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Multiple randomised trials have shown efficacy and safety of endovascular thrombectomy in patients with large ischaemic stroke. The aim of this study was to evaluate long-term (ie, at 1 year) evidence of benefit of thrombectomy for these patients.

ObjectiveSacroiliac (SI) joint and spinal inflammation are characteristic of ankylosing spondylitis (AS), but some patients with AS have been identified who have discordant radiographic disease. We studied an AS subgroup with long-standing disease and fused SI joints. We identified factors associated with discrepant degrees of radiographic damage between the SI joints and spine.MethodsFrom the Prospective Study of Outcomes in AS (PSOAS) cohort, patients with a disease duration ≥ 20 years and fused SI joints were included in a nested case-control design. Patients with and without syndesmophytes were used as cases and controls for analysis. We used classification and regression tree (CART) analysis to determine risk factors for syndesmophytes presence and reexamined the validity of the risk factors using univariable logistic regression models.ResultsThere were 354 patients in the subgroup, 23 of whom lacked syndesmophytes. CART analysis showed females were less likely to have syndesmophytes. The next important predictor was age of symptom onset in males, with age of onset ≤ 16 years being less likely to have syndesmophytes. Univariable analysis confirmed females were less likely to have syndesmophytes (odds ratio [OR] 0.17, 95% CI 0.07-0.41). Syndesmophyte presence was associated with HLA-B27 positivity (P= 0.03) and age of symptom onset > 16 years old (OR 2.72, 95% CI 1.15-6.45). All 23 patients who lacked syndesmophytes were HLA-B27 positive.ConclusionUsing CART analysis and univariable modeling, women were less likely to have syndesmophytes despite advanced disease duration and SI joint disease. Patients with younger age of symptom onset were less likely to have syndesmophytes. All patients without syndesmophytes were HLA-B27 positive, indicating HLA-B27 positivity may be more associated with SI disease than spinal disease.

Gastrointestinal (GI) symptoms often affect children with autism spectrum disorders (ASD) and GI symptoms have been associated with an abnormal fecal microbiome. There is limited evidence of Candidaspecies being more prevalent in children with ASD. We enrolled 20 children with ASD and GI symptoms (ASD + GI), 10 children with ASD but no GI symptoms (ASD - GI), and 20 from typically developing (TD) children in this pilot study. Fecal mycobiome taxa were analyzed by Internal Transcribed Spacer sequencing. GI symptoms (GI Severity Index [GSI]), behavioral symptoms (Social Responsiveness Scale -2 [SRS-2]), inflammation and fungal immunity (fecal calprotectin and serum dectin-1 [ELISA]) were evaluated. We observed no changes in the abundance of total fungal species (alpha diversity) between groups. Samples with identifiable Candidaspp. were present in 4 of 19 (21%) ASD + GI, in 5 of 9 (56%) ASD - GI, and in 4 of 16 (25%) TD children (overall P= 0.18). The presence of Candidaspp. did not correlate with behavioral or GI symptoms (P= 0.38, P= 0.5, respectively). Fecal calprotectin was normal in all but one child. Finally, there was no significance in serum dectin-1 levels, suggesting no increased fungal immunity in children with ASD. Our data suggest that fungi are present at normal levels in the stool of children with ASD and are not associated with gut inflammation.

Cellular therapy is a promising investigational modality to enhance poststroke recovery. We conducted a single‐arm, phase I clinical trial to determine the safety and feasibility of intravenous (IV) administration of autologous bone marrow mononuclear cells (MNCs) after acute ischemic stroke (AIS). Patients with moderate severity of AIS underwent bone marrow harvest followed by IV reinfusion of MNCs within 24–72 hours of onset. A target dose of 10 million cells per kilogram was chosen based on preclinical data. Patients were followed up daily during hospitalization and at 1, 3, 6, 12, and 24 months for incidence of adverse events using laboratory, clinical (12 months), and radiological (24 months) parameters. The trial was powered to detect severe adverse events (SAEs) with incidences of at least 10% and planned to enroll 30 patients. Primary outcomes were study‐related SAEs and the proportion of patients successfully completing study intervention. A propensity score‐based matched control group was used for the estimation of effect size (ES) for day‐90 modified Rankin score (mRS). There were no study‐related SAEs and, based on a futility analysis, enrolment was stopped after 25 patients. All patients successfully completed study intervention and most received the target dose. Secondary analysis estimated the ES to be a reduction of 1 point (95% confidence interval: 0.33–1.67) in median day‐90 mRS for treated patients as compared with the matched control group. Bone marrow harvest and infusion of MNCs is safe and feasible in patients with AIS. The estimated ES is helpful in designing future randomized controlled trials. Stem Cells2019;37:1481–1491 Diffusion tensor tractography using serial multimodel magnetic resonance imaging contrast in a representation patient who received autologous bone marrow‐derived mononuclear cells after acute ischemic stroke.

Ankylosing spondylitis (AS) is characterized by inflammation of the spine and sacroiliac joints causing pain and stiffness and, in some patients, ultimately new bone formation, and progressive joint ankyloses. The classical definition of AS is based on the modified New York (mNY) criteria. Limited data have been reported regarding data quality assurance procedure for multicenter or multisite prospective cohort of patients with AS. Since 2002, 1272 qualified AS patients have been enrolled from five sites (4 US sites and 1 Australian site) in the Prospective Study Of Ankylosing Spondylitis (PSOAS). In 2012, a Data Management and Statistical Core (DMSC) was added to the PSOAS team to assist in study design, establish a systematic approach to data management and data quality, and develop and apply appropriate statistical analysis of data. With assistance from the PSOAS investigators, DMSC modified Case Report Forms and developed database in Research Electronic Data Capture (REDCap). DMSC also developed additional data quality assurance procedure to assure data quality. The error rate for various forms in PSOAS databases ranged from 0.07% for medications data to 1.1% for arthritis activity questionnaire-Global pain. Furthermore, based on data from a sub study of 48 patients with AS, we showed a strong level (90.0%) of agreement between the two readers of X-rays with respect to modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). This paper not only could serve as reference for future publications from PSOAS cohort but also could serve as a basic guide to ensuring data quality for multicenter clinical studies.

Objective.Opioid analgesics may be prescribed to ankylosing spondylitis (AS) patients with pain that is unresponsive to antirheumatic treatment. Our study assessed factors associated with opioid usage in AS.Methods.A prospective cohort of 706 patients with AS meeting modified New York criteria followed at least 2 years underwent comprehensive clinical evaluation of disease activity and functional impairment. These were assessed by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI). Radiographic severity was assessed by the Bath Ankylosing Spondylitis Radiology Index and modified Stokes Ankylosing Spondylitis Scoring System. Medications taken concurrently with opioids, as well as C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR), were determined at each study visit, performed every 6 months. Analyses were carried out at baseline, and longitudinal multivariable models were developed to identify factors independently associated with chronic and intermittent opioid usage over time.Results.Factors significantly associated with opioid usage, especially chronic opioid use, included longer disease duration, smoking, lack of exercise, higher disease activity (BASDAI) and functional impairment (BASFI), depression, radiographic severity, and cardiovascular disease. Patients taking opioids were more likely to be using anxiolytic, hypnotic, antidepressant, and muscle relaxant medications. Multivariable analysis underscored the association with smoking, older age, antitumor necrosis factor agent use, and psychoactive drugs, as well as with subjective but not objective determinants of disease activity.Conclusion.Opioid usage was more likely to be associated with subjective measures (depression, BASDAI, BASFI) than objective measures (CRP, ESR), suggesting that pain in AS may derive from sources other than spinal inflammation alone.

Traditional dose-finding designs do not require assignment of patients to a control group. Motivated by SHRINC (Safety of Pioglitazone for hematoma resolution in intracerebral hemorrhage), we developed a placebo-controlled dose-finding study to identify the maximum tolerated dose for pioglitazone in stroke patients with spontaneous intracerebral hemorrhage. We designed an extension of the continuous reassessment method that allowed to incorporate information from the control group (i.e., the standard of care), and utilized it to determine the maximum tolerated dose in the SHRINC trial. We evaluated the operating characteristics of our design by conducting extensive simulation studies. Our findings from the simulation studies demonstrate that our proposed design is robust and performs well. By estimating the toxicity rate in the control group, we were able to obtain more accurate information about the natural history of the disease and identify appropriate dose for the next phase of this study. The proposed design provides a tool to incorporate the information from the control group into the dose-finding framework for trials with similar objectives.

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Criteria for evaluating faculty are traditionally based on a triad of scholarship, teaching, and service. Research scholarship is often measured by first or senior authorship on peer-reviewed scientific publications and being principal investigator on extramural grants. Yet scientific innovation increasingly requires collective rather than individual creativity, which traditional measures of achievement were not designed to capture and, thus, devalue. The authors propose a simple, flexible framework for evaluating team scientists that includes both quantitative and qualitative assessments. An approach for documenting contributions of team scientists in team-based scholarship, nontraditional education, and specialized service activities is also outlined. Although biostatisticians are used for illustration, the approach is generalizable to team scientists in other disciplines.The authors offer three key recommendations to members of institutional promotion committees, department chairs, and others evaluating team scientists. First, contributions to team-based scholarship and specialized contributions to education and service need to be assessed and given appropriate and substantial weight. Second, evaluations must be founded on well-articulated criteria for assessing the stature and accomplishments of team scientists. Finally, mechanisms for collecting evaluative data must be developed and implemented at the institutional level. Without these three essentials, contributions of team scientists will continue to be undervalued in the academic environment.

The purpose of this study was to assess the incidence of deterioration, fluctuation, and associated risk of poor outcome in patients with subcortical stroke (SCS).

Factor Xa inhibitors are prescribed for stroke prevention in atrial fibrillation. Managing such patients is challenging especially if they are eligible for thrombolysis because there is no rapidly available test to detect the effect of such medications. Thrombelastography analyzes the dynamics of coagulation and can be rapidly performed. We sought to determine whether thrombelastography can detect the anticoagulation effect of factor Xa inhibitors in patients with stroke.

Intracerebral hemorrhage (ICH) has high morbidity, and hematoma enlargement (HE) causes worse outcome. Thrombelastography (TEG) measures the dynamics of clot formation and dissolution, and might be useful for assessing bleeding risk. We used TEG to detect changes in clotting in patients with and without HE after ICH.

Iodinated contrast agents used for computed tomography angiography (CTA) may alter fibrin fiber characteristics and decrease fibrinolysis by tissue plasminogen activator (tPA). Thromboelastography (TEG) measures the dynamics of coagulation and correlates with thrombolysis in acute ischemic stroke patients. We hypothesized that receiving CTA before tPA will not impair thrombolysis as measured by TEG.

The Combined Lysis of Thrombus in Brain Ischemia With Transcranial Ultrasound and Systemic T-PA-Hands-Free (CLOTBUST-HF) study is a first-in-human, National Institutes of Health–sponsored, multicenter, open-label, pilot safety trial of tissue-type plasminogen activator (tPA) plus a novel operator-independent ultrasound device in patients with ischemic stroke caused by proximal intracranial occlusion.

The impact of do-not-resuscitate (DNR) orders has not been systematically evaluated in acute trauma research. We determined the frequency, timing, and impact on mortality-based effect estimates for patients with DNR orders in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study.

Several predictive models have been developed to identify trauma patients who have had severe hemorrhage (SH) and may need a massive transfusion (MT) protocol. However, almost all these models define SH as the transfusion of 10 or more units of red blood cells (RBCs) within 24 hours of emergency department admission (also known as MT). This definition excludes some patients with SH, especially those who die before a 10th unit of RBCs could be transfused, which calls the validity of these prediction models into question. We show how a latent class model could improve the accuracy of identifying the SH patients.

The Focused Assessment with Sonography for Trauma (FAST) examination is an important variable in many retrospective trauma studies. The purpose of this study was to devise an imputation method to overcome missing data for the FAST examination. Owing to variability in patients’ injuries and trauma care, these data are unlikely to be missing completely at random, raising concern for validity when analyses exclude patients with missing values.

Acute lung injury following trauma resuscitation remains a concern despite recent advances. With the use of the PROMMTT study population, the risk of hypoxemia and potential modifiable risk factors are studied.

Missing data are inherent in clinical research and may be especially problematic for trauma studies. This study describes a sensitivity analysis to evaluate the impact of missing data on clinical risk prediction algorithms. Three blood transfusion prediction models were evaluated using an observational trauma data set with valid missing data.

Focused assessment with sonography for trauma (FAST) is commonly used to facilitate the timely diagnosis of life-threatening hemorrhage in injured patients. Most patients with positive findings on FAST require laparotomy. Although it is assumed that an increasing time to operation (T-OR) leads to higher mortality, this relationship has not been quantified. This study sought to determine the impact of T-OR on survival in patients with a positive FAST who required emergent laparotomy.

Acute traumatic coagulopathy (ATC) occurs after severe injury and shock and is associated with increased bleeding, morbidity, and mortality. The effects of ATC and hemostatic resuscitation on outcome are not well-explored. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study provided a unique opportunity to characterize coagulation and the effects of resuscitation on ATC after severe trauma.

Prediction of outcome after injury is fraught with uncertainty and statistically beset by misspecified models. Single–time point regression only gives prediction and inference at one time, of dubious value for continuous prediction of ongoing bleeding. New statistical machine learning techniques such as SuperLearner (SL) exist to make superior prediction at iterative time points while evaluating the changing relative importance of each measured variable on an outcome. This then can provide continuously changing prediction of outcome and evaluation of which clinical variables likely drive a particular outcome.

The trauma transfusion literature has yet to resolve which is more important for hemorrhaging patients, transfusing plasma and platelets along with red blood cells (RBCs) early in resuscitation or gradually balancing blood product ratios. In a previous report of PROMMTT results, we found (1) plasma and platelet:RBC ratios increased gradually during the 6 hours following admission, and (2) patients achieving ratios more than 1:2 (relative to ratios <1:2) had significantly decreased 6-hour to 24-hour mortality adjusting for baseline and time-varying covariates. To differentiate the association of in-hospital mortality with early plasma or platelet transfusion from that with delayed but gradually balanced ratios, we developed a separate analytic approach.

There are few clinical data to guide the use of cryoprecipitate in severely injured trauma patients. Cryoprecipitate is a rich source of fibrinogen and has been associated with improved survival in animal as well as limited human studies. Our objectives were to identify patterns and predictors of cryoprecipitate use and determine whether transfusing cryoprecipitate was associated with improved survival.

Delivery of intravenous crystalloid fluids (IVF) remains a tradition-based priority during prehospital resuscitation of trauma patients. Hypotensive and targeted resuscitation algorithms have been shown to improve patient outcomes. We hypothesized that receiving any prehospital IVF is associated with increased survival in trauma patients compared with receiving no prehospital IVF.

The classic definition of massive transfusion, 10 or more units of red blood cells (RBCs) in 24 hours, has never been demonstrated as a valid surrogate for severe hemorrhage and can introduce survival bias. In addition, the definition fails to capture other products that the clinician may have immediately available, and may use, during the initial resuscitation. Assuming that units of resuscitative fluids reflect patient illness, our objective was to identify a rate of resuscitation intensity (RI) that could serve as an early surrogate of sickness for patients with substantial bleeding after injury.

In the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, waiver of consent was used because previous literature reported low response rates and subsequent bias. The goal of this article was to examine the rationale and tradeoffs of using waiver of consent in PROMMTT.

Because randomized clinical trials in trauma outcomes research are expensive and complex, they have rarely been the basis for the clinical care of trauma patients. Most published findings are derived from retrospective and occasionally prospective observational studies that may be particularly susceptible to bias. The sources of bias include some common to other clinical domains, such as heterogeneous patient populations with competing and interdependent short- and long-term outcomes. Other sources of bias are unique to trauma, such as rapidly changing multisystem responses to injury that necessitate highly dynamic treatment regimens such as blood product transfusion. The standard research design and analysis strategies applied in published observational studies are often inadequate to address these biases.

We aimed to evaluate safety and tolerability of a novel operator-independent ultrasound device among stroke-free volunteers.

AbstractObjectivesWe examined the intention to comply with mandatory hurricane evacuation orders among respondents living in coastal areas with pronounced poverty by demographic and location characteristics.MethodsA 3-county door-to-door survey was conducted with 1 randomly selected resident per household. Households were selected using a 2-stage cluster sampling strategy and stratified by county. The final sample included 3088 households in 100 census tracts across 3 counties.ResultsFindings suggest that the majority of residents living in areas prone to hurricanes intend to comply with mandatory evacuation orders regardless of income level. Variation in intention to comply with mandatory evacuation orders is shown by age, gender, ethnicity, education, acculturation, county, and distance from shoreline.ConclusionsThe demonstrated high intention to comply with evacuation orders in impoverished areas suggests a need for improved planning to evacuate the most vulnerable residents. Demographic and location characteristics associated with decreased intention to comply may be considered for targeting messages and education before disasters to modifying intentions and plans to evacuate. (Disaster Med Public Health Preparedness. 2013;7:46-54)

OBJECTIVE To relate in-hospital mortality to early transfusion of plasma and/or platelets and to time-varying plasma:red blood cell (RBC) and platelet:RBC ratios. DESIGN Prospective cohort study documenting the timing of transfusions during active resuscitation and patient outcomes. Data were analyzed using time-dependent proportional hazards models. SETTING Ten US level I trauma centers. PATIENTS Adult trauma patients surviving for 30 minutes after admission who received a transfusion of at least 1 unit of RBCs within 6 hours of admission (n = 1245, the original study group) and at least 3 total units (of RBCs, plasma, or platelets) within 24 hours (n = 905, the analysis group). MAIN OUTCOME MEASURE In-hospital mortality. RESULTS Plasma:RBC and platelet:RBC ratios were not constant during the first 24 hours (P &lt; .001 for both). In a multivariable time-dependent Cox model, increased ratios of plasma:RBCs (adjusted hazard ratio = 0.31; 95% CI, 0.16-0.58) and platelets:RBCs (adjusted hazard ratio = 0.55; 95% CI, 0.31-0.98) were independently associated with decreased 6-hour mortality, when hemorrhagic death predominated. In the first 6 hours, patients with ratios less than 1:2 were 3 to 4 times more likely to die than patients with ratios of 1:1 or higher. After 24 hours, plasma and platelet ratios were unassociated with mortality, when competing risks from nonhemorrhagic causes prevailed. CONCLUSIONS Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients who received transfusions of at least 3 units of blood products during the first 24 hours after admission. Among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or platelet ratios.

Early predictors of massive transfusion (MT) would prevent undertriage of patients likely to require MT. This study validates triggers using the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study.

Abstract In pulmonary hypertension, as in many other diseases, there is a need for a smarter approach to evaluating new treatments. The traditional randomized controlled trial has served medical science well, but constrains the development of treatments for rare diseases. A workshop was established to consider alternative clinical trial designs in pulmonary hypertension and here discusses their merits, limitations and challenges to implementation of novel approaches.

In pulmonary hypertension, as in many other diseases, there is a need for a smarter approach to evaluating new treatments. The traditional randomized controlled trial has served medical science well, but constrains the development of treatments for rare diseases. A workshop was established to consider alternative clinical trial designs in pulmonary hypertension and here discusses their merits, limitations and challenges to implementation of novel approaches.

Argatroban is a direct thrombin inhibitor that safely augments recanalization achieved by tissue-type plasminogen activator (tPA) in animal stroke models. The Argatroban tPA Stroke Study was an open-label, pilot safety study of tPA plus Argatroban in patients with ischemic stroke due to proximal intracranial occlusion.

OBJECTIVE: To investigate the diagnostic accuracy of antimitochondrial antibodies (AMA), sp100, and gp210 antibodies for primary biliary cirrhosis (PBC) in a large population of patients with systemic sclerosis (SSc); to examine concordance of these antibodies with subsets of SSc. Further, to assess the association of SSc-related antibodies with hepatic parameter abnormalities. METHODS: We obtained medical records to verify the diagnoses of SSc and PBC. Sera from all participants were examined for the presence of SSc- and PBC-related antibodies, as well as for abnormalities in hepatic parameters. RESULTS: We examined 817 patients with SSc, of whom 16 (2%) had confirmed PBC. The sensitivity and specificity of AMA by a MIT3 ELISA for PBC were 81.3% and 94.6%, respectively. Sp100 had a sensitivity and specificity of 31.3% and 97.4%, respectively, while gp210 had an even lower sensitivity. We were able to detect all PBC cases using AMA(MIT3) and sp100 as a combined marker, resulting in a significantly improved sensitivity of 100% (p = 0.042) with an incremental decrease in specificity to 92.6%. Independent of AMA or sp100 status, there was an association of anticentromere B (CENP-B) and anti-topoisomerase antibodies (ATA) with higher alkaline phosphatase levels (p = 0.051 and p = 0.003, respectively) while anti-RNA polymerase III (anti-RNAP) was associated with lower alkaline phosphatase levels (p = 0.019) among the patients with SSc. CONCLUSION: Utilization of AMA(MIT3) and sp100 antibodies as a combined diagnostic marker leads to an improved detection of PBC in patients with SSc. CENP-B and ATA are associated with alkaline phosphatase elevation.

Cardiovascular risks are globally elevated in South Asians, but this masks important ethnic subgroup differences in risk factors, such as hypertension, which have not been fully explored. We conducted this study to explore the variations in hypertension within ethnic subgroups among South Asians.

Background:Good collateral flow has been shown to have better outcomes after acute ischemic stroke (AIS), including for patients receiving IV thrombolysis (IVT) and mechanical thrombectomy (MT).Hypothesis:In patients with AIS who undergo MT, good collateral flow is associated with better functional independence measure (FIM) change.Design/Methods:Data was collected retrospectively for patients who presented with AIS and were treated with MT. A total of 54 patients from 4 inpatient rehabilitation facility (IRF) locations between April 2017 and August 2019 were included. Collateral score was collected from angiograms and CT angiogram (CTA) in cases where an angiogram was not available. FIM change was defined as the difference in FIM at admission to IRF and discharge from IRF. Regression analyses were conducted to estimate the relationship between collateral score and FIM change. The predictors in the model included collateral score, FIM at admission to IRF, age at onset, and gender. Logistic regression was used for categorical variables and linear regression was applied for continuous variables. Statistical significance level was set at 0.05. Collaterals were scored from 0 to 4, with 0 to 2 being poor and good collateral flow defined as scores 3 and 4. The primary outcome of this study was FIM change.Results:The mean age was 70.4 years, and 54.5% was female. Regression analyses did not show any significant differences in FIM change in patients with collaterals ranging from poor to good p = 0.807 (Table 1), when adjusted for age, gender, and severity as represented by FIM at admission to IRF.Conclusion:In this patient cohort, good collateral flow was not associated with improvement in FIM change.

Introduction:We sought to predict the course and rate of functional improvement and length of stay (LOS) in patients with ischemic and hemorrhagic strokes admitted to inpatient rehabilitation facilities(IRF).Aim:To study the course and associating factors affecting functional outcomes among a large cohort of stroke patients admitted to IRFs.Methods:The cohort consists of stroke patients admitted to 5 IRFs in Houston, between 4/17-8/19. Higher order polynomial (quartic, cubic, quadratic) regressions were fitted to predict the temporal relationship between FIM score improvement and LOS, and based on goodness of fit statistics, cubic polynomial fit was selected. Effects of interactions were tested and later dropped from the final model because of non-statistical significance. Models were adjusted for age, gender, stroke type (hemorrhagic vs ischemic), and stroke severity based on NIHSS.Results:The demographics of patients are presented in table 1. Among 679 patients, the univariate analyses reflected that age (F=24.2, p<0.001), admission NIHSS score (F=67, p<0.001), stroke type (F=25.2, p<0.001), and admission FIM (F=283, P<0.001) were significant factors predicting IRF LOS. History of previous stroke, diabetes, hypertension, and hyperlipidemia did not have any significant effects on LOS. In multiple regression model, age at onset (β=-0.18, p<0.001), hemorrhagic vs ischemic stroke (β=3.02, p<0.01) were significant predictors of total FIM change score when adjusting for stroke severity and gender. Total FIM change score was positively correlated with LOS at IRF with a steep improvement in the first 15 days of IRF stay which plateaued afterwards in patients with 1-30 days of IRF stay (Fig. 2).Conclusion:Patient’s age, ischemic vs hemorrhagic stroke were the most significant predictors when deriving the relationship between total FIM score and LOS while adjusting for stroke severity and patient’s gender, which plateaued after 2 weeks of IRF stay.

Introduction:We asked whether intracerebral hemorrhage (ICH) patients admitted to inpatient rehabilitation facilities(IRF) improve differently based on their involvement of the corticospinal tract(CST).Aim:To predict associating radiological factors affecting discharge FIM score.Methods:We reviewed the patients’ characteristics and their respective imaging findings presenting with ICH between 4/17 to 8/19. The ICH volume and edema around the ICH were measured using analyze software. The main outcome measure was FIM score at time of discharge. Statistical significance was set at 0.05.Results:Among the 53 patients included, 49% were female. The median age of the patients was 62 years (IQR 25,89). The median length of stay at IRF was 22days (IQR 14,26). In univariate analysis, FIM score at the time of discharge FIM score at the time of discharge admission were significantly associated with NIHSS (estimate -1.26, p<0.001), and ICH volume (estimate -3.45, p=0.01). However, the univariate analysis did not reveal an association of age (estimate -0.15, p=0.4) and gender (estimate 0.207, p=0.97) with FIM score at the time of discharge.Multiple regression analysis reflected that the CST involvement had a decrement in functional improvement on FIM in comparison with patients with intact CST when adjusting for age (p= 0.008), gender (p<0.01), NIHSS at the time of admission (p<0.01), and the ICH volume (p=0.02).Conclusion:This preliminary study suggests that functional improvement declines in ICH patients with CST involvement.

Introduction:Inpatient rehabilitation (IPR) is crucial to recovery after stroke. COVID-19, however, has led to delays in post-stroke admission to IPR due to transmission concerns.Objective:We evaluated the effect of time from stroke onset to IPR admission on post-stroke recoveryDesign:A retrospective analysis of 680 patients with acute stroke or intracerebral hemorrhage (ICH), admitted to IPR between APR-2017 and AUG-2019. Association between time from stroke onset to IPR and discharge FIM-Motor Total and FIM-Motor Total with transfers scores was studied, after adjusting for sex, age at onset, stroke severity and type. Multiple linear regression models were conducted for outcomes discharge: (FIM-Motor Total)2and (FIM-Motor Total with transfers)2(Table 1). Square transformations were used to satisfy model assumptions. Ordinal logistic regression models were run for outcomes discharge FIM subset scores categorized as independent (6-7), needs supervision (5), and needs assistance (1-4, reference). The primary variable of interest was days onset to IPR, adjusted for stroke severity (admit FIM subset scores), sex, stroke type and age. (Table 2).The proportional odds assumption was verified using Brant test.Results:An inverse relationship was observed between days from onset to IPR and discharge FIM-Motor with and without transfers. Time from stroke onset to IPR admission was associated with decreased discharge FIM-Motor and FIM-Motor with transfers, after adjusting for other covariates. Among FIM subset discharges, an additional day also resulted in a 2-5% decrease in the odds of being more independent.Conclusion:Delays to IPR admission result in decreased motor function gains and lower chance of independence. In addition to current community education practices, acute care hospitals and IPR facilities must review their processes to remove delays. These processes include requirements for COVID disease testing and IPR acceptance policies.

Introduction:We assessed the impact of COVID-19 pandemic on stroke admissions and care metrics within a health system of 10 stroke centers, with 4 comprehensive stroke centers (CSC) in the greater Houston region.Methods:Between January-June 2019 and January-June 2020, we compared the proportion of ischemic strokes (total & direct CSC presentations) & intracerebral hemorrhage (ICH) relative to total admissions using logistic regression, and among the direct CSC presentations, we compared door to tPA and thrombectomy times using Wilcoxon Rank Sum.Results:A total of 4808 cases were assessed (Table 1). There was an initial drop of ~30% in cases at the pandemic onset (Fig.1). Numerically fewer patients in the 2020 period were seen at primary and CSCs (Table 1). Compared to 2019, there was a significant reduction in transferred patients [N(%), 829 (36) vs. 637 (34), p=0.02], in hospital strokes [N(%), 111 (5) vs. 69 (4), p=0.04], and mild strokes (NIHSS 1-5) [N (%), 891 (43) vs. 635 (40),p=0.02], and no significant differences in the proportions of total ischemic strokes [OR (95% CI)=0.92 (0.79, 1.06), p=0.23], direct CSC presentations [OR (95% CI) =0.96 (0.86, 1.08), p=0.48] and ICH [OR (95% CI) =1.14 (0.98, 1.33), p=0.08] in 2020 (Fig. 1). Among the direct ischemic strokes at CSCs, there were similar mean (SD) (mins) door to tPA [44 (17) vs. 42 (17), p=0.14] but significantly prolonged door to thrombectomy times [94 (15) vs. 85 (20), p=0.005] in 2020.Conclusion:COVID-19 pandemic led to reduced mild stroke admissions, transfers and in hospital stroke alerts, & prolonged door to thrombectomy times. Identifying reasons to mitigate this discrepancy is crucial for next pandemic preparedness.

Introduction:Little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care.Methods:We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. Single imputation using fully conditional specification was conducted to impute missing values in NIHSS (N=103). We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke.Results:Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients) (Table 1), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration or incidence of MT utilization (Table 1 & 2).Conclusion:There was a lack of racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care beyond our single-network review, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.

No relevant conflicts of interest to declare.

Introduction:The pathology of sickle cell disease (SCD) includes ischemia / reperfusion events in the vasculature, compromised blood antioxidant defenses and elevated risk of cardiovascular complications. Vitamin C (ascorbate) is a major blood antioxidant; ascorbate inside red blood cells (RBC) furnishes an electron (e-) to recycle plasma ascorbate to its active, reduced state (Fig. 1). A key step, transmembrane e- transfer, involves cytochrome b reductase 1 (CYBRD1). Thus, a deficiency or defect in red cell CYBRD1 could plausibly increase oxidative stress and interconnected inflammatory processes, contributing to cardiovascular complications in SCD patients. Testing for CYBRD1 deficiency requires a quantitative assay for the protein in RBC, so we developed a suitable assay and used it to screen a small number of SCD patients and healthy individuals.