Abstract 3060: Racial Disparities in Early Institution of “Do Not Resuscitate” Orders Influence Survival in Acute Ischemic Strokes.

Background: The importance of early institution of “Do Not Resuscitate” (DNR) orders in determining outcomes from intracerebral hemorrhage is established. In the setting of acute ischemic stroke, African Americans tend to utilize critical care interventions more and palliative care options less than Caucasians. Recent epidemiological studies in acute ischemic stroke have shown a somewhat better survival for African Americans compared with Caucasians. Our hypothesis was that racial differences in early institution of DNR orders would influence mortality in acute ischemic stroke. Methods: a retrospective chart review was conducted on consecutive admissions for acute ischemic stroke across 10 hospitals in Michigan for the year 2006. Subjects with self reported race as African American or Caucasian were selected. Demographics, stroke risk factors, pre morbid status, DNR by day 2 of admission, stroke outcome and discharge destination were abstracted. Results: The study included 574 subjects (144 African American, 25.1%; 430 Caucasian, 74.9%). In-hospital mortality was significantly higher among Caucasians (8.6% vs. 1.4% amongst African Americans, p=0.003). More Caucasians had institution of DNR by day 2 than African Americans (22.5% vs. 4.3%, p<0.0001). When adjusted for racial differences in DNR by day 2 status, Caucasian race no longer predicted mortality. Caucasians were significantly older than African Americans (median age 76 vs. 63.5 years, p<0.0001); and age was a significant predictor of DNR by day 2 and mortality. In the adjusted analysis, however, age marginally influenced the racial disparity in mortality ( table ). Caucasians with coronary disease, atrial fibrillation, severe strokes and unable to walk prior to the stroke tend to be made DNR by day 2 more frequently. Only 27.1% of Caucasians with early DNR orders died in the hospital, whereas 20.8% were eventually discharged home. Conclusions: Early DNR orders result in a racial disparity in mortality from acute ischemic stroke. A substantial proportion of patients with early DNR orders eventually go home. Postponing the use of DNR orders may allow aggressive critical care interventions that may potentially mitigate the racial differences in mortality.

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Comparison of the Genomic Landscape Between Primary Breast Cancer in African American Versus White Women and the Association of Racial Differences With Tumor Recurrence

Journal of Clinical Oncology ◽

10.1200/jco.2015.62.2126 ◽

2015 ◽

Vol 33 (31) ◽

pp. 3621-3627 ◽

Cited By ~ 96

Author(s):

Tanya Keenan ◽

Beverly Moy ◽

Edmund A. Mroz ◽

Kenneth Ross ◽

Andrzej Niemierko ◽

...

Keyword(s):

Breast Cancer ◽

African American ◽

African Americans ◽

African American Women ◽

Racial Differences ◽

Genetic Heterogeneity ◽

Racial Disparity ◽

Tumor Recurrence ◽

Triple Negative ◽

American Women

Purpose African American women are more likely to die as a result of breast cancer than white women. The influence of somatic genomic profiles on this racial disparity is unclear. We aimed to compare the racial distribution of tumor genomic characteristics and breast cancer recurrence. Methods We assessed white and African American women with stage I to III breast cancer diagnosed from 1988 to 2013 and primary tumors submitted to The Cancer Genome Atlas from 2010 to 2014. We used Cox proportional hazards models to evaluate the association of race and genetic traits with tumor recurrence. Results We investigated exome sequencing and gene expression data in 663 and 711 white and 105 and 159 African American women, respectively. African Americans had more TP53 mutations (42.9% v 27.6%; P = .003) and fewer PIK3CA mutations (20.0% v 33.9%; P = .008). Intratumor genetic heterogeneity was greater in African American than white tumors overall by 5.1 units (95% CI, 2.4 to 7.7) and within triple-negative tumors by 4.1 units (95% CI, 1.4 to 6.8). African Americans had more basal tumors by the 50-gene set predictor using the predication analysis of microarray method (PAM50; 39.0% v 18.6%; P < .001) and fewer PAM50 luminal A tumors (17.0% v 34.7%; P < .001). Among triple-negative subtypes, African Americans had more basal-like 1 and mesenchymal stem-like tumors. African Americans had a higher risk of tumor recurrence than whites (hazard ratio, 2.22; 95% CI, 1.05 to 4.67). Racial differences in TP53 mutation, PAM50 basal subtype, and triple-negative tumor prevalence but not intratumor genetic heterogeneity influenced the magnitude and significance of the racial disparity in tumor recurrence. Conclusion African Americans had greater intratumor genetic heterogeneity and more basal gene expression tumors, even within triple-negative breast cancer. This pattern suggests more aggressive tumor biology in African Americans than whites, which could contribute to racial disparity in breast cancer outcome.

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Abstract 3418: Acute Care Nurse Practicioner Led Critical Care Transport Team Leads to Improved Door to Imaging Time in Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.43.suppl_1.a3418 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Michelle M Winfield ◽

Julie A McNeil ◽

Stephanie L Steiner ◽

Christopher F Manacci ◽

Damon Kralovic ◽

...

Keyword(s):

Critical Care ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Outcomes ◽

Care Transitions ◽

Cleveland Clinic ◽

Stroke Patients ◽

Time Intervals ◽

Care Nurse ◽

Transport Team

Background: In evaluating the acute ischemic stroke (AIS) patient, targeting time intervals for imaging and treatment times are paramount in optimizing outcomes. Initial evaluation by skilled providers who can facilitate the extension of a tertiary care facility can positively influence patient outcomes. A collaborative approach with a hospital based Critical Care Transport (CCT) Team can extend primary stroke program care out to a referring facility’s bedside. In the Cleveland Clinic Health System, the suspicion of a large vessel occlusion causing AIS in patients at an outside hospital triggers an “Auto Launch” process, bypassing typical transfer processes to expedite care transitions for patients with time sensitive emergencies. Referring facilities contact a CCT Coordinator, with immediate launching of the transport team that consists of an Acute Care Nurse Practitioner (ACNP) who evaluates the patient at outside facility, performs NIHSS and transitions the patient directly to CT/MRI upon return to Cleveland Clinic facility. Patient is met by the Stroke Neurology Team at CT scanner for definitive care. A CCT Team with an ACNP on board can augment not only door to CT and MRI times, but also time to evaluation by a stroke neurologist and time to intervention, bypassing the Emergency Department upon their arrival and proceeding directly to studies and/or time sensitive intervention as appropriate. Objective: To describe a stroke program with a coordinated approach with a CCT Team to facilitate rapid care transitions as well as decreased time to imaging in patients with AIS by having an ACNP on board during transport and throughout the continuum of care. Methods: A retrospective audit of a database of patients undergoing hyperacute evaluation of acute ischemic stroke symptoms from April 30, 2010 to July 31, 2011 was performed. Demographic information, types of imaging performed, hyperacute therapies administered and time intervals to imaging modalities and treatment were collected and analyzed. Results: 107 patients total, 28 males, and 36 females with a mean age of 70 were included in the analysis. 60% [64] of patients transferred via the CCT Team over 26.42 average nautical miles. The mean time of call to arrival was 1 hr and 19 min. The CCT Team monitored tPA infusion in 27 patients and initiated tPA infusion in 2 patients. 64 patients had CT imaging performed and 64 had MRI performed following the CT. [The average door to CT completion was 22 min, the average door to MRI completion was 1 hr and 29 min, compared to 1 hr and 8 min and 2 hr and 36 min, respectively, in patients not arriving by CCT Team], p<0.05. Conclusion: Collaboration between the Stroke Neurology Team and CCT Team has allowed acute ischemic stroke patients to be taken directly to CT/MRI scanner, allowing for rapid evaluation, definitive treatment decisions, and the potential for improved patient outcomes by decreasing the door to imaging time.

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Racial Differences in Motivators and Barriers to Blood Donation Among Blood Donors

Archives of Pathology & Laboratory Medicine ◽

10.5858/133.9.1444 ◽

2009 ◽

Vol 133 (9) ◽

pp. 1444-1447

Author(s):

Beth H. Shaz ◽

Derrick G. Demmons ◽

Krista L. Hillyer ◽

Robert E. Jones ◽

Christopher D. Hillyer

Keyword(s):

African American ◽

African Americans ◽

Racial Differences ◽

Blood Donors ◽

Blood Donation ◽

Screening Process ◽

Center Staff ◽

Predominately White ◽

Donation Frequency ◽

The Right

Abstract Context.—Nationally, African Americans are underrepresented in community blood donation programs. To increase blood donation by African Americans, differences between motivators and barriers to blood donation between races should be investigated. Objective.—To investigate motivators and barriers to blood donation in African American and white blood donors. Design.—An 18-item, anonymous, self-administered questionnaire regarding demographics and motivators and barriers to donation was completed by blood donors at a predominately African American and a predominately white fixed donation site. Results.—A total of 599 participants (20% African American, 75% white, and 5% other) completed the survey. The most commonly reported reasons to donate included: “because it is the right thing to do” (45% African Americans and 62% white) and “because I want to help save a life” (63% African Americans and 47% white). Unpleasant experiences did not differ as a barrier to continue donation between African Americans and whites. African Americans placed more importance on donating blood to someone with sickle cell disease, convenience of blood donation, treatment of donor center staff, and level of privacy during the screening process. Conclusions.—These data suggest that in a large metropolitan area, reasons for donation among African American and white donors differ. To retain and increase donation frequency of African American donors, these factors should be considered in creating an African American donor recruitment and retention program.

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Abstract P104: Incidence, Characteristics and Outcomes of Large Vessel Stroke in Covid-19: An International Multicenter Study

Stroke ◽

10.1161/str.52.suppl_1.p104 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Priyank Khandelwal ◽

Fawaz Al-Mufti ◽

Ambooj Tiwari ◽

Amit Singla ◽

Adam A Dmytriw ◽

...

Keyword(s):

Ischemic Stroke ◽

African Americans ◽

Acute Ischemic Stroke ◽

Multicenter Study ◽

Significant Risk ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

International Multicenter Study ◽

International Multicenter

Background: While there are reports of acute ischemic stroke (AIS) in COVID-19 patients, the overall incidence of acute ischemic stroke and clinical characteristics of large vessel occlusion in such patient remains to be established. Methods: A retrospective, international multicenter study of large vessel occlusion (LVO) was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Detailed data were collected on consecutive LVOs in hospitalized patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the incidence of AIS/LVO was measured. Among patients who underwent mechanical thrombectomy, stroke outcomes along with COVID-19 symptoms were reported. Results: Out of a total of 6698 COVID-19 patients admitted to 10 stroke centers, the incidence of stroke was found to be 1.3% (range 0.6-2.6%). The median age of patients who presented with LVO was 51 years (range 27-87) and in the US centers, African Americans comprised 28% of all patients. Ten patients (16 %) were less than 50 years of age with no significant risk factors for LVOs the vast majority. Among the LVOs eligible for MT, the average time to presentation from symptom onset to presentation was 9.3 hours. Successful revascularization was achieved in 81% of patients and the intracranial hemorrhage rate was 14% with no symptomatic hemorrhages. Twenty-one (50%) patients were either discharged to home or to acute rehabilitation facilities. Conclusion: LVOs was predominant in patients with AIS and COVID-19, occurring at a significantly younger age and affecting African Americans disproportionately.

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Inflammation in Acute Ischemic Stroke and its Relevance to Stroke Critical Care

Neurocritical Care ◽

10.1007/s12028-007-9035-x ◽

2007 ◽

Vol 9 (1) ◽

pp. 125-138 ◽

Cited By ~ 57

Author(s):

Hedley C. A. Emsley ◽

Craig J. Smith ◽

Pippa J. Tyrrell ◽

Stephen J. Hopkins

Keyword(s):

Critical Care ◽

Ischemic Stroke ◽

Acute Ischemic Stroke

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Abstract TP26: Endovascular Therapy and Outcomes in a Large Biracial Cohort of Patients with Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.tp26 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Leticia C Rebello ◽

Aaron Anderson ◽

Diogo C Haussen ◽

Samir R Belagaje ◽

Jonathan A Grossberg ◽

...

Keyword(s):

African American ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Ethnic Disparities ◽

Stroke Outcomes ◽

Good Outcome ◽

Caucasian Patients ◽

Baseline Characteristics ◽

The Impact

Background: The ethnic disparities in stroke outcomes have been well described. Stroke is twice more common and leads to higher mortality rates among blacks as compared to whites. We compared the outcomes of patients undergoing endovascular stroke therapy (ET) in a high-volume center according to their racial profile after age adjustment. Methods: Retrospective analysis of a prospectively collected ET database between September/2010-September/2015. The baseline characteristics of African-American vs. Caucasian patients were compared. Given the impact of age on stroke outcomes additional analyses were performed dichotomizing patients using the median age of the overall cohort. Primary and secondary efficacy outcomes included the rates of good outcome (90-day mRS 0-2) and successful reperfusion (mTICI 2b-3), respectively. Safety outcome was accessed by rates of any parenchymal hematoma (PH-1 and PH-2) and 90-day mortality. Results: 781 patients fit the inclusion criteria and were included in the analysis; 440 were included in the Caucasian group (56% overall cohort) and 341 in the African-American group (44%). Caucasian patients were significantly older (69±13 vs. 60±14 years-old, p<0.01) but the remaining baseline characteristics were otherwise well-balanced. This included similar baseline CT perfusion core volumes (rCBF<30%, 17.6 ± 20.8 vs. 17.9 ± 32.8; p=0.93). There were no differences in the rates successful reperfusion (mTICI 2b-3: 83% vs. 85%, p=0.37), any PH (8% vs. 5%, p=0.26), or final infarct volume (32 IQR 12-89 vs. 25 IQR 9-67; p=0.12) across the two groups. In the overall cohort, there was a lower proportion of 90-day good outcome (39% vs. 49%; p<0.01) and higher 90-day mortality (32% vs. 16%; p<0.01) among Caucasians presumably due to their older age. Subgroup analysis of patients 65 years-old or younger showed similar rates of 90-day good outcomes (59% vs. 53%; p=0.33) and mortality (17% vs. 12%; p=0.22) across Caucasian and African-American patients. Conclusion: Aggressive treatment of acute ischemic stroke with endovascular therapy leads to similar outcomes across African-American and Caucasian patients. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.

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Spirituality among African Americans

10.1093/oso/9780197565001.003.0008 ◽

2021 ◽

pp. 154-176

Author(s):

Jason E. Shelton

Keyword(s):

African American ◽

Comparative Analysis ◽

African Americans ◽

Personal Identity ◽

Racial Differences ◽

National Survey ◽

African American Community ◽

Black And White ◽

Spiritual But Not Religious ◽

Blacks And Whites

This chapter assesses the importance of spirituality among African Americans. More specifically, it examines the extent to which respondents in a large, multiyear national survey view themselves as a “spiritual person.” Four sets of comparative analysis are offered: (1) racial differences among black and white members of various evangelical Protestant traditions, (2) racial differences among black and white members of various mainline Protestant and Catholic traditions, (3) denominational differences specifically among African Americans, and (4) racial differences among blacks and whites who view themselves as “spiritual but not religious.” The findings reveal significant interracial and intraracial differences in how spirituality shapes one’s personal identity. Because organized religion has historically been so central to African American community life, the implications for the growth in noninstitutional spirituality are considered.

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Effect of Alteplase Administration on International Normalized Ratio in Patients With Acute Ischemic Stroke

The Neurohospitalist ◽

10.1177/1941874419879813 ◽

2019 ◽

Vol 10 (3) ◽

pp. 176-180

Author(s):

Michael J. Erdman ◽

K. Erin Davidson ◽

J. Tyler Haller ◽

Samarth Shah ◽

Whitney Gross ◽

...

Keyword(s):

African American ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Bleeding Risk ◽

International Normalized Ratio ◽

Occurrence Rate ◽

Bleeding Events ◽

Point Increase ◽

Increased Risk ◽

African American Race

Background/Objective: Alteplase may elevate international normalized ratio (INR) results, although the exact rate of elevation occurrence is not firmly established in the literature. The purpose of this study is to determine the occurrence rate of INR elevation following alteplase administration. We also aimed to determine what factors are independently associated with the development of elevated INR following alteplase administration for ischemic stroke. Methods: We conducted a multicenter, retrospective, cohort study of patients who received alteplase for acute ischemic stroke. Patients were screened for baseline INR measurement and a repeat value within 24 hours of alteplase administration. The primary outcome was the percent of patients who experienced ≥0.4-point increase in INR. Secondary outcomes included the rate of adverse bleeding events and identification of factors independently associated with elevated INR following alteplase administration. Results and Conclusions: Two hundred and sixty-one patients were included, with 44 (16.9%) patients having an INR increase of 0.4 or more. Patients with an INR increase ≥0.4 experienced a nonstatistically significant increase in bleeding episodes (8.8% vs 18.2%; P = .10). We identified African American race (odds ratio, 3.48, 95% confidence interval, 1.5-7.6; P = .002) as an independent predictor of INR increase ≥0.04. An INR elevation is common following receipt of alteplase for ischemic stroke. Those of African American race were at increased risk of INR elevation; however, more studies are needed to determine whether these patients are at a higher bleeding risk as a result of INR elevation.

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