Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

BACKGROUND

Literature on the effectiveness of simulation-based medical education programs for caring for acute ischemic stroke (AIS) patients is limited.

OBJECTIVE

To improve coordination and door-to-needle (DTN) time for AIS care, we implemented a stroke simulation training program for neurology residents and nursing staff in a comprehensive stroke center.

METHODS

Acute stroke simulation training was implemented for first-year neurology residents in July 2011. Simulations were standardized using trained live actors, who portrayed stroke vignettes in the presence of a board-certified vascular neurologist. A debriefing of each resident's performance followed the training. The hospital stroke registry was also used for retrospective analysis. The study population was defined as all patients treated with intravenous tissue plasminogen activator for AIS between October 2008 and September 2014.

RESULTS

We identified 448 patients meeting inclusion criteria. Simulation training independently predicted reduction in DTN time by 9.64 minutes (95% confidence interval [CI] -15.28 to -4.01, P = .001) after controlling for age, night/day shift, work week versus weekend, and blood pressure at presentation (> 185/110). Systolic blood pressure higher than 185 was associated with a 14.28-minute increase in DTN time (95% CI 3.36-25.19, P = .011). Other covariates were not associated with any significant change in DTN time.

CONCLUSIONS

Integration of simulation based-medical education for AIS was associated with a 9.64-minute reduction in DTN time.

Abstract WP145: Depression in Stroke and TIA Survivors With Minimal or No Residual Deficits

Background: Depression after stroke can severely inhibit a patient’s recovery. While it affects roughly a third of all stroke survivors, there is a lack of literature evaluating depression in patients with minimal or no residual deficits.

Objectives: To evaluate variables associated with depression in patients with minimal or no residual deficits.

Methods: A retrospective analysis of patients with mild stroke, intracerebral hemorrhage (ICH) or TIA at our institution who presented to the stroke clinic from December 2016-July 2017 was conducted. A questionnaire gathering clinical and sociodemographic information, as well as levels of depression, was administered. Patients were assessed using the PHQ-2 and PHQ-9 depression scales. A Wilcoxon Ranked Sum test was used to analyze variables affecting depression. Statistical significance was set at 0.05.

Results: In total, 72 patients (58 ischemic, 5 ICH and 9 TIA) were identified. Approximately 4% (n=3) presented to clinic <6 weeks, 66.7% (n=48) 6-12 weeks, 23.6% (n=17) 12-24 weeks, and 5.6% (n=4) > 24 weeks from discharge. The median discharge NIH score was 1.5. Roughly 24% of patients (n=17) reported depression via the PHQ-9. Of these patients, 59% (n=10) reported depression prior to stroke and 41% (n=7) developed new depression. The median age was 62.5 years, 63.9% were female, and 70.8% Caucasian. Diabetic and unmarried patients reported significantly more depression ( p=0.005, 0.03) while patients attending occupational therapy were less depressed ( p=0.010 ). Age ( p=0.23 ), history of cancer ( p=0.95 ), prior stroke ( p=0.55 ), incontinence ( p=0. 27), stroke location (Right: p=0.72 ; Left: p=0.244 ), ability to return to work ( p=0.64 ), driving status ( p= 0.36), and discharge destination ( p=0. 09) did not significantly affect depression levels. Of the patients with no prior depression, 11.2% developed new depression after stroke.

Conclusion: In our study, a quarter of stroke and TIA patients with little to no residual deficits reported depression and roughly 1 in 10 reported new depressive symptoms. Depression is still a prevalent and concerning outcome that can have a major effect on a patient’s functional status. Further studies of depression in patients with minimal to no symptoms are needed.

Abstract TP155: Cognitive Impairment in Mild Stroke

Background: Cognitive symptoms are easily overlooked despite its effect on quality of life after stroke. In patients with minimal physical residual symptoms, the true burden of cognitive impairment is unknown.

Objective: To evaluate the risk factors and burden associated with cognitive impairment after mild stroke.

Methods: A retrospective observational cohort study of 56 patients (51 ischemic, 5 hemorrhagic) evaluated at the stroke clinic between July 2016 and June 2017 was performed. Patients completed a questionnaire including demographics and history including previously known cognitive impairment. Cognition was evaluated with the Montreal Cognitive Assessment Score (MOCA).

Results: The median age of the group studied was 61.5 years. Sixty-six percent (66.1%) patients were men and 76.8% Caucasian. The median discharge NIH score was 1. This study group did not have a previous diagnosis of dementia. About 4% (n=2) of patients presented to clinic <6 weeks, 71.4% (n=40) 6-12 weeks, 17.9% (n=10) 12-24weeks and 7.1% (n=4) >24 weeks from discharge. Cognitive assessment at the stroke clinic after discharge identified 19.6% patients with mild impairment, 16.1% with moderate impairment and 14.3% with dementia. MOCA scores were lower in those greater than 65 years of age ( p =0.022), living in facilities post-stroke ( p =0.007), have history of stroke and diabetes mellitus ( p =0.011, 0.019). Education level did not show significant difference in MOCA scores ( p =0.283). Those who were employed prior to their stroke have a higher MOCA score compared to those who were unemployed ( p =0.001). Of those previously working, 50% were able to return to work and this group had higher MOCA scores ( p =0.011). Of those who stopped driving, 19.6% was due to cognitive concerns.

Conclusion: In our study, about 50% of the mild stroke patients were found to have some degree of cognitive impairment. Factors that may suggest a higher risk for cognitive impairment after stroke include those age greater than 65, history of stroke and diabetes, unemployment and living in a facility. Post-stroke cognitive impairment was found to be associated with inability to return to work and drive. Since cognitive impairment can impact life quality, screening even in mild stroke could be beneficial.

Abstract WP286: Code Status Prior to Admission Dose Not Influence Timing of Transition to Inpatient Hospice in Devastating Stroke

Background: The transition of care from an aggressive disease-directed plan to comfort focused hospice care is a difficult choice for patients with devastating stroke and their family members particularly in the absence of advance directives. However, it is not clear if preexisting Do Not Resuscitate (DNR) status influences the timing of this decision.

Objectives: To evaluate factors associated with transfer time to hospice for patients with devastating stroke and, particularly, the influence of defined code status prior to admission.

Methods: A retrospective analysis of patients with stroke admitted to inpatient hospice from January 2013-December 2014 at our institution was conducted yielding 71 patients. The group was dichotomized to those with a preexisting DNR (n=19) or not (n=52). Clinical variables and sociodemographic factors were collected and compared using chi-square tests of proportion and t-tests for independent groups. Specifically, median time from admission to inpatient hospice for both groups was compared using a Wilcoxon Ranked Sum test set at 0.05 to test statistical significance.

Results: For all patients, the mean age was 82.01 +/- 9.64 years, 60.6% female and 84.5% Caucasian. Approximately 66% of strokes were ischemic and 34% hemorrhagic with a mean NIH score of 21.45 +/- 6.03. Age (83.7 +/- 9.8 vs. 81.4 +/- 9.6; p=0.377 ), ethnicity (% Caucasian: 84.2 vs. 84.6; p= 0.967 ), stroke subtype (% ischemic: 73.7 vs. 61.5; p= 0.343 ), severity (NIH: 21.2 +/- 8.8 vs. 20.9 +/- 4.6; p=0.852 ), insurance status (% Medicare Plus: 73.7 vs. 57.7; p=0.219 ), history of prior stroke (26.3% vs. 23.1%; p=0.777 ), dementia (21.1% vs. 28.9%; p=0.511 ), malignancy (10.53% vs. 13.46%; p=0.742 ), and living arrangement (% living with family: 73.7 vs. 51.9; p=0.132 ) were not statistically different in the DNR and no DNR cohorts respectively. The median time from admission to inpatient hospice for preexisting DNR vs. no DNR did not differ (3.0 vs. 4.5 days ; p=0.176 ).

Conclusion: In our study, there were no significant factors, including preexisting DNR status, that influenced transition time to inpatient hospice. Code status on admission is not an indicator of goals of care. Future studies are needed to validate these findings

Abstract WP210: Patterns and Predictors of Stroke Subtypes in Patients With LVAD: Single Center Analysis

Background: Left ventricular assist devices (LVAD) have emerged as the mainstay in advanced heart failure patients either as a bridge to transplant (BTT) or destination therapy (DT). Strokes, ischemic from pump thrombosis and hemorrhagic from combination of anti-platelets and anti-coagulants, remain a major cause of morbidity and mortality.

Objective: To identify the prevalence, timing and risk factors of ischemic and hemorrhagic in LVAD patients

Methods: A retrospective analysis of all the LVAD implantations at HH from July 2012 to December 2016 comprising a total of 78 patients with 63 HMII (axial flow) and 15 Heartware (centrifugal flow) implantations to serve as DT in 51 and BTT in 37 patients. Demographics and clinical variables were collected and analyzed. Categorical variables were analyzed using Chi-square test of proportions with statistical significance set at 0.05.

Results: For all patients the median age was 65 years, 82% Caucasian and 16% female. The overall stroke incidence was 27% (n=21, 16 ischemic in 12 patients and 9 hemorrhagic in 9). Age > 65 years had a higher incidence of stroke (36% vs 14%; p <0.05). Mean time from implantation to ischemic and hemorrhagic strokes were 205 and 98 days respectively, with high peri-operative (35 days post implant) risk at 33% for both cohorts. At least two arterial territories were involved in 45% (n=5) and multi-compartmental hemorrhage noted in 66% (n=6). LVADs as DT had a higher incidence of ischemic stroke (24% vs 6% as BTT; P=0.05). Non-Caucasians had a higher incidence of hemorrhagic stroke (55% vs 20% with p = <0.05). The median INR was 1.7 and 2.8 while the median mean arterial pressures was 75 and 84 in the ischemic and hemorrhagic strokes respectively (p <0.05). Age, gender, history of A.fib, HTN, PAD, or aspirin dosage did not predict risk of stroke. Mortality from stroke was 33% (n =4) with ischemic and 66% (n = 6) with hemorrhagic strokes, with a total risk of 47% compared to 17.5% in the non-stroke LVAD population(p = 0.005).

Conclusion: In our study, 1/3 of strokes occurred in the perioperative period with high risk after age 65 years. Non-Caucasians, high mean arterial pressure and high INR were associated with hemorrhagic stroke. Further studies are needed to evaluate modifiable risk factors among LVAD patients.

Abstract WMP72: The "Three Territory Sign": An Under-Recognized Radiographic Marker of Malignancy-Related Ischemic Stroke

Background: Multiple cerebral territory infarcts of undetermined origin are typically attributed to cardioembolism; and most frequently atrial fibrillation. However the significance of three territory involvement in association with malignancy is under-recognized.

Objective: To highlight the “Three Territory Sign” (bilateral anterior and the posterior circulation DWI lesions), as a radiographic marker of stroke due to malignancy.

Methods: We conducted a retrospective analysis of patients at our institution from Jan 2014-Jan 2016 who suffered an acute ischemic stroke with MRI-DWI. We identified all ischemic strokes of undetermined etiology in patients with known malignancy (60 patients) and patients with stroke, atrial fibrillation and no malignancy (167 patients). Patients with both atrial fibrillation and malignancy were excluded. All DWI images were reviewed for 3, 2, and 1 territory lesions. Fisher Exact tests were used to identify statistical significance between the two groups. Statistical significance was set at 0.05.

Results: There was a significant association between both cohorts (malignancy vs. atrial fibrillation) and the number of territory infarcts found. While the number of 1 {71.6% (n=43) vs. 79% (n=132)} and 2 territory infarcts {10.0% (n=6) vs. 17. 4% (n=29)} were similar between the two groups, 3 territory infarcts were > 5 times more frequent in malignancy as compared to atrial fibrillation {18.3% (n=11) vs. 3.5% (n=6)} ( p < 0.002 ). Post-hoc pairwise comparisons using the Bonferroni correction for multiple tests support that the 3 territory pattern differs from both 1 territory ( p=0.0033 ) and 2 territory ( p =0.0037 ) patterns.

Conclusion: Cerebral territory infarctions involving the bilateral anterior and posterior circulation are 5 times more frequent in malignancy-related ischemic stroke than atrial fibrillation. The “Three territory sign” is a robust marker of malignancy-related stroke and should prompt evaluation for malignancy after exclusion of other known causes.

Abstract TP151: Higher Than Expected Fatigue Among Mild Stroke and TIA Survivors

Background: A growing body of research indicates that fatigue is a common and debilitating sequel of both ischemic and hemorrhagic stroke affecting roughly half of all survivors. However, in patients with minimal to no residual symptoms (mild stroke and TIA) the prevalence and impact is unknown.

Objective: To evaluate the prevalence and functional impact of fatigue among patients with mild stroke and TIA.

Design/methods: A retrospective observational cohort questionnaire-based study from July 2016-July 2017 was conducted on patients presenting to stroke clinic for the first-time after hospital discharge and completed during the visit. A total of 72 patients (58 ischemic, 5 ICH and 9 TIA) were analyzed. Chart review of clinical data including demographics, stroke type, NIHSS, mRS, level of education, work status, living situation, vascular risk factors, and history of depression was completed. The Fatigue Assessment Scale (FAS) was utilized to determine level of fatigue. A score of 22 or higher indicated fatigue. Statistical significance was calculated using Pearson’s Chi-square and Fisher’s exact testing.

Result: Among all patients, median age was 62.5 years 64% were men and 70.8% Caucasian. The median discharge NIH score was 1.5 and 90% were evaluated within the first 12 weeks of hospital discharge. Approximately 42% of patients reported fatigue (n=30) and 19% (n=14) reported new fatigue since their event. Concomitant depression was observed in 45% of fatigued patients (n=13). Fatigue was most commonly observed among patients with an ischemic MCA territory infarction (p=.007). Patients with fatigue were less likely to drive a car (p=.04) and a trend towards being less likely to have returned to work was observed (p=.053).

Conclusions: A higher than expected proportion of patients with mild stroke or TIA report fatigue and roughly 1 in 5 reported new fatigue since their event despite only half of patients experiencing depression. Continued research is needed to better understand predictors of fatigue and its long term impact among these patients.

Abstract WP26: The Effects of Blood Pressure Variation Within 24 Hours of Intracerebral Large Vessel Occlusion Mechanical Thrombectomy and Clinical Outcomes

Introduction: Mechanical thrombectomy (MT) is now the standard of care for acute intracranial large vessel occlusion (LVO). There are currently no established guidelines for post MT blood pressure parameters in LVO patients. Our study examines the influence of blood pressure fluctuation and variation within the first 24 hours on clinical outcomes in post MT LVO patients.

Methods: A hospital based stroke registry retrospectively identified 111 consecutive patients undergoing MT for LVO (2012-2015). Blood pressure recordings within the 1st 24 hours post MT were analyzed: Maximum (Max), minimum, median and standard deviation (SD) of the systolic (SBP), diastolic (DBP) and mean arterial pressures (MAP) were calculated individually and as composite aggregates. Good outcomes were defined as National Institute of Health Stroke Scale (NIHSS) improvement of >=10 at discharge and or discharge NIHSS<=2 Poor outcomes were defined as post-MT intracerebral hemorrhagic (ICH) and mortality. Univariate (UV). and multivariate logistic regression (MV) were used to identify effect of blood pressure variation on good and poor outcomes. IBM-SPSS version 21 was used for data analysis.

Results: On UV analysis a lesser degree of 24 hour post MT SBP (median 16, IQR (Inter Quartile Range) 13, 23 mmHg, p=0.03) and DBP (Median 10, IQR 8, 12 mmHg p .04) SD were associated with good outcome. Maximum SBP was associated with higher rates of mortality (median 188, IQR 174-195 mmHg, p=0.03) and ICH (median 179, IQR 167-196 mmHg, p=0.05). There is no statistically significant association between Post MT 24 hours DBP or MAP maximum, minimum, median and SD values with associated poor outcomes. On MV, SBP variance and maximum SBP were found to be significantly associated with good outcomes (Odds Ratio (OR) 1.09, 95%CI (Confidence interval) 1 - 1.2, p=0.04) and mortality (OR 1.02, 95%CI 1 - 1.004, p=0.02) respectively.

Conclusion: Importance of proper blood pressure regulation within the 1st 24 hours of an LVO MT cannot be understated. To maintain good outcomes after MT, minimizing SBP SD becomes important. With the underlying premise of post cerebral ischemia induced vasomotor dysregulation, controlling Max SBP also decreases ICH and mortality. A prospective study is warranted to reinforce our findings.

Emergency Medicine Residency Applicant Characteristics Associated with Measured Adverse Outcomes During Residency

Introduction

Negative outcomes in emergency medicine (EM) programs use a disproportionate amount of educational resources to the detriment of other residents. We sought to determine if any applicant characteristics identifiable during the selection process are associated with negative outcomes during residency.

Methods

Primary analysis consisted of looking at the association of each of the descriptors including resident characteristics and events during residency with a composite measure of negative outcomes. Components of the negative outcome composite were any formal remediation, failure to complete residency, or extension of residency.

Results

From a dataset of 260 residents who completed their residency over a 19-year period, 26 (10%) were osteopaths and 33 (13%) were international medical school graduates A leave of absence during medical school (p <.001), failure to send a thank-you note (p=.008), a failing score on United States Medical Licensing Examination Step I (p=.002), and a prior career in health (p=.034) were factors associated with greater likelihood of a negative outcome. All four residents with a "red flag" during their medicine clerkships experienced a negative outcome (p <.001).

Conclusion

"Red flags" during EM clerkships, a leave of absence during medical school for any reason and failure to send post-interview thank-you notes may be associated with negative outcomes during an EM residency.

High Mortality among 30-Day Readmission after Stroke: Predictors and Etiologies of Readmission

BACKGROUND

Although some risk factors for stroke readmission have been reported, the mortality risk is unclear. We sought to evaluate etiologies and predictors of 30-day readmissions and determine the associated mortality risk.

METHODS

This is a retrospective case-control study evaluating 1,544 patients admitted for stroke (hemorrhagic, ischemic, or TIA) from January 2013 to December 2014. Of these, 134 patients readmitted within 30 days were identified as cases; 1,418 other patients, with no readmissions were identified as controls. Patients readmitted for hospice or elective surgery were excluded. An additional 248 patients deceased on index admission were included for only a comparison of mortality rates. Factors explored included socio-demographic characteristics, clinical comorbidities, stroke characteristics, and length of stay. Chi-square test of proportions and multivariable logistic regression were used to identify independent predictors of 30-day stroke readmissions. Mortality rates were compared for index admission and readmission and among readmission diagnoses.

RESULTS

Among the 1,544 patients in the main analysis, 67% of index stroke admissions were ischemic, 22% hemorrhagic, and 11% TIA. The 30-day readmission rate was 8.7%. The most common etiologies for readmission were infection (30%), recurrent stroke and TIA (20%), and cardiac complications (14%). Significantly higher proportion of those readmitted for recurrent strokes and TIAs presented within the first week (p = 0.039) and had a shorter index admission length of stay (p = 0.027). Risk factors for 30-day readmission included age >75 (p = 0.02), living in a facility prior to index stroke (p = 0.01), history of prior stroke (p = 0.03), diabetes (p = 0.03), chronic heart failure (p ≤ 0.001), atrial fibrillation (p = 0.03), index admission to non-neurology service (p < 0.01), and discharge to other than home (p < 0.01). On multivariate analysis, index admission to a non-neurology service was an independent predictor of 30-day readmission (p ≤ 0.01). The mortality after a within 30-day readmission after stroke was higher than index admission (36.6 vs. 13.8% p ≤ 0.001) (OR 3.6 95% CI 2.5-5.3). Among those readmitted, mortality was significantly higher for those admitted for a recurrent stroke (p = 0.006).

CONCLUSION

Approximately one-third of 30-day readmissions were infection related and one-fifth returned with recurrent stroke or TIA. Index admission to non-neurology service was an independent risk factor of 30-day readmissions. The mortality rate for 30-day readmission after stroke is more than 2.5 times greater than index admissions and highest among those readmitted for recurrent stroke. Identifying high-risk patients for readmission, ensuring appropriate level of service, and early outpatient follow-up may help reduce 30-day readmission and the high associated risk of mortality.

A Double-Blind, Randomized Trial on the Efficacy and Safety of Hyperbaric Oxygenation Therapy in the Preservation of Erectile Function after Radical Prostatectomy

PURPOSE

We evaluated the efficacy and safety of hyperbaric oxygenation therapy to preserve erectile function as part of penile rehabilitation after robot assisted bilateral nerve sparing radical prostatectomy for prostate cancer.

MATERIALS AND METHODS

We performed a prospective, randomized, double-blind study from January 2009 to April 2013. Men 40 to 65 years old who underwent robot assisted bilateral nerve sparing radical prostatectomy were randomized 1:1 to the control or the treatment group. Participants were exposed to air as the control or to 100% oxygen as the treatment in hyperbaric conditions. The primary outcome was erectile function at 18 months as measured by IIEF (International Index of Erectile Function). Secondary outcomes were 12-month urinary symptoms, and 18-month sexual, urinary, bowel and hormonal related symptoms as measured by EPIC-26 (Expanded Prostate Index Composite-26). Adverse events and long-term cancer outcomes were monitored. Primary and secondary outcomes in the 2 groups were compared by the independent group t-test, the Wilcoxon rank sum test and the chi-square test of proportion.

RESULTS

A total of 109 potent men were randomized to hyperbaric oxygenation therapy or the control group. A total of 43 men in the air group and 40 in the hyperbaric oxygenation therapy group completed the 18-month followup. No statistically significant differences were observed between the 2 groups on any outcome measure.

CONCLUSIONS

This study revealed no difference in erectile recovery in men treated with hyperbaric oxygenation therapy vs placebo. Larger studies involving more diverse comorbidities and different hyperbaric oxygenation therapy regimens are needed to better evaluate the usefulness of hyperbaric oxygenation therapy for penile rehabilitation after radical prostatectomy.

Using simulated family presence to decrease agitation in older hospitalized delirious patients: A randomized controlled trial

BACKGROUND

Simulated family presence has been shown to be an effective nonpharmacological intervention to reduce agitation in persons with dementia in nursing homes. Hyperactive or mixed delirium is a common and serious complication experienced by hospitalized patients, a key feature of which is agitation. Effective nonpharmacological interventions to manage delirium are needed.

OBJECTIVES

To examine the effect of simulated family presence through pre-recorded video messages on the agitation level of hospitalized, delirious, acutely agitated patients.

DESIGN

Single site randomized control trial, 3 groups×4 time points mixed factorial design conducted from July 2015 to March 2016.

SETTING

Acute care level one trauma center in an inner city of the state of Connecticut, USA.

PARTICIPANTS

Hospitalized patients experiencing hyperactive or mixed delirium and receiving continuous observation were consecutively enrolled (n=126), with 111 participants completing the study. Most were older, male, Caucasian, spouseless, with a pre-existing dementia.

METHODS

Participants were randomized to one of the following study arms: view a one minute family video message, view a one minute nature video, or usual care. Participants in experimental groups also received usual care. The Agitated Behavior Scale was used to measure the level of agitation prior to, during, immediately following, and 30min following the intervention.

RESULTS

Both the family video and nature video groups displayed a significant change in median agitation scores over the four time periods (p<0.001), whereas the control group did not. The family video group had significantly lower median agitation scores during the intervention period (p<0.001) and a significantly greater proportion (94%) of participants experiencing a reduction in agitation from the pre-intervention to during intervention (p<0.001) than those viewing the nature video (70%) or those in usual care only (30%). The median agitation scores for the three groups were not significantly different at either of the post intervention time measurements. When comparing the proportion of participants experiencing a reduction in agitation from baseline to post intervention, there remained a statistically significant difference (p=0.001) between family video(60%) and usual care (35.1%) immediately following the intervention CONCLUSION: This work provides preliminary support for the use of family video messaging as a nonpharmacological intervention that may decrease agitation in selected hospitalized delirious patients. Further studies are necessary to determine the efficacy of the intervention as part of a multi-component intervention as well as among younger delirious patients without baseline dementia.

A comparison of preliminary oncologic outcome and postoperative complications between patients undergoing either open or robotic radical cystectomy

Purpose:

To compare complications and outcomes in patients undergoing either open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RRC).

Materials and Methods:

We retrospectively identified patients that underwent ORC or RRC between 2003- 2013. We statistically compared preliminary oncologic outcomes of patients for each surgical modality.

Results:

92 (43.2%) and 121 (56.8%) patients underwent ORC and RRC, respectively. While operative time was shorter for ORC patients (403 vs. 508 min; p<0.001), surgical blood loss and transfusion rates were significantly lower in RRC patients (p<0.001 and 0.006). Length of stay was not different between groups (p=0.221). There was no difference in the proportion of lymph node-positive patients between groups. However, RRC patients had a greater number of lymph nodes removed during surgery (18 vs. 11.5; p<0.001). There was no significant difference in the incidence of pre-existing comorbidities or in the Clavien distribution of complications between groups.

ORC and RRC patients were followed for a median of 1.38 (0.55-2.7) and 1.40 (0.582.59) years, respectively (p=0.850). During this period, a lower proportion (22.3%) of RRC patients experienced disease recurrence vs. ORC patients (34.8%). However, there was no significant difference in time to recurrence between groups. While ORC was associated with a higher all-cause mortality rate (p=0.049), there was no significant difference in disease-free survival time between groups.

Conclusions:

ORC and RRC patients experience postoperative complications of similar rates and severity. However, RRC may offer indirect benefits via reduced surgical blood loss and need for transfusion.

CCL11 (Eotaxin-1) Levels Predict Long-Term Functional Outcomes in Patients Following Ischemic Stroke

Circulating levels of the pro-inflammatory cytokine C-C motif chemokine 11 (CCL11, also known as eotaxin-1) are increased in several animal models of neuroinflammation, including traumatic brain injury and Alzheimer's disease. Increased levels of CCL11 have also been linked to decreased neurogenesis in mice. We hypothesized that circulating CCL11 levels would increase following ischemic stroke in mice and humans, and that higher CCL11 levels would correlate with poor long-term recovery in patients. As predicted, circulating levels of CCL11 in both young and aged mice increased significantly 24 h after experimental stroke. However, ischemic stroke patients showed decreased CCL11 levels compared to controls 24 h after stroke. Interestingly, lower post-stroke CCL11 levels were predictive of increased stroke severity and independently predictive of poorer functional outcomes in patients 12 months after ischemic stroke. These results illustrate important differences in the peripheral inflammatory response to ischemic stroke between mice and human patients. In addition, it suggests CCL11 as a candidate biomarker for the prediction of acute and long-term functional outcomes in ischemic stroke patients.

Abstract TP188: Migraine History is the Only Predictor of Negative Diffusion Weighted Imaging in Patients Treated with IV-Thrombolytic

Background: Migraine, seizures, and psychiatric disorders are frequently reported as “stroke mimics” in patients with negative diffusion weighted imaging (DWI) after IV-tPA. We sought to determine predictors of negative DWI in suspected stroke patients treated with IV-tPA.

Methods: A retrospective case-control study encompassing all acute stroke patients treated with IV-tPA (at our hospital or "dripped and shipped") from January 2013-December 2014 was conducted. A total of 275 patients were identified with 47 negative DWI cases and 228 positive DWI controls. Variables including demographic factors, stroke characteristics, and clinical comorbidities were analyzed for statistical significance. A multivariate logistic regression was performed (SPSS-24) to identify predictors of negative DWI.

Results: Approximately 17% of patients had negative DWI after IV-tPA. Compared to controls, migraine history independently predicted negative DWI (OR 5.0 95% CI 1.03-24.6, p=0.046). Increasing age (OR 0.97 95% CI 0.94-0.99, p=0.02) and atrial fibrillation (OR 0.25 95% CI 0.08-0.77 p=0.01) predicted lower probability of negative DWI. Gender, admission NIHSS, treatment location, pre-admission modified Rankin scale, diabetes mellitus, hypertension, hyperlipidemia, symptom side, seizure history, and psychiatric history did not predict negative DWI status.

Conclusion: In our study, only pre-existing migraine history independently predicted negative DWI after IV-tPA treatment in suspected stroke patients. Although helpful in acute evaluation, this should not preclude treatment with IV-tPA considering the outcomes of missed strokes and low complication risk of IV-tpa in these patients.

Abstract WMP87: Simulation Based Medical Education Improves Door to Needle Times in Acute Ischemic Stroke Management

Introduction: Literature on the effectiveness of simulation based medical education programs used in acute ischemic stroke (AIS) care is scant. In an effort to improve coordination and door to needle time (DNT) for AIS care, a stroke simulation education training program for neurology nursing staff and neurology residents was implemented in a comprehensive stroke center.

Methods: Hospital stroke registry was used for retrospective analysis. The study population was defined as all patients treated with IV-tPA for AIS in the emergency room from October 2008 to September 2014. Simulation training was implemented yearly, for a three month period starting from July 2011. All neurology residents and a group of nurses trained to respond to all AIS cases participated. Simulations were standardized, using deliberate practice with a trained live actor portraying stroke vignettes in the presence of a board certified vascular neurologist. During the period of study, there were no changes in Emergency Department stroke triage protocol, or changes in first provider response to AIS. The data was analyzed using IBM SPSS24 software.

Results: We identified 448 patients admitted with AIS who were treated with IV-tPA. The average DNT on univariate analysis before and after intervention was 67.9 and 58.3 minutes [p <0.001]. A multivariate linear regression analysis was performed controlling for age, night/day shift, weekday/weekend, and blood pressure at presentation (>185/110). After controlling for confounders we found that simulation training independently reduced the DNT by 9.64 minutes [95% confidence interval (CI) 4.01 - 15.28, p=0.001]. Amongst other co-variates, only the systolic blood pressure >185 was associated with 14.27 minutes of delay in DNT [95% CI 3.36 - 25.191, p=0.011].

Conclusion: Time to thrombolysis from symptom onset is a critical factor in AIS management and evidence shows improving the DNT could improve patient outcomes. In our six year study, integration of simulation based medical education for AIS reduced the average DNT by 9.64 minutes in multivariate analysis. Simulation based medical education therefore should be considered as a standard process for providers involved in the care of AIS patients receiving thrombolytic treatment.

Abstract TP282: High Mortality Among 30-Day Readmission After Stroke: Predictors and Etiologies of Readmission

Background: Although risk factors for readmission have been reported, the mortality risk is unclear. We sought to evaluate etiologies and predictors of 30-day readmission and determine the associated mortality risk.

Methods: This is a retrospective case-control study evaluating stroke patients (hemorrhagic, ischemic or TIA) from January 2013-December 2014 and those readmitted within 30 days after index event; including 135 readmitted patients and 1,664 controls. Readmission for hospice or elective surgery were excluded. Socio-demographics, clinical variables and potential risk factors were assessed using chi-square test of proportions and multi variable logistic regression was performed to identify independent predictors of 30-day stroke readmission. Index mortality was compared to readmission mortality and odds associated with readmission was identified.

Results: Overall, 67% of index stroke admissions were ischemic, 19% hemorrhagic, and 14% TIA. The 30-day readmission rate was 7.3%. The most common etiologies for readmission were infection (30%), recurrent stroke (17%), and cardiac complications (14%). Recurrent strokes presented earliest (p=0.047) and had a shorter index admission length of stay (p=0.02.) Risk factors for 30-day readmission included age > 75 ( p=0.04 ), lack of spouse ( p=0.05 ), living in a facility prior to index stroke ( p=0.033 ), history of prior stroke ( p=0.02 ), diabetes ( p=.018 ), CHF ( p=<.0001 ), atherosclerosis ( p=<0.01 ), admission to non-stroke unit ( p=0.02 ), non-home discharge status ( p<0.01 ), and index admission to a non-neurology service was an independent predictor of 30-day readmission (p=<0.01). The overall mortality associated with 30-day readmission after stroke was higher as compared to index admission (37.3% vs 13.3% p =<0.01) (OR 3.7 95%CI 2.5-5.3) and was not influenced by recurrent stroke (p=0.37) .

Conclusion: In our study, infection and recurrent stroke were most common causes and index admission to a non-neurology service was the strongest readmission predictor. The overall mortality is high and not influenced by recurrent stroke. Identifying high risk patients, ensuring appropriate level of service and early outpatient follow-up may help reduce 30-day readmission and risk of mortality.

Abstract WP54: Early MRI Facilitates Stroke Evaluation and Decreases Length of Stay for Ischemic Stroke Patients

Background: Imaging studies are an integral part of stroke evaluation and non-contrast head CT is the initial imaging modality. Although critical for assessing acute hemorrhage, ischemic changes may not be visible on CT for up to 24 hours. MRI brain detects ischemic changes within 20 minutes of symptom onset. It is an invaluable tool to confirm an ischemic stroke and determine its etiology. A focused workup for stroke etiology or evaluation for stroke mimics accelerates management strategies and reduces length of stay in the hospital. Early discharge facilitates early rehabilitation and better functional recovery of stroke patients. Current guidelines for management of acute stroke recommend head CT within 25 minutes of presentation. However, to date, a recommendation regarding timeline for MRI brain in stroke evaluation is lacking. Objective of this study was to investigate the correlation between time to MRI & length of hospital stay to functional outcome in stroke patients.

Methods: 648 patients (mean age 69±0.5 years; 50.4% women) admitted to Hartford Hospital (Comprehensive Stroke Center) with a focal neurological deficit in the year 2014 and got a CT head and MRI brain were enrolled in the study. Data collection was done via stroke database and retrospective chart review. Patients with any hemorrhage or age<18 years, were excluded from the study. We used Mann-Whitney U and Spearman’s correlation co-efficient to compare time from arrival to MRI and length of stay in the hospital.

Results: There was a significant effect of time from arrival to MRI on length of hospital stay (r=0.27, p<0.01). Subgroup analysis revealed a significant decrease in length of stay if MRI was done within 12 hours of admission (p<0.02) as compared to 24 hours or above (p<0.12). Based on MRI findings, 27% patients had a new diagnosis of stroke and in 24.1% patients stroke was ruled out. This change in diagnosis had a significant effect on length of stay (Z=-2.4, p<0.02).

Conclusions: Our study indicates that delay in MRI for a suspected stroke increases hospital length of stay. It suggests MRI within 12 hours of admission to be the new standard of care for stroke patients. Ongoing work will assess the correlation of timing to MRI to functional outcomes in stroke patients.