Implementing a student-centered stroke intervention and prevention education program; evaluating motivation, cognitive load, and performance among middle school students

Background

In this study, we investigated the association between motivation, cognitive load, difficulty, and performance in a stroke education outreach program implemented for middle school students.

Methods

Various interactive instructional activities were developed to engage students throughout the program to assess cognitive and intrinsic load arising from learner implementation of various tasks in a stroke education program for middle school kids. Performance was measured using a post-test to assess knowledge gained by the 6th, 7th, and 8th-grade middle school students. A short questionnaire was also administered to collect data on students' motivation using the ARCS model to asses attention, relevance, confidence, and satisfaction. In addition, we evaluated difficulty level and cognitive load. The relationship between performance and motivation was assessed using Pearson's correlation.

Results

In our results, there was no significant difference (p > 0.05) in performance between the 6th, 7th, and 8th-grade students. The difference in performance, cognitive load (mental effort and difficulty), or motivation between the 6th, 7th, and 8 t-grade students was not significant (p > 0.05). The correlation between motivation and performance was significant (r = 0.87, p = 0.001), while the correlation between mental effort and performance was not significant (r = 0.34, p = 0.270). Also, the correlation between difficulty and performance was not significant (r = 0.38, p = 0.361). In the ARCS motivation model, attention, and confidence received the lowest mean scores (3.9), while relevance received the highest score (4.3).

Conclusion

Our findings reveal the importance of implementing novel activities to enhance students' motivation to improve performance in the implementation of stroke education outreach programs for middle school students.

Research Education Program for Underrepresented Minority Students: Students' Perception of Academic Enrichment and Research Activities

The Research Education Program (REP) is an NIH R25-funded training grant designed to increase the pipeline of underrepresented minority (URM) students entering graduate programs and pursuing biomedical research and health care careers. Each week, students participated in different academic enrichment activities during morning sessions. Research activities were during afternoon sessions. URM students presented their research findings in a local poster session with their peers, graduate medical students, and faculty members. They also attended national conferences to gain experience and expand their professional networks. Our participants included 14.3% rural, 42.85% suburban, and 42.85% urban students. Of this, 83.33% were females, while 16.67% were males. In addition, 100% of students indicated exceptional satisfaction in 64.0% of the academic enrichment activities offered by the REP, and 100% indicated exceptional satisfaction in 63.0% of the research activities. Future research will investigate the long-term effects of REP and graduate enrollments.

Age Stratification in Acute Ischemic Stroke Patients with Heart Failure

Background and Purpose. Heart failure (HF) is considered one of the major risk factors associated with the severity of acute ischemic stroke(AIS). The risk factors associated with stroke severity in AIS with a history of HF is not fully understood. Methods. A prospectively maintained database from comprehensive stroke centers in PRISMA Health Upstate Sc, was analyzed for patients with AIS and a history of HF from January 2010 to 30 June 2016. The primary outcome was risk factors associated with a National Institute of Health Stroke Scale score (NIHSS) < 7 indicating lower severity and a score ≥ 7 indicating high severity for 65−74 age category and ≥75 years age category for AIS-HF patients. Univariate analysis was used to determine risk factors based on age categories and stroke severities, while multivariable analysis was used to adjust for the effect of confounding variables. Results: A total 367 AIS-HF patients were identified in this study, 113 patients were between 65−74 years old, while 254 patients were in the ≥75 years old age category. In the adjusted analysis for 65−74 age category, history of smoking (OR = 0.105, 95% Confidence interval (CI): 0.018−0.614, p = 0.012), triglycerides (Odd ratio(OR) = 0.993, 95% (CI): 0.987−0.999, p = 0.019), and International Normalized Ratio (INR) (OR = 0.454, 95% CI: 0.196−1.050, p = 0.045), and direct admission treatment (OR = 0.355, 95% CI: 0.137−0.920, p = 0.033) were associated with a lower stroke severity, elevated heart rate (OR = 1.032, 95% CI: 1.009−1.057, p = 0.007) was associated with a higher stroke severity. For the ≥75 years old age category, previous stroke (OR = 2.297, 95% CI: 1.171−9.852, p = 0.024), peripheral vascular disease (OR = 6.784, 95% CI: 1.242−37.065, p = 0.027), heart rate (OR = 1.035, 95% CI: 1.008−1.063, p = 0.012), and systolic blood pressure (OR = 1.023, 95% CI: 1.005−1.041, p = 0.012) were associated with a higher severe stroke severity. Conclusions: After adjusting for the effect of potential confounders, more risk factors were associated with a high severity of stroke among ≥75 years old compared with 65−74 years old AIS-HF patients. Elevated heart rate was an independent risk factor associated with stroke severity in 65−74 and ≥75 years old AIS-HF patients. Elevated heart rate and other identified risk factors should be managed to reduce stroke severity among elderly AIS-HF patients.

Stroke Severity in Ischemic Stroke Patients with a History of Diastolic Blood Pressure Treated in a Telestroke Network

Background: The relationship between diastolic blood pressure (DBP), risk factors, and stroke severity in acute ischemic stroke (AIS) patients treated in a telestroke network is not fully understood. The present study aims to determine the effect of risk factors on stroke severity in AIS patients with a history of elevated DBP. Material and Methods: We retrospectively analyzed data on stroke severity for AIS patients treated between January 2014 and June 2016 treated in the PRISMA Health telestroke network. Data on the severity of stroke on admission were evaluated using NIHSS scores ≤7 for reduced, and >7 for increased, stroke severity. DBP was stratified as ≤80 mmHg for reduced DBP and >80 mmHg for elevated DBP. The study’s primary outcomes were risk factors associated with improving neurologic functions or reduced stroke severity and deteriorating neurologic functions or increased stroke severity. The associations between risk factors and stroke severity for AIS with elevated DBP were determined using multi-level logistic and regression models. Results: In the adjusted analysis, AIS patients with a DBP ≤ 80 mmHg, obesity (OR = 0.388, 95% Cl, 0.182−0.828, p = 0.014) was associated with reduced stroke severity, while an increased heart rate (OR = 1.025, 95% Cl, 1.001−1.050, p = 0.042) was associated with higher stroke severity. For AIS patients with a DBP > 80 mmHg, hypertension (OR = 3.453, 95% Cl, 1.137−10.491, p = 0.029), history of smoking (OR = 2.55, 95% Cl, 1.06−6.132, p = 0.037), and heart rate (OR = 1.036, 95% Cl, 1.009−1.064, p = 0.009) were associated with higher stroke severity. Caucasians (OR = 0.294, 95% Cl, 0.090−0.964, p = 0.002) and obesity (OR = 0.455, 95% Cl, 0.207−1.002, p = 0.05) were more likely to be associated with reduced stroke severity. Conclusions: Our findings reveal specific risk factors that can be managed to improve the care of AIS patients with elevated DBP treated in the telestroke network.

Active Learning: Action Potential and Clinical Applications in Neuroscience Medical Education

Active learning in medical education engages adult learners and increases collaborative opportunities for consolidation of concepts. An innovative learning activity was used to engage medical students in an activity about action potentials and its clinical applications, resulting in increased understanding, application, and retention of the clinical relevance of the topic.

Acute Ischemic Stroke and Heart Failure: Stroke Risk Factors Associated with Exclusion from Thrombolytic Therapy

Objective: Acute ischemic stroke (AIS) patients with congestive heart failure (HF) that present with various risk factors are less likely to receive recombinant tissue plasminogen activator (rtPA). The risk factors associated with excluding AIS patients with congestive heart failure (AIS-HF) from rtPA therapy have not been fully established. Methods: Retrospective data for 5469 AIS patients comprised of 590 AIS patients with HF and 4879 AIS patients without HF were collected from a regional stroke registry between January 2010 and June 2016. Baseline risk factors were analyzed using logistic regression analysis to determine the risk factors associated with rtPA exclusion in AIS-HF patients. Results: In the adjusted analysis, AIS-HF patients that that did not receive rtPA were more likely to be older (OR = 0.982, 95% CI, 0.966-1, P = .020), presented with coronary artery disease (OR = 0.618, 95% CI, 0.391-0.98, P = .040), and with an elevated INR (OR = 0.326, 95% CI, 0.129-0.82, P = .018). AIS-HF patients that were included for rtPA therapy were more likely to show improvement in ambulatory status (OR = 1.69, 95% CI, 1.058-2.7, P = .028). The discriminating power of the model was strong with an area under the curve (AUROC) = 0.668 (95% CI, 0.611-0.724, P < .001). Conclusion: Our study establishes the associations between stroke risk factors and exclusion from rtPA therapy. This finding suggests the need to develop management strategies for older HF patients with carotid artery disease and an elevated INR to improve their eligibility for rtPA treatment following an acute ischemic stroke.

Obstructive sleep apnea and stroke severity: Impact of clinical risk factors

BACKGROUND

Specific clinical and demographic risk factors may be associated with improving or worsening neurologic outcomes within a population of acute ischemic stroke (AIS) patients with a history of obstructive sleep apnea (OSA). The objective of this study was to determine the changes in neurologic outcome during a 14-day recovery as it relates to initial stroke severity in AIS patients with OSA.

METHODS

This retrospective study analyzed baseline clinical risk factors and demographic data collected in a regional stroke center from January 2010 to June 2016. Our primary endpoint measure was the National Institutes of Health Stroke Scale (NIHSS) score and our secondary endpoint measures included the clinical factors associated with improving (NIHSS score ≤7) or worsening (NIHSS score >7) neurological outcome. The relative contribution of each variable to stroke severity and related outcome was determined using a logistic regression. The regression models were checked for the overall correct classification percentage using a Hosmer-Lemeshow test, and the sensitivity of our models was determined by the area under the receiver operating characteristic curve.

RESULTS

A total of 5469 AIS patients were identified. Of this, 96.89% did not present with OSA while 3.11% of AIS patients presented with OSA. Adjusted multivariate analysis demonstrated that in the AIS population with OSA, atrial fibrillation (AF) (odds ratio [OR] = 3.36, 95% confidence interval [CI], 1.289-8.762, P = 0.013) and changes in ambulatory status (OR = 2.813, 95% CI, 1.123-7.041, P = 0.027) showed an association with NIHSS score >7 while being Caucasian (OR = 0.214, 95% CI, 0.06-0.767, P = 0.018) was associated with NIHSS score ≤7.

CONCLUSION

In AIS patients with OSA, AF and changes in ambulatory status were associated with worsening neurological outcome while Caucasian patients were associated with improving neurological outcome. Our findings may have significant implications for patient stratification when determining treatment protocols with respect to neurologic outcomes in AIS patients with OSA.

Gender differences in comorbidities and risk factors in ischemic stroke patients with a history of atrial fibrillation

BACKGROUND

Atrial Fibrillation (AF) is a common cardiac arrhythmia and has been identified as a major risk factor for acute ischemic stroke (AIS). Gender differences in the disease process, causative mechanisms and outcomes of AF have been investigated. In the current study, we determined whether there is a gender-based disparity in AIS patients with baseline AF, and whether such a discrepancy is associated with specific risk factors and comorbidities.

METHODS

Baseline factors including comorbidities, risk and demographic factors associated with a gender difference were examined using retrospective data collected from a registry from January 2010 to June 2016 in a regional stroke center. Univariate analysis was used to differentiate between genders in terms of clinical risk factors and demographics. Variables in the univariate analysis were further analyzed using logistic regression. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each factor were used to predict the increasing odds of an association of a specific comorbidity and risk factor with the male or female AIS with AF.

RESULTS

In the population of AIS patients with AF, a history of drug and alcohol use (OR = 0.250, 95% CI, 0.497-1.006, P = 0.016), sleep apnea (OR = 0.321, 95% CI, 0.133-0.777, P = 0.012), and higher serum creatinine (OR = 0.693, 95% CI, 0.542-0.886 P = 0.003) levels were found to be significantly associated with the male gender. Higher levels of HDL-cholesterol (OR = 1.035, 95% CI, 1.020-1.050, P < 0.001), LDL-cholesterol (OR = 1.006, 95% CI, 1.001-1.011, P = 0.012), and the inability to ambulate on admission to hospital (OR = 2.258, 95% CI, 1.368-3.727, P = 0.001) were associated with females.

CONCLUSION

Our findings reveal that in the AIS patients with atrial fibrillation, migraines, HDL, LDL and poor ambulation were associated with females, while drugs and alcohol, sleep apnea, and serum creatinine level were associated with male AIS patients with AF. Further studies are necessary to determine whether gender differences in risk factor profiles and commodities require consideration in clinical practice when it comes to AF as a risk factor management in AIS patients.

Comorbidities associated with different levels of total cholesterol in male and female acute ischemic stroke patients

Men and women differ in their clinical risk factors with respect to various predictors of severity in acute ischemic stroke (AIS). High cholesterol is a risk factor for AIS and the mechanism by which high cholesterol levels lead to an AIS is well established. However, the specific relationship between demographic, clinical risk factors, total cholesterol, and the resulting gender difference in AIS patients is yet to be investigated. This study recruited AIS patients between January 2000 and June 2016 classified into normal, borderline or high total cholesterol (TC). Normal was defined as ≤200 mg/dl, borderline 200 to 239 mg/dl and high ≥240 mg/dl based on Adult Treatment Panel III (ATP III) Guidelines for the classification of TC levels. The logistic regression model was used to predict clinical risk factors associated within men and women AIS patients with different levels of TC. A total of 3532 AIS patients presented with normal TC, 760 patients with borderline TC and 427 patients with high TC. The high total cholesterol group was more likely to be women with increasing age (OR = 1.028, 95% CI, 1.006-1.052, P = .014), body mass index (BMI) (OR = 1.052, 95% CI, 1.004-1.102, P = .033), and high-density lipoprotein cholesterol (HDL-C) (OR = 1.039, 95% CI, 1.019-1.060, P < .001), while those with coronary artery disease (OR = 0.435, 95% CI, 0.234-0.809, P = .003), history of drug or alcohol abuse (OR = 0.261, 95% CI, 0.079-0.867, P = .028), increasing INR (OR = 0.187, 95% CI, 0.047-0.748, P = .018), and elevated diastolic blood pressure (OR = 0.982, 95% CI, 0.970-0.995, P = .006) were associated with being a male AIS patient. There were disparities in demographic and clinical risk factors associated with high TC levels in men when compared to women and more clinical risk factors were associated with high TC levels in men when compared to women with AIS. It is important to take into account specific clinical risk factors associated with gender-related differences in total cholesterol in AIS population to facilitate personalizing their therapeutic actions.

The Impact of Meeting Patients with Neurological Disorders on Medical Student Empathy

PURPOSE

Empathy tends to decline during medical education, typically beginning in the third year of medical school and often continuing throughout residency and the physician's medical career. The purpose of this study was to determine if first year medical student empathy is affected by small group interactions with patients with neurological disorders, and to investigate if changes in empathy persisted over time.

MATERIALS AND METHODS

Eighty first year medical students participating in a Neuroscience Module interacted with a variety of neurological patients in a small group informational session. Prior to the experience, participants completed the Jefferson Scale of Physician Empathy-Student (JSPE-S) version. After the experience, students completed a post-test JSPE-S questionnaire, and a final post-post-test JSPE-S questionnaire was completed 5 weeks later. Empathy scores were compared with a repeated measures MANOVA. The relationship between gender and empathy, and the effect of the age of the neurological patients on empathy scores were also examined.

RESULTS

Empathy scores for seventy-one students who completed the JSPE-S questionnaires were analyzed. Students had significantly higher empathy immediately after the patient interaction experience, and the change in empathy was sustained over the course of 5 weeks (p = 0.015). The age of the neurological patients had a significant effect on empathy scores. There was no significant difference between empathy scores and gender.

CONCLUSIONS

This study supports the incorporation of a group patient interaction experience into the medical school curriculum as an inexpensive and practical method of enhancing medical student empathy in a non-clinical setting.

Ischemic stroke with a preceding Trans ischemic attack (TIA) less than 24 hours and thrombolytic therapy

Background

Acute ischemic stroke attack with and without a recent TIA may differ in clinical risk factors, and this may affect treatment outcomes following thrombolytic therapy. We examined whether the odds of exclusion or inclusion for thrombolytic therapy are greater in ischemic stroke with TIA less than 24 h preceding ischemic stroke (recent-TIA) as compared to those without recent TIA or non-TIA > 24 h and less than 1 month (past-TIA).

Methods

A retrospective hospital-based analysis was conducted on 6315 ischemic stroke patients, of whom 846 had proven brain diffusion-weighted magnetic resonance imaging (DW-MRI) of an antecedent TIA within 24 h prior to ischemic stroke. The logistic regression model was developed to generate odds ratios (OR) to determine clinical factors that may increase the likelihood of exclusion or inclusion for thrombolytic therapy. The validity of the model was tested using a Hosmer-Lemeshow test, while the Receiver Operating Curve (ROC) was used to test the sensitivity of our model.

Results

In the recent-TIA ischemic stroke population, patients with a history of alcohol abuse (OR = 5.525, 95% CI, 1.003–30.434, p = 0.05), migraine (OR = 4.277, 95% CI, 1.095–16.703, p = 0.037), and increasing NIHSS score (OR = 1.156, 95% CI, 1.058–1.263, p = 0.001) were associated with the increasing odds of receiving rtPA, while older patients (OR = 0.965, 95% CI, 0.934–0.997, P = 0.033) were associated with the increasing odds of not receiving rtPA.

Conclusion

In recent-TIA ischemic stroke patients, older patients with higher INR values are associated with increasing odds of exclusion from thrombolytic therapy. Our findings demonstrate clinical risks factors that can be targeted to improve the use and eligibility for rtPA in in recent-TIA ischemic stroke patients.

Functional Outcome Measures of Recombinant Tissue Plasminogen Activator-Treated Stroke Patients in the Telestroke Technology

The efficiency of telestroke programs in improving the rates of recombinant tissue plasminogen activator (rtPA) in stroke patients has been reported. Previous studies have reported favorable treatment outcomes with the use of telestroke programs to improve the use of rtPA, but functional outcomes are not fully understood. This study investigated the effect of telestroke technology in the administration of rtPA and related functional outcomes associated with baseline clinical variables. Retrospective data of a telestroke registry were analyzed. Univariate analysis was used to compare demographic and clinical variables in the rtPA group and the no rtPA group and between the improved functional ambulation group and the no improvement group. A stepwise binary logistic regression identified factors associated with improved functional outcome in the total telestroke population and in the subset of the telestroke population who received rtPA. In adjusted analysis and elimination of any multicollinearity for patients who received rtPA in the telestroke setting, obesity (odds ratio [OR] = 2.138, 95% confidence interval [CI], 1.164-3.928, P < .05), higher systolic blood pressure at the time of presentation (OR = 1.015, 95% CI, 1.003-1.027, P < .05), and baseline high-density lipoprotein at the time of admission (OR = 1.032, 95% CI, 1.005-1.059, P < .05) were associated with improved functional outcomes. Increasing age (OR = 0.940, 95% CI, 0.916-0.965, P < .0001) and higher calculated National Institutes of Health Stroke Scale (OR = 0.903, 95% CI, 0.869-0.937) were associated with a poorer outcome in rtPA-treated patients. Telestroke technology improves functional outcomes at spoke stations where neurological expertise is unavailable. Further studies are necessary to determine how telestroke technology can be optimized, especially to improve contraindications and increase eligibility for thrombolysis therapy.

Drug-sensitive reward in crayfish: an invertebrate model system for the study of SEEKING, reward, addiction, and withdrawal

In mammals, rewarding properties of drugs depend on their capacity to activate appetitive motivational states. With the underlying mechanisms strongly conserved in evolution, invertebrates have recently emerged as a powerful new model in addiction research. In crayfish natural reward has proven surprisingly sensitive to human drugs of abuse, opening an unlikely avenue of research into the basic biological mechanisms of drug addiction. In a series of studies we first examined the presence of natural reward systems in crayfish, then characterized its sensitivity to a wide range of human drugs of abuse. A conditioned place preference (CPP) paradigm was used to demonstrate that crayfish seek out those environments that had previously been paired with the psychostimulants cocaine and amphetamine, and the opioid morphine. The administration of amphetamine exerted its effects at a number of sites, including the stimulation of circuits for active exploratory behaviors (i.e., SEEKING). A further study examined morphine-induced reward, extinction and reinstatement in crayfish. Repeated intra-circulatory infusions of morphine served as a reward when paired with distinct visual or tactile cues. Morphine-induced CPP was extinguished after repeated saline injections. Following this extinction phase, morphine-experienced crayfish were once again challenged with the drug. The priming injections of morphine reinstated CPP at all tested doses, suggesting that morphine-induced CPP is unrelenting. In an exploration of drug-associated behavioral sensitization in crayfish we concurrently mapped measures of locomotion and rewarding properties of morphine. Single and repeated intra-circulatory infusions of morphine resulted in persistent locomotory sensitization, even 5 days following the infusion. Moreover, a single dose of morphine was sufficient to induce long-term behavioral sensitization. CPP for morphine and context-dependent cues could not be disrupted over a drug free period of 5 days. This work demonstrates that crayfish offer a comparative and complementary approach in addiction research. Serving as an invertebrate animal model for the exposure to mammalian drugs of abuse, modularly organized and experimentally accessible nervous systems render crayfish uniquely suited for studying (1) the basic biological mechanisms of drug effects, (2) to explore how the appetitive/seeking disposition is implemented in a simple neural system, and (3) how such a disposition is related to the rewarding action of drugs of abuse. This work aimed to contribute an evolutionary, comparative context to our understanding of a key component in learning, and of natural reward as an important life-sustaining process.