Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage

Background

We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage.

Methods

We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status.

Results

Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity.

Conclusions

Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.

SARS-CoV-2 and Stroke in a New York Healthcare System

Background and Purpose:

With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19.

Methods:

We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls).

Results:

During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P=0.003) and historical controls (25.0%, P<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls.

Conclusions:

We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.

Factors associated with therapeutic anticoagulation status in patients with ischemic stroke and atrial fibrillation

BACKGROUND AND PURPOSE

Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF.

METHODS

The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR <2) anticoagulation status. We used binary logistic regression models to determine factors independently associated with anticoagulation status after adjustment for pertinent confounders. In particular, we sought to determine whether atherosclerosis with 50% or more luminal narrowing in an artery supplying the infarct (a marker for a competing atherosclerotic mechanism) and small stroke size (≤ 10 mL; implying a competing small vessel disease mechanism) related to anticoagulant status.

RESULTS

Of the 2084 patients enrolled in the IAC study, 382 patients met the inclusion criteria. The mean age was 77.4 ± 10.9 years and 52.4% (200/382) were women. A total of 222 (58.1%) subjects presented with subtherapeutic INR. In adjusted models, small stroke size (OR 1.74 95% CI 1.10-2.76, p = 0.019) and atherosclerosis with 50% or more narrowing in an artery supplying the infarct (OR 1.96 95% CI 1.06-3.63, p = 0.031) were independently associated with INR ≥2 at the time of their index stroke.

CONCLUSION

Small stroke size (≤ 10 ml) and ipsilateral atherosclerosis with 50% or more narrowing may indicate a competing stroke mechanism. There may be important opportunities to improve stroke prevention strategies for patients with AF by targeting additional ischemic stroke mechanisms to improve patient outcomes.

Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology

OBJECTIVE

To update the 2016 American Academy of Neurology (AAN) practice advisory for patients with stroke and patent foramen ovale (PFO).

METHODS

The guideline panel followed the AAN 2017 guideline development process to systematically review studies published through December 2017 and formulate recommendations.

MAJOR RECOMMENDATIONS

In patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke (level B). In patients with a higher risk alternative mechanism of stroke identified, clinicians should not routinely recommend PFO closure (level B). Clinicians should counsel patients that having a PFO is common; that it occurs in about 1 in 4 adults in the general population; that it is difficult to determine with certainty whether their PFO caused their stroke; and that PFO closure probably reduces recurrent stroke risk in select patients (level B). In patients younger than 60 years with a PFO and embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (absolute recurrent stroke risk reduction of 3.4% at 5 years) and risks (periprocedural complication rate of 3.9% and increased absolute rate of non-periprocedural atrial fibrillation of 0.33% per year) (level C). In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend an antiplatelet medication such as aspirin or anticoagulation (level C).

Modafinil in Recovery after Stroke (MIRAS): A Retrospective Study

BACKGROUND AND PURPOSE

Acute rehabilitation is known to enhance stroke recovery. However, poststroke lethargy and fatigue can hinder participation in rehabilitation therapies. We hypothesized that in patients with moderate to severe stroke complicated by poststroke fatigue and lethargy early stimulant therapy with modafinil increases favorable discharge disposition defined as transfer to acute inpatient rehabilitation or home.

METHODS

We retrospectively reviewed a cohort of patients with acute stroke admitted to the stroke service over a 3-year period. All patients 18 years or older with confirmed ischemic or hemorrhagic stroke, an NIHSS greater than or equal to 5 and documentation of fatigue/lethargy in clinical documentation were included. We compared patients that were treated with modafinil 50-200 mg to those managed with standard care. The primary outcome measure was discharge disposition. Secondary outcome was 90 day modified Rankin score (mRS). Statistical significance was determined using chi-square test for association and logistic regression models. Logistic regression models were derived in 2 ways with both raw data and an adjusted model that accounted for age, sex, and NIHSS score to account for the lack of randomization.

RESULTS

This study included 199 stroke patients (145 ischemic, 54 hemorrhagic). Seventy-two (36.2%) were treated with modafinil and 129 (64.8%) were discharged to acute inpatient rehabilitation, while none were recommended for discharge home. Median NIHSS for modafinil patients was 13.5 versus 11 for standard care patients (P = .059). In adjusted models, modafinil was associated with higher odds of favorable discharge disposition (OR 2.00, 95% CI 1.01-3.95). Favorable outcome at 90 days defined as mRS less than or equal to 2 occurred more frequently with modafinil (5.6% versus 3.3%) but this did not achieve statistical significance (P > .1). These results occurred despite the modafinil group requiring longer ICU stays and having more in-hospital complications such as infections and need for percutaneous gastrostomy tubes. The benefit of modafinil was seen across all subgroups except those with severe stroke (NIHSS ≥ 15). There were no significant adverse events associated with modafinil administration.

CONCLUSIONS

Modafinil use in acute in-hospital stroke patients with moderate stroke complicated by lethargy and fatigue was associated with improved discharge disposition. Randomized controlled trials are needed to further study the safety, efficacy, and long-term effects of modafinil in this patient population.

Neuroanatomy of the middle cerebral artery: implications for thrombectomy

Our perspective on anatomy frequently depends on how this anatomy is utilized in clinical practice, and by which methods knowledge is acquired. The thrombectomy revolution, of which the middle cerebral artery (MCA) is the most common target, is an example of a clinical paradigm shift with a unique perspective on cerebrovascular anatomy. This article reviews important features of MCA anatomy in the context of thrombectomy. Recognizing that variation, frequently explained by evolutionary concepts, is the rule when it comes to branching pattern, vessel morphology, territory, or collateral potential is key to successful thrombectomy strategy.

Redefined Measure of Early Neurological Improvement Shows Treatment Benefit of Alteplase Over Placebo

Background and Purpose- The first of the 2 NINDS (National Institute of Neurological Disorders and Stroke) Study trials did not show a significant increase in early neurological improvement, defined as National Institutes of Health Stroke Scale (NIHSS) improvement by ≥4, with alteplase treatment. We hypothesized that early neurological improvement defined as a percentage change in NIHSS (percent change NIHSS) at 24 hours is superior to other definitions in predicting 3-month functional outcomes and using this definition there would be treatment benefit of alteplase over placebo at 24 hours. Methods- We analyzed the NINDS rt-PA Stroke Study (Parts 1 and 2) trial data. Percent change NIHSS was defined as ([admission NIHSS score-24-hour NIHSS score]×100/admission NIHSS score] and delta NIHSS as (admission NIHSS score-24-hour NIHSS score). We compared early neurological improvement using these definitions between alteplase versus placebo patients. We also used receiver operating characteristic curve to determine the predictive association of early neurological improvement with excellent 3-month functional outcomes (Barthel Index score of 95-100 and modified Rankin Scale score of 0-1), good 3-month functional outcome (modified Rankin Scale score of 0-2), and 3-month infarct volume. Results- There was a significantly greater improvement in the 24-hour median percent change NIHSS among patients treated with alteplase compared with the placebo group (28% versus 15%; P=0.045) but not median delta NIHSS (3 versus 2; P=0.471). Receiver operating characteristic curve comparison showed that percent change NIHSS (ROC_percent) was better than delta NIHSS (ROC_delta) and admission NIHSS (ROC_admission) with regards to excellent 3-month Barthel Index (ROC_percent, 0.83; ROC_delta, 0.76; ROC_admission, 0.75), excellent 3-month modified Rankin Scale (ROC_percent, 0.83; ROC_delta, 0.74; ROC_admission, 0.78), and good 3-month modified Rankin Scale (ROC_percent, 0.83; ROC_delta, 0.76; ROC_admission, 0.78). Conclusions- In the NINDS rt-PA trial, alteplase was associated with a significant percent change improvement in NIHSS at 24 hours. Percent change in NIHSS may be a better surrogate marker of thrombolytic activity and 3-month outcomes.

Abstract 116: Predicting Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy: The TAG Score

Background: There is limited data on predictors of sICH in patients who underwent mechanical thrombectomy. In this study, we aim to determine those predictors with external validation.

Methods: We evaluated mechanical thrombectomy in a derivation cohort of patients at a comprehensive stroke center over a 30-month period. sICH was defined using the European Cooperative Acute Stroke Study III. We compared clinical and radiographic characteristics between patients with and without sICH to identify independent predictors of sICH with p<0.1. We then derived an sICH prediction score and validated it using the Blood Pressure After Endovascular Treatment (BEST) multicenter prospective registry.

Results: We identified 578 patients with acute ischemic stroke who received thrombectomy, 19 had sICH (3.3%). Predictive factors of sICH were: Thrombolysis in cerebral ischemia score, Alberta stroke program early computed tomography score (ASPECTS), and Glucose level, and using these predictors, we derived the weighted TAG score which was associated with sICH in the derivation (OR per unit increase 1.98, 95% CI 1.48-2.66, AUC=0.79) and validation (OR per unit increase 1.48, 95% CI 1.22-1.79, AUC=0.69) cohorts.

Conclusion: High TAG scores are associated with sICH in patients receiving mechanical thrombectomy. Larger studies are needed to validate this scoring system and test strategies to reduce sICH risk and make thrombectomy safer in patients with elevated TAG scores.

Abstract WP109: Redefining Early Neurological Improvement After Intravenous Tissue Plasminogen Activator Treatment of Stroke

Background and Purpose: Early neurologic improvement (ENI) in patients treated with alteplase has been shown to correlate with functional outcome. However, the definition of ENI remains controversial and has varied across studies. Current definitions take into account the absolute difference between the admission and 24-hour NIHSS but this difference is usually not reported as a function of the baseline NIHSS. We hypothesized that ENI defined as a percentage change in NIHSS (percent change NIHSS) at 24-hours would better correlate with favorable outcomes at 3 months than ENI defined as the change in NIHSS (delta NIHSS) at 24 hours.

Methods: Retrospective analysis of prospectively collected single center quality improvement data was performed of all acute ischemic stroke (AIS) patients treated with alteplase. Delta NIHSS was defined as the difference in admission and 24-hour NIHSS. Percent change NIHSS was defined as delta NIHSS divided by the admission NIHSS. We examined delta NIHSS and percent change NIHSS in unadjusted and adjusted logistic regression models as predictors of a favorable outcome at 3 months (defined as mRS 0-1).

Results: Among 586 patients with AIS treated with alteplase with admission NIHSS, 24-hour NIHSS, and 3-month mRS available, 194 (33.1%) had a favorable outcome at 3 months. The mean age was 65 years and 59% were men. In fully adjusted models, both delta NIHSS (OR per point decrease 1.27; 95% CI, 1.19– 1.36) and percent change NIHSS (OR per 10 percent decrease 1.17; 95% CI, 1.12-1.22) were associated with favorable functional outcome at 3 months. Receiver operating characteristic (ROC) curve comparison showed that the area under the ROC curve for percent change NIHSS (0.755) was greater than delta NIHSS (0.613) or admission NIHSS (0.694).

Conclusion: Percentage change in NIHSS may be a better surrogate marker of ENI and functional outcome in AIS patients after receiving acute thrombolytic therapy. More studies are needed to confirm our findings.

Abstract WP254: Insular Involvement of Ischemic Stroke Suggests a Cardioembolic Mechanism

Introduction: The insular cortex controls several aspects of vital function including autonomic regulation, and strokes affecting the insula have been associated with dysautonomia, cardiac dysfunction, and arrhythmias. Previous studies have shown an association between insular strokes, elevated troponin levels, and atrial fibrillation (AF). In this study, we aim to determine the association between cardiac biomarkers and insular involvement of the infarct and hypothesize that insular involvement implicates a cardioembolic source.

Methods: We abstracted data from a prospective comprehensive stroke center registry of consecutive patients with a discharge diagnosis of acute ischemic stroke who underwent brain imaging (CT or MRI) and work up to determine stroke mechanism. Data included demographics, clinical baseline variables, laboratory tests (including admission troponin level), and transthoracic echocardiographic variables (regional wall motion abnormalities, ejection fraction, and left atrial volume index), and stroke subtype. Multivariable logistic regression models were built to determine associations between AF, and cardiac biomarkers and insular infarcts.

Results: We identified 1224 patients who met the inclusion criteria; 397 (32.4%) had insular involvement of the infarct. In multivariable models, insular infarcts were associated with AF (adjusted OR 1.73, 95% CI 1.23-2.43, p = 0.001) and left atrial volume index (adjusted OR per standard deviation increase 1.30, 95% CI 1.13-1.49, p = 0.001). There was a trend for association between insular involvement and positive troponin level (adjusted OR 1.45 95% CI 0.91-2.33, p = 0.122) but not with regional wall motion abnormalities (adjusted OR 1.13, 95% CI 0.69-1.84, p = 0.627). Insular involvement was associated with cardioembolic stroke subtype (45.8% vs. 26.7%, p<0.001) but not other stroke subtypes.

Conclusion: The insular cortex is commonly involved in patients with atrial fibrillation and/or atrial dilation and maybe a neuroimaging biomarker of cardioembolic stroke. Larger studies are needed to confirm this association and test anticoagulation therapy in patients with insular infarcts.

Abstract WMP47: Poor Risk Factor Control and Lower Levels of Physical Activity Predict Incident Major Cardiovascular Events in Patients With Symptomatic Vertebrobasilar Disease: A Post-Hoc Analysis of the SAMMPRIS Trial

Background: Symptomatic vertebrobasilar (VB) atherosclerotic disease is associated with a high risk of recurrent stroke despite optimal medical therapy.

Objective: In this study, we aim to examine the prognosis and associations between risk factors and recurrent major cardiovascular events (MACE) in patients with symptomatic VB stenosis randomized in the medical arm of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study.

Methods: Data from subjects in the medical arm of the SAMMPRIS trial with an infarct in the territory of vertebral or basilar arteries (n= 73) were analyzed. The primary outcome was MACE: defined as stroke, myocardial infarction, or other cardiovascular death during follow up. Mean risk factor values were compared between subjects who met the primary outcome at 2 years versus those who did not, using T-tests and χ2 tests.

Results: Among 73 patients with VB stenosis randomized to medical treatment, 18 patients (24.6%) had recurrent MACE over a mean follow up of 2.8 years. This was significantly less than the rate of MACE in those with VB enrolled in the WASID trial (9.7 per 100-patient years vs. 20.9 per 100-patient years, p<0.01). Predictors of MACE at 2 years were increased triglyceride level (adjusted OR per 50 units increase in triglyceride 1.94, 95% CI 1.15-3.28) and increased HbA1c level (adjusted OR per 1 unit increase in HbA1c 2.07, 95% CI 0.97-4.45), and lower physical activity status measured by PACE (out of target defined by PACE ≤ 4: moderate activity < 5 days per week or intense activity < 3 days per week) (2.5 ± 1.0 vs. 3.3 ± 1.8, p = 0.028) (Table).

Conclusions: In patients with symptomatic VB disease, improvement of medical treatment over time led to a reduction in cardiovascular event rates but this risk remains elevated as nearly 1 in 5 patients had MACE within 2 years. Further risk factor optimization and lifestyle changes are needed to reduce the rates of MACE in this patient population.

Abstract WP106: Redefined Measure of Early Neurological Improvement Shows Treatment Benefit of Intravenous Tissue Plasminogen Activator Treatment in NINDS Rt-PA Acute Stroke Trial at 24 Hours

Background and Purpose: The first of the 2 NINDS Stroke Study trials did not show a significant increase in early neurological improvement (ENI), defined as NIHSS improvement by ≥ 4, with alteplase treatment. We hypothesized that ENI defined as a percentage change in NIHSS (percent change NIHSS) at 24 hours is superior to other definitions in predicting 3-month functional outcomes and using this definition there would be treatment benefit of alteplase over placebo at 24 hours.

Methods: We analyzed the NINDS rt-PA Stroke Study (Parts 1 and 2) trial data. Percent change NIHSS was defined as [(admission NIHSS score–24-hour NIHSS score)x100/admission NIHSS score] and delta NIHSS as (admission NIHSS score–24-hour NIHSS score). We compared ENI using these definitions between alteplase vs. placebo patients. We also used receiver operating characteristic (ROC) curve to determine the predictive association of ENI with excellent 3-month functional outcomes [Barthel Index (BI) score 95 – 100 and modified Rankin scale (mRS) 0-1], good 3-month functional outcome (mRS 0-2) and 3-month infarct volume.

Results: There was a significantly greater improvement in the 24-hour median percent change NIHSS among patients treated with alteplase compared to the placebo group (28% vs. 15%, p = 0.045) but not median delta NIHSS (3 vs. 2, p = 0.471). ROC curve comparison showed that percent change NIHSS (ROC percent ) was better than delta NIHSS (ROC delta ) and admission NIHSS (ROC admission ) with regards to excellent 3-month BI (ROC percent 0.83, ROC delta 0.76, ROS admission 0.75), excellent 3-month mRS (ROC percent 0.83, ROC delta 0.74, ROS admission 0.78), and good 3-month mRS (ROC percent 0.83, ROC delta 0.76, ROS admission 0.78). Percentage change had a stronger association with 90-day infarct volume than delta NIHSS score and both delta NIHSS and percent change in NIHSS were more pronounced with faster treatment times.

Conclusion: In the NINDS rt-PA trial, alteplase was associated with a significant percent change improvement in NIHSS at 24 hours. Percent change in NIHSS may be a better surrogate marker of thrombolytic activity and 3-month outcomes.

Abstract WP381: Modafinil in Recovery After Stroke: A Retrospective Study

Background: Acute rehabilitation is known to enhance stroke recovery. However, post-stroke lethargy and fatigue can hinder participation in rehabilitation therapies. We hypothesized that in patients with moderate to severe stroke, early stimulant therapy with modafinil increases favorable discharge disposition defined as transfer to acute rehabilitation.

Methods: We retrospectively reviewed a cohort of patients with acute stroke admitted over a 3 year period. Patients were excluded for low NIH Stroke Scale score (below 5) or absence of confirmed stroke on brain imaging. We compared patients that were treated with modafinil 50-200mg to those managed with standard care. The primary outcome measure was discharge disposition. Secondary outcome was modified Rankin Score after discharge. Statistical significance was determined using chi-square test for association and logistic regression models.

Results: The study cohort included 199 patients (145 ischemic, 54 hemorrhagic). 72 (36.2%) were treated with modafinil and 129 (64.8%) were discharged to acute rehab. Median NIHSS for modafinil patients vs standard care patients was higher but did not reach statistical significance (median (IQR): 13.5 (15) vs 11 (10), p=0.059). In adjusted models, modafinil was associated with higher odds of favorable discharge disposition (OR 2.00, 95% CI 1.01-3.95). Favorable outcome at 90 days (mRS ≤ 2) occurred more frequently with modafinil (5.6% vs. 3.3%) but this did not achieve statistical significance (p>0.1). The benefit of modafinil was seen across all subgroups of patients, except those with severe stroke (NIHSS > 15). There were no significant complications clearly linked to modafinil administration.

Conclusions: Modafinil use in acute stroke patients with moderate to severe stroke was associated with improved discharge disposition. Randomized controlled trials are needed to further study the safety, efficacy, and long-term effects of modafinil in this population.

Abstract TP421: Cardiovascular Risk in Patients With Symptomatic Intracranial Atherosclerosis: A Post-Hoc Analysis of the SAMMPRIS Trial

Introduction: Previous studies have shown an elevated risk of MI (MI) in patients with symptomatic intracranial atherosclerotic disease (sICAD), but the mediators of increased risk of MI or death in these patients remain uncertain. We aim to determine risk factors associated with MI or death in patients with symptomatic ICAD.

Methods: Patients enrolled in SAMMPRIS had sICAD and were randomized to aggressive medical management (AMM) vs. stenting and AMM. The primary outcome of this post-hoc analysis is MI or vascular death within 2 years of follow-up. We excluded patients who were lost to follow up, had a stroke during follow up, had non-vascular death or death within 30 days of stenting. Patients meeting the inclusion criteria were divided into two groups: those with vs. those without the primary outcome. We used binary logistic regression to determine predictors of incident MI or death within 2 years.

Results: Of the 451 patients enrolled in SAMMPRIS, 350 patients met the inclusion criteria (reasons for exclusion: 4 deaths occurring within 30 days of stenting, 63 with ischemic stroke, 6 with symptomatic hemorrhage, 7 patients with non-cardiovascular death within 2 years, and 21 lost to follow up). At 2 years, 17 patients (4.9%) had MI/death; 10 patients had MI and 7 had cardiovascular deaths. In a multivariable model, factors associated with MI/death were: history of coronary artery disease (adjusted OR 3.19, 95% CI 1.14 - 8.93, p = 0.027) and systolic blood pressure (adjusted OR per 10 mm increase 1.20, 95% CI 0.98 - 1.44, p = 0.080). This risk was abut 24% with both predictors present and 2.8% with them absent (Figure).

Conclusion: Higher systolic blood pressure and pre-existing cardiovascular disease were independently associated with incident MI or vascular death in patients with sICAD, despite medical management. Further studies are needed to confirm this association and test interventions to reduce this risk.

Abstract TP174: Identifying Predictors for Final Diagnosis of Ischemic Events in an Emergency Department Observation Unit

Introduction: Transient neurologic events have high rates of diagnostic uncertainty. Emergency department observation units (ED-OU) allow an accelerated diagnostic work up for suspected transient ischemic attacks (TIAs). However, clinical decision support regarding which patients to admit to these units is lacking. This study aimed to identify clinical features that differentiate true ischemic events from nonischemic transient neurological attacks (NI-TNA) among patients admitted to an ED-OU for suspected TIA.

Methods: A retrospective analysis was performed on consecutive patients admitted to the ED-OU at a single academic center for suspected TIA. Demographics, vascular risk factors, presenting symptoms, and details of the clinical presentation were abstracted from chart review. Final discharge diagnosis was dichotomized to either ischemic event (TIA or minor stroke, TIAMS) or NI-TNA based on the treating vascular neurologist’s final diagnosis. Standard statistical tests were used for comparison testing between the two groups. Significantly different factors with p<0.2 on univariate analysis were carried forward in a multivariable logistic regression model.

Results: Of 186 consecutive patients, 101 (54%) had a final diagnosis of NI-TNA and 85 (46%) of TIAMS. The median population ABCD2 score was 4 [IQR 3-4]. On univariate analysis, older age (63 vs. 70, p<0.01), history of atrial fibrillation (AF) (12% vs. 26%, p=0.01), and facial weakness (5% vs. 14% p=0.03) were associated with TIAMS. Headache (24% vs. 12%, p=0.04) and symptom duration>60min (57% vs. 40%, p=0.02) were associated with NI-TNA. On multivariable analysis, only symptom duration>60 minutes predicted NI-TNA (OR 0.39, p=0.04) and only history of AF (OR 2.53, p=0.03) predicted TIAMS. Facial weakness was strongly predictive of TIAMS (OR 3.22, p=0.05), but not significant.

Conclusion: We identified two clinical features that distinguished TIAMS from NI-TNA among patients admitted to an ED-OU for suspected TIA.These may be helpful in emergency room triage of TIAMS. Data from ED-OU can be used to identify factors associated with cerebral ischemia and improve current care pathways for patients with suspected TIA, so diagnostic evaluation is received in the most appropriate setting.

Abstract WP183: Borderzone Infarcts Predict Early Recurrence in Patients With Large Artery Atherosclerotic Subtype Despite Medical Treatment

Introduction: Large artery atherosclerosis subtype carries a high risk of early recurrent stroke despite medical management. Predictors of recurrence remain poorly understood. We hypothesized that borderzone infarcts are associated with a higher risk of recurrence.

Objectives: We aim to investigate infarct patterns and 90-day recurrence in patients with symptomatic intracranial and/or extracranial atherosclerotic disease.

Methods: We included consecutive patients admitted to NYU Langone Health (Manhattan and Brooklyn campuses) over 32-months with a diagnosis of acute ischemic stroke secondary to symptomatic intracranial or extracranial atherosclerosis. The primary predictor was infarct pattern (borderzone vs. non-borderzone infarction), defined in accordance to previous studies. Borderzone infarcts were divided into internal borderzone and cortical borderzone. We used univariate and multivariable cox-regression models to determine associations between infarct pattern and recurrent cerebrovascular events (RCVE) at 90-days.

Results: Fifty-five patients met the inclusion criteria; 38 were intracranial, 3 tandem, 14 extracranial. Nearly 71% of patients were treated with dual antiplatelet therapy and 96% were treated with high intensity statin. The RCVE rate was 23.6%. In multivariable models, borderzone infarcts were associated with increased risk of RCVE (adjusted HR 9.8 95% CI 2.1-44.8, p=0.003). The risk of RCVE was highest among internal borderzone infarcts (47.3%) as opposed to cortical borderzone infarcts (33.3%) or non borderzone infarcts (18.8%).

Conclusions: Borderzone (and particularly internal borderzone) infarcts are a surrogate marker of impaired distal blood flow and are associated with RCVE despite medical treatment. This highlights the need to develop alternate treatment strategies for this high-risk cohort.

Abstract TP289: Diagnostic Evaluation of Patients Admitted to Emergency Department Observation Unit for Suspected TIA

Introduction: Emergency department observation units (ED-OU) allow patients with a suspected transient ischemic attack (TIA) an expedited workup without the need for a prolonged inpatient admission. Despite risk stratification scores and physician evaluation, however, the reliability in diagnosis of TIA remains poor, which may lead to unnecessary testing. This study aimed to identify and compare the diagnostic workup between patients with final diagnosis of true vascular events (TIA or minor stroke, TIAMS) versus nonischemic transient neurological attacks (NI-TNA) in suspected TIA patients admitted to an ED observation unit.

Methods: A retrospective analysis was performed on consecutive patients who were admitted to an ED-OU at a single center for suspected TIA. All diagnostic testing obtained during observation stay was abstracted from chart review. Final discharge diagnosis was dichotomized to either TIAMS or NI-TNA. Standard statistical tests were used for comparison testing between the two groups with significance defined as p<0.05.

Results: Of 186 suspected TIA patients admitted to an ED-OU, median ABCD2 score was 4 [IQR 3-4]. Final diagnosis was TIAMS in 85 (46%) patients and NI-TNA in 101 (54%) patients. A total of 182 (98%) patients had non-contrast head CT (NCHCT); 160 (86%) brain MRI; 117 (63%) extracranial vessel imaging; 116 (62%) transthoracic echocardiogram (TTE); and 108 (58%) intracranial vessel imaging. Assessing diagnostic work-up by final diagnosis, TTE (78% vs 40%, p<0.01), and extracranial imaging (75% vs 55%, p<0.01) were more common in patients with TIAMS. Restricted diffusion on MRI (27% vs. 2%, p<0.01) and abnormality on TTE (50% vs. 28% p=0.02) were more common in TIAMS patients. The overall rate of symptomatic stenosis was low: 1 patient had a symptomatic carotid and 4 patients had symptomatic intracranial stenosis.

Conclusion: Extensive diagnostic testing is done on patients with suspected TIA admitted to ED-OU, with more studies acquired on patients with true ischemic events as compared to NI-TNA. As the use of ED-OUs increases, refinement of current diagnostic testing algorithms to reduce workup for cerebrovascular disease among patients with NI-TIA and among different ischemic stroke subtypes is warranted.

Predicting symptomatic intracranial haemorrhage after mechanical thrombectomy: the TAG score

BACKGROUND

There is limited data on predictors of symptomatic intracranial haemorrhage (sICH) in patients who underwent mechanical thrombectomy. In this study, we aim to determine those predictors with external validation.

METHODS

We evaluated mechanical thrombectomy in a derivation cohort of patients at a comprehensive stroke centre over a 30-month period. Clinical and radiographic data on these patients were obtained from the prospective quality improvement database. sICH was defined using the European Cooperative Acute Stroke Study III. We compared clinical and radiographic characteristics between patients with and without sICH using χ² and t tests to identify independent predictors of sICH with p<0.1. Significant variables were then combined in a multivariate logistic regression model to derive an sICH prediction score. This score was then validated using data from the Blood Pressure After Endovascular Treatment multicentre prospective registry.

RESULTS

We identified 578 patients with acute ischaemic stroke who received thrombectomy, 19 had sICH (3.3%). Predictive factors of sICH were: thrombolysis in cerebral ischaemia (TICI) score, Alberta stroke program early CT score (ASPECTS), and glucose level, and from these predictors, we derived the weighted TICI-ASPECTS-glucose (TAG) score, which was associated with sICH in the derivation (OR per unit increase 1.98, 95% CI 1.48 to 2.66, p<0.001, area under curve ((AUC)=0.79) and validation (OR per unit increase 1.48, 95% CI 1.22 to 1.79, p<0.001, AUC=0.69) cohorts.

CONCLUSION

High TAG scores are associated with sICH in patients receiving mechanical thrombectomy. Larger studies are needed to validate this scoring system and test strategies to reduce sICH risk and make thrombectomy safer in patients with elevated TAG scores.

Possible Empirical Evidence of Glymphatic System on Computed Tomography After Endovascular Perforations

BACKGROUND

The glial-lymphatic pathway is a fluid-clearance pathway consisting of a para-arterial route for the flow of cerebrospinal fluid along perivascular spaces and subsequently toward the brain interstitium. In this case series, we aim to investigate an empirical demonstration of glymphatic clearance of extravasated iodine following perforation incurred during endovascular therapy on serial computed tomography.

METHODS

Six consecutive cases of endovascular perforation during thrombectomy performed between 2005 and 2018 were retrospectively collected by searching our internal database of total 446 thrombectomies. Two cases were excluded because care was withdrawn shortly following the procedure and no follow-up imaging was available. One case was excluded because a ventricular drain was placed. Three cases were hence included in this analysis.

RESULTS

All 3 cases demonstrated progressive absorption of contrast by the brain parenchyma with eventual contrast disappearance.

CONCLUSIONS

We described a likely in vivo computed tomography correlate of the glymphatic system in a cohort of patients who sustained intraprocedural extravasation during thrombectomy for acute ischemic stroke.

P686Cancer is not associated with increased cardiac and bleeding events after 2nd- and 3rd-generation drug-eluting stents implantation

Background

Previous studies demonstrated the impact of concomitant cancer on the increased risk of adverse cardiac and bleeding events after percutaneous coronary intervention (PCI). However, the impact in this 2nd- and 3rd-generation drug-eluting stent (DES) era remains to be elucidated.

Purpose

To clarify the impact of cancer on clinical outcomes in patients after 2nd- or 3rd -generation DES implantation.

Methods

A total of 932 patients who underwent PCI with 2nd- or 3rd -generation DES were included. Patients who were diagnosed with cancer after PCI were excluded from the present cohort. The incidence of major adverse cardiac events (MACE) including cardiac death, myocardial infarction and target or non-target vessel revascularization, and bleeding events was compared between the patients with cancer or the history of treatment for cancer (cancer group, n=140) and the patients without cancer (no cancer group, n=792). Bleeding events were evaluated according to the Thrombolysis in Myocardial Infarction definition. Further comparisons were performed between the 2 groups (cancer group, n=126; no cancer group, n=252) after the adjustment of baseline clinical characteristics using 1:2 propensity score-matching analysis.

Results

The incidence of MACE at median 577 [340–1043] days after the PCI was comparable between the 2 groups in both unadjusted (15.0% vs. 15.0%, p=0.984) (Panel A) and adjusted cohorts (14.3 vs. 13.1%, p=0.796), although the incidence of all cause death in the cancer group was significantly greater than the no cancer group (15.1 vs. 9.5%, p=0.007, in the adjusted cohort). The increased risk of MACE was not observed in any types of cancer or treatment (Panel B). The incidence of bleeding events was also comparable between the 2 groups (4.0 vs. 2.0%, p=0.297, in the adjusted cohort).

Conclusion

The increased incidence of MACE and bleeding events in patients with cancer was not demonstrated after the 2nd- or 3rd-generation DES implantation. Further studies are required to clarify the safety and efficacy of PCI in patients with cancer.

Impacts of climate change on snow accumulation and melting processes over mountainous regions in Northern California during the 21st century

A point-location-based analysis of future climate change impacts on snow accumulation and melting processes was conducted over three study watersheds in Northern California during a 90-year future period by means of snow regime projections. The snow regime projections were obtained by means of a physically-based snow model with dynamically downscaled future climate projections. Then, atmospheric and snow-related variables, and their interrelations during the 21st century were investigated to reveal future climate change impacts on snow accumulation and melting processes. The analysis shows large reductions in snow water equivalent (SWE), snowfall to precipitation (S/P) ratio, and snowmelt through the 21st century. Timing of the peak of the SWE and snowmelt will also change in the future. Meanwhile, the analysis in this study shows that air temperature rise will affect, but will not dominate the future change in snowmelt over the study watersheds. This result implies the importance of considering atmospheric variables other than air temperature, such as precipitation, shortwave radiation, relative humidity, and wind speed even if these variables will not clearly change during the 21st century.

P6339Sequential organ failure assessment score on admission predicts long-time mortality of the patients with acute heart failure

Background

Despite the remarkable advances in the treatment options of acute heart failure (HF), prognosis assessment remains an ongoing challenge. Previous studies revealed only a moderate accuracy of models predicting mortality. Sequential Organ Failure Assessment (SOFA) Score are widely used in the intensive care unit (ICU) to predict outcome and predicted higher long-time mortality in unselected patients in cardiac ICU. In addition, the American Heart Association Get With the Guidelines–Heart Failure (GWTG-HF) risk score allows for risk stratification of 30-day outcome for patients hospitalized with HF. The purpose of this study was to evaluate whether SOFA score on admission is useful for long-time mortality prediction in acute HF patients and also to assess the discriminative performance as compared with GWTG-HF risk score.

Methods

This was a single-centre, retrospective cohort study. Between January 2007 and December 2016, we screened eligible 661 consecutive patients with acute HF administered at our hospital. SOFA score on admission of 294 patients was able to calculate retrospectively. We enrolled 269 patients who could complete follow up evaluation for more than 1 year. Endpoint was all-cause mortality after admission. Additive information of SOFA score was evaluated by area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA).

Results

The 269 patients were included in this study (78.5±10.9 years; 136 men; left ventricular ejection fraction [EF], 49.8±16.6%) during a mean follow-up of 32.1±22.3 months. Patients with all-cause death had higher SOFA score (4.2±2.3 versus 2.8±1.8, p<0.001; AUC, 0.689) and GWTG-HF risk score (44.0±7.6 versus 38.1±7.9, P<0.001, AUC, 0.692).

Kaplan-Meier survival analysis demonstrated higher SOFA scores (P<0.001) and GWTG-HF risk scores (P<0.001) appears to be related to increase probabilities of all cause death. A multivariate Cox proportional hazard model were made with adjustment for SOFA score, GWTG-HF risk score, age, gender and ejection fraction. As a result, SOFA score (hazard ratio [HR] 1.227; 95% confidence interval [CI], 1.130 to 1.326; P<0.001), GWTG-HF (HR, 1.054; 95% CI, 1.029 to 1.078; P<0.001) and age (HR, 1.069; 95% CI 1.048 to 1.092; P<0.001) were independent predictors of all cause death and HR of SOFA score was the highest in these parameters. Incorporating SOFA score into GWTG-HF score yielded a significant NRI (0.528 (95% CI 0.291 to 0.765) and IDI (0.046 (95% CI 0.020 to 0.072). In DCA, compared with the reference model, the net benefit for SOFA score model was greater across the range of threshold probabilities.

Conclusions

The SOFA score, simple and validated mortality risk score can predict long-term all-cause mortality in patients with acute HF. Discriminative performance metrics such as NRI, IDI and DCA were improved on incorporation of the SOFA score for prediction of mortality.

Development and validation of the comprehensive assessment scale for chemotherapy-induced peripheral neuropathy in survivors of cancer

Background

Appropriate assessment is essential for the management of chemotherapy-induced peripheral neuropathy (CIPN), an intractable symptom that cannot yet be palliated, which is high on the list of causes of distress for cancer patients. However, objective assessment by medical staff makes it easy to underestimate the symptoms and effects of CIPN in cancer survivors. As a result, divergence from subjective evaluation of cancer survivors is a significant problem. Therefore, there is an urgent need to develop a subjective scale with high accuracy and applicability that reflects the experiences of cancer patients. We developed a comprehensive assessment scale for CIPN in cancer survivors, named the Comprehensive Assessment Scale for Chemotherapy-Induced Peripheral Neuropathy in Survivors of Cancer (CAS-CIPN), and demonstrated its reliability and validity.

Methods

We developed a questionnaire based on qualitative studies of peripheral neuropathy in Japanese cancer patients and literature review. Twelve cancer experts confirmed the content validity of the questionnaire. A draft version comprising 40 items was finalized by a pilot test on 100 subjects. The participants in the present study were 327 Japanese cancer survivors. Construct validity was determined by factor analysis, and internal validity by confirmation factor analysis and Cronbach’s α.

Results

Factor analysis showed that the structure consisted of 15 items in four dimensions: “Threatened interference in daily life by negative feelings”, “Impaired hand fine motor skills”, “Confidence in choice of treatment/management,” and “Dysesthesia of the palms and soles.” The CAS-CIPN internal consistency reliability was 0.826, and the reliability coefficient calculated using the Spearman-Brown formula [q = 2r/(1 + r)] was 0.713, confirming high internal consistency and stability. Scores on this scale were strongly correlated with Gynecologic Oncology Group-Neurotoxicity scores (r = 0.714, p < 0.01), confirming its criterion-related validity.

Conclusions

The CAS-CIPN is an assessment tool with high reliability and validity for the comprehensive evaluation of CIPN in cancer survivors. The CAS-CIPN is simple to use, and can be used by medical professionals for appropriate situational assessment and intervention.

New precise measurements of muonium hyperfine structure at J-PARC MUSE

High precision measurements of the ground state hyperfine structure (HFS) of muonium is a stringent tool for testing bound-state quantum electrodynamics (QED) theory, determining fundamental constants of the muon magnetic moment and mass, and searches for new physics. Muonium is the most suitable system to test QED because both theoretical and experimental values can be precisely determined. Previous measurements were performed decades ago at LAMPF with uncertainties mostly dominated by statistical errors. At the J-PARC Muon Science Facility (MUSE), the MuSEUM collaboration is planning complementary measurements of muonium HFS both at zero and high magnetic field. The new high-intensity muon beam that will soon be available at H-Line will provide an opportunity to improve the precision of these measurements by one order of magnitude. An overview of the different aspects of these new muonium HFS measurements, the current status of the preparation for high-field measurements, and the latest results at zero field are presented.

Analysis of future climate change impacts on snow distribution over mountainous watersheds in Northern California by means of a physically-based snow distribution model

The impacts of climate change on snow distribution through the 21st century were investigated over three mountainous watersheds in Northern California by means of a physically-based snow distribution model. The future climate conditions during a 90-year future period from water year 2010 to 2100 were obtained from 13 future climate projection realizations from two GCMs (ECHAM5 and CCSM3) based on four SRES scenarios (A1B, A1FI, A2, and B1). The 13 future climate projection realizations were dynamically downscaled at 9 km resolution by a regional climate model. Using the downscaled variables based on the 13 future climate projection realizations, snow distribution over the Feather, Yuba, and American River watersheds (FRW, YRW, and ARW) was projected by means of the physically-based snow model. FRW and YRW watersheds cover the main source areas of the California State Water Project (SWP), and ARW is one of the key watersheds in the California Central Valley Project (CVP). SWP and CVP are of great importance as they provide and regulate much of the California's water for drinking, irrigation, flood control, environmental, and hydro-power generation purposes. Ensemble average snow distribution over the study watersheds was calculated over the 13 realizations and for each scenario, revealing differences among the scenarios. While the snow reduction through the 21st century was similar between A1B and A2, the snow reduction was milder for B1, and more severe for A1FI. A significant downward trend was detected in the snowpack over nearly the entire watershed areas for all the ensemble average results.

How Does Preexisting Hypertension Affect Patients with Intracerebral Hemorrhage?

BACKGROUND AND PURPOSE

Patients with intracerebral hemorrhage (ICH) frequently present with hypertension, but it is unclear if this is due to pre-existing hypertension (prHTN) or to the bleed itself or associated pain. We sought to assess the relationship between prHTN and admission systolic blood pressure (aBP) and bleed severity.

METHODS

We retrospectively assessed the relationship between prHTN and aBP and NIHSS in patients with ICH at 3 institutions.

RESULTS

Of 251 patients, 170 (68%) had prHTN based on history of hypertension/antihypertensive use. Median aBP was significantly higher in those with prHTN (155 mm Hg (IQR 135-181) versus 139 mm Hg (IQR 124-158), P < .001). Patients with left ventricular hypertrophy (LVH) on electrocardiogram (ECG) or transthoracic echocardiogram (TTE) had significantly higher aBP than those without LVH (median aBP 195 mm Hg (IQR 155-216) for patients with LVH on ECG versus 147 mm Hg (IQR 129-163) for patients with no LVH on ECG, P < .001; median aBP 181 mm Hg (IQR 153-214) for patients with LVH on TTE versus 152 mm Hg (IQR 137-169) for patients with no LVH on TTE, P = .01). prHTN was associated with a higher median NIHSS (11 (IQR 3-20) for patients with history of hypertension/antihypertensive use versus 6 (IQR 1-14) for patients without this history (P = .02); 9 (IQR 3-19) versus 5 (IQR 2-13) for patients with/without LVH on ECG (P = .085); and 10 (IQR 5-18) versus 5 (IQR 1-13) for patients with/without LVH on TTE (P = .046).

CONCLUSIONS

Patients with ICH who have prHTN have higher aBP and NIHSS, suggesting that prHTN may worsen reactive hypertension in the setting of ICH.

Muons at ISIS

For the last 30 years, muon experiments at ISIS pulsed neutron and muon facility at the Rutherford Appleton Laboratory, Oxfordshire have been making a significant contribution to a number of scientific fields. The muon facilities at ISIS consist of eight experimental areas. The European Commission Muon facility consists of three experimental areas with a fixed momentum (28 MeV c^-1). The RIKEN-RAL facility has a variable momentum (17-90 MeV c^-1) and a choice of negative or positive muons delivering muons to four experimental areas. There is also an area recently used for a muon ionization cooling experiment. In this paper, the ISIS pulsed muon facilities are reviewed, including the beam characteristics that could be useful for muography experiments.This article is part of the Theo Murphy meeting issue 'Cosmic-ray muography'.

Depth dependant element analysis of PbMg1/3Nb2/3O3 using muonic x-rays

The relaxor PbMg_1/3Nb_2/3O₃ (PMN) has received attention due to its potential applications as a piezoelectric when doped with PbTiO₃ (PT). Previous results have found that there are two phases existing in the system, one linked to the near-surface regions of the sample, the other in the bulk. However, the exact origin of these two phases is unclear. In this paper, depth dependant analysis results from negative muon implantation experiments are presented. It is shown that the Pb content is constant throughout all depths probed in the sample, but the Mg and Nb content changes in the near-surface region below 100 μm. At an implantation depth of 60 μm, it is found that there is a 25% increase in Mg content, with a simultaneous 5% decrease in Nb content in order to maintain charge neutrality. These results show that the previously observed skin effects in PMN are due to a change in concentration and unit cell.

Abstract WP290: A Resident-Driven Intervention to Decrease Door-to-Needle Time and Increase Resident Satisfaction in a Resource-Limited Setting

Introduction: Neurology residents are often the first-line responders to emergency department (ED) stroke codes, however their role in initiating stroke systems changes is not well established. At a large, resource-limited public hospital, neurology residents developed a protocol for acute stroke codes focused on improved interdisciplinary communication.

Methods: Process mapping was used to identify current state deficiencies. Poor communication between neurology residents and ED physicians, nurses, and radiology techs and role redundancy were identified as core deficiencies. Ideal and future state maps were used to create a stroke code workflow diagram (the “protocol”). Changes included assigning specific responsibilities to each team member, and forcing interdisciplinary communication at specific points in the process (i.e. ED physician calls tech when patient goes to CT). The protocol was implemented in May 2016. Median door-to-needle (DTN) times were compared in the pre-intervention (January 1, 2014 - April 30, 2016) and post-intervention (May 1, 2016 - June 15, 2017) periods using non-parametric tests. Resident satisfaction with communication during stroke codes was measured using pre- and post-intervention surveys; responses were compared with t-test.

Results: A total of 66 patients received tPA, 20 (30%) in the post-intervention period. Baseline demographics and NIHSS did not differ in the pre- and post-intervention periods, however median DTN decreased (58 vs. 40 min, p=0.02) and proportion of DTN≤45 minutes doubled (30% vs. 60%, p=0.03) in the post-intervention period. Twenty-three residents (79%) completed pre-intervention surveys; 19 residents (64%) completed post-intervention surveys. Resident satisfaction was greater in the post-intervention period with respect to stroke team communication (2.8 vs. 3.6, p=0.01), understanding multidisciplinary roles (3.8 vs. 4.3, p=0.03), and interaction between team members (3.2 vs. 3.8, p=0.03) measured using a five-point scale (higher being better).

Conclusion: In a resource-limited setting, neurology residents are capable of implementing acute stroke workflow changes using basic process improvement methods that have a measurable impact on DTN and resident satisfaction.

Maximizing T c by tuning nematicity and magnetism in FeSe1-x S x superconductors

A fundamental issue concerning iron-based superconductivity is the roles of electronic nematicity and magnetism in realising high transition temperature (T c). To address this issue, FeSe is a key material, as it exhibits a unique pressure phase diagram involving non-magnetic nematic and pressure-induced antiferromagnetic ordered phases. However, as these two phases in FeSe have considerable overlap, how each order affects superconductivity remains perplexing. Here we construct the three-dimensional electronic phase diagram, temperature (T) against pressure (P) and isovalent S-substitution (x), for FeSe1-x S x . By simultaneously tuning chemical and physical pressures, against which the chalcogen height shows a contrasting variation, we achieve a complete separation of nematic and antiferromagnetic phases. In between, an extended non-magnetic tetragonal phase emerges, where T c shows a striking enhancement. The completed phase diagram uncovers that high-T c superconductivity lies near both ends of the dome-shaped antiferromagnetic phase, whereas T c remains low near the nematic critical point.

Trend analysis of watershed-scale precipitation over Northern California by means of dynamically-downscaled CMIP5 future climate projections

The impacts of climate change on watershed-scale precipitation through the 21st century were investigated over eight study watersheds in Northern California based on dynamically downscaled CMIP5 future climate projections from three GCMs (CCSM4, HadGEM2-ES, and MIROC5) under the RCP4.5 and RCP8.5 future climate scenarios. After evaluating the modeling capability of the WRF model, the six future climate projections were dynamically downscaled by means of the WRF model over Northern California at 9km grid resolution and hourly temporal resolution during a 94-year period (2006-2100). The biases in the model simulations were corrected, and basin-average precipitation over the eight study watersheds was calculated from the dynamically downscaled precipitation data. Based on the dynamically downscaled basin-average precipitation, trends in annual depth and annual peaks of basin-average precipitation during the 21st century were analyzed over the eight study watersheds. The analyses in this study indicate that there may be differences between trends of annual depths and annual peaks of watershed-scale precipitation during the 21st century. Furthermore, trends in watershed-scale precipitation under future climate conditions may be different for different watersheds depending on their location and topography even if they are in the same region.

Radiological and clinical comparison of kinematically versus mechanically aligned total knee arthroplasty

AIMS

The aim of this study was to compare the post-operative radiographic and clinical outcomes between kinematically and mechanically aligned total knee arthroplasties (TKAs).

PATIENTS AND METHODS

A total of 60 TKAs (30 kinematically and 30 mechanically aligned) were performed in 60 patients with varus osteoarthritis of the knee using a navigation system. The angles of orientation of the joint line in relation to the floor, the conventional and true mechanical axis (tMA) (the line from the centre of the hip to the lowest point of the calcaneus) were compared, one year post-operatively, on single-leg and double-leg standing long leg radiographs between the groups. The range of movement and 2011 Knee Society Scores were also compared between the groups at that time.

RESULTS

The angles of orientation of the joint line in the kinematic group changed from slight varus on double-leg standing to slight valgus with single-leg standing. The mechanical axes in the kinematic group passed through a neutral position of the knee in the true condition when the calcaneus was considered. The post-operative angles of flexion and functional activity scores were significantly better in the kinematic than in the mechanical group (p < 0.003 and 0.03, respectively).

CONCLUSION

A kinematically aligned TKA results in a joint line which has a more parallel orientation in relation to the floor during single- and double-leg standing, and more neutral weight-bearing in tMA than a mechanically aligned TKA. Cite this article: Bone Joint J 2017;99-B:640-6.

Does Neuroticism Influence Oral Health-Related QOL in Patients with Removable Partial Dentures?

This prospective cohort study investigated the relationship between patient neuroticism and oral health-related quality of life (OHRQoL) before and after prosthetic treatment as well as changes in OHRQoL-namely, treatment efficacy. Sixty-three patients (23 men and 40 women; mean age 67.2 ± 8.6 years), who were scheduled to receive new removable partial dentures (RPDs), were recruited. OHRQoL was assessed using the Japanese version of the Oral Health Impact Profile (OHIP-J). The Japanese version of the NEO Five-Factor Inventory (NEO-FFI) was used to assess neuroticism. Spearman's rank correlation coefficient was calculated to determine the association between neuroticism and OHIP-J scores before and after treatment. After stratifying patients according to neuroticism score, the Wilcoxon signed-rank test was used for intragroup comparison of OHIP-J scores before and after treatment. Moreover, logistic regression analysis was used to determine the impact of covariates on treatment efficacy such as age, sex, Eichner classification, neuroticism, changes in maximal occlusal force, and OHIP-J scores before treatment. Statistical analyses showed that higher neuroticism scores were associated with higher total OHIP-J scores before treatment ( r = 0.41, P = 0.001) but were not associated with OHIP-J scores after treatment ( r = 0.07, P = 0.566). When the effect of all independent variables was analyzed in multivariate analysis, neuroticism and OHIP-J scores before treatment affected treatment efficacy. These results suggest that OHRQoL of patients with higher levels of neuroticism was low before prosthetic treatment but significantly improved by oral rehabilitation with RPDs to the same level as patients with lower levels of neuroticism. Knowledge Transfer Statement: The results of this study may change the clinical perception of the effect of prosthetic rehabilitation with removable partial dentures in patients with higher levels of neuroticism. The study concluded that prosthetic rehabilitation could contribute toward satisfaction even in neurotic patients, who are presumed to show less satisfaction with their oral status.