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Fall risk assessment is a complex phenomenon involving several risk factors, including an individual's balance and mobility status, chronic health conditions, visual impairment, hearing deficits, environmental hazards (e.g., loose rugs, clutter), and being homebound or semi-homebound. Comprehensive fall risk assessment is the cornerstone of fall prevention in older adults throughout the community. The current study was based on secondary data and sought to examine variables associated with death due to accidental fall in a rural, midwestern county in Illinois, and to heighten awareness for consistent screening and risk assessment in older adults residing in the community. Results illustrated that among community-dwelling older adults with accidental falls, blunt injury or subdural hematoma had significantly fewer days until death than a fracture. [ Journal of Gerontological Nursing, 48 (6), 26–32.]

Background: The Los Angeles Motor Scale (LAMS) is a rapid pre-hospital scale used to predict stroke severity which has also been shown to accurately predict large vessel occlusions (LVOs). However, to date there is no study exploring whether LAMS correlates with the computed tomography perfusion (CTP) parameters in LVOs. Methods: Patients with LVO between September 2019 and October 2021 were retrospectively reviewed and included if the CTP data and admission neurologic exams were available. The LAMS was documented based on emergency personnel exams or scored retrospectively using an admission neurologic exam. The CTP data was processed by RAPID (IschemaView, Menlo Park, CA, USA) with an ischemic core volume (relative cerebral blood flow [rCBF] < 30%), time-to-maximum (Tmax) volume (Tmax > 6 s delay), hypoperfusion index (HI), and cerebral blood volume (CBV) index. Spearman’s correlations were performed between the LAMS and CTP parameters. Results: A total of 85 patients were included, of which there were 9 intracranial internal carotid artery (ICA), 53 proximal M1 branch middle cerebral artery M1, and 23 proximal M2 branch occlusions. Overall, 26 patients had LAMS 0–3, and 59 had LAMS 4–5. In total, LAMS positively correlated with CBF < 30% (Correlation Coefficient (CC): 0.32, p < 0.01), Tmax > 6 s (CC:0.23, p < 0.04), HI (CC:0.27, p < 0.01), and negatively correlated with the CBV index (CC:−0.24, p < 0.05). The relationships between LAMS and CBF were < 30% and the HI was more pronounced in M1 occlusions (CC:0.42, p < 0.01; 0.34, p < 0.01 respectively) and proximal M2 occlusions (CC:0.53, p < 0.01; 0.48, p < 0.03 respectively). The LAMS also correlated with a Tmax > 6 s in M1 occlusions (CC:0.42, p < 0.01), and negatively correlated with the CBV index in M2 occlusions (CC:−0.69, p < 0.01). There were no significant correlations between the LAMS and intracranial ICA occlusions. Conclusions: The results of our preliminary study indicate that the LAMS is positively correlated with the estimated ischemic core, perfusion deficit, and HI, and negatively correlated with the CBV index in patients with anterior circulation LVO, with stronger relationships in the M1 and M2 occlusions. This is the first study showing that the LAMS may be correlated with the collateral status and estimated ischemic core in patients with LVO.

Background and Purpose: During the coronavirus disease 2019 (COVID-19) pandemic, the various emergency measures implemented to contain the spread of the virus and to overcome the volume of affected patients presenting to hospitals may have had unintended consequences. Several studies reported a decrease in the number of stroke admissions. There are no data on the impact of the COVID-19 pandemic on stroke admissions and stroke care in Maryland. Methods: A retrospective analysis of quality improvement data reported by stroke centers in the State of Maryland. The number of admissions for stroke, overall and by stroke subtype, between March 1 and September 30, 2020 (pandemic) were compared with the same time period in 2019 (prepandemic). Median last known well to hospital arrival time, the number of intravenous thrombolysis and thrombectomy were also compared. Results: During the initial 7 months of the pandemic, there were 6529 total admissions for stroke and transient ischemic attack, monthly mean 938 (95% CI, 837.1–1038.9) versus prepandemic 8003, monthly mean 1156.3 (CI, 1121.3–1191.2), P P P =0.507. Conclusions: Our findings suggest that the COVID-19 pandemic adversely affected the acute care of unrelated cerebrovascular emergencies.

To extract meaningful and reproducible models of brain function from stroke images, for both clinical and research proposes, is a daunting task severely hindered by the great variability of lesion frequency and patterns. Large datasets are therefore imperative, as well as fully automated image post-processing tools to analyze them. The development of such tools, particularly with artificial intelligence, is highly dependent on the availability of large datasets to model training and testing. We present a public dataset of 2,888 multimodal clinical MRIs of patients with acute and early subacute stroke, with manual lesion segmentation, and metadata. The dataset provides high quality, large scale, human-supervised knowledge to feed artificial intelligence models and enable further development of tools to automate several tasks that currently rely on human labor, such as lesion segmentation, labeling, calculation of disease-relevant scores, and lesion-based studies relating function to frequency lesion maps

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min.Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window.Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed.Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time.Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

Background: Stroke is the second leading cause of death and disability worldwide. Stroke centers have become a central component of modern stroke services in many high-income countries, but their feasibility and efficacy in low, middle, and emerging high-income countries are less clear. Also, despite the availability of international guidelines, many hospitals worldwide do not have organized clinical stroke care. We present a methodology to help hospitals develop stroke centers and review quality data after implementation.Objectives: To describe and compare demographics, performance, and clinical outcomes of the Pacífica Salud, Hospital Punta Pacífica (PSHPP) stroke center during its first 3 years 2017–2019.Methods: Pacífica Salud, Hospital Punta Pacífica was organized to implement protocols of care based on the best practices by international guidelines and a quality improvement process. The methodology for implementation adapts a model for translating evidence into practice for implementation of evidence-based practices in medicine. This is a retrospective study of prospectively collected quality data between March of 2017 to December of 2019 for patients admitted to PSHPP with primary diagnosis stroke. Data collected include demographics, clinical data organized per the Joint Commission's STK Performance Measures, door to needle, door to groin puncture, 90 day modified Rankin Score, and hemorrhagic complications from IV thrombolysis and mechanical thrombectomy (MT). Primary outcome: year over year proficiency in documenting performance measures. Secondary outcome: year over year improvement.Results: A total of 143 patients were admitted for acute ischemic stroke, TIA, or hemorrhagic stroke. Of these, 36 were admitted in 2017, 50 in 2018, and 57 in 2019. Performance measure proficiency increased in the year-over-year analysis as did the total number of patients and the number of patients treated with IV thrombolysis and MT.Conclusions: We present the methodology and results of a stroke program implementation in Panamá. This program is the first in the country and in Central America to achieve Joint Commission International (JCI) certification as a Primary Stroke Center (PSC). We postulate that the dissemination of management guidelines is not sufficient to encourage the development of stroke centers. The application of a methodology for translation of evidence into practice with mentorship facilitated the success of this program.

Introduction Patients' perceptions of healthcare quality have become an important part of quality measurement. We explored patients' and family's lived experiences during acute stroke hospitalization to develop a quantitative instrument. Methods Focus groups were conducted using open-ended scripted questions. Interview data were coded and analyzed using an inductive approach to thematic analysis. Symmetric patient and family instruments were developed based on qualitative domains and serially refined to a set of 30 survey items, 12 stroke knowledge test items, and 5 subject demographic fields. Scales were evaluated for internal consistency reliability using Cronbach α; construct validity with exploratory factor analysis using principal components with varimax rotation was performed to determine the extent to which items in a scale measure the same underlying factor. Feasibility of an electronic cloud-based survey was also tested. Results Three main themes emerged: fast action to diagnose and treat stroke, genuine caring, and education to prevent and respond to stroke. A total of 1029 subjects completed the final instrument with no differences in perception found by race, ethnicity, or length of stay. Scales showed satisfactory internal consistency reliability (Cronbach α scores, .89-.94); factor loadings across each scale ranged from 0.55 to 0.87. Data entry by electronic pad was perceived by 77% to be more confidential than paper surveys; median score for difficulty was 4 ("easy to use"). Conclusion The STROKE Perception Report enables understanding of patients' and family's beliefs about the quality of acute stroke care in essential new domains never explored before.

Background and Purpose: At present, stroke patients receiving intravenous thrombolysis (IVT) undergo monitoring of their neurological status and vital signs every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and every hour thereafter up to 24 hours post-IVT. The present study sought to prospectively evaluate whether post-IVT stroke patients with low risk for complications may safely be cared for utilizing a novel low-intensity monitoring protocol. Methods: In this pragmatic, prospective, single-center, open-label, single-arm safety study, we enrolled 35 post-IVT stroke patients. Adult patients were eligible if their NIH Stroke Scale (NIHSS) was less than 10 at the time of presentation, and if they had no critical care needs by the end of the IVT infusion. Patients underwent a low-intensity monitoring protocol during the first 24 hours after IVT. The primary outcome was need for a critical care intervention in the first 24 hours after IVT. Results: The median age was 54 years (range: 32-79), and the median pre-IVT NIHSS was 3 (interquartile range [IQR]: 1-6). None of the 35 patients required transfer to the intensive care unit or a critical care intervention in the first 24 hours after IVT. The median NIHSS at 24 hours after IVT was 1 (IQR: 0-3). Four (11.4%) patients were stroke mimics, and the vast majority was discharged to home (82.9%). At 90 days, the median NIHSS was 0 (IQR: 0-1), and the median modified Rankin Scale was 0 (range: 0-6). Conclusion: Post-IVT stroke patients may be safely monitored in the setting of a low-intensity protocol.

Ischemic stroke remains the fifth leading cause of death in the United States. Nurses play a pivotal role in the care of patients throughout the continuum. With the advances in stroke care, including mechanical thrombectomy, the American Heart Association/American Stroke Association charged the writing panel to complement the 2009 clinical practice guideline, “Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient,” with current evidence-based nursing care. This update is 1 of a 3-part series focusing on emergency medical services/emergency care, endovascular/intensive care unit care, and postacute care. The aim of this scientific statement is to review and present current evidence, complications, best practices, and clinical practice strategies to provide current comprehensive scientific information for nursing care in the neuroendovascular area and intensive care unit in conjunction with medical treatments, including intravenous thrombolysis and mechanical thrombectomy.

Background: Stroke registries are established with the primary goal of improving health care quality and performance improvement through increased adherence to evidenced based guideline recommendations. As a Joint Commission certified organization, the Comprehensive Stroke Center uses the American Heart Association’s Get With The Guidelines® (GWTG) stroke patient management tool to collect performance improvement data on patients admitted with a principle diagnosis of stroke. Data abstraction is laborious and time consuming which requires manual entry by multiple clinicians. Therefore, we developed an automated internal stroke database to improve efficiency and augment accuracy. Methods: We collaborated with software engineers and EPIC report writers to create an innovative stroke database with the capability to extract data from an Electronic Health Record (EHR) for upload to GWTG. The clinicians identified data elements for automation in the EHR. Based on final ICD-10 coding the report writer retrieved end-user data, which were organized into tables and sent to the software engineer. These variables were processed to match GWTG specifications and then presented to clinicians in the user interface for validation. Next, a CSV file was generated and uploaded to GWTG, where the remaining data was entered. Results: The case completion time was reduced from 45 minutes to one hour to an average of 25 minutes (median 23 minutes), thus achieving our primary goal. Due to the variance in the number of required data elements based on diagnosis and patient specific variables, we aggregated the data elements, automated versus required, and calculated an automation rate of 54%. Approximately half of the 414 fields required in GWTG have the potential for automation, and we continue to strive toward this goal. Due to the complexity of GWTG questions and the way data is captured in the EHR, some data elements require manual entry. Conclusions: An automated stroke registry has the potential to enhance efficiency and limit the opportunity for human error. By minimizing the clinicians’ data entry tasks to those of higher-level data abstraction, there is more time for performance improvement.

Background: The transition period from hospital to home is a highly vulnerable time for patients after stroke. COVID-19 restrictions have exacerbated safety concerns, stressed the health care system, and put patients at high risk after discharge. Here we describe pilot results from the Joint Stroke Transitional Technology-Enhanced Program (JSTTEP) designed to reduce post-stroke complications, avoid hospital readmission, and enhance recovery. Methods: JSTTEP is a novel, interprofessional program for patients discharged from the Johns Hopkins Comprehensive Stroke Center. In the first weeks after hospital discharge, stroke patients complete a series of multidisciplinary telemedicine visits to (1) reduce the risks of adverse events in the transition from hospital to home, and (2) develop a plan to facilitate a full recovery. The first joint visit is with stroke neurology and physical therapy for risk mitigation, and the second is with physiatry and occupational therapy for a recovery plan. Patients and caregivers participate in an interactive, online group education session covering topics about vascular risk factor modification, nutrition, exercise, fall prevention, and self-management skills. Results: In the first 4 months of the program, 50 patients were enrolled. Average age was 61 years; 26/50 (52%) were women, 23/50 (46%) were African American, and mean baseline NIHSS was 5.4. Of those 45/50 (90%) completed their visit, with 4/50 (8%) requiring conversion from video to phone visit. Unexpected 30-day hospital readmission rate was 3/50 (6%), one of whom was readmitted due to neurological issues identified during the JSTTEP appointment. Interpreter services were utilized for 5 completed video visits (Arabic, Mandarin, Spanish, Twi, Urdu). Patients reported the ability to include family members remotely in the visit as an advantage. Conclusions: The data demonstrate the feasibility and potential benefit of an interprofessional stroke telemedicine program designed to enhance post-stroke recovery. JSTTEP increased access to post-hospital care and reduced risks for adverse outcomes. The ongoing benefits and scaling of such a clinic will rely on permanent legislative and insurance changes to support such a care model.

Introduction: During the Coronavirus Disease-2019 (COVID-19) pandemic the “stay-home” public campaign implemented to contain the spread of the virus and the reorganization of hospitals to manage the overwhelming volume of affected patients, may have had unintended consequences. Prior studies reported a decrease in the number of stroke and TIAs admissions. Most reports have been from single hospitals, there is no data available on the impact on a statewide level. Methods: A retrospective analysis of stroke quality improvement data reported to the State of Maryland. These data are from Primary, Thrombectomy-Capable, and Comprehensive Stroke Centers. The number of admissions for stroke overall and by stroke subtype are reported and compared for March-June 2020 vs. March-June 2019. Last known well (LKW) to hospital arrival, intravenous tPA (IV tPA) and thrombectomy rates were analyzed. Results: The overall number of stroke admissions from March-June 2020 compared to March-June 2019 was 1,001 vs. 1,203 in March, 809 vs. 1,112 in April, 950 vs. 1206 in May, and 937 vs. 1,261 in June. There was an average 21% decrease for the 4-month period in 2020 compared to 2019. For ischemic stroke, there was a decrease in hospital admission for each month in 2020 vs. 2019: 740 vs. 922 in March, 606 vs. 866 in April, 721 vs. 906 in May, and 698 vs. 880 in June. TIAs admission rates were similarly decreased in 2020 vs. 2019: 116 vs. 136, 74 vs. 97, 111 vs. 137, and 107 vs. 111. The number of ICH admissions in 2020 vs. 2019 was 100 vs. 107 in March, 90 vs. 112 in April, 96 vs. 116 in May, and 103 vs. 121 in June. Median LKW well to hospital arrival was 292 vs. 254 min in March, 383 vs. 293 min in April, 291.5 vs. 247 min in May, and 320 vs. 292 min in June. There was about 1% decrease in thrombectomy rates in the 4-month period in 2020 compared to 2019. Conclusions: During the COVID-19 pandemic in the State of Maryland there was a consistent decrease in the volume of stroke admissions. Median LKW to hospital arrival was also increased, supporting evidence for of a delay in stroke care. While reasons for these changes need to be further explored, our findings suggest that public health campaigns for the pandemic should take into account and not adversely affect the acute care of unrelated medical emergencies.

Telephone-based consults using remote imaging review and standardization of evaluation but without visualizing the patient are an alternative to video-telestroke consults but are less well-studied. We aim to demonstrate the safety and efficacy of telephone-based acute consults in which IV tPA was administered over nearly a decade within one health system.Clinical characteristics and outcomes were compared between a community hospital (spoke; uses telephone-based consults) and the academic comprehensive stroke center (hub; uses oversight of on-site neurology trainees) from 2008-2017. In both institutions acute therapy decisions are made by the same stroke neurologists.2518 acute ischemic stroke consults were evaluated at hub and 2049 at spoke. Of these, 191 patients received IV tPA at hub and 184 at spoke. Patients at hub were younger (median (IQR): 61 (51-74) vs 69 (56-81) years, p = 0.0021) but admission National Institutes of Health Stroke Scale (NIHSS) was similar. There were no differences between door-to-needle times (69 (56-101) vs 69 (51-92) minutes, p = 0.13), last known well-to-tPA times (157 (113-202) vs 144 (110-175) minutes, p = 0.053), and rates of overall intracranial hemorrhage (ICH) after tPA (n = 23 (13.5%) vs 31 (17.0%), p = 0.35). In multivariable analyses, hospital was not an independent predictor of ICH after tPA.In a large dataset over nearly a decade, assessment for IV tPA administration using telephone assessment along with imaging review and emergency department standardization resulted in similar safety and outcomes as in the presence of on-site stroke/neurology expertise. Future studies are needed to confirm these findings.

Background: Childhood stroke is rare, and diagnosis is frequently delayed. The use of pediatric stroke teams has the potential to decrease time to neurology evaluation and imaging, hastening appropriate diagnosis and treatment for acute neurologic presentations in children. Methods: We performed a retrospective analysis of our institutional pediatric stroke or “brain attack” team (pedsBAT) activations from October 2014 to July 2017. Clinical characteristics and timing parameters were compared between pedsBAT activations in the inpatient vs emergency department (ED) / outpatient settings as well as between pediatric and adult BAT activations in the same time period. Results: We identified 120 pedsBAT activations (75% in the ED/outpatient setting) during the study time period. Inpatient pedsBAT activations were more likely than outpatient activations to have heart disease as a risk factor for ischemic stroke and presented more frequently with altered mental status, but there were no differences in the proportion of cerebrovascular diagnoses or timing parameters between the 2 groups. When compared with adult BAT activations, outpatient pedsBAT activations had a longer time from symptom discovery to arrival at the ED, and inpatient pedsBAT activations had longer time from symptom discovery to BAT activation. Conclusions: Compared with adults, the interval leading up to stroke team activation was longer in children, suggesting delays in symptom recognition. Future interventions should be aimed at reducing these delays in presentation to care and stroke alert activation in pediatric patients.

Objective: To assess feasibility and replicability of a multidisciplinary, specialized clinic in optimization of secondary stroke prevention and stroke related complications. Background: Recommendations exist for secondary stroke prevention, but it is unclear which outpatient model of care optimizes vascular risk factor control and decreases post-stroke complications most effectively. Designed after the Stroke Transitions, Education, and Prevention clinic in Houston, TX, the Follow up After Stroke, Screening and Treatment (FASST) clinic is an integrated, multidisciplinary, specialized clinic designed to optimize secondary stroke prevention. It provides post discharge stroke education and medication adherence counseling by Pharmacists, as well risk factor and complications management by Vascular Neurologists. Validated patient reported surveys screen for complications: depression, anxiety, sleep disorders, cognitive impairment, disability, social support, quality of life and functional status. Our approach and the characteristics of patients enrolled in the clinic is described. Methods: Patients attending one FASST clinic visit are included. Institutional Board Review approved consent is obtained. Demographic and clinical data are recorded including risk factors, surveys and outcome scores. Data is entered in Redcap and analyzed through the Statistical Analysis Software (SAS) program. Results: Of the 25 patients enrolled in the clinic, 83.3% are African American. A high prevalence of hyperlipidemia (100%) and hypertension (100%) exists, with 44% of patients having concomitant diabetes mellitus. Overall 26.7% screened positive for depression with PHQ-9, and 20% screened positive for anxiety with GAD-7. These patients were started on medications and referred for psychotherapy. Abnormal ESS scores were noted in 31.3% and directed for sleep apnea evaluation. Eighteen medical and pharmacy trainees rotated through the clinic. Conclusion: The FASST clinic represents a reproducible model for an integrated approach to post-stroke care. Adapted to academic centers across the country, a collaborative network would provide best practices, and measure patient reported outcomes to optimize stroke care.

Background: Intracranial atherosclerotic stenosis (ICAS), one of most common stroke subtypes worldwide, carries high risk of stroke recurrence despite maximal medical treatment. ICAS more commonly affects non-white populations including Asian, African-American and Hispanic individuals. It is plausible that non-white stroke patients with ICAS might also have more active disease, and thus higher risks of stroke recurrence. We aim to compare the rate of stroke recurrence in stroke patients with ICAS in white and non-white population. Method: We retrospectively reviewed a consecutive series of patients with ischemic stroke due to ICAS in major vessels (MCA, ACA, PCA, intracranial segment of ICA and VA, BA) with >50% stenosis identified on MRA or CTA. The clinical characteristics, risk factors and rate of stroke recurrence were compared in white and non-white patients, using Chi-square (for categorical variables) test and t-test (for continuous variables). Results: A total of 183 patients [66.3% non-white, mean (SD) age, 63 (±14) years] who were hospitalized between January 2005 and December 2010 and satisfied the inclusion criteria were included in the analysis. Compared with white patients, non-white patients had a higher rate of HTN, DM and drug abuse (Table 1), as well a nonsignificantly higher stroke recurrence rate (3 months: OR 1.29, 95% CI 0.59-2.82; long term: OR 1.63, 95% CI 0.84 - 3.18). History of CKD was the only factor associated with 3-month stroke recurrence (OR 3.73, 965 CI 1.13-12.31). Conclusion: White and non-white ischemic stroke patients with ICAS have distinct risk factor profiles and possibly distinct stroke recurrence rates. Analysis with a larger sample size is ongoing to verify this finding.

Introduction: New EMS routing protocols are being proposed to divert acute stroke patients, based on the likelihood of having a large vessel occlusion (LVO), directly to Comprehensive Stroke Centers (CSC), in order to reduce the inherent delay of a secondary transfer from a Primary Stroke Center (PSC) to a CSC. Within Baltimore City, transfer from a PSC to a CSC for mechanical thrombectomy (MT) adds, on average, an additional 90-minute delay in achieving reperfusion. Aim: To determine the feasibility and safety of an EMS routing protocol in which, patients determined to have an LVO-related acute stroke, based on use of a stroke severity score in the field, are directed to the nearest CSC bypassing closer PSCs within Baltimore City. Methods: A prospective observational study was conducted over a six-month period, from September 2017 to March 2018. Acute stroke patients with a LAMS of ≥4 were taken by EMS to the nearest CSC, bypassing closer PSCs, as long as the travel time did not exceed an additional 30 minutes. Data collected at the three CSCs included transport times, IV-tPA and MT use in the diverted patients, time from onset to treatment and 90-day functional outcomes. Descriptive statistics were used to analyze the data. Results: Forty-five patients with LAMS of ≥4 were diverted to a CSC. Approximately 50% (20/45) had a final diagnosis of acute ischemic stroke and 35% of those were eligible for an intervention, either IV-tPA or MT or both. Average onset to IV-tPA bolus time was 114 minutes (93-163 minutes). Average onset to groin puncture was 197 minutes (192-202 minutes). There were 4 in-hospital deaths. Among survivors, the 90 day modified Rankin Scale (mRS) ranged from 0-3. Mean field transport time was 17 minutes (range: 4-63 minutes). None of the re-routed patients were ineligible for IV-tPA due to additional time to CSC. There were no reported adverse outcomes due to increased travel time associated with diversion. Conclusion: Implementation of EMS routing protocols to divert acute stroke patients suspected of having an LVO past PSCs to CSC within cities is feasible and appears safe. The limitations of this study include small size, short duration and small region of implementation. Further study is warranted on a larger scale both in population and geographic area.

Background: Provision of stroke education to patients is a Centers for Medicare/Medicaid (CMS) requirement. However, little is known about retention of the educational content. Methods: Two pilot studies were conducted: Pilot A delivered CMS-required stroke education during hospitalization in a standardized manner and tested knowledge retention in patients returning to the Stroke Clinic for 1-month follow-up; Pilot B randomized patients to either a control group with standardized education or a test-enhanced learning group (target), with measurement of stroke knowledge retention at hospital discharge. Results: A total of 198 patients/caregivers participated in Pilot A, with only 25% scoring 100% correct on required stroke education items. The question most commonly answered incorrectly (n = 117; 59%) was “personal risk factors for stroke,” and 74 (37%) could not correctly identify stroke signs and symptoms. Pilot B found that significantly more target group patients could identify their personal stroke risk factors (100 vs. 67%; p = 0.04) and the purpose of their secondary prevention medications (87 vs. 40%; p = 0.02) compared to controls. Discussion: While stroke education is required during hospitalization, its ability to produce retention may be poor. We propose study of test-enhanced learning methods through the Targeted Education in Stroke Trial (TEST) to examine the effect of novel teaching methods on patient/caregiver knowledge retention.

Introduction: Intracranial atherosclerotic stenosis (ICAS), the most common cause of stroke worldwide, is more prevalent in non-white populations including Asian, African-American and Hispanic individuals. We studied the racial difference (white vs non-white) in the plaque features of stroke patients with ICAS using vessel wall MRI (VWMRI). Methods: We retrospectively included stroke patients with etiology being intracranial atherosclerosis who received VWMRI. VWMRI was read by experienced neuroradiologists blinded to other clinic information. Culprit plaque was defined as a plaque in a relevant vessel responsible for the downstream ischemic lesion. In addition to plaque number and degree of the stenosis, other plaques features were analyzed, including degree of plaque enhancement(minimal, moderate and strong), plaque calcification and eccentricity. The association between race, cardiovascular risk factors and plaque features was tested in multivariable models. Results: In 64 stroke patients (mean age 55.6±13.4 y, 62.5% male, 43.8% non-whites), the median number of plaque was 3 (range 0-11). Compared with whites, non-whites have a higher number of plaques (median, 4 vs 3, p=0.029). Smoking was associated with presence of extensive plaque (defined as ≥3 plaques) and remained significant after adjustment for other risks factors (non-white race, hypertension, age≥55 and HbA1C≥6.5; adjusted OR 6.9, 95% CI 1.27-37.66). For culprit plaques, presence of ≥50% stenosis, strong plaque enhancement, eccentric pattern and calcification did not differ by race. LDL >100 mg/dl, history of hyperlipidemia and eGFR2 were each associated with presence of strong plaque enhancement, eccentric pattern and calcification respectively (OR 1.5, 95% CI 1.5-19.6; OR 9.9, 95% CI 1.1-85.6; OR 24, 95% CI 2.3-247.4; respectively). Conclusion: A higher number of intracranial atherosclerotic plaques was revealed by VWMRI in non-white stroke patients with stroke etiology being intracranial atherosclerosis, while the features of their culprit plaque were similar compared with white patients. History of smoking was significantly associated with presence of ≥3 plaques. Studies with larger sample size are needed to validate the above findings.

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Regular, interdisciplinary group meetings, "huddles," may be useful in improving communication among disciplines, resolving problems, and sharing information. Daily use of huddles may contribute to the development of a highly reliable health care organization. The purpose of this study was to describe safety huddles in relation to (1) problem type, (2) timeliness of resolution, (3) attendance of representatives from each discipline, (4) amount of information sharing, and (5) attendees' satisfaction with the process. Overall, results demonstrated that the primary function of huddles was the exchange of information that posed or had the potential to pose safety risks to patients. Across seven hospitals, the range of information sharing during huddles was 61.0% to 95.6%. Regarding satisfaction with the huddle process, staff reported that huddles were useful in improving awareness of safety concerns and also improved communication between disciplines. Huddles provide a structured format in which staff can positively impact safety concerns, form a greater sense of medical community, increase sharing of information between disciplines, quickly resolve discipline-based problems, and increase awareness of safety concerns. Given the results of this study, it is recommended that health care administrators and managers develop a huddle process.

Objective: The purpose of this review is to evaluate the state of knowledge in regard to stroke literacy in African Americans. This topic is important for assessing the specific gaps in stroke knowledge for this population, as well as to evaluate the methodology that has been used to assess stroke literacy.Methods: This narrative review includes studies that evaluated and reported stroke knowledge in African Americans and were published between January 2000 and October 2015.Results: Our review revealed that disparities may exist in recognition of headache and visual symptoms, knowledge of the organ in which stroke occurs, and identification of tobacco use as a risk factor. Stress may be perceived as a more important risk factor among African Americans than among White Americans. The literature does not suggest disparities in knowledge of the appropriate action to take for stroke.Conclusions: Racial disparities may exist for specific domains of stroke knowledge. Future studies should explore specific gaps in knowledge to be addressed in stroke prevention interventions for African Americans. Standardization of methods is needed to aid comparisons across populations. The relationship between stroke knowledge and clinical outcomes also needs to be evaluated. Ethn Dis. 26(2):255-262; doi:10.18865/ed.26.2.255

Background: Despite delivery of hospital-required stroke education, retention by patients/families is poor. We examined knowledge retention using a test-enhanced learning strategy for provision of stroke education. Methods: An experimental study was conducted, enrolling consecutive consenting English-speaking, literate patients/family members from a comprehensive stroke center to two groups: Control group (routine individual teaching, time for questions, and provision of written materials); or, a Test-Enhanced Stroke education Target (TEST) group (informed on enrollment about a discharge written test requirement, along with provision of the same routine education). Prior to discharge both groups completed a written stroke knowledge test to gauge content retention. Demographic data and correct test items were analyzed using descriptive statistics, Fisher’s Exact test, and Mann-Whitney U. Results: We enrolled and prospectively randomized 30 patients to either the control or TEST group. Patient characteristics were similar between groups: 80% and 93% ischemic strokes, 53% and 47% females, 67% and 53% African Americans, with a median LOS of 3 days in the control and TEST groups respectively. However, patients in the TEST group were significantly older at 64 (range 35-84; p=0.03) vs. 52 (range 24-70) years in controls. Overall median scores for all test items were significantly higher in the TEST group compared to controls (p=0.02), with TEST patients understanding their personal risk factors for stroke (p=0.02) and medication for secondary prevention (p=0.04) significantly better than controls patients (Table). Conclusions: Stroke knowledge retention is improved when patients are alerted to a formal testing requirement. Test-enhanced learning may play an important role in preparing stroke patients and family members for assumption of self-care post-hospitalization.

In this paper, we consider abelian functor calculus, the calculus of functors of abelian categories established by the second author and McCarthy. We carefully construct a category of abelian categories and suitably homotopically defined functors, and show that this category, equipped with the directional derivative, is a cartesian differential category in the sense of Blute, Cockett, and Seely. This provides an abstract framework that makes certain analogies between classical and functor calculus explicit. Inspired by Huang, Marcantognini, and Young's chain rule for higher order directional derivatives of functions, we define a higher order directional derivative for functors of abelian categories. We show that our higher order directional derivative is related to the iterated partial directional derivatives of the second author and McCarthy by a Fa\`a di Bruno style formula. We obtain a higher order chain rule for our directional derivatives using a feature of the cartesian differential category structure, and with this provide a formulation for the $n$th layers of the Taylor tower of a composition of functors $F\circ G$ in terms of the derivatives and directional derivatives of $F$ and $G$, reminiscent of similar formulations for functors of spaces or spectra by Arone and Ching. Throughout, we provide explicit chain homotopy equivalences that tighten previously established quasi-isomorphisms for properties of abelian functor calculus., Comment: v2: final journal version with a number of clarifications and an expanded appendix written in response to the referee's report; 51 pages

Individuals with cerebral palsy (CP) have sensorimotor and developmental issues that affect their daily lives by restricting their mobility, manipulation of objects, and/or communication.1 Within the framework of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF),2,3 the Gross Motor Function Classification System (GMFCS)4 and the Manual Ability Classification System (MACS) for children with CP5 make it possible to classify mobility and handling objects respectively, at the ICF activity/participation level.6 However, no analogous classification of functional communication has been available for use in CP practice and research. The lack of a communication classification tool that is quick, reliable, valid, and easy to use limits the comparison of descriptive CP epidemiology studies as well as the interpretation and generalizability of CP treatment studies. Communication disorders can be described from several perspectives: body structure and function level, activity level, and participation level, as well as environmental and personal levels.2,3,7–13 Estimates of communication disorders in CP have varied from 31%14 to 88%.15 This wide range is partly a result of the lack of a consensus definition of communication disorders within CP research and practice. A recent study from a Norwegian CP registry reported that 51% of children with CP had speech problems as classified by ratings of ‘slightly indistinct’, ‘obviously indistinct’, ‘severely indistinct’, or ‘no speech’, including 19% who had ‘no speech’.16 This population-based estimate reporting indistinct or no speech may underestimate CP communication disorders as it may not capture other types of communication problems resulting from hearing or language impairments. However, reporting speech, language, and hearing difficulties simply suggests the range of associated impairments in CP, not the more pertinent daily-life issues of how well a child with CP communicates with family, friends, acquaintances, and strangers.13 The purpose of this study was to create and validate a communication function classification system (CFCS) for children with CP, for use by a wide variety of individuals interested in CP. This required a shift from the traditional focus on body structure and function (i.e. assessing components of speech, language, and hearing problems), to a focus on activity/participation, specifically the way in which to classify a person’s communication capacity within real-life situations.

We show in this paper that given any reduced, cancellative, torsion-free, atomic monoid, it is possible to construct a possibly non-atomic domain with atomic factorization structure isomorphic to the given monoid. This is significant, since atomic monoids are known to have more freedom in the factorization properties they may possess than atomic domains. This construction is motivated by the paper written by Coykendall and Zafrullah (2004) [5] , in which a non-atomic domain was constructed with factorization structure isomorphic to a singly-generated monoid.

We prove that every intrinsically knotted graph has at least 21 edges.

We study the Taylor towers of the nth symmetric and exterior power functors, Sp n and n . We obtain a description of the layers of the Taylor towers, Dk Sp n and Dk n , in terms of the rst terms in the Taylor towers of Sp t and t for t < n. The homology of these rst terms is related to the stable derived functors (in the sense of Dold and Puppe) of Sp t and t . We use stable derived functor calculations of Dold and Puppe to determine the lowest nontrivial homology groups for Dk Sp n and Dk n .

Background: Door to Needle Time (DNT) for IV tPA administration in acute stroke, has become an important quality metric. The rationale for this is based on evidence that earlier administration of IV tPA, improves patient outcomes. Methods: In 2010 we undertook a review of our hospital’s performance and process for administration of IV tPA for acute stroke. At the time, we were already using 7 elements of the AHA’s Target Stroke 10 best practices. We created a pocket card for our Brain Attack team to record the time at which each task in the process was completed. We found that the greatest delay was in the time between the decision to treat and administration of tPA. The factors that contributed were insertion of a Foley catheter (part of our order set at the time), blood pressure control, and mixing tPA. We instituted the 3 remaining Target Stroke best practices: activation of the Brain Attack team upon EMS advance hospital notification, mixing tPA ahead of time (right after CT scan), and prompt data feedback (case by case and aggregate). We also eliminated the Foley catheter insertion requirement from the order set, instituted a streamlined blood pressure control guideline, created an incentive pin awarded for treatment under 60 minutes, started timely case by case review and feedback, and included DNT on our department’s safety dashboard. Results: From 2007 to 2010, there were 5/43 (11.6%) patients with a DNT less than 60 minutes (DNT After implementation: In 2011, DNT In 2012, DNT In 2013, DNT In 2014, DNT Adjusted (aDNT In 2013, aDNT In 2014, aDNT Conclusions: Efforts to reduce DNT are effective and create incremental improvement over time. The organization required to lower door to needle time, results in an increase of the number of patients treated. This may be a result of the greater efficiency needed to achieve fast administration of IV tPA, which in turn, improves recognition of stroke patients and efficiency of decision making. Our experience demonstrates that these gains are sustainable.

Background: While the incidence and mortality from stroke in the United States has declined in the past 20 years, there are still more than 795,000 strokes per year, of which 185,000 are recurrent events. There remains great disparity between racial groups -the incidence and mortality among African Americans, is two to four times higher than Non-Hispanic Whites. Despite great advances in drug therapies, the impact on stroke prevention has not been fully realized. There is a need for improved delivery of effective treatments. Several randomized clinical trials have demonstrated the effectiveness of a comprehensive; clinic based, navigator-assisted approach to disease management, although in the context of specific clinical situations. Examples are, SAMMPRIS, and Look AHEAD. We propose that learning from the development of the “stroke center” for acute stroke care, we may apply a similar model to stroke prevention. We have created a Stroke Prevention Clinic (SPC), organized like an outpatient “stroke center”, offering evaluation, treatment, and long-term follow up of patients for risk factor control and lifestyle interventions for secondary prevention. Our Stroke Prevention Nurse is an integral part of this model. In this abstract we report the impact of this program on follow up rates. Methods: In 2011 we launched our SPC. The specific elements of this program included: A Stroke Prevention Nurse: a. Meets the patient in the hospital. b. Facilitates scheduling of appointments, including in the SPC, which is given to the patient upon discharge. c. Calls the patient within 7 days to do medication reconciliation and answer questions. Also, at 90 days for a modified Rankin score and whenever it is necessary to follow up on blood pressure readings. d. Administers screening tools upon follow up, consents for research studies. e. Educates the patient on stroke prevention. Dedicated day for clinic. All providers in the same area. Use of Advance Practice Nurse and stroke fellows, as well as vascular neurology attending. Database. We assessed the proportion of completed appointments within 90 days after discharge from the hospital and compared it with the year prior to implementation. Results: A sample from July 2010 to February 2011 revealed completed follow up by 90 days of 28.3% (70/247), for the period July 2011 to February 2012 the proportion was 35.6% (89/250). During calendar year 2014, 54.3% (233/429) completed their appointments within 90 days. Conclusion: Implementation of the Stroke Prevention Clinic increased follow up completion within 90 days of discharge.

We construct a Taylor tower for functors from pointed categories to abelian categories via cotriples associated to cross effect functors. The tower was inspired by Goodwillie’s Taylor tower for functors of spaces, and is related to Dold and Puppe’s stable derived functors and Mac Lane’s Q Q -construction. We study the layers, D n F = fiber ⁡ ( P n F → P n − 1 F ) D_{n}F = \operatorname {fiber}(P_{n}F\rightarrow P_{n-1}F) , and the limit of the tower. For the latter we determine a condition on the cross effects that guarantees convergence. We define differentials for functors, and establish chain and product rules for them. We conclude by studying exponential functors in this setting and describing their Taylor towers.

For all n ≥ 4, and all even 4 ≤ s, t ≤ 2n - 4 with s + t = 2n, we show that every spatial embedding of Kn, n contains a non-trivial link involving and s-cycle and a t-cycle. We use this result to prove that for all n ≥ 3, 3 ≤ u, v ≤ 2n - 2 with u + v = 2n + 1, every spatial embedding of Kn, n, 1 has a non-trivial link involving a u-cycle and a v-cycle. These results imply that every embedding of Kn, for n ≥ 4, has non-trivial links of all possible sizes.