The Trial Innovation Network Liaison Team: building a national clinical and translational community of practice

In 2016, the National Center for Advancing Translational Science launched the Trial Innovation Network (TIN) to address barriers to efficient and informative multicenter trials. The TIN provides a national platform, working in partnership with 60+ Clinical and Translational Science Award (CTSA) hubs across the country to support the design and conduct of successful multicenter trials. A dedicated Hub Liaison Team (HLT) was established within each CTSA to facilitate connection between the hubs and the newly launched Trial and Recruitment Innovation Centers. Each HLT serves as an expert intermediary, connecting CTSA Hub investigators with TIN support, and connecting TIN research teams with potential multicenter trial site investigators. The cross-consortium Liaison Team network was developed during the first TIN funding cycle, and it is now a mature national network at the cutting edge of team science in clinical and translational research. The CTSA-based HLT structures and the external network structure have been developed in collaborative and iterative ways, with methods for shared learning and continuous process improvement. In this paper, we review the structure, function, and development of the Liaison Team network, discuss lessons learned during the first TIN funding cycle, and outline a path toward further network maturity.

Leveraging the Expertise of the CTSA Program to Increase the Impact and Efficiency of Clinical Trials

Importance

Multicenter clinical trials play a critical role in the translational processes that enable new treatments to reach all people and improve public health. However, conducting multicenter randomized clinical trials (mRCT) presents challenges. The Trial Innovation Network (TIN), established in 2016 to partner with the Clinical and Translational Science Award (CTSA) Consortium of academic medical institutions in the implementation of mRCTs, consists of 3 Trial Innovation Centers (TICs) and 1 Recruitment Innovation Center (RIC). This unique partnership has aimed to address critical roadblocks that impede the design and conduct of mRCTs, in expectation of accelerating the translation of novel interventions to clinical practice. The TIN's challenges and achievements are described in this article, along with examples of innovative resources and processes that may serve as useful models for other clinical trial networks providing operational and recruitment support.

Observations

The TIN has successfully integrated more than 60 CTSA institution program hubs into a functional network for mRCT implementation and optimization. A unique support system for investigators has been created that includes the development and deployment of novel tools, operational and recruitment services, consultation models, and rapid communication pathways designed to reduce delays in trial start-up, enhance recruitment, improve engagement of diverse research participants and communities, and streamline processes that improve the quality, efficiency, and conduct of mRCTs. These resources and processes span the clinical trial spectrum and enable the TICs and RIC to serve as coordinating centers, data centers, and recruitment specialists to assist trials across the National Institutes of Health and other agencies. The TIN's impact has been demonstrated through its response to both historical operational challenges and emerging public health emergencies, including the national opioid public health crisis and the COVID-19 pandemic.

Conclusions and Relevance

The TIN has worked to reduce barriers to implementing mRCTs and to improve mRCT processes and operations by providing needed clinical trial infrastructure and resources to CTSA investigators. These resources have been instrumental in more quickly and efficiently translating research discoveries into beneficial patient treatments.

A causal roadmap for generating high-quality real-world evidence

Increasing emphasis on the use of real-world evidence (RWE) to support clinical policy and regulatory decision-making has led to a proliferation of guidance, advice, and frameworks from regulatory agencies, academia, professional societies, and industry. A broad spectrum of studies use real-world data (RWD) to produce RWE, ranging from randomized trials with outcomes assessed using RWD to fully observational studies. Yet, many proposals for generating RWE lack sufficient detail, and many analyses of RWD suffer from implausible assumptions, other methodological flaws, or inappropriate interpretations. The Causal Roadmap is an explicit, itemized, iterative process that guides investigators to prespecify study design and analysis plans; it addresses a wide range of guidance within a single framework. By supporting the transparent evaluation of causal assumptions and facilitating objective comparisons of design and analysis choices based on prespecified criteria, the Roadmap can help investigators to evaluate the quality of evidence that a given study is likely to produce, specify a study to generate high-quality RWE, and communicate effectively with regulatory agencies and other stakeholders. This paper aims to disseminate and extend the Causal Roadmap framework for use by clinical and translational researchers; three companion papers demonstrate applications of the Causal Roadmap for specific use cases.

Decentralized clinical trials in the trial innovation network: Value, strategies, and lessons learned

New technologies and disruptions related to Coronavirus disease-2019 have led to expansion of decentralized approaches to clinical trials. Remote tools and methods hold promise for increasing trial efficiency and reducing burdens and barriers by facilitating participation outside of traditional clinical settings and taking studies directly to participants. The Trial Innovation Network, established in 2016 by the National Center for Advancing Clinical and Translational Science to address critical roadblocks in clinical research and accelerate the translational research process, has consulted on over 400 research study proposals to date. Its recommendations for decentralized approaches have included eConsent, participant-informed study design, remote intervention, study task reminders, social media recruitment, and return of results for participants. Some clinical trial elements have worked well when decentralized, while others, including remote recruitment and patient monitoring, need further refinement and assessment to determine their value. Partially decentralized, or "hybrid" trials, offer a first step to optimizing remote methods. Decentralized processes demonstrate potential to improve urban-rural diversity, but their impact on inclusion of racially and ethnically marginalized populations requires further study. To optimize inclusive participation in decentralized clinical trials, efforts must be made to build trust among marginalized communities, and to ensure access to remote technology.

Approaches for enhancing the informativeness and quality of clinical trials: Innovations and principles for implementing multicenter trials from the Trial Innovation Network

One challenge for multisite clinical trials is ensuring that the conditions of an informative trial are incorporated into all aspects of trial planning and execution. The multicenter model can provide the potential for a more informative environment, but it can also place a trial at risk of becoming uninformative due to lack of rigor, quality control, or effective recruitment, resulting in premature discontinuation and/or non-publication. Key factors that support informativeness are having the right team and resources during study planning and implementation and adequate funding to support performance activities. This communication draws on the experience of the National Center for Advancing Translational Science (NCATS) Trial Innovation Network (TIN) to develop approaches for enhancing the informativeness of clinical trials. We distilled this information into three principles: (1) assemble a diverse team, (2) leverage existing processes and systems, and (3) carefully consider budgets and contracts. The TIN, comprised of NCATS, three Trial Innovation Centers, a Recruitment Innovation Center, and 60+ CTSA Program hubs, provides resources to investigators who are proposing multicenter collaborations. In addition to sharing principles that support the informativeness of clinical trials, we highlight TIN-developed resources relevant for multicenter trial initiation and conduct.

Concomitant Use of Gabapentinoids with Opioids Is Associated with Increased Mortality and Morbidity among Dialysis Patients

BACKGROUND

The opioid epidemic is a public health emergency and appropriate medication prescription for pain remains challenging. Physicians have increasingly prescribed gabapentinoids for pain despite limited evidence supporting their use. We determined the prevalence of concomitant gabapentinoid and opioid prescriptions and evaluated their associations with outcomes among dialysis patients.

METHODS

We used the United States Renal Data System to identify patients treated with dialysis with Part A, B, and D coverage for all of 2010. Patients were grouped into 4 categories of drugs exposure status in 2010: (1) no prescriptions of either an opioid or gabapentinoid, (2) ≥1 prescription of an opioid and no prescriptions of gabapentinoids, (3) no prescriptions of an opioid and ≥1 prescription of gabapenbtinoids, (4) ≥1 prescription of both an opioid and gabapentinoid. Outcomes included 2-year all-cause death, dialysis discontinuation, and hospitalizations assessed in 2011 and 2012.

RESULTS

The study population included 153,758 dialysis patients. Concomitant prescription of an opioid and gabapentin (15%) was more common than concomitant prescription of an opioid and pregabalin (4%). In adjusted analyses, concomitant prescription of an opioid and gabapentin compared to no prescription of either was associated with increased risk of death (hazard ratio [HR] 1.16, 95% CI 1.12-1.19), dialysis discontinuation (HR 1.14, 95% CI 1.03-1.27), and hospitalization (HR 1.33, 95% CI 1.31-1.36). Concomitant prescription of an opioid and pregabalin compared to no prescription of either was associated with increased mortality (HR 1.22, 95% CI 1.16-1.28) and hospitalization (HR 1.37, 95% CI 1.33-1.41), but not dialysis discontinuation (HR 1.13, 95% CI 0.95-1.35). Prescription of opioids and gabepentinoids compared to only being prescribed opioids was associated with higher risk of hospitalizations, but not mortality, or dialysis discontinuation.

CONCLUSIONS

Concomitant prescription of opioids and gabapentinoids among US dialysis patients is common, and both drugs have independent effects on outcomes. Future research should prospectively investigate the potential harms of such drugs and identify safer alternatives for treatment of pain in end-stage renal disease patients.

Regional Patterns and Association Between Obesity and Hypertension in Africa: Evidence From the H3Africa CHAIR Study

Hypertension and obesity are the most important modifiable risk factors for cardiovascular diseases, but their association is not well characterized in Africa. We investigated regional patterns and association of obesity with hypertension among 30 044 continental Africans. We harmonized data on hypertension (defined as previous diagnosis/use of antihypertensive drugs or blood pressure [BP]≥140/90 mmHg/BP≥130/80 mmHg) and obesity from 30 044 individuals in the Cardiovascular H3Africa Innovation Resource across 13 African countries. We analyzed data from population-based controls and the Entire Harmonized Dataset. Age-adjusted and crude proportions of hypertension were compared regionally, across sex, and between hypertension definitions. Logit generalized estimating equation was used to determine the independent association of obesity with hypertension (P value <5%). Participants were 56% women; with mean age 48.5±12.0 years. Crude proportions of hypertension (at BP≥140/90 mmHg) were 47.9% (95% CI, 47.4-48.5) for Entire Harmonized Dataset and 42.0% (41.1-42.7) for population-based controls and were significantly higher for the 130/80 mm Hg threshold at 59.3% (58.7-59.9) in population-based controls. The age-adjusted proportion of hypertension at BP≥140/90 mmHg was the highest among men (33.8% [32.1-35.6]), in western Africa (34.7% [33.3-36.2]), and in obese individuals (43.6%; 40.3-47.2). Obesity was independently associated with hypertension in population-based controls (adjusted odds ratio, 2.5 [2.3-2.7]) and odds of hypertension in obesity increased with increasing age from 2.0 (1.7-2.3) in younger age to 8.8 (7.4-10.3) in older age. Hypertension is common across multiple countries in Africa with 11.9% to 51.7% having BP≥140/90 mmHg and 39.5% to 69.4% with BP≥130/80 mmHg. Obese Africans were more than twice as likely to be hypertensive and the odds increased with increasing age.

Racial/Ethnic Disparities in Atrial Fibrillation Treatment and Outcomes among Dialysis Patients in the United States

BACKGROUND

Because stroke prevention is a major goal in the management of ESKD hemodialysis patients with atrial fibrillation, investigating racial/ethnic disparities in stroke among such patients is important to those who could benefit from strategies to maximize preventive measures.

METHODS

We used the United States Renal Data System to identify ESKD patients who initiated hemodialysis from 2006 to 2013 and then identified those with a subsequent atrial fibrillation diagnosis and Medicare Part A/B/D. Patients were followed for 1 year for all-cause stroke, mortality, prescription medications, and cardiovascular disease procedures. The survival mediational g-formula quantified the percentage of excess strokes attributable to lower use of atrial fibrillation treatments by race/ethnicity.

RESULTS

The study included 56,587 ESKD hemodialysis patients with atrial fibrillation. Black, white, Hispanic, and Asian patients accounted for 19%, 69%, 8%, and 3% of the population, respectively. Compared with white patients, black, Hispanic, or Asian patients were more likely to experience stroke (13%, 15%, and 16%, respectively) but less likely to fill a warfarin prescription (10%, 17%, and 28%, respectively). Warfarin prescription was associated with decreased stroke rates. Analyses suggested that equalizing the warfarin distribution to that in the white population would prevent 7%, 10%, and 12% of excess strokes among black, Hispanic, and Asian patients, respectively. We found no racial/ethnic disparities in all-cause mortality or use of cardiovascular disease procedures.

CONCLUSIONS

Racial/ethnic disparities in all-cause stroke among hemodialysis patients with atrial fibrillation are partially mediated by lower use of anticoagulants among black, Hispanic, and Asian patients. The reasons for these disparities are unknown, but strategies to maximize stroke prevention in minority hemodialysis populations should be further investigated.

Alzheimer's Disease-Related Dementias Summit 2016: National research priorities

Goal 1 of the National Plan to Address Alzheimer's Disease is to prevent and effectively treat Alzheimer disease and Alzheimer disease-related dementias by 2025. To help inform the research agenda toward achieving this goal, the NIH hosts periodic summits that set and refine relevant research priorities for the subsequent 5 to 10 years. This proceedings article summarizes the 2016 Alzheimer's Disease-Related Dementias Summit, including discussion of scientific progress, challenges, and opportunities in major areas of dementia research, including mixed-etiology dementias, Lewy body dementia, frontotemporal degeneration, vascular contributions to cognitive impairment and dementia, dementia disparities, and dementia nomenclature.

Defining Optimal Brain Health in Adults: A Presidential Advisory From the American Heart Association/American Stroke Association

Cognitive function is an important component of aging and predicts quality of life, functional independence, and risk of institutionalization. Advances in our understanding of the role of cardiovascular risks have shown them to be closely associated with cognitive impairment and dementia. Because many cardiovascular risks are modifiable, it may be possible to maintain brain health and to prevent dementia in later life. The purpose of this American Heart Association (AHA)/American Stroke Association presidential advisory is to provide an initial definition of optimal brain health in adults and guidance on how to maintain brain health. We identify metrics to define optimal brain health in adults based on inclusion of factors that could be measured, monitored, and modified. From these practical considerations, we identified 7 metrics to define optimal brain health in adults that originated from AHA's Life's Simple 7: 4 ideal health behaviors (nonsmoking, physical activity at goal levels, healthy diet consistent with current guideline levels, and body mass index <25 kg/m2) and 3 ideal health factors (untreated blood pressure <120/<80 mm Hg, untreated total cholesterol <200 mg/dL, and fasting blood glucose <100 mg/dL). In addition, in relation to maintenance of cognitive health, we recommend following previously published guidance from the AHA/American Stroke Association, Institute of Medicine, and Alzheimer's Association that incorporates control of cardiovascular risks and suggest social engagement and other related strategies. We define optimal brain health but recognize that the truly ideal circumstance may be uncommon because there is a continuum of brain health as demonstrated by AHA's Life's Simple 7. Therefore, there is opportunity to improve brain health through primordial prevention and other interventions. Furthermore, although cardiovascular risks align well with brain health, we acknowledge that other factors differing from those related to cardiovascular health may drive cognitive health. Defining optimal brain health in adults and its maintenance is consistent with the AHA's Strategic Impact Goal to improve cardiovascular health of all Americans by 20% and to reduce deaths resulting from cardiovascular disease and stroke by 20% by the year 2020. This work in defining optimal brain health in adults serves to provide the AHA/American Stroke Association with a foundation for a new strategic direction going forward in cardiovascular health promotion and disease prevention.

Stroke Hospital Characteristics in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study

OBJECTIVES

Although disparities in stroke care and outcomes have been well documented nationally, state-based registries to monitor acute stroke care in Florida (FL) and Puerto Rico (PR) have not been established. The FL-PR Collaboration to Reduce Stroke Disparities (CReSD) was developed to evaluate race-ethnicity and regional disparities in stroke care performance. The objective of this study was to assess and compare hospital characteristics within a large quality improvement registry to identify characteristics associated with better outcomes for acute ischemic stroke care.

METHODS

Trained personnel from 78 FL-PR CReSD hospitals (69 FL, 9 PR) completed a 50-item survey assessing institutional characteristics across seven domains: acute stroke care resource availability, emergency medical services integration, stroke center certification, data collection and use, quality improvement processes, FL-PR CReSD recruitment incentives, and hospital infrastructure.

RESULTS

The rate of survey completion was 100%. Differences were observed both within FL and between FL and PR. Years participating in Get With The Guidelines-Stroke (8.9 ± 2.6 years FL vs 4.8 ± 2.4 years PR, P < 0.0001) and proportion of hospitals with any stroke center certification (94.2% FL vs 11.1% PR, P < 0.0001) showed the largest variations. Smaller hospital size, fewer years in Get With The Guidelines-Stroke, and lack of stroke center designation and acute stroke care practice implementation may contribute to poorer outcomes.

CONCLUSIONS

Results from our survey indicated variability in hospital- and system-level characteristics in stroke care across hospitals in Florida and Puerto Rico. Identification of these variations, which may explain potential disparities, can help clinicians understand gaps in stroke care and outcomes and targeted interventions to reduce identified disparities can be implemented.

Disparities and Trends in Door-to-Needle Time: The FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities)

BACKGROUND AND PURPOSE

In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45.

METHODS

Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45.

RESULTS

DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72-0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57-0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%).

CONCLUSIONS

In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.

Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study

BACKGROUND

Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race-ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals.

METHODS AND RESULTS

Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P<0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%).

CONCLUSIONS

Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico.

Abstract TP2: Disparities in Delivery of Endovascular Therapy: Who Gets it and Where? The Florida Puerto Rico Collaboration to Reduce Stroke Disparities Study

Background and Purpose: Endovascular thrombectomy improves functional outcome in select ischemic stroke patients. In the NINDS-funded CReSD Registry we sought to determine the clinical, hospital and regional characteristics associated with use of this therapy in patients presenting with acute ischemic stroke.

Methods: Ischemic stroke patients within 24 hours of onset were prospectively included from 82 sites in Florida and Puerto Rico from January 2010 to April 2016. Independent predictors of endovascular therapy were evaluated using multivariable logistic regression with generalized estimating equations.

Results: Among 58,204 patients with acute ischemic stroke (50% male, 65% white, 15% black, 20% Hispanic, mean age±SD 71±14 yrs), 2105 (3.6%) received endovascular thrombectomy (50.9% men, 62.3% white, 13.7% black, 24% Hispanic, mean age±SD 70±15yrs) with (35.2%) or without intravenous thrombolysis. Patients who received endovascular therapy had a significantly lower risk of vascular risk factors except for Afib (33.7% vs 19.0%), more severe strokes (median NIHSS 15 vs. 5) and were more likely to arrive quickly (126 min vs. 210 min), via EMS (70.4% vs. 59.6%) or as a transfer from another hospital (20.8% vs 5.8%,) during working hours (47.7% vs. 45.6%), to large hospitals (≥ 680 beds) (48.3% vs 28.8%), and treated in South Florida (47.3% vs. 35.9%) as compared to those not receiving this treatment. In multivariable analysis; age (OR 0.97, 95% CI 0.96- 0.98), Blacks (OR 0.68, 95% CI 0.56-2.28) vs. White, off-hour presentation (OR 0.76, 95% CI 0.66- 0.96), to regions other than South Florida (North OR 0.40, 95% CI 0.17-0.93, Panhandle OR 0.12, 95% CI 0.04-0.36) remained independently associated with lower use of endovascular therapy. In contrast, Hispanics (OR 1.28, 95% CI 1.03- 1.69) vs. White and presenting to large hospital (OR 4.92, 95% CI 1.05- to 22.6) were associated with higher use of endovascular treatment.

Conclusions: There are significant race, regional and hospital disparities in delivery of endovascular care. Efforts should me made to improve access to endovascular treatment in patients presenting across the region to all stroke centers.

Abstract TMP81: Regional, Race-Ethnic and Sex Disparities in Lifestyle Interventions: Data from the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program

Background: As key components of the AHA Life’s Simple 7 campaign, lifestyle modifications play an integral role in the prevention of vascular disease. Little is known about the prevalence of lifestyle modification counseling in patients with acute ischemic stroke (AIS). We sought to investigate disparities in the delivery of lifestyle interventions to AIS patients in the large NINDS-funded FL-PR CReSD Registry of Get With The Guidelines-Stroke (GWTG-S) data.

Methods: GWTG-S collects data on the provision of several lifestyle interventions including counseling on exercise/weight loss, Therapeutic Lifestyle Changes (TLC) diet, diabetes (DM) education and antihypertensive (low sodium) diet. 80,598 AIS cases were prospectively included from 82 sites (69 FL; 13 PR) from 2010-2016. Multilevel logistic regression models adjusted for age, race, and aphasia were used to evaluate differences in the provision of lifestyle interventions as indicated for patients prior to hospital discharge.

Results: Among AIS cases, 51% were men, 62% non-Hispanic White (NHW), 18% NH-Black (NHB), 13% FL-Hispanic (FLH), and 6% PR-Hispanic (PRH). Mean age was 71±14 years. The highest mean BMI was in PRH (29±7 kg/m 2 ), with the lowest in NHW (27±6 kg/m 2 ) and FLH (28±6 kg/m 2 ). Despite this, PRH were less likely to receive exercise/weight loss counseling compared to NHW (OR 0.43, 95% CI 0.20-0.90) and FLH (OR 0.46, 95% CI 0.22-0.97). PRH also had lower odds of receiving TLC diet counseling compared to NHW and FLH (OR 0.32, 95% CI 0.15-0.68). Though NHB presented with higher rates of DM compared to NHW (38% vs. 25%), they were less likely to receive DM education (OR 0.95, 95% CI 0.91-0.99). Women were less likely to receive TLC diet counseling (OR 0.94, 95% CI 0.90-0.98) and DM education (OR 0.94, CI 0.92-0.97) compared to men. Despite higher HTN frequency in women and NHB (67% and 69%), both were less likely to receive low sodium diet recommendations as compared to men (OR 0.94, 95% CI 0.92-0.97) and NHW (OR 0.95, 95% CI 0.91-0.99).

Conclusion: Overall, disparities were identified in the provision of several lifestyle interventions in AIS patients. These interventions can benefit all and providers should continue counseling patients regarding modifiable risk factors to prevent future stroke.

Abstract 89: Differences in Acute Stroke Care in Primary and Comprehensive Stroke Centers in Florida: An Analysis of the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study- the NINDS Stroke Prevention Intervention Research Program

Introduction: Primary stroke center (PSC) and comprehensive stroke center (CSC) designation in Florida aims to improve delivery of care and outcomes for stroke patients. In line with the goals of the NINDS funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study, we sought to compare ischemic stroke performance metrics by stroke center designation in participating Florida hospitals.

Methods: We analyzed 74,623 cases with acute ischemic stroke from 26 CSC and 40 PSC from January 2010-April 2016. We described patient demographics, comorbidities and Get With The Guidelines-Stroke performance metrics of defect free care (compliance with 7 pre-defined performance core measures), door to CT time (DTCT) ≤25 mins and door to needle time (DTN) ≤60 mins.

Results: Compared with PSC patients, CSC patients were younger (70 ± 15 vs. 71 ± 14 years, p<.0001), more likely male (51% vs. 50%, p=.0008), more likely Hispanic (17% vs. 10%, p<.0001) and Black (21% vs. 17%, p<.0001), had more severe strokes (NIHSS median 5 (IQR 2-12) vs. 4 (IQR 1-9); NIHSS ≥16, 12% vs. 9%, p <.0001), were more likely to have atrial fibrillation (19% vs. 17%, p<.0001), and were more likely to arrive by EMS (55% vs. 46%, p<.0001). CSC cases were more likely to have faster DTCT (44 vs. 48 mins, p=.0124 ; < 25 mins 33% vs. 31%, p<.0001). More patients in CSC received thrombolysis (12% vs. 9%, p<.0001), with faster DTN (59 vs. 71 min, p <.0001; ≤60 minutes 53% vs. 37%, p <.0001). Patients in CSC had greater rates of defect free care (85% vs. 82.4%, p<.0001). Blacks had longer median DTCT than Whites and Hispanics in both CSC (56 mins Blacks vs. 41 mins Whites and Hispanics) and PSC (60 mins Blacks, 44 mins Whites, 57 mins Hispanics). Blacks in CSC had longer median DTN (63 mins) than Whites (60 mins) and Hispanics (53 mins). Hispanics had longer median DTN (73 mins) in PSC than Blacks (70 mins) and Whites (70 mins).

Conclusion: Patients treated in CSC, compared with those treated in PSC, received better defect-free care and had lower DTCT and DTN times. Race-ethnic disparities in performance metrics are still evident in both CSC and PSC. Identification of these disparities is important to design interventions to reduce disparities and improve stroke quality of care for all.

Abstract 50: Persistent Racial/Ethnic Disparities Despite Declining Rates of Ischemic Stroke Hospitalizations Among Medicare Beneficiaries, 2001-2013

Background: Stroke hospitalizations in the US have declined over the last decade, but little is known about whether decreases are similar across racial/ethnic groups. We compared ischemic stroke hospitalization rates and geographic patterns across the US from 2001-2013 for elderly Hispanics, Blacks, Whites, and those of other race/ethnicity.

Methods: Ischemic stroke hospitalizations (ICD-9 primary discharge codes 433, 434, 436) were identified among Medicare fee-for-service beneficiaries aged ≥65y in 2001-2003 and 2011-2013. National annualized rates for each period were calculated per 100,000 person-years (PY). A spatial mixed model with a Poisson link function and adjustment for age and sex was fit to calculate and map county-specific risk-standardized stroke hospitalization rates for each racial/ethnic group.

Results: National annualized stroke hospitalization rates decreased by 15% between 2001-2003 and 2011-2013 (1298/100,000 PY to 1103/100,000 PY). County-level risk-standardized hospitalization rates varied across the US and among the four racial/ethnic groups (figure). Regardless of time period, Blacks had the highest rates, followed by Whites, Hispanics, and other races. The absolute and relative declines in risk-standardized hospitalization rates were smallest for Hispanics (173/100,000 PY; 15%) and Blacks (196/100,000 PY; 12%) compared to Whites (243/100,000 PY; 19%) and other races (273/100,000 PY; 33%).

Conclusions: Although national hospitalization rates for ischemic stroke among those aged ≥65y decreased between 2001 and 2013, the decline varied by race/ethnicity, with persistent disparities between groups. Despite the declines in US stroke hospitalizations, these racial/ethnic differences call for greater prioritization of prevention intervention programs to reduce stroke disparities. AHA/ASA efforts to expand stroke systems of care also need to address these disparities.

Genetic variants in CETP increase risk of intracerebral hemorrhage

Objective

In observational epidemiologic studies, higher plasma high‐density lipoprotein cholesterol (HDL‐C) has been associated with increased risk of intracerebral hemorrhage (ICH). DNA sequence variants that decrease cholesteryl ester transfer protein (CETP) gene activity increase plasma HDL‐C; as such, medicines that inhibit CETP and raise HDL‐C are in clinical development. Here, we test the hypothesis that CETP DNA sequence variants associated with higher HDL‐C also increase risk for ICH.

Methods

We performed 2 candidate‐gene analyses of CETP. First, we tested individual CETP variants in a discovery cohort of 1,149 ICH cases and 1,238 controls from 3 studies, followed by replication in 1,625 cases and 1,845 controls from 5 studies. Second, we constructed a genetic risk score comprised of 7 independent variants at the CETP locus and tested this score for association with HDL‐C as well as ICH risk.

Results

Twelve variants within CETP demonstrated nominal association with ICH, with the strongest association at the rs173539 locus (odds ratio [OR] = 1.25, standard error [SE] = 0.06, p = 6.0 × 10⁻⁴) with no heterogeneity across studies (I² = 0%). This association was replicated in patients of European ancestry (p = 0.03). A genetic score of CETP variants found to increase HDL‐C by ∼2.85mg/dl in the Global Lipids Genetics Consortium was strongly associated with ICH risk (OR = 1.86, SE = 0.13, p = 1.39 × 10⁻⁶).

Interpretation

Genetic variants in CETP associated with increased HDL‐C raise the risk of ICH. Given ongoing therapeutic development in CETP inhibition and other HDL‐raising strategies, further exploration of potential adverse cerebrovascular outcomes may be warranted. Ann Neurol 2016;80:730–740

Sex Disparities in Ischemic Stroke Care: FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities)

BACKGROUND AND PURPOSE

Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines-Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment.

METHODS

Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines-Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity.

RESULTS

As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93-1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86-0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71-0.97; P=0.02) as compared with men.

CONCLUSIONS

Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.

The Science of Vascular Contributions to Cognitive Impairment and Dementia (VCID): A Framework for Advancing Research Priorities in the Cerebrovascular Biology of Cognitive Decline

The World Health Organization reports that 47.5 million people are affected by dementia worldwide. With aging populations and 7.7 million new cases each year, the burden of illness due to dementia approaches crisis proportions. Despite significant advances in our understanding of the biology of Alzheimer's disease (AD), the leading dementia diagnosis, the actual causes of dementia in affected individuals are unknown except for rare fully penetrant genetic forms. Evidence from epidemiology and pathology studies indicates that damage to the vascular system is associated with an increased risk of many types of dementia. Both Alzheimer's pathology and cerebrovascular disease increase with age. How AD affects small blood vessel function and how vascular dysfunction contributes to the molecular pathology of Alzheimer's are areas of intense research. The science of vascular contributions to cognitive impairment and dementia (VCID) integrates diverse aspects of biology and incorporates the roles of multiple cell types that support the function of neural tissue. Because of the proven ability to prevent and treat cardiovascular disease and hypertension with population benefits for heart and stroke outcomes, it is proposed that understanding and targeting the biological mechanisms of VCID can have a similarly positive impact on public health.

Abstract TMP67: Sex Disparities in Atrial Fibrillation as a Predictor of Poor Discharge Disposition After Ischemic Stroke Hospitalization: The Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: It is unknown whether atrial fibrillation (AF) is responsible for increased morbidity and disability seen in women with ischemic stroke. We sought to determine whether patients with ischemic stroke and AF had poorer outcomes than ischemic stroke patients without AF and whether this effect is more pronounced among women.

Methods: We analyzed data from the FL-PR CReSD Study, a large quality improvement registry of Florida (N=66) and Puerto Rico (N=9) hospitals based on the Get With The Guidelines-Stroke (GWTG-S) program. Discharge disposition was utilized as a surrogate marker for morbidity and disability, with discharge to home or rehabilitation in comparison to other discharge dispositions (skilled nursing facility, hospice or died). Multilevel generalized linear models were used to evaluate AF and sex disparities in discharge disposition adjusted for demographics, risk factors (hypertension, diabetes, heart failure, previous stroke/TIA), and NIHSS and CHADS2 scores.

Results: We examined a total of 55,945 ischemic stroke patients, of whom 11,797 (21%) had AF at discharge. AF patients were older than non-AF patients (79.0±10.9 years vs. 68.7±14.4 years), had higher proportion of women (54% vs. 49%) and more severe strokes (mean NIHSS 10±9 vs. 7±7). Among AF patients, women were older (81±10 vs. 76±11 years) and had greater NIHSS (11±9 vs. 9±8) and CHADS2 scores (3.9±0.9 vs. 3.7±1.0) than men. Overall, AF patients were less likely discharged to home or rehabilitation than those without AF (54% vs. 71%, OR 0.93, 95% CI 0.89-0.98). There was a significant effect modification between AF and discharge disposition by sex. In stratified analyses by sex, AF was associated with less discharged to home or rehabilitation among women (OR 0.85, 95% CI 0.79-0.91), but not among men (OR 1.04, 95% CI 0.96-1.11).

Conclusion: Women with AF were less likely discharged to home or rehabilitation facility after ischemic stroke. Baseline differences in age, stroke severity, risk factors, and comorbidities between men and women had little impact on the poorer outcome and discharge disposition after ischemic stroke in women. Further studies are warranted to identify the causes of sex-specific differences in stroke outcomes for patients with AF.

Abstract WP285: Sex Disparities in Stroke Care in Puerto Rico Hospitals Participating in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: Sex is a contributing factor to inequalities in stroke care. In line with the aims of the FL-PR CReSD Study to assess Get With The Guidelines-Stroke (GWTG-S) quality improvement data, we sought to compare stroke performance metrics by sex among 9 GWTG-S participating Puerto Rico hospitals from 2010-2014.

Methods: Age and NIHSS-adjusted hierarchical generalized linear models, stratified by sex, were evaluated for the following GWTG-S performance metrics: IV tPA treatment, early antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy for atrial fibrillation (AF) at discharge, statin medication at discharge, smoking cessation counseling, defect-free care (compliance with all performance measures), in addition to CT scan ≤25 minutes and door-to-IV tPA administration ≤60 minutes of hospital arrival.

Results: Among 3,277 acute ischemic stroke cases, 48% were women. As compared to men, women were older (72±14 vs. 68±13 years, P<0.0001) with higher NIHSS scores (10±8.5 vs. 9±7.7, P=0.005). Women were less likely to receive IV tPA ≤ 4.5 hours among eligible patients arriving ≤ 3.5 hours (OR 0.71, 95% CI 0.51-0.98, P=0.04), early antithrombotic therapy (OR 0.86, 95% CI 0.75-0.97, P=0.02), DVT prophylaxis (OR 0.93, 95% CI 0.88-0.99, P=0.03), statin medication at discharge (OR 0.85, 95% CI 0.78-0.93, P=0.0001), and anticoagulation for AF at discharge (OR 0.67, 95% CI 0.49-0.92, P=0.01) despite having higher rates of AF at admission (11% vs. 7%, P=0.001). Rates of IV tPA for patients arriving ≤ 2 hours, antithrombotic therapy at discharge, and smoking cessation counseling showed no sex differences. While women were less likely to have a CT scan ≤ 25 minutes of hospital arrival compared to men (OR 0.83, 95% CI 0.74-0.93, P=0.002), no difference was found in door-to-IV tPA administration ≤ 60 minutes. Although an overall temporal improvement in defect-free care was observed from 2010-2014 (31% to 63%, P<.0001), women were less likely to receive this measure than men (OR 0.91, 95% CI 0.85-0.97, P=0.007).

Conclusions: Overall, stroke care remains lower for Puerto Rican women than men. Continued adoption of the GWTG-S quality improvement program may help reduce sex disparities in quality of care across the island.

Abstract TP315: Predictors of Thrombolysis Administration in Patients with Minor Stroke or TIA in the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: Minor stroke/TIA is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable amongst different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD Study.

Methods: 73,712 patients with ischemic stroke/TIA were prospectively enrolled from January 2010 to April 2015. We included 7,746 patients who had persistent neurological symptoms with NIHSS score ≤5 and arrived within 4 hours of symptom onset. Multilevel logistic regression analysis was used to identify independent predictors of thrombolysis in the subgroup of patients without contraindications to thrombolysis

Results: 6,826 patients (25% final diagnosis TIA, 75% minor stroke) were included (mean age=70±14 years), 52.7% male, 70.3% white, 13% black, 16.7% Hispanic, median NIHSS=2 (IQR=1,4). Patients who received thrombolysis (N=1281, 18.7%) were younger (67 vs. 70.7 years, P<0.001), had less vascular risk factors (HTN, DM, dyslipidemia), lower risk of prior vascular disease (MI, PVD, previous stroke) and had a higher presenting median NIHSS score (4 vs. 2, P<0.0001). In the multivariable analysis, younger age (OR 1.02, 95% CI 1.02-1.03, P<0.0001), white or Hispanic vs. black (OR 1.2, 95% CI 1.04-1.37, P=0.0097), early hospital arrival (unit change in 30 min.) (OR 1.26, 95% CI 1.21-1.31, P<0.0001), arrival by EMS (OR 1.28, 95% CI 1.08-1.49, P<0.0001), higher NIHSS score (OR 1.96, 95% CI 1.87-2.06, P<0.0001), altered level of consciousness (OR 1.43, 95% CI 1.11-1.85, P=0.0062) and aphasia at presentation (OR 1.34, 95% CI 1.13-1.58, P=0.0008) were independent predictors of thrombolysis administration.

Conclusion: Minor acutely presenting stroke patients were more likely to receive thrombolysis if they were young, white or Hispanic, and arrived early to the hospital with more severe neurological presentation specifically aphasia and altered level of consciousness. Identification of predictors of thrombolysis utilization is important in the design of educational programs and randomized trials to increase the use of thrombolysis for minor stroke.

Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme

Background

The Global Alliance for Chronic Diseases comprises the majority of the world’s public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects.

Methods

Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings.

Results

There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation.

Conclusions

The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0331-0) contains supplementary material, which is available to authorized users.

Prophylactic Antiepileptic Drug Use and Outcome in the Ethnic/Racial Variations of Intracerebral Hemorrhage Study

BACKGROUND AND PURPOSE

The role of antiepileptic drug (AED) prophylaxis after intracerebral hemorrhage (ICH) remains unclear. This analysis describes prevalence of prophylactic AED use, as directed by treating clinicians, in a prospective ICH cohort and tests the hypothesis that it is associated with poor outcome.

METHODS

Analysis included 744 patients with ICH enrolled in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study before November 2012. Baseline clinical characteristics and AED use were recorded in standardized fashion. ICH location and volume were recorded from baseline neuroimaging. We analyzed differences in patient characteristics by AED prophylaxis, and we used logistic regression to test whether AED prophylaxis was associated with poor outcome. The primary outcome was 3-month modified Rankin Scale score, with 4 to 6 considered poor outcome.

RESULTS

AEDs were used for prophylaxis in 289 (39%) of the 744 subjects; of these, levetiracetam was used in 89%. Patients with lobar ICH, craniotomy, or larger hematomas were more likely to receive prophlyaxis. Although prophylactic AED use was associated with poor outcome in an unadjusted model (odds ratio, 1.40; 95% confidence interval, 1.04-1.88; P=0.03), this association was no longer significant after adjusting for clinical and demographic characteristics (odds ratio, 1.11; 95% confidence interval, 0.74-1.65; P=0.62).

CONCLUSIONS

We found no evidence that AED use (predominantly levetiracetam) is independently associated with poor outcome. A prospective study is required to assess for a more modest effect of AED use on outcome after ICH.

Comparative effectiveness of home blood pressure telemonitoring (HBPTM) plus nurse case management versus HBPTM alone among Black and Hispanic stroke survivors: study protocol for a randomized controlled trial

Background

Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension.

Methods/Design

A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing.

Discussion

The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence.

Trial registration

ClinicalTrials.gov NCT02011685. Registered 10 December 2013.

Recommendations of the Alzheimer's disease-related dementias conference

The National Alzheimer's Project Act, signed into law in 2011, mandates a National Plan to Address Alzheimer's Disease that is updated annually. In the Plan, the term Alzheimer disease includes not only Alzheimer disease (AD) proper, but also several specified related dementias, namely, frontotemporal, Lewy body, vascular, and mixed dementia. In response to a specific action item in the 2012 National Plan, the National Institute of Neurological Disorders and Stroke, in collaboration with the National Institute on Aging, convened panels of experts and conducted a 2-day public conference to develop research priorities and timelines for addressing Alzheimer disease-related dementias (ADRD) in 5 topic areas: multiple etiology dementias, health disparities, Lewy body dementias including dementia with Lewy bodies and Parkinson disease dementia, frontotemporal dementia and related tauopathies, and vascular contributions to ADRD. By design, the product was up to 8 prioritized research recommendations in each topic area including estimated timelines from when work on a recommendation is started to completion or to full implementation of an ongoing activity, and recognition of shared research themes across recommendations. These included increased education and training of both researchers and health care professionals, addressing health disparities, fundamental neurobiology research, advanced diagnostics, collaborative biosample repositories, and a focus on developing effective interventions to prevent or treat ADRD by the year 2025 as targeted by the National Plan.

Understanding the rise in cardiovascular diseases in Africa: harmonising H3Africa genomic epidemiological teams and tools

Abstract

Cardiovascular diseases, principally ischaemic heart disease and stroke, are the leading causes of global mortality and morbidity. Together with other non-communicable diseases, they account for more than 60% of global deaths and pose major social, economic and developmental challenges worldwide. In Africa, there is now compelling evidence that the major cardiovascular disease (CVD) risk factors are on the rise, and so are the related fatal and non-fatal sequelae, which occur at significantly younger ages than seen in high-income countries. In order to tackle this rising burden of CVD, the H3Africa Cardiovascular Working Group will hold an inaugural workshop on 30 May 2014 in Cape Town, South Africa. The primary workshop objectives are to enhance our understanding of the genetic underpinnings of the common major CVDs in Africa and strengthen collaborations among the H3Africa teams and other researchers using novel genomic and epidemiological tools to contribute to reducing the burden of CVD on the continent.

Abstract W P306: Identifying Stroke Researcher Challenges to Minority Inclusion in Clinical Research

Background: Race-ethnic disparities exist in stroke incidence, recurrence and mortality. Minority participation in stroke clinical trials is staggeringly low. A significant literature describes patient-reported barriers to recruitment, but researcher barriers are not well documented.

Aim: To assess stroke researcher best practices and challenges to minority inclusion in stroke trials.

Methods: The National Initiative for Minority Involvement in Neurological Clinical Trials (NIMICT) uses a mixed methods approach including surveys, focus groups and key informant interviews to expand on understanding of minority recruitment and retention in stroke clinical trials. We designed and tested a 40-item survey based on literature review and used the results to inform semi-structured focus groups and key informant interviews among stroke clinical trial investigators (N=110).

Results: Key stroke investigators, identified through the Princeton Conference, were invited via email to participate in the survey. Over 70% (n=93) responded: 68% White. Less than half (N=43) reported actively setting recruitment goals for minority inclusion. Only 37% (N=29) required cultural sensitivity training for recruitment staff. Over 80% reported treating adults unable to consent and were concerned about acute stroke time constraints negatively impacting patient/family participation decisions. Key themes from focus groups (N=17) included: 1) Role of government in defining valid minority sub analyses and enforcing existing inclusion guidelines; 2) Challenges unique to acute setting including consent in conditions of prognostic uncertainty; 3) Lack of scientific/research literacy in the lay population; 4) Lack of community engagement including Primary Care Physicians; 5) Lack of cost data to adequately budget for inclusion efforts. Best practices included health literate consent forms, cultural competency, and motivational interview training for coordinators.

Conclusion: NIMICT’s mixed methods approach contributes new perspectives on unique challenges in stroke clinical research. These findings will inform strategies to improve minority recruitment and retention among neurological clinical trials.

Investigation of 95 variants identified in a genome-wide study for association with mortality after acute coronary syndrome

Background

Genome-wide association studies (GWAS) have identified new candidate genes for the occurrence of acute coronary syndrome (ACS), but possible effects of such genes on survival following ACS have yet to be investigated.

Methods

We examined 95 polymorphisms in 69 distinct gene regions identified in a GWAS for premature myocardial infarction for their association with post-ACS mortality among 811 whites recruited from university-affiliated hospitals in Kansas City, Missouri. We then sought replication of a positive genetic association in a large, racially diverse cohort of myocardial infarction patients (N = 2284) using Kaplan-Meier survival analyses and Cox regression to adjust for relevant covariates. Finally, we investigated the apparent association further in 6086 additional coronary artery disease patients.

Results

After Cox adjustment for other ACS risk factors, of 95 SNPs tested in 811 whites only the association with the rs6922269 in MTHFD1L was statistically significant, with a 2.6-fold mortality hazard (P = 0.007). The recessive A/A genotype was of borderline significance in an age- and race-adjusted analysis of the entire combined cohort (N = 3095; P = 0.052), but this finding was not confirmed in independent cohorts (N = 6086).

Conclusions

We found no support for the hypothesis that the GWAS-identified variants in this study substantially alter the probability of post-ACS survival. Large-scale, collaborative, genome-wide studies may be required in order to detect genetic variants that are robustly associated with survival in patients with coronary artery disease.

Racial differences in vascular risk factors and outcomes of patients with intracranial atherosclerotic arterial stenosis

BACKGROUND AND PURPOSE

Atherosclerotic intracranial stenosis is an important cause of stroke in blacks, yet there are limited data on vascular risk factors and outcome. We analyzed the vascular risk factors and outcomes of blacks and whites in the Warfarin versus Aspirin for Symptomatic Intracranial Disease (WASID) trial.

METHODS

Baseline characteristics and outcomes (ischemic stroke, brain hemorrhage, or vascular death combined and ischemic stroke alone) were compared between blacks (n=174) and whites (n=331) using univariate and multivariate analyses.

RESULTS

Blacks were significantly (P<0.05) more likely than whites to be/have: female, hypertension history, diabetes history, higher LDL, higher total cholesterol, lower triglycerides, unmarried, unemployed, nonprivate insurance, no insurance, stroke as qualifying event, <70% stenosis, symptomatic anterior circulation vessel, no antithrombotic medication before qualifying event, and no family history of myocardial infarction. Blacks more frequently reached an end point of ischemic stroke, brain hemorrhage or vascular death (28% versus 20%; hazard ratio of 1.49, 95% CI 1.03 to 2.17, P=0.03), had a higher 2-year event rate (0.28 versus 0.19), and reached the end point of ischemic stroke alone (25% versus 16% at 2 years; hazard ratio of 1.62, P=0.017). In multivariate analysis, race was associated with ischemic stroke (P=0.0488) but not with the end point ischemic stroke, brain hemorrhage or vascular death (P=0.188).

CONCLUSIONS

Blacks with intracranial stenosis are at higher risk of stroke recurrence than whites. This risk warrants additional study of factors contributing to stroke in blacks and highlights the need for aggressive risk factor management in blacks to prevent recurrence.

Gender Differences in Outcomes Among Patients With Symptomatic Intracranial Arterial Stenosis

Background and Purpose— There are limited and conflicting data on gender differences in clinical outcomes among patients with symptomatic intracranial arterial stenosis. This study examined gender differences in patients enrolled in the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Study.

Methods— Participants were 569 men and women with symptomatic intracranial arterial stenosis. They were followed-up for the occurrence of ischemic stroke and the combined end point of stroke or vascular death from February 1999 through July 2003 (mean follow-up, 1.8 years).

Results— Two-year rates of the primary end point were 28.4% and 16.6% for women and men, respectively. Cumulative probabilities of the outcomes over time were estimated by the Kaplan-Meier product-limit method and were compared between men and women with the use of the log-rank test. Cox proportional hazards regression analyses were used to estimate the hazard ratio of gender (women to men) for ischemic stroke and for the primary end point. The probabilities of ischemic stroke ( P =0.005) and of the combined end point of stroke or vascular death ( P =0.017) over time were significantly higher in women than men. Women had a greater multivariate-adjusted risk for ischemic stroke (HR, 1.85; 95% CI, 1.14 to 3.01; P =0.013) and for the combined end point of stroke or vascular death (HR, 1.58; 95% CI, 1.01 to 2.48; P =0.045).

Conclusions— Women with symptomatic intracranial arterial stenosis are at significantly greater risk for ischemic stroke and for the combined end point of stroke or vascular death. These findings suggest the need for vigorous screening of risk factors and for aggressive management of risk factors and stroke in women. They also suggest the need to ensure adequate numbers of women in clinical trials designed to explore new and promising therapies for intracranial arterial stenosis.

An epilepsy mutation in the sodium channel SCN1A that decreases channel excitability

Mutations in three voltage-gated sodium channel genes, SCN1A, SCN2A, and SCN1B, and two GABAA receptor subunit genes, GABRG2 and GABRD, have been identified in families with generalized epilepsy with febrile seizures plus (GEFS+). A novel mutation, R859C, in the Nav1.1 sodium channel was identified in a four-generation, 33-member Caucasian family with a clinical presentation consistent with GEFS+. The mutation neutralizes a positively charged arginine in the domain 2 S4 voltage sensor of the Nav1.1 channel alpha subunit. This residue is conserved in mammalian sodium channels as well as in sodium channels from lower organisms. When the mutation was placed in the rat Nav1.1 channel and expressed in Xenopus oocytes, the mutant channel displayed a positive shift in the voltage dependence of sodium channel activation, slower recovery from slow inactivation, and lower levels of current compared with the wild-type channel. Computational analysis suggests that neurons expressing the mutant channel have higher thresholds for firing a single action potential and for firing multiple action potentials, along with decreased repetitive firing. Therefore, this mutation should lead to decreased neuronal excitability, in contrast to most previous GEFS+ sodium channel mutations, which have changes predicted to increase neuronal firing.

Disorders of Coagulation in Stroke

The roles of the coagulopathies in thrombosis have been well established; however, the role in ischemic stroke is poorly understood. This article reviews the recent advances in the genetics of coagulation, the recently identified interactive roles of the coagulation and anticoagulation proteins, and the literature supporting protein dysregulation as a causative agent in cerebral venous thrombosis and ischemic stroke.