Abstract WP32: Addressing Disparate Clinical Stroke Resources With A Telestroke Taskforce

Introduction: Telestroke can enhance the timeliness and overall quality of stroke care for rural populations geographically separated from higher level stroke centers. To help hospitals utilize this resource, the Wisconsin (WI) Coverdell Stroke Program (Coverdell) and American Heart Association® (AHA) partnered with 15 hospital systems for a Telestroke Taskforce (TF) which met monthly June 2021-February 2022.

Methods: A TF Charter and Framework guided the work. Framework items included: decision to call, telestroke consult, treatment and transfer decision, feedback, and patent satisfaction. Challenges, successes, WI consensus criteria, WI document development, Get With The Guidelines® (GWTG), resource needs and availability were addressed for these items. A manual and two videos were developed. The first video is a four clinician panel across four hospital systems sharing perspectives on telestroke implementation. Second, a demonstration video of conducting the National Institutes of Health Stroke Scale (NIHSS) via telestroke was produced to assist those unfamiliar with the process. The WI Telestroke Toolkit, which includes the charter, framework and established resources, will be published to the Coverdell website in Fall 2022.

Results: Five measures were assessed quarterly Q1 2021-Q1 2022 among WI hospitals entering into GWTG® • Proportion of stroke patients w/ telestroke consult - 16.9ppt increase • Thrombolytic administration rate - 0.2ppt increase • Mechanical endovascular rate - 0.6ppt increase • Median time to consult - 2 minute reduction • Door-in-door-out times - 1 minute reduction

Conclusions: Measure improvement, given the timeframe, is likely due to an increased focus on telestroke associated with the TF. As the Toolkit is shared and utilized by hospitals, we are hopeful for continued improvement. The Toolkit will be updated annually. Future considerations are to formally evaluate TS recipient satisfaction.

Abstract WMP24: Developing Interactive Maps To Visualize Wisconsin’S Regional Stroke Systems Of Care

Background and Purpose: Many rural patients experiencing complex strokes are transferred from small hospitals with limited stroke-specific resources (spoke) to larger hospitals (hub). The Wisconsin (WI) Coverdell Stroke Program (Coverdell) utilized the Get with the Guidelines®-Stroke registry to determine the frequency of this spoke-to-hub transfer occurrence in WI in 2020, which was found to be 24.6%. This suggested a need for interactive maps to visualize stroke systems of care (SSoC) linkages between hubs and spoke hospitals across Wisconsin.

Methods: In 2021, Coverdell partnered with eight Stroke Coordinators across five WI public health regions. Stroke Coordinators identified hospital transfer connections in their region where transfers occurred 25% or more of the time. With this data, Coverdell developed maps to visualize transfer lines between hospitals with estimated driving distances and transport times via ambulance. User testing, promotion, and publishing to the WI Department of Health Services Chronic Disease website was completed in April 2022.

Findings: As of July 1, 2022, our maps have had 389 page views and 272 unique page views. These counts exclude DHS Internet Protocol traffic. Our interactive maps visualize transfers across WI and allow users to select individual hospitals to investigate relationships. We discovered a paucity of certified hospitals and stroke transfers in rural and northern WI.

Conclusion: These maps can assist hospitals and Emergency Medical Service providers to visually identify where stroke patients are transported to. In addition, they can help state stroke programs and partners to recognize gaps in SSoC. The maps are a resource for those working with high-risk stroke populations to understand resources available in their communities and wider geographic areas. They also provide a visual representation for policy makers of locations where stroke services may be inadequate.

Abstract WP39: Improving Hospitals Documentation Of Time Last Known Well

Background and Purpose: Correctly identifying a patient’s time of last known well (LKW) is critical for determining eligibility for time-sensitive acute ischemic stroke thrombolytic treatments. Accurately abstracting LKW can be very difficult, given complexities in documentation and coding instructions. The Wisconsin Coverdell Stroke Program (Coverdell) monitors data quality through quarterly re-abstraction of five patient records from participating hospitals to assess agreement between initial and re-abstracted records. The concordance of LKW for Q4 2018-Q4 2019 was 74%-83%. This necessitated a Coverdell performance improvement project of hospitals’ LKW documentation. The project goal was set at 85% to be achieved by Q1 2021.

Methods: Coverdell hospitals quarterly meet as a collaborative. In March and June of 2020 best practices of high performing hospitals in LKW concordance were shared with a consensus on best practices: communication between providers when documenting LKW, developing a source of truth in the EHR where LKW is documented and resourced, and providing feedback to providers when mismatches occur. These practices and scenarios were included in a document published to the Coverdell website in October 2020, Abstracting an Accurate Last Known Well. A second document was created, S teps to take for Accurate Documentation of Last Known Well which graphically summarizes in a flow chart the actions an abstractor or stroke coordinator can take when LKW documentation needs improvement. It was published May 2021. The collaborative continues to review de-identified cases where LKW was not easily recognized.

Findings: Q1 2021 concordance for LKW was 79%. This falls short of the originally established project goal.

Conclusion: During this PI project there was a 20% turnover rate in abstractors and re-abstractors which may have contributed to the results. The goal of 85% concordance will remain an active benchmark. We are hopeful future radiographic technology will assist stroke teams in identification of LKW, and modifications of coding instructions in the data registry will occur. Many hospitals find variances in LKW documentation between providers which could potentially lead to false ineligibility for receipt of thrombolytic therapy.

Bullying Victimization Type and Feeling Unsafe in Middle School

Given their significance to school violence, this study quantifies the association between bullying victimization and perceptions of safety separately for victimization where the type is not specified versus victimization that is physical in nature. Generalized liner mixed modeling was employed with 5,138 sixth- to eighth-grade students in 24 schools who self-reported on their bullying victimization and perceptions of school safety on an anonymous survey in fall 2015. Results indicate a multiplicative interaction exists with regard to the odds of feeling unsafe at school among those who were bullied at all (odds ratio [ OR] = 3.1) compared to those who were bullied physically ( OR = 9.12). For school nurses who work with students with a variety of concerns and health issues, this research indicates that the use of bullying victimization as an outcome, proxy and/or predictor, requires inquiry into the type of bullying experienced to aid in the care and support received.

Disparities in Fitness and Physical Activity Among Children

BACKGROUND

Adequate physical activity and cardiorespiratory fitness aid in the prevention of type 2 diabetes mellitus and obesity. Large sociodemographic/economic disparities exist for these conditions, which develop over time beginning in childhood. This paper examines disparities in both activity and fitness levels among children and adolescents in Wisconsin.

METHODS

The Wisconsin Partnership for Childhood Fitness collected cardiorespiratory fitness and physical activity data on 3,798 6th grade students in 37 schools in fall 2011. Fitness data were collected via testing in physical education classes. Activity data were collected via self-report, 1-day activity logs administered during school. Using hierarchical linear models, disparities in fitness and physical activity by race/ethnicity and school-level characteristics were investigated.

RESULTS

Widespread race and ethnic disparities exist in aerobic fitness, as well as more limited disparities in physical activity levels. In addition, students from schools with higher overall socioeconomic status (SES) were more active and had higher fitness levels than those from schools with overall lower SES levels.

CONCLUSIONS

Among Wisconsin adolescents, race/ethnicity and school-level SES contribute to significant differences in both fitness and physical activity levels. Modifiable elements of the school environment to increase physical activity, and potentially fitness, may provide opportunities to reduce health disparities among children, contributing to improved long-term health outcomes among Wisconsin adults.

Fetal alcohol syndrome surveillance: age of syndrome manifestation in case ascertainment

BACKGROUND

Fetal alcohol syndrome (FAS) is a leading cause of developmental disability (Abel & Sokol, ). Active public health surveillance through medical record abstraction has been used to estimate FAS prevalence rates, typically based on birth cohorts. There is an extended time for FAS characteristics to become apparent in infants and young children, and there are often delays in syndrome recognition and documentation. This methodological study analyzes the age at case ascertainment in a large surveillance program.

METHODS

The Fetal Alcohol Syndrome Surveillance (FASSLink) Project, funded by the Centers for Disease Control and Prevention, sought to estimate FAS prevalence rates in eight U.S. states. FASSLink used linked abstractions from multiple health care records of suspected cases of FAS. The present study analyzed data from this effort to determine the child's age in months at confirming abstraction.

RESULTS

The average age at abstraction for confirmed/probable FAS cases (n = 422) was 48.3 (±19.5) months with a range of 0 to 94 months. Age of ascertainment varied by state and decreased with each birth year; the number of cases ascertained also decreased in a steep stepwise gradient over the 6 birth years in the study.

CONCLUSION

FAS surveillance efforts should screen records of children who are much older than is typical in birth defects surveillance. To best establish rates of FAS using medical records abstraction, surveillance efforts should focus on 1-year birth cohorts followed for a fixed number of years or, if using multi-year cohorts, should implement staggered end dates allowing all births to be followed for up to 8 years of age.

Minus end-directed kinesin-like motor protein, Kcbp, localizes to anaphase spindle poles in Haemanthus endosperm

Microtubule-based motor proteins assemble and reorganize acentrosomal mitotic and meiotic spindles in animal cells. The functions of motor proteins in acentrosomal plant spindles are unknown. The cellulosic cell wall and relative small size of most plant cells precludes accurate detection of the spatial distribution of motors in mitosis. Large cell size and absence of a cellulosic cell wall in Haemanthus endosperm make these cells ideally suited for studies of the spatial distribution of motor proteins during cell division. Immunolocalization of a kinesin-like calmodulin-binding protein (KCBP) in Haemanthus endosperm revealed its mitotic distribution. KCBP appears first in association with the prophase spindle. Highly concentrated within the cores of individual kinetochore fibers, KCBP decorates microtubules of kinetochore-fibers through metaphase. By mid-anaphase (when a barrel-shaped spindle becomes convergent), the protein redistributes and accumulates at the spindle polar regions. In telophase, KCBP relocates toward the phragmoplast and cell plate. These data suggest a role for KCBP in anaphase spindle microtubule convergence, which assures coherence of kinetochore-fibers within each sister chromosome group. Increasing coherence of kinetochore-fibers prevents splitting within each sister chromosome group and formation of multinucleated cells.

Expertise in Caring: A Source of Power

1. Caring generates power in relationships with patients and helps them to evolve. 2. Caring is more than an emotional response. It is acting in ways that demonstrate that people, relationships, and issues are important. 3. Continuity of care providers across settings help yield positive outcomes for patients.

Quantitative contribution of NHE2 and NHE3 to rabbit ileal brush-border Na+/H+ exchange

Intestinal neutral NaCl absorption, which is made up of brush-border (BB) Na+/H+ exchange linked to BB Cl-/HCO3- exchange, is up- and downregulated as part of digestion and diarrheal diseases. Glucocorticoids stimulate ileal NaCl absorption and BB Na+/H+ exchange. Intestinal BB contains two Na+/H+ exchanger isoforms, NHE2 and NHE3, but their relative roles in rabbit ileal BB Na+/H+ exchange has not been determined. A technique to separate the contribution of NHE2 and NHE3 to ileal BB Na+/H+ exchange activity was standardized by using an amiloride-related compound, HOE-694. Under basal conditions, both NHE2 and NHE3 contribute approximately 50% to ileal Na+/H+ exchange. Glucocorticoids (methylprednisolone) increase BB Na+/H+ exchange (2.5 times) but increase only ileal NHE3 activity (4.1 times), without an effect on NHE2 activity. Thus ileal BB Na+/H+ exchange in animals treated with glucocorticoids is 69% via NHE3. A quantitative Western analysis for NHE3 was developed, using as an internal standard a fusion protein of the COOH-terminal 85 amino acids of NHE3 and maltose binding protein. Glucocorticoid treatment increased the amount of BB NHE3. The quantitative Western analysis showed that NHE3 makes up 0.018% of ileal BB protein in control rabbits and 0.042% (2.3 times as much) in methylprednisolone-treated rabbits. Methylprednisolone treatment did not alter the amount of ileal BB NHE2 protein. NHE3 turnover number was estimated to be 458 cycles/s under basal conditions and 708 cycles/s in glucocorticoid-treated ileum. Thus methylprednisolone stimulates ileal BB Na+/H+ exchange activity only by an effect on NHE3 and not on NHE2; it does so primarily by increasing the amount of BB NHE3, although it also increases the NHE3 turnover number.

Localization of a kinesin-like calmodulin-binding protein in dividing cells of Arabidopsis and tobacco

The cloning and characterization of a novel kinesin-like protein (kinesin-like calmodulin-binding protein, KCBP) from Arabidopsis and other plants has recently been described. Unlike all other known kinesin-like proteins, KCBP interacts with calmodulin in the presence of micromolar calcium. An antibody specific to KCBP was raised using a calmodulin-binding synthetic peptide that is unique to KCBP. The KCBP antibody detected a single protein of about 140 kDa in Arabidopsis and tobacco, the size predicted from cDNA sequences. In synchronized cell cultures, the amount of KCBP was abundant during M-phase and very low in interphase. To get some insight into the function of this novel motor protein, KCBP in Arabidopsis and tobacco cells was localized by indirect immunofluorescence microscopy using affinity-purified anti-KCBP antibody. The KCBP was localized to the preprophase band, the mitotic spindle and the phragmoplast. The association of KCBP with microtubule arrays in dividing cells suggests that this minus-end-directed microtubule motor protein is likely to be involved in the formation of these microtubule arrays and/or functions associated with these structures.