Primary Discharge Research Articles

Characteristic studies on positive and negative streamers of double-sided pulsed surface dielectric barrier discharge

The mechanisms of streamer generation and propagation in double-sided pulsed surface dielectric barrier discharge (SDBD) on both sides have been analyzed and investigated by experiment and numerical simulation. The fully exposed asymmetric SDBD has two discharge processes located on the high voltage electrode (HVE) side and the ground electrode (GE) side. Discharge images of the HVE side and GE side are taken by a digital camera under continuous pulse and ICCD (Intensified Charge Coupled Device) is utilized to diagnose the generation and propagation of streamers in single pulse discharge. In order to understand the physical mechanisms of streamer evolution more deeply, we establish a 2D simulation model and analyze it from the aspects of electron density, ion density, reduced electric field and electron impact ionization source term. The results show that the primary and secondary discharges on the HVE side and the GE side of the double-sided SDBD are composed of positive streamer and negative streamer, respectively. On the HVE side, the accumulation of positive charges on the dielectric surface causes the direction of the electric field to reverse, which is the principal factor for the polarity reversal of the streamer. On the GE side, both the negative charges accumulated on the dielectric surface and the falling voltage are the key factors for the streamer polarity switch.

Benefits Of An Interdisciplinary Nurse Practitioner And Clinical Pharmacy Specialist Heart Failure Access Clinic

Background : To help reduce heart failure (HF) readmissions and improve patient outcomes, the Madison VA established a Nurse Practitioner (NP) led Heart Failure Access Clinic (HFAC) to provide patient follow-up within 4-7 days of discharge. Studies have demonstrated medication discrepancies and delayed implementation of guideline-directed medical therapy as potential contributors to 30-day hospital readmission. Thus, a clinical pharmacy specialist (CPS) was incorporated into the Madison VA HFAC model to focus on optimizing medication regimens. The purpose of this project is to evaluate the impact of an interdisciplinary NP-CPS HFAC versus a NP HFAC on 30-day patient outcomes. Methodology A retrospective chart review was completed for all patients hospitalized with a primary discharge diagnosis of acute on chronic systolic heart failure (ADHF) at the Madison VA and seen in a HFAC after discharge between November 2019 and November 2020. Patients with LVEF greater than 50% and those discharged to hospice were excluded. During the early period of the COVID-19 pandemic (mid-March through July 2020), patients were seen by the NP only. Outcomes and interventions for patients who attended an interdisciplinary NP-CPS HFAC were compared to those who attended the NP HFAC. Primary outcomes included rehospitalization, emergency department (ED) visit, and all-cause mortality at 30 days. Secondary outcomes included HF medication adjustments, identification of inappropriate medications in patients with HF, medication discrepancies, alerts to another provider for follow up, referral to another service, or referral to HF CPS for continued optimization of GDMT. Results A total of 90 veterans met the inclusion criteria; 43 were seen in the NP HFAC and 47 were seen in the interdisciplinary NP-CPS HFAC. The incidence of adverse 30-day outcomes in this patient cohort was very low (readmission 5.6%, ED visit 1.1%, death 1.1%) and there were no significant between group differences. Statistically significant secondary outcomes favoring the interdisciplinary HF clinic included identification of medication discrepancies (P=<0.0001), alert to another providers for follow up (P=0.004), as well as referral to the HF CPS for continued medication titration (P=0.02). Conclusion Patients seen in the interdisciplinary NP-CPS HFAC and HP HFAC had similarly low 30-day hospital readmission rates, ED visits and mortality. Involvement of a CPS in the HFAC led to more frequent identification of medication discrepancies, notification to providers regarding medication issues, and referral to a HF CPS for timely GDMT optimization. Further analysis is warranted to assess the impact of these early CPS interventions on long-term patient outcomes. : To help reduce heart failure (HF) readmissions and improve patient outcomes, the Madison VA established a Nurse Practitioner (NP) led Heart Failure Access Clinic (HFAC) to provide patient follow-up within 4-7 days of discharge. Studies have demonstrated medication discrepancies and delayed implementation of guideline-directed medical therapy as potential contributors to 30-day hospital readmission. Thus, a clinical pharmacy specialist (CPS) was incorporated into the Madison VA HFAC model to focus on optimizing medication regimens. The purpose of this project is to evaluate the impact of an interdisciplinary NP-CPS HFAC versus a NP HFAC on 30-day patient outcomes. A retrospective chart review was completed for all patients hospitalized with a primary discharge diagnosis of acute on chronic systolic heart failure (ADHF) at the Madison VA and seen in a HFAC after discharge between November 2019 and November 2020. Patients with LVEF greater than 50% and those discharged to hospice were excluded. During the early period of the COVID-19 pandemic (mid-March through July 2020), patients were seen by the NP only. Outcomes and interventions for patients who attended an interdisciplinary NP-CPS HFAC were compared to those who attended the NP HFAC. Primary outcomes included rehospitalization, emergency department (ED) visit, and all-cause mortality at 30 days. Secondary outcomes included HF medication adjustments, identification of inappropriate medications in patients with HF, medication discrepancies, alerts to another provider for follow up, referral to another service, or referral to HF CPS for continued optimization of GDMT. A total of 90 veterans met the inclusion criteria; 43 were seen in the NP HFAC and 47 were seen in the interdisciplinary NP-CPS HFAC. The incidence of adverse 30-day outcomes in this patient cohort was very low (readmission 5.6%, ED visit 1.1%, death 1.1%) and there were no significant between group differences. Statistically significant secondary outcomes favoring the interdisciplinary HF clinic included identification of medication discrepancies (P=<0.0001), alert to another providers for follow up (P=0.004), as well as referral to the HF CPS for continued medication titration (P=0.02). Patients seen in the interdisciplinary NP-CPS HFAC and HP HFAC had similarly low 30-day hospital readmission rates, ED visits and mortality. Involvement of a CPS in the HFAC led to more frequent identification of medication discrepancies, notification to providers regarding medication issues, and referral to a HF CPS for timely GDMT optimization. Further analysis is warranted to assess the impact of these early CPS interventions on long-term patient outcomes.

Calibration of an evapotranspiration algorithm in a semiarid sagebrush steppe using a 3‐ha lysimeter and Landsat normalized difference vegetation index data

AbstractIn arid and semiarid environments, evapotranspiration (ET) is the primary discharge component in the water balance, with potential ET exceeding precipitation. For this reason, reliable estimates of ET are needed to construct accurate water budgets in these environments. Remote sensing affords the ability to provide fast, accurate, field‐scale ET estimates, but these methods have largely been restricted to deep rooted (phreatophytic) plant communities underlain by shallow groundwater. We used 13 years of data from a 3‐ha drainage lysimeter in a semiarid sagebrush steppe and Landsat normalized difference vegetation index (NDVI) data to calibrate a generalized least squares model capable of predicting vadose zone ET in a high elevation upland ecosystem. Annual precipitation was the best predictor of annual ET, as they were nearly balanced every year analysed (mean difference = 3 mm). We incorporated reference crop ET and a linear combination of NDVI and precipitation to capably predict ET on a subannual, lag‐determined interval of 48 days, with a mean error of only 9.92% across all observations. To our knowledge, this is the first vegetation index‐ET algorithm calibrated in a semiarid upland plant community using field‐scale lysimetry. Vadose zone ET is particularly important at waste disposal sites in the Desert Southwest, where accurate and spatially explicit ET estimates are needed for monitoring potential mobilization and transport of contaminants past the root zone into local aquifers and for monitoring and modelling effects of recharge on flow and transport of contaminants in underlying aquifers.

COVID-19-associated hospitalizations among children less than 12 years of age in the United States

Objectives To describe the characteristics, healthcare resource use and costs associated with initial hospitalization and readmissions among pediatric patients with COVID-19 in the US. Methods Hospitalized pediatric patients, 0–11 years of age, with a primary or secondary discharge diagnosis code for COVID-19 (ICD-10 code U07.1) were selected from 1 April 2020 to 30 September 2021 in the US Premier Healthcare Database Special Release (PHD SR). Patient characteristics, hospital length of stay (LOS), in-hospital mortality, hospital costs, hospital charges, and COVID-19-associated readmission outcomes were evaluated and stratified by age groups (0–4, 5–11), four COVID-19 disease progression states based on intensive care unit (ICU) and invasive mechanical ventilation (IMV) usage, and three sequential calendar periods. Sensitivity analyses were performed using the US HealthVerity claims database and restricting the analyses to the primary discharge code. Results Among 4,573 hospitalized pediatric patients aged 0–11 years, 68.0% were 0–4 years and 32.0% were 5–11 years, with a mean (median) age of 3.2 (1) years; 56.0% were male, and 67.2% were covered by Medicaid. Among the overall study population, 25.7% had immunocompromised condition(s), 23.1% were admitted to the ICU and 7.3% received IMV. The mean (median) hospital LOS was 4.3 (2) days, hospital costs and charges were $14,760 ($6,164) and $58,418 ($21,622), respectively; in-hospital mortality was 0.5%. LOS, costs, charges, and in-hospital mortality increased with ICU admission and/or IMV usage. In total, 2.1% had a COVID-19-associated readmission. Study outcomes appeared relatively more frequent and/or higher among those 5–11 than those 0–4. Results using the HealthVerity data source were generally consistent with main analyses. Limitations This retrospective administrative database analysis relied on coding accuracy and inpatient admissions with validated hospital costs. Conclusions These findings underscore that children aged 0–11 years can experience severe COVID-19 illness requiring hospitalization and substantial hospital resource use, further supporting recommendations for COVID-19 vaccination.

A nationwide retrospective analysis of ventilator-associated pneumonia in the US

Ventilator-associated pneumonia (VAP) is a major cause of healthcare-associated mortality and morbidity in critically ill patients who are mechanically ventilated. The purpose of this study was to describe the various primary discharge diagnoses of hospitalizations with VAP, to identify their demographic characteristics, and to identify risk factors for mortality in hospitalizations with VAP. Hospitalizations with a diagnosis of VAP with mechanical ventilation for over 24 hours were selected from the National Inpatient Sample in 2016 and 2017. In total, 33,140 hospitalizations with VAP were analyzed. The leading principal discharge diagnoses for hospitalizations leading to VAP were sepsis due to an unspecified organism (16.92%), respiratory failure (8.09%), and VAP (6.38%). Mortality among hospitalizations with VAP was 20.9%. Independent risk factors for mortality in hospitalizations with VAP were uninsured status (adjusted odds ratio [aOR] 2.13, 95% confidence interval [CI] 1.49–3.06, P < 0.001), acute renal failure (aOR 2.00, 95% CI 1.75–2.30, P < 0.001), and liver disease (aOR 1.82, 95% CI 1.52–2.18, P < 0.001). In conclusion, VAP is associated with significant mortality. Infective, traumatic, cardiovascular, and respiratory conditions accounted for over 85% of hospitalizations with VAP. Acute renal failure, the presence of liver disease, and lack of insurance are associated with higher mortality in hospitalizations with VAP.

Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007-2018 National Hospital Ambulatory Medical Care Survey Data.

We examined trends in management of headache disorders in United States (US) emergency department (ED) visits. We conducted a cross-sectional study using 2007–2018 National Hospital Ambulatory Medical Care Survey data. We included adult patient visits (≥18 years) with a primary ED discharge diagnosis of headache. We classified headache medications by pharmacological group: opioids, butalbital, ergot alkaloids/triptans, acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, diphenhydramine, corticosteroids, and intravenous fluids. To obtain reliable estimates, we aggregated data into three time periods: 2007–2010, 2011–2014, and 2015–2018. Using multivariable logistic regression, we examined medication, neuroimaging, and outpatient referral trends, separately. Among headache-related ED visits, opioid use decreased from 54.1% in 2007–2010 to 28.3% in 2015–2018 (Ptrend < 0.001). There were statistically significant increasing trends in acetaminophen/NSAIDs, diphenhydramine, and corticosteroids use (all Ptrend < 0.001). Changes in butalbital (6.4%), ergot alkaloid/triptan (4.7%), antiemetic (59.2% in 2015–2018), and neuroimaging (37.3%) use over time were insignificant. Headache-related ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007–2010 to 79.7% in 2015–2018 (Ptrend = 0.02). Reflecting evidence-based guideline recommendations for headache management, opioid use substantially decreased from 2007 to 2018 among US headache-related ED visits. Future studies are warranted to identify strategies to promote evidence-based treatment for headaches (e.g., sumatriptan, dexamethasone) and appropriate outpatient referral and reduce unnecessary neuroimaging orders in EDs.

Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure.

Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP). This is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate. Patients with a primary hospital discharge diagnosis of HF discharged to SNF. Composite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60days post SNF admission. Linear mixed models accounted for patient clustering at the physician level. Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10years, 53% women, and mean ejection fraction 46% ± 15%. At 60days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P= .02). The rate of the composite outcome at 30days for the HF-DMP group was 18% vs 31% in the usual care group (P= .11). Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.

Association Between Ambient Heat and Risk of Emergency Department Visits for Mental Health Among US Adults, 2010 to 2019

The implications of extreme heat for physical health outcomes have been well documented. However, the association between elevated ambient temperature and specific mental health conditions remains poorly understood. To investigate the association between ambient heat and mental health-related emergency department (ED) visits in the contiguous US among adults overall and among potentially sensitive subgroups. This case-crossover study used medical claims data obtained from OptumLabs Data Warehouse (OLDW) to identify claims for ED visits with a primary or secondary discharge psychiatric diagnosis during warm-season months (May to September) from 2010 through 2019. Claims for adults aged 18 years or older with commercial or Medicare Advantage health insurance who were living in 2775 US counties were included in the analysis. Emergency department visits were excluded if the Clinical Classifications Software code indicated that the visits were for screening for mental health outcomes and impulse control disorders. County-specific daily maximum ambient temperature on a continuous scale was estimated using the Parameter-Elevation Relationships on Independent Slopes model. Extreme heat was defined as the 95th percentile of the county-specific warm-season temperature distribution. The daily incidence rate of cause-specific mental health diagnoses and a composite end point of any mental health diagnosis were assessed by identifying ED visit claims using primary and secondary discharge diagnosis International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Conditional logistic regression models were used to estimate the incidence rate ratio (IRR) and 95% CIs for the association between daily temperature and incidence rates of ED visits. Data from 3 496 762 ED visits among 2 243 395 unique individuals were identified (56.8% [1 274 456] women; mean [SD] age, 51.0 [18.8] years); of these individuals, 14.3% were aged 18 to 26 years, 25.6% were aged 27 to 44 years, 33.3% were aged 45 to 64 years, and 26.8% were aged 65 years or older. Days of extreme heat were associated with an IRR of 1.08 (95% CI, 1.07-1.09) for ED visits for any mental health condition. Associations between extreme heat and ED visits were found for specific mental health conditions, including substance use disorders (IRR, 1.08; 95% CI, 1.07-1.10); anxiety, stress-related, and somatoform disorders (IRR, 1.07; 95% CI, 1.05-1.09); mood disorders (IRR, 1.07; 95% CI, 1.05-1.09); schizophrenia, schizotypal, and delusional disorders (IRR, 1.05; 95% CI, 1.03-1.07); self-harm (IRR, 1.06; 95% CI, 1.01-1.12); and childhood-onset behavioral disorders (IRR, 1.11; 95% CI, 1.05-1.18). In addition, associations were higher among men (IRR, 1.10; 95% CI, 1.08-1.12) and in the US Northeast (IRR, 1.10; 95% CI, 1.07-1.13), Midwest (IRR, 1.11; 95% CI, 1.09-1.13), and Northwest (IRR, 1.12; 95% CI, 1.03-1.21) regions. In this case-crossover study of a large population of US adults with health insurance, days of extreme heat were associated with higher rates of mental health-related ED visits. This finding may be informative for clinicians providing mental health services during periods of extreme heat to prepare for increases in health service needs when times of extreme heat are anticipated.

Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years.

There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37-0.50]) and endovascular therapy (aOR, 0.60 [0.46-0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75-0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84-0.91]), while White patients from rural areas (aOR, 1.14 [1.10-1.19]) had the highest mortality of all groups. Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.

Implementation Experience with a 30-Day Hospital Readmission Risk Score in a Large, Integrated Health System: A Retrospective Study.

BackgroundDriven by quality outcomes and economic incentives, predicting 30-day hospital readmissions remains important for healthcare systems. The Cleveland Clinic Health System (CCHS) implemented an internally validated readmission risk score in the electronic medical record (EMR).ObjectiveWe evaluated the predictive accuracy of the readmission risk score across CCHS hospitals, across primary discharge diagnosis categories, between surgical/medical specialties, and by race and ethnicity.DesignRetrospective cohort study.ParticipantsAdult patients discharged from a CCHS hospital April 2017–September 2020.Main MeasuresData was obtained from the CCHS EMR and billing databases. All patients discharged from a CCHS hospital were included except those from Oncology and Labor/Delivery, patients with hospice orders, or patients who died during admission. Discharges were categorized as surgical if from a surgical department or surgery was performed. Primary discharge diagnoses were classified per Agency for Healthcare Research and Quality Clinical Classifications Software Level 1 categories. Discrimination performance predicting 30-day readmission is reported using the c-statistic.ResultsThe final cohort included 600,872 discharges from 11 Northeast Ohio and Florida CCHS hospitals. The readmission risk score for the cohort had a c-statistic of 0.6875 with consistent yearly performance. The c-statistic for hospital sites ranged from 0.6762, CI [0.6634, 0.6876], to 0.7023, CI [0.6903, 0.7132]. Medical and surgical discharges showed consistent performance with c-statistics of 0.6923, CI [0.6807, 0.7045], and 0.6802, CI [0.6681, 0.6925], respectively. Primary discharge diagnosis showed variation, with lower performance for congenital anomalies and neoplasms. COVID-19 had a c-statistic of 0.6387. Subgroup analyses showed c-statistics of > 0.65 across race and ethnicity categories.ConclusionsThe CCHS readmission risk score showed good performance across diverse hospitals, across diagnosis categories, between surgical/medical specialties, and by patient race and ethnicity categories for 3 years after implementation, including during COVID-19. Evaluating clinical decision-making tools post-implementation is crucial to determine their continued relevance, identify opportunities to improve performance, and guide their appropriate use.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07277-4.

Dexamethasone Versus Prednisone in Children Hospitalized With Asthma Exacerbation.

Dexamethasone is increasingly used for the management of children hospitalized with asthma in place of prednisone, yet data regarding the effectiveness of dexamethasone in children with asthma exacerbation severe enough to require hospitalization are limited. Our objective is to compare the effectiveness of dexamethasone versus prednisone in children hospitalized with an asthma exacerbation on 30-day reutilization. We conducted a retrospective cohort study at an urban, quaternary children's hospital of children aged 4 to 17 years, hospitalized from January 1, 2014 to December 31, 2017, with a primary discharge diagnosis of asthma. A covariate-balanced propensity score was derived to account for physician discretion in steroid selection. A generalized linear model, including inverse probability treatment weighting, was used to detect differences in 30-day return utilization (unplanned readmission or emergency department visit) between children whose first dose of corticosteroid was dexamethasone versus prednisone. Inclusion criteria were met by 1161 patients, of which 510 (44%) first received dexamethasone versus 651 (56%) who first received prednisone. The total cohort had a mean age of 8.5 years (SD 3.4). The covariate-balanced cohort had no significant differences in demographic characteristics or illness severity between groups. The dexamethasone group had a return utilization of 3.9% (20 of 510) versus 2.2% (14 of 651) for children treated with prednisone. The propensity score-adjusted analysis revealed the steroid treatment was not found to significantly affect the 30-day reutilization (adjusted odds ratio [aOR] 1.61; 95%CI 0.80-3.31). The initial steroid choice (dexamethasone versus prednisone) was not associated with 30-day reutilization after hospitalization for an asthma exacerbation.

Patient profiles, initial hospital encounter characteristics, and hospital re-encounters of patients with a hospital emergency department visit or inpatient admission for major depressive disorder

Objectives To gain a better understanding of the characteristics of patients with a hospital encounter for major depressive disorder (MDD) and evaluate associated hospital resource utilization, hospital charges and costs, and hospital re-encounters. Methods Adult patients with a hospital encounter (i.e. emergency department [ED] visit only or inpatient admission) with MDD as the primary discharge diagnosis (index event) during July 2018‒March 2019 were selected from the Premier Healthcare Database. Patient characteristics, hospital resource utilization, and hospital charges and costs were evaluated during index events. During a 12-month follow-up, hospital re-encounters (MDD-related and all-cause ED visit only or inpatient readmissions) were examined. Results The study population included 77,178 patients with an index hospital encounter (ED visit only: 49.9%; inpatient admission: 50.1%) for MDD. The most common secondary mental health-related diagnosis was suicidal ideation/behavior, which was recorded in 51.8% of patients. The mean age was 38.2 years, 53.0% were female, and 72.1% were Caucasian. Among patients with an ED visit only, the mean index hospital charges and costs were $3,608 and $639, respectively. Among those with inpatient admissions, the mean length of stay was 4.9 days, and the mean index hospital charges and costs were $17,107 and $6,095, respectively. During the 12-month follow-up, 13.3% of patients in the overall study population had an MDD-related hospital re-encounter (primary or secondary discharge diagnosis code indicating MDD); nearly one-third (31.3%) occurred within 30 days post-discharge. During the follow-up, 28.1% had an all-cause hospital re-encounter with 29.7% having occurred within 30 days post-discharge. Limitations Due to constraints of the Premier Healthcare Database, healthcare resource utilization and costs outside of the hospital could not be evaluated. Conclusions Patients with a hospital encounter for MDD are relatively young, commonly have suicidal ideation/behavior, utilize substantial hospital resources, and have a high risk for a hospital re-encounter in the 30 days post-discharge.

Abstract 146: Stroke Misses Are Rare And Elusive In Telestroke Care

Background: Stroke mimic algorithms have been developed for use in telestroke systems of care but less is known about how frequently and what factors are associated with a clinically significant missed telestroke ischemic stroke diagnosis. We sought to examine the frequency and clinical characteristics of missed strokes (MS) in the VA National TeleStroke Program (NTSP) Methods: We analyzed NTSP consultations from April 2018 to September 2020. Consults with a telestroke diagnosis of “other” (not stroke/TIA) and a primary inpatient discharge diagnosis of ischemic stroke were chart reviewed. We applied the Oxfordshire stroke localization categories to all MRIs positive for acute ischemic stroke. Clinical outcomes were designated as MS-significant (MS-S) if symptoms of stroke persisted at discharge or rehabilitation was required, otherwise they were MS-not significant (MS-NS). Patient demographics, clinical conditions, last known well (LKW) and NIHSS were compared between the MS-S and MS-NS groups using Chi-square and t-tests. Results: Out of 3,163 consultations, 55 (1.7%) were identified as MS; 33 (60%) of these were MS-S, and 22 (40%) were MS-NS. The overall sample had a mean age of 72 years, mean LKW of 219 minutes prior to arrival, and median NIHSS of 3. Of those with MS, 46 (83.6%) had a brain MRI showing acute stroke; 30% partial anterior, 26% lacunar, 24% posterior. MS-S patients did not differ from MS-NS in age, race, LKW, NIHSS, stroke location or clinical diagnoses (Table). The most common diagnosis among MS was stroke recrudescence (25%). Conclusions: Clinically significant missed strokes were present in only 1% of more than 3,000 telestroke cases. Demographic and clinical features did not distinguish clinically significant misses from non-significant misses. Posterior circulation strokes represented almost a quarter of all MS. Implementing a rapid brain MRI protocol may be one way to avoid rare misses of acute ischemic stroke diagnosis via telestroke.

Multicenter Study of the Impact of COVID-19 Shelter-In-Place on Tertiary Hospital-based Care for Pediatric Neurologic Disease.

ObjectiveTo describe changes in hospital-based care for children with neurologic diagnoses during the initial 6 weeks following regional Coronavirus 2019 Shelter-in-Place orders.MethodsThis retrospective cross-sectional study of 7 US and Canadian pediatric tertiary care institutions included emergency and inpatient encounters with a neurologic primary discharge diagnosis code in the initial 6 weeks of Shelter-in-Place (COVID-SiP), compared to the same period during the prior 3 years (Pre-COVID). Patient demographics, encounter length, and neuroimaging and electroencephalography use were extracted from the medical record.Results27,900 encounters over 4 years were included. Compared to Pre-COVID, there was a 54% reduction in encounters during Shelter-in-Place. COVID-SiP patients were younger (median 5 years vs 7 years). The incidence of encounters for migraine fell by 72%, and encounters for acute diagnoses of status epilepticus, infantile spasms, and traumatic brain injury dropped by 53%, 55%, and 56%, respectively. There was an increase in hospital length of stay, relative utilization of intensive care, and diagnostic testing (long-term electroencephalography, brain MRI, and head CT (all P<.01)).ConclusionDuring the initial 6 weeks of SiP, there was a significant decrease in neurologic hospital-based encounters. Those admitted required a high level of care. Hospital-based neurologic services are needed to care for acutely ill patients. Precise factors causing these shifts are unknown and raise concern for changes in care seeking of patients with serious neurologic conditions. Impacts of potentially delayed diagnosis or treatment require further investigation.

Abstract WP73: Impact Of Patient Age On Sex Disparities In Intravenous Alteplase Administration For Acute Ischemic Stroke

Background: Prior research with the National Inpatient Sample (NIS) has shown that women are less likely than men to receive to receive intravenous Alteplase (tPA) for acute ischemic stroke, but more recent analyses have found conflicting results and patient age has not been taken into account, nor has stroke severity. Methods: We included patients in the NIS from 2016-18 with a primary discharge diagnosis of ischemic stroke and who had an admission NIH Stroke Scale (NIHSS). The primary outcome was receipt of tPA and the exposure was patient sex. After survey weighting, we fit logistic regression models adjusted for age, race/ethnicity, NIHSS, patient income by ZIP code, hospital teaching status, hospital Census region, and hospital location according to the NCHS Urban-Rural Classification. We included interactions between our covariates and the exposure of sex. Results: After weighting, we included 384,700 patients, of which 15.1% received tPA and 49.1% were female. The rate of tPA was identical (15.1%) between male and female patients (p=0.880). In the multivariable logistic regression model, female sex had an odds ratio for tPA of 0.97 (95% CI 0.93, 1.01, p=0.163). The only covariate that had a significant interaction with sex was age (p&lt;0.001 for interaction). After stratification, female patients aged ≥75 were 1.5% (95% CI -2.3, -0.7, p&lt;0.001) less likely than men to receive tPA (Figure 1). Conclusion: In the most recent sample of the NIS, women with acute ischemic stroke are no longer less likely than men to receive tPA. We show this holds true after adjustment for stroke severity, although there is still a disparity in older patients aged ≥75, with women being 1.5% less likely than men to receive tPA.

Abstract WP136: Recurrent Intracerebral Hemorrhage In Patients With Cerebral Amyloid Angiopathy

Background: Studies suggest an increased risk of recurrent intracerebral hemorrhage (ICH) in patients with cerebral amyloid angiopathy (CAA). In this study, we sought to compare the rates of recurrent cerebrovascular events in patients admitted for ICH with and without CAA. Methods: We utilized the National Readmissions Database 2016-2018 to identify hospitalizations with the primary discharge diagnosis of ICH with and without a concomitant diagnosis of CAA. Hospitalizations with age &gt;55 years, survival to discharge, and known discharge disposition were included for further analysis. Propensity score matching was used to match for the differences in demographics, comorbidities, and disease severity between the CAA and no CAA groups. Survival analysis was performed to evaluate the rates of recurrent ICH, subarachnoid hemorrhage (SAH), and acute ischemic stroke (AIS) in the propensity-matched groups. Results: A total of 194,290 patients with ICH met the study inclusion criteria; 8,247 with CAA and 186,043 without CAA. After propensity score matching, we identified 7,857 hospitalizations with CAA and 7,874 without CAA. Patients with CAA were more likely to be readmitted due to ICH [hazards ratio (HR): 3.4, 95% confidence interval (CI): 2.6-4.6, P &lt;0.001] and SAH (HR: 2.5, 95% CI: 1.2-5.4, P 0.007) during the mean follow-up period of 6 months. However, there was no statistically significant difference in readmissions due to AIS (HR: 0.7, 95% CI: 0.5-1.0, P 0.061) [Figure 1]. Age (HR: 0.96 per year increase in age, 95% CI: 0.95-0.98, P &lt;0.001) and Medicare payer (HR: 3.23; 95% CI: 1.92-5.41, P &lt;0.001) were independently associated with readmissions due to ICH. Conclusions: Patients admitted for ICH with a secondary diagnosis of CAA are three times more likely to have readmissions for recurrent ICH compared to patients without CAA.

Abstract 92: Delirium In-hospital Leads To Poor Short And Long-term Outcomes Among Treated And Non-treated Patients With Acute Ischemic Stroke

Background: Delirium in-hospital (DIH) is common among the critically ill. However, DIH incidence and outcomes are not well characterized among ischemic stroke (IS) patients, particularly those treated with intravenous tissue plasminogen activator (tPA) and / or mechanical thrombectomy (MT). Methods: Utilizing data from a healthcare system with standardized delirium screening protocols, DIH was determined by a positive 4AT / CAM-ICU screen or diagnosis codes. IS patients with tPA or MT were flagged and a subset with available 90-day modified Rankin Scale (mRS) were analyzed for shifts in mRS scores associated with DIH, via ordinal logistic regression models adjusted for age, stroke severity, tPA or MT, Charlson Comorbidity Index [CCI], prior stroke and sepsis / infections. Common odds ratios (OR) and 95% confidence intervals (CI) are reported. Results: Between May 2016 and June 2021, IS was the primary discharge diagnosis in 12,415 encounters (10,878 unique patients). DIH was documented in 41.6% of IS encounters, compared to 20.0% of non-IS encounters. Stroke-DIH patients (vs no-DIH Stroke) were older (median: 75 vs 65 years), more frequently female (53.3% vs 48.7%), with higher comorbidity burden (median CCI: 7 vs 5), longer hospital stays (median: 6 vs 3 days), higher in-hospital mortality (3.1% vs 0.5%), and fewer home discharges (36.2% vs 75.2%). Among a sub-cohort of 2,785 IS patients with 90-day mRS, fully adjusted model indicated lower mRS (OR, CI: 0.48, 0.41-0.57) for those with tPA or MT, and worse outcomes for DIH patients (OR, CI: 2.70, 2.26-3.23). Among 948 treated IS patients, DIH remained a significant risk for worse outcomes (OR, CI: 2.54, 1.89-3.43). Conclusion: Delirium was twice as common in IS patients and was a negative prognostic indicator of short and long-term outcomes among non-treated and treated IS patients. Active screening and management of DIH is critically important to improve stroke outcomes.

Abstract WP124: Necessity Of Universal Echocardiograms In First-time Stroke: A Retrospective Study

Background: Transthoracic echocardiogram (TTE) is a “moderate” recommendation under the 2021 AHA/ASA Guidelines. We aimed to identify in which patients TTE is most likely to reveal a clinically relevant finding that helps guide workup and secondary stroke prevention. Methods: We reviewed records of patients at an academic stroke center with primary discharge diagnosis of ischemic stroke between January 1-December 31, 2019 excluding those with prior stroke. Stroke location was classified as cortical, subcortical, brainstem, multiple/multifocal. TTE findings defined as clinically significant included reduced ejection fraction, enlarged left atrial size, patent foramen ovale, vegetations, thrombus, and atrial fibrillation during the procedure. Chi-square and Fisher’s exact association tests were used for two-way tables, relative risk, and logistic regressions. Results: Of the 307 identified patients admitted for first time stroke, 181(59.0%) were male, and median age was 63.6+/-14.3 years. Stroke location was cortical in 99(32.2%), subcortical in 41(13.4%), brainstem in 39(12.7%), and multiple/multifocal in 128(41.7%). Clinically significant findings on TTE were found in 150 patients(48.9%). Age predicted clinically significant TTE (risk ratio per 10 year interval 1.11, 95% CI 1.02-1.20). Atrial fibrillation and cortical location predicted clinically significant TTE findings (table). Other locations and risk factors were not associated with clinically significant TTE. Discussion: Cortical stroke was the only location associated with clinically significant TTE findings. The lack of association with multifocal strokes was surprising as they are often presumed cardioembolic. This suggests that TTE may be most beneficial in evaluating cortical stroke, but given that nearly half of all stroke patients had TTE findings that would inform further management suggests that continuing universal TTEs.

Dexamethasone vs Prednisone for Inpatient Asthma

Source: Hemani SA, Glover B, Ball S, et al. Dexamethasone versus prednisone in children hospitalized for acute asthma exacerbations. Hosp Pediatr. 2021 Nov;11(11):1263-1272; doi:10.1542/hpeds.2020-004788Investigators from Emory University, Atlanta, GA, conducted a retrospective study to compare length of stay (LOS) in children hospitalized for asthma exacerbations and treated with dexamethasone (DEX) or prednisone/prednisolone. For the study, they identified patients, 3-21 years old, hospitalized at 1 of 3 hospitals with a primary discharge diagnosis of asthma exacerbation or status asthmaticus between 2013 and 2017 using ICD-9 and ICD-10 codes. Children initially admitted to an ICU were excluded, and only those who received PRED or DEX monotherapy prior to or during their hospitalization were included. The medical records of study participants were reviewed and information on demographics, other medications used during the asthma exacerbation, timing of initial dose of PRED or DEX, and LOS abstracted. Asthma acuity at ED presentation was assessed in study children using a validated clinical respiratory score (CRS). The primary outcome was LOS, and secondary outcomes were transfer to an ICU during hospitalization and ED visit or re-hospitalization within 10 days of discharge. Study patients were categorized as beginning corticosteroids prior to hospitalization or after admission, and these 2 groups were analyzed separately. Regression analyses were used to compare outcomes between those treated with PRED or DEX in each group. Covariates in the regression models included age, sex, race, ethnicity, insurance type, hospital, CRS, and use of other asthma medications during the exacerbation.There were 1,410 children included in the analysis; 981 (69.6%) were treated with DEX, and 429 (30.4%) received PRED. Of 961 patients started on corticosteroids after admission, 826 received DEX and 135 PRED, and among 449 children started on treatment before admission, 155 and 294, respectively, received DEX or PRED. For patients who began corticosteroids after hospitalization, and after controlling for covariates, LOS was significantly shorter in those who received DEX than in children treated with PRED (mean LOS 24.43 hours; 95% CI, 21.13, 28.25, and 29.38 hours; 95% CI, 24.15, 35.73, respectively; P = 0.03). Conversely, when treatment was begun prior to admission there was no significant difference in LOS between those treated with DEX or PRED (mean LOS, 26.72 hours; 95% CI, 21.62, 33.03; and 25.20 hours; 95% CI, 20.49, 30.99, respectively; P = 0.45). Overall, rates of transfer to ICU and hospital readmission were 0% to 2%, with no significant differences between patients treated with DEX or PRED. Among the group of children for whom corticosteroids were started after hospitalization, 18 (2.2%) of those receiving DEX had an ED visit within 10 days of hospital discharge vs 0 of those receiving PRED (P = 0.09).The authors conclude that in children hospitalized with an asthma exacerbation who had corticosteroid treatment initiated after admission, those treated with DEX had a shorter LOS than those receiving PRED.Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.As DEX becomes increasingly utilized for mild-to-moderate asthma exacerbations in pediatric emergency departments,1 questions arise regarding the initiation and continuation of DEX vs PRED for patients admitted for asthma exacerbations not requiring an ICU. The results of the present study illustrate that, in a multisite hospital system, DEX has become the predominant (86%) corticosteroid initiated after hospital arrival. Patients who received DEX after hospital arrival had approximately 20% shorter LOS, even after adjustment for measured potential confounders.However, association does not imply correlation. As a retrospective cohort study, the authors of the present study are unable to determine if giving DEX as compared to PRED shortens LOS. “Indication bias,” any factor, clinical or otherwise, affects the decision to utilize 1 treatment over another and is not accounted for in the current analysis. Adjustment can minimize the effect of measured factors, but a randomized controlled trial is necessary to establish causality.It is important to also acknowledge possible implicit bias based on the idea of “reliability” needed to complete a 5-day course of PRED.1 In the present study, patients with government insurance and Black patients were approximately half as likely to receive PRED as those with private insurance and white patients, respectively. Recognition and investigation of the reasons for differences in practice are necessary to ensure equitable treatment of patients with asthma.Pediatric patients admitted with asthma exacerbation outside of the ICU who receive DEX after hospital arrival have a shorter LOS than those who receive PRED. (See AAP Grand Rounds. 2022;47[1]:10.)2With nearly 10 million children in the US affected by asthma and 80,000 hospitalized annually,3 it is readily apparent why the therapy of asthma continues to pepper these pages.2 Future investigators comparing DEX and PRED need to examine prior home use of corticosteroids and include children with severe asthma exacerbations.

The role of terrestrial productivity and hydrology in regulating aquatic dissolved organic carbon concentrations in boreal catchments.

The past decades have witnessed an increase in dissolved organic carbon (DOC) concentrations in the catchments of the Northern Hemisphere. Increasing terrestrial productivity and changing hydrology may be reasons for the increases in DOC concentration. The aim of this study is to investigate the impacts of increased terrestrial productivity and changed hydrology following climate change on DOC concentrations. We tested and quantified the effects of gross primary production (GPP), ecosystem respiration (RE) and discharge on DOC concentrations in boreal catchments over 3 years. As catchment characteristics can regulate the extent of rising DOC concentrations caused by the regional or global environmental changes, we selected four catchments with different sizes (small, medium and large) and landscapes (forest, mire and forest‐mire mixed). We applied multiple models: Wavelet coherence analysis detected the delay‐effects of terrestrial productivity and discharge on aquatic DOC variations of boreal catchments; thereafter, the distributed‐lag linear models quantified the contributions of each factor on DOC variations. Our results showed that the combined impacts of terrestrial productivity and discharge explained 62% of aquatic DOC variations on average across all sites, whereas discharge, gross primary production (GPP) and RE accounted for 26%, 22% and 3%, respectively. The impact of GPP and discharge on DOC changes was directly related to catchment size: GPP dominated DOC fluctuations in small catchments (<1 km2), whereas discharge controlled DOC variations in big catchments (>1 km2). The direction of the relation between GPP and discharge on DOC varied. Increasing RE always made a positive contribution to DOC concentration. This study reveals that climate change‐induced terrestrial greening and shifting hydrology change the DOC export from terrestrial to aquatic ecosystems. The work improves our mechanistic understanding of surface water DOC regulation in boreal catchments and confirms the importance of DOC fluxes in regulating ecosystem C budgets.