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Background: Hospitalization length of stay (LOS) and cost are used as quality metrics, but there are known racial and ethnic disparities. For individuals with ischemic stroke, the relationship between LOS, cost, and race/ethnicity has not been fully examined. Methods: We included adult discharges from the National Inpatient Sample 2016-2019 with a baseline NIHSS, primary discharge diagnosis of ischemic stroke (I63*), and LOS ≤14 days to limit outlier LOS admissions. The primary outcome was hospitalization cost, which the NIS defines as a cost-to-charge ratio times charges. The exposure was race/ethnicity, which was abstracted from the medical record. We fit linear regression models and compared models with and without LOS to determine if it changed the point estimates of our outcome. Results: The cohort contained 128,399 discharges (mean age 69.5±14.0, 49.0% Female, median NIHSS 4 (1-8), and median LOS of 3 (2-5) days). In the model without LOS, White individuals had the lowest cost. After LOS adjustment, Black individuals had significantly lower cost than other race/ethnicities (Figure 1). As shown in Table 1, after adjusting for LOS, Black stroke hospitalizations cost $256.8 less than White, while hospitalizations for other race/ethnicities cost anywhere from $300-867 more than White. A separate analysis of the same dataset yielded that a greater proportion of Black patients (16.4%) have Medicaid at discharge versus White patients (5.6%). Conclusions: Hospitalization cost for Black patients is confounded by their length of stay. More research into the factors influencing this mediation is necessary; considering for example, the influence of waiting time for public insurance.

Background: Understanding the magnitude and causes of missing data is crucial to ensuring scientific integrity of clinical trials. Missing data threaten statistical and ecological validity, as results will only generalize to those who remain represented in the sample. Goal: Identify factors associated with loss at follow-up in acute ischemic stroke trials. Methods: We harmonized patient-level data from multiple NIH-funded acute ischemic stroke trials including NINDS IV-tPA, ALIAS part 2, SHINE, FAST-MAG, IMS-III, POINT, and DEFUSE 3, all of which had a 90-day study outcome. The primary outcome was the proportion of missing modified Rankin Scale (mRS) scores at 90 days. We compared patients with and without a 90-day mRS score among a variety of baseline patient characteristics. Results: Among 9580 subjects, 459 (4.8%) were missing their 90-day mRS. Age and race were associated with missingness. Compared to those with complete data, participants with missing data were younger (62 vs 66 years, p Conclusion: Bias due to missingness is an important consideration for all clinical trials, including genetic studies. Disparities in the availability of genetic data compounded by missing phenotypic data creates a twofold disadvantage for underrepresented groups. Long term, we need to understand the biomedical and sociological causes of these associations and develop recruitment and retention strategies to ensure the generalizability of trial results.

Background: Acute telestroke consults rely on a rapid, accurate NIH Stroke Scale. An important sign in cortical-based ischemic strokes is a Visual Field Deficit (VFD) contributing up to 3 points on the NIHSS affecting treatment decisions. Remote confrontational VFD testing is challenging and requires a trained assistant. We created a simple, rapid, telecart peripheral device to remotely administer a standardized VF test . The “ V isual fields R apid A ssessment D evice” ( VRAD ) is a wearable eye-glasses device. The device flashes LED lights in the 4 quadrants of each eye via remote control by a teleprovider allowing real-time control and interpretation. Methods: The VRAD Phase I study examined FDA-related human design factors of comfort, speed, and ease of use with direct use of VRAD. The results guided optimization of the prototype in preparation for the Phase II validation clinical trial. Subjects were randomly-selected, consented adult UVA Stroke Unit inpatients, with confirmed ischemic strokes. Following each VF test, blinded teleproviders, the patient ,and the telepresenter (nurse) completed a brief binary response questionnaire with open-ended comments. Biostatistical analysis: N= 20 subjects; 95% confidence interval with precision of +/- 10%. Results: The vast majority of patients, presenters, and providers (95-100%) reported VRAD testing was easy to understand and rapid. Patients: The device was comfortable (90%); 10% felt the stimulus light was too bright and 5% too dim. All identified when the light was on and had enough time to respond. Presenters: All reported rapid testing; 75% felt the device was easy to don on patients. The device was “sturdy and durable” 90%, “easy to use” 75%, “easy to clean” 70%, and “easy to connect” 60%. Providers: Reported the device sufficiently screened standard VFs (90%). All agreed they could remotely administer the test in various settings. Conclusion: The VRAD Phase I trial found the device to be safe, effective, easy to use, and comfortable by patients, providers, and presenters. Based on the results, an upgraded prototype was manufactured for our upcoming Phase II Non-Inferiority Validation Trial (Fall 2021). This data is a proof-of-concept of the value of teleneurology peripheral tools in remote settings.

Introduction: Approximately 50% of stroke patients are discharged to home from the hospital. Post stroke transitional care is fragmented and unorganized leading to poor patient outcomes, hospital readmissions, decreased functional status, and increased caregiver burden. We discuss our experience implementing a multidisciplinary team-based post stroke transitional telehealth program. Methods: Acute stroke patients discharged home were invited to participate in a 90-day telehealth program, iHEAL, upon discharge. Inclusion criteria included 2 or more uncontrolled risk factors requiring medication management, two or more therapy needs, WiFi at home, knowledge of technology, and agreement to follow up with iHEAL program providers. Patients were discharged with remote monitoring devices (blood pressure monitor, medication adherence device) and an iPad for telehealth visits with the stroke NP and both the neurology pharmacist and therapists. Surveys were completed by participants during and after completion of the program. Results: Of approximately 167 patients discharged home within the initial 9 months, 6 patients enrolled in iHEAL. The most common reasons for ineligibility were lack of two therapy needs and lack of two risk factors in need of medication adjustment excluding 69% of patients when combined in addition to limited internet access in the home. There have been no readmissions. Medications were scanned 50% of the time. Blood pressure readings were maintained or decreased for all patients. Telehealth visit completion: 50% NP, 40% Pharmacist , 40% PT, 20% OT and 40% SLP. Most reported feeling comfortable using the iHEAL equipment (80%) and 100% reported satisfaction with the program and would recommend to others. Conclusion: Enrollment in iHEAL has been unexpectedly difficult due to overly stringent enrollment criteria and limited broadband internet access in Central Virginia and surrounding regions. These difficulties led to changing criteria in Month 10 to one therapy need and removing the requirement for medication management of the two identified risk factors. Follow up data to be included in final presentation.

The ability to perform automated neurological assessment could enhance diagnosis and treatment in the pre-hospital setting such as during telemedicine or emergency medical services (EMS) encounters. In this pilot study we present the preliminary analysis of a video-based eye movement assessment workflow (NeuroGaze) for neurological eye examinations. Our workflow uses a pupil detector to detect the center of the pupil for both eyes for a given video and determine the conjugacy of eye movement. The study evaluated the proposed workflow on 18 healthy volunteers while performing a digitally adapted neurological eye examination (NeuroEye) to assess conjugacy of gaze in all cardinal positions. The NeuroGaze performance was compared to the COTS eye tracker. The video-based eye movement assessment workflow reported an average Pearson correlation coefficient of 0.84, compared to the COTS eye tracker with an average of 0.95. The preliminary analysis indicates that NeuroGaze can be used to determine the individuals ability to perform conjugate eye movements. Future study will assess the performance of NeuroGaze in patients with pathological eye movements.

Background: Posterior circulation stroke (PCS) accounts for ~20% of ischemic strokes. Existing EMS screening tools lack accuracy in the diagnosis of PCS. We aim to develop an automated screening tool to detect abnormal eye movements in patients presenting with PCS. Methods: As an initial step, we built a portable platform called RoADIE (Rolling Apparatus to Detect Impairment of the Eyes), equipped with eye-tracking software to acquire gaze data from patients presenting with PCS, acute vestibular syndrome, and normal controls. We first performed a validation study in 19 healthy controls comparing calibration (C) vs non-calibration (NC) techniques. Eye movements were captured using a standard H-Test exam. The NC condition was performed first for each volunteer to avoid a learning effect. Correlation between C and NC tests was determined using the Spearman coefficient (r). Results: Conjugate gaze (i.e. ability of eyes to track in unison) demonstrated strong correlation along the horizontal [r = 0.976 (C), 0.922 (NC)] and vertical axes [r= 0.866 (C), 0.881(NC)]. Smooth pursuit (i.e. ability of each eye to track moving target) also showed strong correlation in the horizontal plane: right eye [r = 0.945 (C), 0.946 (NC), left eye [r=0.945 (C), 0.943 (NC)]. Vertical tracking showed moderate correlation: right eye [r=0.652 (C), 0.575 (NC), left eye [r=0.678 (C), 0.550 (NC)]. Conclusion: In this initial validation test of a portable eye tracking platform, we demonstrated strong correlation for both conjugate gaze and smooth pursuit in the horizontal axis, and moderate correlation for eye tracking in the vertical axis. Given similar performance in non-calibrated tests, a calibration procedure may not be necessary for future data capture. Next steps will include validation of the eye tracking device in prospective patients presenting with PCS and acute vestibular syndrome. Acknowledgement: Funding support through AHA Innovative Project Award 19IPLOI34760692

Automated eye tracking technology could enhance diagnosis and treatment for many neurological diseases, including posterior circulation stroke. Much of the current literature focuses on gaze estimation through a form of calibration. Unlike other fields, medicine has a clear need to better track eye symmetry during movement for better detection of abnormal conjugacy, ductions, and vestibulo-ocular function in a variety of neurological diseases. However, patients with neuro-ocular deficits may have a difficult time completing a calibration procedure due to inattention and other associated neurologic deficits. Here, we investigate the need for calibration to measure the symmetry of eye movements in healthy individuals including testing fixations, smooth pursuits, and saccades. The results of this feasibility study suggest that calibration may not be necessary to measure and track binocular eye movements in tandem. The structure or shape which the eyes draw during visual tracking remain intact even without a calibration procedure. The preliminary study suggests that this technology can be deployed without a calibration procedure within this clinical context. Further research is needed to validate these findings in populations with neuro-ophthalmologic disease, including posterior circulation stroke.

Graphical abstract Venoarterial extracorporeal membrane oxygenation (ECMO) has been used to treat acute massive pulmonary embolism (PE) patients. However, the incremental benefit of ECMO to standard therapy remains unclear. Our meta-analysis objective is to compare in-hospital mortality in patients treated for acute massive PE with and without ECMO. The National Library of Medicine MEDLINE (USA), Web of Science, and PubMed databases from inception through October 2020 were searched. Screening identified 1002 published articles. Eleven eligible studies were identified, and 791 patients with acute massive PE were included, of whom 270 received ECMO and 521 did not. In-hospital mortality was not significantly different between patients treated with vs. without ECMO (OR = 1.24 [95% CI, 0.63–2.44], p = 0.54). However, these findings were limited by significant study heterogeneity. Additional research will be needed to clarify the role of ECMO in massive PE treatment. In-hospital mortality for patients with acute massive pulmonary embolism was not significantly different (OR of 1.24, p = 0.54) between those treated with and without venoarterial ECMO.

Objective: Facial weakness is a common sign of neurological diseases such as Bell's palsy and stroke. However, recognizing facial weakness still remains as a challenge, because it requires experience and neurological training. Methods: We propose a framework for facial weakness detection, which models the temporal dynamics of both shape and appearance-based features of each target frame through a bi-directional long short-term memory network (Bi-LSTM). The system is evaluated on a “in-the-wild”video dataset that is verified by three board-certified neurologists. In addition, three emergency medical services (EMS) personnel and three upper level residents rated the dataset. We compare the evaluation of the proposed algorithm with other comparison methods as well as the human raters. Results: Experimental evaluation demonstrates that: (1) the proposed algorithm achieves the accuracy, sensitivity, and specificity of 94.3%, 91.4%, and 95.7%, which outperforms other comparison methods and achieves the equal performance to paramedics; (2) the framework can provide visualizable and interpretable results that increases model transparency and interpretability; (3) a prototype is implemented as a proof-of-concept showcase to show the feasibility of an inexpensive solution for facial weakness detection. Conclusion: The experiment results suggest that the proposed framework can identify facial weakness effectively. Significance: We provide a proof-of-concept study, showing that such technology could be used by non-neurologists to more readily identify facial weakness in the field, leading to increasing coverage and earlier treatment.

Objectives Like the concept of work ability in occupational health, gait speed is a measure of general fitness and can predict functional decline and morbidity. This is especially important when our care‐takers, i.e. nurses, show decline in fitness and become care‐receivers. The study aims to describe the demographics of hospital nurses in the context of gait speed and work ability as well as to determine the association between them. Methods Three‐hundred and twelve inpatient nurses and nursing assistants were sampled from a level 1 trauma and teaching hospital from several service lines and acuity levels. Spearman correlation tests were utilized to determine the relationship of gait speed and ratings of item 1 on the Work Ability Index (WAI) as well as Cochran‐Armitage test for linear trend of gait speed. Results Maximum gait speed has a significant positive association with work ability with a Rho coefficient of 0.217 (P

Background and Purpose— Clinical trials in spontaneous intracerebral hemorrhage (ICH) have used volume cutoffs as inclusion criteria to select populations in which the effects of interventions are likely to be the greatest. However, optimal volume cutoffs for predicting poor outcome in deep locations (thalamus versus basal ganglia) are unknown. Methods— We conducted a 2-phase study to determine ICH volume cutoffs for poor outcome (modified Rankin Scale score of 4–6) in the thalamus and basal ganglia. Cutoffs with optimal sensitivity and specificity for poor outcome were identified in the ERICH ([Ethnic/Racial Variations of ICH] study; derivation cohort) using receiver operating characteristic curves. The cutoffs were then validated in the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) by comparing the c-statistic of regression models for outcome (including dichotomized volume) in the validation cohort. Results— Of the 3000 patients enrolled in ERICH, 1564 (52%) had deep ICH, of whom 1305 (84%) had complete neuroimaging and outcome data (660 thalamic and 645 basal ganglia hemorrhages). Receiver operating characteristic curve analysis identified 8 mL in thalamic (area under the curve, 0.79; sensitivity, 73%; specificity, 78%) and 18 mL in basal ganglia ICH (area under the curve, 0.79; sensitivity, 70%; specificity, 83%) as optimal cutoffs for predicting poor outcome. The validation cohort included 834 (84%) patients with deep ICH and complete neuroimaging data enrolled in ATACH-2 (353 thalamic and 431 basal ganglia hemorrhages). In thalamic ICH, the c-statistic of the multivariable outcome model including dichotomized ICH volume was 0.80 (95% CI, 0.75–0.85) in the validation cohort. For basal ganglia ICH, the c-statistic was 0.81 (95% CI, 0.76–0.85) in the validation cohort. Conclusions— Optimal hematoma volume cutoffs for predicting poor outcome in deep ICH vary by the specific deep brain nucleus involved. Utilization of location-specific volume cutoffs may improve clinical trial design by targeting deep ICH patients that will obtain maximal benefit from candidate therapies.