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OBJECTIVES To compare risk of reoperation for femoral neck fracture patients undergoing fixation with cancellous screws (CS) or sliding hip screws (SHS) based on surgeon fellowship (trauma-fellowship-trained versus non-trauma-fellowship-trained). DESIGN Retrospective review of FAITH data. SETTING Eighty-one centers across eight countries. PATIENTS/PARTICIPANTS 819 patients ≥ 50 years-old with low energy hip fractures requiring surgical fixation. INTERVENTION Patients were randomized to CS or SHS in the initial dataset. MAIN OUTCOME MEASUREMENTS The primary outcome was risk of reoperation. Secondary outcomes included death, serious adverse events, radiographic healing, discharge disposition, and use of ambulatory devices postoperatively. RESULTS There was no difference in risk of reoperation between the two surgeon groups (p > 0.05). Patients treated by orthopaedic trauma surgeons were more likely to be overweight/obese and have major medical comorbidities (p < 0.05). There was a higher risk of serious adverse events, higher likelihood of radiographic healing, and higher odds of discharge to a facility for patients treated by trauma-fellowship-trained surgeons (p < 0.05). CONCLUSIONS Based on this data, risk of reoperation for low energy femoral neck fracture fixation is equivalent regardless of fellowship training. The higher likelihood of radiographic healing noted in the trauma-trained group does not appear to have a major clinical implication as it did not affect risk of reoperation between the two groups. Patient-specific factors present pre-injury, such as body habitus and medical comorbidities, may account for the lower odds of discharge to home and higher risk of postoperative medical complications for patients treated by orthopaedic trauma surgeons. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Historically, the traditional pathways into plastic surgery required board eligibility in a surgical specialty such as general surgery, orthopedics, urology, neurosurgery, otolaryngology, or ophthalmology. This requirement resulted in plastic surgery residents who had served as chief residents before plastic surgery training. Their maturity emotionally and surgically allowed them to immediately concentrate on the new language and principles of plastic surgery. They had led others and were capable of leading themselves in a new surgical discipline. Today, medical students typically match into surgical specialties directly out of medical school and need to spend their time learning basic surgical skills and patient care because of the contracted time afforded to them. Formal leadership training has historically been limited in surgical training. The authors set out to delineate the creation, implementation, and perceptions of a leadership program within a surgical residency and provide guideposts for the development of engaged, conscious, and dedicated leaders within the residencies they lead.

Introduction: There has been a shift in prehospital systems of care to prioritize transporting acute ischemic stroke (AIS) patients with suspected emergent large vessel occlusion (ELVO) stroke to thrombectomy capable stroke centers (TSCs), as opposed to primary stroke centers (PSCs) which may be closer and offer intravenous thrombolysis faster. Large scale data on clinical outcomes in direct triage are lacking. Methods: We conducted a systematic review and meta-analysis using PRISMA guidelines with the Nested Knowledge AutoLit platform to search PubMed for relevant terms from 01/2015 to 05/2022. Our primary endpoint was proportion of patients with a good clinical outcome [modified Rankin Score (mRS) 0-2] at 90 days. Results: We identified 390 studies, 16 of which compared direct triage to various models and were included. Amongst these, Mobile Stroke Unit (MSU; n=1), Mothership only (n=1), Drip-and-Ship only (n=3), and Mothership + Drip-and-Ship (n=11) were compared to Direct Triage. Among the eleven that reported 90-day functional status outcomes, there were no discernible trends. Four studies that compared 90-day functional outcomes amongst patients who received EVT and compared Direct Triage to Drip-and-Ship + Mothership models were analyzed. Baseline age, sex, and presenting NIHSS were similar. Patients who underwent Direct Triage were more likely to have a good outcome (mRS 0-2) at 90-days (OR 1.35, 95% CI 1.03-1.76). Conclusions: Amongst patients who received EVT, patients who underwent Direct Triage were more likely to have better functional outcomes at 90 days. Direct Triage of AIS patients is a promising strategy to improve clinical outcomes in patients who undergo EVT. More research is needed in patients who do not receive EVT.

Background and Purpose: Despite the Joint Commission’s certification requirement of ≥15 stroke thrombectomy (ST) cases per center and proceduralist annually, the relationship between ST case volumes and outcomes is uncertain. We sought to determine whether a proceduralist or hospital volume threshold exists that is associated with better outcomes among Medicare beneficiaries. Methods: Retrospective cohort study using validated International Classification of Diseases, Tenth Revision , Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ST. We used de-identified, national 100% inpatient Medicare data sets from January 1, 2016, to December 31, 2017 for US individuals aged ≥65 years. We calculated total procedures by proceduralist and hospital. We performed adjusted logistic regression of total cases as a predictor of inpatient mortality, good outcome (defined by dichotomized discharge disposition of inpatient rehabilitation or better), and 30-day readmission. We adjusted for sex, age, Charlson Comorbidity Index, availability of neurocritical care, teaching hospital status, socioeconomic status, 2-year stroke volume, and urban versus rural hospital location. We dichotomized case numbers incrementally to determine a volume threshold for better outcomes. Results: Thirteen thousand three hundred thirty-five patients were treated with ST by 2754 proceduralists at 641 hospitals. For every 10 more proceduralist cases, patients had 4% lower adjusted odds of inpatient mortality (adjusted odds ratio, 0.96 [95% CI, 0.95–0.98], P P P =0.0003) and 2% greater odds of good outcome (adjusted odds ratio, 1.02 [95% CI, 1.01–1.02], P Conclusions: Nationally, higher proceduralist and hospital ST case volumes were associated with reduced inpatient mortality and better outcome. These data support volume requirements in guidelines for ST training and certification.

ObjectiveWe sought to comprehensively evaluate predictors of poststroke depression (PSD) in the United States and to compare PSD to post–myocardial infarction (MI) depression to determine whether ischemic stroke uniquely elevates risk of depression.MethodsThis is a retrospective cohort study of 100% deidentified inpatient, outpatient, and subacute nursing Medicare data from 2016 to 2017 for US patients ≥65 years of age from July 1, 2016, to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression up to 1.5 years after the index admission. We performed Cox regression to report the hazard ratio for diagnosis of depression up to 1.5 years after stroke vs MI and independent predictors of PSD, and we controlled for patient demographics, comorbid conditions, length of stay, and acute stroke interventions.ResultsIn fully adjusted models, patients with stroke (n = 174,901) were ≈50% more likely than patients with MI (n = 193,418) to develop depression during the 1.5-year follow-up period (Kaplan-Meier cumulative risk 0.1596 ± 0.001 in patients with stroke vs 0.0973 ± 0.000778 in patients with MI, log-rank p < 0.0001). History of anxiety was the strongest predictor of PSD, while discharge home was most protective. Female patients, White patients, and patients ConclusionsDespite the similarities between MI and stroke, patients with stroke were significantly more likely to develop depression. There were several predictors of PSD, most significantly history of anxiety. Our findings lend credibility to a stroke-specific process causing depression and highlight the need for consistent depression screening in all patients with stroke.

Objectives This study compares outcomes for patients with displaced femoral neck fractures undergoing hemiarthroplasty (HA) or total hip arthroplasty (THA) by surgeons of different fellowship training. Design Retrospective review of HEALTH trial data. Setting Eighty clinical sites across 10 countries. Patients/participants One thousand four hundred forty-one patients ≥50 years with low-energy hip fractures requiring surgical intervention. Intervention Patients were randomized to either HA or THA groups in the initial data set. Surgeons' fellowship training was ascertained retrospectively, and outcomes were compared. Main outcome measurements The main outcome was an unplanned secondary procedure at 24 months. Secondary outcomes included death, serious adverse events, prosthetic joint infection (PJI), dislocation, discharge disposition, and use of ambulatory devices postoperatively. Results There was a significantly higher risk of PJI in patients treated by surgeons without fellowship training in arthroplasty (P = 0.01), surgeons with unknown fellowship training (P = 0.03), and surgeons with no fellowship training (P = 0.02) than those treated by an arthroplasty-trained surgeon. There were significantly higher odds of being discharged to a facility rather than home in patients who underwent surgery by a surgeon with no fellowship training compared with arthroplasty-fellowship-trained surgeons (P = 0.03). Conclusions Arthroplasty for hip fracture can be performed by all orthopaedic surgeons with equivalent reoperation rates. Infection prevention strategies and use of "care pathways" by arthroplasty-fellowship-trained surgeons may account for the lower risk of PJI and higher rate of discharge to home. The authors advocate for the use of evidence-based infection prevention initiatives and standardized care pathways in this patient population. Level of evidence Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Grazoprevir/elbasvir and glecaprevir/pibrentasvir (G/P) are the two preferred treatment options for patients with chronic hepatitis C virus (HCV) infection and a glomerular filtration rate (GFR)30 mL/min. Both therapies have been separately analyzed in different real-life cohorts; however, a direct comparison has not been performed so far. We, therefore, analyzed safety and effectiveness of both regimens in a concerted real-life population.The Germany Hepatitis C-Registry is a prospective national real-world registry. The analysis is based on 2773 patients with documented GFR at baseline treated with grazoprevir/elbasvir (N = 1041), grazoprevir/elbasvir + ribavirin (N = 53) and glecaprevir/pibrentasvir (N = 1679).A total of 93 patients with GFR30 mL/min were treated with grazoprevir/elbasvir (N = 56), grazoprevir/elbasvir + ribavirin (N = 4), and glecaprevir/pibrentasvir (N = 33). They suffered significantly more frequent from diabetes mellitus, hypertension, and coronary heart disease than individuals with GFR30 mL/min and showed the following baseline characteristics: 20.4, 55.9, 3.2, 12.9, and 5.3% were infected with HCV-genotypes 1a, 1b, 2, 3, and 4; 12.9% suffered from liver cirrhosis; 80.1% were treatment-naïve. Baseline characteristics except distribution of HCV-genotype 1b (n = 43/52 treated with grazoprevir/elbasvir) and sustained virologic response rates (SVR12) did not differ significantly between glecaprevir/pibrentasvir (SVR12: 100%) and grazoprevir/elbasvir (SVR12: 97.9%).Fatigue, headache, abdominal discomfort, and arthralgia were the most frequently reported adverse events without a statistical difference between grazoprevir/elbasvir and glecaprevir/pibrentasvir.In patients with chronic hepatitis C and a baseline GFR ≤30 mL/min grazoprevir/elbasvir and glecaprevir/pibrentasvir show an equally favorable safety profile and antiviral efficacy and can both be recommended for real-life use.

Background and Purpose— Multiple randomized clinical trials have demonstrated the superiority of endovascular therapy (ET) for large vessel occlusion acute ischemic stroke (AIS). Few centers can provide ET, and significant debate exists about the most efficient and effective ways to provide ET. We sought to assess real-world utilization of ET, the extent to which patients are transferred from one hospital to another for therapy and the implications of transfer status on outcomes. Methods— We used the 2015 to 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database, which contains nationwide data on nearly half of US admissions. We identified index AIS admissions, vascular risk factors, and treatment with intravenous thrombolysis and ET using International Classification of Disease, Ninth Revision , and International Classification of Disease, Tenth Revision Clinical Modification codes. Main predictors of outcome were treatment with ET and whether there was an interhospital transfer during the index AIS hospitalization. Among patients with AIS readmitted within 30 days, we examined 3 main outcomes: total charges, length of stay, and in-hospital mortality. Results— A total of 23 121 AIS admissions were treated with ET and 874 229 without. Over 5% of patients who received ET were transferred during the index admission compared with Conclusions— The minority of all patients with AIS receive ET. The majority of patients who receive ET present directly to the center that performs the procedure, and those transferred for ET have higher length of stay, cost, and mortality that those not transferred.

Introduction: Post-stroke depression (PSD) occurs commonly following stroke and is associated with worse outcomes and higher mortality. Previous research has not identified consistent predictors of PSD, and debate remains about whether PSD differs from other types of depression, including depression following other ischemic vascular events. Objective: We sought to comprehensively evaluate predictors of PSD in the US population and compare the hazard of developing PSD to post-myocardial infarction (MI) depression. Methods: Retrospective cohort study of 100% de-identified inpatient, outpatient, and subacute nursing Medicare data from 2016-2017 for US patients aged ≥65 years from July 1, 2016 to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression up to 1.5 years following index admission. We performed Cox regression to report the hazard ratio for diagnosis of depression up to 1.5 years post-stroke vs. MI, as well as independent predictors of PSD, and controlled for patient demographics, comorbidities, length of stay and acute stroke interventions. Results: In fully adjusted models, stroke patients (n=174,901) were approximately 50% more likely than MI patients (n=193,418) to develop depression during the 1.5-year follow-up period (Kaplan-Meier cumulative risk 0.1596 ± 0.001 in stroke patients versus 0.0973 ± 0.000778 in MI patients, log-rank p Conclusions: Despite the similarities between MI and stroke, patients who suffer from stroke were significantly more likely to develop depression. There were several predictors of post-stroke depression, most significantly history of anxiety. Our findings lend credibility to a stroke-specific process causing depression and highlight the need for consistent depression screening in all stroke patients.

Introduction: Post-stroke depression (PSD) occurs in approximately one-third of ischemic stroke patients. However, there is conflicting evidence on sex differences in PSD. Objective: We sought to assess sex differences in risk and time course of PSD in US ischemic stroke (IS) patients. We hypothesized that women are at greater risk of PSD than men, and that a greater proportion of women experience PSD in the acute post-stroke phase. Methods: Retrospective cohort study of 100% de-identified data for US Medicare beneficiaries ≥65 years admitted for ischemic stroke from July 1, 2016 to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression, stratified by sex, up to 1.5 years following index admission. We performed Cox regression to report the hazard ratio (HR) for diagnosis of depression up to 1.5 years post-stroke in males vs. females, adjusting for patient demographics, comorbidities, length of stay, and acute stroke interventions. Results: Female stroke patients (n=90,474) were 20% more likely to develop PSD than males (n=84,427) in adjusted models. Cumulative risk of depression was consistently elevated for females throughout 1.5 years of follow-up (0.2055 [95% CI 0.2013-0.2097] vs. 0.1690 [95% CI 0.1639-0.1741] (log-rank p Conclusions: Over 1.5 years of follow-up, female stroke patients had significantly greater hazard of developing PSD, highlighting the need for long-term depression screening in this population and further investigation of underlying reasons for sex differences.

Introduction: On April 1 2019, New York City EMS began a triage protocol using a modified Los Angeles Motor Scale (S-LAMS for addition of speech) to identify potential endovascular thrombectomy (EVT) eligible patients in the field (S-LAMS 4-6 with last known well (LKW) Methods: Patients brought by EMS to a large multicenter health system across NYC for the year following April 1, 2019 were extracted from a prospectively collected stroke database. S-LAMS triage positive (STP) patients were assessed for diagnostic accuracy and treatment times. They were compared with a cohort that underwent EVT during the same period, but triaged as S-LAMS triage negative (STN). Results: STP patients (N=145) were 56.6% women, mean age of 70, median baseline mRS of 0, S-LAMS score of 5, and arrival NIHSS of 13. Stroke was diagnosed in 110 (75.8%) patients, 32 intracerebral hemorrhage and 78 ischemic. Of the ischemic, 45 were large vessel occlusion stroke (ELVO) and 34 underwent EVT (PPV of 0.31 for ELVO). STN patients (N=65) with LKW of < 5 hours were brought by EMS and underwent EVT; 34 were brought directly to EVT capable centers, and 36 required transfer for EVT. Mean time to hospital arrival from EMS scene arrival was significantly longer for STP patients than STN patients (38 vs. 29 minutes, p Conclusions: Pre-hospital stroke triage using the streamlined S-LAMS scale is comparable with other pre-hospital scales in predictive value for ELVO. While pre-hospital evaluation and transport times are longer, they add minimal delay to the hospital arrival, do not affect tPA times, and improve times to EVT in a large, urban environment. Further analysis on effect of the triage protocol on patient outcomes is warranted.

Introduction: Endovascular therapy (EVT) for large vessel occlusion (LVO) stroke is time-sensitive. At Mount Sinai Health System, we developed a novel Mobile Interventional Stroke Team (MIST) that travels to Thrombectomy Capable Stroke Centers to perform EVT, as opposed to transferring patients in the Drip-and-Ship (DS) model. We have shown significantly faster initial door-to-recanalization times and improved discharge outcomes. The effect of the MIST stratified by time of presentation has yet to be studied. Hypothesis: In patients presenting with a last known well [LKW] of Methods: In a prospectively collected stroke database at a multicenter health system, patients undergoing EVT performed by a MIST or after transfer in a DS model from January 2017 to March 2020 with baseline mRS 0-2 were selected. Patients presenting in the early time window and late time window (LKW >6 hours) were analyzed separately. The primary endpoint was the proportion with a good outcome (mRS of 0-2) at 90 days. Secondary endpoints included discharge NIHSS and mRS. Results: In the 242 selected patients, the MIST and DS cohorts were similar in age, gender, initial NIHSS, pre-stroke mRS, and procedural details. In the early window, 54% (39/72) had a good 90-day outcome in the MIST model, as compared to 28% (25/88) in the DS model (p Conclusions: The MIST model used in the early time window produces better 90-day outcomes compared to the DS model. This is likely due to the MIST’s ability to capture fast progressors in the early window.

Introduction: Studies have demonstrated that aphasia may negatively impact morbidity and mortality among ischemic stroke (IS) patients. However, the association between post-stroke aphasia and readmission with infection (RI) is poorly understood. We sought to assess the impact of aphasia on post-stroke RI. We hypothesized that aphasic patients are at increased risk of infection in the 30-day post-stroke period. Methods: We performed retrospective chart review of the Mount Sinai Hospital IS patients with 30-day all cause readmission from January 2016 - December 2019. All variables were abstracted from the index admission (IA) electronic medical records except for aspects related to the readmission (RA). Aphasia was present if a neurologist diagnosed the patient with acquired language dysfunction during IA. We performed chi square and logistic regression analyses to compare readmitted patients with and without aphasia at IA. Our fully adjusted model controlled for age, sex, medical comorbidities, NIHSS ≥ 8, IA LOS > 7, IA infection, discharge to facility. We completed all analyses with SPSS. Results: During IA, 36% (n=42) were diagnosed with aphasia. At IA, there were no significant differences in age (dichotomized at 65), sex, or medical comorbidities between aphasic and non-aphasic cohorts. However, more aphasic patients had admission NIHSS ≥ 8 (89% vs 35%, p 7 (76% vs 42%, p=0.0004), discharge to facility (79% vs 49%, p=0.0016), and RI (52% vs 19%, p=0.002). The presence of aphasia predicted RI in both unadjusted (OR=4.6, p Conclusions: The adjusted odds of 30-day readmission with infection were significantly greater in those with diagnosis of aphasia at the time of index admission compared to those without. Our study provides preliminary evidence that the presence of aphasia may have negative consequences on a patient’s health beyond the language disturbance. Further study is needed to better understand the reasons and risk reduction strategies in this vulnerable population.

Background: Osteoporosis and heart failure (HF) are age-related disorders that share some pathogenetic features and may influence each other. Previous studies have suggested an association between bone mineral density (BMD) and HF risk, which may be race-dependent. We sought to further investigate race- and sex-specific associations of BMD with HF in a longitudinal study of older adults. Methods: We evaluated the relationship between BMD and HF in the Health, Aging, and Body Composition study, a sample of community-dwelling adults aged 70-79. BMD was measured by dual-energy X-ray absorptiometry (DXA) of the total hip and femoral neck, and in half the cohort by computed tomography of the spine. Analyses were stratified a priori by sex and race, and Cox models were used to estimate risk after adjustment for potential confounders. Results: Of 2835 participants, 572 (49% women, 42% black) developed HF during a median follow up of 12.2 years. Lower BMD of the total hip by DXA was associated with higher risk of HF in black women (adj. HR 1.84 [95% CI, 1.43 - 2.37] per SD decrement), with suggestion of lower risk in black men that was not significant (adj. HR 0.81 [0.64 - 1.02]). Corresponding analyses failed to reveal significant associations in white women (adj. HR 0.86 [0.71-1.04]) or white men (adj. HR 1.10 [0.93 - 1.30]). There were a significant interaction of total hip BMD by sex among blacks (p=0.002), but not whites (p=0.363), as well as by race among women (p=0.026) and men (p=0.049). Relationships of BMD of the femoral neck were similar in all groups. Likewise, lower volumetric BMD of the spine was associated with higher risk in black women (adj. HR 1.34 [1.02 - 1.77] per SD decrement), but there were no significant associations in black men (adj. HR 0.91 [0.78 - 1.18]), white women (adj. HR 0.83 [0.64 - 1.08]), or white men (adj. HR 1.17 [0.95 - 1.44]). Conclusions: Among a biracial cohort of older adults, lower BMD was associated with higher risk of HF in black women, with no clear evidence of an association in white women or in men of either race. Further research is needed to understand the factors that may account for the particular association in black women, and whether these can be leveraged for therapeutic intervention.

Introduction: Prior studies examining sex-related risk of readmission for ischemic stroke after coronary artery bypass grafting (CABG) did not adjust for preoperative co-morbidities and used small study samples that were single center or otherwise poorly generalizable. We assessed risk of readmission for ischemic stroke after CABG for females compared to males in a nationwide sample. Methods: The 2013 Nationwide Readmissions Database contains data on nearly 60% of all U.S. hospitalizations. We used population weighting to determine national estimates. Using all follow-up data up to 1 year after discharge from CABG hospitalization, we estimated Kaplan-Meier cumulative risk of ischemic stroke, stratified by sex, using the log-rank test for significance. We created Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for ischemic stroke readmission, with sex as the main independent variable. We ran unadjusted models and models adjusted for age, vascular risk factors, estimated severity of illness and risk of mortality, hospital characteristics, and income quartile of patient’s zip code. Results: An estimated 53,270 females and 147,396 males survived index CABG admission in 2013. There was a consistently elevated cumulative risk of readmission for ischemic stroke after CABG for females versus males (log-rank p value=0.0014). In the unadjusted Cox model, the HR of ischemic stroke in females vs. males was 1.35 (95% CI 1.12-1.62, p=0.0015). The elevated risk for females remained after adjusting for severity of illness (1.30 [1.08-1.56], p=0.0056) and risk of mortality (1.28 [1.07-1.54], p=0.0086). This elevated risk persisted after adjusting for multiple vascular risk factors, hospital characteristics, and income quartile of patient’s zip code (1.23 [1.02-1.48], p=0.03). Conclusions: In conclusion, we found a 23% increased risk of readmission for ischemic stroke up to 1 year after CABG for females compared to males in a fully adjusted model utilizing a large, contemporary, nationwide database. Further research would clarify mechanisms of this increased risk among women.

Introduction: Patients with emergent large vessel occlusions (ELVO) are often brought to the closest hospital, possibly given intravenous tPA, and transferred to a hospital capable of performing endovascular intervention. This results in significant delays to thrombectomy and worse patient outcomes when compared with patients brought directly to endovascular centers. In New York City, the pre-hospital system has created a protocol for EMS to use a clinical screening tool to triage stroke patients, and bring those with suspected ELVO directly to comprehensive (CSC) or thrombectomy-capable stroke centers (TSC). Objective: To model the impact of EMS triage protocols on administration of tPA, initiation of endovascular therapy, and recanalization of large vessel occlusions using a real life cohort of thrombectomy patients. Methods: Using our system wide prospectively collected stroke database, we selected a consecutive cohort of 80 thrombectomy patients who were brought by EMS to a primary stroke center then transferred to a TSC or CSC for endovascular intervention. The patient’s initial EMS pickup address was used to calculate the closest TSC or CSC using Google Maps API. Driving time was calculated based on traffic patterns at the time of pickup. Using data from a cohort of 69 consecutive patients that were brought directly to a TSC or CSC by EMS and underwent endovascular intervention, we derived median door to needle and door to groin puncture times. These times, combined with calculated driving distance, were used to model the timing of treatment in the triage model. Timings in the actual cohort versus the model were compared. Results: In the “actual” drip and ship cohort versus our model, first medical contact (FMC) to endovascular center door was 211 versus 32 minutes (p Conclusions: Modeled EMS pre-hospital triage of ELVO patients results in a significant decrease in endovascular treatment times without change in tPA times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.

Introduction: Endovascular thrombectomy (ET) has the greatest benefit of all acute ischemic stroke (AIS) therapies. However, ET trials were performed in centers with rigorous protocols, expert procedural skill, and cerebrovascular specialists. Systems of care are evolving to meet LVO clinical demand nationwide, and real-world data are needed regarding case volumes and provider specialty to better evaluate expertise, quality, and capacity. Methods: Using de-identified 100% inpatient Medicare data from 2016-2017 for individuals aged > 65 years in the US, we utilized validated International Classification of Diseases, 10 th Revision, Clinical Modification codes to identify admission with AIS and treatment with ET. We identified proceduralist specialty by linking the ET proceduralist National Provider Identifier (NPI) to the provider specialty listed in the NPI database, grouping specialty into: radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, the ET team specialty composition by hospital, and the number of proceduralists who perform ET at multiple hospitals. Results: Among 13,311 AIS patients treated with ET, 2,754 different proceduralists treated at 641 hospitals. The median number of proceduralists per hospital was 4. 11.7% (n=322) of proceduralists performed ET at multiple hospitals. The ET team included a neurology- or neurosurgery-trained proceduralist at 64.9% (n=407) of hospitals that performed ET, and included both in 25.6% (n=160) of teams. At 175 hospitals that performed 30 ET. As hospital case volume increased, there was a progressive increase in the proportion of cases performed by neurosurgeons and neurologists. Conclusion: Nationally, 65% of ET teams include a neurology- or neurosurgery-trained proceduralist, more often in higher volume hospitals. A minority of LVO stroke is treated by proceduralists who perform ET at multiple hospitals. A better understanding of the impact of ET team structure on access to care and outcomes is essential.

Introduction: Depression after ischemic stroke (IS) and myocardial infarction (MI) is more common than in the general population and associated with morbidity and mortality. There is a lack of data on the relative risk of depression and suicide attempt (SA) comparing IS to MI, and nationally representative data is needed. Methods: The 2013 Nationwide Readmissions Database contains >14 million U.S. admissions. Using validated International Classification of Disease, 9 th Revision, Clinical Modification Codes in the primary diagnosis position, we identified index admission for IS (weighted n=434,495) and MI (weighted n=539,550) and readmission for depression and SA. To arrive at national estimates, we calculated weighted 30-, 60-, and 90-day readmission rates. We performed Cox Regression to calculate hazard ratios (HR) and 95% confidence intervals (CI) for readmission for depression and SA up to 1 year following IS vs. MI, adjusting for age, depression recorded during the index event, sex, length of stay, income quartile of patient zip code, discharge disposition, alcoholism, estimated severity of illness, and smoking. Results: Readmission rates for depression were consistently higher at 30, 60, and 90 days after IS compared to MI (0.04%, 0.09%, 0.12% vs. 0.03%, 0.05%, 0.07%). There was no significant difference in SA readmissions. The HR for readmission due to depression was 1.62 ([1.37-1.92], p=2.49x10 -8 ) comparing IS to MI in an unadjusted model and 1.49 [1.25-1.79] in a fully adjusted model. History of depression (3.70 [3.07-4.46], p=2.00x10 -16) , alcoholism (2.04 [1.34-3.09], p = 8.16x10 -4) , and smoking (1.38 [1.15-1.64], p = 3.98 x10 -4 ) were associated with increased risk of depression readmission. Age >70 years (0.46 [0.37-0.55], p = 7.66 x10 -15 ) and discharge home (0.69 [0.57-0.83], p = 1.54 x10 -3 ) were associated with reduced risk of depression readmission. Conclusion: In conclusion, IS was associated with a greater hazard of readmission for depression compared to MI but there were no differences for SA. Though both are acute ischemic vascular events, the damage to the brain may contribute to depression pathogenesis, and the greater disability from stroke may contribute to higher rates of depression.

Background and Purpose— Emerging evidence suggests that an underlying atrial cardiopathy may result in thromboembolism before atrial fibrillation (AF) develops. We examined the association between various markers of atrial cardiopathy and the risk of ischemic stroke. Methods— The CHS (Cardiovascular Health Study) prospectively enrolled community-dwelling adults ≥65 years of age. For this study, we excluded participants diagnosed with stroke or AF before baseline. Exposures were several markers of atrial cardiopathy: baseline P-wave terminal force in ECG lead V 1 , left atrial dimension on echocardiogram, and N terminal pro B type natriuretic peptide (NT-proBNP), as well as incident AF. Incident AF was ascertained from 12-lead electrocardiograms at annual study visits for the first decade after study enrollment and from inpatient and outpatient Medicare data throughout follow-up. The primary outcome was incident ischemic stroke. We used Cox proportional hazards models that included all 4 atrial cardiopathy markers along with adjustment for demographic characteristics and established vascular risk factors. Results— Among 3723 participants who were free of stroke and AF at baseline and who had data on all atrial cardiopathy markers, 585 participants (15.7%) experienced an incident ischemic stroke during a median 12.9 years of follow-up. When all atrial cardiopathy markers were combined in 1 Cox model, we found significant associations with stroke for P-wave terminal force in ECG lead V 1 (hazard ratio per 1000 μV*ms 1.04; 95% confidence interval, 1.001–1.08), log-transformed NT-proBNP (hazard ratio per doubling of NT-proBNP, 1.09; 95% confidence interval, 1.03–1.16), and incident AF (hazard ratio, 2.04; 95% confidence interval, 1.67–2.48) but not left atrial dimension (hazard ratio per cm, 0.96; 95% confidence interval, 0.84–1.10). Conclusions— In addition to clinically apparent AF, other evidence of abnormal atrial substrate is associated with subsequent ischemic stroke. This finding is consistent with the hypothesis that thromboembolism from the left atrium may occur in the setting of several different manifestations of atrial disease.

Background and Purpose— The relationships between different infection types and stroke subtype are not well-characterized. We examined exposure to infections in different organ systems in different time periods before the acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Methods— We used the New York State Inpatient Databases and Emergency Department Databases (2006–2013). Validated International Classification of Diseases , Ninth Edition definitions identified index hospitalizations for acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, and emergency department visits and hospitalizations for infection (skin, urinary tract infection, septicemia, abdominal, and respiratory). We used case cross-over analysis with conditional logistic regression to estimate odds ratios (OR) for the association between each infection type during case periods compared with control periods 1 year before. Results— Every infection type was associated with an increased likelihood of acute ischemic stroke. The greatest association was for urinary tract infection, with OR of 5.32 (95% CI, 3.69–7.68) within the 7-day window. The magnitude of association between urinary tract infection and intracerebral hemorrhage was of lesser magnitude, with OR of 1.80 (1.04–3.11) in the 14-day exposure period and OR of 1.54 (1.23–1.94) in the 120-day exposure period. Only respiratory infection was associated with subarachnoid hemorrhage, with OR of 3.67 (1.49–9.04) in the 14-day window and 1.95 (1.44–2.64) in the 120-day window. Conclusions— All infection types were associated with subsequent acute ischemic stroke, with the greatest association for urinary tract infection.

We would like to thank Patel et al. for their thoughtful reflection on our study.1 Evaluation setting is important in screening for depression after stroke and myocardial infarction because transient mood changes in the acute inpatient setting have different implications from persistent mood changes in the long-term outpatient setting. We sought to maximize sensitivity by including outpatient and inpatient claims, as recommended by some who have validated case definitions for depression in administrative data, and acknowledge that a greater percentage of patients are discharged home after myocardial infarction than stroke.2

Background: Perfusion imaging currently plays a crucial role in patient selection for endovascular thrombectomy (EVT) in the extended time window i.e. last known well (LKW) to treatment time is 6-24 hours. There is insufficient data about the treatment delays perfusion imaging may pose, especially in the real world. Methods: We retrospectively reviewed all patients who underwent EVT between August 2016 and July 2018 in a large tertiary network. The stroke triage algorithm in our network specifies CT perfusion (CTP) only for patients who present with LKW time 6-24 hours prior to presentation or when otherwise clinically indicated. Patients were classified in two cohorts based on the acquisition of CTP. We compared baseline characteristics, in addition to pre-specified time metrics of post-arrival workflow. Our aim was to compare hospital arrival to GP between CTP and non-CTP cohorts. Results: A total of 284 patients were included; 82 (28.9%) in the CTP and 202 (71.1%) in the non-CTP cohort. Patients in the CTP cohort had longer time from LKW to hospital arrival (521.3 ±434.2 mins vs 249.7 ±233.9 mins, p = 0.0001). There was no difference between the cohorts in EMS arrival versus transfers from other hospitals, or time from arrival to CT. More patients had undergone CTA at the receiving hospital in the CTP cohort (18.9% difference, 95% CI 6.6-29.7, p = 0.003). Similarly, image acquisition time was longer in the CTP cohort (33 ±46mins vs 6 ±21 mins, p = 0.0001). In the CTP cohort, 90.2% (95% CI 81.7-95.7) had Alberta Stroke Program Early CT Score (ASPECTS) ≥6. Time from hospital arrival to groin puncture (GP) was longer in the CTP cohort (126.6 ±121.4 vs 88.3 ±111.0, p = 0.01). Conclusions: While CTP was a determining factor for patient selection in extended time window trials, real world practice is hindered by longer image acquisition and interpretation times of CTP, resulting in significant treatment delay. The majority of patients undergoing EVT after CTP evaluation, would be candidates for treatment based on CT criteria for selection in less than 6h window (i.e. ASPECTS ≥6). Future studies should evaluate using CT for patient selection in extended time window, reserving CTP only for patients who would otherwise be excluded.

Introduction: A stroke code is a standardized pathway for rapidly assessing patients with possible stroke. Inpatients with neurological deficits often trigger repeat stroke codes, even if the etiology is not vascular. We analyzed all repeat stroke codes to look for trends in diagnosis, timing and risk factors as part of a departmental quality improvement project aimed at improving policy in light of new acute stroke treatment guidelines. Methods: We analyzed all stroke codes in our urban, multi-hospital healthcare system by reviewing all cases where an acute stroke code head CT was ordered from January 2017 to April 2018. Patients for whom >1 stroke code was called during the period of interest were analyzed for final diagnosis, timing between stroke codes, and underlying medical and vascular risk factors. A diagnosis of stroke was confirmed by imaging with either CT or MRI. Results: There were 651 stroke codes in total, of which 51 were called on the same patient, representing 8% of all codes. 68.3% of all codes had a confirmed stroke or TIA, and 49% had a history of prior stroke or TIA. These 51 codes were represented by just 25 patients, one of whom triggered 3 stroke codes in one year, and the rest triggering 2. 61% were found to have a stroke the first time as well as the second time the code was called. Among these repeat strokes, 34.1% had atrial fibrillation, 31.4% had critical vascular stenosis and 14.3% had underlying malignancy. Patients without an acute stroke included those with toxic metabolic encephalopathy (21.6%) and seizure/post-ictal state (9.8%). 45.5% of toxic-metabolic patients had ESRD with an equal percentage having uncontrolled blood sugar. The average time between repeat stroke codes was 61.3 days. The average time between repeat stroke codes in patients who had a stroke both times was 17.67 days. Conclusions: We found that patients with a history of stroke remain at high risk for a repeat stroke in a short period of time, reflected by a time to repeat stroke code on confirmed patients of less than 3 weeks. Of these, a large proportion (65.5%), were found to have either atrial fibrillation or critical vascular stenosis. These patients may merit closer monitoring during the first month as they remain at high risk of further vascular events.

Introduction: Given the narrow time window, high acuity, and growing complexity, medical student experience with early management of acute stroke (EMAS) is often limited. However, all medical students need experience recognizing and treating acute stroke regardless of their eventual specialty. Simulation-based education has been demonstrated to improve knowledge acquisition without compromising patient safety. We utilized simulation as part of an educational quality improvement initiative to address a gap in medical student experience and comfort in EMAS. Methods: In the 2017-2018 academic year, 104 third year medical students participated in stroke code simulation during the neurology clerkship. Stroke fellows led groups of ten students through two cases: right M1 occlusion requiring intravenous alteplase (IV tPA) and mechanical thrombectomy (MT) and left thalamic intracerebral hemorrhage complicated by status epilepticus. In each case, students identified and triaged stroke syndromes, performed the NIH Stroke Scale, interpreted CT and CTA images, and formulated treatment plans utilizing IV tPA and MT as well as blood pressure and antiepileptic medications. All participants completed pre- and post-simulation tests targeting clinical knowledge of EMAS (score range 0-7). Additionally, 45 students completed an anonymous post-simulation survey on subjective feelings of confidence managing acute stroke and seizure (Likert scale of 1-5). Results: Mean EMAS test score improved from 4.85 (SEM 0.089) pre-simulation to 5.25 (SEM 0.101) post-simulation (p Conclusion: Simulation improved medical student knowledge and level of comfort with EMAS. All medical school graduates should be trained to recognize signs and initiate management of acute stroke.

Objective: To assess for changes in stroke code volume and yield after implementation of an extended 24-hour acute stroke code window (ASCW). Background: The DAWN and DEFUSE-3 trials showed that extended time windows of 16 to 24 hours benefit select patients with confirmed large vessel occlusion (LVO) of the anterior circulation. The Mount Sinai Hospital emergency department (MSH ED) extended its ASCW from 12 to 24 hours in anticipation of those results. Methods: We retrospectively analyzed de-identified data collected for patients presenting to the MSH ED as stroke codes, estimated by the number of acute stroke non-contrast head CT scans performed. We compared last known well (LKW)-to-arrival time, door-to-CT time, ancillary imaging, and intervention status seven months prior to (baseline cohort), and following (intervention cohort), implementation of the 24-hour ASCW. This work was part of a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines. Results: Baseline cohort: 197 stroke codes were called. Median NIHSS was 7. 27 (14%) presented after 12 hours. Median LKW-to-arrival was 212 minutes and median door-to-CT was 22 minutes. 136 (69%) received a CT angiogram (CTA) and 32 (16%) received CT perfusion (CTP). 25 (13%) were treated with intravenous alteplase (IV tPA). 44 (22%) underwent mechanical thrombectomy (MT) with a median LKW-to-arrival of 209 minutes. Intervention cohort: 200 acute stroke codes were called. Median NIHSS was 6. 58 (29%) presented after 12 hours. Median LKW-to-arrival was 280 minutes, and median door-to-CT was 19 minutes. 135 (68%) received CTA and 27 (14%) received CTP. 36 (18%) were treated with IV tPA. 43 (22%) underwent MT with a median LKW-to-arrival of 283 minutes. Conclusions: The number of stroke codes called with an extended 24-hour ASCW remained stable. Although the number of patients presenting after 12 hours more than doubled, there was no increase in the number of patients who underwent MT. This likely reflects the practice that stroke codes are called whenever there is a high suspicion for LVO regardless of the determined ASCW, so that the change to 24-hour ASCW did not significantly impact demand and work flow.

Introduction: With the continued expansion of acute stroke treatment options, urban tertiary referral centers such as ours are treating an increasingly diverse patient population. As we attempted to better understand barriers to improved door to treatment times in our acute stroke code protocol, we postulated that there might be differences in severity of presentation and swiftness of acute stroke care based on English fluency. Methods: Through a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines, we compared National Institute of Health Stroke Scale (NIHSS) at presentation, time to presentation, and time to treatment of fluent English speakers to patients who were not fluent in English. We analyzed data from 667 acute stroke codes from January 2017 to March 2018 with Statistical Package for the Social Science (SPSS) using two-tailed t-tests. Results: In-Hospital stroke codes included 415 English speakers and 97 non-English speakers, while Outside Hospital (OSH) transfers comprised 92 English speakers and 35 non-English speakers. Non-English-speaking patients had higher average NIHSS scores at time of acute stroke presentation (11 vs 8 (p=0.013) in-hospital and 17 vs 13(p = 0.007) OSH transfer). Last known well (LKW) to stroke code time upon arrival to our center was significantly shorter in non-English speakers compared to English speakers coming from an OSH (315 minutes vs 515 minutes, p = 0.016), but there were no statistically significant differences between language groups for in-hospital codes’ LKW to stroke code times. There were no statistically significant differences in acute treatment times, but in the OSH transfer group, average LKW to groin puncture was 349 minutes for non-English speakers compared to 545 minutes for English speakers (p=0.085). Conclusions: This data suggests that at our center, non-English speakers present with more severe strokes and present more quickly. Increased stroke severity may partially explain an observed trend towards faster times from LKW to thrombectomy for non-English speakers transferred from an OSH.

Background/Objective: Higher volumes in the emergency department (ED) and lower staffing ratios exist during hospital “off hours,” outside of weekday business hours, but the impact of these factors on emergent acute stroke metrics is unknown. As part of a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines, we sought to assess the impact of time of day on acute stroke code process metrics. Methods: We retrospectively analyzed de-identified metrics for 646 stroke codes between January, 2017 and March, 2018. We calculated median times to neuroimaging, tPA administration, and preparation for endovascular therapy (ET) in the endovascular suite based on time of day (“on hours” = weekday business hours vs “off hours” = non-weekday business hours) and patient setting (ED, outside hospital transfer [OSH], inpatient). Results: Of all stroke codes, 57 (8.8%) received tPA and 98 (15.1%) received ET. Of these, 44 (77.2%) occurred during “off hours” for tPA and 69 (70.4%) for ET. Median door-to-needle (n=48) and door-to-groin puncture (n=84) time for ED presentations is higher during “off hours” (56 vs 44 min, 111 vs 92 min, respectively). Median door-to-groin puncture is similar for OSH transfers (n=64) regardless of arrival time (56 vs 60 min). For all groups, median time for preparation for ET in the endovascular suite is higher during “off hours” compared to “on hours” (ED 21 vs 19 min, OSH 20 vs 15 min, inpatient 26.5 vs 20 min). Conclusion: In our center, acute stroke codes during “off hours” have higher median times to tPA, groin puncture, and preparation for ET. Based on this data we are working to implement earlier activation of the endovascular team at triage for potential large vessel occlusion cases and increase staffing availability during “off hours.”

Background: There is expanded focus on stroke systems of care, with emphasis on time to groin puncture (GP) for thrombectomy-eligible patients. For many tertiary networks, favorable time to GP is driven by transferred patients. Patients who present directly to thrombectomy capable sites are at a time disadvantage. There is little information about the specific differences between those populations to inform policy changes. Methods: We analyzed all patients who underwent emergent endovascular thrombectomy (EVT) between July 2017 and June 2018 in a large tertiary network. We divided patients based on mode of arrival to direct presentation (DP) to treating site vs transfer (TT) from spoke hospital. We compared baseline characteristics and different time epochs in post-arrival patient workflow. Results: A total of 155 patients underwent EVT; 52 in the DP and 80 in the TT cohorts. 23 patients were in-house activations and were excluded. The TT cohort had shorter time from arrival to groin puncture 58.82 ± 25.9 vs 142.72 ± 66.45 mins (p = 0.0001). The TT cohort also had shorter image acquisition time 5 ± 8 vs 35 ± 54 mins (p = 0.0001) with more patients in DP cohort undergoing CTA (absolute difference 73.74%, 95% CI 61.12-82.13, p Conclusion: Time to GP is longer in DP vs TT patients. The difference is driven by the back-loading of diagnostic studies (e.g. CTA) and systemic thrombolysis, delay in endovascular team activation and resultant lack of angiography suite readiness. Strategies that aim at earlier endovascular team activation could ameliorate the difference, especially as field triage and bypass to thrombectomy sites becomes wide-spread.

Objectives:. The aim of this study was to determine the educational value of a national virtual fracture conference implemented during the COVID-19 disruption of resident education. Design:. Survey study. Setting:. National virtual conference administered by the Orthopaedic Trauma Association. Participants:. Attendees of virtual fracture conference. Intervention:. Participation at a national virtual fracture conference. Main outcome measure:. Surveys of perception of quality and value of virtual conferences relative to in-person conferences. Results:. Ninety-six percent of participants rated the virtual fracture conference as similar or improved educational quality relative to conventional in-person fracture conference. Participants also felt they learned as much (35%) or more (57%) at each virtual fracture conference compared to the amount learned in-person. The quality of interpersonal interactions at both the resident–faculty level and faculty–faculty level was also perceived to be overall superior to those at participants’ own institutions. Learners felt they were more likely to engage the primary literature as well. Overall, 100% of participants were likely to recommend virtual conference to their colleagues and 100% recommended continuing this conference even after COVID-19 issues resolve. Conclusions:. We found that learners find significant educational value in a national virtual fracture conference compared to in-person fracture conferences at their own institution. COVID-19 has proven to be a disruptor not only in health care but in medical education as well, accelerating our adoption of innovative and novel resident didactics. Level of Evidence:. Therapeutic Level III.

We would like to thank Chen et al.1 for their interest in our study. We agree that it is important to consider stroke severity and the possibility that quality of care was suboptimal during the index admission. Indeed, we specifically designed our analyses to minimize the likelihood that readmissions were related to higher stroke severity or to unsatisfactory treatment at the first hospital. Although the Nationwide Readmissions Database does not include data on stroke severity, we used the All Patient Refined Diagnosis Related Groups (APRDRG) severity of illness and risk of mortality measures as a measure of overall illness severity. Our fully adjusted models account for both APRDRG severity and mortality. To minimize the likelihood that unsatisfactory treatment at the first hospital contributed to readmission, we excluded patients transferred to a higher level of care during index hospitalization. Finally, Table 2 reports the length of hospital stay and total charges of hospitalization during the index admission. In addition to demographics, vascular risk factors, insurance, discharge disposition, and APRDRG severity or mortality, our fully adjusted model also included adjustment for hospital characteristics, length of stay, and total charges during the index hospitalization.

Introduction: The optimal management of patients with recurrent stroke and patent foramen ovale (PFO) is debated. While some are managed medically with antiplatelet/anticoagulant agents, others undergo percutaneous closure of PFO (PC PFO). Device-specific trials have demonstrated a risk of atrial fibrillation/flutter (AF) following closure. To date, nationally representative data has not yet been used to assess the rates and causes of readmission following PC PFO. Methods: The 2013 Nationwide Readmissions Database is a national database of readmissions for all payers and the uninsured with data on >14 million U.S. admissions. We used validated International Classification of Disease, Ninth Revision, Clinical Modification codes to identify PC PFO, ischemic stroke, and medical comorbidities and complications. We calculated readmission rate following PC PFO. We performed Kaplan-Meier analysis to determine the cumulative 1-year risk of readmission with AF and Cox regression modelling to calculate hazard ratios (HR) of AF readmission at 1 year. Results: Among 850 patients who underwent PC PFO, there were 151(17.7%) readmissions within 1 year and 52 within the first 30 days. 11.5% of 30-day readmissions were for atrial fibrillation and 3.9% for flutter. Kaplan-Meier cumulative risk for readmission with AF at 1 year was 2.17%. Readmission rate for ischemic stroke was Conclusion: 1 in 5 of those who undergo PC PFO are readmitted in the first year, and 1/3 of these readmissions occur within 30 days. PC PFO is associated with low readmission rates for stroke and a low risk of the independent vascular risk factor of AF. The hazard for AF is over 3-fold greater for those with CHF and increases with each year increase in age.

Introduction: Several lines of evidence indicate that some cases of cryptogenic stroke may be due to an atrial cardiopathy that forms a nidus for thrombus formation and embolization even in the absence of atrial fibrillation (AF). Hypothesis: We hypothesized that evidence of atrial cardiopathy other than AF is independently associated with stroke. Methods: We examined the association between several markers of atrial cardiopathy and the risk of ischemic stroke among participants in the Cardiovascular Health Study, which prospectively enrolled community-dwelling adults ≥65 years of age. The exposures of interest were P-wave terminal force in electrocardiogram lead V 1 (PTFV 1 ), left atrial dimension on echocardiogram, amino terminal pro-B-type natriuretic peptide (NT-proBNP), and incident AF. The primary outcome was adjudicated ischemic stroke. We used Cox proportional hazards analysis to examine associations with stroke for all four markers together along with adjustment for traditional vascular risk factors. Results: Among 3,723 participants who were free of stroke and AF at baseline and who had data on all atrial cardiopathy markers, 585 patients (15.7%) experienced an incident ischemic stroke during a median 12.9 years of follow-up. When the four atrial cardiopathy markers were combined in one model along with traditional vascular risk factors, we found significant associations with stroke for PTFV 1 (hazard ratio [HR] per 1,000 μV*ms, 1.04; 95% confidence interval [CI], 1.0006-1.08), NT-proBNP (HR per doubling of NT-proBNP, 1.09; 95% CI, 1.03-1.16), and incident AF (HR, 2.04; 95% CI, 1.67-2.48), but not left atrial dimension (HR per cm, 0.96; 95% CI, 0.84-1.10). Conclusions: In a large, prospective, longitudinal study, we found that evidence of abnormal atrial substrate, defined more broadly than just AF, was associated with subsequent ischemic stroke. These findings support the hypothesis that left atrial thromboembolism can occur in the absence of AF.

Background: Intracranial procedures (including craniotomy/ craniectomy, external ventricular drain [EVD], ventriculoperitoneal shunt [VPS], stereotactic craniotomy, and administration of intraventricular alteplase [tPA]) are performed in severe cases of intracerebral hemorrhage (ICH). However, severity-adjusted national estimates of complications after such procedures are not known. Methods: The Nationwide Readmissions Database contains >14 million discharges for all payers and uninsured in 2013. International Classification of Disease, Ninth Revision, Clinical Modification codes were used to identify index cases of ICH, intracranial procedures, and comorbidities. We summarized demographics, comorbidities, and Charlson Comorbidity Index (CCI) during the index admission. Preventable causes of admission were determined by Prevention Quality Indicators. Multivariable Poisson regression models estimated associations between intracranial procedures and readmission rates up to 1 year. Model 1 adjusted for age, discharge status, and CCI; Model 2 adjusted for All Patients Refined Diagnosis Related Groups severity measures. Results: Among 26,160 index admissions for ICH with intracranial procedures, mean age (SD) was 68.6 (14.9) years; 48% were female; 28% diabetic; 70% hypertensive; 23% smokers, mean CCI (SD) was 3.5 (2.2). 25% were discharged home; 24% died during index admission; 30.7% had readmission during follow-up, 13.2% of which were preventable. Top reasons for 30-day readmission were acute cerebrovascular disease (21%), septicemia (8%), and renal failure (4%). In unadjusted models, craniotomy, EVD, and VPS were associated with higher readmission rates. In adjusted models, higher readmission rates were seen only after craniotomy (Model 1 rate ratio [RR] 1.13, 95% CI 1.08-1.19; Model 2 RR 1.10, 1.04-1.15). tPA and stereotactic craniotomy showed no significant associations. Conclusions: This analysis of nationally representative US data of ICH admissions showed a 10-13% increased rate of readmissions after craniotomy, most of which were non-preventable. Further research would clarify causal relationships and suggest ways to reduce readmission risk after this potentially life-saving procedure for ICH.

Introduction: Post-stroke depression (PSD) occurs in approximately one third of stroke patients. Existing literature has elucidated pathophysiology, risk factors, impact, and treatment for PSD. However, there is a lack of nationally representative data assessing patient characteristics and demographics associated with the most severe PSD, manifested by hospitalization for suicide attempt (SA) or depression. Methods: The 2013 Nationwide Readmissions Database contains >14 million U.S. readmissions for all payers and the uninsured. We used validated International Classification of Disease, Ninth Revision, Clinical Modification codes to identify index admission with stroke (n = 215, 802) and readmission with depression (n = 361) and SA (n = 108). We used Cox regression to calculate hazard ratios (HR) of hospital readmissions up to 1 year post-stroke for depression and SA, adjusting for patient and demographic characteristics. Results: Readmission rates with depression were 28 per 100,000, 59 per 100,000 and 82 per 100,000 at 30, 60, and 90 days respectively. Readmission rates with SA were 29 per 100,000, 38 per 100,000, and 43 per 100,000 at 30, 60, and 90 days respectively. For depression readmissions, psychiatric history had the greatest HR of 3.25 (95% CI 2.63-4.01, p -16 ), followed closely by alcoholism (HR of 2.36, 95% CI 1.60-3.50, p = 1.82 x10 -5 ). For SA readmissions, alcoholism had the greatest HR of 3.96 (95% CI 2.22-7.05, p = 2.98 x10 -6 ), followed by psychiatric history (HR 2.87, 95% CI 1.93-4.25, p = 1.52x10 -7 ). Age >70 was protective against readmission with depression and SA, with a HR of 0.45 (95% CI 0.36-0.57, p = 1.86 x10 -11 ) and 0.28 (95% CI 0.18-0.45, p = 1.47 x10 -7 ) respectively. Discharge home was protective against readmissions due to depression only, with a HR 0.71 (95% CI 0.57-0.89, p = 3.1 x10 -3 ). Conclusion: Stroke patients with a history of alcoholism or psychiatric illness are more likely to be admitted with depression or SA in the first year. Age >70 is protective against such readmissions, and discharge home is protective against depression readmissions but failed to reach statistical significance for SA readmission. These factors may be used to screen and identify stroke patients at risk of severe PSD requiring hospitalization.

Background: International trials have suggested benefit of extracranial- intracranial bypass (ECICB) for Moyamoya disease (MMD). However, nationally representative US data on demographics and adverse outcomes after ECICB in MMD are lacking. We aimed to estimate nationally representative 30, 60 and 90-day readmission rates for ischemic stroke (IS), subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) after an index admission for MMD with ECICB. Methods: The Nationwide Readmissions Database contains data on >14 million discharges for all payers and the uninsured in 2013. Index admissions for ECICB for MMD, and readmissions for IS, SAH, and ICH, were identified using validated International Classification of Diseases, 9th Revision, Clinical Modification codes. We summarized demographics, comorbidities, and the Charlson Comorbidity Index (CCI) during the index admission, and calculated 30-, 60-, and 90-day readmission rates per 100,000 index admissions. Preventable causes of admission were determined by Prevention Quality Indicators. Results: Among 201 index admissions for ECICB for MMD, mean age (SD) was 41.7 (12.6) years; 75% were female; 24% had diabetes; 53% had hypertension; 40% had hypercholesterolemia; and mean CCI (SD) was 3.2 (1.5). For concurrent or previous cerebrovascular events, 3% had ICH; 16% had IS; and 1% had SAH. ECICB was performed at large hospitals in 83%, urban hospitals in 85%, and teaching hospitals in 97%. 80% were discharged home. 1% died during index hospitalization. 34% had a readmission during follow-up, 3% of which were preventable. Leading reasons for readmission up to 90 days included MMD (62%), postoperative infection (10%), sickle cell crisis (4%), ischemic stroke (4%), epilepsy (2%), subdural hemorrhage (2%) and headache (2%). Readmission rates (per 100,000 index admissions) were 559 at 30 days, 1829 at 60 days, and 2027 at 90 days for IS. There were no readmissions for SAH or ICH. Conclusions: This analysis of nationally representative US data suggests that although readmission after ECICB for MMD is not uncommon, cerebral hemorrhagic events during the 90-day postoperative period are rare. Readmission for ischemic stroke, in comparison, is more prevalent, and only 3% of readmissions were preventable.

Background: Simulation-based learning has improved medical knowledge, proficiency and performance. The treatment window for acute stroke is limited, making preparedness exceedingly critical. We aimed to assess improvement in performance in first responders to ‘stroke codes’, namely junior Neurology and Emergency Medicine (EM) residents. EM residents were included because EM physicians often make tPA decisions at peripheral and non-academic hospitals. Methods: 14 Neurology and 10 EM residents participated at Upstate Medical University, Syracuse, New York. The simulation consisted of senior Neurology residents playing the roles of stroke patient, CT technician and radiologist, nurse, pharmacist and the stroke fellow on-call. The simulation included the time from patient arrival to acute stroke treatment. Each junior Neurology and EM resident completed this simulation, while the rest of the group observed. Cases included stroke mimics, strokes with large vessel occlusions, dissections, cases ineligible for acute intervention, intracerebral and subarachnoid hemorrhages, basilar thrombosis, wake-up strokes, seizure at onset and dissections. Participants reviewed non-contrast CT head, EKG and CT angiography of the head and neck to make decisions about tPA administration and endovascular interventions. This was followed by a debriefing session by the attending and chief residents. Participants filled a pre-and post-simulation graded questionnaire on medical knowledge and confidence (range 0-25, with higher scores reflecting higher performance). Results: The mean score was 18 (range 14-23) pre-simulation and 22 (range 18-25) post-simulation for Neurology residents and 14 (range 8-24) pre-simulation and 18 (range 10-23) post-simulation for EM residents. For all residents, pre-and post-median score was 17 and 19 (Wilcoxon signed-rank test p Conclusion: Because running an effective stroke code requires coordination and rapid analysis, stroke simulation is an effective way of improving knowledge and confidence among residents and should be integrated into the Neurology and EM residency curriculum.

Background Atrial fibrillation and heart failure are 2 of the most common diseases, yet ready means to identify individuals at risk are lacking. The 12‐lead ECG is one of the most accessible tests in medicine. Our objective was to determine whether a premature atrial contraction observed on a standard 12‐lead ECG would predict atrial fibrillation and mortality and whether a premature ventricular contraction would predict heart failure and mortality. Methods and Results We utilized the CHS (Cardiovascular Health) Study, which followed 5577 participants for a median of 12 years, as the primary cohort. The ARIC (Atherosclerosis Risk in Communities Study), the replication cohort, captured data from 15 792 participants over a median of 22 years. In the CHS , multivariable analyses revealed that a baseline 12‐lead ECG premature atrial contraction predicted a 60% increased risk of atrial fibrillation (hazard ratio, 1.6; 95% CI, 1.3–2.0; P CI , 1.0–1.6; P =0.021). In the negative control analyses, neither predicted incident myocardial infarction. A premature atrial contraction was associated with a 30% increased risk of death (hazard ratio, 1.3; 95% CI, 1.1–1.5; P =0.008) and a premature ventricular contraction was associated with a 20% increased risk of death (hazard ratio, 1.2; 95% CI, 1.0–1.3; P =0.044). Similarly statistically significant results for each analysis were also observed in ARIC . Conclusions Based on a single standard ECG , a premature atrial contraction predicted incident atrial fibrillation and death and a premature ventricular contraction predicted incident heart failure and death, suggesting that this commonly used test may predict future disease.

Background Premature cardiac contractions are associated with increased morbidity and mortality. Though experts associate premature atrial contractions ( PAC s) and premature ventricular contractions ( PVC s) with caffeine, there are no data to support this relationship in the general population. As certain caffeinated products may have cardiovascular benefits, recommendations against them may be detrimental. Methods and Results We studied Cardiovascular Health Study participants with a baseline food frequency assessment, 24‐hour ambulatory electrocardiography (Holter) monitoring, and without persistent atrial fibrillation. Frequencies of habitual coffee, tea, and chocolate consumption were assessed using a picture‐sort food frequency survey. The main outcomes were PAC s/h and PVC s/hour. Among 1388 participants (46% male, mean age 72 years), 840 (61%) consumed ≥1 caffeinated product per day. The median numbers of PAC s and PVC s/h and interquartile ranges were 3 (1–12) and 1 (0–7), respectively. There were no differences in the number of PAC s or PVC s/h across levels of coffee, tea, and chocolate consumption. After adjustment for potential confounders, more frequent consumption of these products was not associated with ectopy. In examining combined dietary intake of coffee, tea, and chocolate as a continuous measure, no relationships were observed after multivariable adjustment: 0.48% fewer PAC s/h (95% CI −4.60 to 3.64) and 2.87% fewer PVC s/h (95% CI −8.18 to 2.43) per 1‐serving/week increase in consumption. Conclusions In the largest study to evaluate dietary patterns and quantify cardiac ectopy using 24‐hour Holter monitoring, we found no relationship between chronic consumption of caffeinated products and ectopy.

Background— Trans -fatty acid (TFA) consumption is associated with risk of coronary heart disease, and trans -18:2, but not trans -18:1, in red blood cell membranes has been associated with sudden cardiac arrest. Abnormal heart rate variability (HRV) reflects autonomic dysfunction and predicts cardiac death. Relationships between TFA consumption and HRV remain understudied. We determined whether total TFA consumption, as well as trans -18:1 and trans -18:2 TFA consumption, was independently associated with HRV in 2 independent cohorts in the United States and Portugal. Methods and Results— In 2 independent cohorts of older US adults (Cardiovascular Health Study [CHS], age 72±5 years, 1989/1995) and young Portuguese adults (Porto, age 19±2 years, 2008/2010), we assessed habitual TFA intake by food frequency questionnaires in CHS (separately estimating trans -18:1 and trans -18:2) and multiple 24-hour recalls in Porto (estimating total TFA only, which in a subset correlated with circulating trans -18:2 but not trans -18:1, suggesting that we captured the former). HRV was assessed using 24-hour Holters in CHS (n=1076) and repeated short-term (5-minute) ECGs in Porto (n=160). We used multivariate-adjusted linear regression to relate TFA consumption to HRV cross-sectionally (CHS, Porto) and longitudinally (CHS). In CHS, higher trans -18:2 consumption was associated with lower 24-hour SD of all normal-to-normal intervals both cross-sectionally (−12%; 95% CI, –19% to –6%; P =0.001) and longitudinally (−15%; 95% CI, –25% to –4%; P = 0.009) and lower 24-hour SD of 5-minute average N-N intervals and mean of the 5-minute SD of N-N intervals calculated over 24 hours ( P trans -18:1 consumption in CHS was associated with more favorable 24-hour HRV in particular time-domain indices (24-hour SD of all normal-to-normal intervals, SD of 5-minute average N-N intervals, mean of the 5-minute SD of N-N intervals calculated over 24 hours; P P =0.04) and 7% lower 5-minute square root of the mean of the squares of successive N-N differences (95% CI, –13% to –1%; P =0.04). Conclusions— Trans -18:2 consumption is associated with specific, less favorable indices of HRV in both older and young adults. Trans -18:1 consumption is associated with more favorable HRV indices in older adults. Our results support the need to investigate potential HRV-related mechanisms, whereby trans -18:2 may increase arrhythmic risk.

To determine if: 1) depressed patients with a recent acute myocardial infarction (AMI) have higher nighttime heart rate (HR) than nondepressed patients, and 2) elevated nighttime HR is associated with decreased survival post AMI. Depression is a risk factor for mortality post AMI. It is also associated with sleep disturbances and with elevated HR, which may be more pronounced at night. Resting and 24-hour HR have been found to predict mortality in patient and community samples.Ambulatory electrocardiographic data were obtained from 333 depressed patients and 383 nondepressed patients with recent AMI. They were followed for up to 30 months (median = 24 months).Depressed patients had higher nighttime HR (70.7 +/- 0.7 versus 67.7 +/- 0.6 beats per minute (bpm); p = .001), and daytime HR (76.4 +/- 0.7 versus 74.2 +/- 0.6 bpm; p = .02) than nondepressed patients, even after adjusting for potential confounds. Depression (hazard ratio (Haz R) = 2.19; p = .02) and nighttime HR (Haz R = 1.03; p = .004), but not daytime HR, predicted survival after adjusting for other major predictors and for each other. The interaction between nighttime HR and depression on survival approached, but did not achieve, significance (p = .08).Mean day and nighttime HR values are higher in depressed patients than in nondepressed patients post AMI. Depression and elevated nighttime HR, but not daytime HR, are independent predictors of survival in these patients. Although depressed patients have a higher nighttime HR than nondepressed patients, nighttime HR predicts mortality in both depressed and nondepressed patients.

Background— Fish and ω-3 fatty acid consumption reduce risk of cardiac death, but mechanisms are not well established. Heart rate variability (HRV) predicts cardiac death and reflects specific electrophysiological pathways and influences. We hypothesized that habitual consumption of fish and marine ω-3 fatty acids would be associated with more favorable HRV, elucidating electrophysiological influences and supporting effects on clinical risk. Methods and Results— In a population-based cohort of older US adults, we evaluated cross-sectional associations of usual dietary fish and ω-3 consumption during the prior year and ECG-derived (n=4263) and 24-hour Holter monitor–derived (n=1152) HRV. After multivariable adjustment, consumption of tuna or other broiled/baked fish was associated with specific HRV components, including indices suggesting greater vagal predominance and moderated baroreceptor responses (eg, higher root mean square successive differences of normal-to-normal intervals [ P =0.001]; higher normalized high-frequency power [ P =0.008]; and lower low-frequency/high-frequency ratio [ P =0.03]) and less erratic sinoatrial node firing (eg, lower Poincaré ratio [ P =0.02] and higher short-term fractal scaling exponent [ P =0.005]) but not measures of circadian fluctuations (eg, 24-hour standard deviation of normal-to-normal intervals). Findings were similar for estimated dietary consumption of marine ω-3 fatty acids. For magnitudes of observed differences in HRV comparing the highest to lowest category of fish intake, differences in relative risk of cardiac death during 10.8 years of follow-up ranged from 1.1% (for difference in standard deviation of normal-to-normal intervals) to 5.9% and 8.4% (for differences in Poincaré ratio and short-term fractal scaling exponent) lower risk. Conclusions— Habitual tuna/other fish and marine ω-3 consumption are associated with specific HRV components in older adults, particularly indices of vagal activity, baroreceptor responses, and sinoatrial node function. Cellular mechanisms and implications for clinical risk deserve further investigation.

Objective: Depression is a risk factor for mortality after acute myocardial infarction (AMI), possibly as a result of altered autonomic nervous system (ANS) modulation of heart rate (HR) and rhythm. The purposes of this study were to determine: a) whether depressed patients are more likely to have an abnormal HR response (i.e., abnormal turbulence) to premature ventricular contractions (VPCs), and b) whether abnormal HR turbulence accounts for the effect of depression on increased mortality after AMI. Methods: Ambulatory electrocardiographic data were obtained from 666 (316 depressed, 350 nondepressed) patients with a recent AMI; 498 had VPCs with measurable HR turbulence. Of these, 260 had normal, 152 had equivocal, and 86 had abnormal HR turbulence. Patients were followed for up to 30 (median = 24) months. Results: Depressed patients were more likely to have abnormal HR turbulence (risk factor adjusted odds ratio = 1.8; 95% confidence interval [CI] = 1.0–3.0; p = .03) and have worse survival (odds ratio = 2.4; 95% CI = 1.2–4.6; p = .02) than nondepressed patients. When HR turbulence was added to the model, the adjusted hazard ratio for depression decreased to 1.9 (95% CI = 0.9–3.8; p = .08), and to 1.6 (95% CI = 0.8–3.4; p = .18) when a measure of HR variability (LnVLF) was added. The hazard was found to differ over time with depression posing little risk for mortality in year 1 but greater risk in years 2 and 3 of the follow up. Conclusion: ANS dysregulation may partially mediate the increased risk for mortality in depressed patients with frequent VPCs after an AMI.

Objective: Depression is a risk factor for cardiac events in patients with coronary heart disease (CHD). Obstructive sleep apnea/hypopnea syndrome (OSAHS) is frequently comorbid with depression and is also a risk factor for cardiac events. Undetected OSAHS could help explain the increased risk associated with depression. Methods: Medically stable patients with CHD and major (MD, n 53), minor (md, n 36), or no depression (ND, n 43) were evaluated for 2 nights in a sleep medicine laboratory. Results: The prevalence of OSAHS did not differ across groups (MD 66%, md 69%, ND 77%; p .05). Patients with MD had a significantly greater frequency of apneic episodes, a significantly longer duration of apneas and hyponeas, and more oxygen desaturations per hour than those with md, but there were no differences between MD and ND in frequency of apneic episodes or oxygen desaturations. However, males with MD tended to have more obstructive episodes per hour than did ND males, whereas females with MD had fewer episodes than did ND females. Apnea duration was longer in patients with MD compared with patients with no ND. There was no difference in the mean duration of apnea per hour between the md and ND groups. Conclusions: Although OSAHS is not more common in depressed patients with CHD, MD is associated with longer obstructive sleep apneic episodes in both men and women and with a higher frequency of episodes in men. Key words: depression, sleep-disordered breathing, coronary heart disease. CHD coronary heart disease; MD major depression; md minor depression; ND nondepressed; OSAHS obstructive sleep apnea/hypopnea syndrome; AHI apnea/hypopnea index; LVEF left ventricular ejection fraction; BDI Beck Depression Inventory; BMI body mass index; DISH Depression Interview and Structured Hamilton.

Background Clinical depression is associated with an increased risk for mortality in patients with a recent myocardial infarction (MI). Reduced heart rate variability (HRV) has been suggested as a possible explanation for this association. The purpose of this study was to determine if depression is associated with reduced HRV in patients with a recent MI. Methods and Results Three hundred eighty acute MI patients with depression and 424 acute MI patients without depression were recruited. All underwent 24-hour ambulatory electrocardiographic monitoring after hospital discharge. In univariate analyses, 4 indices of HRV were significantly lower in patients with depression than in patients without depression. Variables associated with HRV were then compared between patients with and without depression, and potential confounds were identified. These variables (age, sex, diabetes, and present cigarette smoking) were entered into an analysis of covariance model, followed by depression status. In the final model, all but one HRV index (high-frequency power) remained significantly lower in patients with depression than in patients without depression. Conclusions We conclude that greater autonomic dysfunction, as reflected by decreased HRV, is a plausible mechanism linking depression to increased cardiac mortality in post-MI patients.

Background —Atrial fibrillation/flutter (AF) is a frequent complication of coronary artery bypass graft surgery (CABG) that leads to increased costs and morbidity. We hypothesized that heart rate variability (HRV), an indicator of cardiac sympathovagal balance, is altered before the onset of postoperative AF. Because nonlinear methods of HRV analysis provide information about heart rate dynamics not evident from usual HRV measures, we also hypothesized that approximate entropy (ApEn), a nonlinear measure of HRV, might have predictive value. Methods and Results —Analysis of HRV was performed in 3 sequential 20-minute intervals preceding the onset of postoperative AF (24 episodes in 18 patients). These data were compared with corresponding intervals in 18 sex- and age-matched postoperative control subjects who did not develop AF. Patients had left ventricular ejection fractions >45% before surgery and were not receiving β-blockers during ambulatory ECG monitoring after surgery. Logistic regression demonstrated that on the basis of averaged values for the three 20-minute intervals, increased heart rate and decreased ApEn were independently associated with AF. Heart rate dynamics before AF was associated with either lower (n=19) or higher (n=5) RR interval variation by traditional measures of HRV or quantitative Poincaré analysis, suggesting the possibility of divergent autonomic conditions before AF onset. Conclusions —In the hour before AF after CABG surgery, higher heart rate and lower heart rate complexity compared with values in control patients were independent predictors of AF. Decreased ApEn occurs in patients with either increased or decreased HRV by traditional measures and may provide a useful tool for risk stratification or investigation of mechanisms.

Interventions utilized by nurses to manage "difficult" patients and outcomes indicating successful interventions were investigated. Themes included getting the difficult patient label, difficult patient behaviors, reflecting on the label and passing it on, coping with a difficult patient, interventions that worked, and interventions that did not work. Clues indicating that patient behavior was changing were also identified.