Quantitative analysis of printed nanostructured networks using high-resolution 3D FIB-SEM nanotomography

Networks of solution-processed nanomaterials are becoming increasingly important across applications in electronics, sensing and energy storage/generation. Although the physical properties of these devices are often completely dominated by network morphology, the network structure itself remains difficult to interrogate. Here, we utilise focused ion beam - scanning electron microscopy nanotomography (FIB-SEM-NT) to quantitatively characterise the morphology of printed nanostructured networks and their devices using nanometre-resolution 3D images. The influence of nanosheet/nanowire size on network structure in printed films of graphene, WS2 and silver nanosheets (AgNSs), as well as networks of silver nanowires (AgNWs), is investigated. We present a comprehensive toolkit to extract morphological characteristics including network porosity, tortuosity, specific surface area, pore dimensions and nanosheet orientation, which we link to network resistivity. By extending this technique to interrogate the structure and interfaces within printed vertical heterostacks, we demonstrate the potential of this technique for device characterisation and optimisation.

Transparent Conductors Printed from Grids of Highly Conductive Silver Nanosheets

Transparent conductors (TCs) represent key components in many applications from optoelectronic devices to electromagnetic shielding. While commercial applications typically use thin films of indium tin oxide, this material is brittle and increasingly scarce, meaning higher performing and cheaper alternatives are sought after. Solution-processible metals would be ideal owing to their high conductivities and printability. However, due to their opacity to visible light, such films need to be very thin to achieve transparency, thus limiting the minimum resistance achievable. One solution is to print metallic particles in a grid structure, which has the advantages of high tunable transparency and resistance at the cost of uniformity. Here, we report silver nanosheets that have been aerosol jet printed into grids as high-performance transparent conductors. We first investigate the effect of annealing on the silver nanosheets where we observe the onset of junction sintering at 160 °C after which the silver network becomes continuous. We then investigate the effect of line width and thickness on the electrical performance and the effect of varying the aperture dimensions on the optical performance. Using these data, we develop simple models, which allow us to optimize the grid and demonstrate a printed transparent conductor with a transmittance of 91% at a sheet resistance of 4.6 Ω/sq.

Hospital Discharge and Readmissions Before and During the COVID-19 Pandemic for California Acute Stroke Inpatients

BACKGROUND

Acute stroke therapy and rehabilitation declined during the COVID-19 pandemic. We characterized changes in acute stroke disposition and readmissions during the pandemic.

METHODS

We used the California State Inpatient Database in this retrospective observational study of ischemic and hemorrhagic stroke. We compared discharge disposition across a pre-pandemic period (January 2019 to February 2020) to a pandemic period (March to December 2020) using cumulative incidence functions (CIF), and re-admission rates using chi-squared.

RESULTS

There were 63,120 and 40,003 stroke hospitalizations in the pre-pandemic and pandemic periods, respectively. Pre-pandemic, the most common disposition was home [46%], followed by skilled nursing facility (SNF) [23%], and acute rehabilitation [13%]. During the pandemic, there were more home discharges [51%, subdistribution hazard ratio 1.17, 95% CI 1.15-1.19], decreased SNF discharges [17%, subdistribution hazard ratio 0.70, 95% CI 0.68-0.72], and acute rehabilitation discharges were unchanged [CIF, p<0.001]. Home discharges increased with increasing age, with an increase of 8.2% for those ≥85 years. SNF discharges decreased in a similar distribution by age. Thirty-day readmission rates were 12.7 per 100 hospitalizations pre-pandemic compared to 11.6 per 100 hospitalizations during the pandemic [p<0.001]. Home discharge readmission rates were unchanged between periods. Readmission rates for discharges to SNF (18.4 vs. 16.7 per 100 hospitalizations, p=0.003) and acute rehabilitation decreased (11.3 vs. 10.1 per 100 hospitalizations, p=0.034).

CONCLUSIONS

During the pandemic a greater proportion of patients were discharged home, with no change in readmission rates. Research is needed to evaluate the impact on quality and financing of post-hospital stroke care.

Unveiling Charge-Transport Mechanisms in Electronic Devices Based on Defect-Engineered MoS2 Covalent Networks

Device performance of solution-processed 2D semiconductors in printed electronics has been limited so far by structural defects and high interflake junction resistance. Covalently interconnected networks of transition metal dichalcogenides potentially represent an efficient strategy to overcome both limitations simultaneously. Yet, the charge-transport properties in such systems have not been systematically researched. Here, the charge-transport mechanisms of printed devices based on covalent MoS₂ networks are unveiled via multiscale analysis, comparing the effects of aromatic versus aliphatic dithiolated linkers. Temperature-dependent electrical measurements reveal hopping as the dominant transport mechanism: aliphatic systems lead to 3D variable range hopping, unlike the nearest neighbor hopping observed for aromatic linkers. The novel analysis based on percolation theory attributes the superior performance of devices functionalized with π-conjugated molecules to the improved interflake electronic connectivity and formation of additional percolation paths, as further corroborated by density functional calculations. Valuable guidelines for harnessing the charge-transport properties in MoS₂ devices based on covalent networks are provided.

High-Mobility Flexible Transistors with Low-Temperature Solution-Processed Tungsten Dichalcogenides

The investigation of high-mobility two-dimensional (2D) flakes beyond molybdenum disulfide (MoS₂) will be necessary to create a library of high-mobility solution-processed networks that conform to substrates and remain functional over thousands of bending cycles. Here we report electrochemical exfoliation of large-aspect-ratio (>100) semiconducting flakes of tungsten diselenide (WSe₂) and tungsten disulfide (WS₂) as well as MoS₂ as a comparison. We use Langmuir-Schaefer coating to achieve highly aligned and conformal flake networks, with minimal mesoporosity (∼2-5%), at low processing temperatures (120 °C) and without acid treatments. This allows us to fabricate electrochemical transistors in ambient air, achieving average mobilities of μ_MoS2 ≈ 11 cm² V^-1 s^-1, μ_WS2 ≈ 9 cm² V^-1 s^-1, and μ_WSe2 ≈ 2 cm² V^-1 s^-1 with a current on/off ratios of I_on/I_off ≈ 2.6 × 10³, 3.4 × 10³, and 4.2 × 10⁴ for MoS₂, WS₂, and WSe₂, respectively. Moreover, our transistors display threshold voltages near ∼0.4 V with subthreshold slopes as low as 182 mV/dec, which are essential factors in maintaining power efficiency and represent a 1 order of magnitude improvement in the state of the art. Furthermore, the performance of our WSe₂ transistors is maintained on polyethylene terephthalate (PET) even after 1000 bending cycles at 1% strain.

Solution processed, vertically stacked hetero-structured diodes based on liquid-exfoliated WS2 nanosheets: from electrode-limited to bulk-limited behavior

Vertically stacked metal-semiconductor-metal heterostructures, based on liquid-processed nanomaterials, hold great potential for various printed electronic applications. Here we describe the fabrication of such devices by spray-coating semiconducting tungsten disulfide (WS₂) nanosheets onto indium tin oxide (ITO) bottom electrodes, followed by spraying single-walled carbon nanotubes (SWNTs) as the top electrode. Depending on the formulation of the SWNTs ink, we could fabricate either Ohmic or Schottky contacts at the WS₂/SWNTs interface. Using isopropanol-dispersed SWNTs led to Ohmic contacts and bulk-limited devices, characterized by out-of-plane conductivities of ∼10^-4 S m^-1. However, when aqueous SWNTs inks were used, rectification was observed, due to the formation of a doping-induced Schottky barrier at the WS₂/SWNTs interface. For thin WS₂ layers, such devices were characterized by a barrier height of ∼0.56 eV. However, increasing the WS₂ film thickness led to increased series resistance, leading to a change-over from electrode-limited to bulk-limited behavior at a transition thickness of ∼2.6 μm. This work demonstrates that Ohmic/Schottky behavior is tunable and lays the foundation for fabricating large-area 2D nanosheet-based solution-deposited devices and stacks.

Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis

Background

The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a meta-analysis of the current literature on MSU performance.

Methods

Our MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours (“per day”), mechanical thrombectomy (MT)/dispatch and MT/day.

Results

Our MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150–0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074–0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8–9.5%, I² = 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215–0.502, I² = 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2–2.8%, I² = 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046–0.138, I² = 91%).

Conclusions

In this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.

Functional status at 30 and 90 days after mild ischaemic stroke

BACKGROUND/OBJECTIVE

This study compares the global disability status of patients who had a mild ischaemic stroke at 30 and 90 days poststroke, as measured by the modified Rankin Scale (mRS), and identifies predictors of change in disability status between 30 and 90 days.

METHODS

The study population included 1339 patients who had a ischaemic stroke enrolled in the Mild and Rapidly Improving Stroke Study with National Institutes of Health (NIH) stroke score 0-5 and mRS measurements at 30 and 90 days. Outcomes were (1) Improvement defined as having mRS >1 at 30 days and mRS 0-1 at 90 days OR mRS >2 at 30 days and mRS 0-2 at 90 days and (2) Worsening defined as an increase of ≥2 points or a worsening from mRS of 1 at 30 days to 2 at 90 days. Demographic and clinical characteristics at hospital arrival were abstracted from medical records, and regression models were used to identify predictors of functional improvement and decline from 30 to 90 days post-stroke. Significant predictors were mutually adjusted in multivariable models that also included age and stroke severity.

RESULTS

Fifty-seven per cent of study participants had no change in mRS value from 30 to 90 days. Overall, there was moderate agreement in mRS between the two time points (weighted kappa=0.59 (95% CI 0.56 to 0.62)). However, worsening on the mRS was observed in 7.54% of the study population from 30 to 90 days, and 17.33% improved. Participants of older age (per year OR 1.02, 95% CI 1.00 to 1.03), greater stroke severity (per NIH Stroke Scale (NIHSS) point at admission OR 1.17, 95% CI 1.03 to 1.34), and those with no alteplase treatment (OR 1.72, 95% CI 1.11 to 2.69) were more likely to show functional decline after mutual adjustment.

DISCUSSION

A quarter of all mild ischaemic stroke participants exhibited functional changes between 30 and 90 days, suggesting that the 30-day outcome may insufficiently represent long-term recovery in mild stroke and longer follow-up may be clinically necessary.

TRIAL REGISTRATION NUMBER

NCT02072681.

Highly Conductive Networks of Silver Nanosheets

Although printed networks of semiconducting nanosheets have found success in a range of applications, conductive nanosheet networks are limited by low conductivities (<10⁶ S m^-1 ). Here, dispersions of silver nanosheets (AgNS) that can be printed into highly conductive networks are described. Using a commercial thermal inkjet printer, AgNS patterns with unannealed conductivities of up to (6.0 ± 1.1) × 10⁶  S m^-1 are printed. These networks can form electromagnetic interference shields with record shielding effectiveness of >60 dB in the microwave region at thicknesses <200 nm. High resolution patterns with line widths down to 10 µm are also printed using an aerosol-jet printer which, when annealed at 200 °C, display conductivity >10⁷  S m^-1 . Unlike conventional Ag-nanoparticle inks, the 2D geometry of AgNS yields smooth, short-free interfaces between electrode and active layer when used as the top electrode in vertical nanosheet heterostructures. This shows that all-printed vertical heterostructures of AgNS/WS₂ /AgNS, where the top electrode is a mesh grid, function as photodetectors demonstrating that such structures can be used in optoelectronic applications that usually require transparent conductors.

Abstract WP41: Mobile Stroke Unit Operational Performance: A Retrospective Single Institution Analysis And Meta-Analysis

Introduction: Mobile stroke units (MSU) have become increasingly common and now span a diverse range of communities. Reporting has previously focused on clinical outcomes, and metrics reporting the operational performance of MSUs have not been standardized. The aim of this study was to establish normalized metrics to evaluate MSUs and to a complete a meta-analysis of the current literature on MSU performance.

Methods: Our MSU serves a population of 741,000 people in upstate New York. Data was prospectively collected and retrospectively analyzed from its inception in October of 2018 through March of 2021. We report rates of transportation/dispatch and MSU utilization rates. MEDLINE and Cochrane Library databases were utilized to perform a meta-analysis. Pooled rates of tPA/dispatch, tPA/day, mechanical thrombectomy (MT)/dispatch and MT/day were calculated. An assessment of inter-study heterogeneity was also completed.

Results: In 606 days, our MSU was dispatched 1,719 times for an average rate of 2.8 dispatches/day. 324 patients (18.8%) were transported to the hospital by the MSU. Intravenous tPA was administered in 64 patients (3.7% of all dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150 to 0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074 to 0.163). Of the 290,760 total minutes the MSU was available, it was in use for 38,742 minutes (13.3% utilization rate). Our meta-analysis included 18 total articles. Eight studies were included in the pooled analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8% to 9.5%, I2 = 92%) and nine were included in the analysis of tPA/day (785/1,998) for a rate of 0.359 (95% CI 0.150 to 0.567, I2 = 99%). Seven studies met criteria for analysis of MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2% to 2.8%, I2 = 67%) and for MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046 to 0.138, I2 = 91%).

Conclusions: Future studies investigating MSUs should focus on the following normalized metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and the newly described utilization rate. These normalized metrics are also useful at an institutional level when evaluating the overall utilization and efficacy of an MSU.

Abstract TMP28: Decision For Tpa Administration, Not Drive Time, Contributes Most To Variance In Thrombolysis Times Onboard Mobile Stroke Unit

Introduction: Hospitals have improved stroke thrombolysis times through rigorous assessment of care delays. While mobile stroke units (MSU) expedite intravenous thrombolysis for acute ischemic stroke, the same rigor has not been applied to this novel setting.

Methods: We reviewed all cases of intravenous tissue plasminogen activator (tPA) administration onboard our mobile stroke unit in Rochester, NY since its inception in 2019. The dispatch timeline was divided into six intervals: (1) drive time, (2) onboarding time, (3) HCT collection, (4) HCT reading, (5) decision time, and (6) tPA administration. Cases in which tPA was delayed due to medical contraindications or inability to obtain consent were not included in the analysis.

Results: The mean ± SD total time between MSU dispatch and tPA was 42 ± 8.4 min (range: 26-60 min; N = 53). The longest interval was (1) drive time (between dispatch and arrival, 12.0 ± 4.7 min). However, the inter-case variation was greatest in (5) decision time (between HCT reading and treatment decision, 6.3 ± 6.2 min). After ranking cases by total time, the interval that had the widest variance between the first and fourth quartiles was decision time (2.45x). The other intervals varied by a factor of 1.50x for (6) tPA administration and less than 1.00x for the other four intervals. Decision time was the interval most closely correlated with total time (Spearman’s ρ = 0.46; p = 0.00051), which was reduced in our second year of operation (38.8 from 44.6 minutes; Mann-Whitney, Z = 2.38, p = 0.02). Decision time was negatively correlated with time since inception of the MSU (Spearman’s ρ = -0.29, p = 0.037), suggesting that improvements in decision time drove improvements in overall thrombolysis time.

Conclusion: The largest driver of variation in total time from emergency alert to tPA administration is provider decision time in our MSU program. This observation should be investigated in other settings but may ultimately inform MSU training and staffing.

Prognostication in neurology

Prognosticating is central to primary palliative care in neurology. Many neurologic diseases carry a high burden of troubling symptoms, and many individuals consider health states due to neurologic disease worse than death. Many patients and families report high levels of need for information at all disease stages, including information about prognosis. There are many barriers to communicating prognosis including prognostic uncertainty, lack of training and experience, fear of destroying hope, and not enough time. Developing the right mindset, tools, and skills can improve one's ability to formulate and communicate prognosis. Prognosticating is subject to many biases which can dramatically affect the quality of patient care; it is important for providers to recognize and reduce them. Patients and surrogates often do not hear what they are told, and even when they hear correctly, they form their own opinions. With practice and self-reflection, one can improve their prognostic skills, help patients and families create honest roadmaps of the future, and deliver high-quality person-centered care.

Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy

BACKGROUND

The number of mobile stroke programmes has increased with evidence, showing they expedite intravenous thrombolysis. Outstanding questions include whether time savings extend to patients eligible for endovascular therapy and impact clinical outcomes.

OBJECTIVE

Our mobile stroke unit (MSU), based at an academic medical centre in upstate New York, launched in October 2018. We reviewed prospective observational data sets over 26 months to identify MSU and non-MSU emergency medical service (EMS) patients who underwent intravenous thrombolysis or endovascular thrombectomy for comparison of angiographic and clinical outcomes.

RESULTS

Over 568 days in service, the MSU was dispatched 1489 times (2.6/day) and transported 300 patients (20% of dispatches). Intravenous tissue plasminogen activator (tPA) was administered to 57 MSU patients and the average time from 911 call-to-tPA was 42.5 min (±9.2), while EMS transported 73 patients who received tPA at 99.4 min (±35.7) (p<0.001). Seven MSU patients (12%) received tPA from 3.5 hours to 4.5 hours since last known well and would likely have been outside the window with EMS care. Endovascular thrombectomy was performed on 21 MSU patients with an average 911 call-to-groin puncture time of 99.9 min (±18.1), while EMS transported 54 patients who underwent endovascular thrombectomy (ET) at 133.0 min (±37.0) (p=0.0002). There was no difference between MSU and traditional EMS in modified Rankin score at 90-day clinic follow-up for patients undergoing intravenous thrombolysis or endovascular thrombectomy, whether assessed as a dichotomous or ordinal variable.

CONCLUSIONS

Mobile stroke care expedited both intravenous thrombolysis and endovascular thrombectomy. There is an ongoing need to show improved functional outcomes with MSU care.

Highly Sensitive Composite Foam Bodily Sensors Based on the g-Putty Ink Soaking Procedure

Electrically conductive composite materials are highlighted as a potential tech path toward future flexible devices for wearable health technologies. To be commercially viable, these materials must not only be mechanically soft, highly sensitive to deformation, and report a sustainable signal but also utilize manufacturing methods that facilitate large-scale production. An ideal candidate for these envisioned technologies is the viscous, electromechanically sensitive composite material g-putty. Inks based on g-putty here are shown to transform a commercial polymer foam into a sensitive strain sensing material through a simple, scalable soaking procedure. Foam composites reported here have sensitives as high as ∼20 in terms of compressive strain and ∼0.4 kPa^-1 with respect to applied compressive stress; both values being comparable to the parent g-putty material. Through g-putty's self-adhering nature, the foams used acted as an elastic scaffolding that aided in overcoming many of the hysteresis effects associated with g-putty without the need for further encapsulation methods. From this, these composite foams were demonstrated to have a sustainable signal that allowed for effective impact and vital sign sensing.

Frequency and Prognostic Significance of Clinical Fluctuations Before Hospital Arrival in Stroke

BACKGROUND AND PURPOSE

Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized.

METHODS

A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines-Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes.

RESULTS

Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations.

CONCLUSIONS

Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02072681.

Printable G-Putty for Frequency- and Rate-Independent, High-Performance Strain Sensors

While nanocomposite electromechanical sensors are expected to display reasonable conductivity and high sensitivity, little consideration is given to eliminating hysteresis and strain rate/frequency dependence from their response. For example, while G-putty, a composite of graphene and polysiloxane, has very high electromechanical sensitivity, its extreme viscoelasticity renders it completely unsuitable for real sensors due to hysteretic and rate-/frequency-dependent effects. Here it is shown that G-putty can be converted to an ink and printed into patterned thin films on elastic substrates. A partial graphene-polymer phase segregation during printing increases the thin-film conductivity by ×10⁶ compared to bulk, while the mechanical effects of the substrate largely suppress hysteresis and completely remove strain rate and frequency dependence. This allows the fabrication of practical, high-gauge-factor, wearable sensors for pulse measurements as well as patterned sensors for low-signal vibration sensing.

Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: MaRISS

[Figure: see text].

Covalently interconnected transition metal dichalcogenide networks via defect engineering for high-performance electronic devices

Solution-processed semiconducting transition metal dichalcogenides are at the centre of an ever-increasing research effort in printed (opto)electronics. However, device performance is limited by structural defects resulting from the exfoliation process and poor inter-flake electronic connectivity. Here, we report a new molecular strategy to boost the electrical performance of transition metal dichalcogenide-based devices via the use of dithiolated conjugated molecules, to simultaneously heal sulfur vacancies in solution-processed transition metal disulfides and covalently bridge adjacent flakes, thereby promoting percolation pathways for the charge transport. We achieve a reproducible increase by one order of magnitude in field-effect mobility (µ_FE), current ratio (I_ON/I_OFF) and switching time (τ_S) for liquid-gated transistors, reaching 10^-2 cm² V^-1 s^-1, 10⁴ and 18 ms, respectively. Our functionalization strategy is a universal route to simultaneously enhance the electronic connectivity in transition metal disulfide networks and tailor on demand their physicochemical properties according to the envisioned applications.

Trends of Acute Ischemic Stroke Reperfusion Therapies from 2012 to 2016 in the United States

BACKGROUND

American Heart Association/American Stroke Association guidelines recommend endovascular stroke therapy (EST) with recombinant tissue plasminogen activator (rt-PA) for eligible patients in acute ischemic stroke (AIS). Using the National Inpatient Sample database, we evaluated trends in treatment with rt-PA and EST for AIS and their outcomes.

METHODS

This is a cross-sectional observational study of patients with AIS admitted in US hospitals from 2012 to 2016. Patients were grouped into those who received rt-PA alone, EST alone, and rtPA+EST. Survey statistical procedures were performed. Multivariable regression analysis with pairwise comparisons of each treatment group with no treatment group was performed for discharge outcomes.

RESULTS

The study included 2,290,520 patients with AIS with the mean age of 70.46 years. Treatment rates increased from 2012 to 2016 for rt-PA by 7% per year (5.86%-7.67%, odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.05-1.08) and EST by 38% per year (0.55%-1.75%, OR = 1.38, 95% CI: 1.31-1.45) but not rt-PA+EST (0.54%-0.57%, OR = 1.04, 95% CI: 0.99-1.08). The mean length of stay reduced from 2012 to 2016 for rt-PA (6.07-4.91 days, P < 0.0001) and rt-PA+EST (9.19-7.10 days, P = 0.0067) but not for EST (9.61-8.51 days, P = 0.5074). The odds of patients discharged home increased by 8%, 9%, and 15% among patients who received rt-PA alone, EST alone, and rt-PA+EST, respectively, compared with no treatment group.

CONCLUSION

The utilization of rt-PA alone and EST alone increased but that of rt-PA+EST remained unchanged from 2012 to 2016 in the National Inpatient Sample.

Abstract P310: Impact of COVID-19 Pandemic on Stroke Care at the University of Rochester Medical Center

Introduction: The impact of the COVID-19 pandemic response on medical care for stroke is unknown.

Methods: We used local “Get With The Guidelines” stroke data for patients with ischemic stroke (IS), transient ischemic attack (TIA), and intracerebral hemorrhage/subarachnoid hemorrhage (ICH/SAH) from March 20–April 14, 2020 (study period) and January 1–March 19, 2020 (control period #1) and March 20–April 14, 2019 (control period #2). We examined daily admission rates, transfers, tPA administration, thrombectomy, and time from last well to hospital arrival.

Results: There were 349 patients (n=40 study period, n=225 control period #1, n=84 control period #2); 263 with IS, 37 with TIA, and 49 with ICH/SAH. Overall, 46% were female, 82% white, with median age 70 years (IQR 58-82 years).

Daily admission rates were 1.4 IS/day for the study period compared to 2.1 IS/day (Incident rate ratio [IRR] 1.49 95% CI 1.05-2.13, p=0.027) and 2.2 IS/day (IRR 1.57 1.04-2.37, p=0.033) for control periods #1 and #2 ( Table ), respectively. There was only one admission for TIA in the study period compared to approximately one every 4 days in control period #1 (IRR 7.2 95% CI 1.0-53.7, p=0.053) and one every 2 days in control period #2 (IRR 14.0 95% CI 1.8-106.5, p=0.011). ICH/SAH admissions were fewer in the study period. Transfers were less common with approximately one transfer every four days in the study period compared to one each day of the control periods. Rates of tPA, thrombectomy, and time from last well to first hospital contact did not differ across the epochs.

Conclusions: Our data suggest the COVID-19 pandemic response has led to reduced admission volumes for all stroke types in the University of Rochester Medical Center catchment area, partly due to decreases in hospital transfers. These data raise the question whether fewer patients sought care for stroke symptoms at the height of the COVID-19 pandemic.

Proceedings from the Neurotherapeutics Symposium on Neurological Emergencies: Shaping the Future of Neurocritical Care

Effective treatment options for patients with life-threatening neurological disorders are limited. To address this unmet need, high-impact translational research is essential for the advancement and development of novel therapeutic approaches in neurocritical care. "The Neurotherapeutics Symposium 2019-Neurological Emergencies" conference, held in Rochester, New York, in June 2019, was designed to accelerate translation of neurocritical care research via transdisciplinary team science and diversity enhancement. Diversity excellence in the neuroscience workforce brings innovative and creative perspectives, and team science broadens the scientific approach by incorporating views from multiple stakeholders. Both are essential components needed to address complex scientific questions. Under represented minorities and women were involved in the organization of the conference and accounted for 30-40% of speakers, moderators, and attendees. Participants represented a diverse group of stakeholders committed to translational research. Topics discussed at the conference included acute ischemic and hemorrhagic strokes, neurogenic respiratory dysregulation, seizures and status epilepticus, brain telemetry, neuroprognostication, disorders of consciousness, and multimodal monitoring. In these proceedings, we summarize the topics covered at the conference and suggest the groundwork for future high-yield research in neurologic emergencies.

Prehospital time intervals and management of ischemic stroke patients

OBJECTIVE

Quantify prehospital time intervals, describe prehospital stroke management, and estimate potential time saved if certain procedures were performed en route to the emergency department (ED).

METHODS

Acute ischemic stroke patients who arrived via emergency medical services (EMS) between 2012 and 2016 were identified. We determined the following prehospital time intervals: chute, response, on-scene, transport, and total prehospital times. Proportions of patients receiving the following were determined: Cincinnati Prehospital Stroke Scale (CPSS) assessment, prenotification, glucose assessment, vascular access, and 12-lead electrocardiography (ECG). For glucose assessment, ECG acquisition, and vascular access, the location (on-scene vs. en route) in which they were performed was described. Difference in on-scene times among patients who had these three interventions performed on-scene vs. en route was assessed.

RESULTS

Data from 870 patients were analyzed. Median total prehospital time was 39 min and comprised the following: chute time: 1 min; response time: 9 min; on-scene time: 15 min; and transport time: 14 min. CPSS was assessed in 64.7% of patients and prenotification was provided for 52.0% of patients. Glucose assessment, vascular access initiation, and ECG acquisition was performed on 84.1%, 72.6%, and 67.2% of patients, respectively. 59.0% of glucose assessments, 51.2% of vascular access initiations, and 49.8% of ECGs were performed on-scene. On-scene time was 9 min shorter among patients who had glucose assessments, vascular access initiations, and ECG acquisitions all performed en route vs. on-scene.

CONCLUSIONS

On-scene time comprised 38.5% of total prehospital time. Limiting on-scene performance of glucose assessments, vascular access initiations, and ECG acquisitions may decrease prehospital time.

Abstract WP47: Combined Treatment of Rt-PA With Mechanical Thrombectomy is Associated With Better Outcome Than Mechanical Thrombectomy Alone and Possibly Underutilized - A National Inpatient Sample Study

Background and Purpose: 2015 AHA/ASA guidelines recommend mechanical thrombectomy (MT) with rt-PA for eligible patients within 6 hours of acute ischemic stroke (AIS). We evaluated the real world impact of the guidelines by analyzing trends and outcomes of stroke patients discharged from 2012 to 2016 in National Inpatient Sample database.

Methods: Patients discharged with primary diagnosis of AIS were identified with ICD-9 codes for 2012 to third quarter of 2015 and ICD-10 codes for 2016 and last quarter of 2015. Patients who received only rt-PA, only MT, rt-PA+MT or no treatment were analyzed for discharge outcomes including length of stay (LOS), inpatient mortality and discharge status to home. Survey procedures were used for analysis. Multivariable regression analysis with pairwise comparison of treatment groups with no treatment group was performed to evaluate outcomes controlling for risk factors and all patient refined DRG severity of illness and risk of mortality scores.

Results: A total of 2,290,520 adult AIS patients were in the study with mean age 70.4 years (SE 0.03) and 51.1% (SE 0.08) women. There was a significant increase in treatment with rt-PA (5.86% in 2012 to 7.67% in 2016, OR=1.07, 95% CI 1.05-1.08); and MT (0.55% in 2012 to 1.75% in 2016, OR=1.38, 95%CI 1.31-1.45); but not combination rt-PA+MT (0.54% in 2012 to 0.57% in 2016, OR=1.04, 95% CI 0.99 - 1.08). LOS was significantly reduced for rt-PA (mean 6.07 days in 2012 to 4.91 days in 2016, p<0.0001, 1.7 percent reduction/year), and rt-PA+MT (mean 9.19 days in 2012 to 7.10 days in 2016, p=0.0067, 2.9 percent reduction/year) but not for MT alone (9.61 days in 2012 to 8.51 days in 2016, p=0.50). The odds of patients discharged home was significantly higher by 8%, 9% and 15% among patients who received rt-PA (p<0.0001), MT (p=0.0095) and rt-PA+MT group (p=0.0004), respectively, compared to those who did not receive treatment. There was no significant change in inpatient mortality between the groups.

Conclusion: The utilization of MT increased but that of rt-PA+MT remained unchanged from 2012 to 2016. Patients with AIS have better LOS and discharge disposition to home when treated with rt-PA+MT than MT alone. Combined treatment of rt-PA with MT may be underutilized in clinical practice.

Common Data Elements for Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Working Group on Hospital Course and Acute Therapies-Proposal of a Multidisciplinary Research Group

INTRODUCTION

The Common Data Elements (CDEs) initiative is a National Institute of Health/National Institute of Neurological Disorders and Stroke (NINDS) effort to standardize naming, definitions, data coding, and data collection for observational studies and clinical trials in major neurological disorders. A working group of experts was established to provide recommendations for Unruptured Aneurysms and Aneurysmal Subarachnoid Hemorrhage (SAH) CDEs.

METHODS

This paper summarizes the recommendations of the Hospital Course and Acute Therapies after SAH working group. Consensus recommendations were developed by assessment of previously published CDEs for traumatic brain injury, stroke, and epilepsy. Unruptured aneurysm- and SAH-specific CDEs were also developed. CDEs were categorized into "core", "supplemental-highly recommended", "supplemental" and "exploratory".

RESULTS

We identified and developed CDEs for Hospital Course and Acute Therapies after SAH, which included: surgical and procedure interventions; rescue therapy for delayed cerebral ischemia (DCI); neurological complications (i.e. DCI; hydrocephalus; rebleeding; seizures); intensive care unit therapies; prior and concomitant medications; electroencephalography; invasive brain monitoring; medical complications (cardiac dysfunction; pulmonary edema); palliative comfort care and end of life issues; discharge status. The CDEs can be found at the NINDS Web site that provides standardized naming, and definitions for each element, and also case report form templates, based on the CDEs.

CONCLUSION

Most of the recommended Hospital Course and Acute Therapies CDEs have been newly developed. Adherence to these recommendations should facilitate data collection and data sharing in SAH research, which could improve the comparison of results across observational studies, clinical trials, and meta-analyses of individual patient data.

High Performance Na-O2 Batteries and Printed Microsupercapacitors Based on Water-Processable, Biomolecule-Assisted Anodic Graphene

Integrated approaches that expedite the production and processing of graphene into useful structures and devices, particularly through simple and environmentally friendly strategies, are highly desirable in the efforts to implement this two-dimensional material in state-of-the-art electrochemical energy storage technologies. Here, we introduce natural nucleotides (e.g., adenosine monophosphate) as bifunctional agents for the electrochemical exfoliation and dispersion of graphene nanosheets in water. Acting both as exfoliating electrolytes and colloidal stabilizers, these biomolecules facilitated access to aqueous graphene bio-inks that could be readily processed into aerogels and inkjet-printed interdigitated patterns. Na-O₂ batteries assembled with the graphene-derived aerogels as the cathode and a glyme-based electrolyte exhibited a full discharge capacity of ∼3.8 mAh cm^-2 at a current density of 0.2 mA cm^-2. Moreover, shallow cycling experiments (0.5 mAh cm^-2) boasted a capacity retention of 94% after 50 cycles, which outperformed the cycle life of prior graphene-based cathodes for this type of battery. The positive effect of the nucleotide-adsorbed nanosheets on the battery performance is discussed and related to the presence of the phosphate group in these biomolecules. Microsupercapacitors made from the interdigitated graphene patterns as the electrodes also displayed a competitive performance, affording areal and volumetric energy densities of 0.03 μWh cm^-2 and 1.2 mWh cm^-3 at power densities of 0.003 mW cm^-2 and 0.1 W cm^-3, respectively. Taken together, by offering a green and straightforward route to different types of functional graphene-based materials, the present results are expected to ease the development of novel energy storage technologies that exploit the attractions of graphene.

Solvent exfoliation stabilizes TiS2 nanosheets against oxidation, facilitating lithium storage applications

Titanium disulfide is a promising material for a range of applications, including lithium-ion battery (LIB) anodes. However, its application potential has been severely hindered by the tendency of exfoliated TiS2 to rapidly oxidize under ambient conditions. Herein, we confirm that, although layered TiS2 powder can be exfoliated by sonication in aqueous surfactant solutions, the resultant nanosheets oxidise almost completely within hours. However, we find that upon performing the exfoliation in the solvent cyclohexyl-pyrrolidone (CHP), the oxidation is almost completely suppressed. TiS2 nanosheets dispersed in CHP and stored at 4 °C in an open atmosphere for 90 days remained up to 95% intact. In addition, CHP-exfoliated nanosheets did not show any evidence of oxidation for at least 30 days after being transformed into dry films even when stored under ambient conditions. This stability, probably a result of a residual CHP coating, allows TiS2 nanosheets to be deployed in applications. To demonstrate this, we prepared lithium ion battery anodes from nano : nano composites of TiS2 nanosheets mixed with carbon nanotubes. These anodes displayed reversible capacities (920 mA h g-1) close to the theoretical value and showed good rate performance and cycling capability.

Percolation Effects in Electrolytically Gated WS2/Graphene Nano:Nano Composites

Mixed networks of conducting and nonconducting nanoparticles show promise in a range of applications where fast charge transport is important. While the dependence of network conductivity on the loading level of conductive additive is well understood, little is known about the loading dependence of mobility and carrier density. This is particularly important as the addition of graphene might lead to increases in the mobility of semiconducting nanosheet network transistors. Here, we use electrolytic gating to investigate the transport properties of spray-coated composite networks of graphene and WS₂ nanosheets. As the graphene loading is increased, we find that both conductivity and carrier density increase in line with the percolation theory with percolation thresholds (∼8 vol %) and exponents (∼2.5) consistent with previous reporting. Perhaps surprisingly, we find the mobility increases modestly from ∼0.1 cm²/V s (for a WS₂ network) to ∼0.3 cm²/V s (for a graphene network) which we attribute to the similarity between WS₂-WS₂ and graphene-graphene junction resistances. In addition, we find both the transistor on- and off-currents to scale with loading according to the percolation theory, changing sharply at the percolation threshold. Through fitting, we show that only the current in the WS₂ network changes significantly upon gating. As a result, the on-off ratio falls sharply at the percolation threshold from ∼10⁴ to ∼2 at higher loading. Reflecting on these results, we conclude that the addition of graphene to a semiconducting network is not a viable strategy to improve transistor performance as it reduces the on:off ratio far more than it improves the mobility.

Abstract WP245: Demographics, Risk Factors and Outcomes of Stroke in Young Adults Aged 18-45 Years in Comparison With Those Older Than 45 Years

Introduction: The prevalence of stroke in young adults have increased with the prevalence of cerebrovascular risk factors in this population. The objective of this study was to compare stroke prevalence in age groups 18-45 years versus more than 45 years by demographics, risk factors, and outcome.

Methods: We analyzed the National Inpatient Sample Database from the Healthcare Cost and Utilization Project for the years 2008-14. Patients with stroke were identified based on discharge DRG codes 61-66 for acute ischemic stroke with use of thrombolytic therapy, intracranial hemorrhage or cerebral infarction. Demographics, risk factors from comorbid condition codes, and outcomes were analyzed.

Results: Out of a total of 3,624,243 adult patients with stroke hospitalized during the years 2008-14, 189103 (5.21%) hospitalizations were of patients aged 18-45 years. The ratio of stroke hospitalizations to overall hospitalizations increased from 154 to 185 per 10,000 hospitalizations from the year 2008 to 2014 with increase in stroke hospitalizations in both age groups. Stroke in young adults aged 18-45 years was more common in men, Blacks and Hispanics compared to those older than 45 years. Cerebrovascular risk factors were common in young adults with stroke and the prevalence of obesity, arterial malformation, tobacco use or alcohol abuse was higher in stroke patients aged 18-45 years compared to those older than 45 years (Table 1). There was up to 6% increase in the prevalence of cerebrovascular risk factors from 2008 to 2014. Young adults with stroke aged 18-45 years were more likely to be discharged home while older adults were more likely to be discharged to skilled nursing facility.

Conclusions: There are gender and racial differences in stroke among adults aged 18-45 years compared to those older than 45 years age. Modifiable cerebrovascular risk factors are common in young adults with stroke. Most notably, both obesity and smoking were particularly higher in younger patients.

Abstract TMP113: Vascular Dementia Amongst Patients Included in the National Inpatient Sample Database 2006-2014 is not on the Decline

Introduction: Vascular dementia is a significant cause of cognitive decline, gait instability, and is associated with stroke risk factors, ischemic and hemorrhagic stroke. The incidence of ischemic stroke has been declining over the past several decades with improved secondary stroke prevention and care systems. Of several stroke risk factors, diabetes and atrial fibrillation have been identified as co-variates associated with rates of vascular dementia in hospitalized patients. We hypothesize that the frequency of secondary diagnosis for vascular dementia will decline over time between 2006 to 2014 and that the rates of vascular dementia diagnosis may vary by region (Northeast, Midwest, South, West).

Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database from 2006-2014 was used to query patients with vascular dementia using ICD-9 codes 290.40, 290.41, 290.43. Two-way ANOVA was used to assess for differences in vascular dementia diagnosis frequency over time. Multivariable logistic regression was performed to test the trend of vascular dementia diagnosis code usage in the database over study years and its interaction with region while, controlling for age, gender, race, and diagnosis of diabetes and atrial fibrillation.

Results: On average, there were 31,123,558 ± 800,912 total admissions per year between 2006-2014. The mean age was 79, 55% female, 31% non-Caucasian. There were no significant differences in patient demographics between the regions. The mean frequency of vascular dementia diagnosis per year nationwide was 0.33% (SD, 0.03), ranging from 0.28% in 2006 to 0.34% in 2014. The frequency of vascular dementia diagnosis did not decrease during the study period. After controlling for race, age, gender, diagnosis of atrial fibrillation, and diabetes, there was no association between frequency of vascular dementia diagnoses and region.

Conclusion: Despite advances in cardiovascular disease risk reduction, the frequency of hospitalizations associated with vascular dementia diagnoses in this database remained unchanged over a nine-year time span. This demonstrates that more research is needed to develop more effective preventative therapies to decrease vascular dementia.