Faculty Bibliography

Importance/UNASSIGNED:Despite secondary prevention strategies with proven efficacy, recurrent stroke rates remain high, particularly in racial/ethnic minority populations who are disproportionately affected by stroke. Objective/UNASSIGNED:To determine the efficacy of a culturally tailored skills-based educational intervention with telephone follow-up compared with standard discharge care on systolic blood pressure reduction in a multiethnic cohort of patients with mild/moderate stroke/transient ischemic attack. Design, Setting, and Participants/UNASSIGNED:Randomized clinical trial with 1-year follow-up. Participants were white, black, and Hispanic patients with mild/moderate stroke/transient ischemic attack prospectively enrolled from 4 New York City, New York, medical centers during hospitalization or emergency department visit between August 2012 and May 2016. Through screening of stroke admissions and emergency department notifications, 1083 eligible patients were identified, of whom 256 declined to participate and 275 were excluded for other reasons. Analyses were intention to treat. Interventions/UNASSIGNED:The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) intervention is a skills-based, culturally tailored discharge program with follow-up calls delivered by a community health coordinator. This intervention was developed using a community engagement approach. Main Outcomes and Measures/UNASSIGNED:The primary outcome was systolic blood pressure reduction at 12 months postdischarge. Results/UNASSIGNED:A total of 552 participants were randomized to receive intervention or usual care (281 women [51%]; mean [SD] age, 64.61 [2.9] years; 180 Hispanic [33%], 151 non-Hispanic white [27%], and 183 non-Hispanic black [33%]). At 1-year follow-up, no significant difference in systolic blood pressure reduction was observed between intervention and usual care groups (β = 2.5 mm Hg; 95% CI, -1.9 to 6.9). Although not powered for subgroup analysis, we found that among Hispanic individuals, the intervention arm had a clinically and statically significant 9.9 mm Hg-greater mean systolic blood pressure reduction compared with usual care (95% CI, 1.8-18.0). There were no significant differences between arms among non-Hispanic white (β = 3.3; 95% CI, -4.1 to 10.7) and non-Hispanic black participants (β = -1.6; 95% CI, -10.1 to 6.8). Conclusions and Relevance/UNASSIGNED:Few behavioral intervention studies in individuals who have had stroke have reported clinically meaningful reductions in blood pressure at 12 months, and fewer have focused on a skills-based approach. Results of secondary analyses suggest that culturally tailored, skills-based strategies may be an important alternative to knowledge-focused approaches in achieving sustained vascular risk reduction and addressing racial/ethnic stroke disparities; however, these findings should be tested in future studies. Trial Registration/UNASSIGNED:ClinicalTrials.gov identifier: NCT01836354.

BACKGROUND AND PURPOSE/OBJECTIVE:The relationship between in-hospital hyperglycemia and neurological outcome after intracerebral hemorrhage (ICH) is not well studied. METHODS:We analyzed the relationships between pre-hospital and hospital variables including highest in-hospital glucose (HIHGLC) and discharge Glasgow Coma Scale (GCS), discharge Modified Rankin Scale (MRS) and 3-month MRS using a single-institution cohort of ICH patients between 2013 and 2015. RESULTS:There were 106 patients in our sample. Mean HIHGLC was 154 ± 58mg/dL for patients with discharge GCS of 15 and 180 ± 57mg/dL for patients with GCS < 15; 146 ± 55mg/dL for patients with discharge MRS 0-3 and 175 ± 58mg/dL for patients with discharge MRS 4-6; and 149 ± 52mg/dL for patients with 3-month MRS of 0-3 and 166 ± 61mg/dL for patients with 3-month MRS of 4-6. On univariate analysis, discharge GCS was associated with HIHGLC (P = .01), age (P = .006), ICH volume (P = .008), and length of stay (LOS) (P = .01); discharge MRS was associated with HIHGLC (P < .001), age (P < .001), premorbid MRS (P = .046), ICH volume (P < .001), and LOS (P < .001); and 3-month MRS was associated with HIHGLC (P = .006), discharge MRS (P < .001), age (P = .001), sex (P = .002), ICH volume (P = .03), and length of stay (P = .004). On multivariate analysis, discharge GCS only had a significant relationship with ICH volume (odds ratio [OR] .949, .927-.971); discharge MRS had a significant relationship with age (OR 1.043, 1.009-1.079), premorbid MRS (OR 2.622, 1.144-6.011), and ICH volume (OR 1.047, 1.003-1.093); and 3-month MRS only had a significant relationship with age (OR 1.039, 1.010-1.069). CONCLUSIONS:The relationship between in-hospital hyperglycemia and neurological outcomes in ICH patients was meaningful on univariate, but not multivariate, analysis. Glucose control after ICH is important.

Objective/UNASSIGNED:Systemic inflammatory response syndrome (SIRS) may be related to poor outcomes after intracerebral hemorrhage (ICH). Methods/UNASSIGNED:The Ethnic/Racial Variations of Intracerebral Hemorrhage study is an observational study of ICH in whites, blacks, and Hispanics throughout the United Sates. SIRS was defined by standard criteria as 2 or more of the following on admission: (1) body temperature <36°C or >38°C, (2) heart rate >90 beats per minute, (3) respiratory rate >20 breaths per minute, or (4) white blood cell count <4,000/mm3 or >12,000/mm3. The relationship among SIRS, infection, and poor outcome (modified Rankin Scale [mRS] 3-6) at discharge and 3 months was assessed. Results/UNASSIGNED:Of 2,441 patients included, 343 (14%) met SIRS criteria at admission. Patients with SIRS were younger (58.2 vs 62.7 years; p < 0.0001) and more likely to have intraventricular hemorrhage (IVH; 53.6% vs 36.7%; p < 0.0001), higher admission hematoma volume (25.4 vs 17.5 mL; p < 0.0001), and lower admission Glasgow Coma Scale (GCS; 10.7 vs 13.1; p < 0.0001). SIRS on admission was significantly related to infections during hospitalization (adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 1.04-1.78). In unadjusted analyses, SIRS was associated with poor outcomes at discharge (OR 1.96, 95% CI 1.42-2.70) and 3 months (OR 1.75, 95% CI 1.35-2.33) after ICH. In analyses adjusted for infection, age, IVH, hematoma location, admission GCS, and premorbid mRS, SIRS was no longer associated with poor outcomes. Conclusions/UNASSIGNED:SIRS on admission is associated with ICH score on admission and infection, but it was not an independent predictor of poor functional outcomes after ICH.

BACKGROUND: To explore the effect of end of life and other palliative decision making scenarios on the mental health of family members of patients in the neuro-intensive care unit. METHODS: Decision makers of patients in the neuro-ICU at a large, urban, academic medical center meeting palliative care triggers were identified from November 10, 2014, to August 27, 2015. Interviews were conducted at 1 and 6 months post-enrollment. At 1 month, the Inventory of Complicated Grief-Revised (ICG-R), Impact of Events Scale-Revised (IES-R), and the Family Satisfaction-ICU (FS-ICU) were performed along with basic demographic questionnaires. At 6 months, only the ICG-R and IES-R were repeated. RESULTS: At 1 month, 9 (35%) subjects had significant symptoms in at least one of the three domains of traumatic response. Two (7.7%) subjects met full criteria for PTSD (IES-R >/= 1.5). At 6 months, 5 (22%) subjects met criteria for PTSD and 5 (22%) for Complicated Grief (ICG-R >/= 36). Fifteen (50%) had at least one domain of PTSD symptoms identified in follow-up. Time spent at bedside and lower household income were associated with PTSD at 1 and 6 months, respectively. In all, clinically significant psychological outcomes were identified in 9 (30%) of subjects. CONCLUSIONS: Clinically significant grief and stress reactions were identified in 30% of decision makers for severely ill neuro-ICU patients. Though factors including time at bedside during hospitalization and total household income may have some predictive value for these disorders, further evaluation is required to help identify family members at risk of psychopathology following neuro-ICU admissions.

BACKGROUND: The morbidity, mortality, and monetary cost associated with intracerebral hemorrhage (ICH) is devastatingly high. Several scoring systems have been proposed to prognosticate outcomes following ICH, though the original ICH Score is still the most widely used. However, recent research suggests that systemic physiological factors, such as those included in the APACHE II score, may also influence outcome. Additionally, no scoring systems to date include pre-morbid functional status. Therefore, we propose a scoring system that incorporates these factors to prognosticate 3- and 12-month functional outcomes. METHODS: We used the Random Forest machine learning technique to identify factors from a dataset of over 200 data points per patient that were most strongly affiliated with functional outcome. We then used linear regression to create an initial model based on these factors and modified weightings to improve accuracy. Our scoring system was compared to the ICH Score for prognosticating functional outcomes. RESULTS: Two separate scoring systems (ICHOP3 and ICHOP12) were developed for 3- and 12-month functional outcomes using GCS, NIHSS, APACHE II, pre-morbid modified Rankin scale (mRS), and hematoma volume (3-month only). Patient outcomes were dichotomized into good (mRS 0-3) and poor (mRS 4-6) categories based on functional status. AUCs in the derivation cohort for predicting mRS were 0.89 (3-month) and 0.87 (12-month); both were significantly more discriminatory than the original ICH Score. CONCLUSION: The ICHOP scores may provide more comprehensive evaluation of a patient's long-term functional prognosis by taking into account systemic physiological factors as well as pre-morbid functional status.

Background and Aims: Secondary stroke prevention strategies have proven suboptimal in underserved and minority populations. The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial tested the efficacy of a culturally-tailored, innovative, skills-based intervention focused on risk perception, medication adherence, and patient-physician communication (vs. usual care enhanced with educational material [EUC]) on systolic blood pressure (SBP) reduction among mild/moderate stroke/TIA patients at 1 year post-discharge. Method: We assessed the difference in mean SBP reduction between trial arms, overall and by race/ethnicity, among those with prehypertension/ hypertension at baseline using linear regression, adjusting for any characteristics that differed between trial arms at baseline. Results: A total of 321 of 552 stroke/TIA patients assessed at baseline were included in analyses (intervention, n=163; EUC, n=158; 29% white, 33% black, 33% Hispanic). Overall, there was a trend toward greater mean BP reduction in the intervention vs. EUC group (12.6 vs. 8.4 mmHg, p=0.101). Mean SBP reduction was significantly greater in the intervention vs. EUC group among Hispanics (15.6 vs. 1.7 mmHg, p=0.002). Among Hispanics, after adjusting for age, interview language, education, place of birth, and baseline SBP, mean SBP reduction was 8.2 mmHg greater in the intervention vs. EUC group (p=0.041). Mean SBP reduction did not differ significantly between trial arms among non- Hispanics. Conclusion: Few behavioral intervention studies in stroke survivors have reported significant long-term differences in vascular risk reduction, and fewer have focused on a skills-based approach. Culturally-tailored, skills-based interventions may be more useful than knowledge-focused interventions in achieving sustained vascular risk reduction and addressing race/ethnic stroke disparities

BACKGROUND AND PURPOSE: The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. METHODS: We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. RESULTS: The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents' institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. CONCLUSION: Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.

We describe two unusual cases of cardiopulmonary death in mechanically ventilated patients in the neurological intensive care unit. After cardiac arrest, both patients were pulseless for a protracted period. Upon extubation, both developed agonal movements (gasping respiration) resembling life. We discuss these cases and the literature on the ethical and medical controversies associated with determining time of cardiopulmonary death. We conclude that there is rarely a single moment when all of a patient's physiological functions stop working at once. This can pose a challenge for determining the exact moment of death.