curve [AUC-ROC] = 0.95;Hosmer-Lemeshow p-value = 0.09, with p > 0.05 indicating good calibration). Internal validation revealed an AUC-ROC = 0.93 and Hosmer-Lemeshow-p-value = 0.76 (n = 161).

CONCLUSIONS

Certain ICU complications are independent predictors of in-hospital mortality and strengthen outcome prediction in msTBI when combined with validated admission predictors of mortality. However, external validation is needed to determine robustness and practical applicability of our model given the high potential for residual confounders.

Association between the LACE+ index and unplanned 30-day hospital readmissions in hospitalized patients with stroke

Background

The LACE+ index is used to predict unplanned 30-day hospital readmissions, but its utility to predict 30-day readmission in hospitalized patients with stroke is unknown.

Methods

We retrospectively analyzed 1,657 consecutive patients presenting with ischemic or hemorrhagic strokes, included in an institutional stroke registry between January 2018 and August 2020. The primary outcome of interest was unplanned 30-day readmission for any reason after index hospitalization for stroke. The 30-day readmission risk was categorized by LACE+ index to high risk (≥78), medium-to-high risk (59–77), medium risk (29–58), and low risk (≤ 28). Kaplan-Meier analysis, Log rank test, and multivariable Cox regression analysis (with backward elimination) were used to determine whether the LACE+ score was an independent predictor for 30-day unplanned readmission.

Results

The overall 30-day unplanned readmission rate was 11.7% (194/1,657). The median LACE+ score was higher in the 30-day readmission group compared to subjects that had no unplanned 30-day readmission [74 (IQR 67–79) vs. 70 (IQR 62–75); p < 0.001]. On Kaplan-Meier analysis, the high-risk group had the shortest 30-day readmission free survival time as compared to medium and medium-to-high risk groups (p < 0.01, each; statistically significant). On fully adjusted multivariable Cox-regression, the highest LACE+ risk category was independently associated with the unplanned 30-day readmission risk (per point: HR 1.67 95%CI 1.23–2.26, p = 0.001).

Conclusion

Subjects in the high LACE+ index category had a significantly greater unplanned 30-day readmission risk after stroke as compared to lower LACE+ risk groups. This supports the validity of the LACE+ scoring system for predicting unplanned readmission in subjects with stroke. Future studies are warranted to determine whether LACE+ score-based risk stratification can be used to devise early interventions to mitigate the risk for unplanned readmission.

Abstract WMP58: Association Of The Lace+ Score With Unplanned 30-day Hospital Readmissions After Stroke

The LACE+ score is used to predict unplanned 30-day hospital readmissions, but its association with 30-day readmission after stroke is unknown. We retrospectively analyzed 1,656 consecutive patients presenting with strokes, included in an institutional stroke registry between January 2018 and August 2020. The primary outcome of interest was unplanned 30-day readmission. The 30-day readmission risk was categorized by LACE+ scores: high risk (>81), medium high (59-80) and medium risk (29-58). Kaplan-Meier curve, Log rank test, and multivariable cox regression analysis (with backward elimination) were used to determine whether the LACE+ score was associated with 30-day readmission. The overall incidence of 30-day unplanned readmission was 11.7% (194/1,656). The median LACE+ score was higher in the 30-day readmission group compared to subjects that had no unplanned 30-day readmission (74 (IQ 67-79) vs. 70 (IQ 62-75); p<0.001). On univariate analysis, readmitted patients were older, had a longer index admission length of stay, higher index admission cost, were more likely to be discharged to inpatient rehab, and with higher presence of hypertension, diabetes, history of prior stroke/TIA, and cardiovascular risk factors (p<0.05, each) as compared to non-readmitted group. On Kaplan-Meier analysis, the cumulative 30-day readmission free survival stratified by LACE+ risk category was lowest in the high-risk group and greatest in the medium risk group (Log-rank p<0.001). On multivariable Cox-regression, LACE+ score was independently associated with the unplanned 30-day readmission risk (HR 1.033; 95% CI 1.017-1.050, p<0.001) after adjustment for other variables. This is the first study looking at the association between LACE+ scores and unplanned readmissions in stroke, noting higher LACE+ scores associated with a greater unplanned 30-day readmission after stroke. Future studies on 30-day readmission risks in stroke are needed for quality improvement.

12 versus 24 h bed rest after acute ischemic stroke thrombolysis: a preliminary experience

BACKGROUND

The practice of ≥24 h of bed rest after acute ischemic stroke thrombolysis is common among hospitals, but its value compared to shorter periods of bed rest is unknown.

METHODS

Consecutive adult patients with a diagnosis of ischemic stroke who had received intravenous thrombolysis treatment from 1/1/2010 until 4/13/2016, identified from the local ischemic stroke registry, were included. Standard practice bed rest for ≥24 h, the protocol prior to 1/27/2014, was retrospectively compared with standard practice bed rest for ≥12 h, the protocol after that date. The primary outcome was favorable discharge location (defined as home, home with services, or acute rehabilitation). Secondary outcome measures included incidence of pneumonia, NIHSS at discharge, and length of stay.

RESULTS

392 patients were identified (203 in the ≥24 h group, 189 in the ≥12 h group). There was no significant difference in favorable discharge outcome in the ≥24 h bed rest protocol compared with the ≥12 h bed rest protocol in multivariable logistic regression analysis (76.2% vs. 70.9%, adjusted OR 1.20 CI 0.71-2.03). Compared with the ≥24 h bed rest group, pneumonia rates (8.3% versus 1.6%, adjusted OR 0.12 CI 0.03-0.55), median discharge NIHSS (3 versus 2, adjusted p = .034), and mean length of stay (5.4 versus 3.5 days, adjusted p = .006) were lower in the ≥12 h bed rest group.

CONCLUSION

Compared with ≥24 h bed rest, ≥12 h bed rest after acute ischemic stroke reperfusion therapy appeared to be similar. A non-inferiority randomized trial is needed to verify these findings.

Abstract TP39: 12 versus 24 Hour Bed Rest After Acute Ischemic Stroke Thrombectomy

Background: The practice of 24 hours of bed rest after acute ischemic stroke thrombectomy is common among hospitals, but its value compared to shorter periods of bed rest is unknown. We sought to compare discharge outcomes and in-hospital complications of shorter (12 hour) and 24 hour bed rest protocols following reperfusion therapy.

Methods: Consecutive adult patients with a diagnosis of ischemic stroke who underwent thrombectomy treatment between 1/1/2010 until 4/13/2016 identified from the local ischemic stroke registry were included. Standard practice bed rest for 24 hours, the protocol prior to 1/27/2014, was retrospectively compared with standard practice bed rest for 12 hours, the protocol after that date. The primary outcome was favorable discharge location (defined as home, home with services, or acute rehabilitation). Secondary outcome measures included incidence of pneumonia, readmission within 30 days, NIHSS at discharge, and hospital length of stay.

Results: 193 patients were identified, 59 patients in the 24 hour and 134 in the 12 hour bed rest groups. There was no significant difference in favorable discharge outcome in the 24 hour bed rest protocol compared with the 12 hour bed rest protocol in multivariable logistic regression analysis (54.2% vs. 68.7%, p=0.14, OR 1.73 CI 0.84-3.56). Compared with the 24 hour bed rest group, the incidence rates of pneumonia (13.6% versus 3.7%, p=0.03, OR 0.27 CI 0.08-0.88), median discharge NIHSS (8 versus 4, p=0.036, mean length of stay (7.5 versus 3.9 days, p<0.0001), and 30-day readmission rates (10.2% versus 3.2%, p=0.017, adjusted OR 0.16 CI 0.04-0.72) were lower in the 12 hour bed rest group.

Conclusion: Compared with 24 hour bed rest, 12 hour bed rest after acute ischemic stroke thrombectomy therapy appeared to be safe and may be associated with reduced neurological deficit at discharge, shorter length-of-stay, and reduced rates of readmission within 30 days. A randomized trial is needed to verify these findings.

Prevalence of Pelvic Vein Pathology in Patients with Cryptogenic Stroke and Patent Foramen Ovale Undergoing MRV Pelvis

Background: A substantial proportion of ischemic strokes has no any identified underlying cause. Notably, the prevalence of a patent foramen ovale (PFO) is increased in cryptogenic stroke (CS) populations, which may serve as a conduit for paradoxical emboli originating from deep vein thrombosis (DVT) including the pelvic veins. Yet, there are no published guidelines for the assessment of pelvic veins as part of the stroke workup and few studies have systematically investigated pelvic veins as a potential source for paradoxical emboli in CS patients. Further, there is a relative paucity of data regarding pelvic DVT in CS and results have been conflicting. Hence, we sought to determine the prevalence of pelvic DVT in select CS patients with PFO who underwent magnetic resonance venography (MRV). Methods: We retrospectively identified patients (n = 50) who underwent contrast-enhanced pelvic MRV at the discretion of the treating physician for the evaluation of CS in the presence of a PFO during hospitalization at a single academic stroke center between January 2011 through December 2013. Multivariable logistic regression analyses were used to assess for factors independently associated with the presence of an abnormal MRV pelvis. Results: Patients (47 ± 13 years of age) had MRV performed 4 ± 3 days after their incident stroke. Nine patients had an abnormal MRV (18%). Of these, four (8%) had pelvic vein thrombosis and 5 (10%) a May-Thurner anatomic variant. All patients with pelvic DVT were subsequently anticoagulated with warfarin (none had abnormal hypercoagulability testing). Clinical clues suggesting paradoxical embolism were present in as many as 40% of patients. On multivariable logistic regression, a history of any risk factors predisposing to DVT (OR 6.7; coefficient 1.9; BCa 95% CI 0.08-20.2; p = 0.014) as well as the number of predisposing risk factors (OR 3.9; coefficient 1.4; BCa 95% CI 0.25-4.2; p = 0.005) predicted the presence of pelvic vein pathology on MRV. Conclusion: We demonstrate a relatively high prevalence of pelvic DVT among select CS patients emphasizing the importance of considering the pelvic veins as a potential source for emboli particularly in the presence of risk factors known to predispose DVT. Because patients were included at the treating physician's discretion, our results reflect ‘real-life' practice. Our results may be of clinical importance as inclusion of pelvic vein imaging in CS patients with PFO had impactful therapeutic and nosologic implications. Further study is needed to define patients most likely to benefit from pelvic vein imaging.

Heat-shock-mediated conditional regulation of hedgehog/gli signaling in zebrafish

BACKGROUND

Hedgehog (Hh) signaling is required for embryogenesis and continues to play key roles postembryonically in many tissues, influencing growth, stem cell proliferation, and tumorigenesis. Systems for conditional regulation of Hh signaling facilitate the study of these postembryonic Hh functions.

RESULTS

We used the hsp70l promoter to generated three heat-shock-inducible transgenic lines that activate Hh signaling and one line that represses Hh signaling. Heat-shock activation of these transgenes appropriately recapitulates early embryonic loss or gain of Hh function phenotypes. Hh signaling remains activated 24 hr after heat shock in the Tg(hsp70l:shha-EGFP) and Tg(hsp70l:dnPKA-BGFP) lines, while a single heat shock of the Tg(hsp70l:gli1-EGFP) or Tg(hsp70l:gli2aDR-EGFP) lines results in a 6- to 12-hr pulse of Hh signal activation or inactivation, respectively. Using both in situ hybridization and quantitative polymerase chain reaction, we show that these lines can be used to manipulate Hh signaling through larval and juvenile stages. A ptch2 promoter element was used to generate new reporter lines that allow clear visualization of Hh responding cells throughout the life cycle, including graded Hh responses in the embryonic central nervous system.

CONCLUSIONS

These zebrafish transgenic lines provide important new experimental tools to study the embryonic and postembryonic roles of Hh signaling.

Construction and evaluation of a self-luminescent biosensor

The genes encoding bioluminescence (lux genes), derived from the marine bacterium V. fischeri, have been fused next to the genes encoding mercury detoxification (mer genes), derived from a clinical isolate of S. marcescens. The fusion has been made so that the expression of the light genes comes under the control of the mer regulatory gene and promoter. These genetic elements activate the expression of the light genes in the presence of mercury. The light can readily be collected and quantitated, resulting in a biosensor for the detection of mercury.

Electron nuclear double resonance (ENDOR) of the Qc.- ubisemiquinone radical in the mitochondrial electron transport chain

We present an electron nuclear double resonance (ENDOR) study of the bound Qc.- ubisemiquinone in the mitochondrial quinol cytochrome c reductase complex. An ENDOR probe specifically modified for insertion into our electron paramagnetic resonance cavity was used for this study. We observed strongly hyperfine-coupled protons whose exchangeable nature indicated they were hydrogen-bonded to the quinone oxygen(s). It is thought that such hydrogen bonds are critical in binding the ubiquinone to protein, in stabilizing its semiquinone form, and in modulating the thermodynamic properties of the bound ubiquinone in the mitochondrial quinol cytochrome c reductase complex. Additional ENDOR features were assigned to protons of the quinone ring itself and to weakly coupled protons that may be associated with nearby amino acids. From very weakly hyperfine-coupled, distant, exchangeable protons there was also ENDOR evidence to suggest proximity and accessibility of the ubiquinone site to the solvent.