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In the 21st century, cancer is a disease that captures much of our attention for its complexity, and its physical, emotional, and financial impacts on one’s life. Research attention and investment in cancer management has made it the most studied disease in clinical trials globally. Clinical trials nurses are part of the oncology research team and a fundamental factor in trial success. Their direct relationship with research subjects is the key connection in the operation of clinical trials at the front line. The influx and complexity of oncology clinical trials has transformed both oncology nursing practice in general and led to the development of the unique subspecialty of the oncology clinical trials nurse. This scoping review investigated the role and future practice of the clinical trials nurse.

We examined the longitudinal association between blood pressure (BP) and stroke incidence in young and middle-aged adults. BP measured during 9 examinations of the CARDIA study (Coronary Artery Risk Development in Young Adults) from 1985-1986 to 2015-2016 was used to classify participants (n=5079) according to the 2017 Hypertension Clinical Practice Guidelines. We used the highest BP obtained through the third examination (1990–1991) to define baseline BP categories; time-dependent categories (accounting for change in BP over time) were determined incorporating follow-up measurements. BP groups at ages 30 and 40 years were also defined. Stroke events were adjudicated until 2018. Mean age at baseline was 29.8 years. Stroke occurred in 100 participants. Stroke incidence (per 100 000 person-years) was higher ( P

Systemic racism is a public health crisis. Systemic racism and racial/ethnic injustice produce racial/ethnic disparities in health care and health. Substantial racial/ethnic disparities in stroke care and health exist and result predominantly from unequal treatment. This special report aims to summarize selected interventions to reduce racial/ethnic disparities in stroke prevention and treatment. It reviews the social determinants of health and the determinants of racial/ethnic disparities in care. It provides a focused summary of selected interventions aimed at reducing stroke risk factors, increasing awareness of stroke symptoms, and improving access to care for stroke because these interventions hold the promise of reducing racial/ethnic disparities in stroke death rates. It also discusses knowledge gaps and future directions.

Supplemental Digital Content is available in the text., Background and Purpose: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. Methods: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. Results: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P

Background and Purpose: In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. Methods: We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. Results: Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P P Conclusions: IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.

ObjectivesWe aimed to explore the impact of the COVID-19 pandemic on cardiac diagnostic testing and practice and to assess its impact in different regions in Europe.MethodsThe online survey organised by the International Atomic Energy Agency Division of Human Health collected information on changes in cardiac imaging procedural volumes between March 2019 and March/April 2020. Data were collected from 909 centres in 108 countries.ResultsCentres in Northern and Southern Europe were more likely to cancel all outpatient activities compared with Western and Eastern Europe. There was a greater reduction in total procedure volumes in Europe compared with the rest of the world in March 2020 (45% vs 41%, p=0.003), with a more marked reduction in Southern Europe (58%), but by April 2020 this was similar in Europe and the rest of the world (69% vs 63%, p=0.261). Regional variations were apparent between imaging modalities, but the largest reductions were in Southern Europe for nearly all modalities. In March 2020, location in Southern Europe was the only independent predictor of the reduction in procedure volume. However, in April 2020, lower gross domestic product and higher COVID-19 deaths were the only independent predictors.ConclusionThe first wave of the COVID-19 pandemic had a significant impact on care of patients with cardiac disease, with substantial regional variations in Europe. This has potential long-term implications for patients and plans are required to enable the diagnosis of non-COVID-19 conditions during the ongoing pandemic.

Objective Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)‐capable center is controversial. We sought to estimate the accuracy of field‐based identification of potential EST candidates in a hypothetical best‐of‐all‐worlds situation. Methods In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility. Results Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral. Conclusions Even if field‐based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST‐capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door‐to‐needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST‐capable centers.

BACKGROUND In Kaiser Permanente Northern California (KPNC), members had similar access to care and a very high overall rate of hypertension control. However, blacks had poorer blood pressure (BP) control than whites. The Shake Rattle & Roll (SRR) trial aimed to improve BP control rates in blacks and to reduce disparities in hypertension control. METHODS SRR was a cluster randomized controlled trial conducted at an urban medical center. All 98 adult primary care physicians (PCP) and their panels of hypertensive black patients were randomized, stratified by panel size, to one of three arms: 1) Usual Care (n = 33 PCPs, N = 1129 patients); 2) Enhanced Monitoring arm with an emphasis on improving pharmacotherapy protocol adherence (n = 34 PCPs, N = 349 patients); or 3) Lifestyle arm with a culturally tailored diet and lifestyle coaching intervention focusing on the Dietary Approaches to Stop Hypertension eating plan (n = 31 PCPs, N = 286 patients). The intervention period was for 12-months post-enrollment. Follow-up was planned for one and three years post-intervention completion. Primary outcome measure was the proportion of participants with controlled BP, defined as

Background The interpretation of the presence of AR-V7 in circulating tumour cells (CTCs) in men with metastatic castration-resistant prostate cancer (mCRPC) remains to be elucidated. AR-V7 may hold promise as a predictive biomarker, but there may be prognostic impact of AR-V7 positivity as well. To investigate the clinical value of AR-V7, we determined whether AR-V7 detection in CTCs in patients with mCRPC is associated with CTC counts and survival. Methods Between December 2011 and January 2019, three prospective clinical trials collected clinical data of patients with mCRPC, who progressed after docetaxel and/or enzalutamide or abiraterone. Baseline (and follow-up) blood samples were withdrawn determining CTC count and AR-V7 expression. The majority of patients started cabazitaxel as the next line of treatment after AR-V7 characterisation. Results A total of 127 samples were evaluable for the analysis of CTC count versus AR-V7 status. Although an association was observed between AR-V7 and CTC count in all patients with mCRPC (p = 0.017), no such association was found in the prognostic unfavourable subgroup of patients with ≥5 CTCs. After adjusting for clinical prognostic factors, AR-V7 expression in CTCs was not associated with overall survival (hazard ratio = 1.33, 95% confidence interval = 0.81–2.15, p = 0.25). Conclusion We found that AR-V7 expression in CTCs had no additional prognostic value in patients with mCRPC, mostly treated with cabazitaxel. In patients with mCRPC with a predefined worse prognosis of a higher CTC count (≥5), a predictive biomarker is an important unmet medical need. Prospective trials should investigate whether AR-V7 detection in CTCs may guide treatment selection for these adverse prognosis patients.

Background: Published data suggest that treating qualified acute strokes within the extended window (EW) or 6-24 hours of last seen normal with endovascular therapy (EST) is associated with better 90-day outcome. In a real-world multi-ethnic practice setting, we assessed our experience in triaging and treating patients in the EW. Methods: In 2016, our system of care launched a telestroke program for 19 primary and 2 comprehensive stroke centers to include immediate video evaluation by a stroke neurologist. In 2018, screening in the EW began. If the patient met clinical criteria (baseline independence and initial NIHSS ≥ 6), neuroimaging was performed to assess for a large vessel occlusion (LVO). Referral for EST was made for patients with an LVO and appropriate CT perfusion criteria. Our study included all health plan members presenting within the EW in 2019. Assessment included demographics, NIHSS, neuroimaging data, LVO, discharge outcomes, 90-day mRS and mortality with 95% confidence interval. Results: In 2019, there were 5349 suspected strokes (1255 EW) evaluated by teleneurologists; 2130 (39.8%) patients were appropriate for acute stroke imaging workup. Of 2130, final study cohort included 388 (18.2%) EW patients who met clinical criteria and underwent neuroimaging workup, and 117 of these patients (30.2%) had an LVO. There were 57 (14.7%) meeting CT perfusion criteria and referred for EST. Compared to 331 who were not referred for EST, the 57 patients were older and more likely to have atrial fibrillation, higher NIHSS, and to be discharged to a short-term facility than home. The 51 patients who went for EST within our system had 90-day good (mRS 0-2), bad (mRS 5-6), and mortality rates comparable to those from DAWN and DEFUSE-3 trials [Table]. Conclusions: In our system, only a small proportion of suspected strokes met criteria for EST during the EW. It was possible in a community setting to achieve 90-day outcomes that were comparable to those from clinical trials.

Background: Stroke patients have high rates of all-cause rehospitalization at 30 days (7-24%) and within one year (30-62%). Limited information is available on how to predict these outcomes. We assessed two existing predictive models and whether adding NIHSS or modified Rankin scale (mRS) score improved their predictive ability for 30-day non-elective rehospitalization and/or mortality post-stroke. Methods: Using a cohort of ischemic stroke patients in a large multi-ethnic integrated healthcare system from June 2010 to December 2017, we tested 2 existing predictive models for a composite outcome (30-day non-elective hospitalization or death). The models were based on administrative data (LACE) as well as a comprehensive model (Transition Support Level, TSL) that included multiple clinical data elements from the electronic health record, including admission acute physiology and discharge care directives. LACE score included information on length of stay, acuity, comorbidities, and emergency department visits. The models, NIHSS and mRS scores were tested independently, and in combination and combined with age and sex. We assessed model performance using the area under the receiver operator characteristic (c statistic), Nagelkerke pseudo-R 2 , and Brier score. Results: The study cohort included 4843 patients with 5,014 stroke hospitalizations. Average age was 71.9 ± 14 years with 50.6% female and 52.1% White. Median initial NIHSS was 4. Median length of stay was 4 days, and 55.6% were discharged home. There were 527 non-elective readmissions within 30 days. The logistic models revealed that the best performing models were TSL (c-statistic = 0.685) and TSL plus mRS score at discharge (c-statistic = 0.694) [Table]. Conclusions: We found that neither the initial NIHSS nor the mRS score at discharge enhanced the predictive ability of the LACE or TSL models. Future efforts at prediction of short-term stroke outcomes will need to incorporate new data elements.

Introduction Dysphagia occurs in up to 50% of patients with acute stroke symptoms, resulting in increased aspiration pneumonia rates and mortality. The purpose of this study was to validate a health system's dysphagia (swallow) screening tool used since 2007 on all patients with suspected stroke symptoms. Annual rates of aspiration pneumonia for ischemic stroke patients have ranged from 2% to 3% since 2007. Methods From August 17, 2015 through September 30, 2015, a bedside dysphagia screening was prospectively performed by 2 nurses who were blinded to all patients age 18 years or older admitted through the emergency department with suspected stroke symptoms at 21 Joint Commission accredited primary stroke centers in an integrated health system. The tool consists of 3 parts: pertinent history, focused physical examination, and progressive testing from ice chips to 90 mL of water. A speech language pathologist blinded to the nurse's screening results performed a formal swallow evaluation on the same patient. Results The end study population was 379 patients. Interrater reliability between 2 nurses of the dysphagia screening was excellent at 93.7% agreement (Ƙ = 0.83). When the dysphagia screenings were compared with the gold standard speech language pathologist professional swallow evaluation, the tool demonstrated both high sensitivity (86.4%; 95% confidence interval = 73.3-93.6) and high negative predictive value (93.8%; 95% confidence interval = 87.2-97.1). Conclusion This tool is highly reliable and valid. The dysphagia screening tool requires minimal training and is easily administered in a timely manner.

Extramammary Paget’s disease (EMPD) is an uncommon entity, and secondary EMPD is even rarer. To our knowledge, this report involves one of the only three cases in the literature to date regarding the use of neoadjuvant radiation therapy in the treatment of secondary EMPD. A 65-year-old woman’s EMPD had become more widespread over the years to involve buttocks, perineum, anus, vulva, and vagina. Given the knowledge of potential secondary EMPD, suspicious perianal lesions were biopsied. Histology and immunohistochemistry staining confirmed adenocarcinoma. Our patient was treated with neoadjuvant radiation therapy, along with concurrent chemotherapy. This was followed by pelvic exenteration, which confirmed a complete response from the neoadjuvant treatment. We discuss her presentation, investigations, and treatment regimen in detail. In addition, we review the treatment of secondary EMPD as reported in previously published literature.

Introduction: Incidence of heart failure (HF), specifically with preserved ejection fraction (HFpEF), is rising in the general population, yet is understudied. To provide a population-based estimate of HF in breast cancer (BC) survivors, we compared risk of HF in women with and without BC history in the Kaiser Permanente Northern California (KPNC) integrated health system. Methods: Data were extracted from KPNC electronic health records. All invasive BC cases diagnosed from 2005-2013 were identified and matched 1:5 with non-BC controls on birth year, race/ethnicity, and KPNC membership at BC diagnosis. Cox regression models assessed the hazard of HF by EF status: HFpEF (EF ≥ 45%), HF with reduced EF (HFrEF; EF < 45%), and unknown EF. Women with prior history of HF were excluded. Models were adjusted for factors known to affect BC risk or CVD and for prevalent CVD at BC diagnosis. We also examined case subgroups who received cardiotoxic chemotherapy, left-sided radiation therapy, and/or endocrine therapy, versus their controls. Results: A total of 14,804 women diagnosed with invasive BC and with no history of HF were identified and matched to 74,034 women without BC history. Women were on average 61 years at BC diagnosis and 65% white. Women with HFpEF were older and more likely to have hypertension (p Conclusions: Increased surveillance is warranted for women with BC receiving cardiotoxic chemotherapy for development of both HFrEF and HFpEF.

Objective Investigation of asymptomatic carotid stenosis treatment is hindered by the lack of a contemporary population-based disease cohort. We describe the use of natural language processing (NLP) to identify stenosis in patients undergoing carotid imaging. Methods Adult patients with carotid imaging between 2008 and 2012 in a large integrated health care system were identified and followed through 2017. An NLP process was developed to characterize carotid stenosis according to the Society of Radiologists in Ultrasound (for ultrasounds) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) (for axial imaging) guidelines. The resulting algorithm assessed text descriptors to categorize normal/non-hemodynamically significant stenosis, moderate or severe stenosis as well as occlusion in both carotid ultrasound (US) and axial imaging (computed tomography and magnetic resonance angiography [CTA/MRA]). For US reports, internal carotid artery systolic and diastolic velocities and velocity ratios were assessed and matched for laterality to supplement accuracy. To validate the NLP algorithm, positive predictive value (PPV or precision) and sensitivity (recall) were calculated from simple random samples from the population of all imaging studies. Lastly, all non-normal studies were manually reviewed for confirmation for prevalence estimates and disease cohort assembly. Results A total of 95,896 qualifying index studies (76,276 US and 19,620 CTA/MRA) were identified among 94,822 patients including 1059 patients who underwent multiple studies on the same day. For studies of normal/non-hemodynamically significant stenosis arteries, the NLP algorithm showed excellent performance with a PPV of 99% for US and 96.5% for CTA/MRA. PPV/sensitivity to identify a non-normal artery with correct laterality in the CTA/MRA and US samples were 76.9% (95% confidence interval [CI], 74.1%-79.5%)/93.1% (95% CI, 91.1%-94.8%) and 74.7% (95% CI, 69.3%-79.5%)/94% (95% CI, 90.2%-96.7%), respectively. Regarding cohort assembly, 15,522 patients were identified with diseased carotid artery, including 2674 exhibiting equal bilateral disease. This resulted in a laterality-specific cohort with 12,828 moderate, 5283 severe, and 1895 occluded arteries and 326 diseased arteries with unknown stenosis. During follow-up, 30.1% of these patients underwent 61,107 additional studies. Conclusions Use of NLP to detect carotid stenosis or occlusion can result in accurate exclusion of normal/non-hemodynamically significant stenosis disease states with more moderate precision with lesion identification, which can substantially reduce the need for manual review. The resulting cohort allows for efficient research and holds promise for similar reporting in other vascular diseases.

Informed debate regarding the optimal use of carotid endarterectomy (CEA) for stroke risk reduction requires contemporary assessment of both long-term risk and periprocedural risk. In this study, we report long-term stroke and death risk after CEA in a large integrated health care system.All patients with documented severe (70%-99%) stenosis from 2008 to 2012 who underwent CEA were identified and stratified by asymptomatic or symptomatic indication. Those with prior ipsilateral interventions were excluded. Patients were followed up through 2017 for the primary outcomes of any stroke/death within 30 days of intervention and long-term ipsilateral ischemic stroke; secondary outcomes were any stroke and overall survival.Overall, 1949 patients (63.2% male; mean age, 71.3 ± 8.9 years) underwent 2078 primary CEAs, 1196 (58%) for asymptomatic stenosis and 882 (42%) for symptomatic stenosis. Mean follow-up was 5.5 ± 2.7 years. Median time to surgery was 72.0 (interquartile range, 38.5-198.0) days for asymptomatic patients and 21.0 (interquartile range, 5.0-55.0) days for symptomatic patients (P .001). Most of the patients' demographics and characteristics were similar in both groups. Controlled blood pressure rates were similar at the time of CEA. Baseline statin use was seen in 60.5% of the asymptomatic group compared with 39.9% in the symptomatic group (P .001), and statin adherence by 80% medication possession ratio was 19.3% asymptomatic vs 12.4% symptomatic (P .001). The crude overall 30-day any stroke/death rates were 0.9% and 1.5% for the asymptomatic group and the symptomatic group, respectively. The 5-year risk of ipsilateral stroke and a combined end point of any stroke/death by Kaplan-Meier survival analysis were 2.5% and 28.7% for the asymptomatic group and 4.0% and 31.4% for the symptomatic group, respectively. Unadjusted cumulative all-cause survival was 74.2% for the asymptomatic group and 71.8% for the symptomatic group at 5 years.In a contemporary review of CEA, outcomes for either operative indication show low adverse events perioperatively and low long-term stroke risk up to 5 years. These results are well within consensus guidelines and published trial outcomes and should help inform the discussion around optimal CEA use for severe carotid stenosis.

Background: Published data suggest that the faster acute stroke patients are treated with IV alteplase the better they do post discharge. It is not clear that reducing door-to-needle (DTN) time by 15 minutes (from 60 to 45 to 30) is associated with better functional outcome and/or less mortality. In a real-world practice setting, we assessed the effect of different DTN times on clinical outcomes. Methods: In 2016, a new standardized telestroke program for 21 stroke centers in an integrated healthcare system was launched. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic study, and expedited transfer and treatment for patients with large vessel occlusion. From 2/15/18 to 2/25/19, we collected 90-day modified Rankin Score (mRS) for adult members who received IV alteplase. We also collected data on demographics, NIHSS, DTN times, thrombectomy, length of stay, discharge outcomes, 90-day mRS and mortality in those treated with IV alteplase stratified by the DTN time (60 vs. 45 vs. 30 minutes). Multivariate logistic regression was used to examine whether DTN category was predictive of good functional outcome (mRS=0-2) adjusted for age, gender, race, and NIHSS. Results: During the study period, the full cohort had 784 patients treated with IV alteplase. Average age was 71.5 ± 14.9 years with 51.8% female. Median NIHSS was 6. Median DTN time was 34 minutes. Those with faster DTN arrived more by EMS, had higher NIHSS, higher rate of thrombectomy, and shorter length of stay. A smaller cohort of 340 patients had a 90-day mRS. Multivariate models revealed a trend for faster DTN time being associated with less 90-day mortality (OR=0.81, p=0.24) and good functional outcome (OR=1.73, p=0.07) among EMS arrival (Table). Conclusions: In our study cohort, every 15-minute reduction in DTN had stronger association with better outcomes. Further efforts are underway to capture more complete mRS data for the full cohort.

Background: Risks and benefits of thrombectomy in elderly stroke patients remained unclear. We evaluated outcomes in the elderly who underwent endovascular therapy (EST) in a large integrated healthcare system. Methods: In 2016, our integrated healthcare system launched a new standardized acute telestroke care workflow for all 21 stroke centers. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic investigation, and expedited transfer and EST for patients with large vessel occlusion (LVO). From January 2016 through December 2018, our study cohort included adult members who had EST within our care system. We compared patient characteristics, door-to-needle (DTN) times, door-to-groin (DTG) times, inpatient and 90-day mortality between those treated with EST aged Results: There were 291 acute stroke patients who underwent EST [Table]. The older subgroup had a higher percentage of female and higher rates of atrial fibrillation. They were more likely to arrive by EMS, to have a higher initial NIHSS and to have a faster DTN time. Average DTG times and inpatient mortality rates were not different between groups. The elderly had a higher rate of 90-day mortality. In multivariate model, being elderly was associated with higher 90-day mortality (OR=2.56, 95% CI 1.29-5.09, p=0.007). Conclusions: For those who underwent EST in a large community setting with a standardized approach to acute stroke treatment, being elderly was associated with a higher risk of 90-day mortality. Further data analyses are being carried out with additional co-morbidities, inpatient complications, and 90-day functional outcome to better understand outcomes in older patients undergoing EST.

Supplemental Digital Content is available in the text., Background and Purpose— Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California’s Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates. Methods— The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge. Results— This study included 310 patients treated with alteplase in the pre–EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (P

Objectives: To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS). Methods : A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out. Results : No significant differences among the 3 groups were observed at all time points ( p =0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations. Conclusion : Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect. Saudi Med J 2017; Vol. 38 (10): 994-999 doi: 10.15537/smj.2017.10.20294 How to cite this article: Mismar AA, Mahseeri MI, Al-Ghazawi MA, Obeidat FW, Albsoul MN, Al-Qudah MS, et al. Wound infiltration with bupivacaine 0.5% with or without adrenaline does not decrease pain after thyroidectomy. A randomized controlled study. Saudi Med J . 2017 Oct;38(10):994-999. doi: 10.15537/smj.2017.10.20294.

This creative work features three poems: Charges Against a Newborn, Unanswered, For the First Generation.

Our society is facing a growing threat from data breaches where confidential information is stolen from computer servers. In order to steal data, hackers must first gain entry into the targeted systems. Commercial off-the-shelf intrusion detection systems are unable to defend against the intruders effectively. This research uses cyber behavior analytics to study and report how anomalies compare to normal behavior. In this paper, we present methods based on machine learning algorithms to detect intruders based on the file access patterns within a user file directory. We proposed a set of behavioral features of the user’s file access patterns in a file system. We validate the effectiveness of the features by conducting experiments on an existing file system dataset with four classification algorithms. To limit the false alarms, we trained and tested the classifiers by optimizing the performance within the lower range of the false positive rate. The results from our experiments show that our approach was able to detect intruders with a 0.94 F1 score and false positive rate of less than 3%.

Many breast cancer therapies have adverse effects on the cardiovascular health of patients. Breast cancer patients who are members of racial/ethnic minority and disadvantaged socioeconomic groups suffer disproportionately from cardiotoxicity during and after cancer treatment, leading to disparities in overall survival. These disparities may exist, in part, because of inequality in the management of pre-existing cardiovascular diseases and its risk factors such as hypertension and diabetes. Shared lifestyle risk factors for breast cancer and cardiovascular diseases, including obesity, poorer diet, and lack of physical activity may contribute to disparate outcomes in cardiotoxicity. In addition, patients of racial/ethnic minority and disadvantaged socioeconomic groups may have limited access to cardio-oncology care due to lack of insurance coverage and longer geographic distance from their health care provider. Patients living in disadvantaged neighborhoods may lack healthy food options and exercise facilities, thus are unable to follow a heathier lifestyle. We present evidence from prior studies on these potential mechanisms of disparities in cardiotoxicity and accompanying gaps in research. Finally, we introduce our ongoing Pathways Heart Study (R01 CA21 4057, mPI: Kwan, Greenlee), a large population-based study of nearly 15,000 breast cancer survivors and 75,000 noncancer controls who are members of Kaiser Permanente Northern California, which is an extension of the Pathways Study of 4,505 breast cancer survivors (U01 CA19 5565, mPI: Kushi, Ambrosone). Our study provides a unique opportunity to better understand the individual and health care system level contributors to risk of cardiotoxic outcomes. Citation Format: Zaixing Shi, Heather Greenlee, Romain S. Neugebauer, Carlos Iribarren, Mai N. Nguyen-huynh, Jamal S. Rana, Dawn L. Hershman, Lawrence H. Kushi, Marilyn L. Kwan. Disparities in cardiovascular disease incidence in breast cancer survivors [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr IA28.

12016 Background: Breast cancer (BC) survivors are at increased risk of cardiovascular disease (CVD) following diagnosis, as compared to women without BC. To provide a population-based estimate of CVD risk in BC survivors, we compared risk of CVD events in women with and without BC history enrolled in the Kaiser Permanente Northern California (KPNC) integrated health system. Methods: Data were extracted from KPNC electronic health records. All invasive BC cases diagnosed between 2005-2013 were identified and matched 1:5 with non-BC controls on birth year, race/ethnicity and KPNC membership at date of BC diagnosis. Cox regression models were used to assess differences in the hazard of four major CVD events (ischemic heart disease (IHD), heart failure (HF), cardiomyopathy, and stroke). Models were adjusted for factors known to influence risk of breast cancer or CVD.Other CVD events included arrhythmia, cardiac arrest, carotid disease, myocarditis/pericarditis, transient ischemic attack, valvular disease, and venous thromboembolism (VTE). We additionally examined subgroups of cases who received chemotherapy, radiation, and endocrine therapy, and their controls. Results: A total of 14,942 women with a new diagnosis of invasive BC were identified and matched to 74,702 women without BC history. On average, women were 62.0 years, 28.3 kg/m2BMI, 64.9% non-Hispanic white. Among all cases and controls, there were no significant differences in hazard of developing IHD, cardiomyopathy, and stroke; there was a borderline difference in HF (HR: 1.08, 95% CI: 0.99, 1.19). Cases were more likely to have a cardiac arrest (HR: 1.39, 95% CI: 1.09, 1.78) and develop VTE (HR: 1.97, 95% CI: 1.74, 2.23). Women treated with chemotherapy were more likely than controls to develop HF (HR: 1.44, 95% CI: 1.21, 1.72), cardiomyopathy (HR: 2.01, 95% CI: 1.02, 3.98), and VTE (HR: 3.15, 95% CI: 2.62, 3.79). Women who received radiation therapy were more likely to develop carotid disease (HR: 5.49, 95% CI: 1.22, 24.66) and VTE (HR: 1.65, 95% CI: 1.35, 2.03) than controls. Women who received endocrine therapy were more likely to experience a cardiac arrest (HR: 1.49, 95% CI: 1.07, 2.09) and develop VTE (HR: 1.70, 95% CI: 1.42, 2.03) than controls. Conclusions: Women with BC were at increased risk of heart failure, cardiomyopathy, cardiac arrest, VTE and carotid disease. These risks varied by cancer treatment, with higher risk in those who received chemotherapy. Future studies should explore the effects of chemotherapy class and radiation dose exposure on diverse CVD endpoints in BC survivors.

12017 Background: Women with a history of breast cancer (BC) are at increased long-term risk of dying from cardiovascular disease (CVD). However, the onset of CVD risk factors in women with BC has not been well-described. We compared risk of incident CVD risk factors in women with and without BC enrolled in the Kaiser Permanente Northern California (KPNC) integrated health system. Methods: Data were extracted from KPNC electronic health records. All invasive BC cases diagnosed between 2005-2013 were identified and matched 1:5 with controls on birth year, race/ethnicity and KPNC membership at the date of BC diagnosis. Cox regression models assessed the hazard of incident hypertension (based on diagnosis codes and filled prescriptions), dyslipidemia (based on diagnosis codes, filled prescriptions, and lab values), and diabetes (KPNC Diabetes Registry). Models were adjusted for baseline BMI, menopausal status, smoking status, neighborhood median household income, education, prevalent CVD conditions, and other baseline CVD risk factors. Subgroups of women who received chemotherapy, radiation therapy, and endocrine therapy were compared with controls. Results: A total of 14,942 women with a new diagnosis of invasive BC were identified and matched to 74,702 controls. On average, women were 62.0 years, 28.3 kg/m2BMI, 64.9% non-Hispanic white. Overall, cases were more likely to develop hypertension (HR: 1.18, 95% CI: 1.13, 1.24) and diabetes (HR: 1.23, 95% CI: 1.16, 1.31). Across the board, receipt of any of the three therapies (chemotherapy, radiation therapy and endocrine therapy) was associated with increased risk of hypertension and diabetes, compared to controls. Risk-factor specific hazard ratios for receipt of chemotherapy were (HR 1.18, 95% CI: 1.10, 1.27) and (HR 1.38, 95% CI: 1.26, 1.51), for hypertension and diabetes, respectively. For receipt of radiation therapy, risk-factor specific hazard ratios were (HR: 1.17, 95% CI: 1.09, 1.26) and (HR: 1.15, 95% CI: 1.04, 1.27), for hypertension and diabetes, respectively. Risk-factor specific hazard ratios for receipt of endocrine therapy were (HR: 1.22, 95% CI: 1.14, 1.30) and (HR: 1.16, 95% CI: 1.06, 1.27), for hypertension and diabetes, respectively. Conclusions: The risk of developing hypertension and diabetes is increased in women with BC who received chemotherapy, radiation therapy, and/or endocrine therapy. Future studies should examine the roles of CVD risk factor diagnosis and management on cardiometabolic risk in women with a BC history.

Background: Whether patients with acute stroke and large vessel occlusion (LVO) may benefit from prehospital identification and diversion by EMS to a center offering endovascular therapy (EST) is controversial. The accuracy of prehospital scales as predictors of LVO is only one feature of whether EMS can effectively identify patients suitable for EST. Other factors include accuracy of last known well time (LTKW) and identification of stroke mimics. We performed a population-based estimate of potential accuracy of field based identification of potential EST candidates in a large community setting. Methods: In Kaiser Permanente Northern California, all acute stroke patients arriving at its 19 primary stroke centers (PSC) between 7am and 12am were evaluated on arrival by stroke neurologists by video. We reviewed the teleneurology notes to determine the potential accuracy of EST selection based on NIHSS score > 7. Results: For 2016, there were 2546 total potential stroke alerts triaged by EMS as having potential acute strokes [Figure]. Of these, 1268 (50%) were not candidates for acute stroke treatment for various reasons including stroke mimics and inaccurate LTKW. Out of 1241 cases deemed candidates for acute stroke treatment, 638 (25.1%) had potential LVO based on NIHSS > 7. Of these, 116 (4.6% of total “potential strokes” and 18.2% of patients who had “severe” strokes) were diagnosed with LVO and treated with EST. Conclusions: Even if field based tools were as accurate as clinical scoring by stroke neurologists, less than 1 in 4 patients diverted to endovascular stroke centers and away from closer PSC would benefit by receiving EST. Given that 50% of patients triaged by EMS did not qualify for any acute stroke treatment, a lower percentage of patients would actually benefit from field based diversion. Stroke systems may be better served by focusing on rapid treatment, evaluation, and transfer to endovascular centers than field based diversion strategies.

Background: In Kaiser Permanente Northern California (KPNC), an integrated healthcare system with a high overall hypertension (HTN) control rate, blacks still had poorer blood pressure (BP) control than whites. The “Shake, Rattle and Roll” (SRR) trial is named for: 1) “shake” the salt habit; 2) “rattle” the intensity of current BP management; and 3) adapt and “roll” out the interventions to other communities. Successful lifestyle (LS) interventions tend to be short-lived. We evaluated the effect of LS intervention in SRR on BP control at 12 months after the trial ended. Methods: SRR is a pragmatic cluster-randomized controlled trial conducted at Kaiser Oakland. All PCPs and their panels of black patients were randomized, stratified by panel size, to one of 3 arms: 1) usual care (UC); or 2) enhanced monitoring (EM) of KPNC BP management protocol; or 3) culturally tailored LS coaching focused on the DASH eating plan. Black patients from KPNC HTN Registry with a persistent high BP reading ≥ 140/90 qualified to be recruited into SRR. The intervention period lasted 12 months followed by 15 months of data collection with no participant contact. We assessed BP control rates using the latest follow-up BP measurements between enrollment and 27 months post-enrollment. Data on demographics and medications were collected from participants’ EMRs. Results: We randomized 98 PCPs. There were 1,129 enrolled in UC, 346 in EM and 286 in LS. Median age was 61 years. At the end of 12 months post-intervention, BP control rates were higher in LS than in UC (73.2% vs. 60.6%, p Conclusions: Participants in LS arm continued to have better BP control than UC at 12 months after intervention ended in SRR. The sustainability of a culturally appropriate LS intervention with a focus on DASH should be studied further for implementation in adults with uncontrolled HTN.

Background: Risks and benefits of acute thrombolysis in elderly stroke patients remained unclear, especially in those aged ≥90 years. We evaluated the safety of thrombolysis in the elderly in a large integrated healthcare system. Methods: In 2016, Kaiser Permanente Northern California (KPNC) launched a new standardized acute telestroke care workflow for all 21 stroke centers. It included immediate evaluation by a stroke neurologist via video, an expedited IV alteplase treatment program, rapid CT angiographic investigation, and expedited transfer and treatment for patients with large vessel occlusion (LVO). We compared patient characteristics, door-to-needle (DTN) times and symptomatic intracranial hemorrhage (sICH) rates between those treated with IV alteplase aged Results: For 2016, our Telestroke program gave IV alteplase to 646 KP members [Table]. The oldest subgroup had a higher percentage of female and higher rates of vascular risk factors. They were more likely to arrive by EMS, to have a higher initial NIHSS and to have a LVO. Average DTN times were not different between the three age groups. There were no differences in the rates of sICH and length of stay. The in-hospital mortality rate was higher in the elderly, possibly due to higher rates of comorbidities. In multivariable model, after adjusting for demographics, co-morbidities, EMS arrival, sICH, NIHSS, and DTN, being elderly did not affect the likelihood of being discharged home post-thrombolysis (OR=0.56, 95% CI 0.29-1.07, p=0.08). Conclusions: In a large community setting with a standardized approach to acute stroke treatment, our data supported IV alteplase use in elderly patients. It is important to consider pre-stroke disability when deciding on thrombolysis in the elderly.

Background: In 2015, trials showed that rapid endovascular stroke treatment (EST) of qualified patients with large vessel occlusion (LVO) resulted in improved outcomes over treatment with IV tPA alone. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for its 21 stroke centers, which included expedited IV t-pa treatment, rapid CTA investigation, expedited transfer of appropriate patients for EST. We assessed for predictors of LVO post-implementation. Methods: The KPNC Stroke EXPRESS program was live in all centers by January 2016. Using clinical data for 1/1/16 - 7/10/16, we evaluated the frequency and locations of LVO, and patient characteristics of those with LVO. Multivariate logistic regression was used to examine whether age, gender, race, or an NIHSS ≥ 8 are predictors of LVO. Results: There were 2,204 tele-stroke alert cases from the ED. Among 993 (39.3%) that proceeded as likely acute stroke, 812 (81.8%) were evaluated with CTA. Out of those who had a CTA, 152 (18.7%) were found to have LVO as followed: 27 (17.8%) ICA, 87 (57.2%) M1, 24 (15.8%) M2, 6 (4.0%) basilar, 5 (3.3%) PCA, and 3 (2.0%) vertebral. Of those with LVO, 97 (63.8%) were treated with EST. Patients with LVO had a higher median NIHSS (15 vs. 5 in those without LVO). Neglect (27% vs. 7%) and gaze deviation (16% vs. 1%) were more likely to be seen among those with LVO and treated with EST compared to those without LVO. In multivariate analysis, age (OR=1.02, 95% CI 1.00 - 1.03, p=0.01) and NIHSS ≥8 (OR = 4.99, 95% CI 3.32- 7.49, p < 0.001) were associated with LVO. PPV for NIHSS ≥8 was 75.7%. Conclusions: In our large multi-ethnic population of acute stroke patients, a relatively small percentage (19%) was found to have LVO and only a subset qualified for EST. Predictors of LVO included NIHSS ≥8, increasing age, and presence of neglect and gaze preference. Given the low numbers of patients brought in for acute stroke treatment who ended up with a LVO requiring EST, further research is needed to assess a given system’s ability to rapidly evaluate and transfer as appropriate for EST rather than paramedic based diversion.

Background: Faster treatment with tPA in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke workflow across all 21 KPNC stroke centers to have all stroke alerts actively managed by a core group of vascular neurologists via telemedicine. We examined the effect of KPNC’s Stroke EXPRESS (EXpediting the PRrocess of Evaluating and Stopping Stroke) program on door-to-needle (DTN) time and symptomatic intracranial hemorrhage (sICH) rates. Methods: The Stroke EXPRESS program was rolled out across KPNC in a staggered fashion from 9/2015 to 1/2016 with the goals of expediting the evaluation and determination for tPA and speeding up the assessment for large vessel occlusion to allow for timely transfer for thrombectomy. We compared DTN times for 6 months before implementation to the same 6-month calendar period after implementation. Results: After implementation, tPA administrations increased from 38/month at baseline to 80/month (P Conclusions: Implementation of the Stroke EXPRESS regional telemedicine program in KPNC was associated with an increase in tPA administrations, markedly shorter DTN times, and no change in the rate of sICH.

Background: Field-based diversion for potential stroke patients who may qualify for endovascular stroke therapy (EST) has been proposed more widely in 2015. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for all its 21 stroke centers, which included rapid evaluation of all stroke alerts by a stroke neurologist via teleneurology. We investigated the accuracy of EMS-activated stroke alerts. Methods: From 1/1/16 to 7/10/16, all acute strokes presenting to an ED between 7 AM and midnight were assessed upon arrival by a teleneurologist. We reviewed all telestroke cases to determine the frequency of tPA given, cancelled stroke alerts, and the reasons for not treating with IV t-PA, particularly among ambulance arrivals. Multivariate logistic regression was used to assess age, gender, race, Kaiser membership, and mode of ED arrival as predictors of stroke alert cancellation. Results: There were 2192 stroke alerts activated. Of these, 1332 (60.7%) arrived by EMS and 860 (39.2%) by non-EMS transport. Of patients arriving by EMS, 651 (48.9%) were cancelled and deemed ineligible for IV t-PA. Most common reasons for cancellation were: last time known well (LTKW) out of range (23%), stroke mimic (33%), symptom resolution (19%), new data regarding goals of care (2%), and other (22.5%). The remaining 681 (51.1%) ambulance arrivals were potential candidates for IV tPA. Subsequently, 334 (50.4%) of them received tPA. Reasons for tPA not given included subsequent resolution of symptoms, concerning CT findings (such as bleed), INR>1.7 in patients on warfarin, further information clarifying time of onset. Among those who arrived by EMS and received IV t-PA, all had CTA and 103 (30.8%) were found to have a large vessel occlusion and 74 (71.8%) underwent EST. In multivariate analysis for all cancelled stroke alerts, arrival by non-EMS transport (OR=1.74, 95% CI 1.44-2.10, p Conclusions: Close to half of EMS-activated stroke alerts were cancelled upon initial assessment. Only 5% of patients initially identified by EMS as having a potential acute stroke ultimately underwent EST. Better determination of LTKW and stroke symptoms would improve the accuracy of EMS-initiated stroke alerts.

Background: Dysphagia or difficulty swallowing occurs in up to 50% of patients with acute stroke symptoms. Dysphagia screening is considered standard stroke care. Few dysphagia screening tools have been well validated with high sensitivity and specificity. Purpose: The purpose was to validate our system’s dysphagia screening tool. Methods: From August 17, 2015 through September 30, 2015, bedside dysphagia screening was prospectively performed by 2 blinded nurses on all patients age ≥18 years admitted through the emergency department with stroke symptoms at 22 stroke centers in an integrated healthcare system. The tool consisted of three parts: history, physical exam and progressive testing from ice chips to water. A speech language pathologist blinded to the results performed an evaluation on the same patient. Patients with a feeding tube or intubation on arrival, treated with alteplase, or were discharged with a diagnosis other than stroke were excluded from final study analyses. The study quantified the reproducibility of the dysphagia screening tool by computing the percent agreement and kappa score for inter-rater reliability. Validity of dysphagia screening tool was determined using the speech pathologist evaluation as the reference standard. We assessed the sensitivity, specificity, and negative (NPV) and positive predictive values (PPV) for the dysphagia screening tool. The point estimate and 95% confidence interval (CI) were calculated. Results: Dysphagia screening was performed in 726 patients with stroke symptoms. There were 370 patients included in the analysis. Average age was 70 ± 14 years, and 48.2% female. Inter-rater reliability of the dysphagia screen was excellent between both raters at 93.5% agreement (k’= 0.83). The screen performed well when compared to speech language pathologist evaluation, demonstrating both high sensitivity (86.4%, CI: 73.3% to 93.6%) and high NPV (93.6%, CI: 86.8% to 97.0%). Conclusion: Our bedside dysphagia screening tool is highly reliable and valid. The tool had been used in over thirty-five facilities since 2007. The hospital acquired pneumonia rate for ischemic stroke patients has averaged 2-3% a year. This dysphagia screening tool requires minimal training and is easily administered in a timely manner.

Background: Prior published studies reported disparities in timely treatment with tPA for stroke patients who were older, African American or female. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for the entire region, which included immediate evaluation by a stroke neurologist via video, an expedited IV tPA treatment program, rapid CT angiographic investigation, and expedited transfer of appropriate patients with large vessel occlusion (LVO) for endovascular stroke treatment (EST). We sought to evaluate whether disparities exist in acute stroke treatment within the redesigned process. Methods: KPNC is an integrated health care system with 21 certified stroke centers serving 3.9+ millions members. All centers implemented the new program by January 2016. Using clinical data from 1/1/16 to 7/10/16, we evaluated the frequency of IV tPA administration by gender, race, and age groups after implementation of the new process. We performed multivariate analysis with age, gender, race-ethnicity, Kaiser membership, mode of ED arrival (by ambulance vs. private transportation) to assess for any disparities in achieving DTN time. Results: Post implementation, we found no significant differences in the rates of IV t-pa administration in eligible patients based on race, gender, age category ( Conclusions: Thus far, we have found no disparities in the use of IV tPA or DTN time for a large integrated healthcare system after implementation of the Stroke EXPRESS program. A consistent standardized approach to acute stroke care may help to reduce disparities on the basis of race, gender, age, or even membership in healthcare system.

(1) Background: Markers identifying which patients with metastatic, castration-resistant prostate cancer (mCRPC) will benefit from cabazitaxel therapy are currently lacking. Therefore, the aim of this study was to identify markers associated with outcome to cabazitaxel therapy based on counts and gene expression profiles of circulating tumor cells (CTCs). (2) Methods: From 120 mCRPC patients, CellSearch enriched CTCs were obtained at baseline and after 6 weeks of cabazitaxel therapy. Furthermore, 91 genes associated with prostate cancer were measured in mRNA of these CTCs. (3) Results: In 114 mCRPC patients with an evaluable CTC count, the CTC count was independently associated with poor progression-free survival (PFS) and overall survival (OS) in multivariable analysis with other commonly used variables associated with outcome in mCRPC (age, prostate specific antigen (PSA), alkaline phosphatase, lactate dehydrogenase (LDH), albumin, hemoglobin), together with alkaline phosphatase and hemoglobin. A five-gene expression profile was generated to predict for outcome to cabazitaxel therapy. However, even though this signature was associated with OS in univariate analysis, this was not the case in the multivariate analysis for OS nor for PFS. (4) Conclusion: The established five-gene expression profile in CTCs was not independently associated with PFS nor OS. However, along with alkaline phosphatase and hemoglobin, CTC-count is independently associated with PFS and OS in mCRPC patients who are treated with cabazitaxel.

Disparities in health care access and socioeconomic status (SES) have been associated with racial-ethnic differences in blood pressure (BP) control. We examined post-ischemic stroke BP in a multiethnic cohort with good health care access. We included all hypertensive patients (n = 2972) from a randomized quality improvement trial on secondary stroke prevention, conducted in 14 Kaiser Permanente hospitals in Northern California from 2004-2006 (QUISP). Average age 73.2 ± 12.2 years; 52% female, 66% non-Hispanic white, 14% African-American, 11% Asian, 8% Hispanic, and 1% other. Demographics, diagnoses, health care utilization, BP measurements, and medications were obtained as part of routine care. We used random effects logistic regression models to examine race as a predictor of blood pressure control (140/90 mm Hg) at 6 months post-discharge, adjusted for SES, age, gender, dementia, antihypertensive therapy, and attendance at follow-up visits. At 6 months, BP was controlled in 52.7% of blacks compared to 61.4% of whites (OR = 0.63, 95% CI, 0.48-0.82, P = .001). Black race remained independently associated with poorer BP control in adjusted analysis, although blacks were as likely to attend post-discharge visits, and more likely to be on any antihypertensive therapy than whites. Greater difficulty in controlling BP and lifestyle differences may account for this difference.

Multidrug-resistant tuberculous meningitis is fatal without rapid diagnosis and use of second-line therapy. It is more common in human immunodeficiency virus (HIV)-positive patients. Beijing genotype strains of Mycobacterium tuberculosis are associated with drug resistance, particularly multidrug resistance, and their prevalence is increasing worldwide. The prevalence of Beijing genotype strains among Mycobacterium tuberculosis isolates from the cerebrospinal fluid of HIV-positive ( n = 35) and HIV-negative ( n = 187) patients in Ho Chi Minh City was determined. The Beijing genotype was significantly associated with HIV status (odds ratio [OR] = 2.95 [95% confidence interval {CI}, 1.38 to 6.44]; P = 0.016), resistance to any drug (OR = 3.34 [95% CI, 1.87 to 5.95]; P < 0.001) and multidrug resistance (Fisher's exact test; P = 0.001). The association of the Beijing genotype with drug resistance was independent of HIV status. This is the first report of Beijing genotype association with HIV status, which may be an association unique to tuberculous meningitis.

We used large sequence polymorphisms to determine the genotypes of 397 isolates of Mycobacterium tuberculosis from human immunodeficiency virus-uninfected Vietnamese adults with pulmonary ( n = 235) or meningeal ( n = 162) tuberculosis. We compared the pretreatment radiographic appearances of pulmonary tuberculosis and the presentation, response to treatment, and outcome of tuberculous meningitis between the genotypes. Multivariate analysis identified variables independently associated with genotype and outcome. A higher proportion of adults with pulmonary tuberculosis caused by the Euro-American genotype had consolidation on chest X-ray than was the case with disease caused by other genotypes ( P = 0.006). Multivariate analysis revealed that meningitis caused by the East Asian/Beijing genotype was independently associated with a shorter duration of illness before presentation and fewer cerebrospinal fluid (CSF) leukocytes. Older age, fewer CSF leukocytes, and the presence of hemiplegia (but not strain lineage) were independently associated with death or severe disability, although the East Asian/Beijing genotype was strongly associated with drug-resistant tuberculosis. The genotype of M. tuberculosis influenced the presenting features of pulmonary and meningeal tuberculosis. The association between the East Asian/Beijing lineage and disease progression and CSF leukocyte count suggests the lineage may alter the presentation of meningitis by influencing the intracerebral inflammatory response. In addition, increased drug resistance among bacteria of the East Asian/Beijing lineage might influence the response to treatment. This study suggests the genetic diversity of M. tuberculosis has important clinical consequences.

Summary Salmonellosis is a public health concern in both the developed and developing countries. Although the majority of human non‐typhoidal Salmonella enterica (NTS) cases are the result of foodborne infections or person‐to‐person transmission, NTS infections may also be acquired by environmental and occupational exposure to animals. While a considerable number of studies have investigated the presence of NTS in farm animals and meat/carcasses, very few studies have investigated the risk of NTS colonization in humans as a result of direct animal exposure. We investigated asymptomatic NTS colonization in 204 backyard chicken farms, 204 farmers and 306 matched individuals not exposed to chicken farming, in southern Vietnam. Pooled chicken faeces, collected using boot or handheld swabs on backyard chicken farms, and rectal swabs from human participants were tested. NTS colonization prevalence was 45.6%, 4.4% and 2.6% for chicken farms, farmers and unexposed individuals, respectively. Our study observed a higher prevalence of NTS colonization among chicken farmers (4.4%) compared with age‐, sex‐ and location‐ matched rural and urban individuals not exposed to chickens (2.9% and 2.0%). A total of 164 chicken NTS strains and 17 human NTS strains were isolated, and 28 serovars were identified. Salmonella Weltevreden was the predominant serovar in both chickens and humans. NTS isolates showed resistance (20–40%) against tetracycline, chloramphenicol, sulfamethoxazole‐trimethoprim and ampicillin. Our study reflects the epidemiology of NTS colonization in chickens and humans in the Mekong delta of Vietnam and emphasizes the need of larger, preferably longitudinal studies to study the transmission dynamics of NTS between and within animal and human host populations.

Stroke is the fourth killer and number one cause of adult disability in the United States. The estimated direct and indirect costs of stroke care in this country are $68.9 billion for 2009. The prevalence of stroke and its cost will undoubtedly rise as the aging population increases. In addition, stroke incidence and mortality are increasing in less developed countries in which the lifestyles and population restructuring are rapidly changing. More population-based research to assess incidence, risk factors, and outcomes are needed in these countries. Epidemiologic studies can help identify groups of individuals or regions at higher risk for stroke. They can also help us better understand the natural history of certain conditions and therefore push the direction of therapeutic investigations. Furthermore, the study of trends across different time periods and different populations can help investigators evaluate the effects of stroke care programs and treatment options.

BACKGROUND AND PURPOSE: It is unclear whether the costs and risks of mechanical therapies make them cost-effective. We examined whether interventions such as mechanical clot removal or disruption with angioplasty are cost-effective for acute ischemic stroke compared with best medical therapy. MATERIALS AND METHODS: We performed a cost-utility analysis of patients with acute stroke due to large intracranial artery occlusion presenting beyond the 3-hour window for IV tPA. Model inputs for the mechanical arm were derived from Multi MERCI trial data and a recent meta-analysis. For best medical therapy, we used rates of spontaneous recanalization, ICH, and functional outcomes based on a systematic literature review. Discounted QALYs were determined by using the Markov modeling for 65-year-old patients with acute ischemic stroke. RESULTS: On the basis of a systematic literature review, we modeled an 84% rate of recanalization with mechanical intervention and a 6.3% rate of symptomatic ICH. For best medical therapy, we modeled a spontaneous recanalization rate of 24% with a 2% rate of symptomatic ICH. Mechanical therapies were associated with a $7718 net cost and a gain of a 0.82 QALYs for each use, thus yielding a net of $9386/QALY gained. In sensitivity analyses, results were dependent on the rates of recanalization, symptomatic ICH rates, and costs of treatment. CONCLUSIONS: On the basis of available data, mechanical therapies in qualified patients with acute stroke beyond the window for IV tPA appear to be cost-effective. However, the inputs are not derived from randomized trials, and results are sensitive to several assumptions.

Background and Purpose— Clinical scores help predict outcome after transient ischemic attack (TIA), and imaging studies may improve the accuracy of predictions. Intracranial large vessel occlusion (LVO) predicts poor outcome after stroke, but the natural history of symptomatic intracranial LVO in patients with TIA is unknown. Methods— We studied patients presenting with TIA in the STOP Stroke Study, a prospective imaging-based study of stroke outcomes. All patients underwent brain CTA. If an intracranial vascular occlusion was found in an appropriate territory to account for clinical findings, then it was judged to be a symptomatic LVO. Baseline characteristics, follow-up events, and outcomes were collected. Characteristics of patients with and without LVO were compared using χ 2 and t tests. Predictors of LVO were analyzed by univariate and multivariate analysis. LVO was assessed as a predictor of asymptomatic outcome (modified Rankin scale [mRS] score, 0), poor outcome (mRS score ≤3), and increase in mRS score over the study period. Results— Of 97 patients with TIA, 13 (13%) had symptomatic intracranial LVO. Patients with LVO had higher baseline NIHSS on emergency department arrival, which was an independent predictor of LVO (OR, 1.15 per point; 95% CI, 1.02–1.29; P =0.02). Patients with LVO were more likely to have an increase in mRS score during the 90-day follow-up ( P =0.03). LVO independently predicted an increase in mRS score (OR, 4.76; 95% CI, 1.23–18.43; P =0.02) and was a borderline predictor of poor outcome (mRS score ≥3; OR, 5.07; 95% CI, 0.92–28.03; P =0.06). Conclusions— LVO is found in >1 in 10 patients presenting with TIA and predicts a decline in functional status, likely attributable to new brain ischemia.

Background and Purpose— Gender differences in carotid endarterectomy (CEA) rates after transient ischemic attack are not well studied, although some reports suggest that eligible men are more likely to have CEA than women after stroke. Methods— We retrospectively identified all patients diagnosed with transient ischemic attack and ≥70% carotid stenosis on ultrasound in 2003 to 2004 from 19 emergency departments. Medical records were abstracted for clinical data; 90-day follow-up events, including stroke, cardiovascular events, or death; CEA within 6 months; and postoperative 30-day outcomes. We assessed gender as a predictor of CEA and its complications adjusting for demographic and clinical variables as well as time to CEA between groups. Results— Of 299 patients identified, 47% were women. Women were older with higher presenting systolic blood pressure and less likely to smoke or to have coronary artery disease or diabetes. Fewer women (36.4%) had CEA than men (53.8%; P =0.004). Reasons for withholding surgical treatment were similar in women and men, and there were no differences in follow-up stroke, cardiovascular event, postoperative complications, or death. Time to CEA was also significantly delayed in women. Conclusions— Women with severe carotid stenosis and recent transient ischemic attack are less likely to undergo CEA than men, and surgeries are more delayed.

Objectives Heart disease and stroke remain among the leading causes of death nationally. We examined whether differences in recent trends in heart disease, stroke, and total mortality exist in the United States and Kaiser Permanente Northern California (KPNC), a large integrated healthcare delivery system. Methods The main outcome measures were comparisons of US and KPNC total, age-specific, and sex-specific changes from 2000 to 2015 in mortality rates from heart disease, coronary heart disease, stroke, and all causes. The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research data system was used to determine US mortality rates. Mortality rates for KPNC were determined from health system, Social Security vital status, and state death certificate databases. Results Declines in age-adjusted mortality rates were noted in KPNC and the United States for heart disease (36.3% in KPNC vs 34.6% in the United States), coronary heart disease (51.0% vs 47.9%), stroke (45.5% vs 38.2%), and all-cause mortality (16.8% vs 15.6%). However, steeper declines were noted in KPNC than the United States among those aged 45 to 65 years for heart disease (48.3% KPNC vs 23.6% United States), coronary heart disease (55.6% vs 35.9%), stroke (55.8% vs 26.0%), and all-cause mortality (31.5% vs 9.1%). Sex-specific changes were generally similar. Conclusions Despite significant declines in heart disease and stroke mortality, there remains an improvement gap nationally among those aged less than 65 years when compared with a large integrated healthcare delivery system. Interventions to improve cardiovascular mortality in the vulnerable middle-aged population may play a key role in closing this gap.

Young adults may be introducing Beijing strains., Tuberculosis case notification rates (CNRs) for young adults in Vietnam are increasing. To determine whether this finding could reflect emergence of Mycobacterium tuberculosis Beijing genotype, we studied all new sputum smear–positive pulmonary tuberculosis patients registered for treatment in 3 rural districts in Vietnam during 2003–2006. Beijing strain infections were more frequent in younger patients (15–24 years of age, 53%) than in older patients (31%; p65 years of age, respectively (p

Purpose. To evaluate the role of spectral-domain optical coherence tomography (SD-OCT) in early detection of Chloroquine maculopathy in rheumatoid arthritis (RA) patients.Methods. 40 left eyes of 40 female rheumatoid arthritis patients who received treatment chloroquine for more than one year were recruited in the study. All patients had no symptoms or signs of Chloroquine retinopathy. They were evaluated using SD-OCT, where the Central Foveal Thickness (CFT), parafoveal thickness and perifoveal thickness, average Retinal Nerve Fiber Layer (RNFL) thickness, and Ganglion Cell Complex (GCC) measurements were measured and compared to 40 left eyes of 40 normal females.Results. The mean CFT was found to be thinner in the Chloroquine group (238.15 µm ± 22.49) than the normal controls (248.2 µm ± 19.04), which was statistically significant (pvalue = 0.034). The mean parafoveal thickness was lesser in the Chloroquine group than the control group in all quadrants (pvalue<0.05). The perifoveal thickness in both groups showed no statistically significant difference (pvalue>0.05) in all quadrants. No significant difference was detected between the two groups regarding RNFL, GCC, or IS/OS junction.Conclusions. Preclinical Chloroquine toxicity can lead to early thinning in the central fovea as well as the parafoveal regions that is detected by SD-OCT.