Abstract W MP61: Prevalence of Echocardiographic Abnormalities in Acute Ischemic Stroke

Introduction: Non-invasive cardiac imaging is an important tool in evaluation of acute ischemic stroke, as a cardiac source can be implicated in approximately 20% of cases. However, the preferred imaging method is unclear due in part to the lack of consistent data regarding the yield of the two most commonly employed modalities, transthoracic and transesophageal echocardiography (TTE and TEE). Here we examine, in a large, biracial population, the prevalence of abnormalities detected by echocardiography during evaluation of acute ischemic stroke. Methods: Acute ischemic stroke cases were identified from a population of 1.3 million in the Greater Cincinnati area in 2005. Medical history and echocardiography results were determined by retrospective chart review. Echocardiographic abnormalities were pre-defined based on possibility of change in clinical decision making. All cases were abstracted by study nurses and subsequently verified by study physicians. Results were stratified by cardiac history and choice of echocardiographic technique; groups were compared using chi-square test or Fisher’s Exact test. Results: There were 2197 hospital-ascertained ischemic stroke cases in 2005. Median age was 73 (IQR 61-81), 22% were black, and 55% were female. TTE was performed in 68% of cases; TEE was performed in 7%. TEE revealed at least one abnormality in 55% of cases with cardiac history and 32% of cases without (Table). Yield of TTE was 20% in cases with cardiac history and 3% in cases without. Discussion: TEE is of considerable yield in selected patients, irrespective of cardiac history. This is in keeping with prior cost-effectiveness analyses recommending TEE alone for patients in whom suspicion of occult source of cardiac embolism is high. Prevalence of abnormalities on TTE in this population is similar to that of previously published series.

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Abstract TP69: Safety and Outcomes of IV Thrombolysis with Alteplase for Acute Ischemic Stroke Patients with Thrombocytopenia

Stroke ◽

10.1161/str.48.suppl_1.tp69 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Haris Kamal ◽

Nour Abdelhamid ◽

Liang Zhu ◽

Sean Savitz ◽

James Grotta ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Strong Evidence ◽

Demographic Data ◽

Categorical Variables ◽

Continuous Variables ◽

Chi Square ◽

Exact Test ◽

Chi Square Test ◽

Iv Tpa

Background: Intravenous tPA (IV tPA) has been the mainstay for reperfusion therapies for acute ischemic stroke (AIS) patients for 2 decades. Many contraindications from the initial NINDS trial were derived from experts’ consensus and not tested in the trial. Many AIS patients present with thrombocytopenia (< 100,000) and may be excluded from treatment in spite of lack of strong evidence. Some clinicians opt to treat these patients weighing the benefits and risks along with the lack of strong evidence behind this exclusion. We sought to evaluate the safety in AIS patients with low platelets receiving IV tPA as compared to those who do not. Methods: Restrospective chart review of all patients presenting with AIS between 1/2006 to 7/2016 at our center. We analyzed patients who had platelets <100,000 among this cohort and stratified them into those who were treated with IV tPA and those who received antiplatelet therapy only. Demographic data, medical history, medications, presence of sICH after treatment, presenting NIHSS were collected. Two sample Wilcoxon rank sum test was used to compare continuous variables between the two groups, and chi-square test or Fisher’s exact test used to compare categorical variables. Results: 21 patients were treated with IV tPA while 122 patients were treated with antiplatelets. Table 1 lists the demographic variables of the two groups with and without IV tPA. Patients included had moderate thrombocytopenia with very few <50,000. No significant differences were found in presenting NIHSS, race, gender, and history of atrial fibrillation between the two groups except platelets (p=0.0128), age (p=0.0462) and glucose (p=0.0279). Table 2 lists the outcome variables of mRS and symptomatic ICH. There was no petechial or sICH among 21 treated patients. Conclusion: While limited by small numbers and lack of randomization, our data suggest that IV tPA is safe in patients with moderately reduced platelet counts.

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Influenza With and Without Fever: Clinical Predictors and Impact on Outcomes in Patients Requiring Hospitalization

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa268 ◽

2020 ◽

Vol 7 (7) ◽

Author(s):

Benjamin J Smith ◽

David J Price ◽

Douglas Johnson ◽

Bruce Garbutt ◽

Michelle Thompson ◽

...

Keyword(s):

Clinical Decision Making ◽

Antiviral Treatment ◽

Delayed Diagnosis ◽

Clinical Decision ◽

Case Definition ◽

Influenza B ◽

Clinical Predictors ◽

Chi Square ◽

Chi Square Test ◽

The Impact

Abstract Background The Infectious Diseases Society of America influenza guidelines no longer require fever as part of their influenza case definition in patients requiring hospitalization. However, the impact of fever or lack of fever on clinical decision-making and patient outcomes has not been studied. Methods We conducted a retrospective review of adult patients admitted to our tertiary health service between April 2016 and June 2019 with laboratory-confirmed influenza, with and without fever (≥37.8ºC). Patient demographics, presenting features, and outcomes were analyzed using Pearson’s chi-square test, the Wilcoxon rank-sum test, and logistic regression. Results Of 578 influenza inpatients, 219 (37.9%) had no fever at presentation. Fever was less likely in individuals with a nonrespiratory syndrome (adjusted odds ratio [aOR], 0.44; 95% CI, 0.26–0.77), symptoms for ≥3 days (aOR, 0.53; 95% CI, 0.36–0.78), influenza B infection (aOR, 0.45; 95% CI, 0.29–0.70), chronic lung disease (aOR, 0.55; 95% CI, 0.37–0.81), age ≥65 (aOR, 0.36; 95% CI, 0.23–0.54), and female sex (aOR, 0.69; 95% CI, 0.48–0.99). Patients without fever had lower rates of testing for influenza in the emergency department (64.8% vs 77.2%; P = .002) and longer inpatient stays (median, 2.4 vs 1.9 days; P = .015). These patients were less likely to receive antiviral treatment (55.7% vs 65.6%; P = .024) and more likely die in the hospital (3.2% vs 0.6%; P = .031), and these differences persisted after adjustment for potential confounders. Conclusions Absence of fever in influenza is associated with delayed diagnosis, longer length of stay, and higher mortality.

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Agreement between Impression of Stroke in the Emergency Department and Diagnosis at the Neurology Department

Advances in Bioscience and Clinical Medicine ◽

10.7575/aiac.abcmed.v.7n.3p.7 ◽

2019 ◽

Vol 7 (3) ◽

pp. 7

Author(s):

Samad Shams-Vahdati ◽

Alireza Ala ◽

Eliar Sadeghi-Hokmabad ◽

Neda Parnianfard ◽

Maedeh Gheybi ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Statistical Significance ◽

Retrospective Chart Review ◽

Chi Square ◽

Prevention Therapy ◽

Significant Difference ◽

Chi Square Test ◽

Academic Teaching Hospital ◽

The Mean

Background: Missing to detect an ischemic stroke in the emergency department leads to miss acute interventions and treatment with secondary prevention therapy. Our study examined the diagnosis of stroke in the emergency department (ED) and neurology department of an academic teaching hospital. Methods and Materials: A retrospective chart review was performed from March 2017 to March 2018. ED medical document (chart) were reviewed by a stroke neurologist to collect the clinical diagnosis and characteristics of ischemic stroke patients. For determining the cases of misdiagnosed and over diagnosed data, the administrative data codes were compared with the chart adjudicated diagnosis. The adjusted estimate of effect was estimated through testing the significant variables in a multivariable model. The comparisons were done with chi square test. Statistical significance was considered at P < 0.05. Results: Of 861 patients of the study, 54% were males and 43% were females; and the mean age of them was 66.51 ± 15.70. We find no statically significant difference between patient’s Glasgow Coma Scale (GCS) in the emergency department (12.87±3.25) and patients GCS in the neurology department (11.77±5.15). There were 18 (2.2%) overdiagnosed of ischemic stroke, 8 (0.9%) misdiagnosed of ischemic stroke and 36 (4.1%) misdiagnosed of hemorrhagic strokes in the emergency department. Conclusion: There was no significant difference between impression of stroke in the emergency department and diagnosis at the neurology department.

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Adherence to Symptom-Based Care Guidelines for Down Syndrome

Clinical Pediatrics ◽

10.1177/0009922816652416 ◽

2016 ◽

Vol 56 (2) ◽

pp. 150-156 ◽

Cited By ~ 8

Author(s):

Stephanie L. Santoro ◽

Han Yin ◽

Robert J. Hopkin

Keyword(s):

Down Syndrome ◽

Tissue Transglutaminase ◽

Retrospective Chart Review ◽

Pediatric Care ◽

Chi Square ◽

Sleep Study ◽

Exact Test ◽

Spine Radiograph ◽

Chi Square Test ◽

Cervical Spine Radiograph

To assess adherence to symptom-based studies recommended in the health supervision guidelines for Down syndrome from the American Academy of Pediatrics (AAP), 24 pediatric care sites participated in retrospective chart review. Symptom-based screening and 4 associated recommendations, including cervical spine radiograph, video swallow study, celiac study with tissue transglutaminase and sleep study were analyzed by reviewing well-child visit notes of 264 children with Down syndrome. Given trends toward symptom-based screens, Pearson’s chi-square test and Fisher’s exact test were used to determine the association between symptom presence and receiving corresponding symptom-based screens. Adherence rates were widely variable ranging from 0% to 79% completion. Symptom-based studies were performed in 22% to 36% of patients. Symptom screens were documented positive in many patients, but the presence of symptoms did not correlate with completion of symptom-based screens. Symptom-based screening is low; associated studies were performed in patients without documented symptoms contrary to AAP recommendation.

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Mortality after large artery occlusion acute ischemic stroke

Scientific Reports ◽

10.1038/s41598-021-89638-x ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Rahul R. Karamchandani ◽

Jeremy B. Rhoten ◽

Dale Strong ◽

Brenda Chang ◽

Andrew W. Asimos

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Decision Making ◽

Clinical Decision ◽

Artery Occlusion ◽

Large Artery ◽

Multivariable Logistic Regression Model ◽

Stroke Registry ◽

Social Security Death Index ◽

Revascularization Therapy

AbstractDespite randomized trials showing a functional outcome benefit in favor of endovascular therapy (EVT), large artery occlusion acute ischemic stroke is associated with high mortality. We performed a retrospective analysis from a prospectively collected code stroke registry and included patients presenting between November 2016 and April 2019 with internal carotid artery and/or proximal middle cerebral artery occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality. Among 764 patients, mortality rate was 26%. Increasing age (per 10 years, OR 1.48, 95% CI 1.25–1.76; p < 0.0001), higher presenting NIHSS (per 1 point, OR 1.05, 95% CI 1.01–1.09, p = 0.01), and higher discharge modified Rankin Score (per 1 point, OR 4.27, 95% CI 3.25–5.59, p < 0.0001) were independently associated with higher odds of mortality. Good revascularization therapy, compared to no EVT, was independently associated with a survival benefit (OR 0.61, 95% CI 0.35–1.00, p = 0.048). We identified factors independently associated with mortality in a highly lethal form of stroke which can be used in clinical decision-making, prognostication, and in planning future studies.

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Abstract P591: A Significant Dose-Response in Elevated Troponin Levels for Case-Fatality Among Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p591 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Dawn Kleindorfer ◽

Heidi Sucharew ◽

Mary Haverbusch ◽

Kathleen S Alwell ◽

Florence Rothenberg ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Hospital Admissions ◽

Case Fatality ◽

Retrospective Chart Review ◽

Medical Attention ◽

Chi Square ◽

Normal Ranges ◽

The Impact ◽

Dose Dependent

Introduction: About 21% of acute ischemic stroke (AIS) patients present to medical attention with an elevated cardiac troponin (cTn). Previously, we described that elevated cTn is associated with an increased case-fatality at 1 year. However, it is not clear if there is a dose-dependent relationship between cTn and case-fatality, or if this effect is related to causes of death. Methods: Within a catchment area of 1.3 million we screened local hospital admissions using ICD-9/10 codes 430-436/I60-I68, G45-46 in 2014/2015, and ascertained all physician-confirmed AIS cases by retrospective chart review. Positive cTn was defined by the standard 99th percentile. To account for by hospital variance in cTn results in machine brands and normal ranges, cTn values were log-transformed and centered. Case fatality at 1 year and cause of death was obtained from the National Death Index database. Logistic regression evaluated the impact of cTn on case fatality, and included demographic and clinical risk factors in the model. The percentage with all-cause and cardiac/non-cardiac case-fatality was computed by quartiles of centered cTn levels and compared using the chi-square test. Results: In 2014/2015, there were 2989 AIS cases ascertained, which were 53% female, 30% black, with a mean age of 70 (SD 14). 441 patients with hypertropinemia were included in the analysis. See Table for case fatality at 1 year by quartile of centered cTn levels. There was no association between cTN and non-cardiac case-fatality. After adjustment for demographic and clinical characteristics, every 0.5 point increase in the centered cTn level increased the cardiac case-fatality by OR 1.19 (1.09, 1.31), p<0.01. Discussion: We found that the impact of hypertropinemia on case fatality after AIS appears to be a dose-dependent association: as cTn increases, so does the cardiac case-fatality. This suggests that the degree of cTn elevation is likely an important prognostic marker for cardiac death in AIS patients.

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Antiepileptic Drug Management in Acute Ischemic Stroke: Are Vascular Neurologists Utilizing Electroencephalograms? An Observational Cohort Study

BioMed Research International ◽

10.1155/2020/6250531 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Rahul Rao ◽

Dominique J. Monlezun ◽

Tara Kimbrough ◽

Brian J. Burkett ◽

Alyana Samai ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Antiepileptic Drug ◽

Clinical Decision Making ◽

Epileptiform Activity ◽

Clinical Decision ◽

Prior History ◽

Continuous Eeg ◽

Continuous Eeg Monitoring ◽

History Of

Introduction. This study examines the utility of electroencephalography (EEG) in clinical decision making in acute ischemic stroke (AIS) patients in regards to the prescription of antiseizure medications. Methods. Patients were grouped as having positive EEG (+) for epileptiform activity or negative EEG (-). These studies were no more than 30 minutes in length. Patients’ charts were retrospectively reviewed for antiepileptic drug (AED) use before, during, and on discharge from AIS hospitalization. Results. Of the 509 patients meeting inclusion criteria, 24 (4.7%) had a positive EEG. Patients did not significantly differ with respect to any demographic or baseline characteristics with the exception of prior history of seizure. In the EEG- group, AEDs were discontinued in only 3.5% of patients. In the EEG+ group, only 37.5% of patients had an initiation or change to their AED regimen within 36 hours of the study. 62.5% of the EEG+ group had a cortical stroke. Significance. Our results indicate that vascular neurologists are not using spot EEGs to routinely guide inpatient AED management. EEGs may have greater utility in those with a prior history of seizures and cortical strokes. Longer or continuous EEG monitoring may have better utility in the AIS population if there is clinical suspicion of seizure.

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Biostatistics in Clinical Decision Making What can We Get from a 2×2 Contingency Table

E3S Web of Conferences ◽

10.1051/e3sconf/202123302014 ◽

2021 ◽

Vol 233 ◽

pp. 02014

Author(s):

Shanshan Zhang

Keyword(s):

Prospective Studies ◽

Clinical Decision Making ◽

Contingency Tables ◽

Roc Curves ◽

Clinical Decision ◽

Chi Square ◽

Predictive Values ◽

Duodenal Diverticula ◽

Chi Square Test ◽

Relationship Of

Biostatistics is an essential part when making clinical decisions. Applications of 2×2 contingency tables playing a key role in conducting analysis involving binary variables. When it comes to analysis based on 2×2 contingency tables, most people are familiar with the concept of sensitivity and specificity for evaluating a new test, but predictive values and receiver operating characteristic (ROC) curves would also provide information. Besides, Odds Ratio (OR), Risk Ratio (RR), and Chi-square test are measures based on 2×2 tables and commonly applied in retrospective and prospective studies. This article will first review the two kinds of application of 2×2 contingency tables, evaluating a new test compared with a reference standard, and exploring the relationship of exposures and outcomes in retrospective or prospective studies. Two clinical examples are presented to demonstrate these basic biostatistical concepts: diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) to identify periampullary duodenal diverticula, and a randomized clinical trial (RCT) to examine the effectiveness of Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery. Correctly understanding these concepts will assist clinicians and medical researchers to analyze the data and interpret the results, and therefore make accurate decisions in clinical practice.

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1331. Interpretation and Application of Rapid Diagnostic Methodologies: The Positive Impact of Online, Curriculum-Based Learning

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1195 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S481-S481

Author(s):

Simi Thomas. Hurst ◽

James Martorano ◽

Catherine Capparelli

Keyword(s):

Online Education ◽

Clinical Decision Making ◽

Positive Impact ◽

Clinical Decision ◽

Antibiotic Use ◽

Considerable Effect ◽

Chi Square ◽

Noticeable Effect ◽

Chi Square Test ◽

Post Assessment

Abstract Background Antibiotic resistance has become one of the most serious public health threats today. Used appropriately, newer rapid diagnostic methodologies have the potential to positively impact care by informing a more targeted treatment approach that can reduce inappropriate antibiotic use, support antimicrobial stewardship, shorten hospital stays, and improve clinical outcomes. Methods To improve ID specialists’ knowledge and application of rapid diagnostic tests, a CME/ABIM MOC/ACCENT certified curriculum was developed. The curriculum comprised a series of 4 educational episodes, each with a video commentary from a clinical expert and each focused on a different site of infection: (a) Episode 1: CNS; (b) Episode 2: Gastrointestinal tract; (c) Episode 3: Respiratory tract; and (d) Episode 4: Bloodstream. The episodes in the curriculum were launched in serial fashion between October 30, 2018 and February 11, 2019, on a website dedicated to continuous professional development. Educational effectiveness was assessed with a repeated-pairs pre-/post-assessment study design; each individual served as his/her own control. A chi-square test assessed changes pre- to post-assessment. P values of < 0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (<0.05 modest; 0.06–0.15 noticeable effect; 0.16–0.26 considerable effect; >0.26 extensive effect). Results 15,092 HCPs, including 10,894 physicians have participated in the curriculum. This initial analysis comprises data from the subset of ID specialists from each episode who answered all pre-/post-assessment questions through March 18, 2019; data collection is ongoing. Following participation, significant improvements were observed overall (P ≤ 0.002 for each episode) and on the specific topics assessed in each episode (Graph). Additionally, 51%–55% of ID specialists indicated an intent to modify their diagnostic approach and 15%–29% had increased confidence in applying the rapid diagnostic results into patient care. Conclusion This educational curriculum significantly improved ID specialists’ knowledge of the strengths and limitations of different rapid diagnostic methodologies and improved the applications of test findings into clinical decision-making. These findings highlight the positive impact of well-designed online education. Disclosures All authors: No reported disclosures.

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Abstract 2840: Aspect Score: DWI or CT Scan, Which One Is Better Marker For Stroke Morbidity And Outcome?

Stroke ◽

10.1161/str.43.suppl_1.a2840 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Manoj Mittal ◽

Raymond Seet ◽

Zhang Yi ◽

Alejandro Rabinstein

Keyword(s):

Ischemic Stroke ◽

Ct Scan ◽

Acute Ischemic Stroke ◽

Predictive Value ◽

Univariate Analysis ◽

Fisher Exact Test ◽

Chi Square ◽

Exact Test ◽

Good Outcome ◽

The Difference

Background and Objective The Alberta Stroke Program Early CT Score (ASPECTS) is a validated grading system to assess ischemic changes on CT in acute ischemic stroke. Magnetic resonance imaging with diffusion weighted imaging (DWI) sequence is commonly used to identify the final ischemic changes. We examined the difference between the relationship of NIHSS at admission and ASPECT score calculated using CT scan versus MRI DWI sequence. Methods We conducted a retrospective analysis of prospectively collected data from 99 cases of acute ischemic stroke treated with IV rt-PA by time criteria, admitted to Mayo Clinic from March, 2002 through June, 2011. CT head at 24 hours and MRI DWI sequence were used to assign ASPECT score. We dichotomized ASPECTS (categorized as 0 to 7 versus 8 to 10) and favorable patient outcome at 3 month (modified Rankin score less than equal to 2 and more than 2). Univariate analysis including t-test, Chi-square, and Fisher Exact test was used when appropriate. Results Mean age was 70±14 years. Mean admission NIHSS score was 8±4. DWI ASPECTS (p<0.001) and CT ASPECTS (p=0.127) were inversely associated with admission NIHSS. Higher (8-10) CT ASPECTS (p=0.001) or DWI ASPECTS (p=0.002) were associated with good outcome (mRS ≤2) at 3 months. Sensitivity, specificity, positive predictive value and negative predictive value for good outcome identified by CT ASPECTS versus DWI ASPECTS were 81% vs 52%, 54% vs 54%, 83% vs 59% and 50% vs 47% respectively. Conclusion CT and MRI DWI are comparably useful to calculate the ASPECTS for estimation of functional outcome, but CT scan at 24 hours may be more sensitive for the prediction of good recovery.

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