Cerebrovascular Events and Hospital Discharge Outcomes Associated With Drug Use: A Retrospective Case-Matched Study

Introduction Individuals using cocaine, methamphetamines, cannabis, and other mood-altering drugs (MADs) have been reported to have greater stroke risk when compared to individuals who do not use these drugs. Yet, the impact that MAD use has on stroke outcomes has not been adequately explored, with existing research not agreeing on the extent to which the use of these drugs influences stroke outcomes. This study aimed to determine the impact that the use of common MADs has on stroke outcome factors such as length of stay (LOS), discharge modified Rankin Scale (mRS), and discharge disposition. Methods A retrospective case-matched study was conducted with two adult cohorts treated for cerebrovascular accidents: those who use MADs and those who do not use MADs prior to their stroke. Subjects identified for the users of MADs cohort were matched at a 1:1 ratio to those who do not use MADs (control cohort) by age, sex, and stroke type (e.g., hemorrhagic or ischemic). Logistic regression was used to calculate odds ratios for functional outcomes for stroke patients with and without prior MAD use. Results Active users of MADs had an increased overall risk of poor stroke outcome, i.e., increased length of stay, discharge disposition other than to home or to rehabilitation, discharge modified Rankin scale (mRS) 3-6 after controlling for stroke severity from initial National Institutes of Health Stroke Scale (NIHSS) (X2{9}=21.68, p<0.01, Cox adjusted R2=0.31). This finding was driven predominately by increased hospital LOS (p=0.006) among the MAD cohort, whereas discharge mRS 3-6 (p=0.24) and discharge disposition to care facility (p=0.27) and expired (p=0.26) did not vary significantly between groups. Conclusion Our study suggests that patients who had actively used MADs prior to their stroke may be at risk of poorer stroke outcomes, namely an increased LOS. Future research should be conducted to further elucidate which factors, such as individual drugs, amount of drug, acute or recreational use versus chronic or long-term use, and route of administration, for instance, specifically contribute to a longer LOS so that they may be targeted for mitigation.

Conversion From Intravenous Alteplase to Tenecteplase for Treatment of Acute Ischemic Stroke Across a Large Community Hospital Health System

BACKGROUND

Recent evidence suggests tenecteplase at an intravenous dose of 0.25 mg/kg is as safe and efficacious as intravenous alteplase standard dose and demonstrates a more favorable pharmacokinetic profile for treatment of acute ischemic stroke.

OBJECTIVE

The purpose was to compare the safety and efficacy of alteplase versus tenecteplase for the treatment of acute ischemic stroke at a large community hospital health system following conversion in the preferred formulary thrombolytic.

METHODS

Prior to converting, medication safety and operationalization analyses were conducted. A multicenter, retrospective medical record review was performed for patients who received alteplase 6 months prior to formulary thrombolytic conversion and for tenecteplase 6 months post-conversion for the treatment of acute ischemic stroke. Primary outcomes included the rate of symptomatic intracranial and extracranial hemorrhage complications. Secondary outcomes included door-to-needle time, reduction in National Institute Health Stroke Scale at 24 hours and at discharge, order-to-administration time, and thrombolytic errors. The rates of hemorrhage were compared using binomial regression.

RESULTS

Of the 287 patients reviewed, 115 received alteplase and 172 received tenecteplase. Symptomatic intracranial hemorrhagic complications occurred in 1 patient (1%) who received alteplase compared with 3 patients (2%) who received tenecteplase (P = 0.9). There was no statistical difference in rates of symptomatic intracranial or extracranial hemorrhagic complications.

CONCLUSION AND RELEVANCE

Conversion from alteplase to tenecteplase can be safely and effectively achieved at a large community hospital health system with differing levels of stroke certification. There were also additional cost savings and practical advantages including workflow benefits.

Abstract TP51: The Effect Of Biological Sex On A County Prehospital Stroke Initiative

Introduction: It has been found that women are disproportionately affected by stroke when compared to men. This can be partially attributed to the presence of non-traditional stroke symptoms in women but also sex variance in stroke care. The FAST-ED is a prehospital initiative used to triage patients presenting with typical stroke symptoms and serves as a proxy for stroke severity directing EMS transportation to the appropriate care center. This study explored sex discrepancies in our community’s prehospital stroke initiative and its effects on patient care.

Methods: An internal hospital registry created in 2017 evaluated EMS FAST-ED compliance and monitored the effects on patient outcome. This database contains two existing cohorts; one cohort prior to FAST-ED implementation and one cohort after implementation. Using this data set we added another cohort of cases 2-years after implementation. The inclusion criteria consisted of patients ≥18 years, arriving via EMS as stroke alerts. No exclusion criteria were included in this study. Variables that were evaluated for sex differences included EMS FAST-ED compliance, FAST-ED score, final diagnoses, door-to-needle DTN and door-to groin DTG, and stroke treatment volumes.

Results: A total of 1419 cases were included in the dataset with 55% (n=781) being women. EMS FAST-ED compliance was 80.6% for men and 78.7% for women. The average FAST-ED score did not statistically differ between men (M=3.34, SD=2.34) and women (M=3.30, SD=2.25). There was also no sex difference in stroke treatment times or volumes. In this study, the only significant sex difference was in the final diagnoses’ code, where women were 54% (95CI: 51%-58%) CI) more likely to have CVA, 71% (95CI: 51%-88% CI) more likely to have a SAH, and 65% (95CI: 56%-74%) more likely to have a TIA when compared the men.

Discussion: The results of this study did not show sex differences in the pre-hospital approach to stroke care in our community. Specifically, no difference in stroke EMS triage, stroke treatment times (DTN and DTG), or stroke treatment volumes. Our findings regarding sex differences in final stroke diagnoses code deserves further study.

Anticoagulation After Ischemic Stroke or Transient Ischemic Attack (TIA) in the Time of Direct Oral Anticoagulation (DOAC) and Thrombectomy

Objective

To assess anticoagulation (AC) timing and appropriateness in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) due to atrial fibrillation (AF) in a predominantly Hispanic community hospital in the era of direct oral AC (DOAC) and endovascular thrombectomy (EVT).

Methods

Adult patients presenting with known or new-onset AF and primary diagnosis of AIS/TIA admitted to Baptist Hospital of Miami between January 2018 and January 2019 were included. AC appropriateness was determined on medical history and concordance with American Heart Association AHA/American Stroke Association (ASA) AC guidelines. Median time from AIS/TIA diagnosis to AC initiation was the primary endpoint. AC guideline concordance on admission and at discharge, discordant justification, and AC selection were secondary endpoints.

Results

The sample included 120 patients. AC initiation was five days (interquartile range (IQR) 2-9) following AIS/TIA. Patients’ receiving intravenous (IV) alteplase experienced a 1.4-day delay in AC initiation (x̅=5.44, SE=1.05, p<.05). There was no significant delay for those receiving EVT. A symptomatic hemorrhagic transformation occurred in 3% (n=3) of patients; only one patient was initiated on AC prior to the event. No recurrent AIS/TIAs occurred prior to discharge. Guideline-based AC concordance increased by 14% to 96% from admission to discharge. Apixaban (78%, n=52) was the most prescribed anticoagulant during hospitalization.

Discussion

This study suggests that early AC initiation for patients with AF and AIS/TIA with or without IV alteplase and/or EVT is a safe and effective stroke prevention intervention. Further, it identified a need for improved concordance with guideline-based AC within the clinic setting.

Abstract P286: The Effects of COVID-19 on the Reasons for Not Calling 911 for Acute Stroke

Objective: Our Stroke Program regularly provides community outreach and stroke education. The stroke team educates on signs and symptoms of stroke, risks factors, and 911 activation. Within a few days of discharge, Neuroscience nurses call stroke patients to ensure patients have obtained their prescription medications, have follow-up appointments, inquire about their satisfaction with our services, and reinforce stroke education. As part of these calls, our team asked why patients/families did not call 911. The purpose of this study was to determine if the COVID-19 crisis influenced the reasons why 911 was not called for possible stroke to better plan for targeted stroke education.

Method: Discharge phone survey data from our stroke network was collected from Feb-Jul 2019 and compared to Feb-Jul 2020. Our stroke network includes 1 comprehensive stroke center and 2 primary stroke centers. Emergency Department (ED) stroke activation data was gathered for the same time periods. Discharge phone calls data was based on discharge date, whereas ED stroke alert data was based on admission date.

Results: There was a notable decline in stroke volume between 2019 to 2020 with the largest decline occurring during the first peak (Apr 2020) in COVID-19 cases within our state. This decline was driven by a 16% decline in walk-in ED stroke arrivals as compared to a 1% decline in EMS stroke arrivals. Of those who did not call 911 in 2020, there was a 7% increase in failing to recognize stroke symptoms as an emergency, a 6% increase in concern about EMS cost, and 6% decrease in hospital preference.

Conclusion: The COVID-19 crisis negatively influenced stroke volumes within our system stroke program. Reductions in stroke walk-ins accounted for this decline. COVID-19 affected the reasons why 911 was not called. The largest increase was in not recognizing stroke symptoms as an emergency and increased concern about EMS associated costs. Surprisingly, COVID-19 was not listed as a reasons for avoiding 911. Targeted community educational efforts on these concerns may lead to improved 911 usage for suspected stroke during the COVID-19 pandemic.

Limitations: Further research is needed to investigate why those with a stroke who would have been walk-ins decided not to seek urgent medical attention.

Prenatal light exposure influences gait performance and body composition in bobwhite quail chicks

Maternal nesting behavior, which includes periods of patterned inattention, provides key elements essential for avian embryonic development, including regulation of temperature and light. For example, avian research consistently shows the importance of prenatal light exposure for several developmental processes; however, this research has primarily focused on artificial light regimens (i.e. 24 hr, 0 hr light). Comparatively less is known about how exposure to naturally occurring light patterns during incubation influence motor performance, body composition (i.e. body mass, bone length), and developmental age (incubation length). Here we conducted two experiments which investigated the effects of prenatal light exposure on developmental age, body composition, and gait performance in 1-day-old bobwhite quail. Experiment 1 investigated crepuscular light exposure during the last two days of incubation under two light duration treatments (2 hr & 6 hr) compared to a 12 hr continuous light schedule. Results indicated crepuscular prenatal light experience extended the incubation period for 2 hr exposed embryos, but not for 6 hr exposed embryos and negatively influenced postnatal body composition and postnatal gait performance when compared to 12 hr continuous light embryos. Experiment 2 examined the influence of prenatal light duration (2 hr vs 6 hr) and light presentation (crepuscular vs sporadic). Results demonstrated sporadic light presentation improved gait performance in 2 hr exposed hatchlings, but not 6 hr exposed hatchlings, improved body composition in 6 hr exposed hatchlings, but not 2 hr exposed hatchlings, and did not alter incubation length when compared to crepuscular light counterparts. This study provides further evidence for the importance of maternally regulated sensory stimulation during the prenatal period on early postnatal motor development.

Coordinated movement is influenced by prenatal light experience in bobwhite quail chicks (Colinus virginianus)

Sensory-motor development begins early during embryogenesis and is influenced by sensory experience. Little is known about the prenatal factors that influence the development of motor coordination. Here we investigated whether and to what extent prenatal light experience can influence the development of motor coordination in bobwhite quail hatchlings. Quail embryos were incubated under four light conditions: no light (dark), 2h of total light (2HR), 6h of total light (6HR), and diffused sunlight (controls). Hatchlings were video recording walking down a runway at three developmental ages (12, 24, and 48h). Videos were assessed for forward locomotion, a measurement of motor coordination, falls, a measurement of motor instability, and motivation to complete the task. We anticipated a linear decline of coordination with a reduction in prenatal light experience and improved coordination with age. Furthermore, as motor coordination becomes more laborious we anticipated motivation to complete the task would decline. However, our findings revealed hatchlings did not uniformly improve with age as expected, nor did the reduction of light result in a linear reduction in motor coordination. Instead, we found a more complex relationship with 6HR and 2HR hatchlings showing distinct patterns of stability and instability. Similarly, we found a reduction in motivation within the 6HR light condition. It appears that prenatal light exposure influences the development of postnatal motor coordination and we discuss these finding in light of neurodevelopmental processes influenced by light experience.

Maternal behavior influences development of a reflexive action pattern in the newborn rat

This study examined the effect of maternal behavior on the expression and postnatal development of a reflexive behavior in rat pups. In neonatal rats, the leg extension response (LER) is a bilateral hyperextension of the hindlimbs in response to maternal anogenital licking (AGL). Past research has found that intranasal application of zinc sulfate (ZnSO₄ ) to the dam induces hyponosmia, thereby reducing the incidence of AGL. In this study, pregnant dams received intranasal application of air (control), distilled water (control), or ZnSO₄ on the day before birth and every other day thereafter until postnatal day 9 (P9). The LER was experimentally evoked in pups, using a vibrotactile device, at P1, P5, or P10. Pups born to ZnSO₄ -treated dams showed significantly shorter bilateral LER durations and significantly smaller ankle angles than pups born to control dams. Reduction of overall maternal AGL approached significance, and afternoon AGL was significantly reduced. These data suggest that maternal behavior influenced development of the LER in rat pups, demonstrating the influence of maternal care on behavioral development during the perinatal period.

Sensorimotor training during expression of the leg extension response (LER) in 1-day-old rats

In newborn rats, the leg extension response (LER) is a coordinated hyperextension of the hindlimbs that is shown in response to anogenital stimulation. Here we examined the influence of sensorimotor training on LER expression in postnatal day 1 rats. In Experiment 1, we examined if proprioceptive feedback facilitates LER expression. We did this by repeatedly stimulating the pup's anogenital region with a vibrotactile device, to experimentally evoke the LER, thus increasing LER-relevant hindlimb proprioceptive feedback during training. In trained subjects, the LER was evoked every 4 min for 15 trials, followed by a final LER test. Results indicated that proprioceptive feedback on its own did not alter later expression of the LER. In Experiment 2, we examined the effect of both proprioceptive and cutaneous feedback on LER expression, through the use of a range of motion (ROM) restriction during training. During ROM restriction, a Plexiglas plate was placed beneath the pup at 50% of limb length. After the 15th training trial, a final LER test occurred with no ROM restriction in place. Compared to controls, pups that experienced ROM restriction exhibited a significantly shorter LER duration, and smaller hip and ankle angles during the LER test (indicating greater limb flexion). Together these findings show that concurrent proprioceptive and cutaneous feedback, but not proprioceptive feedback alone, has persistent effects on expression of this newborn action pattern.