Kanamycin treatment in the pre-symptomatic stage of a Drosophila PD model prevents the onset of non-motor alterations

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor alterations, which is preceded by a prodromal stage where non-motor symptoms are observed. Over recent years, it has become evident that this disorder involves other organs that communicate with the brain like the gut. Importantly, the microbial community that lives in the gut plays a key role in this communication, the so-called microbiota-gut-brain axis. Alterations in this axis have been associated to several disorders including PD. Here we proposed that the gut microbiota is different in the presymptomatic stage of a Drosophila model for PD, the Pink1^B9 mutant fly, as compared to that observed in control animals. Our results show this is the case: there is basal dysbiosis in mutant animals evidenced by substantial difference in the composition of midgut microbiota in 8-9 days old Pink1^B9 mutant flies as compared with control animals. Further, we fed young adult control and mutant flies kanamycin and analyzed motor and non-motor behavioral parameters in these animals. Data show that kanamycin treatment induces the recovery of some of the non-motor parameters altered in the pre-motor stage of the PD fly model, while there is no substantial change in locomotor parameters recorded at this stage. On the other hand, our results show that feeding young animals the antibiotic, results in a long-lasting improvement of locomotion in control flies. Our data support that manipulations of gut microbiota in young animals could have beneficial effects on PD progression and age-dependent motor impairments.

Barriers and facilitators of weight bearing after hip fracture surgery among older adults. A scoping review

PURPOSE

This scoping review aimed to synthesise the available evidence on barriers and facilitators of weight bearing after hip fracture surgery in older adults.

METHODS

Published (Cochrane Central, MEDLINE, EMBASE, CINAHL, and PEDro) and unpublished (Global Health, EThOS, WorldCat dissertation and thesis, ClinicalTrials.gov , OpenAIRE, DART-Europe) evidence was electronically searched from database inception to 29 March 2022. Barriers and facilitators of weight bearing were extracted and synthesised into patient, process (non-surgical), process (surgical), and structure-related barriers/facilitators using a narrative review approach.

RESULTS

In total, 5594 were identified from the primary search strategy, 1314 duplicates were removed, 3769 were excluded on title and abstract screening, and 442 were excluded on full-text screening. In total, 69 studies (all from published literature sources) detailing 47 barriers and/or facilitators of weight bearing were included. Of barriers/facilitators identified, 27 were patient-, 8 non-surgical process-, 8 surgical process-, and 4 structure-related. Patient facilitators included anticoagulant, home discharge, and aid at discharge. Barriers included preoperative dementia and delirium, postoperative delirium, pressure sores, indoor falls, ventilator dependence, haematocrit < 36%, systemic sepsis, and acute renal failure. Non-surgical process facilitators included early surgery, early mobilisation, complete medical co-management, in-hospital rehabilitation, and patient-recorded nurses' notes. Barriers included increased operative time and standardised hip fracture care. Surgical process facilitators favoured intramedullary fixations and arthroplasty over extramedullary fixation. Structure facilitators favoured more recent years and different healthcare systems. Barriers included pre-holiday surgery and admissions in the first quarter of the year.

CONCLUSION

Most patient/surgery-related barriers/facilitators may inform future risk stratification. Future research should examine additional process/structure barriers and facilitators amenable to intervention. Furthermore, patient barriers/facilitators need to be investigated by replicating the studies identified and augmenting them with more specific details on weight bearing outcomes.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

Effect of inpatient rehabilitation treatment ingredients on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with unplanned admission: an overview review

BACKGROUND

To synthesise the evidence for the effectiveness of inpatient rehabilitation treatment ingredients (versus any comparison) on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with an unplanned hospital admission.

METHODS

A systematic search of Cochrane Library, MEDLINE, Embase, PsychInfo, PEDro, BASE, and OpenGrey for published and unpublished systematic reviews of inpatient rehabilitation interventions for older adults following an unplanned admission to hospital from database inception to December 2020. Duplicate screening for eligibility, quality assessment, and data extraction including extraction of treatment components and their respective ingredients employing the Treatment Theory framework. Random effects meta-analyses were completed overall and by treatment ingredient. Statistical heterogeneity was assessed with the inconsistency-value (I2).

RESULTS

Systematic reviews (n = 12) of moderate to low quality, including 44 non-overlapping relevant RCTs were included. When incorporated in a rehabilitation intervention, there was a large effect of endurance exercise, early intervention and shaping knowledge on walking endurance after the inpatient stay versus comparison. Early intervention, repeated practice activities, goals and planning, increased medical care and/or discharge planning increased the likelihood of discharge home versus comparison. The evidence for activities of daily living (ADL) was conflicting. Rehabilitation interventions were not effective for functional mobility, strength, or quality of life, or reduce length of stay or mortality. Therefore, we did not explore the potential role of treatment ingredients for these outcomes.

CONCLUSION

Benefits observed were often for subgroups of the older adult population e.g., endurance exercise was effective for endurance in older adults with chronic obstructive pulmonary disease, and early intervention was effective for endurance for those with hip fracture. Future research should determine whether the effectiveness of these treatment ingredients observed in subgroups, are generalisable to older adults more broadly. There is a need for more transparent reporting of intervention components and ingredients according to established frameworks to enable future synthesis and/or replication.

TRIAL REGISTRATION

PROSPERO Registration CRD42018114323 .

Abstract P853: Covid-19: A Catalyst for Change in the Code Brain Pathway

Background: Acute stroke care is constantly evolving and often necessitates rapid change. When COVID-19 struck our community, our team determined that we needed to change our approach to emergent stroke cases without sacrificing efficiency and safety. Our goals with the changes in our hyperacute stroke response pathway (called Code Brain) in our ED was to minimize COVID-19 exposure to our team, reduce PPE usage, and maintain an environment of safety and readiness, all while providing the same high-quality stroke care.

Purpose: The purpose of this study was to determine if the changes we made to our Code Brain pathway in the ED effected our door-to-needle time for tissue plasminogen activator (t-PA) administration our door-to-groin puncture (DTG) times, or our CT scan turn-around times (CT TAT) under 45 minutes percentage. Implementation: It was decided that the stroke team RNs would respond to the bedside and a neurology resident or fellow would respond via telemedicine robot at bedside. The stroke team nurse is the safety monitor who ensures proper PPE use. The patient is moved through the Code Brain pathway with the telemedicine robot in tow, assuring constant contact with the patient by the stroke physician and stroke nurse. We implemented our revised Code Brain pathway on March 17, 2020. We retrospectively collected data from November 2019 to July 2020 and extracted our DTN, DTG and CT TAT times for a 4 ½ month comparison.

Results: From November 2019 through March 17, 2020, our DTN median time was 39 minutes, DTG median time was 101 minutes, and CT TAT under 45 minutes was 97%. From March 18, 2020 to July 2020, our DTN median time was 54 minutes, DTG median time was 101 minutes, and CT TAT under 45 minutes was 95%. Variables to consider are the length of time it takes to apply the appropriate PPE for the stroke nurse, obtaining the telemedicine robot from our ED storage area and connectivity issues.

Conclusion: Although we radically changed the way we approach our Code Brain patients, our response and treatment times changed only slightly. We will continue to streamline this process for optimal outcomes.

Abstract WP439: "You Gotta Troll to Enroll!" Nurses Actively Scouting Patients for Clinical Trials

Problem/ Background: Evidence- based practice is the cornerstone in delivery of stroke care to optimize outcomes for patients. Research is the foundation to build and advance clinical practice. As a Comprehensive Stroke Center, we are charged with participating in IRB approved research. In 2016 the SUCCEED trial was stopped here as a result of low enrollment. The stroke nurses were not directly involved in that trial. In 2017, the stroke nurses partnered with our physicians and began the ARAMIS trial. This is a multicenter study of acute stroke patients taking anticoagulation therapy prior to admission and suffering a stroke. We recognized the need for our stroke nurses to collaborate, participate and use their expertise in identifying appropriate research patients for this study.

Quality Question: Will tasking Stroke Nurses with identifying patients improve the enrollment of patients in ARAMIS trial?

Methods: Stroke nurses attended an ARAMIS training session for physicians. Included in the meeting was review of inclusion/exclusion criteria for patient enrollment. A group e-mail was created for all participating in the study to help identify potential patients. When a patient was discovered an email was sent to the group alerting those responsible for obtaining consent for the study and data collection for the registry.

Results: After one trial was ended due to low enrollment, the new ARAMIS trial opened. The stroke team nurses took the lead on identifying patients. Reviewing retrospective data starting in November 2017 until March 2019, 56 patients were enrolled in Aramis. Stroke nurses identified 43 patients (77%), Neurology fellows 10 (18%) and Faculty physicians 3 (5%).

Conclusion: When including expert nurses in the patient identification process, the nurse plays a pivotal role in identifying appropriate patient for the MDs to enroll, thus, increasing enrollment in clinical trials. While additional tracking and trending needs to take place as new trails open, this trial makes clear the need for nurse involvement in identifying appropriate patients.

Abstract TP456: Code Brain or Code Cluster: The Significance of Stroke Education for In-House Patients

Background: The AHA/ASA guidelines for acute stroke management recommends stroke education. Rapid recognition and response to acute stroke warning signs is linked to improved functional outcome. Delays in recognition and inefficiencies during the code process lead to delays in care, which correlate with poorer outcomes.

Purpose: Does increasing staff education via Code Brain In-services impact patient care for in-house stroke patients?

Method: The target population was in-house stroke patients and 42 units were identified. Education highlighted Stroke Team Nurses as staff resources, stroke warning signs, Code Brain Pathway, and strategies to improve efficiency during a code. A retrospective analysis of the Acute Stroke Quality Improvement database was done. We compared the number of in-house Code Brain Activations and the number of Patients Treated for acute stroke.

Results: 3/17-7/17 average of 25.2 calls per month and patients treated for acute stroke was 4%. 8/17 -12/17 average number of calls increased to 39 and patients treated increased to 7%. During 9/17 when most in-services had been completed, a surge was noted. There were 56 calls and 6 patients were treated for acute stroke, compared to an average of only 1 per month prior to in-services. The trend for increased number of patients who were treated, continue to be evident through 12/17.

Implications: Preliminary data suggests that Code Brain In-services provided to the nurses, appears to have directly led to an increased number of stroke patients identified and treated. Data review is ongoing. We continue to experience higher call volumes and treatments than before the education was implemented. This preliminary study demonstrates the merit of increased education over the standard practice of annual competencies. The hurdles of staff turnover and infrequent exposure to code brain, are best surmounted with frequent education. We seek to improve efficiency and effectiveness by focusing our attention to units that require more education and recognize units that are high performing. Our hope is that with these efforts, we will continue inspiring excellence in stroke care and demonstrate the value of a stroke-educated staff nurse.

Increased risk of asthma in overweight children born large for gestational age

BACKGROUND

Being born large for gestational age (LGA) is a marker of increased growth velocity in fetal life and a risk factor for childhood overweight. Both being born LGA and childhood overweight may influence the development of asthma, although the role of overweight in the association between LGA and childhood asthma is unclear. Importantly, recent studies have suggested that the association between overweight and asthma may be related to non-allergic pathways. If this also applies to the association between LGA and asthma, the association between being born LGA and asthma may be different for atopic and non-atopic children.

OBJECTIVE

We investigated the association of being LGA with the prevalence of asthma at age 8 in atopic and non-atopic children and the role of overweight in this association.

METHODS

Complete data on asthma, anthropometry and atopy at age of 8 years, and potential confounders were available for 1608 participants of the PIAMA birth cohort. Odds ratios for the association between LGA and asthma in atopic and non-atopic children were estimated by logistic regression analysis adjusting for potential confounders. Overweight was assessed as a potential modifier of the association between LGA and asthma.

RESULTS

Being born LGA was not significantly associated with asthma at age of 8 in atopic and non-atopic children. However, overweight at age of 8 years modified the association between asthma at age of 8 and LGA. In non-atopic children, children who were born LGA and were overweight at age of 8 years had a significantly increased odds of asthma compared to non-LGA, non-overweight children (adj OR 7.04; 95% CI 2.2-24).

CONCLUSIONS

We observed that non-atopic children born LGA, who were overweight by 8 years have an increased risk of asthma. If confirmed, these findings suggest that non-atopic children born LGA may be identified early in life as a high-risk group for asthma.

Abstract WP349: How Long Do I Have to Stay for a TIA?

Background: It is estimated that in the US, between 200 and 500 thousand TIA’s are reported each year. Half of those patients never report it to their physician. TIA’s once regarded as benign are now recognized as an emergent warning sign of underlying disease and possible impending stroke. By the time many of these patients get to Cedars Sinai, they are asymptomatic and can’t understand the need for a long hospital admission. In 2011 we started our TIA program that enabled us to work up a patient and potentially discharge them from the hospital in 23 hours. The program was a success and patient length of stay decreased dramatically. In 2013, we noted that the length of stay was gradually increasing again. Re-Education efforts for staff about the TIA program proved ineffective, and made only a slight decrease in length of stay. We noted that TIA patients could potentially be admitted anywhere in the hospital and many were not being captured in the system. We needed a better, more consistent solution. We decided to admit and cohort all TIA patients to the Medical Observation Unit (MOU).

Researchable Questions: Would cohorting all TIA patients in the Medical Observation Unit show a consistent decrease in length of stay? Is there a benefit to putting all TIA patients in the Medical Observation Unit?

Methods: We began extensive education with staff and management of the MOU. We educated on the importance of monitoring asymptomatic TIA patients, testing specific to these patients, and how we smoothly expedite them through the system under CODE TIA. In April 2015 all TIA patients were admitted into the MOU

Conclusion: Cohorting TIA patients to the MOU has proven to be a success. Prior to the initiation of the cohorting process, TIA length of stay was 1.9 days. The current length of stay for a TIA patient in the MOU is 0.87 days. This has been dramatic and consistent decrease for almost two years. We also noted that several Code Brains have been called from this unit as the nurses are hypervigilant at monitoring these asymptomatic patients. Several of these patients have been quickly treated with tPA and have had only small or averted strokes because of the quick response from MOU nurses.

Abstract WP369: Knowing the Score: Documentation of Bleeding Scores for Hemorrhagic Stroke Patients

Background: Intracranial hemorrhage (ICH) scores and Hunt and Hess/Fisher scores (HHF) are important components in the documentation of hemorrhagic strokes. The accurate and timely documentation of these scores is a mandatory data point measure for Joint Commission (JC) certified Comprehensive Stroke Centers. The purpose of this project is to discuss the measures we implemented to improve documentation of the ICH and HHF scores and to highlight the remarkable improvement of documentation of the scores with our efforts.

Purpose: The purpose of this project was to discover if a specific, user-friendly template and targeted education would increase documentation compliance.

Methods: We did a retrospective review of percentage of compliance in documentation of ICH and HHF scores before the measure was mandated by the JC. We implemented the ICH and HHF score template into the Neuro ICU template and educated practitioners on the JC measure requirement and awareness of the template. We also educated our Code Brain team to document the scores upon initial assessment. We track and trended documentation with monthly review of percentage of compliance. We continue to provide feedback to practitioners when score documentation is not present in medical record and continue to monitor percentage of compliance.

Results: The percentage of compliance at the beginning of the data capture for this measurement (Jan 2015) was approximately 6% for the first two quarters of 2015. After the implementation of the score template, the percentage of compliance was 50% for the last two quarters of 2015. We continued to meet with the Neuro ICU for targeted education of the measure requirement and provided feedback in cases of missing documentation. With the continued feedback and education, the percentage of compliance increased to approximately 92% in 2016, a huge improvement from 2015.

Conclusions: Providing an user friendly template for practitioners along with education and feedback helped dramatically increase the compliance of documentation for an mandatory JC measure.

FACILE FUNCTIONALIZATION OF sp2 CARBON ALLOTROPES WITH A BIOBASED JANUS MOLECULE

A simple, versatile, sustainable, not expensive method for the functionalization of sp2 carbon allotropes, both nano-sized and nano-structured, without altering their bulk crystalline organization, is presented. Carbon materials available at the commercial scale were used: furnace carbon black (CB), nano-sized graphite with high surface area, and multiwalled carbon nanotubes. A bio-sourced molecule, 2-(2,5-dimethyl-1H-pyrrol-1-yl)-1,3-propanediol (serinol pyrrole), was used for the functionalization. Serinol pyrrole (SP) was obtained from serinol through a reaction with atomic efficiency of about 82%, performed in the absence of solvents or catalysts. Synthesis of serinol pyrrole was performed as well on carbon allotropes as the solid support. Adducts of serinol pyrrole with a carbon allotrope were prepared with the help of either thermal or mechanical energy. Functionalization yield was in all cases larger than 90%. With such adducts, stable dispersions in water and in NR latex were prepared. A few layers of graphene were isolated from the water dispersions, and NR-based composites precipitated from the latex revealed very even distribution of fine graphitic particles. Composites were prepared, based on NR, IR, and BR as the rubbers and CB and silica as the fillers, with different amounts of CB–SP adduct, and were cross-linked with a sulfur-based system without observing appreciable effect of functionalization on vulcanization kinetics. The CB–SP adduct led to appreciable reduction of the Payne effect.

Abstract TP374: Stroke versus Stroke Mimic for Inpatient Code Brain

Introduction/Background: Functional outcome from stroke is better if the stroke is identified and treated immediately. The acute stroke pathway at Cedars Sinai is known as Code Brain. This pathway is often activated for inpatients and is a large part of the total number of Code Brain activations. The inpatient Code Brain pathway is inherently a nursing-driven process, most often initially activated by an inpatient nurse. The purpose of this project is to look at the number of Code Brain activations that are truly acute stroke versus stroke “mimics” - common conditions that appear to be consistent with acute stroke, but turn out to be diagnoses that are not stroke related.

Methods: Plan: Retrospective patient case review of all in-house Code Brain activations, excluding prehospital/ED activations from January 2015 through December 2015.

Do: We meet weekly to asses every Code Brain and evaluate and adjudicate patients

Study: Examined results of adjudicated diagnoses to determine how many in-house Code Brain patients had a stroke/TIA diagnosis versus other diagnoses

Act: Hospital-wide staff education regarding Code Brain activation criteria, including symptoms of acute stroke/sudden neurologic change in patient status

Results: Out of 242 Code Brain in-house activations, 128 were adjudicated to stroke/TIA diagnoses and 114 were adjudicated to “other diagnoses”. Some of the most common non-stroke/non-TIA diagnoses were encephalopathy, migraine and seizure.

Conclusions: The national average of over-triage of inpatient stroke activations is a little over 20%. Our study shows that in this time period, 47% of the inpatient Code Brain activations turn out to be non-stroke related diagnoses. There are many factors that can be taken into account for this. However, these outcomes also prove that with the education provided, the nursing staff is empowered to call a Code brain independent of physician advice, which is an excellent example of nursing autonomy. We will continue to monitor this data and educate the staff as needed.

Abstract TP291: Swallow Screens: A Hard Act to Follow a Collaborative Effort Between the Stroke Program and the Emergency Department

Background: After stroke, up to 65 percent of stroke patients suffer dysphagia, with increased risk of aspiration pneumonia and disability. Aspiration risk is reduced by swallow assessment on every acute ischemic stroke (AIS) prior to medication or food intake. Annually, about 88,000 patients enter the Cedars-Sinai Emergency Department (ED). Although only 1% of these patients are AIS, 100% of these patients require a swallow screen. In busy EDs where stroke is infrequent, swallow screens are missed. Jointly with our ED Educator and our Electronic Information Systems (EIS) application specialist we created a user-friendly, reliable solution to improve swallow screen compliance in the ED.

Purpose: To implement a valid swallow screening tool and optimize nurse awareness and compliance in a busy, urban ED.

Method: We emphasized educating and listening to staff concerns and requests and collaboration with EIS. The Barnes Jewish Hospital stroke screening tool is a validated, evidence based screening tool for assessing swallowing. We defined “fall outs” as patients who received anything by mouth prior to a swallow assessment. EIS created an electronic alert linked to chief complaints that fired in response to a wide range of stroke symptoms. The alert was also linked to the medication administration record.

Result: Prior to deployment, fall outs ranged from 40 to 65% of cases. Following deployment of the alert fall out numbers decreased (see graph) significantly (Chi-Square p<0.001 for trend), despite an overall increase in AIS volumes. While education was somewhat successful, linking the alert to the MAR prompted the nurse to complete the swallow screen prior to administering oral medications.

Conclusion: We successfully improved ED compliance with swallow screening in a busy urban ED in which AIS represents less than 1% of the annual volume. A similar strategy should work well in a variety of other hospitals and medical centers.

Paving the way of systems biology and precision medicine in allergic diseases: the MeDALL success story: Mechanisms of the Development of ALLergy; EU FP7-CP-IP; Project No: 261357; 2010-2015

MeDALL (Mechanisms of the Development of ALLergy; EU FP7-CP-IP; Project No: 261357; 2010-2015) has proposed an innovative approach to develop early indicators for the prediction, diagnosis, prevention and targets for therapy. MeDALL has linked epidemiological, clinical and basic research using a stepwise, large-scale and integrative approach: MeDALL data of precisely phenotyped children followed in 14 birth cohorts spread across Europe were combined with systems biology (omics, IgE measurement using microarrays) and environmental data. Multimorbidity in the same child is more common than expected by chance alone, suggesting that these diseases share causal mechanisms irrespective of IgE sensitization. IgE sensitization should be considered differently in monosensitized and polysensitized individuals. Allergic multimorbidities and IgE polysensitization are often associated with the persistence or severity of allergic diseases. Environmental exposures are relevant for the development of allergy-related diseases. To complement the population-based studies in children, MeDALL included mechanistic experimental animal studies and in vitro studies in humans. The integration of multimorbidities and polysensitization has resulted in a new classification framework of allergic diseases that could help to improve the understanding of genetic and epigenetic mechanisms of allergy as well as to better manage allergic diseases. Ethics and gender were considered. MeDALL has deployed translational activities within the EU agenda.

Oxidative Stress, DNA, Cell Cycle/Cell Cycle Associated Proteins and Multidrug Resistance Proteins: Targets of Human Amniotic Membrane in Hepatocellular Carcinoma

The anticancer effects of human amniotic membrane (hAM) have been studied over the last decade. However, the action mechanisms responsible for these effects are not fully understood until now. Previously results reported by our team proved that hAM is able to induce cytotoxicity and cell death in hepatocellular carcinoma (HCC), a worldwide high incident and mortal cancer. Therefore, this experimental study aimed to investigate the cellular targets of hAM protein extracts (hAMPE) in HCC through in vitro studies. Our results showed that hAMPE is able to modify oxidative stress environment in all HCC cell lines, as well as its cell cycle. hAMPE differently targets deoxyribonucleic acid (DNA), P21, P53, β-catenin and multidrug resistance (MDR) proteins in HCC cell lines. In conclusion, hAMPE has several targets in HCC, being clear that the success of this treatment depends of a personalized therapy based on the biological and genetic characteristics of the tumor.

Abstract TP394: Stroke Education- Are you REaDy?

Introduction/Background: Patients stay healthier when informed, making communication the key to better outcomes. An informed and educated patient actively participates in their own treatment, improves outcomes, and reduces length of stay. We call and evaluate every patient 30 days post discharge. We found that many reported either not receiving stroke education, or could not recall if they had received it. The principle of Occam’s razor states: “The simplest idea is usually the best idea.” This principle was utilized to solve our problem.

Quality Questions:

1. How do we increase the likelihood that patients will remember that they have received stroke education?

2. How do we assure that patients recall health information provided to them.

Methods: Stroke patients are given extensive, personalized stroke education during their admission, and reinforced daily by stroke team. Education materials were given to patients in white folders with a Cedars-Sinai logo. Stroke patients are phoned in 30 days and asked a series of 18 questions to assess well-being & assess patient’s experience during hospital stay, and after discharge. These calls revealed an unusual number of patients who were unable to recall being educated or receiving educational materials. We decided to simply change the stroke education folder from white to bright red. We instructed the call center to use the red folder as a prompt to help the patient recall receiving stroke education.

Conclusion: A collaborative approach was used to ascertain an appropriate stimulus for the patient to recall their stroke specific education. Stroke education had to stand out amidst the myriad of information patients are bombarded with in the hospital. The team came up with the simple idea of using a bright red folder. When patients were called the call center would prompt the patient by saying “The stroke education was given to you in a bright red folder.” Prior to implementation of the red folders, only 81.5% of patients recalled receiving stroke education. After implementation of the red folders, 96.8% recalled receiving stroke education. The principle of Occam’s Razor proved to be correct in our study. A very simple idea such as changing the color of the folders to bright red proved to have very meaningful results.

Selective cytotoxicity and cell death induced by human amniotic membrane in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has a worldwide high incidence and mortality. For this reason, it is essential to invest in new therapies for this type of cancer. Our team already proved that human amniotic membrane (hAM) is able to inhibit the metabolic activity of several human cancer cell lines, including HCC cell lines. Taking into account the previously performed work, this experimental study aimed to investigate the pathways by which hAM protein extracts (hAMPEs) act on HCC. Our results showed that hAMPE reduce the metabolic activity, protein content and DNA content in a dose- and time-dependent manner in all HCC cell lines. This therapy presents selective cytotoxicity, since it was not able to inhibit a non-tumorigenic human cell line. In addition, hAMPE induced cell morphology alterations in all HCC cell lines, but death type is cell line dependent, as proved by in vitro and in vivo studies. In conclusion, hAMPE have a promising role in HCC therapy, since it is capable of inducing HCC cytotoxicity and cell death.

Are allergic multimorbidities and IgE polysensitization associated with the persistence or re-occurrence of foetal type 2 signalling? The MeDALL hypothesis

Allergic diseases [asthma, rhinitis and atopic dermatitis (AD)] are complex. They are associated with allergen-specific IgE and nonallergic mechanisms that may coexist in the same patient. In addition, these diseases tend to cluster and patients present concomitant or consecutive diseases (multimorbidity). IgE sensitization should be considered as a quantitative trait. Important clinical and immunological differences exist between mono- and polysensitized subjects. Multimorbidities of allergic diseases share common causal mechanisms that are only partly IgE-mediated. Persistence of allergic diseases over time is associated with multimorbidity and/or IgE polysensitization. The importance of the family history of allergy may decrease with age. This review puts forward the hypothesis that allergic multimorbidities and IgE polysensitization are associated and related to the persistence or re-occurrence of foetal type 2 signalling. Asthma, rhinitis and AD are manifestations of a common systemic immune imbalance (mesodermal origin) with specific patterns of remodelling (ectodermal or endodermal origin). This study proposes a new classification of IgE-mediated allergic diseases that allows the definition of novel phenotypes to (i) better understand genetic and epigenetic mechanisms, (ii) better stratify allergic preschool children for prognosis and (iii) propose novel strategies of treatment and prevention.

The locus C11orf30 increases susceptibility to poly-sensitization

A number of genetic variants have been associated with allergic sensitization, but whether these are allergen specific or increase susceptibility to poly-sensitization is unknown. Using data from the large multicentre population-based European Community Respiratory Health Survey, we assessed the association between 10 loci and specific IgE and skin prick tests to individual allergens and poly-sensitization. We found that the 10 loci associate with sensitization to different allergens in a nonspecific manner and that one in particular, C11orf30-rs2155219, doubles the risk of poly-sensitization (specific IgE/4 allergens: OR = 1.81, 95% CI 0.80-4.24; skin prick test/4+ allergens: OR = 2.27, 95% CI 1.34-3.95). The association of rs2155219 with higher levels of expression of C11orf30, which may be involved in transcription repression of interferon-stimulated genes, and its association with sensitization to multiple allergens suggest that this locus is highly relevant for atopy.

Abstract T P62: Safety Scans after Intravenous Thrombolytic Therapy Fail to Alter Course or Management

Introduction: The risk of intracranial hemorrhage (ICH) following IV-rtPA is 20%, and symptomatic ICH is 6%. Due to this concern, many practitioners obtain a 24-hour safety image after administration of t-PA for acute ischemic stroke (AIS). We sought to determine whether 24-hour safety imaging influenced clinical management or outcomes

Methods: We conducted a retrospective analysis of suspected AIS patients treated with IV t-PA at our medical center between January 2012 and February 2014. Medical records were reviewed for clinical decision-making, neurologic deterioration, and ICH. All patients were examined on admission by NIHSS-certified neurologists. Baseline characteristics were captured from a department database. A stepwise linear regression was used to identify variables predicting change in management and discharge modified Rankin scores (mRS).

Results: Our study included 172 patients who received IV t-PA. After exclusion for endovascular treatment, clinical research trials that required follow-up imaging, and missing demographics, 116 patients were included in the final analysis. Neurologic deterioration was seen in 20 (17.2%) patients, intracranial hemorrhage was seen in 19 (16.3%) patients, and clinical management changed in 11 (9.4%) patients. Clinical deterioration was the only variable that predicted a change in management (logistic regression p<0.05). After adjusting for deterioration, neither 24-hour imaging nor presence of ICH predicted a change in management. Using a linear regression model, baseline NIHSS and clinical deterioration predicted mRS at discharge, whereas 24-hour imaging and change in clinical management did not (r 2 =0.43, p<0.001).

Conclusion: Our data suggests frequent examination for neurologic deterioration is superior to 24-hour imaging in guiding clinical decision making. These findings should be investigated prospectively.

Abstract T P329: Coo-Coo For Compliance: Improving Compliance of Acute Stroke Patient Documentation

Introduction/Background: As a Joint Commission Comprehensive Stroke Center we are charged with the task of meticulous monitoring of vital signs and neurologic status after thrombolytic therapy to prevent complications. This can be difficult to document in real time. In accordance with best practices and the AHA guidelines and the American Association of Neuroscience Nurses, we sought to improve the documentation of vital signs and neurologic evaluations during and after t-PA. During our Joint Commission Comprehensive Stroke Survey we were cited for improving the documentation of vital signs and neurological checks after t-PA.

Background: We identified nurses were starting documentation at awkward times, i.e. 1538 and attempting to add 15min to this time over a 24 hour period. The nurses were educated about rounding up to the 15min mark, making it easier to add 15min each time. We auditied documentation of every patient who received Acute Stroke Treatment, and sent feed back to nurses in “real time”. We discovered transportation from one department to another caused missed documentation. A transport monitor was purchased that can easily take a full set of vital signs during transport, and nurses were instructed to “back time” the documentation. We found that intensive documentation required the nurse to sift through multiple screens to document findings. The entire neuro team collaborated to create a Stroke Navigator for EPIC. This navigator contains all pieces of expected documentation of the stroke patient in one area of EPIC.

Conclusion: From January to December 2013, our Stroke Team saw 970 patients. 82 were treated with IV tPA, 18 were sent for Interventional clot retrieval, 6 received both IV tPA and Interventional clot retrieval, and 4 received tPA at another facility and transported to Cedars Sinai for higher level of care. We found issues within the system, that increased the chances of having vital documentation missed, or delayed by the nursing staff. Prior to the implementation of these new strategies our compliance rate with documentation was 32%. The results after the implementation of our new strategies were staggering. Our nurses were 94% compliant with documentation.

Abstract T P356: Functional Outcomes of the Acute Ischemic Stroke Patient Population

Background: Stroke is the leading cause of long-term disability and affects 795,000 in the U.S. each year. This study is conducted to enhance knowledge ofoutcomes after an acute ischemic stroke (AIS).Comprehensive Stroke Certification tasks hospitals with expanding knowledge of functional and quality of life outcomes for AIS patients through the early acute and post-acute phase of recovery and examining the effects of stroke severity, functional impairment,discharge destinations, functional independence, and quality of life post discharge.

Researchable question: What are most common setbacks after AIS affetcing functional outcome & readmission?

Methods: Looked at AIS patients from 12/2012 -12/ 2013 at Cedars-Sina. Of total of 709 patients 318 were contacted by phone. Measures collected by MedTel Outcomes LLC on all AIS patients one month after discharge. This included the Functional Independence Measure and standardized quality of life and participation measures.The median age was 65 years at the time of the stroke.

Results: Most common setbacks were recurrent strokes, pneumonia, falls& heart failure.All caused re-hospitalization after stroke. Discharge destinations 30 days post stroke hospitalization were: home independent 144 (43.3%). No significant disability 49 (14.7%), Slight disability 21 (6.3%) Moderate disability 44 ( 13.2%), moderate to severe disability 43 ( 12.9%) and finally severe disability 31( 9.3%). 83.7 % were home without assistance and 1.3 % were in board and care, 15 patients, (4.7 %) had been readmitted for recurrent stroke, 48 patients had fallen since discharge

Conclusions: Over 83.7 % of AIS patients were back living in the community at home with over 60 % having slight disability.The long-term outcomes have implications for late secondary and tertiary prevention and creating a model for predictors of these At follow-up, in terms of physical functioning measures,mostpatients were independent in toileting and self-care activities,half were independent in mobility excluding stairs.Data from this study can be used to understand the functional trajectory of recovery based on severity of stroke, discharge destination and other factors. It is important to understand patients’ characteristics to help prevent readmissions.

Abstract T P330: Depression Cognition Screens

Introduction/Background: Evidence suggests that approximately 1/3 of stroke survivors suffer from post stroke depression (PSD) and changes to their cognition. Delay in identifying these patients can effect rehabilitation resulting in poorer functional outcomes, reduced cognitive performance and possibly increase mortality. PSD can occur in all phases of stroke recovery with a peak incidence at 3 - 6 months. Early diagnosis is essential so to apply effective treatment or interventions that can result in enhanced recovery. As a Comprehensive Stroke Center, we at Cedar Sinai hospital are charged with the task of efficiently indentifying patients that are at risk by administrating the Patient Health Questionnaire (PHQ 2) to those who can participate.

Research Question: Does administering the PHQ 2 during the acute phase of stroke/TIA adequately identify those at risk for Depression and cognitive decline?

Methods: Plan: As per Joint Commission standard, depression cognition screens are to be conducted prior to discharge.

Do: Chose a tool that efficiently and skillfully identifies patients at risk.

Study: Analyze the results.

Act: Administer the PHQ 2 to those patients who have the capacity. For those patients that have a positive screen, notify their primary care provider for further evaluation or possible intervention.

Conclusions: We retrospectively reviewed from September 2012 to September 2013 Stroke/TIA patients that had the capacity to participate in the PHQ 2 Depression Cognition screen. We identified that of 442 patients that completed the screen, 43 or 9.7% had depression screen of 3 or greater or demonstrated cognitive decline with score of 1 or less. If not for these evaluations these patient may have not been identified so to assure follow-up and/or treatment which could improve functional outcomes for this patient population. Furthermore it demonstrates the need for continued reevaluation since the incidence of this issue has not reached its peak.

Arterial blood pressure responses to short-term exposure to low and high traffic-related air pollution with and without moderate physical activity

BACKGROUND

Short-term exposure to traffic-related air pollution (TRAP) has been associated with adverse cardiovascular outcomes. Physical activity (PA) in polluted air may increase pollutant uptake and increase these effects.

METHODS

Crossover real-world exposure study in 28 healthy participants comparing systolic (SBP) and diastolic blood pressure (DBP) responses to four different exposure scenarios: 2 h exposure in high or low-TRAP environment, each at rest and combined with intermittent moderate PA consisting of 15 min intervals alternating rest and cycling on a stationary bicycle. Data was analyzed using mixed effect models for repeated measures.

RESULTS

Exposure to high TRAP was associated with higher DBP (1.1 mm/Hg, p = 0.002) post-exposure, irrespective of exercise status. Ultrafine particles (UFP) increased DBP post-exposure (0.9 mm/Hg, p = 0.004). Interquartile increases in black carbon (BC), fine particulate matter (PM10 and PMcoarse), UFP, and nitric oxides (NOx) were associated with statistically significantly higher SBP post-exposure (1.2, 1.0, 1.1, and 1.1 mm/Hg, respectively). Intermittent PA compared with rest was associated with lower SBP post-exposure (-2.4 mm/Hg, p < 0.001). PA lowered SBP more after exposure to the low-TRAP site (-2.3 mm/Hg) compared with the high-TRAP site (-1.6 mm/Hg). We only found evidence of an interaction between PA and both PM10 and PMcoarse, increasing SBP.

CONCLUSION

Both SBP and DBP increase after exposure to TRAP. Intermittent PA attenuates the TRAP-related increases in SBP, with the exception of PM10 and PMcoarse, which potentiate these increases. We showed that in low-TRAP environments intermittent PA has stronger beneficial effects on SBP than in high-TRAP environments.

Abstract NS13: Road to Recovery after Stroke: Understanding Predictors of Discharge Destination, Functional Independence, and Quality of Life after Hospital Discharge

Introduction: Stroke is the leading cause of long-term disability and affects 795,000 people in the U.S. each year. This study was conducted to enhance knowledge of outcomes during recovery and the options for participating in rehabilitation and preventive care during patients’ transitions to the community. Comprehensive Stroke Certification charges hospitals with the task of expanding knowledge of functional and quality of life outcomes for all stroke patients through the continuum examining effects of stroke severity, functional impairment, and patient characteristics on discharge destinations, functional independence, and quality of life after discharge.

Methods: Retrospective analysis of an acute stroke quality improvement database which includes measures collected by MedTel Outcomes LLC on all stroke patients one month after discharge. Included, is the Functional Independence Measure and standardized quality of life and participation measures. In the database are standardized measures from the medical record such stroke type, Modified Rankin score, and acute functional independence measure score for 719 patients with a 30-day follow-up phone assessment for functional and quality of life measures from January 1, 2011 to December 31, 2012.

Preliminary Findings: Over 75% of patients had hemiparesis, & over 90% survived 30-days post discharge and were living in the community. At follow-up, mostwere independent in self-care, and half were independent in mobility excluding stairs. Those with right brain involvement had a complicated, slower recovery. Those with left brain involvement,had lower functional scores and a higher percentage of them were not living in the community, rather, living in institutions.

Conclusions: All patients experiencing a stroke should have evidence-based information on their options & what to expect during their recovery during their transitions into the community. The data base is useful as a source of outcome data for comparative effectiveness and to build a regional collaborative outcomes database for Comparative Effectiveness Research and quality benchmarking. Findings can be used to understand the functional trajectory of recovery based on severity of stroke and other factors.

Abstract W P287: Does Comprehensive Stroke Certification Demonstrate a Significant Effect on Volume and Quality of Care?

Introduction/Background information: At the onset of acute stroke symptoms, speed, capability, safety and skill are essential-lost minutes can be the difference between full recoveries, poor outcome, or even death. The Joint Commission's Certificate of Distinction for Comprehensive Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. While many hospitals have been surveyed, Cedars Sinai was the 5 th hospital in the nation to receive this certification.

Researchable question: Does Comprehensive stroke certification (CSC) demonstrate a significant effect on volume and quality of care?

Methods: We assembled a cross-functional, multidisciplinary expert team representing all departments and skill sets involved in treating stroke patients. We carefully screened eligible patients with acute ischemic stroke We assessed the number of patients treated at Cedars-Sinai with IV-T-pa t 6 months before and then 6 months after CSC and the quality of their care including medical treatment and door to needle time.

Results: In the 6 months prior to Joint Commissions Stroke Certification we treated 20 of 395acute stroke patients with t-PA with an average CT turnaround time of 31±19minutes and an average Door to needle time (DTNT) of 68±32minutes. In the 6 months since Joint Commission Stroke Certification we have increased the number of acute stroke patients treated by almost double. There were 37 out of 489(P=0.02, Chi Square) patients treated with IV t-PA with an average CT turnaround time of 22±7minutes (p=0.08, t-test, compared to pre-CSC) and an average DTNT of 61± 23minutes (not different than pre-CSC).

Conclusion: We conclude that Joint Commission Certification for stroke was associated with an increased rate of treatment with IV rt-PA in acute ischemic stroke patients. We were not able to document an effect on quality of care. Further studies of the impact of CSC certification are warranted.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Respiratory health and endotoxin: associations and modification by CD14/-260 genotype

Exposure to endotoxin has been associated with increased respiratory symptoms and decrements in lung function in occupational settings but little is known about the health effects of domestic exposure in adults. Here, we describe the association of respiratory disease, immunoglobulin (Ig)E sensitisation, bronchial reactivity and lung function with mattress endotoxin levels in adults, and determine whether these associations are modified by polymorphisms in CD14. Endotoxin levels in mattress dust from a population-based sample of 972 adults were measured. Associations were examined using generalised linear mixed models, adjusting for individual and household confounders. Effect modification of these associations by CD14/-260 (rs2569190) was assessed. Mattress endotoxin levels varied from 0.1 to 402.6 EU · mg(-1). Although there was no overall association of lung function with endotoxin exposure, there was evidence that the association of forced expiratory volume in 1 s and forced vital capacity with endotoxin was modified by CD14/-260 genotype (p-value for interaction 0.005 and 0.013, respectively). There was no evidence that symptoms, IgE sensitisation or bronchial reactivity were associated with mattress endotoxin levels. In this large epidemiological study of adults, there was no evidence that mattress endotoxin level was associated with respiratory symptoms or IgE sensitisation but the association of lung function with endotoxin levels may be modified by CD14 genotype.

Abstract 2258: Ambulance Directed Care for Acute Stroke Patients at Cedars-Sinai Medical Center

Quality Improvement Study: Background: Advances over the last decade highlight the important role of Emergency Medical Services (EMS) agencies in optimizing stroke care. Los Angeles County’s Department of Health Services (LA County DHS) Stroke Patient Policy was instituted on November 16, 2009. As a result, ambulances now transport suspected stroke patients directly to approved Stroke Centers. In a single institution-TJC certified as a PSC since 2008, we studied the effect of the Stroke Patient Destination Policy and ambulance-directed care on the percentage of ischemic stroke patients receiving acute stroke treatments (IV tPA, intra-arterial thrombolysis or clot-retrieval, or bridge therapy).

Methods: 2, 156 patient charts were retrospectively reviewed from the 16 months prior to the implementation of ambulance-directed care compared to a 16-month period between after implementation of ambulance-directed stroke care.

Results: In the pre-policy period, 344 suspected stroke patients arrived by EMS versus 491 suspected stroke patients arriving by EMS in the post-policy period - a 30% increase. (Chi 2 p=0.07). Of 344 patients, 34 (9.9%) received acute stroke treatment in the pre-policy period, compared to 63 of 491 patients receiving acute stroke treatments in the post-policy period (12.8%, NS). The median age of patients pre and post policy change was 69.5 years old. The median gender distribution was 46% male and 54% female. Neither age nor gender differed before or after the policy change.

Conclusions: Implementation of the LA County DHS Stroke Patient Destination Policy appeared to cause a higher volume of acute stroke patients receiving treatment at one Joint Commission certified academic medical center. The data suggests that 29 additional patients were treated with acute stroke treatments due to ambulance directed care. Additional confirmatory data is needed from other centers.

Abstract 2191: A Multidiciplinary Team Approach To Improving The Quality Of Care In The Setting Of Tissue Plasminogen Activator

Background and Purpose: Monitoring of vital signs and neurolgic status is imperative after thrombolytic therapy to prevent complications but can be difficult to document in real time. We sought to improve the documentation of vital signs and neurologic evaluations during and after t-PA.

Methods: We retrospectively audited all acute ischemic strokes receiving t-PA March through June 2010. A total of 12 patients received t-PA. The average age was 68.4 years with 48% of this population being male. These patients did not have adequate and consistent vital sign and neurologic check documentation. Of the 12 patients receiving t-PA, only 27.5% of patients had proper documentation as defined by the NINDS. In June and July 2010, the stroke team held 7 meetings with the nursing staff, ED, Neuro ICU, pharmacy and physicians to gather ideas for methods to improve compliance. An aggressive education endeavor was developed with nursing, physicians and pharmacy staff. The stroke team reinforced and re-educated staff regarding the standard order sets, stroke competencies and stroke guidelines. The nursing staff developed signage to place above the patient’s bed when receiving t-PA, to remind the staff of the required time frames for documentation. The ED staff created a reminder ticket/ flyer that the pharmacist carries in the t-PA administration box to hand to the nurse when t-PA is about to be administered. We moved the vital sign frequency from the second page to the front page of the standard t-PA administration order set.

Result: Between July 2010 and February 2011, we gave t-PA to 39 patients, of whom the average age was 61.0 years with 47.4% of this population being male. Utilizing all of the methods and extraordinary collaboration, 91% were fully compliant for neurologic checks and vitals signs during and following t-PA administration.

Conclusion: We conclude that ongoing education and reinforement is effective for promoting change in adherence to documentation guidelines after thrombolytic therapy. When we have the occasional fallout, we reach out to that area immediately to talk with and educate the staff to determine the cause and most importantly what we can do to prevent this. Working together has greatly improved documentation compliance.