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  • 2015-2019  (10)
  • 1
    Online-Ressource
    Online-Ressource
    Early Prediction of Prognosis in Elderly Acute Stroke Patients
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Critical Care Explorations Vol. 1, No. 4 ( 2019-04), p. e0007-
    Details
    In: Critical Care Explorations, Ovid Technologies (Wolters Kluwer Health), Vol. 1, No. 4 ( 2019-04), p. e0007-
    Kurzfassung: Acute stroke has a high morbidity and mortality in elderly population. Baseline confounding illnesses, initial clinical examination, and basic laboratory tests may impact prognostics. In this study, we aimed to establish a model for predicting in-hospital mortality based on clinical data available within 12 hours of hospital admission in elderly (≥ 65 age) patients who experienced stroke. Design: Retrospective observational cohort study. Setting: Academic comprehensive stroke center. Patients: Elderly acute stroke patients—2005–2009 ( n = 462), 2010–2012 ( n = 122), and 2016–2017 ( n = 123). Interventions: None. Measurements and Main Results: After institutional review board approval, we retrospectively queried elderly stroke patients’ data from 2005 to 2009 (training dataset) to build a model to predict mortality. We designed a multivariable logistic regression model as a function of baseline severity of illness and laboratory tests, developed a nomogram, and applied it to patients from 2010 to 2012. Due to updated guidelines in 2013, we revalidated our model (2016–2017). The final model included stroke type (intracerebral hemorrhage vs ischemic stroke: odds ratio [95% CI] of 0.92 [0.50–1.68] and subarachnoid hemorrhage vs ischemic stroke: 1.0 [0.40–2.49]), year (1.01 [0.66–1.53] ), age (1.78 [1.20–2.65] per 10 yr), smoking (8.0 [2.4–26.7] ), mean arterial pressure less than 60 mm Hg (3.08 [1.67–5.67]), Glasgow Coma Scale (0.73 [0.66–0.80] per 1 point increment), WBC less than 11 K (0.31 [0.16–0.60]), creatinine (1.76 [1.17–2.64] for 2 vs 1), congestive heart failure (2.49 [1.06–5.82]), and warfarin (2.29 [1.17–4.47] ). In summary, age, smoking, congestive heart failure, warfarin use, Glasgow Coma Scale, mean arterial pressure less than 60 mm Hg, admission WBC, and creatinine levels were independently associated with mortality in our training cohort. The model had internal area under the curve of 0.83 (0.79–0.89) after adjustment for over-fitting, indicating excellent discrimination. When applied to the test data from 2010 to 2012, the nomogram accurately predicted mortality with area under the curve of 0.79 (0.71–0.87) and scaled Brier’s score of 0.17. Revalidation of the same model in the recent dataset from 2016 to 2017 confirmed accurate prediction with area under the curve of 0.83 (0.75–0.91) and scaled Brier’s score of 0.27. Conclusions: Baseline medical problems, clinical severity, and basic laboratory tests available within the first 12 hours of admission provided strong independent predictors of in-hospital mortality in elderly acute stroke patients. Our nomogram may guide interventions to improve acute care of stroke.
    Materialart: Online-Ressource
    ISSN: 2639-8028
    URL: Article
    DOI: 10.1097/CCE.0000000000000007
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2019
    ZDB Id: 3015728-6
    Standort Signatur Einschränkungen Verfügbarkeit
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  • 2
    Online-Ressource
    Online-Ressource
    Abstract WP377: Implementation Of A Stroke Clinical Operations Nurse (scon) Decreases Door To Needle Time
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. Suppl_1 ( 2018-01-22)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. Suppl_1 ( 2018-01-22)
    Kurzfassung: Introduction: Evidence-based practice shows that the earlier a patient presenting with an acute ischemic stroke receives IV-tpa the better the outcomes. The stroke clinical operations nurse role was developed to help streamline door-to-needle (DTN) time for patients being treated with Alteplase (IV-tPA). Adding experienced, stroke trained, critical care nurses, or Stroke Clinical Operations Nurses, on the stroke team as part of the response to acute stroke patients presenting within 12 hours of stroke, our hospital has been able to drive DTN time down and increase the number of patients treated within the 45 and 60 minute window since implementation. Method: Retrospective review of all patients who received IV-tPA from Jan 2013 –June 2017. January 2013- June 2016 is the pre-implementation data and July 2016- June 2017 is post implementation data. We compared DTN time and percentage of DTN less than 45 minutes after implementation of stroke dedicated nursing service. Mean and median were calculated. Two-tailed student T-test was used for comparison and a statistical significance was determined at 0.05 level. Results: Total of 313 patients who received Iv-tPA from 2013 to June 2016, and 85 patients from July 2016 to June 2017. There was significant decrease in mean (44.5 ± 0.6 vs 41.6+1.3 min) and median (45 vs 40 min) of DTN within 60 min after the start of the service. Meanwhile, there was a significant increase of percentage of DTN within 45 min (37.7% vs 49.4%). There was a significant decrease in DTN time (mean: 37.5 ± 0.5 vs 35.0 ± 1 min; and median: 39 vs 36.7 min) in groups of DTN within 45 min. Conclusion: Implementation of the SCON decreased the Door-to-Needle (DTN) time and improves the number of patients being treated with IV Alteplase in the 45 and 60 minute time window goals. The implementation of the SCON will serve as a new model for early management of patients with acute ischemic stroke to deliver the highest quality patient services across the state and nationwide.
    Materialart: Online-Ressource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.49.suppl_1.WP377
    RVK:
    XA 10000
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2018
    ZDB Id: 1467823-8
    Standort Signatur Einschränkungen Verfügbarkeit
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    Online-Ressource
  • 3
    Online-Ressource
    Online-Ressource
    Abstract TP66: IV Thrombolysis May be Safe in Patients With Lower Platelet Counts
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. Suppl_1 ( 2018-01-22)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. Suppl_1 ( 2018-01-22)
    Kurzfassung: Background & Purpose: It has been well established that intravenous alteplase (IVa) administration for treatment of acute ischemic stroke (AIS) improves clinical outcome at 3 months, and earlier treatment is more likely to result in a favorable outcome with reduced symptomatic intracranial hemorrhage (sICH). A platelet count (PC) of 〈 100,000/mm3 remains a contraindication IVa, but the incidence is low. With the limited time to diagnose an AIS and candidacy for IVa, often lab results are received after drug initiation. Research indicates that IVa for AIS may be safe and the risk of developing sICH is low if IVa is given before PC is resulted. According to AHA/ASA guidelines, treatment is not delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test. The purpose of this study is to evaluate the incidence of asymptomatic hemorrhage (aICH), functional outcome, and safety of IVa in AIS patients with PC 〈 100,000/mm3 prior to PC results. Methods: We retrospectively reviewed charts of patients who received IVa from January, 2009 to July, 2017 at our facility. Patients were identified and treated based on standard FDA approved guidelines. We identified patients with admission PC 〈 100,000/mm3. We compared admission and discharge PC and NIHSS, baseline and discharge mRS, and discharge disposition. We evaluated their medical and social history and antiplatelet use prior to admission. Brain MRI and 24 hour noncontrast CT head were reviewed. Results: 511 patients received IVa for treatment of AIS at our facility during the study period. Four patients (0.97%) with a PC of 〈 100,000/mm3 (70,000/mm3 – 97,000/mm3) received full dose IVa. None of the 4 subjects had a hemorrhagic complication on 24 hour CT. Upon discharge, all 4 patients had an improvement in the NIHSS (mean 3.7 points) and were functionally independent at discharge (mRS 0-1). All 4 patients were discharged home. Conclusion: IVa treatment in AIS with PC 〈 100,000/mm3 did not result in aICH in this group of patients. Our study supports the claim that lower PC is rare in AIS patients and there is no need to wait for PC results before starting IVa. Full dose IVa in lower PCs may be safe, but a larger sample size should be studied to further evaluate safety.
    Materialart: Online-Ressource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.49.suppl_1.TP66
    RVK:
    XA 10000
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2018
    ZDB Id: 1467823-8
    Standort Signatur Einschränkungen Verfügbarkeit
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  • 4
    Online-Ressource
    Online-Ressource
    704 : ASSOCIATION OF FIRST 24-HOUR OXYGENATION LEVELS WITH FUNCTIONAL OUTCOME AFTER STROKE THROMBECTOMY
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Critical Care Medicine Vol. 47 ( 2019-01), p. 332-
    Details
    In: Critical Care Medicine, Ovid Technologies (Wolters Kluwer Health), Vol. 47 ( 2019-01), p. 332-
    Materialart: Online-Ressource
    ISSN: 0090-3493
    URL: Article
    DOI: 10.1097/01.ccm.0000551455.51800.20
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2019
    ZDB Id: 2034247-0
    Standort Signatur Einschränkungen Verfügbarkeit
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    Online-Ressource
  • 5
    Online-Ressource
    Online-Ressource
    Abstract TP4: Do Lower Blood Pressure Levels in the First 24 Hours After Mechanical Thrombectomy Have an Impact on the Short-Term Outcomes?
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Kurzfassung: Introduction: Mechanical thrombectomy (MT) is a part of the standard treatment of LVO stroke. Peri-interventional blood pressure variability may impact the outcomes of MT. In this study, we assessed whether lower mean blood pressure levels for longer than 12 hours has any impact on the short-term functional outcomes of MT. Methods: With the approval of the Human Studies Committee at the University of Louisville (IRB #: 13.0396), we performed a retrospective analysis of LVO stroke MT patients from 2016-18 (n=86). Blood pressure (BP) data collected at admission baseline, precanalization, immediate post-canalization, and 24 hours post-canalization. Baseline and post-canalization 24-hour BP data collected hourly. MBP lower than 20% of the “mean baseline” values recorded in the first few hours of admission was considered as “ clinically low ” BP, and a total of 12 hours of clinically low MBP levels within the first 24-hour of post-thrombectomy period was considered as “ potentially hypoperfused ”. Changes in NIHSS within the first 24 hours post canalization and NIHSS at discharge were assessed as main outcomes. Results: Mean age was 65±13 years. About 83% of patients TICI 2b/3 was accomplished. Baseline MBP levels were 103 ± 16mmHg. When the “ potentially hypoperfused ” patients (MBP 〈 80 of baseline for 〉 12 hours) were compared with the patients who were not (n=29 vs. n=57), the change in NIHSS at 24 hours and the NIHSS score at discharge were statistically significantly worse in patients who were potentially hypoperfused . (Table) Discussion: In this retrospective analysis, we assessed the contribution of clinically lower MBP levels after MT to the short-term functional outcome. Our preliminary results showed that the patients who were exposed to hypoperfusion for longer than 12 hours had worse NIHSS scores. Impact of maintaining baseline blood pressure needs to be further studied under prospective and controlled study designs.
    Materialart: Online-Ressource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.TP4
    RVK:
    XA 10000
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2019
    ZDB Id: 1467823-8
    Standort Signatur Einschränkungen Verfügbarkeit
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    Online-Ressource
  • 6
    Online-Ressource
    Online-Ressource
    Abstract WP405: Age, Race, and Gender Disparities in Door to Needle Time: A Single Center Joint Commission Certified Comprehensive Stroke Center Experience
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Kurzfassung: Introduction: Functional outcomes and quality of life are known benefits of Activase treatment in acute ischemic stroke (AIS), however, benefit is highly time dependent. Prior studies demonstrate that women and black patients with AIS are less likely to be treated with Activase in 〈 60 minutes. Utilization of best practice strategies identified in Target Stroke I & II has been an ongoing process improvement initiative at our facility since 2009. Purpose: Our goal was to understand if disparities in Door to Needle Time (DTNT) exist by age, race, or gender at our Joint Commission certified CSC with utilization of best practice strategies. Methods: A retrospective chart analysis with comparison of average DTNT by age, race and gender was performed on all AIS patients receiving Activase in our CSC from 2009-2015 (n=297). Differences in DTNT were analyzed using Student’s t-tests, ANOVA, and linear regression. Results: Median DTNT for all patients was 56 minutes (Male 58, Female 56, Black 61, and White 56). Average DTNT by age did not show any significant correlation with a R 2 =0.003 (F:0.98 p=0.322). Additionally, there were no significant differences among classified age categories (18-55, 56-80, 81-90, 91+; p=0.50). Average DTNT for females and males were observed to be 62.6 (95% CI 58.6-66.7) and 61.0 (95% CI 57.1-65.0), (p=0.57). Average DTNT for Blacks and Whites were observed to be 64.9 (95% CI 56.8-73.0) and 61.1 (95% CI 58.1-64.2), (p=0.35). Further analysis of gender by race classification demonstrated no significant differences in average DTNT (Black-Female 66.7, Black-Male 64.0, White-Female 62.1, White-Male 60.4 - F:0.44 p=0.73). Conclusion: No disparities in DTNT were found for age, race or gender at our CSC from 2009-2015. Target Stroke may have contributed to the absence of disparities. Comparison of DTNTs by age, race and gender before and after instituting Target Stroke at our CSC, other certified centers, and non-certified centers, is planned for our region. Further analyses will include arrival mode, payer source, stroke severity on arrival, off hour presentation, symptomatic hemorrhagic transformation rates, functional outcomes, and discharge disposition.
    Materialart: Online-Ressource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.wp405
    RVK:
    XA 10000
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2017
    ZDB Id: 1467823-8
    Standort Signatur Einschränkungen Verfügbarkeit
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    Online-Ressource
  • 7
    Online-Ressource
    Online-Ressource
    527 : ASSOCIATION BETWEEN HYPEROXIA AND OUTCOMES IN CRITICALLY ILL STROKE AND ICH PATIENTS
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Critical Care Medicine Vol. 43 ( 2015-12), p. 133-
    Details
    In: Critical Care Medicine, Ovid Technologies (Wolters Kluwer Health), Vol. 43 ( 2015-12), p. 133-
    Materialart: Online-Ressource
    ISSN: 0090-3493
    URL: Article
    DOI: 10.1097/01.ccm.0000474355.88277.73
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2015
    ZDB Id: 2034247-0
    Standort Signatur Einschränkungen Verfügbarkeit
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  • 8
    Online-Ressource
    Online-Ressource
    Abstract TP299: Early Mortality Prediction in Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. Suppl_1 ( 2018-01-22)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. Suppl_1 ( 2018-01-22)
    Kurzfassung: Introduction: Ischemic stroke (IS) is a medical emergency with a high risk of morbidity, leading to disability, and mortality. IS’s impact on our patients’ lives and healthcare system make it essential to optimize its immediate management, triage requirements, and plans for transfer to comprehensive stroke centers. In this study, we hypothesized that it is possible to predict the mortality of IS patients within the first hour of hospital admission. Methods: With the approval of the Human Studies Committee (IRB #: 13.0396), we performed a retrospective analysis from the Stroke Quality Database. Patients who were admitted between 2007-2012 were included. In-hospital mortality was the main outcome of the study. Patients’ demographics, baseline illnesses, home medications, baseline neurological assessment scores, and basic laboratory values on admission were included in the analysis as potential factors. Multivariate analysis was performed to assess the independent contributing factors. Data is presented as odds ratio and 95% confidence intervals. Results: IS in-hospital mortality was about 10% in our study population. Multivariate analysis was performed in 2,131 patients. NIH Stroke Scale on admission, recurrent stroke, high WBC levels ( 〉 11K), elderly age, AHA Stage II hypertension, baseline use of Ca-channel blockers, and beta-blockers, admission glucose levels and albumin levels independently contributed to in-hospital mortality (Table). Conclusions: IS patients’ baseline characteristics, hospital admission assessment scales, and laboratory values on admission contributed to prediction of in-hospital mortality. Therefore, it is essential to rapidly initiate acute care for high-risk and complex stroke patients. Additionally, focusing on the modifiable factors such as blood pressure management, treating acute infections, and managing glucose levels may help to decrease acute IS mortality.
    Materialart: Online-Ressource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.49.suppl_1.TP299
    RVK:
    XA 10000
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2018
    ZDB Id: 1467823-8
    Standort Signatur Einschränkungen Verfügbarkeit
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  • 9
    Online-Ressource
    Online-Ressource
    Abstract 180: Stroke Mimics in Drip and Ship Thrombolytic Therapy
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. suppl_1 ( 2016-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. suppl_1 ( 2016-02)
    Kurzfassung: Introduction: Drip and ship (DS) thrombolysis provides immediate acute ischemic stroke treatment and follow-up tertiary stroke care at a certified Comprehensive Stroke Center (CSC) for one quarter of the US population living in rural areas. Studies reveal that patients with stroke mimic (SM) inadvertently receive treatment due to lack of immediate access to specialists and the limited treatment time window. Hypothesis: We hypothesized that a higher percentage of SM would receive thrombolysis via the DS paradigm than those directly presenting to the CSC. Methods: We reviewed consecutive DS tPA cases transferred to the University of Louisville Hospital (ULH) and tPA cases originating at ULH from January, 2013 to June, 2015. ULH is a CSC that provides rural Kentucky and Southern Indiana hospitals with 24-hour telephone access to stroke specialists. We compared the percentage of SMs via a DS paradigm to those originating at ULH. SM data collected included demographics, medical history, NIHSS, complications, discharge diagnosis, discharge disposition, and the length of hospitalization. Etiology of SM was evaluated in the Old (≥ 65 years old) and the Young ( 〈 65 years old) group, respectively. Comparative analyses with t-tests and Fisher Exact tests were performed. Results: Total numbers of tPA cases were similar between the DS (201) and the ULH (200) groups, but the percentage of SM in the DS group was double the ULH group (27.4% vs 13.5%). Clinical features, NIHSS on admission, and percentage of SM patients who were 65 years or older were similar in both groups. None of SM had intracranial hemorrhage or severe adverse events. One patient in the DS had minor hematemesis without transfusion. All except one patient returned home or to an assisted living facility. One patient who was from home was discharged to a nursing home due to Parkinson’s disease. Psychiatric disease was more common in the Young SM than the old (45.3% vs 7.4%, p 〈 0.05). Encephalopathy for various reasons (25.9%) and seizures (22.2%) were the two most common causes in the Old SM. Conclusions: SMs are treated with tPA more often in the DS paradigm than when presenting to a CSC. Although the thrombolysis caused no harm, adequate access to specialists (i.e telestroke) may decrease unnecessary treatment with tPA.
    Materialart: Online-Ressource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.47.suppl_1.180
    RVK:
    XA 10000
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2016
    ZDB Id: 1467823-8
    Standort Signatur Einschränkungen Verfügbarkeit
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    Online-Ressource
  • 10
    Online-Ressource
    Online-Ressource
    Abstract WP84: Thrombolysis is Safe in the Nonagenarians With Acute Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. suppl_1 ( 2016-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. suppl_1 ( 2016-02)
    Kurzfassung: Introduction: People aged 90 years or older are the fastest growing group in North America. This group was excluded from traditional clinical trials of intravenous tissue plasminogen activator (iv tPA) thrombolysis. IV tPA is the most beneficial emergent therapy in acute ischemic stroke (AIS). We have compassionately treated AIS patients in this age group with iv tPA in recent years. Hypothesis: Our aim is to evaluate the safety and outcome of iv tPA use in nonagenarian patients with AIS Methods: Consecutively iv tPA-treated AIS patients who were older than 90 years and were admitted at our institution from January 2004-June 2015 were included. The administration of iv tPA was within 3 hours after the stroke onset. We reviewed the clinical features of the patients at presentation, complications, and outcomes. Outcome measures at discharge included improvement of NIHSS, mRS, symptomatic intracranial hemorrhage (sICH), and discharge disposition. We also assessed the rate of complications of iv tPA. Multiple logistic regression analysis was used to evaluate association between the outcome versus the severity of stroke, or versus pre-stroke dependence. Results: A total of 35 AIS patients who were 90 years or older (female 80%; and median age 93 years old) were treated with iv tPA. At baseline twenty-two patients (62.9%) had a history of atrial fibrillation without anticoagulation, and more than half (20/35) patients needed assistance for gait instability, but they were otherwise functional. Median NIHSS on admission was 16 (IQR 9-22). Two patients (5.7%) had symptomatic intracerebral hemorrhage. At discharge the median NIHSS was 10 (IQR 1-19). Ten patients (28.6%) had favorable outcome (mRS ≤ 2) while sixteen patients (45.7%) had good outcome (mRS ≤ 3). Four patients were discharged home and 16 patients went to rehabilitation facility. Fifteen patients (42.9%) succumbed to cardio-pulmonary failure or were discharged to hospice. Mild AIS patients (NIHSS 〈 7) had better outcomes (p 〈 0.05). The pre-existing dependence (mRS ≥3) did not predict poor outcome. Conclusion: It is safe to administer iv tPA to AIS patients who are 90 years or older although the benefits are less robust compared to younger patients. Patients with milder deficits had more favorable outcomes.
    Materialart: Online-Ressource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.47.suppl_1.wp84
    RVK:
    XA 10000
    Sprache: Englisch
    Verlag: Ovid Technologies (Wolters Kluwer Health)
    Publikationsdatum: 2016
    ZDB Id: 1467823-8
    Standort Signatur Einschränkungen Verfügbarkeit
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    Online-Ressource
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