Wood cookstove use is associated with gastric cancer in Central America and mediated by host genetics

Biomass cookstove food preparation is linked to aero-digestive cancers, mediated by ingested and inhaled carcinogens (e.g., heterocyclic amines, and polycyclic aromatic hydrocarbons). We investigated the association between gastric adenocarcinoma, wood cookstove use, H. pylori CagA infection and risk modification by variants in genes that metabolize and affect the internal dose of carcinogens. We conducted a population-based, case-control study (814 incident cases, 1049 controls) in rural Honduras, a high-incidence region with a homogeneous diet and endemic H. pylori infection, primarily with the high-risk CagA genotype. We investigated factors including wood cookstove use, H. pylori CagA serostatus, and 15 variants from 7 metabolizing genes, and the interactions between wood stove use and the genetic variants. Male sex (OR 2.0, 1.6-2.6), age (OR 1.04, 1.03-1.05), wood cookstove use (OR 2.3, 1.6-3.3), and CagA serostatus (OR 3.5, 2.4-5.1) and two SNPs in CYP1B1 (rs1800440 and rs1056836) were independently associated with gastric cancer in multivariate analysis. In the final multivariate model, a highly significant interaction (OR 3.1, 1.2-7.8) was noted between wood cookstove use and the rs1800440 metabolizing genotype, highlighting an important gene-environment interaction. Lifetime wood cookstove use associates with gastric cancer risk in the high-incidence regions of Central America, and the association is dependent on the rs1800440 genotype in CYP1B1. H. pylori CagA infection, wood cookstove use and the rs1800440 genotype, all of which are highly prevalent, informs who is at greatest risk from biomass cookstove use.

Optimizing remote access to urinary incontinence treatments for women veterans (PRACTICAL): Study protocol for a pragmatic clinical trial comparing two virtual care options

OBJECTIVES

In this pragmatic clinical trial, the primary objective is to increase access to behavioral treatment of urinary incontinence (UI) for women Veterans by comparing the effectiveness of two virtual care delivery modalities.

METHODS

Veterans Affairs (VA) clinical sites in AL, GA, NC will virtually randomize 286 women Veterans with UI (ie, stress, urge, or mixed). We will compare the effectiveness of our mHealth UI application (MyHealtheBladder) to a single VA Video Connect (VVC) session delivered by trained UI providers. Women without improvement after 8 weeks will receive an optimization VVC visit using a sequential, multiple assignment, randomized trial (SMART) design. The primary outcome is UI symptom improvement at 12-weeks with or without optimization; secondary outcomes include improvements in lower urinary tract symptoms, adherence, retention rates, perceptions of improvement, and visit-related miles saved. Sample size needed to identify a 2.5-point change (range 0-21) in the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) from baseline to 12-weeks post-randomization is 200 participants. Allowing for an attrition rate of 25%, 286 participants are required.

KEY RESULTS

Study team initiated remote recruitment on April 2020. Recruitment is on target with a 75% retention rate. We expect completion in fall of 2023 (clinicaltrials.govNCT04237753).

DISCUSSION/CONCLUSION

Engaging women Veterans with virtual modalities for initial UI treatment may increase access to UI care while also improving symptoms. After assessing efficacy, adherence, and retention, the next step is to implement the most effective option for remote delivery of evidence-based behavioral UI treatment for women Veterans.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT04237753.

Sociodemographic Disparities in Postoperative Nausea and Vomiting

BACKGROUND

Postoperative nausea and vomiting (PONV) prophylaxis is consistently considered a key indicator of anesthesia care quality. PONV may disproportionately impact disadvantaged patients. The primary objectives of this study were to examine the associations between sociodemographic factors and the incidence of PONV and clinician adherence to a PONV prophylaxis protocol.

METHODS

We conducted a retrospective analysis of all patients eligible for an institution-specific PONV prophylaxis protocol (2015-2017). Sociodemographic and PONV risk data were collected. Primary outcomes were PONV incidence and clinician adherence to PONV prophylaxis protocol. We used descriptive statistics to compare sociodemographics, procedural characteristics, and protocol adherence for patients with and without PONV. Multivariable logistic regression analysis followed by Tukey-Kramer correction for multiple comparisons was used to test for associations between patient sociodemographics, procedural characteristics, PONV risk, and (1) PONV incidence and (2) adherence to PONV prophylaxis protocol.

RESULTS

Within the 8384 patient sample, Black patients had a 17% lower risk of PONV than White patients (adjusted odds ratio [aOR], 0.83; 95% confidence interval [CI], 0.73-0.95; P = .006). When there was adherence to the PONV prophylaxis protocol, Black patients were less likely to experience PONV compared to White patients (aOR, 0.81; 95% CI, 0.70-0.93; P = .003). When there was adherence to the protocol, patients with Medicaid were less likely to experience PONV compared to privately insured patients (aOR, 0.72; 95% CI, 0.64-1.04; P = .017). When the protocol was followed for high-risk patients, Hispanic patients were more likely to experience PONV than White patients (aOR, 2.96; 95% CI, 1.18-7.42; adjusted P = .022). Compared to White patients, protocol adherence was lower for Black patients with moderate (aOR, 0.76; 95% CI, 0.64-0.91; P = .003) and high risk (aOR, 0.57; 95% CI, 0.42-0.78; P = .0004).

CONCLUSIONS

Racial and sociodemographic disparities exist in the incidence of PONV and clinician adherence to a PONV prophylaxis protocol. Awareness of such disparities in PONV prophylaxis could improve the quality of perioperative care.

Early intervention with double balloon enteroscopy for higher yield for inpatient overt obscure gastrointestinal bleeding: A propensity matched analysis

Background and Aim

Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding.

Methods

We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan-Meir survival curve showed GI bleed-free survival following initial bleed and was compared using the log rank test.

Results

A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity-score-matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed-free survival compared to those in the nonemergent group (P = 0.009).

Conclusion

Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE.

Predictive models for abdominal aortic aneurysms using polygenic scores and PheWAS-derived risk factors

Abdominal aortic aneurysms (AAA) are common enlargements of the abdominal aorta which can grow larger until rupture, often leading to death. Detection of AAA is often by ultrasonography and screening recommendations are mostly directed at men over 65 with a smoking history. Recent large-scale genome-wide association studies have identified genetic loci associated with AAA risk. We combined known risk factors, polygenic risk scores (PRS) and precedent clinical diagnoses from electronic health records (EHR) to develop predictive models for AAA, and compared performance against screening recommendations. The PRS included genome-wide summary statistics from the Million Veteran Program and FinnGen (10,467 cases, 378,713 controls of European ancestry), with optimization in Vanderbilt's BioVU and validated in the eMERGE Network, separately across both White and Black participants. Candidate diagnoses were identified through a temporally-oriented Phenome-wide association study in independent EHR data from Vanderbilt, and features were selected via elastic net. We calculated C-statistics in eMERGE for models including PRS, phecodes, and covariates using regression weights from BioVU. The AUC for the full model in the test set was 0.883 (95% CI 0.873-0.892), 0.844 (0.836-0.851) for covariates only, 0.613 (95% CI 0.604-0.622) when using primary USPSTF screening criteria, and 0.632 (95% CI 0.623-0.642) using primary and secondary criteria. Brier scores were between 0.003 and 0.023 for our models indicating good calibration, and net reclassification improvement over combined primary and secondary USPSTF criteria was 0.36-0.60. We provide PRS for AAA which are strongly associated with AAA risk and add to predictive model performance. These models substantially improve identification of people at risk of a AAA diagnosis compared with existing guidelines, with evidence of potential applicability in minority populations.

Warfarin Dosing in Patients with CYP2C9*5 Variant Alleles

Pharmacogenetic dosing improves the accuracy of warfarin dosing, but current pharmacogenetic dosing algorithms are less accurate in populations of African ancestry. The cytochrome P450 2C9*5 (CYP2C9*5) allele is found almost exclusively in populations of African ancestry, and in-vitro studies suggest CYP2C9*5 is associated with reduced clearance of warfarin. The clinical relevance of this SNP is uncertain. In this multi-centered study of 2298 patients (49% female, 35% Black) taking warfarin, we quantified the association between the CYP2C9*5 allele and warfarin requirements. The CYP2C9*5 SNP was present in 2.3% of Black and 0.07% of White patients. Without taking CYP2C9*5 into account, pharmacogenetic algorithms that include other SNPs overestimated the warfarin dose by 30% (95% CI [19%-40%], p<0.001), an average of 1.87 mg/d (SD 1.64) in heterozygotes (p < 0.001). Non-carriers required a slightly (0.23 mg/d, SD 2.09) higher than predicted dose. Genotyping for CYP2C9*5 corrected the potential overdose and halved overall dosing error in heterozygotes. Patients carrying CYP2C9*5 require a clinically relevant reduction in warfarin dose. Given the potential to improve the accuracy and safety of warfarin dosing in populations of African ancestry, we have incorporated this SNP into a non-profit website to assist warfarin initiation (www.WarfarinDosing.org).

Pharmacogenetic Predictors of Cannabidiol Response and Tolerability in Treatment-Resistant Epilepsy

In patients with treatment‐resistant epilepsy (TRE), cannabidiol (CBD) produces variable improvement in seizure control. Patients in the University of Alabama at Birmingham CBD Expanded Access Program (EAP) were enrolled in the genomic study and genotyped using the Affymetrix Drug Metabolizing Enzymes and Transporters plus array. Associations between variants and CBD response (≥50% seizure reduction) and tolerability (diarrhea, sedation, and abnormal liver function) was evaluated under dominant and recessive models. Expression quantitative trait loci (eQTL) influencing potential CBD targets was evaluated in the UK Brain Expression Consortium data set (Braineac), and genetic co‐expression examined. Of 169 EAP patients, 112 (54.5% pediatric and 50.0% female) were included in the genetic analyses. Patients with AOX1 rs6729738 CC (aldehyde oxidase; odds ratio (OR) 6.69, 95% confidence interval (CI) 2.19–20.41, P = 0.001) or ABP1 rs12539 (diamine oxidase; OR 3.96, 95% CI 1.62–9.73, P = 0.002) were more likely to respond. Conversely, patients with SLC15A1 rs1339067 TT had lower odds of response (OR 0.06, 95% CI 0.01–0.56, P = 0.001). ABCC5 rs3749442 was associated with lower likelihood of response and abnormal liver function tests, and higher likelihood of sedation. The eQTL revealed that rs1339067 decreased GPR18 expression (endocannabinoid receptor) in white matter (P = 5.6 × 10⁻³), and rs3749442 decreased hippocampal HTR3E expression (serotonin 5‐HT_3E; P = 8.5 × 10⁻⁵). Furthermore, 75% of genes associated with lower likelihood of response were co‐expressed. Pharmacogenetic variation is associated with CBD response and influences expression of CBD targets in TRE. Implicated pathways, including cholesterol metabolism and glutathione conjugation, demonstrate potential interactions between CBD and common medications (e.g., statins and acetaminophen) that may require closer monitoring. These results highlight the role of pharmacogenes in fundamental biologic processes and potential genetic underpinnings of treatment‐resistance.

Rhesus monkeys as a translational model for late-onset Alzheimer's disease

Age is a major risk factor for late-onset Alzheimer's disease (AD) but seldom features in laboratory models of the disease. Furthermore, heterogeneity in size and density of AD plaques observed in individuals are not recapitulated in transgenic mouse models, presenting an incomplete picture. We show that the amyloid plaque microenvironment is not equivalent between rodent and primate species, and that differences in the impact of AD pathology on local metabolism and inflammation might explain established differences in neurodegeneration and functional decline. Using brain tissue from transgenic APP/PSEN1 mice, rhesus monkeys with age-related amyloid plaques, and human subjects with confirmed AD, we report altered energetics in the plaque microenvironment. Metabolic features included changes in mitochondrial distribution and enzymatic activity, and changes in redox cofactors NAD(P)H that were shared among species. A greater burden of lipofuscin was detected in the brains from monkeys and humans of advanced age compared to transgenic mice. Local inflammatory signatures indexed by astrogliosis and microglial activation were detected in each species; however, the inflamed zone was considerably larger for monkeys and humans. These data demonstrate the advantage of nonhuman primates in modeling the plaque microenvironment, and provide a new framework to investigate how AD pathology might contribute to functional loss.

Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies Using Near Real-Time Feedback and Individualized Electronic Reporting

BACKGROUND

Postoperative pulmonary complications can have a significant impact on the morbidity and mortality of patients undergoing major surgeries. Intraoperative lung protective strategies using low tidal volume (TV) ventilation and positive end-expiratory pressure (PEEP) have been demonstrated to reduce the incidence of pulmonary injury and infection while improving oxygenation and respiratory mechanics. The purpose of this study was to develop decision support systems designed to optimize behavior of the attending anesthesiologist with regards to adherence with established intraoperative lung-protective ventilation (LPV) strategies.

METHODS

Over a 4-year period, data were obtained from 49,386 procedures and 109 attendings. Cases were restricted to patients aged 18 years or older requiring general anesthesia that lasted at least 60 minutes. We defined protective lung ventilation as a TV of 6-8 mL/kg ideal body weight and a PEEP of ≥4 cm H2O. There was a baseline period followed by 4 behavioral interventions: education, near real-time feedback, individualized post hoc feedback, and enhanced multidimensional decision support. Segmented logistic regression using generalized estimating equations was performed in order to assess temporal trends and effects of interventions on adherence to LPV strategies.

RESULTS

Consistent with improvement in adherence with LPV strategies during the baseline period, the predicted probability of adherence with LPV at the end of baseline was 0.452 (95% confidence interval [CI], 0.422-0.483). The improvements observed for each phase were relative to the preceding phase. Education alone was associated with an 8.7% improvement (P < .01) in adherence to lung-protective protocols and was associated with a 16% increase in odds of adherence (odds ratio [OR] = 1.16; 95% CI, 1.01-1.33; P = .04). Near real-time, on-screen feedback was associated with an estimated 15.5% improvement in adherence (P < .01) with a 69% increase in odds of adherence (OR = 1.69; 95% CI, 1.46-1.96; P < .01) over education alone. The addition of an individualized dashboard with personal adherence and peer comparison was associated with a significant improvement over near real-time feedback (P < .01). Near real-time feedback and dashboard feedback systems were enhanced based on feedback from the in-room attendings, and this combination was associated with an 18.1% (P < .01) increase in adherence with a 2-fold increase in the odds of adherence (OR = 2.23; 95% CI, 1.85-2.69; P < .0001) between the end of the previous on-screen feedback phase and the start of the individualized post hoc dashboard reporting phase. The adherence with lung-protective strategies using the multidimensional approach has been sustained for over 24 months. The difference between the end of the previous phase and the start of this last enhanced multidimensional decision support phase was not significant (OR = 1.08; 95% CI, 0.86-1.34; P = .48).

CONCLUSIONS

Consistent with the literature, near real-time and post hoc reporting are associated with positive and sustained behavioral changes aimed at adopting evidence-based clinical strategies. Many decision support systems have demonstrated impact to behavior, but the effect is often transient. The implementation of near real-time feedback and individualized post hoc decision support tools has resulted in clinically relevant improvements in adherence with LPV strategies that have been sustained for over 24 months, a common limitation of decision support solutions.

Implementing the DEcision-Aid for Lupus (IDEAL): study protocol of a multi-site implementation trial with observational, case study design : Implementing the DEcision-Aid for Lupus

Objective

To provide the details of the study protocol for an observational, case study design, implementation trial.

Methods

Implementing the DEcision-Aid for Lupus (IDEAL) study will put into practice a shared decision-making (SDM) strategy, using an individualized, culturally appropriate computerized decision-aid (DA) for lupus patients in 15 geographically diverse clinics in the USA. The overarching frameworks that guide this implementation study are the Consolidated Framework for Implementation Research (CFIR) and Powell’s typology of implementation strategies. All 15 clinics will receive standardized capacity-building activities for lupus DA implementation in the clinic, including education, training, technical assistance, re-training, and incorporation of a clinic champion in the core team of each site. In addition, clinics will also choose among clinic-targeted activities to integrate the DA into existing work processes and/or patient-targeted activities to raise awareness and educate patients about the DA. These activities will be chosen to stimulate participant recruitment and retention activities that support the implementation of the DA at their clinic. In study aim 1, using surveys and semi-structured interviews with clinic personnel in 15 lupus clinics, we will assess stakeholder needs and identify clinic and contextual characteristics that inform the implementation strategy component selection and influence implementation effectiveness. Study aim 2 is to implement and assess the effectiveness of the IDEAL (standardized and tailored) strategy in 15 lupus clinics by examining the changes in our primary outcome of penetration, i.e., the proportion of all eligible patients in the clinic that receive the lupus DA, and secondary outcomes include DA appropriateness, acceptability, success, permanence, and feasibility. Study aim 3 is to identify ways to sustain and disseminate our lupus DA via semi-structured debriefing interviews with key clinic personnel and patients.

Discussion

The study will enroll at least 500 patient participants with lupus across all 15 sites and assess the effectiveness in implementing the DA in various clinic settings across the USA.

Trial registration

ClinicalTrials.gov, NCT03735238. Protocol version number: 15, date 6/8/2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00118-9.

Molecular and Functional Networks Linked to Sarcopenia Prevention by Caloric Restriction in Rhesus Monkeys

Caloric restriction (CR) improves survival in nonhuman primates and delays the onset of age-related morbidities including sarcopenia, which is characterized by the age-related loss of muscle mass and function. A shift in metabolism anticipates the onset of muscle-aging phenotypes in nonhuman primates, suggesting a potential role for metabolism in the protective effects of CR. Here, we show that CR induced profound changes in muscle composition and the cellular metabolic environment. Bioinformatic analysis linked these adaptations to proteostasis, RNA processing, and lipid synthetic pathways. At the tissue level, CR maintained contractile content and attenuated age-related metabolic shifts among individual fiber types with higher mitochondrial activity, altered redox metabolism, and smaller lipid droplet size. Biometric and metabolic rate data confirm preserved metabolic efficiency in CR animals that correlated with the attenuation of age-related muscle mass and physical activity. These data suggest that CR-induced reprogramming of metabolism plays a role in delayed aging of skeletal muscle in rhesus monkeys.

Evaluation of the exposure prediction component of Control of Substances Hazardous to Health Essentials

The exposure prediction component of the Control of Substances Hazardous to Health (COSHH) Essentials model (paper version) was evaluated using field measurements from National Institute of Occupational Safety and Health (NIOSH) Health Hazard Evaluation (HHE) reports. Overall 757 measured exposures for 94 similar exposure groups (SEGs) were compared with the COSHH Essentials predicted exposure range (PER). The SEGs were stratified based on the magnitude of measured exposures (high, medium, or low) and physical state of the substance (vapor or particulate). The majority of measured exposures observed involved low-level exposure to vapors; thus, overall findings from the current study are limited to low-level vapor exposure scenarios. Overall, the exposure prediction component of COSHH Essentials vastly overestimated low-level exposures to vapors. This study went beyond the scope of previous studies and investigated which model components led to the overestimation. It was concluded that COSHH Essential's tendency to overestimate was due to multiple complex interactions among model components. Overall, the magnitude of overestimation seems to increase exponentially as values for predictor variables increase. This is likely due to the log-based scale used by the model to allocate concentration ranges. In addition, the current banding scheme used to allocate volatility appears to play a role in the overestimation of low-level exposures to vapors.

Stroke Center Certification and Performance: A Longitudinal Analysis of the Northeast Cerebrovascular Consortium Region

Background: The NorthEast Cerebrovascular Consortium (NECC) was established in 2006 to improve stroke-systems-of-care models. Methods: This study evaluates the increase in stroke quality over time in NECC and Non-NECC regions, defined as the change in proportion of hospitals over time who received State or National Primary/Comprehensive Stroke Center (PSC/CSC) certification, participated in a national quality program (Get-With-The-Guidelines-Stroke (GWTG-S)), or received GWTG-S Performance Achievement Awards (PAA) from 2005-2013. Analysis of trends was performed (Cochran-Armitage/Cochran-Mantel-Haenszel tests; Generalized-Estimating Equations). As an exploratory analysis eight NECC region Departments of Health (DOH) were surveyed regarding perceptions of the NECC. Results: During the study period, there were 433.1 ± 10.2 vs 3986.4 ± 187.7 hospitals per year in the NECC vs non-NECC regions. Rate of growth per year increased in both groups for each measure but to a greater degree in the NECC vs Non-NECC regions: PSC/CSC (5.4%/yr vs 3.2%/yr), GWTG-S participation (5.0%/yr vs 2.9%/yr), and PAAs (5.2%/yr vs 2.1%/yr), with state-based certification growth also being higher in the NECC region (4.2%/yr vs 0.4%/yr; all comparisons p < 0.0001). After adjusting for year, significantly more NECC hospitals had PSC/CSC certification, GWTG-S participation, and GWTG-S PAAs than non-NECC sites (all analyses p < 0.0001). One hundred percent of NECC region DOHs were aware of the NECC and involved in functions, 87.5% indicated the NECC provided beneficial assistance. Conclusions: There has been a higher rate of growth of state certification contrasted to national PSC/CSC certification, and a higher rate of growth of participation and achievement in GWTG-S in the northeast region compared to other US regions.

Comparing Vitamin D Supplementation Versus Placebo for Urgency Urinary Incontinence: A Pilot Study

OBJECTIVES

To estimate the efficacy of vitamin D supplementation to reduce urgency urinary incontinence (UUI) episodes.

DESIGN

Pilot, two-arm, randomized trial conducted from 2013 to 2017. Interventions were 12 weeks of weekly oral 50,000 IU vitamin D3 or placebo.

SETTING

Academic, university-based outpatient clinic.

PARTICIPANTS

Community-dwelling postmenopausal women, 50 years or older, with at least three UUI episodes on 7-day bladder diary and serum vitamin 25-hydroxyvitamin D (25[OH]D) of 30 ng/mL or less.

MEASUREMENTS

The primary efficacy estimate was the percentage change in UUI episodes. Secondary estimates included changes in other lower urinary tract symptoms, along with exploratory subgroup analysis by race/ethnicity and obesity.

RESULTS

We randomized 56 women (aged 50-84 years; mean = 60.5 ± 8.2 years), 28 to vitamin D and 28 to placebo; 51 completed treatments. Mean serum 25(OH)D at baseline (21.2 ± 5.2 and 18.2 ± 5.6, P = .30) improved to 57.9 ± 16.3 ng/mL with vitamin D3 and 21.9 ± 8.2 ng/mL with placebo (P < .001). UUI episodes per 24-hour day decreased by 43.0% with vitamin D3 compared to 27.6% with placebo (P = .22). Among black women (n = 33), UUI episodes decreased by 63.2% with vitamin D3 compared to 22.9% with placebo (P = .03). Among obese women, UUI episodes decreased by 54.1% with vitamin D compared to 32.7% with placebo (P = .29). For all women, changes in voiding frequency (P = .40), nocturia (P = .40), urgency (P = .90), incontinence severity (P = .81), and overactive bladder symptom severity (P = .47) were not different between arms.

CONCLUSIONS

Postmenopausal women with UUI and vitamin D insufficiency demonstrated a greater than 40% decrease in UUI episodes, which did not reach statistical significance compared to placebo, except in the subset of black women. The results of this pilot study support further investigation of vitamin D3 alone or in combination with other treatments for UUI, particularly for women in higher-risk subgroups. J Am Geriatr Soc 67:570-575, 2019.

Factor VIII in Acute Cerebral Ischemia Pilot Study: Biomarker in Patients With Large Vessel Occlusion?

We conducted a prospective serial laboratory cohort study to assess the correlation of factor VIII (FVIII) levels in response to thrombolysis in patients with large vessel occlusion (LVO) and acute ischemic stroke (AIS). Patients with AIS with anterior circulation LVO were eligible for enrollment if treated within 4.5 hours from last seen normal with intravenous tissue plasminogen activator (tPA). Patients (n = 29) had a mean age of 71 years and median National Institute of Health Stroke Scale of 14. Baseline pre-tPA FVIII was not significantly correlated with clot burden score (-0.147, P = .447) or vessel recanalization (-0.133, P = .499). Median FVIII decreased significantly from baseline to 6 hours post-tPA (282% to 161%, P = .002), but delta in FVIII level did not correlate with vessel recanalization (0.013, P = .948). There was no difference between median FVIII level at baseline and 90 days post-AIS. FVIII level decreased significantly after tPA, but baseline FVIII level and early change in FVIII level were not significant predictors of clot burden, vessel recanalization after thrombolysis, or symptomatic hemorrhage.

Trajectories of Community Mobility Recovery After Hospitalization in Older Adults

OBJECTIVES

To identify trajectories of recovery of community mobility in acutely ill older adults using the University of Alabama at Birmingham Life-Space Assessment (LSA).

DESIGN

Prospective observation cohort study.

SETTING

Central Alabama, Birmingham Veterans Affairs Medical Center.

PARTICIPANTS

Community-dwelling adults aged 65 and older hospitalized for nonsurgical medical reasons (N=173).

MEASUREMENTS

We determined LSA scores for the month before and monthly for 6 months after hospitalization (composite scores ranging from 0-120, with 120 reflecting completely unrestricted mobility).

RESULTS

In the month after hospitalization, 92 (53%) participants had a clinically significant decrease in life-space mobility, while 42 (24%) were unchanged, and 39 (23%) had an increase from the month preceding hospitalization. Of participants with a life-space decrease, the majority recovered their prehospitalization mobility status during 6 months of follow-up, whereas 34% did not recover. Participants whose life-space decreased were hospitalized significantly longer (P=.01) and, on average, had higher prehospital life-space scores (P=.01) than those who maintained or increased their life-space.

CONCLUSION

A clinically significant loss of community mobility was common after hospitalization, but most participants recovered to prehospitalization mobility within 6 months of discharge. Research examining in-hospital and posthospitalization interventions to achieve faster recovery of community mobility is needed.

The relationship between single and two-dimensional indices of left ventricular size using hemodynamic transesophageal echocardiography in trauma and burn patients

BACKGROUND

Conventional echocardiographic technique for assessment of volume status and cardiac contractility utilizes left ventricular end-diastolic area (LVEDA) and fractional area of change (FAC), respectively. Our goal was to find a technically reliable yet faster technique to evaluate volume status and contractility by measuring left ventricular end-diastolic diameter (LVEDD) and fractional shortening (FS) in a cohort of mechanically ventilated trauma and burn patients using hemodynamic transesophageal echocardiographic (hTEE) monitoring.

METHODS

Retrospective chart review performed at trauma/burn intensive care unit (TBICU). Data on 88 mechanically ventilated surgical intensive care patients cared for between July 2013 and July 2015 were reviewed. Initial measurements of LVEDA, left ventricular end-systolic area (LVESA) and FAC were collected. Post-processing left ventricular end-systolic (LVESD) and end-diastolic diameters (LVEDD) were measured and fractional shortening (FS) was calculated. Two orthogonal measurements of LV diameter were obtained in transverse (Tr) and posteroanterior (PA) orientation.

RESULTS

There was a significant correlation between transverse and posteroanterior left ventricular diameter measurements in both systole and diastole. In systole, r = 0.92, p < 0.01 for LVESD-Tr (mean 23.47 mm, SD ± 6.77) and LVESD-PA (mean 24.84 mm, SD = 8.23). In diastole, r = 0.80, p < 0.01 for LVEDD-Tr (mean 37.60 mm, SD ± 6.45), and LVEDD-PA diameters (mean 42.24 mm, SD ± 7.97). Left ventricular area (LVEDA) also significantly correlated with left ventricular diameter LVEDD-Tr (r = 0.84, p < 0.01) and LVEDD-PA (r = 0.90, p < 0.01). Both transverse and PA measurements of fractional shortening were significantly (p < 0.0001) and similarly correlated with systolic function as measured by FAC. Bland-Altman analyses also indicated that the assessment of fractional shortening using left ventricular posteroanterior diameter measurement shows agreement with FAC.

CONCLUSIONS

Left ventricular diameter measurements are a reliable and technically feasible alternative to left ventricular area measurements in the assessment of cardiac filling and systolic function.

Influence of Kidney Transplant Status on Warfarin Dose, Anticoagulation Control, and Risk of Hemorrhage

STUDY DESIGN

To assess whether warfarin dose requirement, anticoagulation control, and risk of hemorrhage differ in kidney transplant recipients (KTRs) compared with patients without kidney transplants (non-KTRs).

DESIGN

Analysis of data from the Warfarin Pharmacogenetics Cohort, a prospective cohort of first-time warfarin users followed at two anticoagulation clinics.

SETTING

Two outpatient anticoagulation clinics at two large, academic, tertiary care hospitals.

PATIENTS

Adults aged 20 years or older starting warfarin for anticoagulation with a therapeutic international normalized ratio (INR) goal of 2-3 who were KTRs (n=65) or non-KTRs (n=1630).

MEASUREMENTS AND MAIN RESULTS

Warfarin dose requirement, anticoagulation control, and risk of hemorrhage were assessed in each group. KTRs required an approximately 20% lower warfarin dose (4.7 vs 5.6 mg/day, p=0.0005) compared with non-KTRs. Genetic variants had similar effects on dose in both groups. Mean percentage of time in therapeutic range (PTTR) was similar among KTRs and non-KTRs. Although the proportion of patients achieving good anticoagulation control (PTTR ≥ 60%) was low in both groups, it was similar among KTRs and non-KTRs. KTRs had a higher risk of major hemorrhage (hazard ratio 2.1, p=0.0081), but this difference was not statistically significant after controlling for kidney function, clinical, and genetic factors.

CONCLUSION

KTRs initiating warfarin require lower doses and closer monitoring to optimize anticoagulation therapy. Additional studies are needed to confirm these findings.

Age and Sex Disparities in Discharge Statin Prescribing in the Stroke Belt: Evidence From the Reasons for Geographic and Racial Differences in Stroke Study

BACKGROUND

Stroke is a costly and debilitating disease that disproportionately affects blacks. Despite the efficacy of statins, evidence suggests racial disparities may exist in statin prescribing.

METHODS AND RESULTS

We analyzed discharge medications for participants hospitalized for an ischemic stroke during follow-up of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Medications on admission and discharge were abstracted from medical records. Among the 666 eligible incident strokes (2003-2013), analyses were restricted to 323 participants who were not statin users at the time of admission and had no history of atrial fibrillation. Overall, 48.7% were prescribed a statin on discharge. In the Stroke Belt, participants aged 65 years and older were 47% less likely to be discharged on a statin compared with those younger than 65 years (relative risk [RR], 0.53; 95% CI, 0.38-0.74). This association was not observed in non-Stroke Belt residents. Outside the Stroke Belt, blacks were more likely than whites to be discharged on a statin (RR, 1.42; 95% CI, 1.04-1.94), while no black:white association was present among Stroke Belt residents (RR, 0.93; 95% CI, 0.69-1.26; P for interaction=0.228). Compared with women, men in the Stroke Belt were 31% less likely to be discharged on a statin (RR, 0.69; 95% CI, 0.50-0.94) while men outside the Stroke Belt were more likely to be discharged on a statin (RR, 1.38; 95% CI, 0.99-1.92; P for interaction=0.004).

CONCLUSIONS

Statin discharge prescribing may differ among Stroke Belt and non-Stroke Belt residents, particularly in older Americans and men.

Influence of common and rare genetic variation on warfarin dose among African-Americans and European-Americans using the exome array

AIM

We conducted a genome-wide association study using the Illumina Exome Array to identify coding SNPs that may explain additional warfarin dose variability.

PATIENTS & METHODS

Analysis was performed after adjustment for clinical variables and genetic factors known to influence warfarin dose among 1680 warfarin users (838 European-Americans and 842 African-Americans). Replication was performed in an independent sample.

RESULTS

We confirmed the influence of known genetic variants on warfarin dose variability. Our study is the first to show the association between rs12772169 and warfarin dose in African-Americans. In addition, genes COX15 and FGF5 showed significant association in European-Americans.

CONCLUSION

We identified some novel genes/SNPs that underpin warfarin dose response. Further replication is needed to confirm our findings.

Racial differences in statin adherence following hospital discharge for ischemic stroke

OBJECTIVE

To compare nonadherence to statins in older black and white adults following an ischemic stroke.

METHODS

We studied black and white adults ≥66 years of age with Medicare fee-for-service insurance coverage hospitalized for ischemic stroke from 2007 to 2012 who filled a statin prescription within 30 days following discharge. Nonadherence was defined as a proportion of days covered <80% in the 365 days following hospital discharge. In addition, we evaluated factors associated with nonadherence for white and black participants separately.

RESULTS

Overall 2,763 beneficiaries met the inclusion criteria (13.5% black). Black adults were more likely than white adults to be nonadherent (49.7% vs 41.5%) even after adjustment for demographics, receipt of a low-income subsidy, and baseline comorbidities (adjusted relative risk [RR] 1.14, 95% confidence interval [CI] 1.01-1.29). Among white adults, receipt of a low-income subsidy (adjusted RR 1.13, 95% CI 1.02-1.26), history of coronary heart disease (adjusted RR 1.15, 95% CI 1.01-1.30), and discharge directly home following stroke hospitalization (adjusted RR 1.26, 95% CI 1.10-1.44) were associated with a higher risk of nonadherence. Among black adults, a 1-unit increase in the Charlson comorbidity index (adjusted RR 1.04, 95% CI 1.01-1.09), history of carotid artery disease (adjusted RR 2.38, 95% CI 1.08-5.25), and hospitalization during the 365 days prior to the index stroke (adjusted RR 1.34, 95% CI 1.01-1.78) were associated with nonadherence.

CONCLUSIONS

Compared with white adults, black adults were more likely to be nonadherent to statins following hospitalization for ischemic stroke.

Caloric restriction improves health and survival of rhesus monkeys

Caloric restriction (CR) without malnutrition extends lifespan and delays the onset of age-related disorders in most species but its impact in nonhuman primates has been controversial. In the late 1980s two parallel studies were initiated to determine the effect of CR in rhesus monkeys. The University of Wisconsin study reported a significant positive impact of CR on survival, but the National Institute on Aging study detected no significant survival effect. Here we present a direct comparison of longitudinal data from both studies including survival, bodyweight, food intake, fasting glucose levels and age-related morbidity. We describe differences in study design that could contribute to differences in outcomes, and we report species specificity in the impact of CR in terms of optimal onset and diet. Taken together these data confirm that health benefits of CR are conserved in monkeys and suggest that CR mechanisms are likely translatable to human health.

Caloric restriction (CR) delays ageing of model organisms, but whether it works in nonhuman primates has been controversial. Here, the authors pool and reanalyse data from two long-running CR primate studies, concluding that moderate CR indeed improves health and survival of rhesus monkeys.

Effect of Left Ventricular Systolic Dysfunction on Response to Warfarin

Candidates for chronic warfarin therapy often have co-morbid conditions, such as heart failure, with reduced left ventricular ejection fraction. Previous reports have demonstrated an increased risk of over-anticoagulation due to reduced warfarin dose requirement in patients with decompensated heart failure. However, the influence of left ventricular systolic dysfunction (LVSD), defined as left ventricular ejection fraction <40%, on warfarin response has not been evaluated. Here, we assess the influence of LVSD on warfarin dose, anticoagulation control (percent time in target range), and risk of over-anticoagulation (international normalized ratio >4) and major hemorrhage. Of the 1,354 patients included in this prospective cohort study, 214 patients (16%) had LVSD. Patients with LVSD required 11% lower warfarin dose compared with those without LVSD (p <0.001) using multivariate linear regression analyses. Using multivariate Cox proportional hazards model, patients with LVSD experienced similar levels of anticoagulation control (percent time in target range: 51% vs 53% p = 0.15), risk of over-anticoagulation (international normalized ratio >4; hazard ratio 1.01, 95% confidence interval 0.82 to 1.25; p = 0.91), and risk of major hemorrhage (hazard ratio 1.11; 95% confidence interval 0.70 to 1.74; p = 0.66). Addition of LVSD variable in the model increased the variability explained from 35% to 36% for warfarin dose prediction. In conclusion, our results demonstrate that patients with LVSD require lower doses of warfarin. Whether warfarin dosing algorithms incorporating LVSD in determining initial doses improves outcomes needs to be evaluated.

Systemic lupus erythematosus in a multi-ethnic cohort (LUMINA): contributions of admixture and socioeconomic status to renal involvement

Renal involvement in systemic lupus erythematosus (SLE) is more frequent in minorities. We examined whether genetic or socioeconomic status (SES) explain these disparities in a large multiethnic (Hispanics from Texas and Puerto Rico, African Americans and Caucasians) SLE cohort. Renal involvement was defined as WHO Class II-V and/or proteinuria (>0.5 g/24 h or 3+) attributable to SLE and/or abnormal urinary sediment, proteinuria 2+, elevated serum creatinine/decreased creatinine clearance twice, 6 months apart present any time over the course of the disease. Ancestry informative markers (AIMS) were used to define the admixture proportions in each patient and group. Logistic regression models were examined to determine the percentage variance ( R2) in renal involvement related to ethnicity that is explained by socio-economic status (SES) and admixture (adjusting for age, gender and disease duration, basic model). Four-hundred and fifty-nine (out of 575) patients were included; renal involvement occurred in 44.6% Texas Hispanics, 11.3% Puerto Rico Hispanics, 45.8% African Americans, 18.3% Caucasians. SES accounted for 14.5% of the variance due to ethnicity (after adjusting for basic model variables), admixture 36.8% and both, 12.2%; 45.9% of the variance remained unexplained. Alternative models for decreased glomerula filtration rate and end-stage renal disease were comparable in the distribution of the explanatory variables. Our data indicate that genetic factors appear to be more important than SES in explaining the ethnic disparities in the occurrence of renal involvement.

Effects of Sex, Strain, and Energy Intake on Hallmarks of Aging in Mice

Calorie restriction (CR) is the most robust non-genetic intervention to delay aging. However, there are a number of emerging experimental variables that alter CR responses. We investigated the role of sex, strain, and level of CR on health and survival in mice. CR did not always correlate with lifespan extension, although it consistently improved health across strains and sexes. Transcriptional and metabolomics changes driven by CR in liver indicated anaplerotic filling of the Krebs cycle together with fatty acid fueling of mitochondria. CR prevented age-associated decline in the liver proteostasis network while increasing mitochondrial number, preserving mitochondrial ultrastructure and function with age. Abrogation of mitochondrial function negated life-prolonging effects of CR in yeast and worms. Our data illustrate the complexity of CR in the context of aging, with a clear separation of outcomes related to health and survival, highlighting complexities of translation of CR into human interventions.

Common scientific and statistical errors in obesity research

This review identifies 10 common errors and problems in the statistical analysis, design, interpretation, and reporting of obesity research and discuss how they can be avoided. The 10 topics are: 1) misinterpretation of statistical significance, 2) inappropriate testing against baseline values, 3) excessive and undisclosed multiple testing and "P-value hacking," 4) mishandling of clustering in cluster randomized trials, 5) misconceptions about nonparametric tests, 6) mishandling of missing data, 7) miscalculation of effect sizes, 8) ignoring regression to the mean, 9) ignoring confirmation bias, and 10) insufficient statistical reporting. It is hoped that discussion of these errors can improve the quality of obesity research by helping researchers to implement proper statistical practice and to know when to seek the help of a statistician.

Race-Specific Influence of CYP4F2 on Dose and Risk of Hemorrhage Among Warfarin Users

OBJECTIVE

The p.V433M in cytochrome P450 4F2 (rs2108622, CYP4F2*3) is associated with a higher warfarin dose and lower risk of hemorrhage among European Americans. We evaluate the influence of CYP4F2*3 on warfarin dose, time to target international normalized ratio (INR), and stable dose, proportion of time spent in target range (PTTR), as well as the risk of overanticoagulation and hemorrhage among European and African Americans.

DESIGN

CYP4F2*3 was genotyped in 1238 patients initiated on warfarin in a prospective inception cohort. Multivariable linear regression was used to assess warfarin dose and PTTR; proportional hazards analysis was performed to evaluate time to target INR and stable dose, overanticoagulation, and hemorrhage.

SETTING

Two outpatient anticoagulation clinics.

PARTICIPANTS

A total of 1238 anticoagulated patients.

OUTCOMES

Warfarin dose (mg/day), time to target INR and stable dose, PTTR, overanticoagulation (INR more than 4), and major hemorrhage.

RESULTS

Minor allele frequency for the CYP4F2*3 variant was 30.3% among European Americans and 8.4% among African Americans. CYP4F2*3 was associated with higher dose among European Americans but not African Americans. Compared to CYP4F2*1/*1, *1/*3 was associated with a statistically nonsignificant increase in dose (4.5%, p=0.22) and *3/*3 was associated with a statistically significant increase in dose (13.2%, p=0.02). CYP4F2 genotype did not influence time to target INR, time to stable dose, or PTTR in either race group. CYP4F2*3/*3 was associated with a 31% lower risk of over anticoagulation (p=0.06). Incidence of hemorrhage was lower among participants with CYP4F2 *3/*3 compared with *1/*3 or *1/*1 (incidence rate ratio = 0.45, 95% confidence interval 0.14-1.11, p=0.09). After controlling for covariates, CYP4F2 *3/*3 was associated with a 52% lower risk of hemorrhage, although this was not statistically significant (p=0.24).

CONCLUSION

Possession of CYP4F2*3 variant influences warfarin dose among European Americans but not African Americans. The CYP4F2-dose, CYP4F2-overanticoagulation, and CYP4F2-hemorrhage association follows a recessive pattern with possession of CYP4F2*3/*3 genotype likely demonstrating a protective effect. These findings need further confirmation.

Multireader evaluation of lesion conspicuity in small pancreatic adenocarcinomas: complimentary value of iodine material density and low keV simulated monoenergetic images using multiphasic rapid kVp-switching dual energy CT

OBJECTIVE

Perform multireader analysis of objective and subjective lesion conspicuity for small pancreatic adenocarcinomas using rapid switching dual energy CT (rsDECT).

MATERIALS AND METHODS

With IRB approval, 51 abdominal multiphasic rsDECT scans in 46 subjects with small (<3 cm) pancreatic adenocarcinomas were retrospectively reviewed by three independent readers for objective and subjective lesion conspicuity. Measured variables during individual, blinded interpretive sessions of separate low (52) keV, PACS-equivalent (70) keV, and iodine material density (MD) image sets included Hounsfield units (HU) and mg/cc iodine for tumor, nontumoral pancreas, and subcutaneous fat. Objective measures included absolute lesion contrast (LC) and contrast to noise ratios (CNR). Subjective measures included image quality, lesion conspicuity, and reader confidence. Reader agreement was measured with kappa statistic; correlation with truth by Pearson coefficient, CNR with repeated mANOVA; subjective quality measures utilized Tukey-Cramer corrections for multiple testing, p < 0.05 considered significant.

RESULTS

Demographics: 26 F, 20 M, mean age 68 years, weight 75 kg, tumor size of 2.3 cm. LC was highest on 52 keV images for all three readers (mean 90.1 HU). Mean CNR for iodine MD images (4.87) was significantly higher than 52 keV (4.13) or 70 keV (3.9). Very high to near-perfect kappa values were observed for all individual measured objective variables but were best for 52 keV images (52 keV 0.89-0.95, 70 keV 0.76-0.83, iodine 0.87-0.92). 70 keV images scored best for subjective image quality; iodine MD images scored best for lesion conspicuity and reader confidence.

CONCLUSION

We observed very high reader agreement for independent objective rsDECT image variables and subjective rsDECT image scores in patients with small pancreatic adenocarcinomas. Maximal objective tumor to nontumoral LC was depicted on 52 keV and highest CNR on iodine MD images; readers scored the iodine MD images best for lesion conspicuity and confidence.

Pancreatic adenocarcinoma: a pilot study of quantitative perfusion and diffusion-weighted breath-hold magnetic resonance imaging

PURPOSE

To confirm the feasibility of breath-hold DCE-MRI and DWI at 3T to obtain the intra-abdominal quantitative physiologic parameters, K(trans), k ep, and ADC, in patients with untreated pancreatic ductal adenocarcinomas.

METHODS

Diffusion-weighted single-shot echo-planar imaging (DW-SS-EPI) and dynamic contrast-enhanced (DCE) MRI were used for 16 patients with newly diagnosed biopsy-proven pancreatic ductal adenocarcinomas. K(trans), k ep, and apparent diffusion coefficient (ADC) values of pancreatic tumors, non-tumor adjacent pancreatic parenchyma (NAP), liver metastases, and normal liver tissues were quantitated and statistically compared.

RESULTS

Fourteen patients were able to adequately hold their breath for DCE-MRI, and 15 patients for DW-SS-EPI. Four patients had liver metastases within the 6 cm of Z axis coverage centered on the pancreatic primary tumors. K(trans) values (10(-3) min(-1)) of primary pancreatic tumors, NAP, liver metastases, and normal liver tissues were 7.3 ± 4.2 (mean ± SD), 25.8 ± 14.9, 8.1 ± 5.9, and 45.1 ± 15.6, respectively, k ep values (10(-2) min(-1)) were 3.0 ± 0.9, 7.4 ± 3.1, 5.2 ± 2.0, and 12.1 ± 2.8, respectively, and ADC values (10(-3) mm(2)/s) were 1.3 ± 0.2, 1.6 ± 0.3, 1.1 ± 0.1, and 1.3 ± 0.1, respectively. K(trans), k ep, and ADC values of primary pancreatic tumors were significantly lower than those of NAP (p < 0.05), while K(trans) and k ep values of liver metastases were significantly lower than those of normal liver tissues (p < 0.05).

CONCLUSIONS

3T breath-hold quantitative physiologic MRI is a feasible technique that can be applied to a majority of patients with pancreatic adenocarcinomas.

Abstract WP416: African Americans are Less Likely to be Adherent to Statins After Ischemic Stroke: an Analysis of Medicare Beneficiaries Following Hospital Discharge

Introduction: Statins have been shown to decrease cardiovascular disease morbidity and mortality. Although statins have proven efficacious in reducing the risk of recurrent stroke, little is known about adherence among older adults following ischemic stroke.

Methods: We compiled a retrospective cohort of Caucasian and African-American Medicare beneficiaries in the 5% sample to estimate statin adherence among older adults initiating therapy following hospitalization for ischemic stroke in 2007 - 2011. To be included, beneficiaries were required to have 365 days of Medicare fee-for-service coverage with no claims for stroke-related events or statins prior to the index stroke event. The cohort was limited to beneficiaries with an initial Part D claim for a statin within 30 days plus at least 1 additional claim during follow-up. Adherence was determined by percent of days covered (PDC) for the 365 days following discharge home (time spent in rehabilitation or skilled nursing was excluded); non-adherence was defined as a PDC <80%. Relative risk of statin non-adherence was determined using modified Poisson regression.

Results: Among 6,251 statin-naïve beneficiaries with stroke, 2,070 (33.1%) initiated statin therapy and were included in the analysis. Among them, 13.1% (n=271) were African American. African Americans were more likely than Caucasians to have a PDC <80%, 15.4% vs. 11.7%, respectively (crude RR 1.21, 95% CI 1.04-1.40). The racial disparity remained after adjusting for demographics, dual Medicare-Medicaid eligibility, and baseline comorbidities (adjusted RR 1.17, 95% CI 0.99-1.37).

Conclusions: African Americans may not be obtaining the recurrent stroke prevention therapy provided by statins, possibly contributing to the higher rate of recurrent stroke in this population.

Addressing Stroke Risk Factors in Black and White Americans: Findings from the National Health and Nutrition Examination Survey, 2009-2010

OBJECTIVE

Recurrent stroke affects 5%-15% of stroke survivors, is higher among Blacks, and preventable with secondary stroke prevention medications. Our study aimed to examine racial differences in risk factors being addressed (defined as either on active treatment or within guideline levels) among stroke survivors and those at risk for stroke.

METHODS

A cross-sectional study using NHANES 2009-2010 standardized interviews of Whites and Blacks aged ≥18 years. Risk factors were defined as being addressed if: 1) for hypertension, SBP <140, DBP <90 (SBP<130, DBP<80 for diabetics) or using BP-lowering medications; 2) for current smoking, using cessation medications; and 3) for hyperlipidemia, LDL<100 (LDL<70 for stroke survivors) or using lipid-lowering medications. Participants were stratified by stroke history. Prevalence of addressed risk factors was compared by race.

RESULTS

Among 4005 participants (mean age 48, 52% women, 15% Black), 4% reported a history of stroke. Among stroke survivors, there were no statistically significant differences in Blacks and Whites having their hypertension or hyperlipidemia addressed. Among stroke naïve participants, the prevalence of addressed hypertension (P<.01) and hyperlipidemia (P<.01) was lower in Blacks compared with Whites.

CONCLUSIONS

We found that addressed hypertension and hyperlipidemia in stroke naïve participants were significantly lower in Blacks than Whites. Our observations call attention to areas that require further investigation, such as why Black Americans may not be receiving evidence-based pharmacologic therapy for hypertension and hyperlipidemia or why Black Americans are not at goal blood pressure or goal LDL. A better understanding of this information is critical to preventing stroke and other vascular diseases.

Psychometric evaluation of an online and paper accidental bowel leakage questionnaire: The ICIQ-B questionnaire

AIMS

To evaluate the psychometric properties of an online versus paper US-English version of the International Consultation on Incontinence Questionnaire-Bowel (ICIQ-B).

METHODS

The ICIQ-B includes 17 items under 3 domains: bowel pattern (5 items), bowel control (7 items), and quality of life (5 items). We recruited community-dwelling adults seeking treatment for ≥monthly bowel leakage from specialty clinics within a VA medical center and university affiliate. An online versus paper version was evaluated at baseline, 2 weeks later, and 3 months after nonsurgical treatments per usual care. We assessed test-retest reliability (Pearson correlations) at 2 weeks, internal consistency (Cronbach's alpha), and convergent validity (Pearson correlations). Sensitivity to change was the difference between the baseline and post-treatment (3-month) scores.

RESULTS

Mean age was 58.0 ± 11.9; 36% Veterans, 52% women. At baseline, 2 weeks, and 3 months, we found no differences in the online vs paper scores for the bowel control and quality of life domains. The ICIQ-B demonstrated fair internal consistency for the bowel pattern domain (Cronbach's α = 0.36-0.54). Internal consistency on the bowel pattern domain was better with the paper version than the online version at 2 weeks (P < 0.05) and 3 months (P < 0.01) with no difference at baseline. All other domains had good internal consistency (Cronbach's α > 0.80), good retest reliability (r ≥ 0.70, P < 0.001), domain-specific convergent validity for stool consistency (P < 0.05), incontinence severity (P ≤ 0.002), and quality of life impact (P < 0.05). After nonsurgical treatments, we found a reasonable response to change (P ≤ 0.05).

CONCLUSIONS

Online and paper versions had robust psychometric data for use among U.S. men and women, including Veterans. Neurourol. Urodynam. 36:166-170, 2017. © 2015 Wiley Periodicals, Inc.

Hyperinsulinemia/diabetes, hearing, and aging in the University of Wisconsin calorie restriction monkeys

The purpose of this study was to determine the effects of hyperinsulinemia/Type 2 diabetes mellitus (HI-T2DM) on hearing impairment using rhesus monkeys to obtain control over diet and lifestyle factors that confound human studies. The study is a retrospective evaluation of rhesus monkeys from the Wisconsin National Primate Research Center (WNPRC) study on caloric restriction and aging. The research questions were the following: 1. Is HI-T2DM related to hearing impairment? 2. If so, what is the site of lesion in the auditory system? and 3. What physiological factors affect the risk of hearing loss in HI-T2DM? Three groups of eight monkeys each were matched by sex and age; the caloric restricted (CR) monkeys had a reduced risk of diabetes, the normal control (NL) group had a normal risk, and the hyperinsulinemia/diabetes (HI-D) group had already developed HI-T2DM. Auditory testing included distortion product otoacoustic emissions (DPOAEs) with f2 frequencies from 2211 to 8837 Hz and auditory brainstem responses (ABRs) obtained with clicks and tone bursts (8, 16, and 32 kHz). DPOAEs had signal-to-noise ratios 8-17 dB larger in the NL group than in the HI-D and CR groups, signifying that cochlear function was best in the NL group. ABR thresholds were 5-8 dB better in the NL group than in the HI-D group, although no significant differences across the groups were evident for the thresholds, latencies, interwave intervals, or amplitudes. Correlations were significant for quadratic relations between body mass index (BMI) and DPOAE, with largest DPOAEs for animals in the middle of the BMI range. ABR thresholds elicited with 16 and 32 kHz signals were significantly correlated, positively with BMI and HbA1c, and negatively with KG (glucose tolerance), SI (insulin sensitivity index) and DI (disposition index). These findings suggest that the hearing loss associated with HI-T2DM is predominantly cochlear, and auditory structures underlying the higher frequencies are at risk with HI-T2DM. Loss of auditory function begins in the hyperinsulinemia, pre-diabetic state.

Influence of kidney function on risk of supratherapeutic international normalized ratio-related hemorrhage in warfarin users: a prospective cohort study

BACKGROUND

Anticoagulation management is difficult in chronic kidney disease, with frequent supratherapeutic international normalized ratios (INRs ≥ 4) increasing hemorrhagic risk. We evaluated whether the interaction of INR and lower estimated glomerular filtration rate (eGFR) increases hemorrhage risk and whether patients with lower eGFRs experience slower anticoagulation reversal.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Warfarin pharmacogenetics cohort (1,273 long-term warfarin users); warfarin reversal cohort (74 warfarin users admitted with INRs ≥ 4).

PREDICTOR

eGFR, INR as time-dependent covariate, and their interaction in the pharmacogenetics cohort; eGFR in the reversal cohort.

OUTCOMES & MEASUREMENTS

In the pharmacogenetics cohort, hemorrhagic (serious, life-threatening, and fatal bleeding) risk was assessed using proportional hazards regression. In the reversal cohort, anticoagulation reversal was assessed from changes in INR, warfarin and metabolite concentrations, clotting factors (II, VII, IX, and X), and PIVKA-II (protein induced by vitamin K absence or antagonist II) levels at presentation and after reversal, using linear regression and path analysis.

RESULTS

In the pharmacogenetics cohort, 454 (35.7%) had eGFRs < 60 mL/min/1.73 m(2). There were 137 hemorrhages in 119 patients over 1,802 person-years of follow-up (incidence rate, 7.6 [95% CI, 6.4-8.9]/100 person-years). Patients with lower eGFRs had a higher frequency of INR ≥ 4 (P<0.001). Risk of hemorrhage was affected significantly by eGFR-INR interaction. At INR<4, there was no difference in hemorrhage risk by eGFR (all P ≥ 0.4). At INR≥4, patients with eGFRs of 30 to 44 and < 30 mL/min/1.73 m(2) had 2.2-fold (95% CI, 0.8-6.1; P=0.1) and 5.8-fold (95% CI, 2.9-11.4; P<0.001) higher hemorrhage risks, respectively, versus those with eGFRs ≥ 60 mL/min/1.73 m(2). In the reversal cohort, 35 (47%) had eGFRs < 45 mL/min/1.73 m(2). Patients with eGFRs < 45 mL/min/1.73 m(2) experienced slower anticoagulation reversal as assessed by INR (P=0.04) and PIVKA-II level (P=0.008) than those with eGFRs ≥ 45 mL/min/1.73 m(2).

LIMITATIONS

Limited sample size in the reversal cohort, unavailability of antibiotic use and urine albumin data.

CONCLUSIONS

Patients with lower eGFRs have differentially higher hemorrhage risk at INR ≥ 4. Moreover, because the INR reversal rate is slower, hemorrhage risk is prolonged.

Predictors of recovery of functional swallow after gastrostomy tube placement for Dysphagia in stroke patients after inpatient rehabilitation: a pilot study

OBJECTIVE

To determine predictors of early recovery of functional swallow in patients who had gastrostomy (percutaneous endoscopic gastrostomy [PEG]) placement for dysphagia and were discharged to inpatient rehabilitation (IPR) after stroke.

METHODS

A retrospective study of prospectively identified patients with acute ischemic and hemorrhagic stroke from July 2008 to August 2012 was conducted. Patients who had PEG during stroke admission and were discharged to IPR, were studied. We compared demographics, stroke characteristics, severity of dysphagia, stroke admission events and medications in patients who remained PEG-dependent after IPR with those who recovered functional swallow.

RESULTS

Patients who remained PEG dependent were significantly older (73 vs. 54 years, p=0.009). Recovery of swallow was more frequent for hemorrhagic stroke patients (80% vs. 47%, p=0.079). Age, adjusting for side of stroke (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.82-0.98; p=0.016) and left-sided strokes, adjusting for age (OR, 15.15; 95% CI, 1.32-173.34; p=0.028) were significant predictors of swallow recovery. Patients who recovered swallowing by discharge from IPR were more likely to be discharged home compared to those who remained PEG-dependent (90% vs. 42%, p=0.009).

CONCLUSION

Younger age and left-sided stroke may be predictive factors of early recovery of functional swallow in patients who received PEG. Prospective validation is important as avoidance of unnecessary procedures could reduce morbidity and healthcare costs.

Quantitative perfusion- and diffusion-weighted magnetic resonance imaging of gastrointestinal cancers treated with multikinase inhibitors: a pilot study

BACKGROUND

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion-weighted imaging (DWI) are often used to detect the early response of solid tumors to an effective therapy. The early changes in intratumoral physiological parameters measured by DCE-MRI/DWI have been evaluated as surrogate biomarkers allowing a tailored treatment for the individual patient.

METHODS

Patients with newly diagnosed, biopsy-proven, treatment-naïve gastrointestinal stromal tumor (GIST) or hepatocellular carcinoma (HCC) were enrolled prospectively after institutional review board (IRB)-approved informed consent (5 patients per tumor type). Patients with GIST were treated with sunitinib over 6 weeks. DCE-MRI/DWI was applied before therapy (baseline imaging) and at 2 and 6 weeks after therapy initiation. Patients with HCC were treated with radiation during the first 2 weeks and then with sorafenib for the next 6 weeks. DCE-MRI/DWI was applied in all patients with HCC before and after radiation therapy and at the end of sorafenib therapy. Tumor volume, perfusion parameters (K (trans), the forward volume-transfer constant, and k ep, the reverse reflux-rate constant) and the apparent diffusion coefficient (ADC) were measured.

RESULTS

During 2 weeks of sunitinib therapy, GIST volume, K (trans), and k ep decreased 32 ± 13, 45 ± 24, and 42 ± 15%, respectively, whereas ADC increased 76 ± 24%. After 6 weeks of sunitinib therapy, GIST volume, K (trans), and k ep decreased 56 ± 7, 70 ± 7, and 50 ± 12%, respectively, whereas ADC increased 85 ± 33%. After completion of radiation therapy, HCC volume, K (trans), and k ep decreased 34 ± 14, 35 ± 12, and 4 ± 21%, respectively, but ADC increased 21 ± 9%. During the entire 10-week therapeutic period, HCC volume, K (trans), and k ep decreased 65 ± 15, 40 ± 9, and 26 ± 2%, respectively, whereas ADC increased 28 ± 10%.

CONCLUSION

DCE-MRI/DWI can measure the perfusion and diffusion changes in GISTs or HCCs treated with multikinase inhibitors.

Persistent leukocytosis-is this a persistent problem for patients with acute ischemic stroke?

BACKGROUND

In the setting of acute ischemic stroke (AIS), leukocytosis has been shown to be an indicator of inflammatory response. Although leukocytosis on admission has been shown to correlate with initial stroke severity in AIS patients, no work has been done to assess if there are differences in transient or persistent leukocytosis in patients without infection. The objective of this study is to determine the clinical significance of persistent versus transient leukocytosis during the early phase of AIS.

METHODS

Patients who presented with AIS to our center within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified by chart review. Patients were included if they had leukocytosis on admission (defined as white blood cell count >11,000/μL based on laboratory reference range values). A logistic regression model was used to evaluate persistent leukocytosis (leukocytosis 48 hours after admission) as a predictor of several outcome measures, including good functional outcome (discharge modified Rankin Scale score of 0-2). Marginal effects were used to estimate the probability of poor functional outcome.

RESULTS

Of the 438 patients screened, 49 had leukocytosis on admission and of those 24 (49%) had persistent leukocytosis. NIHSS score correlated significantly with persistence of leukocytosis (r = .306; P = .0044). More people with transient leukocytosis (leukocytosis lasting <48 hours) had a good functional outcome (44% versus 16%; P = .006). After adjusting for baseline NIHSS score, persistent leukocytosis was not a significant independent predictor of good functional outcome, but showed an association (OR, 2.5; 95% CI, .562-10.7; P = .2322). Persistent leukocytosis after adjusting for age and NIHSS score at admission is associated with a poor functional outcome, but it is not statistically significant (OR, 2.43; 95% CI, .59-9.87; P = .2151). After controlling for age and NIHSS score on admission, for patients with persistent leukocytosis, the probability of having poor functional outcome at discharge was increased by 16 percentage points.

CONCLUSIONS

Persistent leukocytosis is associated with higher baseline NIHSS scores. Persistent leukocytosis is tightly linked with baseline stroke severity and is associated with poor patient outcomes. Our study found that patients with persistent leukocytosis are more likely to present with severe strokes and maintain a high NIHSS score at 24 hours after admission, unlike patients without leukocytosis or patients with transient leukocytosis. Furthermore, it appears that persistent leukocytosis outside the setting of an infection negatively impacts the short-term functional outcome of AIS patients. Identifying patients with persistent leukocytosis could help to prognosticate and target patients that may benefit from future anti-inflammatory interventions.

Abstract W P225: The Relationship between Leukocytosis and Time to Neurodeterioration

Background: Previous research has illustrated how leukocytosis after acute ischemic stoke (AIS) is related to poor functional outcome. A main predictor of poor functional outcome is neurodeterioration (ND). We sought to explore the relationship between leukocytosis and time to ND to identify a risk factor for a process that predicts poor functional outcome.

Methods: Patients admitted to our stroke center (07/08-06/12) were retrospectively assessed. Leukocytosis was defined as WBC >11,000, ND was characterized as ≥ 2 point increase in NIHSS scale and poor functional outcome was classified as modified Rankin Scale (mRS) of 3-6. Patients were grouped into 2 categories: (1) the leukocytosis group- those who developed leukocytosis ≥24 hours after admission and those who presented with leukocytosis and remained at 24 hours and, (2) the non-leukocytosis group- those that did not have leukocytosis and those where the leukocytosis resolved within 24 hours of admission.

Results: A cohort of AIS patients (N=476) with median age 64 years, 43% female and 69% Black were assessed. Of the patients with ND (27%), median time to ND was 43 hours. In the leukocytosis group (N=84), 42 (50.6%) of them developed ND. In the non-leukocytosis group (N=312), 75 (24.5%) developed ND. Leukocytosis within 24 hours of admission is predictive of earlier time to ND (p<0.0001; Figure 1). Adjusting for age, stroke severity, glucose, tPA and infection, the leukocytosis group had a 2 times greater risk for developing ND (HR 2.49, 95%CI 1.61-3.84, p<0.0001).

Conclusion: Having leukocytosis persist from admission to 24 hours or developing leukocytosis within 24 hours of admission is a significant predictor of early ND, which often results in poor functional outcome. Identifying such a predictor can enable physicians to identify those at risk for ND and subsequent poor functional outcomes. Future studies are needed to identify if interventions targeting leukocytosis may improve outcome after stroke.

Abstract W P230: A Simple Prediction Score for Hospital-Acquired Infections in Acute Ischemic Stroke

Background: Hospital-acquired infections (HAI) are a major cause of morbidity and mortality in acute ischemic stroke (AIS) patients. While prior scoring systems have been developed to predict pneumonia (PNA) in AIS patients, these scores were not designed to predict other infections that complicate hospital stays. We sought to develop a simple scoring system for any HAI.

Methods: Patients admitted to our stroke center (07/08-06/12) were retrospectively assessed. Patients were excluded if they had an in-hospital stroke, unknown time from symptom onset, or delay from symptom onset to hospital arrival >48 hours. Infections were diagnosed via clinical, laboratory and imaging methods using standards set forth by our center. A scoring system was created to predict infections based on patient characteristics available at the time of admission.

Results: Of the 568 people who met inclusion criteria, 84 (14.8%) developed an infection during their inpatient stay. Patients who developed infection were older (73 vs. 64, p<0.0001), were more frequently diabetic (43.9% vs. 29.1%, p=0.0077), and had more severe strokes on admission (NIHSS 12 vs. 5, p15 5 points). Patients with an infection score of >4 were at 5 times greater odds of developing an infection (OR 5.67, 95% CI 3.28-9.81, p<0.0001). The area under the curve for this score showed fair sensitivity and specificity for predicting HAI after AIS (AUC=0.7311).

Conclusion: In our sample of AIS patients, clinical and laboratory characteristics available on presentation identified patients at risk for infections during their acute hospitalizations. Validation is required in other populations. If validated, this score could assist providers in predicting and preventing infections after hospitalization for AIS.

Abstract W P319: Isolated National Institute of Health Stroke Scale Subscore Worsening is Predictive of Poor Outcomes in Acute Ischemic Stroke Patients

Background and Objective: Neurological deterioration is common and contributes to poor outcome after acute ischemic stroke (AIS). The aim of this study is to determine if National Institutes of Health Stroke Scale (NIHSS) subscore changes, in the absence of an increase in total NIHSS score, are associated with poor outcomes.

Methods: We conducted a retrospective analysis on patients with AIS who presented to our center (07/08-12/10). Two-point ND was defined as ≥2-point worsening on the total NIHSS within 24 hours of admission. NIHSS subscore neurologic deterioration (sND) was defined as a ≥1-point worsening on one or more individual NIHSS item, in the absence of 2-point ND, within 24 hours of admission. Poor functional outcome at the time of discharge (discharge mRS >2) was the primary outcome measure and was compared among patients who experienced sND, those who experienced 2-point ND, and patients with no worsening. Individual NIHSS worsening of particular items on the scale were analyzed.

Results: A total of 522 patients met inclusion criteria. Patients with sND were at increased odds of poor functional outcome (discharge mRS >2, OR 2.08, 95% CI 1.33-3.25, p=0.001) even after adjusting for age, baseline NIHSS score, and glucose on presentation (Table 1). The association of sND with unfavorable discharge disposition was not maintained after covariate adjustment (OR 1.45, 95% CI 0.82-2.55, p=0.200). The odds of poor functional outcome and unfavorable discharge disposition were highest for isolated deterioration of level of consciousness (LOC) 1a followed by a worsening for motor in any limb (Table 2).

Conclusion: In our population of patients with AIS, an isolated sND in the absence of 2-point ND was shown to be predictive of poor outcome. This suggests that sND, specifically for LOC 1a and motor limbs, should be included in the scope of the ND definition.

Low-density lipoprotein and intracerebral hematoma expansion in daily alcohol users

Background

Epidemiological studies suggest that the intracerebral hemorrhage (ICH) rate correlates with alcohol consumption. Alcohol leads to elevated blood pressure (BP) and inhibition of platelet aggregation. These factors could promote excessive bleeding. To our knowledge, in the setting of normal liver function tests, there are no studies that have systematically evaluated the relationship between daily alcohol use and hematoma expansion. The aim of this study is to compare the baseline ICH characteristics, frequency of hematoma expansion, and outcomes in patients with ICH who are daily alcohol users with those who are not daily alcohol users.

Methods

A retrospective chart review was performed on consecutive patients who presented from July 2008 to July 2013 to the Tulane University Hospital in New Orleans, La., USA, with a spontaneous ICH. Ninety-nine patients who met these criteria were admitted. Patients who underwent hematoma evacuation were excluded. Hemorrhage volumes were calculated based on the ABC/2 method. Low-density lipoprotein (LDL) was dichotomized into low (<100 mg/dl) and high (≥100 mg/dl) values. Comparisons were made using t tests, χ² and nonparametric equivalents where appropriate. ICH growth in 24 h and LDL were evaluated using linear regression.

Results

Of the 226 patients who met inclusion criteria, 20.4% had a history of daily alcohol use. The average age was 61 years (range 19-94), 55.6% of the patients were males, and 67.1% were of African American origin. Daily alcohol use was associated with male gender, lower rate of home antihypertensive, higher presenting BP, and lower platelet counts, but there was no difference in ICH characteristics, ICH growth, or clinical outcome. Daily alcohol use in patients with a low LDL level was associated with supratentorial location and trends for lower baseline Glasgow Coma Scale score, higher ICH score, and follow-up ICH volume, but no significant difference in significant hematoma expansion or clinical outcome except for a trend for higher mortality was found (25 vs. 9.5%, p = 0.1311) compared to patients with high LDL values.

Conclusions

Our data suggest that neither chronic daily alcohol use nor a low LDL level in combination with daily alcohol use can be used to predict ICH growth. Daily alcohol use was associated with untreated hypertension and higher BP on presentation. A low LDL level in combination with daily alcohol use may be linked with larger and more severe ICH, but we were unable to demonstrate a relationship with hematoma expansion or poor clinical outcome. The role of LDL in vessel fragility and clot stabilization needs to be further explored before concluding that a low LDL level confers risk of bleeding.

Predictors of systemic inflammatory response syndrome in ischemic stroke undergoing systemic thrombolysis with intravenous tissue plasminogen activator

BACKGROUND

Systemic inflammatory response syndrome (SIRS) is an inflammatory process associated with poor outcomes in acute ischemic stroke (AIS) patients. However, no study to date has investigated predictors of SIRS in AIS patients treated with intravenous (IV) tissue plasminogen activator (tPA).

METHODS

Consecutive patients were retrospectively reviewed for evidence of SIRS during their acute hospitalization. SIRS was defined as the presence of 2 or more of the following: (1) body temperature less than 36°C or greater than 38°C, (2) heart rate greater than 90, (3) respiratory rate greater than 20, or (4) white blood cell count less than 4000/mm or greater than 12,000/mm or more than 10% bands for more than 24 hours. Those diagnosed with an infection were excluded. A scoring system was created to predict SIRS based on patient characteristics available at the time of admission. Logistic regression was used to evaluate potential predictors of SIRS using a sensitivity cutoff of ≥65% or area under the curve of .6 or more.

RESULTS

Of 212 patients, 44 had evidence of SIRS (21%). Patients with SIRS were more likely to be black (61% versus 54%; P = .011), have lower median total cholesterol at baseline (143 versus 167 mg/dL; P = .0207), and have history of previous stroke (51% versus 35%; P = .0810). Ranging from 0 to 6, the SIRS prediction score consists of African American (2 points), history of hypertension (1 point), history of previous stroke (1 point), and admission total cholesterol less than 200 (2 points). Patients with an SIRS score of 4 or more were 3 times as likely to develop SIRS when compared with patients with a score of ≤3 (odds ratio = 2.815, 95% confidence interval 1.43-5.56, P = .0029).

CONCLUSIONS

In our sample of IV tPA-treated AIS patients, clinical and laboratory characteristics available on presentation were able to identify patients likely to develop SIRS during their acute hospitalization. Validation is required in other populations. If validated, this score could assist providers in predicting who will develop SIRS after treatment with IV tPA.

Social History Matters–The Impact of Illicit Drug Use on tPA Use and In-Hospital Mortality in Acute Ischemic Stroke

Aims

The objective of this descriptive study was to compare time to medical evaluation, intravenous tissue plasminogen activator (IV tPA) use, and short-term outcomes in illicit drug users compared to non-users presenting with acute ischemic stroke (AIS).

Study Design

This is a retrospective study performed from our stroke registry using deidentified patient information.

Place and Duration of Study

Tulane Medical Center Primary Stroke Center (PSC). Consecutive AIS patients presenting to our PSC from July 2008 to December of 2010 were identified from our prospectively collected stroke registry.

Methodology

Patients were categorized as toxicology positive (TP) or toxicology negative (TN). We compared baseline characteristics, clinical presentation, tPA use, and short-term outcomes in TP and TN patients.

Results

Two hundred and sixty-three patients met inclusion criteria (median age 63, 35.4% female, 66.5% Black). Nearly 40% of toxicology screens were positive. Stroke severity was similar with the median National Institute of Health Stroke Scale (NIHSS) of 6 in both groups; however, a higher proportion of TN patients were treated with IV tPA (32.1% vs. 21.2%). After adjustment for time from last seen normal to emergency department arrival (LSN-to-ED arrival), the odds of being treated with tPA for TP patients were similar to TN patients (OR 0.69, 95% CI 0.36–1.31, p=0.255). After adjustment for age, NIHSS, glucose, and tPA, the odds of in-hospital mortality in TP patients was 3 times that of TN patients (OR 3.17, 95% CI 1.07–9.43, p=0.038).

Conclusion

We found that the disparities observed in tPA use were attenuated after adjustment for time from LSN-to-ED arrival, suggesting an area for future intervention. Additionally, we found that TP patients may be at higher risk for in-hospital mortality. Further study on the role of substance abuse in time to ED arrival, tPA use, and outcome in AIS patients is warranted.

Social History Matters-The Impact of Illicit Drug Use on tPA Use and In-Hospital Mortality in Acute Ischemic Stroke

AIMS

The objective of this descriptive study was to compare time to medical evaluation, intravenous tissue plasminogen activator (IV tPA) use, and short-term outcomes in illicit drug users compared to non-users presenting with acute ischemic stroke (AIS).

STUDY DESIGN

This is a retrospective study performed from our stroke registry using deidentified patient information.

PLACE AND DURATION OF STUDY

Tulane Medical Center Primary Stroke Center (PSC). Consecutive AIS patients presenting to our PSC from July 2008 to December of 2010 were identified from our prospectively collected stroke registry.

METHODOLOGY

Patients were categorized as toxicology positive (TP) or toxicology negative (TN). We compared baseline characteristics, clinical presentation, tPA use, and short-term outcomes in TP and TN patients.

RESULTS

Two hundred and sixty-three patients met inclusion criteria (median age 63, 35.4% female, 66.5% Black). Nearly 40% of toxicology screens were positive. Stroke severity was similar with the median National Institute of Health Stroke Scale (NIHSS) of 6 in both groups; however, a higher proportion of TN patients were treated with IV tPA (32.1% vs. 21.2%). After adjustment for time from last seen normal to emergency department arrival (LSN-to-ED arrival), the odds of being treated with tPA for TP patients were similar to TN patients (OR 0.69, 95% CI 0.36-1.31, p=0.255). After adjustment for age, NIHSS, glucose, and tPA, the odds of in-hospital mortality in TP patients was 3 times that of TN patients (OR 3.17, 95% CI 1.07-9.43, p=0.038).

CONCLUSION

We found that the disparities observed in tPA use were attenuated after adjustment for time from LSN-to-ED arrival, suggesting an area for future intervention. Additionally, we found that TP patients may be at higher risk for in-hospital mortality. Further study on the role of substance abuse in time to ED arrival, tPA use, and outcome in AIS patients is warranted.

The Impact of Myocardial Infarction vs. Pneumonia on Outcome in Acute Ischemic Stroke

The aim of this study was to examine the association between MI and PNA in the setting of acute ischemic stroke and patient outcome. Eligible patients were identified from a prospectively collected stroke registry and included if transthoracic echocardiography (TTE) was performed during their inpatient stay. 426 patients met inclusion criteria (mean age 64, 73% Black, 48% female). Twenty-one patients (4.9%) experienced an MI. Patients who later suffered a MI initially presented with more severe strokes (median NIHSS 7 vs. 5, p=0.014). More patients in the MI group experienced pneumonia (26% vs. 9%, p=0.004). After adjusting for age, baseline glucose and NIHSS, the odds of in-hospital mortality for patients with MI was 3 times that of those without MI (OR 3.2 95% CI 1.1-9.7, p=0.036). When adjustment was made for pneumonia, age, baseline glucose and NIHSS, MI was no longer significantly related to in-hospital mortality (OR 2.5 95% CI 0.8-8.2, p=0.131). In our sample, while MI was significantly associated with in-hospital mortality, this association was attenuated after adjusting for presence of pneumonia. Our findings raise the question as to whether the prevention of pneumonia could improve in-hospital mortality among patients who experience MI in the setting of ischemic stroke.