Abstract TP243: IMPACT: I nfluence of M ultiple P rocess of care A ssessment times on C erebral ischemia T reatment and outcomes

Background: Get With the Guidelines (GWTG) emphasizes a focus on process of care times in the acute stroke evaluation to optimize door to needle time. We looked at acute process of care time points to evaluate individual impact on time to treatment and 90 day outcome.

Methods: The UCSD SPOTRIAS prospectively collected database was analyzed for patients seen in acute stroke code, excluding inpatient codes. Multivariable regression models using an independent variable of 90 day mRS were used. Groups were defined as ≤/ > GWTG time points: arrival to stroke code 10 minutes, arrival to neurologic exam 15 minutes, arrival to imaging 25 minutes, and arrival to lab results 45 minutes. Models were adjusted for pre-specified covariates: pre-stroke mRS, age, gender, smoking, baseline NIHSS and glucose, and IV tPA.

Results: We analyzed 2903 patients- 481 treated with IV tPA, and 1023 with 90 day outcomes. All timeline goals led to significantly shorter arrival to decision times (all p<0.0001). These timepoints were also associated with decreased arrival to treatment time in IV tPA treated patients (all p<0.0001). However, after adjusting for baseline characteristics, no significant difference in 90 day mRS was observed in any comparison. Good outcome was more frequent with time to treatment ≤ 60 minutes (50.91% vs 41.76%, p=0.0522).

Conclusions: Time to decision and treatment were significantly shorter when the Get With the Guidelines timeline was followed. This reinforces that each aspect of the acute stroke evaluation must be efficient to expedite time to treatment. No difference was seen in 90 day outcome despite an expedited acute evaluation, emphasizing the importance of symptom onset to treatment time, and especially onset to arrival time, as integral to patient outcome. Further analyses focusing solely on the acute ischemic stroke subset, particularly those arriving within the tPA treatment window, are ongoing.

Abstract WP59: IV rt-PA Treatment Response of The STROKE100 Club: Sy stematic Te chnique for Ri sk and Ou tcome Measurements Using Key El ements Totaling 100

Background: Advanced age and high NIHSS are independent predictors of poor AIS outcome. While not excluded from IV rtPA, response is debated in these groups. Patients in the “STROKE 100 Club” (AIS with any combination of age + NIHSS ≥100) have worse outcome without increased sICH. Treatment response has not been evaluated. We evaluated 90 day outcome in the “STROKE 100 Club” with or without rt-PA.

Methods: The UCSD SPOTRIAS prospectively collected database was analyzed for “STROKE 100 Club” patients, and all AIS patients either ≥ 80 years old or with NIHSS ≥ 20. Multivariable regression models were used with treatment group as independent variable. Models were adjusted for pre-specified covariates: pre-stroke mRS, diabetes, and atrial fibrillation.

Results: We identified 82 STROKE 100 Club patients; 24 were untreated, 58 received IV rtPA. IV tPA treated patients were less likely to have prior history of stroke (22.8% vs 54.2%, p=0.0089). No treatment difference was seen in discharge destination, death, or poor outcome (mRS 3-6) at 90 days. In patients either ≥ 80 years old or with NIHSS ≥ 20, no difference was seen in 90 day outcomes between IV tPA and untreated patients, controlling for baseline variables. In patients ≥ 80 years old, poor outcome was associated with higher NIHSS (OR 1.16, 95% CI 1.09-1.24, p<0.0001) and mRS 3-6 (OR 5.28, 95% CI 1.64-16.96, p=0.0052). Higher NIHSS was also associated with death (OR 1.11, 95% CI 1.06-1.16, p<0.0001) and discharge to facility (OR 1.17 95% CI 1.10-1.24, p<0.0001).

Conclusions: Prognosis remains a concern in patients with various permutations of stroke severity and advanced age. Patients ≥80 with higher NIHSS had worse outcome, confirming our prior findings in the STROKE 100 club. Interestingly, IV tPA in the STROKE 100 Club did not lead to worse outcome. IV rtPA remains a safe treatment option for patients in the STROKE 100 club. Ongoing analyses may identify subgroups at greater or lesser benefit of thrombolysis. Planned analyses include assessment in a larger NIH-SPOTRIAS cohort.

Comprehensive stroke centers and the 'weekend effect': the SPOTRIAS experience

BACKGROUND AND PURPOSE

Previous studies have found mortality among ischemic stroke patients to be higher on weekends. We sought to evaluate whether weekend admission was associated with worse outcomes in a large comprehensive stroke center (CSC) cohort.

METHODS

Consecutive ischemic stroke patients presenting within 6 h of symptom onset were identified using the 8 CSC SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) database. Patients who received intra-arterial therapy or who were enrolled in a nonobservational clinical trial were excluded. All patients meeting the inclusion criteria were then divided into two groups: weekday admissions or weekend admissions. Weekend admission was defined as Friday 17:01 to Monday 08:59. The remainder were classified as weekday admissions. Multivariate logistic regression was used, adjusting for age, stroke severity on admission [according to the National Institutes of Health Stroke Scale (NIHSS)] and admission glucose, in order to compare the outcomes of the weekend versus the weekday groups.

RESULTS

Eight thousand five hundred and eighty-one subjects from the combined SPOTRIAS database were screened from 2002 to 2009; 2,090 (24.4%) of these met the inclusion criteria. There was no significant difference in tissue plasminogen activator treatment rates between the weekday and weekend groups (58.5 vs. 60.4%, p = 0.397). Weekend admission was not a significant independent predictor of inhospital mortality (8.4 vs. 9.9%, p = 0.056), length of stay (4 vs. 5 days, p = 0.442), favorable discharge disposition (38.0 vs. 42.2%, p = 0.122), favorable functional outcome at discharge (41.6 vs. 43.4%, p = 0.805), favorable 90-day functional outcome (54.2 vs. 46.9%, p = 0.301), or 90-day mortality (18.2 vs. 19.8%, p = 0.680) when adjusting for age, NIHSS and admission glucose.

CONCLUSIONS

In this large cohort of ischemic stroke patients treated at CSCs, we did not observe the 'weekend effect.' This may be due to access to stroke specialists 24 h a day on 365 days a year, nurses with stroke experience and the organized system for delivering care that is available at CSCs. These results suggest that EMS protocol should be reexamined regarding the preferential delivery of weekend stroke victims to hospitals that provide all levels of reperfusion therapy. This further highlights the importance of organized stroke care.

Diffusion-weighted imaging-fluid attenuated inversion recovery mismatch in nocturnal stroke patients with unknown time of onset

BACKGROUND

More than a quarter of patients with ischemic stroke (IS) are excluded from thrombolysis because of an unknown time of symptom onset. Recent evidence suggests that a mismatch between diffusion-weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR) imaging could be used as a surrogate for the time of stroke onset. We compared used the DWI-FLAIR mismatch and the FLAIR/DWI ratio to estimate the time of onset in a group of patients with nocturnal strokes and unknown time of onset.

METHODS

We used a prospectively collected acute IS patient database with MRI as the initial imaging modality. Nineteen selected nocturnal stroke patients with unknown time of onset were compared with 22 patients who had an MRI scan within 6 hours from stroke onset (control A) and 19 patients who had an MRI scan between 6 and 12 hours (control B). DWI and FLAIR signal was rated as normal or abnormal. FLAIR/DWI ratio was calculated from independent DWI and FLAIR ischemic lesion volumes using semiautomatic software.

RESULTS

The DWI-FLAIR mismatch was different among groups (unknown 43.7%; control A 63.6%; control B 10.5%; Fisher-Freeman-Halton test; P = .001). There were significant differences in FLAIR/DWI ratio among the 3 groups (unknown 0.05 ± 0.12; control A 0.17 ± 0.15; control B 0.04 ± 0.06; Kruskal-Wallis test; P < .0001). Post-hoc pairwise comparisons revealed that FLAIR/DWI ratio from the unknown group was significantly different from the control B group (P = .0045) but not different from the control A group. DWI volumes were not different among the 3 groups.

CONCLUSIONS

A large proportion of patients with nocturnal IS and an unknown time of stroke initiation have a DWI-FLAIR mismatch, suggesting a recent onset of stroke.

Abstract 2703: In-hospital Versus Out-of-hospital Stroke Treated With Iv Tpa And 3 Month Outcomes

Background: Most hospitals set up Code Stroke alert teams in the Emergency Departments. Expanding sufficient Code Stroke coverage to in-hospital areas requires additional resources, often through Neuro-hospitalist teams. Most data on outcomes after stroke are based on out-of-hospital stroke. We evaluated the outcomes of patients with stroke that occurs in the hospital versus out-of-hospital.

Methods: We included all adult patients with Code Stroke alerts, diagnosis of acute ischemic stroke, who had 90-days post Code Stroke modified Rankin Scale from the UCSD SPOTRIAS database (2004 to 2011) and excluded patients transferred from acute care facilities. The patients were grouped into 1: out-of-hospital Code Stroke alerts (EMS or ED) and 2: in-hospital (all inpatient units) and analyzed by baseline demographics, time to treatment decision, frequency of IV tPA use, 90-day modified Rankin Scale (mRS) and adjusted for multiple co-variables. Symptomatic intracranial hemorrhage (SICH) was defined as ≥4 point increase in NIHSS and ICH that was deemed the cause of the clinical change.

Results: We identified 590 Code Stroke alerts; 563 in group 1 and 27 in group 2. Baseline demographics were balanced, except group 2 patients younger (64.26±16 vs 70.2±15.5 years of age, p=0.0497) and were more likely to be Hispanic (29.6 vs 14.2%, p=0.047). IV tPA was given in 13/27 (48.2%) patients in Group 2 and 266/563 (47.3%) in Group 1 (NS). Anticoagulation was the reason for exclusion in 4/14 (28.6%) of patients in Group 2 vs 18/266 (6.5%) (p=0.017). The frequency of other diagnoses and reasons for exclusion were similar between groups. The time from stroke onset to tPA treatment in group 2 was 135.1±57.9 vs 151.4±121.2 min (NS). A 90-day mRS of 0 or 1 was achieved in 9/27 (33.3%) patients in Group 2 and 221/563 (39.3%) patients in Group 1 (NS); in tPA treated patients: Group 2 3/13 (23.1%), Group 1 83/266 (31.2%) (NS). SICH occurred in the tPA treated patients: Group 2 1/13 (7.7%); Group 1 9/266 (3.4%) (NS).

Conclusion: We identified a relatively small group of ischemic stroke patients with in-hospital onset. In those patients, however, rates of tPA use and outcomes were similar to out-of-hospital stroke.

Abstract 2345: Do the 10 PSC Measures Improve Outcome in Stroke Patients

Background and Purpose- While many healthcare systems are currently attempting to achieve Primary Stroke Center (PSC) certification, no study has evaluated the impact of the 10 PSC measures on long term outcome. The purpose of this study was to determine the compliance with and association between the 10 PSC measures and 90 day outcome in a certified PSC vs a non-certified center.

Methods- A retrospective review of prospectively collected data was performed. Analysis included patients presenting between 01/01/2009 and 12/31/2010 as stroke codes to the University of California San Diego Medical Center (PSC) and Sharp Hospital (non-PSC, practicing under Brain Attack Coalition (BAC) guidelines). Both centers utilize the same acute ED stroke code team, though decisions to activate these codes and inpatient stroke code protocols are different. All patients or surrogates provided consent and had 90 day outcome data available. Analysis plan included the statistical association of each PSC measure with stroke outcome (90 day mRS) using Fisher's Exact. Data analysis plan also included comparing 90 day outcome for a PSC center to those of a non-PSC center using chi squared. Good outcome was defined as mRS 0-2 at 90 days.

Results- 138 patients were included in the analysis (UCSD=52; Sharp=86). 47.3% were female. There was no significant difference in good outcome (p>0.99) or mortality (p=0.309) between the sites. Significant differences existed for compliance with 1) “DVT prophylaxis” (p=0.004); 2) “antiplatelet on discharge” (p<0.001); 3) “thrombolytics administered” (p<0.001); 4)“stroke education” (p<0.001); 5) “rehab considered” (p=0.001) and 6) “lipid evaluation” (p=0.002), all in favour of the PSC. “Antiplatelet on discharge” (p=0.001), “thrombolytics administered” (p=0.011), and “lipid evaluation” (p=0.012) were the only PSC measures that were significant predictors of 90 day outcome.

Conclusions- This study found that the PSC provided significantly more compliance with the 10 PSC measures. Only 3 of the PSC measures are independent predictors of outcome at 90 days. It is vital to re-examine the PSC requirements to ensure that guidelines are in place to significantly impact patient outcome.

Abstract 3436: Specific NIH Stroke Scale Items Strongly Predict Hospital Arrival Mode, Thrombolysis Administration, and Clinical Outcomes in Acute Ischemic Stroke

Background: The 11-item National Institutes of Health Stroke Scale (NIHSS) is widely used as an index of stroke severity and prognostication. However, no studies have specifically examined the influence of NIHSS items on care processes and outcomes in Acute Ischemic Stroke (AIS). Furthermore, potential distinctions in neurologic signs of AIS that may contribute to disparities in race-ethnic treatment rates and outcomes have not been evaluated. We assessed the relation of neurological signs on the NIHSS to arrival mode, thrombolysis treatment and clinical outcomes in AIS, and also evaluated the influence of race-ethnicity.

Methods: We analyzed the dataset of a hospital network comprising prospectively collected data on AIS patients presenting within 12 hours of ictus between June 2004 and May 2011. Outcomes evaluated were mode of arrival (ambulance vs. other), IV thrombolysis (yes vs. no), discharge destination (home vs. other), unfavorable day-90 functional activity (modified Rankin Scale (mRS) score >1), unfavorable day-90 disability (Barthel Index <95), and day-90 mortality. Outcomes were adjusted for pre-specified covariates in a multivariable logistic regression model.

Results: Of 972 AIS patients 462 (48%) were women, 635 (65%) Non-Hispanic White, 162 (17%) White Hispanic, 106 (11%) Black, and 69 (7%) other race/ethnicity. Overall, the presence of extinction/neglect was the strongest predictor of arriving by ambulance (adjusted OR 2.32, 95% CI: 1.53-3.51), and abnormal level of consciousness (LOC) was the strongest predictor of receipt of IV thrombolysis (adjusted OR 2.25, 95% CI: 1.67-3.04), while limb ataxia was the only NIHSS item not significantly associated with either arrival mode or thrombolysis treatment. Presence of gaze preference was the strongest predictor of not going home directly from the hospital (adjusted OR 0.2, 95% CI: 0.14-0.29), unfavorable day-90 functional activity (adjusted OR 0.21, 95% CI: 0.12-0.37) and poor mortality outcome (adjusted OR 5.92, 95% CI: 3.42-10.25), while abnormal LOC was the strongest predictor of unfavorable day-90 disability (adjusted OR 0.27, 95% CI: 0.15-0.47). White Hispanic AIS patients with sensory symptoms were less likely to arrive by ambulance (adjusted OR 0.31, 95%CI: 0.13-0.74) but more likely to go home directly (adjusted OR 2.81, 95% CI: 21.31-6.02), while Black AIS patients with abnormal level of consciousness were more likely to receive IV thrombolysis (adjusted OR 4.69, 1.80-12.26).

Conclusions: Specific items on the NIHSS are strongly related to hospital arrival mode, thrombolysis treatment, and clinical outcomes among AIS patients. Some of these associations vary by race and ethnicity. These results could aid prognostication and identify areas in the community, pre-hospital and emergency department phases of stroke care requiring more education, training, or intervention, to boost AIS outcomes.

Abstract 2354: Prospective Determination of %NODS (Not consistent with Organic Deficit of Stroke) Likelihood with Resultant rt-PA Safety and Functional Outcome

Objective: To assess safety and functional outcomes of rt-PA patients prospectively assigned a high %NODS score. NODS include mimics, functional overlay and complex presentations of mild symptoms. Background: Evidence exists that mimics may be safe to treat but the act of giving rt-PA often results in a stroke diagnosis. Additionally, patients with ICH are unlikely to be coded as non-strokes. Attempts to assess mimics are usually done retrospectively, however after treatment there is often uncertainty in classification of patients as ‘NODS’ or ‘True Stroke.’ Prospective designations of such may not be recorded. To our knowledge, this is the first outcome study for patients prospectively labeled with a high %NODS score prior to rt-PA treatment.

Methods: We reviewed the UCSD SPOTRIAS database, (8/09-Present) for patients prospectively defined as NODS (% likelihood that deficits are Not consistent with Organic Deficits of Stroke) ≥75% and NODS≥50%. Baseline characteristics, safety (SxICH), and outcome (90-day mRS(0-2)) were compared to ‘True Strokes’ (NODS≤25%). Continuous variables were compared using Wilcoxon-Rank Sum. Categorical variables were compared with Fisher's Exact.

Results: There were 114 'True Strokes', 7 NODS≥75%, and 12 NODS≥50%. Mean age was 70.7, 51.9 (p=0.0064) and 51.1 years (p<0.001) respectively. Pre-stroke mRS(0-2) was 85.1%, 100% (p=0.59) and 91.7% (p>0.999). Baseline NIHSS was 11.5, 7.7 (p=0.36) and 6.6 (p=0.08). Outcomes were adjusted for baseline mRS. Home d/c was 40.95%, 71.4% and 66.7%. 90-day mRS(0-2) was 50%, 66.7% and 70%. Ambulance use was 85.1%, 57.1% and 58.3%. SxICH was 6.2%, 0%, 0%. Timelines were similar except for “Onset to Arrival” (74min, 42min, 61min), and “CT to decision” (22min, 43min, 38min).

Conclusions: Small numbers precluded statistical significance, but absolute numbers were of clinical interest. NODS patients were younger, had less prior deficit, had milder strokes, activated EMS less frequently (possibly due to mild or less “real” deficit), had better 90-day mRS, less ICH, shorter 'onset-arrival' (perhaps arriving earlier due to improved recognition, increased fear of true or perceived deficit, or even EMS issues) but longer 'CT-decision' (perhaps requiring more time to consider pros and cons of rt-PA therapy). This intriguing exploratory analysis serves to generate hypotheses for our subsequent larger studies. If verified, high %NODS score patients may be considered safe for rt-PA therapy.

Abstract 132: In-hospital Versus Out-of-hospital Code Stroke: Iv Tpa Rate And Clinical Outcomes

Background: Patients with Code Stroke alert in the hospital may have different risk factors, demographics and differential diagnoses than patients who are admitted with Code Stroke Alert to the ED. Hospitals and health care systems use considerable resources to provide 24/7 acute stroke care access to in-hospital Code Stroke alerts. Most of the utility analyses are based on data from out-of-hospital stroke. We analyzed the frequency of IV tPA use and the likelihood of home discharge in patients with Code Stroke alert in the hospital versus out-of-hospital.

Methods: All adult patients with Code Stroke alerts in the UCSD SPOTRIAS Database from 2004 to 2011, excluding patients transferred from acute care facilities; grouped into 1: out-of-hospital Code Stroke alerts (EMS or ED) and 2: in-hospital (all inpatient units) and analyzed by baseline demographics; time to treatment decision; frequency of IV tPA use; diagnosis (Acute Ischemic Stroke, SAH, ICH, TIA, mimic, unknown); discharge disposition (home versus other), 90 day modified Rankin Scale (mRS) and adjusted for multiple co-variables.

Results: We identified 2,699 Code Stroke alerts; 2,498 in group 1 and 201 in group 2. Patients in group 2 were younger (63.6±15.5 vs 66.8±16.8 years of age, p=0.005), more likely to have diabetes (27.9 vs 21.3%, p=0.03), had higher baseline NIHSS (11.6±11.6 vs 9.0±10.0, 0.007) and likelihood to have a pre-stroke mRS >1 (35.8 vs 27.4%, p=0.01); had fewer acute ischemic strokes (38.8 vs 46.6%), but more stroke mimics (39.8 vs 29.5%), p=0.01,had shorter time from stroke onset to treatment decision (202.2±282.3 vs 275.2±423.1 min, p<0.0001) and were less likely to receive IV tPA (10.0 vs 16.0%, p=0.03). The time from onset to IV tPA treatment in Group 2 was 162.9±69.8 min; vs 150.1±106.0, p=0.07. Multivariable logistic regression analysis adjusting for age, history of diabetes and admission NIHSS show that the rates of being discharge home (OR=0.83, 95%CI = 0.59, 1.17, p=0.29) and having a 90-day mRS of 0-1 (OR-1.35, 95% CI = 0.64, 2.86), p=0.44) are similar in the two groups.

Conclusion: In-hospital are less likely to lead to IV tPA treatment than out-of-hospital Code Stroke alerts. Patient outcome based on discharge disposition and 90-day mRS is not significantly different from out-of-hospital Code Stroke.

Abstract 3572: Clinical Outcomes of the “Stroke100 Club”

Background: Patients with advanced age or high NIHSS have poorer tPA outcomes. When combined, old age (≥80yo) and elevated NIHSS (≥20) may have an even worse outcome. Patients who are also in this “Stroke100 Club” (any combination of age and NIHSS ≥100) by other means, have not been fully assessed. We evaluated discharge destination, 90-day mRS, sICH and death in treated and untreated Stroke100 Club patients. We further compared patients with age ≥ 80 and NIHSS ≥ 20 (“80/20s”), those who reached 100 without both characteristics (“non80/20s”) and ‘controls’.

Methods: The UCSD SPOTRIAS prospectively collected database was analyzed for AIS patients (with and without tPA). Multivariable regression models including the Stroke100 group as an independent variable was used. Outcomes were adjusted for baseline mRS. For comparing categorical outcomes between controls, “80/20s” and “non80/20s” subgroups, a Fisher’s exact was used.

Results: The IV tPA subset included 257 patients (mean age 71, 52% male, 85% white, mean NIHSS 12). 53 were in the “Stroke100 Club” (28 80/20, 25 non80/20), with more women (68% p= 0.002), higher NIHSS (22.5 p<0.0001), older age (mean age 86.4 p<0.0001), higher pre stroke mRS (34.6% mRS 3-6 vs 7.84%, p<0.0001), more HTN (p=0.045) and more afib (p= 0.008). There were 284 non tPA patients (mean age 69.52, 54% male, 85% white, mean NIHSS 5.92). 21 were in the “Stroke100 Club” (14 80/20, 7 non80/20), with higher NIHSS (23 p<0.0001), older age (mean 86.2 p<0.0001), higher pre stroke mRS (45.5% 3-6 vs 9.5%, p= 0.0001), and more afib (p= 0.0002). Stroke100 Club 90day mRS(3-6) outcomes were worse in both tPA treated patients (OR=6.77, p= 0.0001) and nontreated patients (OR 31.57, p= 0.001). sICH rates (in tPA subjects) were not different (3.8% vs 3.4%, p> 0.99).

Conclusions: There is a question of treatment outcome in patients with various permutations of stroke severity and advanced age. Our data corroborates the concern of poor outcomes for Stroke100 Club patients, but notes no increased sICH with tPA. Though outcome may be poor, withholding tPA should be discouraged as worse outcomes were not due to sICH. Young patients with severe strokes or old patients with mild strokes may have outcomes similar to the standard “80/20” Stroke100 patients, however further adjusted analysis is ongoing. In addition, further analyses are being done to compare tPA to non tPA patients.

Abstract 3621: Predicting 90 Day Outcome in Acute Ischemic Stroke Patients

Background and Purpose- Predictive scales for outcome in intracerebral hemorrhage patients have been used to provide prognostic information on mortality. Valid and reliable scales do not exist for acute ischemic stroke patients. The purpose of this study was to create a statistically valid model on which to predict 90 day functional outcome in acute ischemic stroke patients.

Methods- This was a retrospective analysis of prospectively collected data on acute ischemic stroke patients. A univariate logistic regression analysis was done to assess for independent predictor variables. Any variable with a p<0.15 at the univariate level was included in a stepwise logistic regression model and appropriate interaction effects were tested. A model was constructed to predict 90 day stroke outcome. Good outcome was defined as mRS 0-2 and bad outcome was defined as mRS 3-6 at 90 days.

Results- 569 patients were included in the analysis. Age ranged from 21-98 (mean 70), baseline NIHSS 0-40 (median 6), 48% of patients were treated with rt-PA (n=277), 10% were black (n=57), and 15% were Hispanic (n=89). In univariate analysis, independent predictors of outcome were age (p<0.0001), weight (p=0.0003), baseline NIHSS (p<0.0001), diastolic blood pressure (p=0.02), treatment with rt-PA (p<0.0001), history of hypertension (p=0.0009), history of CAD/MI (p=0.002), history of stroke (p=0.02), current smoker (p=0.02), and history of atrial fibrillation (p=0.0001). Ethnicity (p=0.09) was included in the model. On stepwise linear regression, age (p<0.001, β-0.03), baseline NIHSS (p<0.001, β -0.15), Hispanic ethnicity (p=0.02, β -0.66) remained as independent predictors of 90 day outcome.

Conclusions- A prognostic scale for acute ischemic stroke patient outcome would be clinically useful. This analysis based on sound statistical procedures can serve as a basis for the creation of a valid and reliable scale for predicting 90 day outcome in acute ischemic stroke patients. A scoring system is currently being developed for testing.

Sex differences in antiplatelet response in ischemic stroke

Sex differences exist in the occurrence, treatment and outcome of ischemic stroke. Compared with men, women have more stroke events and are less likely to fully recover from a stroke. Given the rapidly aging population, stroke incidence and mortality among women are projected to substantially rise by 2050. This has important public health consequences. Mitigating the burden of stroke among women will require a fundamental understanding of sex differences and sex-specific issues including cerebrovascular disease pathophysiology, treatment and outcome. An aspect of stroke treatment receiving increasing but insufficient attention involves possible interactions between estrogen levels, antiplatelet drugs and stroke outcome. Emerging evidence suggests that antiplatelet therapy may provide primary stroke protection but not primary myocardial infarction prevention in women, while the opposite may be true among men. Understanding sex-specific issues related to women who experience stroke is critical to clinicians who treat women with antiplatelet medications as part of a secondary stroke prevention regimen; however, the ideal antiplatelet medication, and dose, in women requires further research. In this article we present a conceptual framework for sex differences in antiplatelet treatment response in ischemic stroke, thrombus formation and the mediating role of estrogen, sex differences in antiplatelet treatment response in clinical trials, and sex differences in antiplatelet treatment use in ischemic stroke.

Effect of pyruvate and HEPES on rat lung allograft acidosis and cell death after long-term hypothermic storage

BACKGROUND

We have previously demonstrated that adding pyruvate to Perfadex increased graft metabolism during 24-hour storage and improved reperfusion lung function. This increased metabolism was associated with progressively lower pH of the storage solution during the preservation interval.

OBJECTIVE

To determine whether more effective pH regulation would result in further improvements in lung survival after hypothermic storage.

MATERIALS AND METHODS

Rat lungs were stored for 24 hours in Perfadex, Perfadex with HEPES (N-2-hydroxyethylpiperazine-propanesulfonic acid) buffer, pyruvate-modified Perfadex, and pyruvate-modified Perfadex with HEPES. Change in pH in the storage solution was measured. Structural lung injury was evaluated using hematoxylin-eosin stained tissue sections. Cell death was quantified by measuring necrotic cells using trypan blue exclusion and apoptotic cells via the TUNEL (terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate nick-end labeling) assay.

RESULTS

Lungs stored in Perfadex demonstrated the greatest degree of cell death. Lungs in the Pyruvate group exhibited decreased cell death despite greater acidosis. The addition of HEPES reduced cell death and preservation solution acidosis in both Perfadex and pyruvate-modified Perfadex (P < .05). Almost all cell death resulted from necrosis. Adding pyruvate to the preservation solution increases acid formation during storage, but decreases cell death. HEPES ameliorates this acidosis and decreases allograft cell destruction.

CONCLUSION

Increasing the preservation solution buffering capacity may be a simple strategy for improving lung preservation for transplantation.

Intra-articular injection of tumor necrosis factor-alpha in the rat: an acute and reversible in vivo model of cartilage proteoglycan degradation

OBJECTIVE

To develop an in vivo model for rapid assessment of cartilage aggrecan degradation and its pharmacological modulation.

DESIGN

Tumor necrosis factor-alpha (TNFalpha) was injected intra-articularly (IA) in rat knees and aggrecan degradation was monitored at various times following challenge. Articular cartilage was assessed for aggrecan content by Safranin O staining and by immunohistochemistry for the NITEGE epitope. Synovial fluids (SFs) were analyzed for sulfated glycosaminoglycans (GAGs) using the dimethylmethylene blue dye assay and for aggrecan fragments generated by specific cleavage at aggrecanase-sensitive sites by Western blot analysis with neoepitope antibodies. Indomethacin, dexamethasone, and an aggrecanase inhibitor were evaluated for their ability to modulate TNFalpha-induced proteoglycan degradation in vivo.

RESULTS

(1) IA injection of TNFalpha in the knee joint of rats resulted in transient aggrecan degradation and release of aggrecanase-generated aggrecan fragments from the articular cartilage into the SF; (2) a correlation was observed between histologically assessed depletion of aggrecan from the articular cartilage and the appearance of specific neoepitopes in the SF; (3) aggrecan degradation was inhibited by an aggrecanase inhibitor as well as by dexamethasone, but not by the non-steroidal anti-inflammatory drug (NSAID), indomethacin.

CONCLUSION

TNFalpha injection in the knee joints of rats results in rapid transient cartilage proteoglycan degradation, mediated by cleavage at the aggrecanase sites. Biomarker read-out of specific neoepitopes in the SF enables the use of this mechanism-based model for rapid evaluation of aggrecanase-mediated aggrecan degradation in vivo.

Can comprehensive stroke centers erase the 'weekend effect'?

BACKGROUND

Prior epidemiological work has shown higher mortality in ischemic stroke patients admitted on weekends, which has been termed the 'weekend effect'. Our aim was to assess stroke patient outcomes in order to determine the significance of the 'weekend effect' at 2 comprehensive stroke centers.

METHODS

Consecutive stroke patients were identified using prospective databases. Patients were categorized into 4 groups: intracerebral hemorrhage (ICH group), ischemic strokes not treated with IV t-PA (intravenous tissue plasminogen activator; IS group), acute ischemic strokes treated with IV t-PA (AIS-TPA group), and transient ischemic attack (TIA group). Weekend admission was defined as the period from Friday, 17:01, to Monday, 08:59. Patients treated beyond the 3-hour window, receiving intra-arterial therapy, or enrolled in nonobservational clinical trials were excluded. Patient demographics, NIHSS scores, and admission glucose levels were examined. Adverse events, poor functional outcome (modified Rankin scale, mRS, 3-6), and mortality were compared.

RESULTS

A total of 2,211 patients were included (1,407 site 1, 804 site 2). Thirty-six percent (800/2,211) arrived on a weekend. No significant differences were found in the ICH, IS, AIS-TPA, or TIA groups with respect to the rate of symptomatic ICH, mRS on discharge, discharge disposition, 90-day mRS, or 90-day mortality when comparing weekend and weekday groups. Using multivariate logistic regression to adjust for site, age, admission NIHSS, and blood glucose, weekend admission was not a significant independent predictive factor for in-hospital mortality in all strokes (OR = 1.10, 95% CI 0.74-1.63, p = 0.631).

CONCLUSIONS

Our results suggest that comprehensive stroke centers (CSC) may ameliorate the 'weekend effect' in stroke patients. These results may be due to 24/7 availability of stroke specialists, advanced neuroimaging, or ongoing training and surveillance of specialized nursing care available at CSC. While encouraging, these results require confirmation in prospective studies.

The effectiveness of sealants in managing caries lesions

A barrier to providing sealants is concern about inadvertently sealing over caries. This meta-analysis examined the effectiveness of sealants in preventing caries progression. We searched electronic databases for comparative studies examining caries progression in sealed permanent teeth. We used a random-effects model to estimate percentage reduction in the probability of caries progression in sealed vs. unsealed carious teeth. Six studies, including 4 randomized-controlled trials (RCT) judged to be of fair quality, were included in the analysis (384 persons, 840 teeth, and 1090 surfaces). The median annual percentage of non-cavitated lesions progressing was 2.6% for sealed and 12.6% for unsealed carious teeth. The summary prevented fraction for RCT was 71.3% (95%CI: 52.8%-82.5, no heterogeneity) up to 5 years after placement. Despite variation among studies in design and conduct, sensitivity analysis found the effect to be consistent in size and direction. Sealing non-cavitated caries in permanent teeth is effective in reducing caries progression.

Transcriptional profiling and pathway analysis of monosodium iodoacetate-induced experimental osteoarthritis in rats: relevance to human disease

OBJECTIVE

The objective of this study was to characterize the rat monosodium iodoacetate (MIA)-induced model for osteoarthritis (OA) and determine the translatability of this model to human disease. This was accomplished through pathway, network and system level comparisons of transcriptional profiles generated from animal and human disease cartilage.

METHODS

An OA phenotype was induced in rat femorotibial joints following a single injection of 200mug MIA per knee joint for a period of 2 or 4 weeks. Lesion formation in the rat joints was confirmed by histology. Gene expression changes were measured using the Agilent rat whole genome microarrays. Cartilage was harvested from human knees and gene expression changes were measured using the Agilent human arrays.

RESULTS

One thousand nine hundred and forty-three oligos were differentially expressed in the MIA model, of these, approximately two-thirds were up-regulated. In contrast, of the 2130 differentially expressed oligos in human disease tissue, approximately two-thirds were down-regulated. This dramatic difference was observed throughout each level of the comparison. The total overlap of genes modulated in the same direction between rat and human was less than 4%. Matrix degradation and inflammatory genes were differentially regulated to a much greater extent in MIA than human disease tissue.

CONCLUSION

This study demonstrated, through multiple levels of analysis, that little transcriptional similarity exists between rat MIA and human OA derived cartilage. As disease modulatory activities for potential therapeutic agents often do not translate from animal models to human disease, this and like studies may provide a basis for understanding the discrepancies.

FDI report on adverse reactions to resin-based materials

Resin-based restorative materials are considered safe for the vast majority of dental patients. Although constituent chemicals such as monomers, accelerators and initiators can potentially leach out of cured resin-based materials after placement, adverse reactions to these chemicals are rare and reaction symptoms commonly subside after removal of the materials. Dentists should be aware of the rare possibility that patients could have adverse reactions to constituents of resin-based materials and be vigilant in observing any adverse reactions after restoration placement. Dentists should also be cognisant of patient complaints about adverse reactions that may result from components of resin-based materials. To minimise monomer leaching and any potential risk of dermatological reactions, resin-based materials should be adequately cured. Dental health care workers should avoid direct skin contact with uncured resin-based materials. Latex and vinyl gloves do not provide adequate barrier protection to the monomers in resin-based materials.

Isolation and characterization of 1-O -α-2-acetamido-2-deoxy-D-galactopyranosyl-myo -inositol from pregnancy urine

A new neutral glycoside of myo-inositol was isolated from the pregnancy urine of a single donor. Its structure was investigated by 1H-NMR spectroscopy and mass spectroscopy. It was identified as 1-O-alpha-2-acetamido-2-deoxy-D-galactopyranosyl-myo-inositol. No such structure or sequence has previously been reported in either myo-inositol or glucose glycosides.

Single vs bilateral, sequential lung transplantation for end-stage emphysema: influence of recipient age on survival and secondary end-points

BACKGROUND

The appropriate age to perform bilateral, sequential lung transplants (BSLT) in patients with chronic obstructive pulmonary disease (COPD) remains controversial. Although single lung transplant (SLT) offers an advantage in terms of organ availability, the long-term survival may not warrant this strategy in all age groups.

METHODS

We analyzed 2,260 lung transplant recipients (1835 SLT, 425 BSLT) with COPD recorded in the International Society for Heart and Lung Transplantation/United Network for Organ Sharing thoracic registry between January 1991 and December 1997. To assess mortality, we performed univariate (Kaplan-Meier method and the chi-square statistic) and multivariate analyses (proportional hazards method). Because of incomplete morbidity data in the international registry, only data from U.S. centers (n = 1778, 1467 SLT, 311 BSLT) were used in the morbidity analysis.

RESULTS

Survival rates (%) computed using the Kaplan-Meier method at 30 days, 1 year, and 5 years for the patients aged < 50 years were 93.6, 80.2, and 43.6, respectively, for the SLT patients, and 94.9, 84.7, and 68.2, respectively, for the BSLT patients. For patients aged 50 to 60 years, survival rates (%) were 93.5, 79.4, and 39.8 for the SLT patients compared with 93.0, 79.7, and 60.5 for the BSLT patients. For those aged > 60 years, SLT survival (%) was 93.0, 72.9, and 36.4, compared with 77.8 and 66.0 for the BSLT group (a 5-year rate could not be completed in this group). The multivariate model showed a higher risk ratio for mortality in patients aged 40 to 57 years who received SLT vs BSLT. Recipient age and procedure type did not appear to affect the development of rejection, bronchiolitis obliterans, bronchial stricture, or lung infection.

CONCLUSIONS

Single lung transplant may offer acceptable early survival for patients with end-stage respiratory failure. However, long-term survival data favors BSLT in recipients until approximately age 60 years. These data suggest that a BSLT approach offers a significant survival advantage to recipients younger than 60 years of age.

Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma.

METHODS

A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI.

RESULTS

One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound.

CONCLUSIONS

In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.

Load versus humoral activation in the genesis of early hypertensive heart disease

BACKGROUND

The role of load versus angiotensin II (Ang II) and endothelin-1 (ET) in the pathogenesis of hypertensive heart disease is controversial. We sought to determine whether alterations in cardiac structure and function due to hypertension (HTN) were dependent on Ang II or ET activation. Methods and Results-- Bilateral renal wrapping to produce HTN (n=12) or sham surgery (n=6) was performed in adult dogs. Weekly blood pressure, plasma renin activity, Ang II, ET, and catecholamines were measured. Systolic (end-systolic elastance, Ees) and diastolic (tau) function were assessed in sham and HTN dogs at 5 (HTN-5wk) or 12 (HTN-12wk) weeks. Ang II and ET were assayed in the left ventricle (LV) and kidney. Mean arterial pressure was higher in renal wrap dogs at week 1 (*P<0.05 versus controls: 139+/-4* versus 123+/-4 mm Hg), week 5 (174+/-7* versus 124+/-4 mm Hg), and week 12 (181+/-12* versus 124+/-4 mm Hg). LV mass index was increased in HTN-5wk (22%*) and HTN-12wk (39%*). LV fibrosis was increased in HTN-12wk. Ees was preserved in HTN-5wk and HTN-12wk. tau was increased in HTN-5wk (50+/-3* ms) and HTN-12wk (62+/-10* ms) dogs compared with sham (41+/-2 ms). Plasma Ang II, ET, catecholamines, and plasma renin activity were unchanged during the progressive HTN. Ang II and ET in LV and kidney were not different from controls.

CONCLUSIONS

Systemic HTN induces LV hypertrophy, myocardial fibrosis, and isolated diastolic dysfunction in the absence of local or systemic activation of Ang II or ET. These findings suggest that load is the prevailing stimulus for the structural and functional changes associated with early hypertensive heart disease.

Differential effects of natriuretic peptides and NO on LV function in heart failure and normal dogs

beta-Adrenergic hyporesponsiveness in congestive heart failure (CHF) is mediated, in part, by nitric oxide (NO). NO and brain natriuretic peptide (BNP) share cGMP as a second messenger. Left ventricular (LV) function and inotropic response to intravenous dobutamine (Dob) were assessed during sequential intracoronary infusion of saline, HS-142-1 (a BNP receptor antagonist), and HS-142-1 + N(G)-monomethyl-L-arginine (L-NMMA) in anesthetized dogs with CHF due to rapid pacing and in normal dogs during intracoronary infusion of saline, exogenous BNP, and sodium nitroprusside (SNP). In CHF dogs, intracoronary HS-142-1 did not alter the inotropic response to Dob [percent change in first derivative of LV pressure (% Delta dP/dt) 47 +/- 4% saline vs. 54 +/- 7% HS-142-1, P = not significant]. Addition of intracoronary L-NMMA to HS-142-1 enhanced the response to Dob (% Delta dP/dt 73 +/- 8% L-NMMA + HS-142-1, P < 0.05 vs. H142-1). In normal dogs, intracoronary SNP blunted the inotropic response to Dob (% Delta dP/dt 93 +/- 6% saline vs. 71 +/- 5% SNP, P < 0.05), whereas intracoronary BNP had no effect. In CHF dogs, the time constant of LV pressure decay during isovolumic relaxation increased with intracoronary HS-142-1 (48 +/- 4 ms saline vs. 58 +/- 5 ms HS-142-1, P < 0.05) and further increased with intracoronary L-NMMA (56 +/- 6 ms HS-142-1 vs. 66 +/- 7 ms L-NMMA + HS-142-1, P < 0.05). Endogenous BNP and NO preserve diastolic function in CHF, whereas NO but not BNP inhibits beta-adrenergic responsiveness.

Effect of donor age and ischemic time on intermediate survival and morbidity after lung transplantation

BACKGROUND

Pressure to expand the donor pool has required the use of lungs from older donors or from more-distant procurement areas. The long-term consequences of this policy have not yet been fully addressed. The effect of donor age and donor ischemic time on intermediate survival and important secondary end points after lung transplantation was therefore examined.

METHODS

A cohort of 1,800 lung transplant recipients with complete 2-year follow-up, operated on in the United States between April 1, 1993, and March 31, 1996, was studied to assess survival. For analysis of secondary end points, the cohort was limited to 1,450 patients.

RESULTS

Donor age when analyzed independently did not significantly affect intermediate survival (p = 0.4). Secondary end points were also not affected by age, with the exception of the incidence of hospitalization for rejection in the univariate analysis (p = 0.02) and in the multivariate analysis (p = 0.04). Moreover, there was not a significant impact of donor age or ischemic time independently on survival in the multivariate analysis. Similarly, when the interaction between ischemic time and donor age was examined in all of the multivariate models, none of the secondary end points were found to be significantly influenced. However, the combined interaction between donor age and ischemia time demonstrated a significantly worse survival at 2 years (p = 0.02) with donor age of > 50 years and donor ischemic time > 7 h.

CONCLUSIONS

Donor age and donor ischemic time did not independently influence survival or important secondary end points after lung transplantation. However, intermediate-term survival was affected by the use of older donors when combined with a prolonged ischemic time. The impact of this combination should be considered when attempting to expand the donor pool.

Effects of adrenomedullin on load and myocardial performance in normal and heart-failure dogs

Myocardial actions of the vasodilator peptide adrenomedullin (ADM) in the intact animal are unknown. Negative and positive inotropic actions have been reported in ex vivo experiments. Myocardial and load-altering actions of ADM in dogs before and after development of heart failure were studied. With controlled heart rate (atrial pacing) and after beta-blockade, ADM was administered to five normal dogs in doses of 20 ng. kg(-1). min(-1) iv, 100 ng. kg(-1). min(-1) iv, and 200 ng. kg(-1). min(-1) into the left ventricle (LV). LV peak systolic pressure and end-systolic volume decreased with each dose of ADM. End-systolic pressure decreased with the two higher doses. At the highest dose, arterial elastance and the time constant of LV isovolumic relaxation (tau) decreased, and LV end-systolic elastance (E(es)) increased. LV end-diastolic pressure and volume were unchanged. In five additional normal dogs receiving only the highest dose of ADM (200 ng. kg(-1). min(-1) intra-LV), to control for increased heart rate and sympathetic activation observed with the cumulative infusion, ADM produced arterial vasodilation but no change in E(es) or tau. In four dogs with pacing-induced heart failure, ADM (200 ng. kg(-1). min(-1) intra-LV) was without effect on tau, E(es), and systolic or diastolic pressure and volume. In vivo, ADM appears to be a selective arterial dilator without inotropic or lusitropic effects. The vasodilatory actions are attenuated in heart failure.