Acute Stroke Admissions Research Articles

Abstract TP43: Trends in Interhospital Transfers and Mechanical Thrombectomy for Acute Ischemic Stroke

Introduction: Stroke care in the US is becoming increasingly regionalized. Many patients undergo interhospital transfer to obtain access to specialized, time-sensitive interventions such as mechanical thrombectomy. Methods: We used the stratified survey design of the US Nationwide Inpatient Sample, 2009-2014, to examine nationwide trends in interhospital transfers for ischemic stroke and the relationship between transfers and thrombectomy. International Classification of Disease—Ninth Revision diagnosis and procedure codes were used to identify acute stroke admissions and inpatient procedures (tissue plasminogen activator [tPA] administration and thrombectomy), respectively. The analysis was restricted to hospitals with the capabilities to perform thrombectomy. Trends were assessed using a Cochran-Armitage test. Results: From 2009 to 2014, an estimated 759,648 ischemic stroke admissions were identified within hospitals offering thrombectomy (102,674 in 2009; 154,280 in 2014). The proportion of stroke admissions to these hospitals that underwent interhospital transfer prior to arrival increased from 13.5% (n=13,811) in 2009 to 18.9% (n=19,175) in 2014 ( P trend<0.001). Compared to “front door” patients, transfers were more likely to receive tPA (10.7% vs. 26.5%; P <0.001) and thrombectomy (2.7% vs. 5.7%; P <0.001). The proportion of transfers that received thrombectomy increased from 4.5% (n=625) to 6.0% (n=1,745) from 2009 to 2014 ( P trend=0.016). Approximately 30% of patients receiving thrombectomy for ischemic stroke were transferred from another acute care facility (n=7,328). Among patients receiving tPA, transferred patients were slightly less likely to receive thrombectomy compared to those arriving by “front door” at thrombectomy performing centers (13.9% vs. 15.4%; P =0.004). Conclusions: From 2009 to 2014, interhospital stroke transfers to thrombectomy performing hospitals more than doubled. For every ~5 additional stroke transfers over the time period examined, one additional transferred patient received thrombectomy. As stroke systems of care continue to evolve across the US, the optimization of stroke transfers presents an opportunity to increase access to meaningful interventions such as thrombectomy.

Abstract 21112: Trends in Acute Ischemic Stroke Admissions in Patients With Atrial Fibrillation and Flutter From 2004 to 2014

Introduction: Atrial Fibrillation and Flutter (AF) predispose patients to acute ischemic strokes and increased mortality. We aim to assess the impact of new guidelines, innovations in technology and several new drugs on mortality and morbidity of patients hospitalized for ischemic stroke with concurrent AF over 10 years. We assessed the hypothesis that these advances would be associated with improvements in mortality over that time period. Methods: This is a retrospective cohort study using the 2004-2014 National Inpatient Sample, the largest publicly available inpatient database in the United States. We included women and men >18 years of age admitted between 2004 and 2014 with primary diagnoses of atrial fibrillation or flutter and with secondary diagnoses of acute ischemic stroke and transient ischemic attack (using ICD-9 CM codes). The primary outcome was in-hospital mortality and the secondary outcomes were total hospital cost and mean length of stay (LOS). STATA 13.0 was used for data analysis. Results: 222,074 patients were included in this study. The mean age was 79.2 years and 58.8% were female. The inpatient mortality rate in 2004 was 11.6% and it decreased consistently until 2014 at 8.0% (p trend <0.001). Mean total hospital cost was $10,582 in 2004 and it increased consistently until 2014 at $13,849 (p trend < 0.001). Mean length of stay steadily decreased from 6.9 days in 2004 to 5.7 days in 2014. Conclusion: Over the past 10 years, new innovations in technology and the approval and use of several novel oral anticoagulants for use in AF have been implemented. While there is a trend of increasing costs, these measures seem to show a trend of improving mortality and decreasing length of stay in patients hospitalized with ischemic strokes and AF.

Ambient temperature and added heat wave effects on hospitalizations in California from 1999 to 2009

Investigators have examined how heat waves or incremental changes in temperature affect health outcomes, but few have examined both simultaneously. We utilized distributed lag nonlinear models (DLNM) to explore temperature associations and evaluate possible added heat wave effects on hospitalizations in 16 climate zones throughout California from May through October 1999–2009. We define heat waves as a period when daily mean temperatures were above the zone- and month-specific 95th percentile for at least two consecutive days. DLNMs were used to estimate climate zone-specific non-linear temperature and heat wave effects, which were then combined using random effects meta-analysis to produce an overall estimate for each. With higher temperatures, admissions for acute renal failure, appendicitis, dehydration, ischemic stroke, mental health, non-infectious enteritis, and primary diabetes were significantly increased, with added effects from heat waves observed for acute renal failure and dehydration. Higher temperatures also predicted statistically significant decreases in hypertension admissions, respiratory admissions, and respiratory diseases with secondary diagnoses of diabetes, though heat waves independently predicted an added increase in risk for both respiratory types. Our findings provide evidence that both heat wave and temperature exposures can exert effects independently.

Evaluation of the Patient Health Questionnaire-2 as a Screening Tool for Depression during the Acute Stroke Admission

The ideal time to screen for poststroke depression remains uncertain. We evaluated the 2-item Patient Health Questionnaire (PHQ-2) as a screening tool for depression during the acute stroke admission by determining the prevalence of positive depression screen during admission and by calculating the level of agreement between positive screens during admission and follow-up. This was a retrospective cohort of adult stroke survivors discharged January to December 2013 with principal discharge diagnosis of acute ischemic stroke or intracerebral hemorrhage. Depression screening was systematically performed during the hospital admission using the PHQ-2. The 9-item Patient Health Questionnaire (PHQ-9), which includes the PHQ-2, was completed by patients at outpatient follow-up. The study cohort consisted of 337 patients with mean age of 66.3 years. Median time from admission to PHQ-2 was 3 days (interquartile range 1-4 days). The screen was positive for depression in 4.7% (95% confidence interval 2.7%-7.6%) of patients. Of the 150 patients with PHQ-9 data at outpatient follow up, 19.3% screened positive for depression. In both the inpatient setting and at outpatient follow-up, the prevalence of a positive depression screen was similar between patients with and without a history of depression or antidepressant use. Systematic screening for depression using PHQ-2 during hospitalization for acute stroke identified few patients. Most patients with depressive symptoms were identified only at the time of outpatient follow-up. Further study is needed to evaluate the usefulness of other depression screens for stroke patients in the acute hospital setting and the optimal timing for depression screening after stroke.

Disparities and Trends in Door-to-Needle Time: The FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities).

In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45. Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45. DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72-0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57-0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%). In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.

Abstract 504: Regional Variations of Ischemic Stroke in The United States

Geographic Distribution of Acute Ischemic Stroke admissions in the United States Background: The geographic distribution of acute ischemic stroke in the United States has not been evaluated, unlike the association shown with acute MI by Patel et al., (International Journal of Cardiology, 2014, 172.3). Our study looked at the geographic distribution and seasonal variation of acute ischemic stroke using the National Inpatient Sample (NIS) from 2011 - 2013. Methods: Adult admissions with a primary diagnosis of acute ischemic stroke were extracted from the NIS database using the ICD 9 code 434.91 from 2011 - 2013. Admission information included hospital region (West, South, Mid-Atlantic and Northwest) and seasonal admission rates (Winter=December-February, Spring=March-May, Summer=June-August, Fall=September-November). A Chi square analysis was used to analyze differences in categorical variables (we assumed a normal distribution of 25% per region). Results: A total of 120714 admissions were identified (weighted = 603361). There were more cases of acute ischemic stroke in the South (41.52 percent of admissions) compared to the mid Atlantic (21.4), Northwest (17.98) or West (19.08) with a p value < 0.0001. Each year between 2011 to 2013 showed a higher rate of admissions for acute ischemic stroke in the South. Taking the years into summation showed no statistically significant difference in seasonal variation in any of the regions. Conclusion: Our study shows a higher number of admissions for acute ischemic stroke in the South, but failed to show any seasonal differences. However, there are several studies that suggest a preponderance of admissions for acute myocardial infarction during the winter season, Spencer et al., (Journal of the American College of Cardiology, 1998, 31.2.) Further studies are needed to identify why there is a significant regional difference in the admission rates for acute ischemic stroke.

Continuing or Temporarily Stopping Prestroke Antihypertensive Medication in Acute Stroke: An Individual Patient Data Meta-Analysis.

Over 50% of patients are already taking blood pressure-lowering therapy on hospital admission for acute stroke. An individual patient data meta-analysis from randomized controlled trials was undertaken to determine the effect of continuation versus temporarily stopping preexisting antihypertensive medication in acute stroke. Key databases were searched for trials against the following inclusion criteria: randomized design; stroke onset ≤48 hours; investigating the effect of continuation versus stopping prestroke antihypertensive medication; and follow-up of ≥2 weeks. Two randomized controlled trials were identified and included in this meta-analysis of individual patient data from 2860 patients with ≤48 hours of acute stroke. Risk of bias in each study was low. In adjusted logistic regression and multiple regression analyses (using random effects), we found no significant association between continuation of prestroke antihypertensive therapy (versus stopping) and risk of death or dependency at final follow-up: odds ratio 0.96 (95% confidence interval, 0.80-1.14). No significant associations were found between continuation (versus stopping) of therapy and secondary outcomes at final follow-up. Analyses for death and dependency in prespecified subgroups revealed no significant associations with continuation versus temporarily stopping therapy, with the exception of patients randomized ≤12 hours, in whom a difference favoring stopping treatment met statistical significance. We found no significant benefit with continuation of antihypertensive treatment in the acute stroke period. Therefore, there is no urgency to administer preexisting antihypertensive therapy in the first few hours or days after stroke, unless indicated for other comorbid conditions.

Increased infections with β-blocker use in ischemic stroke, a β2-receptor mediated process?

Strokes promote immunosuppression, partially from increased sympathetic activity. Altering sympathetic drive with β-blockers has variably been shown to improve stroke outcomes. This study adds to this literature using propensity score matching to limit confounding and by examining the effects of selective and non-selective β-blockers. Prospective data from acute ischemic stroke admissions at a single center from July 2010-June 2015 were analyzed. Outcomes included infection (urinary tract infection [UTI], pneumonia, or bacteremia), discharge modified Rankin Score (mRS), and in-hospital death. Any selective and non-selective β-blocker use during the first 3days of admission were investigated with propensity score matching. A sensitivity analysis was also performed. This study included 1431 admissions. Any β-blocker use was associated with increased infections (16.4 vs. 10.7%, p=0.030). Non-selective β-blocker use was associated with increased infections (18.9 vs. 9.7%, p=0.005) and UTIs (13.0 vs. 5.5%, p=0.009). Selective β-blocker use was not associated with infection. There were no associations between β-blocker use and in-hospital death or discharge mRS. In the sensitivity analysis, the association between non-selective β-blocker use and urinary tract infections persisted (12.5 vs. 4.2%, p=0.044). No associations with death or mRS were found. Early β-blocker use after ischemic stroke may increase the risk ofinfection but did not change disability or mortality risk. The mechanism may be mediated by β2-adrenergic receptor antagonism given the different effects seen with selective versus non-selective β-blocker use.

Diagnostic Accuracy of Transient Ischemic Attack from Physician Claims.

Hospitalization data underestimate the occurrence of transient ischemic attack (TIA). As TIA is frequently diagnosed in primary care, methodologies for the accurate ascertainment of a TIA from physician claims data are required for surveillance and health systems planning in this population. The present study evaluated the diagnostic accuracy of multiple algorithms for TIA from a longitudinal population-based physician billing database. Population-based administrative data from the province of British Columbia were used to identify the base population (1992-2007; N=102,492). Using discharge records for hospital admissions for acute ischemic stroke with a recent (<90 days) TIA as the reference standard, we performed receiver-operating characteristic analyses to calculate sensitivity, specificity, positive and negative predictive values and overall accuracy, and to compare area under the curve for each physician billing algorithm. To evaluate the impact of different case definitions on population-based TIA burden, we also estimated the annual TIA occurrence associated with each algorithm. Physician billing algorithms showed low to moderate sensitivity, with the algorithm for two consecutive physician visits within 90 days showing the highest sensitivity at 37.7% (CI 95%=37.4-38.1). All algorithms demonstrated high specificity and moderate to high overall accuracy, resulting in low positive predictive values (≤5%), low discriminability (0.53-0.57) and high false positive rates (1 - specificity). Population-based estimates of TIA occurrence were comparable to prior studies and declined over time. Physician billing data have insufficient sensitivity to identify TIAs but may be used in combination with hospital discharge data to improve the accuracy of estimating the population-based occurrence of TIAs.

Abstract TMP94: Outcomes in Hospitalized Stroke and TIA Patients with Dementia - A Population-based Study

Background: Dementia prevalence is rising, and will double in the next 20 years. This study sought to understand the prevalence of dementia in hospitalized patients with stroke and TIA, differences in characteristics and impact on outcomes. Methods: Using the Canadian Institute of Health Information (CIHI) Discharge Abstract Database (DAD), all acute stroke and TIA admissions from April 2003 to March 2015 in Canada (excluding Quebec) were analyzed. Concurrent dementia at time of admission was assessed based on hospital diagnostic codes. Characteristics and in-hospital outcomes were compared in patients with vs. without dementia using chi-square and logistic regression. Results: During the observed period 464,741 patients were admitted to hospital for cerebrovascular syndromes (ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage (SAH) and TIA). Of those, 29,812 (6.4%) had a concurrent diagnosis of dementia, including 8.4% of patients ≥65 years. People with dementia had older median age (84 vs. 75 years; p&lt;0.01), were more often female (59.6% vs. 49.3%; p&lt;0.01) and more often had Charlson-Deyo comorbidity index ≥ 2 (62.1% v. 38.4%; p&lt;0.01). They were less likely admitted with SAH (1.3% vs. 5.3%; p&lt;0.01) and more likely coded as strokes with unidentified subtype (29.4% vs. 20.8%; p&lt;0.01). Median length of stay (13 vs. 7 days; p&lt;0.01) was longer. Patients with dementia were less likely discharged to another acute care facility (7.6% vs. 14.7%; p&lt;0.01), rehabilitation facility (5.4% vs. 12.0%; p&lt;0.01) or home independently (22.9% 48.9%; p&lt;0.01); other outcomes are shown in the Table. Conclusions: Approximately 1 in 10 hospitalized stroke and TIA patients age ≥65 has coded dementia. Patients with stroke or TIA and dementia have higher mortality, face significantly more dependence after stroke and utilize greater healthcare resources than stroke patients without dementia. Early care planning and coordination are essential to optimize outcomes.

Abstract WP411: Evaluation of Strategies to Reduce Time to Revascularization in Acute Ischemic Stroke

Background: There is growing support for the need for process improvement surrounding treatment of acute ischemic stroke, specifically, reducing time to reperfusion in endovascular therapy (EVT). Streamlining protocols from patient presentation to revascularization can lead to improved timelines to treatment and functional outcomes. Purpose: The purpose of this study was to identify the impact on specific hospital based process improvement strategies in the acute ischemic stroke patient population undergoing endovascular therapy with specific intent to decrease median arrival to revascularization time, thus increasing the potential for good functional outcome. Methods: The study includes a pre- and post-intervention retrospective review of patients 18 years or older, hospital admission between January 1, 2014 and December 31, 2015, who underwent EVT for treatment acute ischemic stroke. The primary outcome variable was time from arrival to revascularization during the acute ischemic stroke admission. The secondary outcome variables were specific to functional outcome analysis in the acute ischemic stroke patient. The data points were collected from the local America Heart Association’s Get with the Guidelines-Stroke (GWTG) dataset. Results: Twenty eight consecutive endovascular ischemic stroke patients were reviewed, pre process improvement (PI) (Group 1, n=10) and post PI (Group 2, n=18). There were no significant differences between baseline characteristics between the groups. The primary outcome analysis revealed significant improvement in door to revascularization between the pre and post PI groups, 2:56 and 2:11 (p=.002) respectively, a 45 minute decrease in time to treatment. Rates of good clinical outcomes (modified Rankin Scale 0-2 at 3 months) were similar in both groups, 33.3% pre PI and 46.2% post PI (p=0.59). Conclusions: Hospital based PI initiatives including: early notification, streamlined transport process, and utilization of feedback tool significantly improve door to revascularization times and can potentially lead to improved functional outcomes in the acute ischemic stroke patient undergoing EVT.

Abstract TP297: Type II Myocardial Infarction is Significantly Associated with Admission NIHSS and Discharge Disposition Following Ischemic Stroke

Introduction: Troponin elevations due to Type II myocardial infarction (T2MI) are associated with increased mortality after hemorrhagic stroke but there is little data on stroke severity or outcome following ischemic stroke. Methods: All stroke discharges from UH-Case Medical Center between 1/2013- 4/2015 were reviewed for demographics, vascular risk factors, admission stroke severity, labs, echocardiogram results and discharge disposition. Troponin levels were normal (&lt;0.04ng/ml), high (0.04-0.5ng/ml), or critical (&gt;0.5ng/ml). A T2MI was diagnosed by a trending troponin elevation; patients with T1MI were excluded. Analyses used SPSS. Results: Troponin levels were normal in 65%, high in 28% and critical in 7% in 1655 patients (1052 ischemic stroke, 434 intracerebral hemorrhage, 169 subarachnoid hemorrhage) and were associated with admission stroke severity (figure). Ischemic stroke patients were mean age 69 yrs (20-101), 50.4% female with mean admission NIHSS 9.3 (0-36). T2MI was associated with higher NIHSS &gt;10 (p=.000), SCr (p=.000) and age (p=.005), lower LDL (p=.000) and SBP (p=.012), and history of AF (p=.021), CAD (p=.000), and HF (p=.000). The significant association with admission NIHSS (p=.002) persisted after adjustment for age (p = .056), gender, LDL (p = .007), CAD (p= .023), heart failure (p = .003), atrial fibrillation, systolic BP, A1C, BMI, and SCr (p=.009). Initial troponin levels for the 8.3% who died or DC to hospice were high in 43% and critical in 24%. Initial and peak troponin levels were significantly associated with DC disposition (p=.000). Conclusion: Elevated troponin due to T2MI is significantly associated with admission ischemic stroke severity, persisting after adjustment of other risk factors, and predicts a poorer outcome. Troponin levels should be obtained on admission for acute stroke to establish the diagnosis of T2MI and capture its impact as a major comorbid condition.

Abstract TMP54: Seasonal Patterns of Ischemic Stroke in the United States

Background: Seasonal variation in stroke occurrence and outcomes has been reported in small populational studies but the significance of a seasonal effect is uncertain. The important patient and climate variables underlying this phenomenon have not yet been identified. Methods: Using Get With The Guidelines-Stroke data from 2011 to 2015, we studied 457,638 consecutive ischemic stroke patients at 896 sites. We calculated the relative prevalence of acute stroke admissions in each season. Baseline characteristics and discharge outcomes were compared across seasons and the effects of season, climate region (as defined by the National Climatic Data Center), and climate variables on outcomes were analyzed using logistic regression. In secondary analyses, odds ratios were calculated for various outcomes. Results: Among all cases of ischemic stroke, there was significant difference in the frequency distributions of cases across seasons (p&lt;.0001), with the highest percentage of strokes occurring in winter (25.5%). Across seasons, winter patients had the highest percentage of atrial fibrillation (17.7%), longest median time to arrival (202 minutes), highest in-hospital mortality (4.4%), and most discharge mRS scores &gt; 3 (43.7%). P&lt;.0001 for all the above. Higher precipitation and temperature were associated with reduced mortality independent of climate region or season (OR .93, CI .89-.97, p=.0005 and OR .97, CI .97-.98, p&lt;.0001, respectively). Odds ratios for in-hospital mortality are summarized in the accompanying table. Conclusions: More patients presented with acute ischemic stroke in winter relative to other seasons, accompanied by trends toward poorer outcomes. Although an association with mortality was seen for winter in our unadjusted analysis, confounding variables likely exist. Precipitation and temperature were independently associated with stroke mortality.

Seasonality of stroke in Finland

Introduction: The burden of stroke is increasing globally. Reports on seasonal variations in stroke occurrence are conflicting and long-term data are absent.Methods: A retrospective cohort study using discharge registry data of all acute stroke admissions in Finland during 2004–2014 for patients ≥18 years age. A total of 97,018 admissions for ischemic stroke (IS) were included, 18,252 admissions for intracerebral hemorrhage (ICH) and 11,271 admissions for subarachnoid hemorrhage (SAH).Results: The rate of IS admissions increased (p = 0.025) while SAH admission rate decreased (p < 0.0001), and ICH admission rate remained stable during the study period. The lowest seasonal admission rates were detected in summer and the highest in autumn for all stroke subtypes. Seasonal variation of IS was more pronounced in men (p = 0.020), while no sex difference was detected in ICH or SAH. The seasonal patterns of in-hospital mortality and length of stay (LOS) differed markedly by stroke subtype. Diagnoses of hypertension, atrial fibrillation, or diabetes showed no seasonality.Conclusions: All major stroke subtypes occurred most commonly in autumn and most infrequently in summer. Seasonality of in-hospital mortality and length of hospital stay appears to vary by stroke subtype. The seasonal pattern of ischemic stroke occurrence appears to have changed during the past decades.Key messagesAll major stroke subtypes (ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage) occurred most frequently in autumn and least frequently in summer.Seasonal patterns of in-hospital mortality and length of stay differed markedly by stroke subtype.The seasonal pattern of ischemic stroke occurrence in Finland seems to have changed compared to 1982–1992.

Clinical features of patients who died within 24 h after admission to a stroke care center.

ObjectiveIn Japan, stroke care is provided through medical cooperation and standardized treatment. However, various factors affect mortality in the hyperacute phase. The present study investigated factors associated with death within 24 h after admission for acute stroke.MethodsAmong 2335 patients admitted within 24 h after stroke onset from 1 January 2007 to 31 December 2012, a total of 139 deaths occurred. Forty-eight deaths occurred within 24 h after admission. We retrospectively examined the clinical features of these 48 patients.ResultsThe overall mortality rate was 6.0%. When the initial 72-h period was divided into ≤24 h (Period I), >24 to 48 h (Period II), and >48 to 72 h (Period III), deaths were significantly more frequent in Period I than in the other two periods. The frequency of intracerebral haemorrhage (ICH) was also significantly higher in Period I than in the other two periods. Factors significantly associated with death from ICH were systolic blood pressure, hematoma volume, and surgery.ConclusionThe mortality rate was low among patients with stroke transported to the authors’ medical center within 24 h of onset. Blood pressure management and the timing of determining indications for surgery are important factors in acute haemorrhagic stroke care.

Do studies of the weekend effect really allow for differences in illness severity? An analysis of 14 years of stroke admissions.

An increased mortality rate among patients admitted to hospital at weekends has been found in many studies, and this ‘weekend effect’ has been used to justify major health service reorganisation. Most studies have used routine administrative data to adjust for potential confounding factors, and are unable to measure differences in illness severity due to the tendency of patients with milder symptoms to stay home at weekends. We set out to estimate the importance of such unmeasured ‘confounding by severity’, using data from a hospital stroke register. All suspected acute stroke admissions in Gateshead were prospectively registered over a period of 14.3 years, including information on premorbid factors, measures of stroke severity and survival to hospital discharge. We examined whether each factor differed between weekday and weekend admissions, then used logistic regression to estimate the main contributors to variation in mortality rates. Stroke severity, measured by the Scandinavian Stroke Scale (SSS), was significantly greater among weekend admissions and strongly associated with mortality, and after adjustment for SSS score in logistic regression, the weekend effect completely disappeared. By contrast, most indicators of pre-stroke function, comorbidity or stroke type did not differ between weekday and weekend admissions, although some of them had prognostic significance. The sorts of factors measurable in administrative databases only account for a small part of the prognostically important differences in case-mix between weekday and weekend stroke admissions. While increasing weekend staffing might improve adherence to care standards, evidence that it could save lives is unreliable.

Effect of aphasia on acute stroke outcomes.

To determine the independent effects of aphasia on outcomes during acute stroke admission, controlling for total NIH Stroke Scale (NIHSS) scores and loss of consciousness. Data from the Tulane Stroke Registry were used from July 2008 to December 2014 for patient demographics, NIHSS scores, length of stay (LOS), complications (sepsis, deep vein thrombosis), and discharge modified Rankin Scale (mRS) score. Aphasia was defined as a score >1 on question 9 on the NIHSS on admission and hemiparesis as >1 on questions 5 or 6. Among 1,847 patients, 866 (46%) had aphasia on admission. Adjusting for NIHSS score and inpatient complications, those with aphasia had a 1.22 day longer LOS than those without aphasia, whereas those with hemiparesis (n = 1,225) did not have any increased LOS compared to those without hemiparesis. Those with aphasia had greater odds of having a complication (odds ratio [OR] 1.44, confidence interval [CI] 1.07-1.93, p = 0.0174) than those without aphasia, which was equivalent to those having hemiparesis (OR 1.47, CI 1.09-1.99, p = 0.0137). Controlling for NIHSS scores, aphasia patients had higher odds of discharge mRS 3-6 (OR 1.42 vs 1.15). Aphasia is independently associated with increased LOS and complications during the acute stroke admission, adding $2.16 billion annually to US acute stroke care. The presence of aphasia was more likely to produce a poor functional outcome than hemiparesis. These data suggest that further research is necessary to determine whether establishing adaptive communication skills can mitigate its consequences in the acute stroke setting.

PP.16.08] HYPERTENSIVE DIABETIC AND THE INCIDENCE OF CARDIOVASCULAR OUTCOMES AND COMMITMENT RENAL IN ELEVEN YEARS OF HISTORICAL COHORT

Objective: To identify non-lethal cardiovascular outcomes and indicative of decrease of kidney function in a cohort of diabetic and non-diabetic hypertensive type 2 in regular and continuous treatment in a specialized center for hypertensive patients. Design and method: Historical cohort of diabetic hypertensive (exposed group) and nondiabetic (unexposed group) in regular treatment for at least 11 years in a reference center for hypertension treatment. Initial cohort assessment in 2004, with intermediate follow-up in 2009 and final follow-up in 2015; variables studied: gender, race, age, blood pressure, body mass index, glycated hemoglobin, duration of hypertension diagnosis, diabetes and specialized treatment, non-fatal cardiovascular events, indicative of decrease in renal function using creatinine clearance. For the variables association analysis was used chi-square test or Fisher's exact, at a 5% significance level. Results: Included 139 hypertensive patients (diabetics: 55; nondiabetic: 84), with a mean time of hypertension treatment at the first analisis of 6 years. Most patients were females(75.5%) and the white race was predominant (55.8%). Initially the average overall age was 57.4 years, similar in both groups. In eleven years, the exposed group had a higher risk of being affected by acute myocardial infarction(12.2 times), stroke(6.1 times more) and hospital admissions (2.2 times) compared to the unexposed. The diabetes diagnosis time in this cohort was not associated with the incidence of the analyzed events. Also the exposed group had 2.3 times greater risk to not controll the blood pressure. Regarding kidney function the exposed group decreased more significantly creatinine clearance. They started with 82,9 min/1.73 m2 and finished with 64,2 min/1.73 m2 and the unexposed group began with 70,2 min/1.73 m2 and finished 61,9 min /1.73 m2 (p < 0.05). Categorizing the glomerular filtration rate to <60 min/1.73 m2 and >/=60 min/1.73 m2 there was no major loss of renal function in diabetic patients since they had at the end renal injury rates of 43.4% and 45.2% nondiabetic (p > 0.05). Conclusions: Hypertensive diabetics had higher chance to be affected by cardiovascular outcomes compared to non-diabetic patients in this cohort. Hypertensive diabetics has an increas risk for the occurrence of cardiovascular outcomes, thereby this population requires more intensive actions to minimize health hazards.

An interdisciplinary visual team in an acute and sub-acute stroke unit: Providing assessment and early rehabilitation.

To describe the work of an interdisciplinary visual team in a stroke unit providing early identification and assessment of patients with visual symptoms, and secondly to investigate frequency, type of visual deficits after stroke and self-evaluated impact on everyday life after stroke. For a period of three months, all stroke patients with visual or visuo-attentional deficits were registered, and data concerning etiology, severity and localization of the stroke and initial visual symptoms were registered. One month after discharge patients were contacted for follow-up. Of 349 acute stroke admissions, 84 (24.1%) had visual or visuo-attentional deficits initially. Of these 84 patients, informed consent was obtained from 22 patients with a mean age of 67.7 years(SD 10.1), and the majority was female (59.1%). Based on the initial neurological examination, 45.4% had some kind of visual field defect, 27.2% had some kind of oculomotor nerve palsy, and about 31.8% had some kind of inattention or visual neglect. The patients were contacted for a phone-based follow-up one month after discharge, where 85.7% reported changes in their vision since their stroke. In this consecutive sample, a quarter of all stroke patients had visual or visuo-attentional deficits initially. This emphasizes how professionals should have increased awareness of the existence of such deficits after stroke in order to provide the necessary interdisciplinary assessment and rehabilitation.

A time-series analysis of the relation between unemployment rate and hospital admission for acute myocardial infarction and stroke in Brazil over more than a decade

BackgroundThe effect of socioeconomic stressors on the incidence of cardiovascular disease (CVD) is currently open to debate. Using time-series analysis, our study aimed to evaluate the relationship between unemployment rate and hospital admission for acute myocardial infarction (AMI) and stroke in Brazil over a recent 11-year span. Methods and resultsData on monthly hospital admissions for AMI and stroke from March 2002 to December 2013 were extracted from the Brazilian Public Health System Database. The monthly unemployment rate was obtained from the Brazilian Institute for Applied Economic Research, during the same period. The autoregressive integrated moving average (ARIMA) model was used to test the association of temporal series. Statistical significance was set at p<0.05. From March 2002 to December 2013, 778,263 admissions for AMI and 1,581,675 for stroke were recorded. During this time period, the unemployment rate decreased from 12.9% in 2002 to 4.3% in 2013, while admissions due to AMI and stroke increased. However, the adjusted ARIMA model showed a positive association between the unemployment rate and admissions for AMI but not for stroke (estimate coefficient=2.81±0.93; p=0.003 and estimate coefficient=2.40±4.34; p=0.58, respectively). ConclusionsFrom 2002 to 2013, hospital admissions for AMI and stroke increased, whereas the unemployment rate decreased. However, the adjusted ARIMA model showed a positive association between unemployment rate and admissions due to AMI but not for stroke. Further studies are warranted to validate our findings and to better explore the mechanisms by which socioeconomic stressors, such as unemployment, might impact on the incidence of CVD.