From discharge planner to "concierge": recommendations for hospital social work by clients with intracerebral hemorrhage.

The Affordable Care Act and budget cuts have changed the role of hospital social workers by placing pressure on them to conduct speedy discharges and decrease readmission rates. This qualitative study aimed to assess if hospital social work is meeting the needs of clients in the hospital and postdischarge. Semistructured interviews with 10 clients with intracerebral hemorrhage (ICH) and 11 caregivers were conducted. Participants reported that social work services were not meeting their needs. Clients with ICH and their caregivers expressed needs from social workers that surpassed their roles as discharge planners, including counseling, help with finances and insurance, and advocacy. Participants wanted social work services to begin early in acute treatment with continuity postdischarge. Social workers should conduct ethical social work by meeting clients where they are, addressing needs as prioritized by the client, and advocating individually and organizationally for clients.

Ethnic Differences in Withdrawal of Life Support After Intracerebral Hemorrhage.

Minorities are less likely to decide on withdrawal of life support (WOLS) after acute severe illness. However, the decision-making process for WOLS after intracerebral hemorrhage (ICH) among Native Hawaiians and other Pacific Islanders (NHOPI) has not been described. To address this gap in the literature, a retrospective study was conducted on consecutive spontaneous ICH patients admitted to a tertiary center in Honolulu between 2006 and 2010. The occurrence of WOLS and time-to-WOLS were the outcome measures. Unadjusted and multivariable logistic regression models were performed to determine associations between NHOPI ethnicity and WOLS. This study assessed 396 patients (18% NHOPI, 63% Asians, 15% non-Hispanic whites [NHW], 4% others) with ICH. NHOPI was associated with lower rate of WOLS than NHW in the univariate analysis (OR 0.35, 95% CI: 0.15, 0.80). However, NHOPI ethnicity was no longer significant when adjusted for age (OR 0.59, 95% CI: 0.25, 1.43) and in the fully adjusted model (OR 0.68, 95% CI: 0.20, 2.39). Although NHOPI with ICH were initially perceived to have less WOLS compared to NHW, this observed difference was largely driven by the younger age of NHOPI rather than from underlying cultural differences that are inherent to their ethnicity.

Investigation of Stroke Needs (INVISION) Study: Stroke Awareness and Education.

The objective of this study was to assess the overall understanding and effectiveness of current inpatient stroke education practice by using the data from the Investigation of Stroke Needs (INVISION) Study, a qualitative study assessing various challenges and barriers of the hemorrhagic stroke survivors and their caregivers. Semi-structured interviews were conducted on patients who were recently hospitalized with intracerebral hemorrhage (ICH) and their caregivers during the follow-up visits. The electronic medical record for each patient was reviewed to assess whether they received standard stroke education material during their hospitalization. A phenomenological approach was utilized to identify gaps of education and knowledge in the targeted sample. A total of 21 participants were interviewed. Despite receiving formal stroke education material during their hospitalization, there were three major gaps in stroke knowledge that participants noted, including (1) lack of stroke knowledge/awareness, (2) need for stroke education, and (3) fear of recurrent stroke and comorbid diseases. The majority of ICH survivors had no memory of their hospitalization. This study suggests a need for increased continuity and communication with health-care providers to address the evolving educational and practical needs of stroke patients and their caregivers after hospital discharge.

Racial disparities in methamphetamine-associated intracerebral hemorrhage.

OBJECTIVE: To assess racial disparities in the prevalence of methamphetamine-associated intracerebral hemorrhage (Meth-ICH) among Native Hawaiians and other Pacific Islanders (NHOPI). METHODS: Prospectively collected data from an ongoing, multiethnic, single-center cohort study were analyzed. The inclusion criteria for the cohort study required that patients be adult (age 18 years or older) residents of Hawaii with nontraumatic spontaneous intracerebral hemorrhage (ICH). Patients of race other than white, Asian, or NHOPI were excluded. Determination of Meth-ICH was made prospectively by positive urine toxicology result and lack of other clinically suspected ICH etiology. Prevalence of Meth-ICH among NHOPI was compared with that of white and Asian patients. RESULTS: A total of 193 patients (white 16%, Asian 61%, NHOPI 23%) were analyzed. NHOPI were younger than white (54 ± 15 vs 68 ± 15 years, respectively, p = 0.0001) and Asian (vs 65 ± 16 years, p = 0.0001) patients. Overall, 25 (13%) Meth-ICHs (mean age: 49 ± 6 years, range: 33-56 years) were identified. NHOPI had higher prevalence of Meth-ICH compared with white (24% vs 0%, respectively, p = 0.003) and Asian (vs 12%, p = 0.046) patients. The observed age differences between the racial groups persisted even after excluding the Meth-ICH group (p < 0.01 for all comparison). CONCLUSIONS: NHOPI have higher prevalence of Meth-ICH compared with white and Asian patients. However, the age disparity is not entirely driven by methamphetamine abuse.

Impact of diabetes on prolonged hospital stay among Native Hawaiians and other Pacific Islanders with ischemic stroke.

Recent evidence suggests that minority groups have prolonged hospital stays after ischemic stroke. However, disparities in the hospital stay after ischemic stroke among Native Hawaiians and other Pacific Islanders (NHPI) have not been studied. A retrospective study on consecutive patients hospitalized for ischemic stroke at a single tertiary center in Honolulu between 2008 and 2010 was performed. Logistic regression analyses were performed to assess the independent predictors of prolonged hospital stay (hospitalization > 12 days after admission) after ischemic stroke. A total of 740 patients (whites 22%, Asians 53%, NHPI 21%, others 4%) hospitalized for ischemic stroke were studied. NHPI were significantly younger (59 ± 14 years vs 72 ± 13 years) and had significantly higher prevalence of female sex (51% vs 38%), no insurance (10% vs 4%), diabetes (53% vs 18%), hypertension (82% vs 62%), obesity (55% vs 20%) and prolonged hospital stay (20% vs 11%), and lower prevalence of residence outside of O'ahu (12% vs 23%) compared to whites. Univariate analyses showed that NHPI were more likely to have prolonged hospital stay (OR 1.87, 95% CI: 1.01, 3.49) compared to whites. After adjusting for age, sex, race, risk factors, health insurance status, and geographical factor, diabetes (OR 1.76, 95% CI: 1.07, 2.89) was the only independent predictor of prolonged hospital stay. NHPI are associated with prolonged hospitalization after ischemic stroke. However, this effect was attenuated by the impact of diabetes. Further prospective studies are needed to understand the relationship between diabetes and prolonged hospital stay after ischemic stroke.

A qualitative study of transportation challenges among intracerebral hemorrhage survivors and their caregivers.

Post-discharge barriers of hemorrhagic stroke survivors in Hawai'i have not been extensively studied. The purpose of this qualitative study was to identify common driving and transportation barriers among patients with intracerebral hemorrhage (ICH) and their caregivers in the Honolulu community. Semi-structured interviews were conducted with ICH patients (n = 10) and caregivers (n = 11) regarding their driving and transportation barriers. Inductive content analysis was used to analyze the interviews. Participants reported that they needed transportation to attend to their recovery and remain safe. Informal transportation was desired, yet not always available to patients. A local paratransit service for people with disabilities was the most common form of alternative transportation used by patients; however, they reported difficulty obtaining this method of transportation. Participants with no other option used costly, private transportation. Most ICH survivors expressed great challenges with the available transportation services that are essential to their reintegration into the community after hospitalization. Greater effort to provide transportation options and eligibility information to the ICH patients and their caregivers may be needed to improve their post-discharge care.

Sex differences in the use of early do-not-resuscitate orders after intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Studies show that women are more likely to receive do-not-resuscitate (DNR) orders after acute medical illnesses than men. However, the sex differences in the use of DNR orders after acute intracerebral hemorrhage (ICH) have not been described. METHODS: We conducted a retrospective study of consecutive patients hospitalized for acute ICH at a tertiary stroke center between 2006 and 2010. Unadjusted and multivariable logistic regression analyses were performed to test for associations between female sex and early (<24 hours of presentation) DNR orders. RESULTS: A total of 372 consecutive ICH patients without preexisting DNR orders were studied. Overall, 82 (22%) patients had early DNR orders after being hospitalized with ICH. In the fully adjusted model, early DNR orders were more likely in women (odds ratio, 3.18; 95% confidence interval, 1.51-6.70), higher age (odds ratio, 1.09 per year; 95% confidence interval, 1.05-1.12), larger ICH volume (odds ratio, 1.01 per cm(3); 95% confidence interval, 1.01-1.02), and lower initial GCS score (odds ratio, 0.76 per point; 95% confidence interval, 0.69-0.84). Early DNR orders were less likely when the patients were transferred from another hospital (odds ratio, 0.28, 95% confidence interval, 0.11-0.76). CONCLUSIONS: Women are more likely to receive early DNR orders after ICH than men. Further prospective studies are needed to determine factors contributing to the sex variation in the use of early DNR order after ICH.

The effects of para-chloromercuribenzoic acid and different oxidative and sulfhydryl agents on a novel, non-AT1, non-AT2 angiotensin binding site identified as neurolysin.

A novel, non-AT1, non-AT2 brain binding site for angiotensin peptides that is unmasked by p-chloromercuribenzoate (PCMB) has been identified as a membrane associated variant of neurolysin. The ability of different organic and inorganic oxidative and sulfhydryl reactive agents to unmask or inhibit 125I-Sar1Ile8 angiotensin II (SI-Ang II) binding to this site was presently examined. In tissue membranes from homogenates of rat brain and testis incubated in assay buffer containing losartan (10 µM) and PD123319 (10 µM) plus 100 µM PCMB, 5 of the 39 compounds tested inhibited 125I-SI Ang II binding in brain and testis. Mersalyl acid, mercuric chloride (HgCl2) and silver nitrate (AgNO3) most potently inhibited 125I-SI Ang II binding with IC50s ~1-20 µM. This HgCl2 inhibition was independent of any interaction of HgCl2 with angiotensin II (Ang II) based on the lack of effect of HgCl2 on the dipsogenic effects of intracerebroventricularly administered Ang II and 125I-SI Ang II binding to AT1 receptors in the liver. Among sulfhydryl reagents, cysteamine and reduced glutathione (GSH), but not oxidized glutathione (GSSG) up to 1mM, inhibited PCMB-unmasked 125I-SI Ang II binding in brain and testis. Thimerosal and 4-hydroxymercuribenzoate moderately inhibited PCMB-unmasked 125I-SI Ang II binding in brain and testis at 100 µM; however, they also unmasked non-AT1, non-AT2 binding independent of PCMB. 4-Hydroxybenzoic acid did not promote 125 I-SI Ang II binding to this binding site indicating that only specific organomercurial compounds can unmask the binding site. The common denominator for all of these interacting substances is the ability to bind to protein cysteine sulfur. Comparison of cysteines between neurolysin and the closely related enzyme thimet oligopeptidase revealed an unconserved cysteine (cys650, based on the full length variant) in the proposed ligand binding channel (Brown et al., 2001) [45] near the active site of neurolysin. It is proposed that the mercuric ion in PCMB and closely related organomercurial compounds binds to cys650, while the acidic anion forms an ionic bond with a nearby arginine or lysine along the channel to effect a conformational change in neurolysin that promotes Ang II binding.