Differential Impact of Smoking on Methylome and Transcriptome in Crohn's Disease and Ulcerative Colitis

BACKGROUND

Smoking is an environmental factor that differentially impacts Crohn's disease (CD) and ulcerative colitis (UC). The mechanism of impact of smoking on disease risk and clinical outcomes remains to be established.

METHODS

This study used a prospective cohort of patients with CD or UC. Self-reported smoking status was validated using serum cotinine measurement. We profiled methylation changes in peripheral blood using the Illumina Methylation BeadChip. Transcriptomic profiling was performed on ileal and colonic tissue using an Illumina TruSeq platform. We compared the methylation and transcriptional changes in current, former, and never smokers stratified by disease type.

RESULTS

Our cohort included 200 patients with CD or UC with methylation profiles and 160 with transcriptomic data. The mean serum cotinine level was higher in current compared with former or never smokers. Epigenetic changes common to both CD and UC included hypomethylation at AHRR. Smoking-associated MGAT3 hypomethylation was associated with severe disease course only in UC, while IER3 hypomethylation was associated with worse course only in CD. Smoking downregulated several inflammatory pathways in UC. Current smoking in CD but not in UC was associated with upregulation of several genes mediating Paneth cell function. Genes with opposite direction of effects in CD and UC include HSD3B2 and GSTA1.

CONCLUSIONS

Our findings suggest both common and differential effects of cigarette smoking on CD and UC. Paneth cell dysfunction may mediate adverse impact of smoking on CD. Bile acid and oxidative stress pathways may be relevant for the differential effect of smoking on CD and UC.

Multi-modal skin atlas identifies a multicellular immune-stromal community associated with altered cornification and specific T cell expansion in atopic dermatitis

In healthy skin, a cutaneous immune system maintains the balance between tolerance towards innocuous environmental antigens and immune responses against pathological agents. In atopic dermatitis (AD), barrier and immune dysfunction result in chronic tissue inflammation. Our understanding of the skin tissue ecosystem in AD remains incomplete with regard to the hallmarks of pathological barrier formation, and cellular state and clonal composition of disease-promoting cells. Here, we generated a multi-modal cell census of 310,691 cells spanning 86 cell subsets from whole skin tissue of 19 adult individuals, including non-lesional and lesional skin from 11 AD patients, and integrated it with 396,321 cells from four studies into a comprehensive human skin cell atlas in health and disease. Reconstruction of human keratinocyte differentiation from basal to cornified layers revealed a disrupted cornification trajectory in AD. This disrupted epithelial differentiation was associated with signals from a unique immune and stromal multicellular community comprised of MMP12 + dendritic cells (DCs), mature migratory DCs, cycling ILCs, NK cells, inflammatory CCL19 + IL4I1 + fibroblasts, and clonally expanded IL13 + IL22 + IL26 + T cells with overlapping type 2 and type 17 characteristics. Cell subsets within this immune and stromal multicellular community were connected by multiple inter-cellular positive feedback loops predicted to impact community assembly and maintenance. AD GWAS gene expression was enriched both in disrupted cornified keratinocytes and in cell subsets from the lesional immune and stromal multicellular community including IL13 + IL22 + IL26 + T cells and ILCs, suggesting that epithelial or immune dysfunction in the context of the observed cellular communication network can initiate and then converge towards AD. Our work highlights specific, disease-associated cell subsets and interactions as potential targets in progression and resolution of chronic inflammation.

Long-Term Outcomes of NRG/RTOG 0126, a Randomized Trial of High Dose (79.2 Gy) vs. Standard Dose (70.2 Gy) Radiation Therapy (RT) for Men with Localized Prostate Cancer

PURPOSE/OBJECTIVE(S)

NRG/RTOG 0126, a phase III trial for men with localized prostate cancer testing whether dose escalation to 79.2 Gy with 3DCRT/IMRT improved overall survival (OS). Long-term results of this trial are presented.

MATERIALS/METHODS

Patients with clinical stage T1b-T2b and either Gleason Score (GS) 2-6 and 10 ≤ PSA < 20 or GS 7 and PSA < 15 were eligible and randomized to receive 79.2 Gy or 70.2 Gy. No previous or concurrent androgen withdrawal therapy was administered. Treatment was delivered with 3DCRT/IMRT to a dose of 79.2 Gy in 44 fractions or 70.2 Gy in 39 fractions to the PTV encompassing the prostate and seminal vesicles. Image guidance was not required. ASTRO and Phoenix definitions were used for biochemical failure (ABF and PBF, respectively). OS was estimated by the Kaplan-Meier method and arms compared with the log-rank test. ABF, PBF, local progression (LP), distant metastases (DM) and time to late GI/GU toxicities were estimated by the cumulative incidence method and arms compared with Gray's test.

RESULTS

One thousand five hundred thirty-two men were randomized, 763 to 79.2 Gy and 769 to 70.2 Gy. 1499 were eligible, 748 and 751 in the 79.2 Gy and 70.2 Gy arms respectively. Median age was 71, 70% had PSA < 10 ng/ml, 84% with GS 7, 57% had T1 disease, and 66% treated with 3D-CRT. Outcomes are shown in the TABLE: . With a median follow up of 12 years, there was no significant difference in OS. There was a statistically significant decrease in the cumulative incidence of ABF, PBF, DM, LP, and salvage therapies in the 79.2 Gy arm. There were significantly higher rates of grade 2+ GI and GU toxicity in the 79.2 Gy arm. There were no statistically significant differences in the rates of grade 3+ GU or GI toxicity between either arm.

CONCLUSION

Long term follow up confirms no improvement in OS with dose escalation in this study population. However, there are significant improvements in ABF, PBF, DM, LP, and need for salvage therapy. Despite the use of more salvage therapy in the low dose arm, dose escalated RT resulted in lower rates of DM, a clinically relevant endpoint. Patients receiving dose escalation do experience a higher rate of grade 2+ GU and GI toxicity but no worse grade 3+ toxicities.

Long-Term Toxicity in Patients Receiving Radiotherapy for Ultracentral Stage I Non-Small Cell Lung Cancer - A Secondary Analysis of the LUSTRE Randomized Trial

PURPOSE/OBJECTIVE(S)

Hypofractionated and stereotactic body radiotherapy (SBRT) are increasingly used in the treatment of centrally located, early-stage non-small cell lung cancer (NSCLC), though there are concerns of increased morbidity and mortality in patients with ultracentral tumors (UC). We report on the long-term toxicity of patients with UC lung cancer treated on a prospective randomized clinical trial of SBRT versus conventionally hypofractionated radiotherapy (CRT) for stage I NSCLC (NCT01968941).

MATERIALS/METHODS

Patients with UC tumors, defined as those where the planning target volume directly overlaps with the proximal bronchial tree (PBT), were identified from the larger cohort of patients treated on the trial. These patients received either SBRT with 60 Gy in 8 fractions or CRT with 60 Gy in 15 fractions. The primary endpoint of this secondary analysis was development of any grade 3 or higher toxicity defined using CTCAE version 3.0. Secondary endpoints included local control, as well as dosimetric analysis of the PBT, using EQD2 with α/β ratio of 3 to assess the relationship between dose to the PBT and toxicity.

RESULTS

Twenty-nine patients were identified with UC tumors; 21 received SBRT and 8 received CRT. Median age was 72 years (range 55-88 years) and 59% were female. Median FEV1 was 1.46L (range 0.64-2.37L). Patients had either T1 (59%) or T2 (41%) lesions, with median tumor size 2.5cm (range 1.1-4.9cm). Most patients had histologically confirmed disease (squamous cell, n = 10; adenocarcinoma, n = 8; radiographically suspicious, n = 11). The median follow-up was 2.9 years (range 0.7-5.2 years). The 3-year local control rate of all patients was 88.3% (95% confidence interval: 75.7-100%). There were 3 patients with late (>3 months) grade 3 toxicity (bronchial stricture, chest pain, and atelectasis) and 1 patient with late grade 5 toxicity (bleeding/hemorrhage), all treated in the SBRT arm. Median EQD2 dose to PBT in patients with grade ≥3 late toxicity compared to the rest of the cohort was: Dmax, 132 vs 129 Gy; D0.1cc, 129 vs 119 Gy; D1cc, 124 vs 80 Gy; and D5cc, 83 vs 41 Gy. Median EQD2 volumetric doses in grade ≥3 patients (compared to the rest) to PBT were: V65 Gy, 9.7 vs 2.2cc; V80 Gy, 7.9 vs 1.1cc; V90 Gy, 6.2 vs 0.4cc; and V100 Gy, 4.8 vs 0.3cc. The single patient with grade 5 toxicity had the highest D5cc (116 Gy) and V100 Gy (7cc) among all patients.

CONCLUSION

Stereotactic radiation with 60 Gy in 8 fractions for UC lung cancer provides good local control but carries an approximately 15-20% rate of late grade ≥3 toxicity. There appears to be a dosimetric association between toxicity and dose to the PBT. It may be more important to minimize volumetric PBT dose rather than maximum point dose to reduce risk of severe late toxicity.

The landscape of immune dysregulation in Crohn's disease revealed through single-cell transcriptomic profiling in the ileum and colon

Crohn's disease (CD) is a chronic gastrointestinal disease that is increasing in prevalence worldwide. CD is multifactorial, involving the complex interplay of genetic, immune, and environmental factors, necessitating a system-level understanding of its etiology. To characterize cell-type-specific transcriptional heterogeneity in active CD, we profiled 720,633 cells from the terminal ileum and colon of 71 donors with varying inflammation status. Our integrated datasets revealed organ- and compartment-specific responses to acute and chronic inflammation; most immune changes were in cell composition, whereas transcriptional changes dominated among epithelial and stromal cells. These changes correlated with endoscopic inflammation, but small and large intestines exhibited distinct responses, which were particularly apparent when focusing on IBD risk genes. Finally, we mapped markers of disease-associated myofibroblast activation and identified CHMP1A, TBX3, and RNF168 as regulators of fibrotic complications. Altogether, our results provide a roadmap for understanding cell-type- and organ-specific differences in CD and potential directions for therapeutic development.

The CD4+ T cell response to a commensal-derived epitope transitions from a tolerant to an inflammatory state in Crohn's disease

Reciprocal interactions between host T helper cells and gut microbiota enforce local immunological tolerance and modulate extra-intestinal immunity. However, our understanding of antigen-specific tolerance to the microbiome is limited. Here, we developed a systematic approach to predict HLA class-II-specific epitopes using the humanized bacteria-originated T cell antigen (hBOTA) algorithm. We identified a diverse set of microbiome epitopes spanning all major taxa that are compatible with presentation by multiple HLA-II alleles. In particular, we uncovered an immunodominant epitope from the TonB-dependent receptor SusC that was universally recognized and ubiquitous among Bacteroidales. In healthy human subjects, SusC-reactive T cell responses were characterized by IL-10-dominant cytokine profiles, whereas in patients with active Crohn's disease, responses were associated with elevated IL-17A. Our results highlight the potential of targeted antigen discovery within the microbiome to reveal principles of tolerance and functional transitions during inflammation.

Cloxacillin-induced acute vanishing bile duct syndrome: a case study and literature review

Ductopenia is often regarded as a chronic process where ≥50% of portal tracts lack bile ducts, which is also known as vanishing bile duct syndrome (VBDS). One etiology is drug-induced liver injury. Cloxacillin, an anti-staphylococcal penicillin, typically causes "bland" cholestasis. We present the first case of cloxacillin-induced acute ductopenia or VBDS and a review of published cloxacillin-induced liver injuries. A 66-year-old woman with no prior liver disease, but known penicillin allergy, was treated for post-carotid angioplasty staphylococcal infection with 6 weeks of cloxacillin. She presented with a two-week history of weakness and jaundice. Laboratory work-up showed elevated liver enzymes with a cholestatic pattern, hyperbilirubinemia, and eosinophilia. She required ICU transfer for hypotension and was started empirically on prednisone. Liver biopsy revealed severe centrilobular cholestasis, mild necroinflammation, and ductopenia with epithelial injury, but no ductular reaction. Two-month later, she was discharged on hydrocortisone and ursodiol with persistently elevated alkaline phosphatase and bilirubin. She was considered for liver transplantation but died of liver failure four months later. Four additional articles were found with histopathologic descriptions of cloxacillin-related liver injury. These included portal inflammation, cholestasis and mild necroinflammation. Clinical features were reported in two cases; both had mild symptoms with cholestatic liver enzymes and hyperbilirubinemia. Both patients recovered completely within 10-60 days. Cloxacillin-induced cholestasis can be secondary to acute ductopenia, which can result in worse clinical outcomes than previously described "bland" cholestasis. Liver biopsy is recommended to identify cases with acute VBDS.

Multi-omics reveal microbial determinants impacting responses to biologic therapies in inflammatory bowel disease

The intestinal microbiome is a key determinant of responses to biologic therapy in inflammatory bowel disease (IBD). However, diverse therapeutics and variable responses among IBD patients have posed challenges in predicting clinical therapeutic success. In this prospective study, we profiled baseline stool and blood in patients with moderate-to-severe Crohn's disease or ulcerative colitis initiating anti-cytokine therapy (anti-TNF or -IL12/23) or anti-integrin therapy. Patients were assessed at 14 weeks for clinical remission and 52 weeks for clinical and endoscopic remission. Baseline microbial richness indicated preferential responses to anti-cytokine therapy and correlated with the abundance of microbial species capable of 7α/β-dehydroxylation of primary to secondary bile acids. Serum signatures of immune proteins reflecting microbial diversity identified patients more likely to achieve remission with anti-cytokine therapy. Remission-associated multi-omic profiles were unique to each therapeutic class. These profiles may facilitate a priori determination of optimal therapeutics for patients and serve as targets for newer therapies.

Chronic Kidney Disease as Risk Factor for Enlarged Perivascular Spaces in Patients With Stroke and Relation to Racial Group

BACKGROUND AND PURPOSE

Enlarged perivascular spaces (EPVS) are considered subclinical markers of small vessel disease, associated with increased risk of stroke and dementia. Increasing evidence links chronic kidney disease (CKD) to small vessel disease. We explored the relationship between CKD and EPVS burden and the influence of racial group in this relation.

METHODS

Consecutive patients with stroke who underwent brain magnetic resonance imaging were included (n=894). Racial group was categorized as White, Black, or other (other racial groups). CKD was defined by glomerular filtration rate <60 mL/minute per 1.73 m² for >3 months. EPVS were rated following a standardized method, dichotomized for analyses (mild [<20] versus severe [≥20]), and stratified by brain region (basal ganglia and centrum semiovale).

RESULTS

In multivariable-adjusted analysis, the association of CKD with severe EPVS varied across racial groups. Comparing patients with and without CKD within racial groups, we found that Whites with CKD had higher odds of severe centrum semiovale EPVS (odds ratio [OR], 2.41 [95% CI, 0.98-5.88]). Among patients with CKD, Black patients had higher odds of severe EPVS in the basal ganglia and centrum semiovale compared with Whites (OR, 1.93 [95% CI, 1.18-3.16] and OR, 1.90 [95% CI, 1.16-3.11], respectively) and other racial groups (OR, 2.03 [95% CI, 1.23-3.36] and OR, 2.02 [95% CI, 1.22-3.34], respectively).

CONCLUSIONS

CKD was more prevalent in our sample of patients with stroke with severe EPVS in the centrum semiovale. The relation differed when stratified by racial group and brain topography. Further studies are needed to confirm that CKD may relate differently to subclinical measures of small vessel disease according to race.

Perihematomal edema surrounding spontaneous intracerebral hemorrhage by CT: Ellipsoidal versus morphometric volumetry

Perihematomal edema (PHE) surrounding intracerebral hemorrhage (ICH) may contribute to disease-associated morbidity. Before quantifying PHE's effects on morbidity, a fast, accurate, and reproducible method for measuring PHE volume is needed. The aim of this study is to demonstrate the use of a semiautomated dual clustering segmentation algorithm to generate PHE volumetrics on noncontrast computed tomography (CT) of the head and compare this technique to physicians' manual calculations.This is a single-center, retrospective imaging study that included head CTs performed from January 2008 to December 2014 on 154 patients with ICH. Subjects ≥ 18 years old who were admitted to the hospital with spontaneous ICH were included. Included subjects had head CTs performed upon admission and within 6 to 24 hours. Two neurologists, 2 neuroradiologists, and a computer program all calculated hemorrhage and PHE volumes. Inter-rater correlation was evaluated using 2 statistical methods: intraclass correlations (ICCs) and limits of agreement (LOA). Additionally, correlation between volumes was separately evaluated using Pearson correlation coefficient.There was an excellent correlation between measurements performed by neurologists and neuroradiologists using ABC/2 for ICH (0.93) and PHE (0.78). There was a good correlation between measurements performed by neurologists using ABC/2 and the volume measurements generated by the algorithm for ICH (0.69) and PHE (0.70). There was a fair correlation between measurements performed by neuroradiologists using ABC/2 and volume measurements generated by the algorithm for ICH (0.47) and good correlation for PHE (0.73).Although the ABC/2 method for measuring PHE is quick and practical, algorithms that do not assume ellipsoidal shape may be more accurate.

Evaluating the massive underreporting and undertesting of COVID-19 cases in multiple global epicenters

BACKGROUND

With continuous global COVID-19 outbreak, differing case numbers and mortality rates are observed. While actual case numbers appear vague, mortality numbers related to COVID-19 seem more precise. In this study, we used the mortality rate as the main indicator to evaluate the extent of underreporting and underdetection of COVID-19 cases.

METHODS

We have analyzed all available data provided by the World Health Organization on the development of international COVID-19 cases and mortality numbers on March 17th, 2020. A crude case-fatality risk (cCFR) and adjusted case-fatality risk (aCFR) was calculated for China, South Korea, Japan, Italy, France, Spain, Germany, Iran and the United States. Additionally, a fold-change (FC) was derived for each country.

RESULTS

The highest aCFR and FC were detected for Spain. Based on their FC values, an extremely high number of undetected COVID-19 cases was displayed in France, the United States, Italy and Spain. For these countries, our findings indicate a detection rate of only 1-2% of total actual COVID-19 cases.

CONCLUSIONS

Due to limited testing capacities, mortality numbers may serve as a better indicator for COVID-19 case spread in many countries. Our data indicate that countries like France, Italy, the United States, Iran and Spain have extremely high numbers of undetected and underreported cases. Differences in testing availability and capacity, containment as well as overall health care and medical infrastructure result in significantly different mortality rates and COVID-19 case numbers for each respective country.

Contributions of anterior cingulate cortex and basolateral amygdala to decision confidence and learning under uncertainty

The subjective sense of certainty, or confidence, in ambiguous sensory cues can alter the interpretation of reward feedback and facilitate learning. We trained rats to report the orientation of ambiguous visual stimuli according to a spatial stimulus-response rule that must be learned. Following choice, rats could wait a self-timed delay for reward or initiate a new trial. Waiting times increase with discrimination accuracy, demonstrating that this measure can be used as a proxy for confidence. Chemogenetic silencing of BLA shortens waiting times overall whereas ACC inhibition renders waiting times insensitive to confidence-modulating attributes of visual stimuli, suggesting contribution of ACC but not BLA to confidence computations. Subsequent reversal learning is enhanced by confidence. Both ACC and BLA inhibition block this enhancement but via differential adjustments in learning strategies and consistent use of learned rules. Altogether, we demonstrate dissociable roles for ACC and BLA in transmitting confidence and learning under uncertainty.

Abstract WP249: Illicit Drug Use and Cerebral Microbleeds in Stroke and Transient Ischemic Attack Patients

Background: Cerebral microbleeds (CMB) signal cerebral small vessel disease and are associated with ischemic stroke (IS) incidence, recurrence, and complications. While illicit drug use (IDU) is associated with cerebral small vessel disease, the association between CMB and IDU is understudied. We sought to delineate differences in vascular risk factors between IDU and CMB and determine the effect of this relationship on outcomes in IS/transient ischemic attack (TIA) patients.

Methods: We included 2001 consecutive IS and TIA patients (years 2009-2018) with a readable T2*gradient-echo MRI sequence. CMB rating followed standardized guidelines and CMB were grouped topographically into lobar, deep or infratentorial. IDU data (history and/or urine toxicology) was available for 1746 patients. The adverse composite outcome included pneumonia, urinary tract infection, deep venous thrombosis or death during hospitalization. Good functional outcome was defined as modified Rankin scale score < 3 and ambulatory on discharge. Univariate analysis was used to assess vascular risk factors and multivariable logistic regression was used to characterize the IDU/CMB relationship on outcomes.

Results: We observed IDU in 13.8 % (n=241), and CMB in 32.9% (n=575, 53.8% lobar, 27.3% deep and 18.8% infratentorial). Patients with IDU and at least one CMB were older (53.6±10.5 vs. 56.9±11.5, p=0.04), had a lower BMI (28.1±5.9 vs. 26.6±4.4, p=0.04), and were more likely to have had a previous IS/TIA (25.1% vs. 41.9%, p=0.01). IDU trended higher for those with severe CMB (10+) compared with those without CMB and 1-9 CMB (25% [n=9] vs 14.3% [n=1171] and 12.1% [n=65] respectively; p=0.07) without individual drug deviations from this pattern. Adverse and good functional outcomes were observed in 177 and 905 total patients, respectively. No significant interaction was observed between IDU and CMB with either adverse or functional composite outcomes.

Conclusion: IDU prevalence was high in our urban study population, and showed a borderline association with increasing CMB burden. Patients with CMB and IDU history were older and more likely to have had a previous IS/TIA. Further studies are required to clarify the clinical consequences related to the relationship between IDU and CMB.

Abstract TP206: Prevalence and Predictors of Cerebral Microbleeds Among Racial Minorities With Ischemic Stroke and Transient Ischemic Attack

Background: Cerebral microbleeds (CMB) are associated with dementia and stroke. CMB are attributed to cerebral amyloid angiopathy (lobar CMB), and hypertensive angiopathy (deep CMB). Racial minorities (RM) have a higher prevalence and poorer control of vascular risk factors, thus CMB may differ in prevalence and distribution in RM. We determined the prevalence, burden and vascular risk factors of CMB across racial groups in patients with stroke and transient ischemic attack, and CMB influence in short term outcomes.

Methods: We included 2001 consecutive (year 2009-2018) patients with a readable T2*gradient-echo MRI sequence. CMB rating followed standardized guidelines and grouped topographically into lobar, deep or infratentorial. Race was self-reported based on U.S. census procedures and categorized as White, Black or Other racial groups (ORG). Univariate analyses were done to compare vascular risk factors between CMB groups, and multivariate logistic regression analyses were used to relate CMB and short term functional (modified Ranking scale score <3 vs. higher) and adverse hospital outcomes (pneumonia, UTI, DVT, death), across racial groups.

Results: We observed CMB in 679 (34%) patients. The respective distribution in lobar, deep and infratentorial regions were: Whites (n=174; 67.2%, 20.7% and 12%); Blacks (n=374; 53%, 28.4% and 18.5%); ORG (n=131; 45.5%, 25.3% and 29.3%). Blacks and ORG with CMB were younger than Whites (66 and 66 vs 70; p<0.01); and had higher prevalence of diabetes (44% and 41% vs 28%, p<0.01). Blacks had higher prevalence of previous stroke when compared with Whites (36% vs 27%, p<0.05). Patients with 10+ CMB, compared with no CMB and 1-9 CMB, had higher in-hospital pneumonia (8% vs 2.1% and 2.4% respectively; p=0.02) and were less likely to have mRS 0-2 at discharge (44.8% vs 55.3% and 48.7%; p=0.06). No difference was observed in mortality and other hospital adverse events.

Conclusion: Racial minorities had higher proportion of CMB in non-lobar regions, suggesting that RM are more likely to have hypertensive angiopathy. RM with CMB were younger and differed in several risk factors compared to Whites. High CMB burden affected adversely outcomes. Further studies are needed to better characterize the clinical impact of CMB in RM.

Abstract TP425: Prevalence and Predictors of Cortical Superficial Siderosis Among African Americans with Ischemic Stroke and Transient Ischemic Attack

Background: Cortical Superficial Siderosis (cSS) detected on brain MRI affects 0.7% of the general population. In studies of predominantly White individuals, cSS is considered a sensitive marker of cerebral amyloid angiopathy (CAA) associated with increased risk of intracerebral hemorrhage. However, its prevalence and predictors in ischemic stroke (IS) —particularly in African Americans (AA)—has not been well studied. We sought to characterize the prevalence and vascular risks associated with cSS in AA with IS and transient ischemic attack (TIA).

Methods: We included 2001 consecutive (year 2009-2018) IS and TIA patients, wherein 1048 patients (52%) were AA with available T2*gradient-echo MRI sequence. cSS rating was performed according to standardized guidelines. Race was determined by self-report based on U.S. census procedures, categorized as White, AA or Other racial groups (ORG). Vascular risk factors included age, diabetes, hypertension, systolic blood pressure (SBP), dyslipidemia, BMI, smoking, prior stroke, coronary artery disease; and illicit drug use (IDU). Differences in associations with cSS were assessed using univariate analyses.

Results: We observed cSS in 1.15% (n=23) of AA, 0.4% (n=9) Whites and 0.6% (n=12) ORG patients. Compared to Whites with cSS, AA were younger (63 vs. 69 years), had higher proportion of men (70 vs 56%), hypertension (83 vs 78%), IDU (22 vs 11%), higher SBP (166±33 vs 162±15mmHg), and lower CAD prevalence (13 vs 33%), although differences did not reach statistical significance. Compared to AA without cSS, AA with cSS had higher proportion of men (69.6 vs 49.7%), prior stroke (39.1 vs 29.7%), IDU (21.7 vs 12.9%), and higher SBP (166±33 vs 153±37mmHg), the latter being the only statistically significant (p=0.038). The remaining vascular risk factors did not differ in patients with and without cSS, or between racial groups.

Conclusion: The prevalence of cSS in AA with IS/TIA at our urban center is higher than in the general population and higher than in Whites. The vascular risk factor profile seems to differ between AA and White patients with and without cSS. Our results may be relevant in studies of cSS in AA wtih IS/TIA patients as the underlying angiopathy may not represent CAA, but require replication in larger samples.

Alberta CancerBridges development of a care plan evaluation measure

Background

No standardized measures specifically assess cancer survivors' and healthcare providers' experience of Survivor Care Plans (scps). We sought to develop two care plan evaluation (cpe) measures, one for survivors (cpe-s) and one for healthcare providers (cpe-p), examine initial psychometric qualities in Alberta, and assess generalizability in Manitoba, Canada.

Methods

We developed the initial measures using convenience samples of breast (n = 35) and head and neck (n = 18) survivors who received scps at the end of active cancer-centre treatment. After assessing Alberta's scp concordance with Institute of Medicine (iom) recommendations using a published coding scheme, we examined psychometric qualities for the cpe-s and cpe-p. We examined generalizability in Manitoba, Canada, with colorectal survivors discharged to primary care providers for follow-up (n = 75).

Results

We demonstrated acceptable internal consistency for the cpe-s and cpe-p subscales and total score after eliminating one item per subscale for cpe-s, two for cpe-p, resulting in revised scales with four 7-item and 6-item subscales, respectively. Subscale scores correlated highly indicating that for each measure the total score may be the most reliable and valid. We provide initial cpe-s discriminant, convergent, and predictive validity using the total score. Using the Manitoba sample, initial psychometrics similarly indicated good generalizability across differences in tumour groups, scp, and location.

Conclusions

We recommend the revised cpe-s and cpe-p for further use and development. Studies documenting the creation and standardization of scp evaluations are few, and we recommend further development of patient experience measures to improve both clinical practice and the specificity of research questions.

Abstract WP189: Prevalence and Risk Factors for Cerebral Enlarged Perivascular Spaces in Relation to Race and Stroke Severity

Purpose: Racial minorities have a higher prevalence of vascular risk factors (VRF), as well as higher incidence and greater severity of stroke. Enlarged perivascular spaces (EPVS) are considered a marker of small vessel disease reflecting the long term effect of VRF. We aim to determine the prevalence and burden of EPVS in racial minorities, and examine their association with VRF and stroke severity.

Methods: We included 894 consecutive stroke patients who underwent brain MRI admitted to an academic stroke center. EPVS were rated in the basal ganglia (BG), centrum semiovale (CSO) and midbrain (MB) following a standardized method, and dichotomized for analyses (mild <20 vs severe ≥20). Race was assessed based on US census procedures and categorized as White, Black or Other racial groups (ORG). Stroke severity was determined at time of admission using the NIH stroke scale. We used univariate analysis to assess the relation of VRF and EPVS severity, and multivariable logistic regression analysis to relate EPVS and stroke severity.

Results: EPVS were present in the entire sample (219 White, 455 Black, 220 ORG). Severe EPVS prevalence for Whites, Blacks and ORG was for BG 19.6%, 18%, and 15.4%; for CSO, 38.8%, 42.6%, and 33.6%; and for MB, 88.6%, 84.8%, and 84.1%, respectively. In univariate analyses, increasing age was associated with severe EPVS in the BG and CSO in all racial groups (p=< .0001); White and Black women were more likely to have severe EPVS in the BG and CSO (p<0.05). Hypertension was associated with EPVS severity in the BG in the entire sample (p=0.0004), with severe EPVS in MB and BG among Blacks, and with severe EPVS in BG and CSO in ORG (p<0.0001). Dyslipidemia was associated with severity of EPVS in BG only in ORG (p=0.01), while diabetes showed an inverse relation with EPVS severity in BG among Blacks only (p=0.003). EPVS severity was not associated with stroke severity when evaluating different NIHSS thresholds.

Conclusion: Race was not related to EPVS severity in our study, but traditional risk factors were, supporting their role as markers of small vessel disease. Severe EPVS were more frequent in MB, CSO and less common in BG. Further studies are required to clarify the relation of EPVS with stroke severity, assessing other measures and functional outcomes.

Abstract WP170: Chronic Kidney Disease as a Risk Factor for Enlarged Perivascular Spaces, and Relation to Racial Group

Purpose: Enlarged perivascular spaces (EPVS) are brain MRI markers of subclinical small vessel disease (SVD). Recent studies suggest that basal ganglia (BG) EPVS represent hypertensive vasculopathy, while centrum semiovale (CSO) EPVS represent cerebral amyloid angiopathy. Increasing evidence links chronic kidney disease (CKD) to SVD, but the relation to EPVS topography has not been studied, and data are lacking among racial groups. In this study, we explore the relationship between CKD and burden of EPVS across racial groups.

Methods: We included 894 consecutive stroke patients who underwent brain MRI admitted to an academic stroke center. EPVS were rated in the BG, and CSO following a standardized method, where severe burden of EPVS is considered when counts are 20 or greater. Race was assessed by self-report based on US census procedures and categorized as White, Black or Other racial groups (ORG). CKD was defined by past medical history or GFR < 60mL/min/1.73m 2 . We used multivariable logistic regression analysis to relate CKD and EPVS severity (mild [<20] vs severe [20 or greater]), adjusting for age, sex, hypertension, smoking and diabetes.

Results: CKD was present in 22% of the sample, in 17.7% Whites, 27.9% Blacks and 13.2% ORG. Severe EPVS prevalence for Whites, Blacks and ORG was for BG 19.6%, 18%, and 15.4%; and for CSO 38.8%, 42.6%, and 33.6%, respectively. In multivariate analysis, CKD was associated with severe EPVS in the CSO in the entire sample (OR 1.39, 95% CI 1, 1.94). The relation differed depending on EPVS topography and racial group. For BG, Whites had lower odds of severe EPVS compared to Blacks and ORG (OR 0.33, 9%% CI 0.12, 0.95), while for CSO, Whites with CKD had higher odds of severe EPVS (OR 2.18, 95% CI 1.03, 4.63).

Conclusion: CKD was associated with severity of EPVS in our sample of stroke patients. The relation differed across racial groups and by EPVS topography, suggesting that CKD may relate differently to the main forms of SVD (hypertensive and cerebral amyloid angiopathy) according to race. In Whites, the strong association of CKD with EPVS severity in the CSO may result from impaired amyloid clearance, but this hypothesis requires further study.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Delay in Diagnosis of Basilar Artery Stroke

BACKGROUND

Basilar artery stroke causes substantial morbidity and mortality. Although its unusual clinical presentation potentially contributes to a delay in diagnosis, this problem has not been systematically studied. We compared intervals between symptom onset, initial presentation, and diagnosis in stroke due to basilar artery (BA) versus left middle cerebral artery (LMCA) occlusion to determine the presence of and potential reasons for diagnostic delay in BA stroke.

METHODS

We retrospectively identified 21 consecutive adult patients diagnosed with BA stroke between 2009 and 2011 from our hospital's prospective stroke registry. Patients were age-, sex-, and race-matched with 21 LMCA stroke patients from the same period. All subjects had confirmed clinical and radiographic diagnosis of stroke due to occlusion or stenosis of the BA, LMCA, or left internal carotid artery. Time to diagnosis was determined independently by two investigators through medical record review. The pre-specified primary outcome was latency from emergency department (ED) arrival to stroke diagnosis.

RESULTS

Median time from ED arrival to diagnosis was 8 h 24 min (IQR: 2:43-26:32) for BA and 1 h 23 min (IQR: 0:41-1:45; p < 0.001) for LMCA. Median time from symptom onset to ED arrival was 7 h 44 min (IQR 1:23-21:30) for BA and 1 h 2 min (IQR 0:36-9:41; p = 0.06) for LMCA. Four of 21 (19 %) BA patients were diagnosed within a 4-h time frame to make intravenous thrombolysis possible compared to 13 of 21 (62 %) LMCA patients (p = 0.01).

CONCLUSIONS

Our results suggest that both pre-hospital and in-hospital processes cause substantial, clinically significant delays in the diagnosis of BA stroke.

Treatment patterns from 647 patients with Gaucher disease: An analysis from the Gaucher Outcome Survey

The Gaucher Outcome Survey (GOS) is an international disease-specific registry established in 2010 for patients with a confirmed diagnosis of Gaucher disease (GD), regardless of GD type or treatment status. For insight into how GD management varies among countries, we analyzed treatment patterns in GOS. As of October 30, 2015, data on GD-specific treatment (enzyme replacement therapy, substrate reduction therapy, or chemical chaperone therapy) received at any time were available for 647 patients. At analysis, velaglucerase alfa (316/573, 55.1%) and imiglucerase (184/573, 32.1%) were the treatments most widely used. Of the 647 treated patients, 446 (68.9%) had been treated for >5years and 368 (56.9%) had received only one GD-specific drug therapy. There were 377 patients who received velaglucerase alfa. Velaglucerase alfa was most widely used at 60U/kg every other week (134/492 dose entries, 27.2%), but there were differences in dosing between the three highest-enrolling countries (defined as >100 GOS patients enrolled in each), with most patients in Israel receiving <20U/kg, most patients in the United Kingdom receiving 20 to <40U/kg, and most in the United States receiving 60U/kg. This analysis provides a foundation upon which to examine real-life outcomes data from different treatment regimens globally.

Recurrent vascular events in lacunar stroke patients with metabolic syndrome and/or diabetes

OBJECTIVES

We used a prospective clinical trial to examine the risks conferred by metabolic syndrome (METS) and diabetes mellitus (DM) to recurrent strokes in the Secondary Prevention of Small Subcortical Strokes (SPS3) study cohort.

METHODS

The SPS3 trial enrolled 3,020 patients with lacunar strokes. Participants were stratified into groups of METS only, DM only, both, or neither using American Heart Association/National Heart, Lung, and Blood Institute and World Health Organization guidelines. Annualized event rates of strokes, myocardial infarction (MI), and all-cause mortality were calculated, and hazard ratios (HRs) referencing the “neither” group were computed, controlling for significantly associated baseline characteristics.

RESULTS

Among 2,999 participants, 25% had METS only, 6% had DM only, 32% had both conditions, and 37%had neither. Over a median of 3.8 years of follow-up, there were 274 recurrent strokes (240 ischemic, 34 hemorrhagic) and 74 MIs; among the 240 ischemic strokes, 134 (56%) were lacunar. The rates of any recurrent stroke (HR 1.7, 95% confidence interval [CI] 1.3–2.3) or lacunar stroke (HR 2.4, 95% CI 1.5–3.7) were significantly higher for those with concurrent METS and DM compared with those who had neither. Risk of incident MI was higher in participants with DM (HR 2.8, 95% CI 1.1–7.0) or concurrent DM and METS (HR 2.6, 95% CI 1.4–4.9).

CONCLUSION

METS and DM were significant comorbid conditions in lacunar stroke patients and they were associated with stroke recurrence. In patients with lacunar infarcts, a vigilant approach to prevent development of DM in those with METS may be a potential strategy to reduce recurrent strokes.

Can blood pressure be lowered safely in older adults with lacunar stroke? The Secondary Prevention of Small Subcortical Strokes study experience

OBJECTIVES

To determine safety and tolerability of lowering blood pressure in older adults with lacunar stroke.

DESIGN

Cohort study.

SETTING

The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, which compared the efficacy of two systolic blood pressure (SBP) targets (<130 mmHg and 130-149 mmHg) for secondary stroke prevention.

PARTICIPANTS

Of 3,020 SPS3 participants, 494 aged 75 and older at baseline were used in these analyses.

MEASUREMENTS

Rates of side effects related to lowering SBP and clinical outcomes, including stroke recurrence and vascular death, were examined.

RESULTS

Older participants achieved SBP levels similar to those of younger participants (mean SBP of 125 mmHg and 137 mmHg in lower and higher SBP target groups, respectively). At least once during the approximately 3.5 years of follow-up, 21% reported dizziness, and 15% reported lightheadedness when standing; the only significant difference between the younger and older groups was unsteadiness when standing (23% vs 32% respectively, P < .001). There was no difference according to treatment group. In younger adults, recurrent stroke was less likely in the lower than the higher SBP group (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.59-1.01) but not in older participants (HR = 1.01, 95% CI = 0.59-1.73), although the interaction was not significant (P = .39). The lower SBP target was associated with a significant reduction in vascular death in older participants (HR = 0.42, 95% CI = 0.18-0.98), with a significant interaction between age and SBP group (P = .049).

CONCLUSION

Except for unsteadiness when standing, there was no difference according to age in individuals with lacunar stroke with respect to side effects potentially related to lowering blood pressure. Although the lower SBP target was not associated with lower likelihood of recurrent stroke, these exploratory analyses suggested a possible benefit related to vascular death.

Health care delivery for head-and-neck cancer patients in Alberta: a practice guideline

BACKGROUND

The treatment of head-and-neck cancer is complex and requires the involvement of various health care professionals with a wide range of expertise. We describe the process of developing a practice guideline with recommendations about the organization and delivery of health care services for head-and-neck cancer patients in Alberta.

METHODS

Outcomes of interest included composition of the health care team, qualification requirements for team members, cancer centre and team member volumes, infrastructure needs, and wait times. A search for existing practice guidelines and a systematic review of the literature addressing the organization and delivery of health care services for head-and-neck cancer patients were conducted. The search included the Standards and Guidelines Evidence (sage) directory of cancer guidelines and PubMed.

RESULTS

One practice guideline was identified for adaptation. Three additional practice guidelines provided supplementary evidence to inform guideline recommendations. Members of the Alberta Provincial Head and Neck Tumour Team (consisting of various health professionals from across the province) provided expert feedback on the adapted recommendations through an online and in-person review process. Selected experts in head-and-neck cancer from outside the province participated in an external online review.

SUMMARY

The recommendations outlined in this practice guideline are based on existing guidelines that have been modified to fit the Alberta context. Although specific to Alberta, the recommendations lend credence to similar published guidelines and could be considered for use by groups lacking the resources of appointed guideline panels. The recommendations are meant to be a guide rather than a fixed protocol. The implementation of this practice guideline will depend on many factors, including but not limited to availability of trained personnel, adequate funding of infrastructure, and collaboration with other associations of health care professionals in the province.

Qualitative evaluation of care plans for Canadian breast and head-and-neck cancer survivors

BACKGROUND

Survivorship care plans (scps) have been recommended as a way to ease the transition from active cancer treatment to follow-up care, to reduce uncertainty for survivors in the management of their ongoing health, and to improve continuity of care. The objective of the demonstration project reported here was to assess the value of scps for cancer survivors in western Canada.

METHODS

The Alberta CancerBridges team developed, implemented, and evaluated scps for 36 breast and 21 head-and-neck cancer survivors. For the evaluation, we interviewed 12 of the survivors, 9 nurses who delivered the scps, and 3 family physicians who received the scps (n = 24 in total). We asked about satisfaction, usefulness, emotional impact, and communication value. We collected written feedback from the three groups about positive aspects of the scps and possible improvements (n = 85). We analyzed the combined data using qualitative thematic analysis.

RESULTS

Survivors, nurses, and family physicians agreed that scps could ease the transition to survivorship partly by enhancing communication between survivors and care providers. Survivors appreciated the individualized attention and the comprehensiveness of the plans. They described positive emotional impacts, but wanted a way to ensure that their physicians received the scps. Nurses and physicians responded positively, but expressed concern about the time required to implement the plans. Suggestions for streamlining the process included providing survivors with scp templates in advance, auto-populating the templates for the nurses, and creating summary pages for physicians.

CONCLUSIONS

The results suggest ways in which scps could help to improve the transition to cancer survivorship and provide starting points for larger feasibility studies.

Abstract W P367: Anterior Cerebral Artery Diameter Predicts Anterior Cerebral Artery Territorial Stroke

Background: Anterior cerebral artery strokes (ACAS) account for only 1-2% of cerebral infarctions, and typically result from embolism in western populations. The cause of the low frequency of ACAS in relation to MCA strokes (MCAS) is uncertain, but differences in arterial anatomy may affect flow-directed embolism rates. We aimed to determine whether variability in ACA A1 diameters (A1D) and A1D/MCA M1 diameter (M1D) ratios predict ACAS

Methods: Consecutive patients admitted to Boston Medical Center with a diagnosis of ACAS between 01/2008-10/2012 were reviewed. Patients with an interpretable CT angiogram (CTA) or magnetic resonance angiogram (MRA) of the cerebral vasculature were eligible. Excluded were patients with ACAS ipsilateral (ipsi) to an aplastic ACA, concomitant ipsi MCAS, and those with lacunar, watershed, aneurysm clipping or local intracranial atherosclerosis as stroke etiology. Patient demographics were compiled. Ipsilateral and contralateral (contra) A1D, M1D, as well as ICA-ACA and ICA-MCA angles were measured from CTA and MRA images. Consecutive MCAS admitted between 01/2011-10/2012 served as controls.

Results: The study comprised 55 individuals (27 ACA, 28 MCA) with mean age of 69 years. Stroke etiology was cardioembolism in 56%, internal carotid artery embolism in 16% and idiopathic in 27%. Patients with ACAS had larger mean ipsi A1D (2.47 vs. 2.05 mm,p<0.01), ipsi A1D/M1D ratios (0.95 vs. 0.73,p<0.001) and were more likely to have a contra aplastic/hypoplastic ACA (41 vs. 4%,<0.001). Ipsi A1D (OR per 1 mm increment: 8.52 [95% CI 1.36, 53.26]) and ipsi A1D/M1D ratio (OR per 10% increment: 1.83 [95% CI 1.15, 2.91]) remained significant following multivariate analysis. Ipsilateral M1D was protective for ACAS (OR per 1 mm increment: 0.17 [95% CI 0.03, 0.90]) after adjusting for ipsi A1D. There were no significant differences in demographic variables, stroke etiologies, terminal ICA-ACA or ICA-MCA angles between ACAS and MCAS.

Conclusions: Larger ipsilateral A1D and A1D/M1D ratio are independent predictors of ACAS. These findings concur with the notion that A1D and M1D are important in determining the path of emboli that reach the terminal ICA.

Abstract W P157: Radiographic Markers of Small Vessel Disease in Young Stroke Patients

Background: White-matter hyperintensities (WMH) and cerebral microbleeds (CMBs) are considered radiographic markers of small vessel disease (SVD). Literature on CMB and WMH prevalence and associated risk factors in young patients presenting with stroke is limited. We have reported high prevalence of both WMH and CMBs in our cohort of young stroke patients. The aim of this report is to better characterize independent determinants of WMH and CMBs in the same cohort

Methods: Charts of consecutive patients ≤49 years of age admitted with a diagnosis of ischemic stroke (IS) or spontaneous intraparenchymal hemorrhage (IPH) between 01/06-02/10 were reviewed (n=146). Patients with interpretable T2*-GRE (104) and/or T2/FLAIR (107) sequences on MRI were eligible. WMH was graded according to the Age-Related White Matter Changes Scale, and cerebral volume using the Global Cortical Atrophy Scale. Using multivariable regression analysis, we compared baseline demographics and vascular risk factors between patients with MRI markers of SVD and those without.

Results: CMBs were present in 17% and moderate-severe WMH in 27% of individuals. Male gender (OR 4.93 [95%CI 1.01, 24.1]), hypertension (HTN) (OR 8.84 [95%CI 1.76, 40.5]), moderate-severe WMH (OR 5.25 [95%CI 1.54, 17.9]), and IPH (OR 6.97 [95%CI 1.81, 26.8]) were independently associated with the presence of CMBs. CMBs (OR 4.27 [95% CI 1.35, 13.5]), HTN (OR 4.14 [95% CI 1.42, 12.1]), serum creatinine on admission (OR per 1 mg/dl increment: 3.02 [95% CI 1.14, 7.99]) and moderate-severe cortical atrophy (OR 6.26 [95% CI 1.40, 27.94]) were significantly associated with moderate-severe WMH.

Conclusions: Our data suggest male gender, HTN, IPH and moderate-severe WMH are associated with CMBs, while HTN, CMBs, elevated serum creatinine and moderate-severe cortical atrophy are associated with moderate-severe WMH. The association of CMBs with higher WMH severity and IPH supports the notion that CMBs are an indicator of an advanced stage of SVD that is prone to bleeding. Further studies are needed to examine if presence of CMBs and/or WMH may impact outcomes after ischemic stroke in young adults.

The effect of a neurocritical care service without a dedicated neuro-ICU on quality of care in intracerebral hemorrhage

BACKGROUND

Introduction of neurocritical care services to dedicated neuro-ICUs is associated with improved quality of care. The impact of a neurocritical care service without a dedicated neuro-ICU has not been studied.

METHODS

We retrospectively identified all patients admitted to our institution with intracerebral hemorrhage (ICH) in two 12-month periods: immediately before the arrival of the first neurointensivist ("before") and after the neurocritical care service was established ("after"). There was no nursing team, ICU housestaff/physician extender team, or physical unit dedicated to the care of patients with critical neurologic illness during either period. Using an uncontrolled before-after design, we compared clinical outcomes and performance on quality metrics between groups.

RESULTS

We included 74 patients with primary supratentorial ICH. Mortality, length of stay (LOS), proportion of patients with modified Rankin Score 0-3, and destination on discharge did not differ between groups when adjusted for confounders. Time to first two consecutive systolic blood pressure (SBP) measurements <180 mmHg was shorter in the "after" cohort (mean 4.5 vs. 3.2 h, p = 0.001). Area under the curve measurement for change in SBP from baseline over the first 24 h after ED arrival demonstrated greater, sustained SBP reduction in the "after" cohort (mean -187.9 vs. -720.9, p = 0.04). A higher proportion of patients were fed without passing a dysphagia screen in the "before" group (45 vs. 0%, p < 0.001).

CONCLUSIONS

Introduction of a neurocritical service without a neuro-ICU at our institution was associated with a trend toward longer ICU LOS and improvement in some key metrics of quality of care for patients with ICH.

Quality of life after lacunar stroke: the Secondary Prevention of Small Subcortical Strokes study

BACKGROUND

We sought to describe the course and predictors of quality of life (QOL) after lacunar stroke. We hypothesized that there is a decline in QOL after recovery from lacunar stroke.

METHODS

The Secondary Prevention of Small Subcortical Strokes is a clinical trial in lacunar stroke patients with annual assessments of QOL with the stroke-specific QOL score. The overall score was used and analyzed as a continuous variable (range 0-5). We fit linear mixed models to assess the trend in QOL over time, assuming linearity of time, and adjusted for demographics, medical risk factors, cognitive factors, and functional status in univariable and multivariable models.

RESULTS

Among 2870 participants, mean age was 63.4 years (SD 10.7), 63% were men, 51% White, 32% Hispanic, 36% had college education, 36% had diabetes, 89% had hypertension, and 10% had prior stroke. Mean poststroke Barthel Index (BI) score was 95.4 (assessed on average 6 months after stroke). In the final multivariable model, there was an average increase in QOL of .6% per year, and factors associated with decline in QOL over time included age (-.0003 per year, P < .0001), any college education (-.0013 per year, .01), prior stroke (-.004 per year, P < .0001), and BI (-.0002 per year, P < .0001).

CONCLUSIONS

In this clinical trial of lacunar stroke patients, there was a slight annual increase in QOL overall, and age, level of education, and prior stroke were associated with changes in QOL over time. Multiple strokes may cause decline in QOL over time in the absence of recurrent events.