Medium-term outcome of liver recipients from COVID-19 donors

Background

COVID-19 is associated with thrombotic complications and can result in hepatobiliary injury. Excellent early outcomes have been reported in recipients of solid non-lungs organs from SARS-CoV-2-infected donors, however longer follow-up data are lacking. We aimed to describe the medium-term outcome of our liver transplants (LT) from COVID-19 donors.

Methods

From 11/2020 to 03/2022, we consecutively enrolled all patients who received a graft from COVID-19 donor in our Centre. Protocol liver biopsy and magnetic resonance cholangiopancreatography (MRCP) after 1-year from LT were reported.

Results

In the study period 12/213 (5.6%) adult LT patients received a COVID-19 donor (11 active, 1 resolved COVID-19)¹. Eleven patients underwent end-to-end biliary anastomosis and 1 biliodigestive anastomosis. Recipients’ and donors’ characteristics are reported in table 1. Two recipients tested SARS-CoV-2 RNA positive on nasopharyngeal swab at LT and one was treated with sotrovimab on day-1 after LT. None of the patients developed COVID-19 after LT. One patient underwent hepatic artery thrombectomy at day-1 and died after 320 days for HCC recurrence. Until now: -10 patients underwent protocol MRCP (median time from LT 562 days, IQR 245-614), which showed: 7 no visible abnormalities, 1 donor-recipient's bile duct size discrepancy, 2 caliber changes <50% at the anastomotic level (untreated for the absence of cholestasis); -7 patients underwent protocol liver biopsy (median time from LT 553 days, IQR 311-557) which showed 1 acute cellular rejection (RAI 4/9) successfully treated with steroids; no signs of fibrosis, rejection or biliopathy in the other 6 patients.

Conclusions

11/12 patients who received a LT from COVID-19 donors are alive, without evidence of SARS-CoV-2 transmission. At a median follow-up of 1.5 years, protocol liver biopsy and MRCP did not show biliopathy, supporting the utilization of COVID-19 donors to expand the donor pool and reduce the waiting list mortality.

Association of Glucose-6-Phosphate Dehydrogenase Deficiency With Outcomes in US Veterans With COVID-19

Importance

The underlying biological risk factors for severe outcome due to SAR-CoV-2 infection are not well defined.

Objective

To determine the association between glucose-6-phosphate dehydrogenase (G6PD) deficiency and severity of COVID-19.

Design, Setting, and Participants

This retrospective cohort study included analysis of 24 700 veterans with G6PD enzyme testing prior to January 1, 2020, obtained through the US Veterans Health Administration national databases. These veterans were cross-referenced with the Veterans Administration COVID-19 Shared Data Resource for SARS-CoV-2 testing from February 15, 2020, to January 1, 2021. The final study population consisted of 4811 veterans who tested positive for SARS-CoV-2. Statistical analysis was performed from June to December 2021.

Exposures

G6PD deficiency.

Main Outcomes and Measures

COVID-19 severe illness, as defined by the Centers for Disease Control and Prevention: hospitalization, need for mechanical ventilation and/or intensive care unit admission, or in-hospital mortality after a positive SARS-CoV-2 test.

Results

Among 4811 veterans in the Veterans Health Administration who had historical G6PD enzyme activity test results and SARS-CoV-2 positivity included in this study, 3868 (80.4%) were male, 1553 (32.3%) were Black, and 1855 (39%) were White; 1228 (25.5%) were 65 years or older and 3583 (74.5%) were younger than 65 years. There were no significant differences in age, body mass index, or Charlson Comorbidity Index were present between the veterans with G6PD deficiency and without G6PD deficiency. Among these veterans with SARS-CoV-2 infection, G6PD deficiency was more prevalent in Black male veterans (309 of 454 [68.1%]) compared with other racial and ethnic groups. Black male veterans less than 65 years of age with G6PD deficiency had approximately 1.5-fold increased likelihood of developing severe outcomes from SARS-CoV-2 infection compared with Black male veterans without G6PD deficiency (OR, 1.47; 95% CI, 1.03-2.09). In the small subset of White male veterans with G6PD deficiency, we observed an approximately 3.6-fold increased likelihood of developing severe outcomes from SARS-CoV-2 infection compared with White male veterans aged 65 years or older without G6PD deficiency (OR, 3.58; 95% CI, 1.64-7.80). This difference between veterans with and without G6PD deficiency was not observed in younger White male veterans or older Black male veterans, nor in smaller subsets of other male veterans or in female veterans of any age.

Conclusions and Relevance

In this cohort study of COVID-19-positive veterans, Black male veterans less than 65 years of age and White male veterans 65 years of age or older with G6PD deficiency had an increased likelihood of developing severe COVID-19 compared with veterans without G6PD deficiency. These data indicate a need to consider the potential for G6PD deficiency prior to treatment of patients with SARS-CoV-2 infection as part of clinical strategies to mitigate severe outcomes.

Changing Trends in Demographics, Risk Factors, and Clinical Features of Patients With Infective Endocarditis-Related Stroke, 2005-2015

BACKGROUND

There is a rising incidence of infective endocarditis-related stroke (IERS) in the United States attributed to the opioid epidemic. A contemporary epidemiologic description is necessary to understand the impact of the opioid epidemic on clinical characteristics of IERS. We describe and analyze trends in the demographics, risk factors, and clinical features of IERS.

METHODS

This is a retrospective cohort study within a biracial population of 1.3 million in the Greater Cincinnati/Northern Kentucky region. All hospitalized patients with hemorrhagic or ischemic stroke were identified and physician verified from the 2005, 2010, and 2015 calendar years using ICD-9 and -10 codes. IERS was defined as an acute stroke attributed to infective endocarditis meeting modified Duke Criteria for possible or definite endocarditis. Unadjusted comparison of demographics, risk factors, outcome, and clinical characteristics was performed between each study period for IERS and non-IERS. An adjusted model to compare trends used Cochran-Armitage test for categorical variables and a general linear model or a Kruskal-Wallis test for numerical variables. Examination for interaction of endocarditis status in trends was performed using a general linear or logistic model.

RESULTS

A total of 54 patients with IERS and 8204 without IERS were identified during the study periods. Between 2005 and 2015, there was a decline in rates of hypertension (91.7% vs 36.0%; p=0.0005) and increased intravenous drug users (IVDU) (8.3% vs 44.0%; p=0.02) in the IERS cohort. The remainder of the stroke population demonstrated a significant rise in hypertension, diabetes, atrial fibrillation, and peri-operative stroke. Infective endocarditis status significantly interacted with the trend in hypertension prevalence (p=0.001).

CONCLUSION

From 2005 to 2015, infective endocarditis-related stroke was increasingly associated with intravenous drug use and fewer risk factors, specifically hypertension. These trends likely reflect the demographics of the opioid epidemic, which has affected younger patients with fewer comorbidities.Non-standard Abbreviations and Acronyms IERS: infective endocarditis-related stroke; IVDU: intravenous drug users; GCNKSS: Greater Cincinnati Northern Kentucky Stroke Study; NIHSS: National Institute of Health Stroke Scale; tPA: tissue plasminogen activator.

Substance Use and Performance of Toxicology Screens in the Greater Cincinnati Northern Kentucky Stroke Study

BACKGROUND

Though stroke risk factors such as substance use may vary with age, less is known about trends in substance use over time or about performance of toxicology screens in young adults with stroke.

METHODS

Using the Greater Cincinnati Northern Kentucky Stroke Study, a population-based study in a 5-county region comprising 1.3 million people, we reported the frequency of documented substance use (cocaine/marijuana/opiates/other) obtained from electronic medical record review, overall and by race/gender subgroups among physician-adjudicated stroke events (ischemic and hemorrhagic) in adults 20 to 54 years of age. Secondary analyses included heavy alcohol use and cigarette smoking. Data were reported for 5 one-year periods spanning 22 years (1993/1994-2015), and trends over time were tested. For 2015, to evaluate factors associated with performance of toxicology screens, multiple logistic regression was performed.

RESULTS

Overall, 2152 strokes were included: 74.5% were ischemic, mean age was 45.7±7.6, 50.0% were women, and 35.9% were Black. Substance use was documented in 4.4%, 10.4%, 19.2%, 24.0%, and 28.8% of cases in 1993/1994, 1999, 2005, 2010, and 2015, respectively (Ptrend<0.001). Between 1993/1994 and 2015, documented substance use increased in all demographic subgroups. Adjusting for gender, comorbidities, and National Institutes of Health Stroke Scale, predictors of toxicology screens included Black race (adjusted odds ratio, 1.58 [95% CI, 1.02-2.45]), younger age (adjusted odds ratio, 0.70 [95% CI, 0.53-0.91], per 10 years), current smoking (adjusted odds ratio, 1.62 [95% CI, 1.06-2.46]), and treatment at an academic hospital (adjusted odds ratio, 1.80 [95% CI, 1.14-2.84]). After adding chart-reported substance use to the model, only chart-reported substance abuse and age were significant.

CONCLUSIONS

In a population-based study of young adults with stroke, documented substance use increased over time, and documentation of substance use was higher among Black compared with White individuals. Further work is needed to confirm race-based disparities and trends in substance use given the potential for bias in screening and documentation. Findings suggest a need for more standardized toxicology screening.

One-Year Costs Associated With the Veterans Affairs National TeleStroke Program

OBJECTIVES

Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP).

METHODS

We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect.

RESULTS

NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care.

CONCLUSIONS

Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.

Impact of Telestroke Implementation on Emergency Department Transfer Rate

BACKGROUND

and Purpose: Telestroke networks are associated with improved outcomes from acute ischemic stroke(AIS) patient and facilitate greater access to care, particularly in underserved regions. These networks also have the potential to influence patient disposition through avoiding unnecessary interhospital transfers. This study examines the impact of implementation of the VA National Telestroke Program (NTSP) on interhospital transfer among Veterans.

METHODS

We analyzed AIS patients presenting to the emergency department 21 VA hospitals before and after telestroke implementation. Transfer rates were determined through review of administrative data and chart review and patient and facility level characteristics were collected to identify predictors of transfer. Comparisons were made using t-test, Wilcoxon rank sum, and chi-square analysis. Multivariable logistic regression with sensitivity analyses were conducted to assess the influence of telestroke implementation on transfer rates.

RESULTS

We analyzed 3,488 stroke encounters (1,056 pre-NTSP and 2,432 post-NTSP). Following implementation, we observed an absolute 14.4% decrease in transfers across all levels of stroke center designation. Younger age, higher stroke severity, and shorter duration from symptom onset were associated with transfer. At the facility level, hospitals with lower annual stroke volume were more likely to transfer although only one hospital actually saw an increase in transfer rates following implementation. After adjusting for patient and facility characteristics, the implementation of VA NTSP resulted in a nearly 60% reduction in odds of transfer (OR = 0.39, [0.19, 0.77]).

CONCLUSIONS

In addition to improving treatment in acute stroke, telestroke networks have the potential to positively impact the efficiency of interhospital networks through disposition optimization and the avoidance of unnecessary transfers.

Abstract TP220: Clinical And Demographic Characteristics Associated With Poor Posterior Circulation Stroke Outcomes: Greater Cincinnati/Northern Kentucky Stroke Study

Background: Posterior circulation strokes (PCS) make up 20% of all strokes, yet there is poor understanding of what factors contribute to poor clinical outcomes. We investigated clinical and demographic characteristics associated with poor clinical outcomes in PCS using a population-based biracial cohort.

Methods: Greater Cincinnati Northern Kentucky Stroke Study (GSNKSS) 2010 and 2015 data was utilized to identify 1842 patients who were >20 years old with MRI-proven PCS. Eligible patients were then stratified based on functional outcomes (modified Rankin Scale<3 vs >/= 3, with >= 3 considered poor) according to demographics, stroke risk factors, tPA treatment, stroke location, and stroke mechanism. A multivariable logistic model was used to identify the predictors for poor functional outcomes.

Results: Age, higher NIHSS, higher baseline mRS, hypertension, temporal, thalamus, and brainstem location, and cardioembolic mechanism were associated with poor clinical outcomes (Table). After multivariable analysis, age, higher NIHSS, higher baseline mRS, hypertension, temporal, thalamus, and brainstem location, and cardioembolic mechanism remained associated with poor outcomes.

Conclusion: Understanding these factors associated with poor prognosis after posterior circulation stroke will allow for better prognostication and family counseling.

Abstract WMP77: Anticoagulation-Associated Intracerebral Hemorrhage Incidence Rates: A Longitudinal Population-Based Assessment

Background: Anticoagulant-associated intracerebral hemorrhage (AA-ICH) quintupled in the Greater Cincinnati/Northern Kentucky (GC/NK) region from 1988 to 1999 in association with increasing warfarin use. Direct-acting oral anticoagulants (DOACs), available in 2010, have evidence of less bleeding risk, while atrial fibrillation detection rates have increased. We sought to determine if rates of AA-ICH continued to increase in the last decade within a large, bi-racial population.

Methods: We identified all patients, 20 years or older, hospitalized with first-ever intracerebral hemorrhage (ICH) in GC/NK region in 1993/4, 1999, 2005, 2010 and 2015. AA-ICH was defined as ICH in patients prescribed warfarin, heparin or low molecular weight heparin, or a DOAC at the time of their ICH. Incidence rates were age-, sex- and race-adjusted to the 2010 US population. Change over time was tested using regression. All-cause case fatality was adjusted for age, sex and race and trend over time evaluated using a general linear model.

Results: There was no significant change over time in the incidence rate for total ICH or AA-ICH from 1993 through 2015 (Table). As compared to ICH patients without anticoagulant use, patients with AA-ICH were more likely to be older, white, have hypertension, diabetes mellitus, hyperlipidemia, prior ischemic stroke and atrial fibrillation, but less likely to smoke. The age-, sex- and race-adjusted 30-day case fatality for ICH overall and AA-ICH also did not change significantly from 1993/4 to 2015 (Table). Warfarin utilization increased in our ICH population from 1993/4 (7.6%) to 2005 (17.7%), then decreased through 2015 (11.8%/DOAC 6.4%); p<0.0001.

Conclusion: Despite increased incidence rates of AA-ICH in the late 1980s to 1990s, we observed no overall change in incidence or case-fatality rate from AA-ICH over the full 20-year period despite higher rates of atrial fibrillation detection which may be explained by higher rates of DOAC (vs warfarin) use.

Abstract 146: Stroke Misses Are Rare And Elusive In Telestroke Care

Background: Stroke mimic algorithms have been developed for use in telestroke systems of care but less is known about how frequently and what factors are associated with a clinically significant missed telestroke ischemic stroke diagnosis. We sought to examine the frequency and clinical characteristics of missed strokes (MS) in the VA National TeleStroke Program (NTSP)

Methods: We analyzed NTSP consultations from April 2018 to September 2020. Consults with a telestroke diagnosis of “other” (not stroke/TIA) and a primary inpatient discharge diagnosis of ischemic stroke were chart reviewed. We applied the Oxfordshire stroke localization categories to all MRIs positive for acute ischemic stroke. Clinical outcomes were designated as MS-significant (MS-S) if symptoms of stroke persisted at discharge or rehabilitation was required, otherwise they were MS-not significant (MS-NS). Patient demographics, clinical conditions, last known well (LKW) and NIHSS were compared between the MS-S and MS-NS groups using Chi-square and t-tests.

Results: Out of 3,163 consultations, 55 (1.7%) were identified as MS; 33 (60%) of these were MS-S, and 22 (40%) were MS-NS. The overall sample had a mean age of 72 years, mean LKW of 219 minutes prior to arrival, and median NIHSS of 3. Of those with MS, 46 (83.6%) had a brain MRI showing acute stroke; 30% partial anterior, 26% lacunar, 24% posterior. MS-S patients did not differ from MS-NS in age, race, LKW, NIHSS, stroke location or clinical diagnoses (Table). The most common diagnosis among MS was stroke recrudescence (25%).

Conclusions: Clinically significant missed strokes were present in only 1% of more than 3,000 telestroke cases. Demographic and clinical features did not distinguish clinically significant misses from non-significant misses. Posterior circulation strokes represented almost a quarter of all MS. Implementing a rapid brain MRI protocol may be one way to avoid rare misses of acute ischemic stroke diagnosis via telestroke.

Acute Ischemic Stroke, Depressed Left Ventricular Ejection Fraction, and Sinus Rhythm: Prevalence and Practice Patterns

BACKGROUND

There are limited data about the epidemiology and secondary stroke prevention strategies used for patients with depressed left ventricular ejection fraction (LVEF) and sinus rhythm following an acute ischemic stroke (AIS). We sought to describe the prevalence of LVEF ≤40% and sinus rhythm among patients with AIS and antithrombotic treatment practice in a multi-center cohort from 2002 to 2018.

METHODS

This was a multi-center, retrospective cohort study comprised of patients with AIS hospitalized in the Greater Cincinnati Northern Kentucky Stroke Study and 4 academic, hospital-based cohorts in the United States. A 1-stage meta-analysis of proportions was undertaken to calculate a pooled prevalence. Univariate analyses and an adjusted multivariable logistic regression model were performed to identify demographic, clinical, and echocardiographic characteristics associated with being prescribed an anticoagulant upon AIS hospitalization discharge.

RESULTS

Among 14 338 patients with AIS with documented LVEF during the stroke hospitalization, the weighted pooled prevalence of LVEF ≤40% and sinus rhythm was 5.0% (95% CI, 4.1-6.0%; I², 84.4%). Of 524 patients with no cardiac thrombus and no prior indication for anticoagulant who survived postdischarge, 200 (38%) were discharged on anticoagulant, 289 (55%) were discharged on antiplatelet therapy only, and 35 (7%) on neither. There was heterogeneity by site in the proportion discharged with an anticoagulant (22% to 45%, P<0.0001). Cohort site and National Institutes of Health Stroke Severity scale >8 (odds ratio, 2.0 [95% CI, 1.1-3.8]) were significant, independent predictors of being discharged with an anticoagulant in an adjusted analysis.

CONCLUSIONS

Nearly 5% of patients with AIS have a depressed LVEF and are in sinus rhythm. There is significant variation in the clinical practice of antithrombotic therapy prescription by site and stroke severity. Given this clinical equipoise, further study is needed to define optimal antithrombotic treatment regimens for secondary stroke prevention in this patient population.

Durability of Dolutegravir-Based Regimens: A 5-Year Prospective Observational Study

This study evaluates the frequency and causes of dolutegravir (DTG) discontinuation along 5 years of follow-up, in both antiretroviral treatment (ART)-naive and experienced people living with HIV (PLWH). This is a prospective multi-center cohort study enrolling PLWH on DTG from July 2014 until November 2020. DTG-durability was investigated using the Kaplan-Meier survival curve. The Cox proportional-hazards model was used for estimating the hazard ratio (HR) of DTG discontinuation for any cause, and for adverse events (AEs). Nine hundred sixty-three PLWH were included, 25.3% were women and 28.0% were ART-naive. Discontinuations for any causes were 10.1 [95% confidence interval (95% CI) 8.9-11.5] per 100 person-years, similar in most regimens, with the apparent exception of tenofovir alafenamide/emtricitabine+DTG (p < 0.0001). In the multivariable Cox regression model, non-Caucasian ethnicity, age ≥50 years, and lower estimated glomerular filtration rate (eGFR) were associated with a higher probability of DTG interruption. The incidence rate of virological failure was 0.4 (95% CI 0.2-0.7) per 100 person-years, while the estimated discontinuation rate for AEs was 4.0 (3.2-4.9) per 100 person-years. Thirty-four DTG interruptions were due to grade ≥3 events (10 central nervous system, 6 hypersensitivity, 3 renal, 3 myalgia/asthenia, 3 abdominal pain, 2 gastrointestinal, and 7 other events). People with lower body mass index, age ≥50 years, and lower eGFR were at higher risk of AEs, while dual combinations were protective (HR 0.41 compared with abacavir/lamivudine/DTG, 95% CI 0.22-0.77). In this prospective observational study, we found high DTG durability and a low rate of virological failures. Dual therapies seemed protective toward AEs and might be considered, when feasible, a suitable option to minimize drug interactions and improve tolerability.

Evaluation of the effectiveness of three sticky traps to monitor four species of cockroaches (Hexapoda: Blattaria) with simulated use tests

Background

Cockroaches are the pest of major concern for the disinfestation programs of the sanitary system in Italy. Hygienic-sanitary interest is linked to the role of mechanical vectors of pathogens and to their allergological potential. Sticky traps are the best tool to monitor the presence of these insects and several types of them are available on the market. In most of the cases the traps are not indicated for a given species, but, instead, generically for cockroaches. Domestic cockroaches differ in morphology, size and habits. Consequently, the effectiveness of the trap can change in relation to the target species.

Materials and methods

In this study three of the most employed traps in Italy were compared: the INDIA trap with and without its attractant tablet (hereafter mentioned as INDIA-A and INDIA-E, respectively), the ZAPI Simply trap and the CATCHMASTER Spider & Insect Glue trap. We chose the four most common species of cockroach (Blattodea) in Italy, Blatta orientalis (L.), Periplaneta americana (L.) (Blattidae), Blattella germanica (L.) and Supella longipalpa (F.) (Blattellidae). Each species of cockroach was tested separately inside arenas containing one of the traps. Each test (one species with one kind of trap) was replicated five times.

Results and discussion

The INDIA-A trap collected more cockroaches of every species, followed by the INDIA-E. The ZAPI trap caught less specimens of each species in respect to the INDIA traps, with the only exception of B. orientalis, for which the ZAPI trap caught more than the INDIA-E. The CATCHMASTER trap performed significantly less for all the species. B. orientalis was the species most abundantly caught by all traps, followed by B. germanica, S. longipalpa and P. americana. No significant difference was observed in the catch according to the developmental stage. In general, there was no particular predisposition of any trap to catch a particular species.

Conclusions

It is not possible to indicate a model of trap for each species of cockroach, but it is clear that different traps have different performances in terms of attractiveness and capture. Therefore, the choice of the trap affects the results of the monitoring, and as consequence, the evaluation of the infesting population of the pest.

Insects and SARS-CoV-2: Analysis of the Potential Role of Vectors in European Countries

Abstract

SARS-CoV-2 is a coronavirus responsible for the pandemic that developed in China in late 2019. Transmission of the virus is predominantly direct, through exposure to infected respiratory secretions. As far as we know, arthropods play a key role in the transmission and spread of several viruses, and thus their role in the spread of COVID-19 deserves to be studied. The biological transmission of viral agents through insects is very complex. While mechanical transmission is more likely to happen, biological transmission is possible via blood-sucking arthropods, but this requires a high grade of compatibility between the vector and the pathogen. If the biological and mechanical transmission of SARS-CoV-2 by blood-sucking arthropods is excluded, a mechanical transmission by urban pests could take place. This risk is very low but it could be important in isolated environmental conditions, where other means of transmission are not possible. The presence of SARS-CoV-2 in non-blood-sucking arthropods in infected buildings, like hospitals and retirement homes, should be investigated.

Abstract P638: Racial Disparities in Blood Pressure at Time of Acute Ischemic Stroke Emergency Department Presentation Within a Population

Background: Hypertension is an important risk factor in the development of acute ischemic stroke (AIS). African American (AA) race is strongly associated with both hypertension and uncontrolled hypertension despite treatment, yet little is known about racial differences in presenting blood pressure (BP) in AIS. This study sought to describe differences in presenting BP and acute antihypertensive treatment between AA and white AIS patients who received and did not receive alteplase within a population.

Methods: Using the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) database for years 2005, 2010 and 2015, we selected patients with a diagnosis of AIS using ICD-9/10 codes in adults ≥ 18 yrs of age presenting to a local ED within 4.5 hrs of symptom onset. Candidates were stratified by race and alteplase use. Socio-demographics, stroke risk factors, stroke severity, BP on arrival, and acute BP treatment were compared using chi-square, t-tests or Wilcoxon rank sum test, as appropriate.

Results (Table 1): Of 1838 AIS patients included in the analysis, 392 (21%) received IV alteplase. AA patients were younger in both groups who received and did not receive alteplase. On presentation, AA stroke patients had higher diastolic BP. AA patients were more likely to receive 2 or more BP lowering medications compared to white patients in the alteplase treated group and the untreated group.

Conclusion: AA patients presenting within 4.5 hours of AIS symptom onset are more likely to have elevated diastolic BP and to receive multiple BP lowering medications compared to white patients. These findings were significant regardless of alteplase treatment. To our knowledge, we report the first population-based distribution of BP, and medical treatment of BP, upon presentation to an ED in AIS. Further study is needed to determine if these racial differences in elevated BP and refractoriness of BP and/or aggressive treatment contribute to outcome differences.

Abstract P275: Predicting Stroke Mimics in Telestroke Consultations

Background: Telestroke consultation is increasingly used to provide stroke care. Much like in-person stroke consults, stroke mimics are common. This study sought to identify patient and hospital characteristics more likely to be associated with a Telestroke diagnosis of stroke mimic.

Methods: We analyzed 2 years of video consults by the VA National Telestroke Program (NTSP). Stroke mimic was defined as a Telestroke consult coded as a diagnosis of “other.” Text responses for “other” diagnoses were grouped into clinical categories. We used Chi-squared and t-tests analysis to compare characteristics of patients with a stroke mimic diagnosis and those without. Co-variates studied included age, gender, co-morbid conditions (history of dementia, cancer, or alcohol abuse), NIHSS, time of consult (night/weekend vs day), location of consult (emergency department vs inpatient), hospital rurality; hospital consult volume, and duration of institutional participation in NTSP at time of consult. Variables with a p-value < 0.25 in the bivariate analysis were included in the multivariate model.

Results: There were 561 stroke mimics. The most common mimics were toxic metabolic encephalopathy (19%) and seizure (12%). Variables significantly associated with stroke mimic in bivariate analyses were age, gender, history of alcohol abuse, history of atrial fibrillation, history of dementia, NIHSS, nights/weekend consults, and hospital rurality. In multivariate analyses, female sex [OR=1.63, p=0.001], inpatient consultations [OR=1.55, p= 0.019], history of dementia [OR=1.85, p=0.0002], and alcohol abuse [OR=1.42, p=0.002] were associated with a stroke mimic. Consults during nights/weekends [OR=0.76, p=0.001], and patients with atrial fibrillation [OR=0.81, p=0.031], increasing age [OR=0.90, p=0.019], and increasing NIHSS [OR=0.97, p=0.0042] were less likely to be a mimic.

Conclusion: Patient and consult characteristics influenced the likelihood of a stroke mimic diagnosis. Medical history may reflect conditions likely to cause neurologic symptoms, and patients hospitalized who have new symptoms represent a challenging subset to accurately distinguish stroke from mimics. Awareness of these factors may alert providers to diagnoses other than stroke.

Racial Differences in Atrial Cardiopathy Phenotypes in Patients With Ischemic Stroke

OBJECTIVE

To test the hypothesis that thrombogenic atrial cardiopathy may be relevant to stroke-related racial disparities, we compared atrial cardiopathy phenotypes between Black vs White patients with ischemic stroke.

METHODS

We assessed markers of atrial cardiopathy in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of stroke incidence in a population of 1.3 million. We obtained ECGs and reports of echocardiograms performed during evaluation of stroke during the 2010/2015 study periods. Patients with atrial fibrillation (AF) or flutter (AFL) were excluded. Investigators blinded to patients' characteristics measured P-wave terminal force in ECG lead V1 (PTFV1), a marker of left atrial fibrosis and impaired interatrial conduction, and abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and atrial cardiopathy markers after adjustment for demographics, body mass index, and vascular comorbidities.

RESULTS

Among 3,426 ischemic stroke cases in Black or White patients without AF/AFL, 2,391 had a left atrial diameter measurement (mean, 3.65 ± 0.70 cm). Black race was associated with smaller left atrial diameter in unadjusted (β coefficient, -0.11; 95% confidence interval [CI], -0.17 to -0.05) and adjusted (β, -0.15; 95% CI, -0.21 to -0.09) models. PTFV1 measurements were available in 3,209 patients (mean, 3,434 ± 2,525 μV*ms). Black race was associated with greater PTFV1 in unadjusted (β, 1.59; 95% CI, 1.21-1.97) and adjusted (β, 1.45; 95% CI, 1.00-1.80) models.

CONCLUSIONS

We found systematic Black-White racial differences in left atrial structure and pathophysiology in a population-based sample of patients with ischemic stroke.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that atrial cardiopathy phenotypes differ in Black people with acute stroke compared to White people.

Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program

BACKGROUND

As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support.

METHODS

We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction.

RESULTS

Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP.

CONCLUSION

A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.

Provider Communication and Telepresence Enhance Veteran Satisfaction With Telestroke Consultations

BACKGROUND AND PURPOSE

Telestroke has been demonstrated to be a cost-effective means to expand access to care and improve outcomes in stroke; however, information on patient perceptions of this system of care delivery are limited. This study seeks to examine patient feedback of a national telestroke system within the Veterans Health Administration.

METHODS

Patients who received a telestroke consultation were eligible for a phone interview 2 weeks later, including questions about technology quality, telepresence, and telestroke provider communication. Satisfaction scores ranged from 1 to 7 (higher=more satisfied) and for analyses were dichotomized as 6 to 7 indicating high satisfaction versus <6. Patient variables including stroke severity (measured by the National Institutes of Health Stroke Scale) were obtained from study records. Generalized estimating equation models were used to determine what factors were associated with patient satisfaction.

RESULTS

Over 18 months, 186 interviews were completed, and 142 (76%) reported high satisfaction with telestroke. Patients with more severe stroke were less likely to recall the consultation. Factors significantly associated with patient satisfaction were higher ratings of the technology (P<0.0001), telepresence (P<0.0001), provider communication ratings (P<0.0001), and overall Veterans Affairs satisfaction (P=0.02). In the multivariate model, telepresence (odds ratio, 3.10 [95% CI, 1.81-5.31]) and provider ratings (odds ratio, 2.37 [95% CI, 1.20-4.68]) were independently associated with satisfaction. Veterans who were satisfied were more likely to recommend the technology (P<0.0001).

CONCLUSIONS

Provider qualities, including telepresence and provider ratings, were associated with overall Veteran satisfaction with the telestroke consultation. Technology quality may be necessary but not sufficient to impact patient experience. Training providers to improve telepresence could improve patient experience with telestroke consultation.

Cavitation clusters in lipid systems - Ring-up, bubble population, and bifurcated streamer lifetime

The processing of oils is vital to their ultimate use within the food industry. Control over the physical properties of such materials could be achieved through the application of high-intensity ultrasound (HIU). However, the exact mechanism, centred upon acoustic cavitation, is currently unclear. To investigate the cavitation environment in oils further, the ring-up of a HIU source in an oil media is studied in the presence and absence of a pre-existing bubble population. High-speed imaging and acoustic measurements within the system is demonstrated to be extremely useful in characterising the dynamics present under non steady-state conditions. The behaviour of the clusters generated in the first 1000 ms under these conditions is shown to be significantly different depending on the bubble population. A bifurcated streamer (BiS), originating from a unique bi-cluster event, is only observable in the presence of a bubble population during the ring-up process to higher cluster orders. In addition, the lifetime of this BiS event is highly temperature dependent and is shown to be a good marker for the viscosity of the oil employed.

SHadow Under the Lamp (SHUL): Smoking behavior of the health professionals

Background

Smoking cessation is the best option a health professional can offer to the patients for averting the preventable causes of mortality and morbidity.

Purpose

To determine smoking behavior, preferred cessation methods, and attitudes towards smoking cessation amongst health professionals.

Methods

The cross-sectional study, conducted in six countries, included doctors and nurses working at different hospital settings. Participants responded anonymously to an online questionnaire.

Results

Among 1109 participants, 36% were from Saudi Arabia, 14% from Nepal, 14% from Indonesia, 12% from Australia, 12% from Jordan, and 12% from Pakistan. Mean age was 33 years, 61% were females and 58% were nurses. One in eight (12%) was daily smoker. Among current smokers, 42% smoked 2-9 cigarettes/day, and 26% had their first cigarette within 5-30 minutes after waking up. Half of the smokers perceived it as 'very important' to quit smoking, 30% had tried to quit in the last six months, and 31% preferred to have a group quit program with the same health professionals. Only 17% had formal training on smoking cessation, but 57% were interested to receive one. Half of the participants said they (53%) 'always' asked patients if they smoked, but 89% said they advised to quit, 76% said they assessed intention to quit, 28% said they assisted by providing materials on cessation, and 33% said they arranged follow up for cessation. Compared to current smokers, never smokers were more likely to 'always' ask patients if they smoked (78% vs. 22%, p = 0.044, ORs 1.39, 95%CIs 1.01-1.91), assist smokers by setting quit dates (74% vs. 26%, p = 0.039, ORs 1.54, 95%CIs 1.03-2.29), arrange follow up (77% vs. 23%, p = 0.044, ORs 1.40, 95%CIs 1.01-1.94).

Conclusions

Health professionals reported moderately good behavior around advice to smokers, but it is much worse among current smokers. Health professionals who smoke should be both encouraged to quit and to better support their patients to do so.

Key messages

Smoking cessation support for patients was not good among health professionals, who were smokers. Health professionals need to quit smoking in order to provide better cessation support for patients.

Exo-Ocean Exploration with Deep-Sea Sensor and Platform Technologies

One of Saturn's largest moons, Enceladus, possesses a vast extraterrestrial ocean (i.e., exo-ocean) that is increasingly becoming the hotspot of future research initiatives dedicated to the exploration of putative life. Here, a new bio-exploration concept design for Enceladus' exo-ocean is proposed, focusing on the potential presence of organisms across a wide range of sizes (i.e., from uni- to multicellular and animal-like), according to state-of-the-art sensor and robotic platform technologies used in terrestrial deep-sea research. In particular, we focus on combined direct and indirect life-detection capabilities, based on optoacoustic imaging and passive acoustics, as well as molecular approaches. Such biologically oriented sampling can be accompanied by concomitant geochemical and oceanographic measurements to provide data relevant to exo-ocean exploration and understanding. Finally, we describe how this multidisciplinary monitoring approach is currently enabled in terrestrial oceans through cabled (fixed) observatories and their related mobile multiparametric platforms (i.e., Autonomous Underwater and Remotely Operated Vehicles, as well as crawlers, rovers, and biomimetic robots) and how their modified design can be used for exo-ocean exploration.

Temporal Trends in Stroke Incidence Over Time by Sex and Age in the GCNKSS

Background and Purpose- Sex differences in stroke incidence over time were previously reported from the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study). We aimed to determine whether these differences continued through 2015 and whether they were driven by particular age groups. Methods- Within the GCNKSS population of 1.3 million, incident (first ever) strokes among residents ≥20 years of age were ascertained at all local hospitals during 5 periods: July 1993 to June 1994 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100 000 were adjusted for age and race and standardized to the 2010 US Census. Trends over time by sex were compared (overall and age stratified). Sex-specific case fatality rates were also reported. Bonferroni corrections were applied for multiple comparisons. Results- Over the 5 study periods, there were 9733 incident strokes (56.3% women). For women, there were 229 (95% CI, 215-242) per 100 000 incident strokes in 1993/1994 and 174 (95% CI, 163-185) in 2015 (P<0.05), compared with 282 (95% CI, 263-301) in 1993/1994 to 211 (95% CI, 198-225) in 2015 (P<0.05) in men. Incidence rates decreased between the first and last study periods in both sexes for IS but not for intracerebral hemorrhage or subarachnoid hemorrhage. Significant decreases in stroke incidence occurred between the first and last study periods for both sexes in the 65- to 84-year age group and men only in the ≥85-year age group; stroke incidence increased for men only in the 20- to 44-year age group. Conclusions- Overall stroke incidence decreased from the early 1990s to 2015 for both sexes. Future studies should continue close surveillance of sex differences in the 20- to 44-year and ≥85-year age groups, and future stroke prevention strategies should target strokes in the young- and middle-age groups, as well as intracerebral hemorrhage.

Abstract 72: Temporal Trends in Stroke Incidence Over Time by Sex and Age in the Greater Cincinnati Northern Kentucky Stroke Study

Introduction: Data from the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) through 2010 showed that over time, stroke incidence rates decreased to a greater extent in men than in women. We aimed to determine whether this difference continued through 2015 and whether the differences are driven by particular age groups.

Methods: Within the GCNKSS population of 1.3 million, all incident strokes among residents ≥20 years old were ascertained at all local hospitals during 7/93–6/94 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100,000 were adjusted for age and race, standardized to the 2010 U.S. Census. Trends over time by sex were compared (overall and age-stratified); a Bonferroni correction was applied for multiple comparisons.

Results: In total over the five study periods, there were 9721 incident strokes (ischemic, ICH, and SAH); 56.4% were women. Incidence of ischemic strokes decreased from 254 (95%CI 236,272) in 1993/4 to 177 (95%CI 164,189) in 2015 among men (p<.0001 for trend over time) and from 204 (95%CI 192,217) in 1993/4 to 151 (95%CI 141,161) in 2015 among women (p<.0001). Incidence of ICH/ SAH did not change significantly over time in either sex. In age-stratified analyses, among women, incidence of all strokes decreased among older adults (65–84 years) but not in other age categories (Figure). Among men, incidence over time decreased among older adults (65–84 and ≥ 85 years) but increased in young adults (20–44 years).

Conclusions: Stroke incidence decreased between the early 1990s and 2015 for both sexes, contrary to previous data on trends through 2010 which demonstrated a significant decrease in men but not women. Temporal changes are being driven by the 65–84 year age group in both men and women, as well as the ≥ 85 age group in men. Future prevention strategies should target young and middle age adults for both sexes as well as those over 85 for women.

Abstract WMP51: Ischemic Stroke Rates in Those With Diabetes in the Black and White Population: An Update

Background: We previously reported an increased incidence of stroke in the population with diabetes. This was particularly pronounced in those under 65 years of age. With guidelines now including glycemic monitoring during hospitalization, we examined incidence attributable to diabetes in 2010 and 2015.

Methods: Ischemic strokes in the 5-county Greater Cincinnati/Northern Kentucky region were ascertained, then physician verified, at all 15 area hospitals using ICD-9 codes 430 to 436 or ICD10 codes I60 to I68. First ever ischemic strokes in patients aged 20 years and older were included in this analysis. Population age-specific rates of diabetes were estimated using the 2009-2010 and 2015-2016 NHANES databases, then applied to local population numbers, extracted from the US Census Bureau website, to estimate the denominator for calculation of incidence rates. Incidence rates were adjusted by age race and sex, as appropriate, to the 2010 US population. Diabetes was defined as reported in the electronic medical record or glycohemoglobin A1c &gt 6.4% during hospitalization.

Results: There were a total of 4141 ischemic strokes; 55% female and 22% black. Stroke rates continue to be substantially higher in those with diagnosed diabetes, than those without diabetes overall and for those less than 65 years in both time periods, as well as those 65 years and older except for the black population in 2010. Racial disparities continue in both the less than 65 and 65 years and older age groups. Stroke rates were higher for Blacks in the less than 65 year age group for those both with and without diabetes; with risk ratios ranging from 1.3 to 2.7. Of note the stroke rate has decreased between 2010 and 2015 for those with diabetes <65 years of age. (Table)

Conclusions: The population with diabetes continues to be at increased risk of stroke, especially in those less than 65 years of age and those of black race.

Abstract TMP74: Telepresence and Provider Communication Predict Satisfaction With Telestroke

Background: In 2016 the Veterans Health Administration implemented the first nationwide Telestroke program; 800 consults were completed in the first 18 months. Preliminary analysis showed Veterans reported high satisfaction and acceptance of the program. This study sought to understand patient, provider, and hospital-level factors associated with patient satisfaction.

Methods: Patients who received a Telestroke consultation were eligible for a phone interview two weeks later, including standard questions about technology quality, telepresence (how much the encounter felt like face-to-face), Telestroke provider communication, and overall satisfaction. Satisfaction scores ranged from 1-7, (higher = more satisfied), and for analyses were dichotomized as 6-7 indicating high satisfaction vs. < 6. Patient variables including stroke severity (NIH Stroke Scale) were obtained from study records. We used Student’s t-tests and Chi-square tests to compare variables related to patient-reported satisfaction, and used a logistic regression model to determine factors independently associated with high satisfaction.

Results: Over 18 months, 208 interviews were completed and 156 (75%) reported high satisfaction with Telestroke. Patients with more severe stroke were less likely to recall the consultation (p = 0.01). Factors significantly associated with patient satisfaction were higher ratings of the technology (p < 0.0001), telepresence (p < 0.0001), provider communication ratings (p < 0.0001) and overall VA satisfaction (p = 0.01). Among 13 providers with at least 10 consultations, there was no difference in mean patient satisfaction scores. In the multivariate model, telepresence (OR 3.10, 95% CI 1.81-5.31) and provider communication scores (OR 2.37, 95% CI 1.20-4.68) were independently associated with satisfaction.

Conclusion and Potential Impact: Provider qualities, including telepresence and provider ratings, were associated with overall Veteran satisfaction with Telestroke. Technology quality may be necessary but not sufficient to impact patient experience. Training providers to improve telepresence and communication skills could improve patient experience with Telestroke consultation.

Abstract TP221: Cerebellar Infarction Presentations: A Population-Based Study From the Greater Cincinnati/Northern Kentucky Stroke Study

Background: Cerebellar lesions reportedly account for 2-7% of acute infarct visits, but this may be an underestimate since prior studies were not population-based or from the modern imaging era. Cerebellar symptoms are also often nonspecific such that increased MRI use might lead to a higher proportion of stroke due to cerebellar lesions. Details about presenting features of cerebellar infarcts and baseline medication use are also not well known.

Methods: We used the 2010 Greater Cincinnati/Northern Kentucky Stroke Study. Strokes were identified by screening ICD9 codes 430-436 and physician verification. Infarct location was categorized as isolated cerebellar, mixed cerebellar (cerebellar plus ≥1 other location), or non-cerebellar. Isolated dizziness was defined as dizziness/vertigo without other focal symptoms. Atherosclerotic cardiovascular disease (ASCVD) 10-year risk scores were calculated. Descriptive statistics and multivariable logistic regression were used to compare infarct categories.

Results: Isolated cerebellar lesions occurred in 4.6% (90/1940; 95% CI, 3.7%-5.7%) of infarct events. An additional 4% (77/1940; 95%CI, 3.1%-4.9%) were mixed cerebellar infarcts. Mixed cerebellar infarcts had clinical characteristics more similar to non-cerebellar events than to cerebellar events. The multivariable model found an association of isolated cerebellar infarct with low NIHSS (odds ratio [OR] 2.3, 95% CI 1.1-4.8) and any dizziness/vertigo (OR 5.1, 95% CI, 2.4-10.6), but not with isolated dizziness/vertigo, age, or sex. Median ASCVD scores were high in all infarct categories (21, interquartile range [IQR] 9-35 for isolated cerebellar; 32, IQR 15-42 for mixed cerebellar; 31, IQR 16-52 for all others). Both cerebellar and non-cerebellar strokes had a high frequency of baseline antiplatelet or anticoagulant use (52.1% vs 56.2%), whereas baseline statin therapy was less common in isolated cerebellar infarcts (34.1% vs 43.8%).

Conclusions: This population-based study during the modern imaging era found that about 5% of stroke cases have isolated cerebellar infarcts and nearly 9% have any cerebellar infarct. Both cerebellar and non-cerebellar presentations have high baseline vascular risk and antiplatelet/anticoagulant use.

Abstract TP311: Organizational Culture Drives Confidence in Implementing Telestroke Care

Background: In its first 18 months, the VA National Telestroke Program (NTSP) conducted 800 consults at 30 sites. Data from staff at participating sites are collected in anonymous surveys. We aimed to determine factors associated with confidence in providing stroke care at these sites, and whether confidence is associated with performance on NTSP quality indicators.

Methods: Surveys were sent to providers at participating sites at baseline (BL) and 6 - 12 months post-NTSP implementation (post-I). Survey questions included items about confidence providing stroke care and items from the Organizational Readiness to Change Assessment (ORCA). Confidence (0-10) was dichotomized into fully confident (mean score of 10) and not fully confident sites (mean <10). ORCA score was averaged by site. Covariates included site performance, volume, and time in the NTSP. We used a Kruskal Wallis analysis to examine the association of BL variables with post-I confidence, and a Pearson correlation test to examine the association between performance indicators and confidence.

Results: 16 sites, with 54 staff members total responding (57% nurses, 26% providers, 17% administrators/other), had BL and post-I data. Five sites were fully confident at the post-I assessment, the remaining 11 had mean confidence scores 8.32 - 9.5. Site confidence improved over time (mean 7.97 at BL vs. 9.44 post-I, p = 0.004), but confidence was not associated with site performance on any NTSP indicator. Higher ORCA scores were significantly associated with post-I confidence (mean ORCA 4.46 vs. 4.01, p=0.04). Fully confident sites also had shorter NTSP participation times (mean 5.40 months in the fully confident sites vs. 13.45, P=0.01). BL confidence, rurality, and consultation volume were not associated with post-I confidence. Periodic retraining was the most commonly suggested program addition.

Conclusions: Organizational culture, but not performance or consult volume, is significantly associated with staff confidence in providing stroke care via telestroke. The finding that less confident sites have longer participation times suggests that planned retraining should be a part of telestroke programs to help sustain site confidence in providing stroke care.

Genetic Determinants of Cerebral Arterial Adaptation to Flow-loading

BACKGROUND

In animal models, flow-loading is a necessary and sufficient hemodynamic factor to express the Cerebral Aneurysm (CA) phenotype. Using a rat model, this study characterizes the molecular events that comprise the cerebral arterial response to flow-loading and reveals their significance relating to the CA phenotype.

OBJECTIVE

To characterize the molecular events that underlie expansive remodeling of cerebral arteries in two genetically distinct inbred rat strains with differential susceptibility to flow-dependent cerebrovascular pathology.

METHODS

Thirty-two rats underwent bilateral common carotid artery ligation (BCL) (n=16) or Sham Surgery (SS) (n=16). Nineteen days later, vertebrobasilar arteries were harvested, histologically examined and analyzed for mRNA and protein expression. Flow-induced changes in histology, mRNA and protein expression were compared between BCL and SS rats. Differences between aneurysm-prone (Long Evans, LE) and resistant (Brown Norway, BN) strains were evaluated.

RESULTS

Basilar Artery (BA) medial thickness/luminal diameter ratio was significantly reduced in BCL rats, without significant differences between LE (2.02 fold) and BN (1.94 fold) rats. BCL significantly altered BA expression of mRNA and protein but did not affect blood pressure. Eight genes showed similarly large flow-induced expression changes in LE and BN rats. Twenty-six flow responsive genes showed differences in flow-induced expression between LE and BN rats. The Cthrc1, Gsta3, Tgfb3, Ldha, Myo1d, Ermn, PTHrp, Rgs16 and TRCCP genes showed the strongest flow responsive expression, with the largest difference between LE and BN rats.

CONCLUSIONS

Our study reveals specific molecular biological responses involved in flow-induced expansive remodeling of cerebral arteries that may influence differential expression of flowdependent cerebrovascular pathology.

Smoking among female daily smokers in Surabaya, Indonesia

OBJECTIVES

Nationally representative studies suggest 1-2% of Indonesian women (2.3 million) smoke various tobacco products daily; however, in recent years, there has been concern that the tobacco industry has successfully increased female smoking. Our objective was to describe current cigarette smoking behaviors, past quit attempts, and intention to quit of female daily smokers in Surabaya, Indonesia.

STUDY DESIGN

Survey.

METHODS

Female daily smokers (n = 112) in Surabaya, Indonesia, the country's second largest city, were recruited to participate in a survey during 2018. Convenience sampling was utilized in two malls. Potential participants were intercepted in or near designated smoking areas and invited to the nearby data collection site. Survey items from Global Adult Tobacco Survey and the International Tobacco Control Policy Evaluation Project were utilized.

RESULTS

Participants self-reported smoking 13.8 cigarettes per day (7.3 white machine-rolled cigarettes per day, 4.2 kreteks per day, and 2.4 roll-your-own cigarettes per day). Over 75% smoked their first cigarette within 30 min of waking. Over 53% had a heaviness of smoking index score suggesting moderate or high addiction. Approximately half (51%) did not attempt to quit smoking in the previous 12 months, and 55% planned to quit beyond 6 months or not at all.

CONCLUSIONS

Our sample smoked five to six more cigarettes per day than female daily smokers in previous national surveys. Relative to previous studies, our data suggest an unexpected preference for white machine-rolled cigarettes and that there could be, at a minimum, pockets of increased smoking and addiction among female daily smokers in Indonesia.

Stroke Center Certification Is Associated With Improved Guideline Concordance

Measurement of quality of stroke care has become increasingly important, but data come mostly from programs in hospitals that choose to participate in certification programs, which may not be representative of the care provided in nonparticipating hospitals. The authors sought to determine differences in quality of care metric concordance for acute ischemic stroke among hospitals designated as a primary stroke center, comprehensive stroke center, and non-stroke center in a population-based epidemiologic study. Significant differences were found in both patient demographics and in concordance with guideline-based quality metrics. These differences may help inform quality improvement efforts across hospitals involved in certification as well as those that are not.

Abstract WP265: Racial Differences in Left Atrial Size Among Patients With Ischemic Stroke

Introduction: Blacks in the U.S. face twice the risk of ischemic stroke as whites, and this disparity is not fully explained by established stroke risk factors. Although atrial fibrillation (AF) is a major risk factor for stroke, blacks are less often diagnosed with AF than whites. It is unclear whether this paradox exists because AF is less thoroughly ascertained in blacks compared to whites or because blacks have less predisposing substrate and thus a truly lower risk of AF.

Hypothesis: Based on our prior work, we hypothesized that black patients with ischemic stroke less often have left atrial enlargement, a major predisposing factor for AF.

Methods: We compared left atrial size in black versus white patients in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of racial disparities in stroke incidence in a nationally representative population of 1.3 million. We obtained reports of echocardiograms performed for stroke evaluation among patients in the 2010 and 2015 study periods. Patients with known AF or atrial flutter were excluded. Investigators blinded to patients’ characteristics abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and left atrial diameter after adjustment for demographics, body mass index, and comorbidities.

Results: Among 2,980 cases of ischemic stroke without AF, the median age was 66 years, 52% were female, and 30% were black. The overall mean left atrial diameter was 3.65 (±0.69) cm. Despite a higher burden of vascular risk factors and comorbidities, blacks had significantly smaller left atrial diameters (mean difference, -0.10 cm; 95% CI, -0.04 to -0.17 cm). This difference persisted after adjustment for demographics, comorbidities, and body mass index (adjusted mean difference, -0.15 cm; 95% CI, -0.09 to -0.21 cm).

Conclusions: In a population-based sample, we found that black patients with ischemic stroke had smaller left atrial size than white patients. Our results suggest that the paradox of greater stroke risk but lower AF risk in blacks compared with whites at least partly stems from a lesser degree of AF substrate in blacks.

Abstract WMP54: Updated Population Trends in Substance Abuse Preceding Stroke in Young Adults: 1993/1994 to 2015

Objective: To update trends on documented substance abuse among young adults (18-54 years old) with stroke within the Greater Cincinnati/Northern Kentucky Stroke Study population, to include preliminary results from 2015.

Background: Substance abuse is associated with stroke. In our population, we previously reported increases in overall substance abuse, smoking history, and use of alcohol or drugs <24 hours prior to stroke onset. We also found increased illicit drug use in the 35 to 54 age group from 1993/94 through 2010. We now report trends after adding 2015 preliminary results.

>Design/Methods: Using ICD-9 discharge codes 430-436, potential acute stroke events are identified among 18- to 55-year-old residents of the 5 county study region. Five one-year study periods are included (7/93-6/94, 1999, 2005, 2010, 2015). Study nurses abstract all events which then undergo physician review. We searched for trends in smoking history, illicit drug use, heavy alcohol consumption, overall substance abuse (current smoking, alcohol, and illicit drug), and urine/blood test positive for alcohol or illicit drugs at presentation.

Results: There were 2220 stroke events (75 % ischemic). Sex and age distribution remained stable; however, percent black increased from 35% to 46% between 1993/94 and 2015, as did the proportion of ischemic strokes (74% to 77%). Current smoking and alcohol use remained stable while illicit drug use increased significantly overall and within the age subgroups of 18-34 years and 35-54 years (see table).

Conclusions: Illicit drug use continues to increase among young adults with stroke. Even though the possibility of testing bias needs to be explored further, our reported results are likely an under estimation of true rates as there are no readily available tests for new designer drugs which have become more available since the early 2000’s. Future analysis will also focus on the relationship between our findings and the U.S. opioid epidemic.

Abstract TP384: Effective Communication and Engagement Cultivates Teamwork Among Virtual Telestroke Providers

Background: In most hub-and-spoke telestroke systems, geographically co-located hub stroke specialists support regional spoke sites. In the VA’s National Telestroke Program (NTSP), a virtual hub of stroke specialists located around the country provides 24/7 consults nationwide. We examined how stroke specialists adapted to virtual teamwork, and identified factors important in developing and sustaining a high-functioning virtual team.

Methods: Semi-structured, confidential interviews with hub stroke specialists were audiotaped and transcribed. Probes were used to explore the extent to which providers had developed a sense of a teamness or a community of practice, and what factors helped or hindered this development. Core elements of a high-functioning team were defined using Mitchell's taxonomy, developed as part of the IOM's Best Practices Innovation Collaborative. Each interview transcript was independently coded by two investigators using NVivo11. The constant comparative method and matrix displays were used to identify themes, with special attention to themes about team, communication, trust, and satisfaction.

Results: Of 13 hub providers with > 8 months NTSP participation, 12 were interviewed; 7 had prior telestroke experience. Participants reported high levels of trust and sense of teamwork with their virtual colleagues, sometimes even more than with local colleagues. Factors facilitating perceived teamness included communicating via a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and leadership support. Lack of in-person contact decreased perceived teamness, but having an in-person NTSP meeting helped mitigate this issue. Despite technical challenges, providers reported high levels of satisfaction with the NTSP.

Conclusions: Practicing as a virtual Telestroke hub provider can provide an equal or greater sense of trust and sense of teamwork with colleagues compared with traditional practice. Engaging in transparent discussion of challenging cases and contributing to program improvements may be key to promoting high-functioning virtual teams. Ongoing surveys will assess providers’ satisfaction with program outcomes over time.

Abstract TMP63: Patient Perceptions of Remotely Delivered Acute Stroke Care

Introduction: Telestroke has been demonstrated to be a cost-effective means to expand access to care and improve outcomes in stroke. However, information on patient perceptions of this system of care delivery are limited. This study seeks to examine patient feedback of a national telestroke system within the Veterans Health Administration.

Methods: All Veterans receiving a telestroke consultation with a video component were considered for telephone interview 2 weeks post-consult. Those who died within 30 days, who were placed on palliative care/hospice, or who were still hospitalized 30 days after the consult were excluded. If the Veteran could not recall the teleconsult, another person present who could recall it could complete a proxy interview. The interview included 18 standardized questions about technical quality, experience with the telestroke provider, telepresence (the extent to which the consult felt like a face-to-face visit), and overall satisfaction. Open-ended responses were also recorded.

Results: Over a 9-month period, 174 telestroke consults were completed. Of these, we obtained patient responses from 72 (41%) veterans (56 had a final diagnosis of stroke). Twenty-one responses were completed by a proxy. Veterans reported high levels of satisfaction with technical quality (Figure 1A). While patients felt comfortable with interacting with the telestroke provider, we did identify opportunities for improvement with patient involvement in decision making and communication of treatment recommendations (Figure 1B). Overall, veterans indicated high levels of satisfaction with the telestroke providers and service platform (Figure 1C). Importantly, 91% of respondents indicated that this service allowed them to receive the care that they needed.

Conclusions: Overall, Veterans report high levels of satisfaction with the technology, expertise, professionalism, and service with a telestroke platform.

Abstract TMP58: Preliminary Population-Based Temporal Trends in Stroke Incidence: Racial Disparity and Stroke Incidence From 1993-2015

Introduction: We previously reported that the incidence of stroke was decreasing for whites but stable for blacks from 1993/94 to 2005. We sought to describe recent temporal trends and racial disparities in stroke incidence within our large, bi-racial population, by including 2010 and preliminary data from 2015.

Methods: The Greater Cincinnati/Northern Kentucky region includes two southern Ohio and three Northern Kentucky counties on the Ohio River, a population of 1.3 million representative of the US population in terms of sociodemographics and percent black race. Our study ascertained all hospitalized strokes that occurred in the population between 7/1/93 and 6/30/94 and in calendar years 1999, 2005, 2010 and 2015. For 2015, nursing review of medical records is complete but physician review is not; thus 2015 rates are preliminary. The denominator for the calculation of incidence rates (in those aged ≥20 years) was estimated from the U.S. Census Bureau website (www.census.gov). The 95% confidence intervals (CI) for the incidence rates were calculated assuming a Poisson distribution. Rates are age, sex, and race adjusted, as appropriate, and standardized to the 2010 U.S. population.

Results: First-ever stroke incidence rates stratified by subtype, race, and study period are presented in the Table. We project that stroke incidence did not significantly change in 2015 vs. 2010 for either blacks or whites, regardless of stroke subtype. Blacks have a substantially higher incidence of stroke compared with whites in all study periods, without significant change in disparity over time.

Discussion: In contrast to the significant decline in stroke incidence among whites from 1993-94 to 2005, we did not observe a statistically significant decrease in 2010 and 2015. This may be due to true stabilization of rates over time, or less statistical power to detect smaller declines. The substantial black/white racial disparity in stroke incidence has not changed over time.

Abstract 11: Stroke in the Young: Preliminary Results for Temporal Trends in the Age of Stroke Incidence in a Large, Bi-Racial Population

Introduction: Previously, we reported that stroke incidence in the young (age < 55) significantly increased in both blacks and whites over four study periods between 1993 and 2010. Here we further describe this temporal trend, adding data from 2015.

Methods: The Greater Cincinnati/Northern Kentucky region includes 2 southern Ohio and 3 contiguous Northern Kentucky counties (estimated population, 1.3 M). Our study determined first-ever hospital-ascertained strokes that occurred in the population from 7/1/93 to 6/30/94 and in calendar years 1999, 2005, 2010, and 2015 by screening ICD9 (and ICD10, in 2015) codes of all inpatient and emergency department visits. Cases were abstracted by study nurses and verified by study physicians. Results for 2015 are preliminary. The denominator for the calculation of incidence rates (in those aged ≥20 years) was extracted from the U.S. Census Bureau website (www.census.gov). Age- and race -specific incidence rates with 95% confidence intervals (CI) were calculated assuming a Poisson distribution. We tested for differences in age trends using Student’s t-test, X 2 , and Poisson regression as appropriate.

Results: The mean± SD age of stroke was 71.3±13.6 in 1993-94, 70.9±14.4 in 1999, 68.4±15.5 in 2005, 68.5±15.6 in 2010, and 68.7±15.4 in 2015 (p<0.0001 for trend). The proportion of all strokes under age 55 went from 12% to 15% to 20% to 22%, then 18% in 1993-94, 1999, 2005, 2010, and 2015, respectively. Poisson regression showed a shift toward younger strokes across the five periods studied (p<0.0001). Age-specific stroke incidence rates by study period are presented in the Table.

Discussion: The disturbing trend of increasing stroke in the young (age < 55) has leveled off slightly since 2010 but is still of great public health significance as younger strokes carry the potential for greater lifetime burden of disability. Further study is needed to determine the reasons for these results, including examination of race-specific trends.

Abstract WP371: Effects of VA National Telestroke Program Implementation Training

Background: In July 2017, the VA initiated implementation “Go-Live” Training to support the VA National TeleStroke Program (NTSP). NTSP Go-Live Training incorporates systems redesign methods with iterative interprofessional whole-hospital medical simulations.

Methods: A qualitative questionnaire with 4 open-ended questions was developed based on Kirkpatrick’s learning hierarchy. Participants’ responses were analyzed using direct content analysis to identify themes related to “reaction & satisfaction” with the training and “knowledge or skills acquired”. To determine learning transfer to practice, process measures (telestroke activation time and door-to-needle time) were collected in “live” facilities.

Results: A total of 12 VA facilities participated in NTSP Go-Live trainings and 8 were live by 3/31/18. Of the 296 employees who participated in Go-Live training, 178 (60%) completed the questionnaire. Participants identified “process mapping”, “simulations” and “debrief sessions” as the most valuable aspect of the training. Three themes emerged based on participants’ reactions: 1) reinforced “time-is-brain”, 2) telestroke provides “opportunity to help veterans” and 3) the “hands-on experience tied it all together”. Participants’ indicated that the training “created confidence”, “instilled motivation” and stimulated “recognized value” for the NTSP. Participants indicated acquiring new knowledge and skill in how to “trouble-shoot the telestroke process”, “communicate while using tele-technology” and that “teamwork is key”. In the first 2 quarters, 93 telestroke consults were completed and 92% of all eligible patients (N=12) received thrombolytic therapy. The percent of patients with a telestroke consult initiated within 10 minutes of arrival increased from 13.5% in Quarter 1 to 31.6 % in Quarter 2, with median door to activation decreasing from 32 to 19 minutes. Median door to needle times also decreased, from 72 to 62 minutes.

Conclusions: The VA’s NTSP Go-Live Training is a novel approach for implementation of telestroke care in facilities without experience administering alteplase. Moreover, the training improves provider skills/confidence as well as improving quality of acute stroke care.

Prehospital neurological deterioration in stroke

BACKGROUND AND PURPOSE

Patients with stroke can experience neurological deterioration in the prehospital setting. We evaluated patients with stroke to determine factors associated with prehospital neurological deterioration (PND).

METHODS

Among the Greater Cincinnati/Northern Kentucky region (population ~1.3 million), we screened all 15 local hospitals' admissions from 2010 for acute stroke and included patients aged ≥20. The GCS was compared between emergency medical services (EMS) arrival and hospital arrival, with decrease ≥2 points considered PND. Data obtained retrospectively included demographics, medical history and medication use, stroke subtype (eg, ischaemic stroke (IS), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH)) and IS subtype (eg, small vessel, large vessel, cardioembolic), seizure at onset, time intervals between symptom onset, EMS arrival and hospital arrival, EMS level of training, and blood pressure and serum glucose on EMS arrival.

RESULTS

Of 2708 total patients who had a stroke, 1092 patients (median (IQR) age 74 (61-83) years; 56% women; 21% black) were analysed. PND occurred in 129 cases (12%), including 9% of IS, 24% of ICH and 16% of SAH. In multivariable analysis, black race, atrial fibrillation, haemorrhagic subtype and ALS level of transport were associated with PND.

CONCLUSION

Haemorrhage and atrial fibrillation is associated with PND in stroke, and further investigation is needed to establish whether PND can be predicted. Further studies are also needed to assess whether preferential transport of patients with deterioration to hospitals equipped with higher levels of care is beneficial, identify why race is associated with deterioration and to test therapies targeting PND.