Consensus Competencies for Postgraduate Fellowship Training in Global Neurology

BACKGROUND AND OBJECTIVES

Use a modified Delphi approach to develop competencies for neurologists completing ≥1 year of advanced global neurology training.

METHODS

An expert panel of 19 United States-based neurologists involved in global health was recruited from the American Academy of Neurology Global Health Section and the American Neurological Association International Outreach Committee. An extensive list of global health competencies was generated from review of global health curricula and adapted for global neurology training. Using a modified Delphi method, United States-based neurologists participated in 3 rounds of voting on a survey with potential competencies rated on a 4-point Likert scale. A final group discussion was held to reach consensus. Proposed competencies were then subjected to a formal review from a group of 7 neurologists from low- and middle-income countries (LMICs) with experience working with neurology trainees from high-income countries (HICs) who commented on potential gaps, feasibility, and local implementation challenges of the proposed competencies. This feedback was used to modify and finalize competencies.

RESULTS

Three rounds of surveys, a conference call with United States-based experts, and a semistructured questionnaire and focus group discussion with LMIC experts were used to discuss and reach consensus on the final competencies. This resulted in a competency framework consisting of 47 competencies across 8 domains: (1) cultural context, social determinants of health and access to care; (2) clinical and teaching skills and neurologic medical knowledge; (3) team-based practice; (4) developing global neurology partnerships; (5) ethics; (6) approach to clinical care; (7) community neurologic health; (8) health care systems and multinational health care organizations.

DISCUSSION

These proposed competencies can serve as a foundation on which future global neurology training programs can be built and trainees evaluated. It may also serve as a model for global health training programs in other medical specialties as well as a framework to expand the number of neurologists from HICs trained in global neurology.

Improving delivery room and admission efficiency and outcomes for infants < 32 weeks: ELGAN+ (Extremely Low Gestational Age Neonate)

OBJECTIVE

To evaluate the implementation of a systematic approach to improve the resuscitation, stabilization, and admission of infants <  32 weeks gestation and also to ascertain its effect on organization, efficiency, and clinical outcomes during hospitalization.

METHODS

Retrospective study involving a multidisciplinary team with checklists, role assignment, equipment organization, step by step protocol, and real time documentation for the care of infants <  32 weeks gestation in the delivery room to the neonatal intensive care unit. Pre-data collection (cases) period was from Aug, 2015 to July, 2017, and post-data collection(controls) period was from Aug, 2017 to Aug, 2019.

RESULTS

337 infants were included (179 cases; 158 controls). Increase surfactant use in the resuscitation room (41% vs. 27%, p = 0.007) and reduction in median time to administer surfactant (34 minutes (range, 6-120) vs. 74 minutes (range, 7-120), p = 0.001) observed in control-group. There was a significant reduction in incidence of bronchopulmonary dysplasia (27% vs. 39%), intraventricular hemorrhage (11% vs. 17%), severe retinopathy of prematurity (3% vs. 9%), and necrotizing enterocolitis (4% vs. 6%), however these results were not statistically significant after controlling for severity of illness.

CONCLUSIONS

A systematic approach to the care of infants <  32 weeks gestation significantly improved mortality rates and reduced rates of comorbidities.

Trends in Utilization of Magnetic Resonance Imaging for Stroke Patients With Cardiac Rhythm Devices

Background and Purpose

Magnetic resonance imaging (MRI) is safe for most patients with cardiovascular implantable electronic devices (CIEDs). However, patients presenting with acute ischemic stroke or transient ischemic attack (AIS/TIA) who have CIEDs may undergo MRI less frequently than patients without devices. We assessed contemporary use of MRI for patients with AIS/TIA and the effect of a recent coverage revision by the Center for Medicare and Medicaid Services (CMS) on MRI utilization.

Methods

Using Optum® claims data from January 2012 to June 2019, we performed an interrupted time series analysis of MRI utilization during AIS/TIA hospitalizations with the April 2018 CMS coverage revision serving as the intervention. For patients treated after the coverage revision, we used multivariable logistic regression to determine the association between lack of CIED and MRI utilization for AIS/TIA.

Results

We identified 417,899 patient hospitalizations for AIS/TIA, of which 30,425 (7%) had a CIED present (CIED vs non-CIED patients: age 77.6 ± 9.8 vs 72.7 ± 12.3 years; 45.5% vs 54.3% female). From 2012 to 2019, annual MRI utilization increased from 3% to 20% for CIED patients and 58% to 66% for non-CIED patients. The CMS coverage revision was associated with a 4.2% absolute additional increase in MRI utilization for CIED patients. Non-CIED patients treated after the CMS coverage revision were substantially more likely than CIED patients to undergo MRI (adjusted OR 6.7, 95% CI: 6.3-7.1, P<.001).

Conclusions

MRI utilization has increased for stroke patients with CIEDs but remains far lower than in similar patients without devices.

Early identification and treatment of women's cardiovascular risk factors prevents cardiovascular disease, saves lives, and protects future generations: Policy recommendations and take action plan utilizing policy levers

Cardiovascular diseases (CVD) including heart attacks, strokes, heart failure, and uncontrolled hypertension are leading causes of death among women of all ages. Despite efforts to increase awareness about CVD among women, over the past decade there has been stagnation in the reduction of CVD in women, and CVD among younger women and women of color has in fact increased. We recommend taking action using policy levers to address CVD in women including: (1) Promoting periodic screening for risk factors including blood pressure, lipids/cholesterol, diabetes for all women starting at 18-21 years, with calculated atherosclerotic CVD (ASCVD) risk score use among women 40 years or older. (2) Considering coronary artery calcium (CAC) screening for those with intermediate risk per current guidelines. (3) Enhancing Obstetrics and Gynecology and primary care physician education on reproductive age CVD risk markers, and that follow-up is needed, including extended postpartum follow-up. (4) Offering Health Coaching/motivational Interviewing to support behavior change. (5) Funding demonstration projects using different care models. (6) Creating a Stop High Blood Pressure consult line (for providers and patients) and providing other support resources with actions consumers can take, modeled after the California tobacco quit line. And (7) Requiring inclusion of adverse pregnancy outcomes in all Electronic Health Records, with reminder systems to follow-up on hypertension post-partum.

Feasibility and safety of a rapid-access transient ischemic attack clinic

BACKGROUND

In the United States, patients with transient ischemic attacks (TIAs) are commonly admitted to the hospital despite evidence that low-risk TIA patients achieve improved outcomes at lower costs at specialized rapid-access TIA clinics (RATCs).

LOCAL PROBLEM

All patients experiencing TIAs at a hospital system in the Pacific Northwest were being admitted to the hospital. This project aimed to implement an RATC to relocate care for low-risk TIA patients, showing feasibility and safety.

METHODS

Following implementation of the RATC, a retrospective chart review was performed. Outcomes included days to RATC; days to magnetic resonance imaging (MRI); final diagnosis; stroke-related admissions and deaths within 90 days of the RATC visit.

INTERVENTIONS

From 2016 to 2018, implementation of an RATC included patient triage tools; multidisciplinary collaboration between departments; a direct scheduling pathway; and emphasis on stroke prevention.

RESULTS

Ninety-nine patients were evaluated in the RATC, 69% (69/99) were referred from the emergency department. Sixty-six percent of patients were seen in the TIA clinic in 2 days or less, 19% at 3 days, and 15% at 4 days or more. Mean days to TIA clinic was 2.5 days (SD 2.4). Mean days (SD) to MRI was 2.1 days (SD 2.3). Forty-eight percent (48/99) had a final diagnosis of probable TIA, followed by 32% (32/99) who had other diagnoses; 15% (15/99) migraine variant; 4% (4/99) with stroke. Two percent (2/99) of patients had a stroke-related admission within 90 days, another 2% (2/99) died of non-stroke-related causes within 90 days of the RATC visit.

CONCLUSIONS

Utilization of RATCs is feasible and safe. Nurse practitioners are integral in delivering this innovative, cost-effective model of care.

Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings

Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.

Abstract WP185: Not All Asians Are Alike: Disaggregation Of Stroke Mortality Among Asian Subgroups

Background: Stroke is the 5th leading cause of death in the US. National stroke mortality among Asian subgroups has never been reported. Our objective is to disaggregate national stroke mortality data among the largest Asian American groups by sex and characterize mortality trends across a 12-year period.

Methods: We extracted National Vital Statistics System mortality data from 2006 to 2017 for 6 Asian subgroups and non-Hispanic Whites (NHWs). Stroke mortality was classified by ICD-10, including ischemic stroke (I630-699), intracerebral hemorrhage (I610-629), and subarachnoid hemorrhage (I601-609). 2006-2017 American Community Survey population data was extracted to calculate age-standardized mortality rates (AMRs) stratified by sex and race.

Results: Participants included 2,593 Asian Indians, 7,585 Filipinos, 8,212 Chinese, 2,551 Koreans, 3,179 Vietnamese, 4,667 Japanese, and 781,966 NHWs. Mortality from hemorrhagic strokes exceeded ischemic stroke in groups except NHW (Figure 1A). From 2006-2017, deaths from ischemic stroke increased for all groups, with higher mortality in Filipino males compared to females (figure 1B). Deaths from subarachnoid hemorrhage increased only in the Vietnamese subgroup (figure 1D). A similar trend was observed for intracerebral hemorrhage in Vietnamese males (figure 1C).

Conclusion: Disaggregation of US stroke mortality revealed important variations within the 6 largest Asian subgroups, including increased ischemic stroke mortality in all subgroups and increased hemorrhagic stroke mortality among Vietnamese. Considerations for this variation include differences in risk factor prevalence (cigarette smoking, obstructive sleep apnea) and social determinants of health. Future studies must collect disaggregated Asian subgroup data to provide tailored interventions to further reduce stroke mortality.

Figures: See below

Abstract WP92: Healing Strokes: Virtually Improving Stroke Survivors And Caregivers’ Well-being Through Student-run Art Therapy Support Group

Background: Depression and anxiety impact recovery and quality of life in 1 in 3 stroke survivors. Caregivers also experience burnout. Creative art-based therapy boosts feelings of accomplishment, self-esteem, and neuroplasticity by stimulating diverse brain regions. Few outpatient art therapy programs exist for stroke survivors and caregivers, limited further during the COVID-19 pandemic. We aim to implement an outpatient, student-run virtual art therapy curriculum using a patient-carer team approach to foster a supportive peer community, reduce depressive symptoms in survivors, and increase relief for caregivers.

Methods: A multidisciplinary team of stroke physician, nurse, occupational therapist, clinic managers, and undergraduate student volunteers created an evidenced-based art therapy curriculum feasible for stroke survivors. An art educator trained volunteers in empathetic communication, teaching techniques, and patient privacy. Participants pre-registered for weekly 1 hour classes held via video conference and received art materials by mail. We administered surveys at initial registration and quarterly. An institutional grant provided funding.

Results: From September 2020 - July 2021, Healing Strokes hosted 30 classes using the curriculum (Table 1) for 71 survivors and caregivers from 9 states at a 1:5 volunteer-to-participant ratio. 20 participants (14 survivors, 6 caregivers) self-reported benefits of peer support, creative inspiration, increased sense of accomplishment, and improvement in speech and fine motor skills.

Conclusion: Implementation of a virtual outpatient art-based therapy program for stroke survivors and caregivers is feasible with participants self-reporting benefits in functional recovery and mood. Post-stroke supportive care programs can expand to include art therapy during a pandemic. Future studies can validate the impact on peer support, function, and post-stroke depression and anxiety.

Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor Ischemic Stroke

BACKGROUND

In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke [POINT] Trial), the combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage in comparison to aspirin alone.

METHODS

In a secondary analysis of POINT (N=4881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models.

RESULTS

Through 90 days, the rate of major ischemic events was initially high then decreased markedly, whereas the rate of major hemorrhage remained low but relatively constant throughout. With the use of a model-based approach, the optimal change point for major ischemic events was 21 days (0-21 days hazard ratio 0.65 for clopidogrel-aspirin versus aspirin; 95% CI, 0.50-0.85; P=0.0015, in comparison to 22-90 days hazard ratio, 1.38; 95% CI, 0.81-2.35; P=0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset.

CONCLUSIONS

The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of the CHANCE trial (Clopidogrel in High-Risk Patients With Non-disabling Cerebrovascular Events), a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest that limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk transient ischemic attack or minor ischemic stroke.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00991029.

Abstract WP219: Decision Analysis Tool for Prehospital Stroke Triage in the Era of Endovascular Therapy

Introduction: With the undisputed benefit of acute endovascular therapy and anticipated extended treatment window among select stroke patients, there is an urgent and unmet need for a regional prehospital decision-making tool to triage patients to centers with endovascular therapy). Existing tools with severity-based triage do not capture important regional variation.

Objectives: To create a model to guide prehospital triage of suspected acute stroke patients.

Methods: We designed a model to estimate the probability of a favorable functional outcome at 90 days when a patient receives acute stroke therapy with either IV thrombolysis (modified Rankin Scale 0-1) or endovascular therapy (modified Rankin Scale 0-2) at stratified time thresholds. We used published pooled patient-level outcomes data with region-specific variables including distribution of door to needle, door to groin, and estimated travel times, as well as time last normal. We created an online tool based on the model for easy use by emergency medical services and other stakeholders in acute stroke care to choose the triage destination with the highest estimated probability of the desired outcome.

Results: Figure 1 illustrates the basic structure of the decision tool from which optimal transportation decisions can be found by applying region specific time data (top) and presents an example plot using hypothetical variables where the model estimates a 36% likelihood of a favorable outcome in a patient who is 75% likely to be eligible for endovascular therapy if triaged to either a primary or comprehensive stroke center (bottom).

Conclusions: This novel decision analysis tool demonstrates that region-specific triage algorithms can be designed for acute stroke care. Future objectives are to validate this decision model in multiple stroke systems. The tool may help guide regional policy decisions on when to bypass a hospital capable of IV thrombolysis for one capable of endovascular therapy.

Abstract 140: Reducing Costs and Length of Stay Using Standardized Dysphagia Evaluation in Acute Stroke Patients

Introduction: Dysphagia is common after acute stroke. Variability in predicting who will require a gastrostomy tube (G-tube) prior to discharge can prolong length of hospital stay (LOS) and increase costs.

Objectives: We propose a novel protocol to standardize speech therapy evaluation and G-tube recommendations among acute stroke patients with dysphagia to reduce LOS and costs.

Methods: A cohort of acute stroke patients with dysphagia was identified through an administrative data set using ICD-10 codes for ischemic stroke and CPT codes for speech therapy evaluation, and if applicable, CPT code for G-tube placement. Patients with tracheostomy, comfort care orders, or discharge to hospice were excluded. A multidisciplinary team from speech therapy, neurology, and radiology applied quality improvement principles to design and implement a G-tube indicator score (Figure 1) to address variability in dysphagia evaluation. Median LOS and duration from initial speech therapy evaluation to final diet recommendation were compared between the pre- and post-intervention period. Cost savings were calculated using LOS and average daily institutional bed cost.

Results: Between January 2016 to January 2017, 174/278 (62%) of acute stroke patients had dysphagia and 61/174 (35%) of these patients received G-tubes. Their median LOS was 21.7 days compared to 5 days for stroke patients without G-tube. In the post-implementation period from Feb-May 2017, 25/45 (55%) of acute stroke patients had dysphagia and 5/25 (20%) received G-tubes. Their median LOS was 16.4 days following the protocol implementation. This resulted in cost savings of $14,654 per G-tube patient.

Conclusions: This novel G-tube indicator score standardized speech therapy evaluation and reduced LOS by more than 5 days among acute stroke patients requiring G-tube prior to discharge. Future studies will prospectively validate the score. Increased adoption would result in significant cost savings.

Abstract WP291: Stroke Code Simulation Improves Resident Preparedness for Call

Introduction: Didactic lectures on acute stroke do not teach neurology residents nuances of the stroke code process. Successful execution of this process requires functioning in a high stress environment, interaction with a multidisciplinary team, and ability to enter the correct orders. Simulation technology is increasingly available for resident education, but underutilized in neurology.

Hypothesis: Medical education innovation with stroke code simulation can improve resident understanding of the stroke code process and achievement of learning goals in preparation for call.

Methods: Learning goals derived from the stroke code process were written into 4 clinical scenarios enacted by a standardized patient, nurse, CT technician, and stroke fellow at the institution’s simulation center (see Table 1). Junior neurology residents alternated leading or observing simulated stroke codes, followed by debriefing sessions to review learning goals. Achievement of learning goals was measured with a pre- and post- multiple-choice quiz. Residents submitted anonymous written feedback that the authors analyzed with thematic coding.

Results: Between July 2016 and July 2017, 22 junior adult and pediatric neurology residents completed stroke code simulation. Quiz grades improved from 67.5% to 78.3% after the simulation. Common feedback themes reference comfort with code logistics, imaging order entry, team member roles, benefit of realistic scenarios, and desire for more scenarios. The residents perceived simulation would relieve the stress of stroke call. The use of simulation was overall highly valued.

Conclusions: Medical education innovation with stroke code simulation targeting specific learning goals improves residents comprehension of the acute stroke code process and can prepare junior neurology residents for call.

Burkitt non-Hodgkin lymphoma presenting with mental neuropathy ('numb chin' syndrome) in an HIV-positive patient

Mental nerve neuropathy is usually due to local trauma or dental causes, but may be a manifestation of malignancy. A patient with virologically controlled human immunodeficiency virus (HIV) infection presented with a 'numb chin' on the background of long-standing night sweats, malaise and weight loss, worsening respiratory symptoms, and lymphadenopathy. Burkitt non-Hodgkin lymphoma was diagnosed from histology of a lymph node. Imaging (magnetic resonance imaging and ¹⁸fluorodeoxyglucose [FDG]-positron emission tomography-computed tomography [PET-CT]) showed abnormal intracranial enhancement of the right mandibular nerve and extensive ¹⁸FDG-avid lymphadenopathy above and below the diaphragm, focal lesions in the spleen and within the right mandible. The patient received chemotherapy and remains in clinical and radiological remission seven years later. This case highlights the need for clinicians to maintain a high index of suspicion for underlying malignancy when an HIV-infected patient presents with new onset of a 'numb chin'. Additionally, it demonstrates the importance of functional ¹⁸FDG-PET-CT and neuroimaging in order to identify site(s) of pathology.

Decreasing Stroke Code to CT Time in Patients Presenting with Stroke Symptoms

Guided quality improvement (QI) programs present an effective means to streamline stroke code to computed tomography (CT) times in a comprehensive stroke center. Applying QI methods and a multidisciplinary team approach may decrease the stroke code to CT time in non-prenotified emergency department (ED) patients presenting with symptoms of stroke. The aim of this project was to decrease this time for non-prenotified stroke code patients from a baseline mean of 20 minutes to one less than 15 minutes during an 18-week period by applying QI methods in the context of a structured QI program. By reducing this time, it was expected that the door-to-CT time guideline of 25 minutes could be met more consistently. Through the structured QI program, we gained an understanding of the process that enabled us to effectively identify key drivers of performance to guide project interventions. As a result of these interventions, the stroke code to CT time for non-prenotified stroke code patients decreased to a mean of less than 14 minutes. This article reports these methods and results so that others can similarly improve the time it takes to perform nonenhanced CT studies in non-prenotified stroke code patients in the ED. ^©RSNA, 2017.

Abstract WMP8: Results of Trevo Acute Ischemic Stroke Thrombectomy Registry: Predictors of Clinical Outcome

Background and Purpose: Recent randomized clinical trial (RCTs) demonstrated efficacy of mechanical thrombectomy using stent-retrievers in acute ischemic stroke (AIS) patients. The main purpose of TRevo ACute Ischemic StroKe (TRACK) stent-retriever thrombectomy multicenter registry is to demonstrate safety and efficacy in real life clinical practice.

Methods: The investigator-initiated TRACK multicenter registry recruited 24 sites in north America to submit demographic, clinical, site-adjudicated angiographic, and outcome data on consecutive AIS patients treated with Trevo stent-retriever device as the first treatment option. Standard clinical safety (symptomatic intracranial hemorrhage (sICH), and mortality) and efficacy (revascularization and disability) outcomes and predictors of clinical outcome were analyzed.

Results: 624 patients were enrolled in the TRACK registry. Median age was 68 years (range 16-94, 118 (18.1%) >80), male gender was 51.4%, and 67.7% were white. The median National Institutes of Health Stroke Severity Scale (NIHSS) was 17 (IQR 13-22). Transfer cases were 50.6% with IV-rtPA use in 318 cases (51.3%). Median onset to groin puncture (OTG) time was 283 min (IQR 198.5-443), and groin puncture to revascularization was 66 min (IQR 37.5-103). Anterior circulation occlusion was 86.2% (MCA/M2 in 55.2% followed by ICA in 15.9% and M2 in 12.7%). Use of GA was in 389 cases (62.3%), number of passes were ≤ 3 in 92% of the cases (1: 45.2%, 2:28%, and 3:18.7%), 291 (46.7%) had BGC use. Rescue use was seen in 21.7%. Revascularization of ≥ TIMI 2 was 81.8% and ≥ TICI 2b was 70%. The primary outcome of mRS of ≥ 2 was 48.3% in the full cohort, and 50.6% in TREVO-2 like group. sICH and mortality were 7.2%, and 20.1% in the full cohort vs 6.9% and 17.5% in the TREVO-2 like group, respectively. The independent predictors of clinical outcome were lower baseline NIHSS, younger age, use of BGC, successful recanalization, and no general anesthesia (GA).

Conclusions: The real life clinical practice Trevo registry demonstrated good clinical outcome and high rate of recanalization. Younger age, lower baseline NIHSS, use of balloon guide catheter, successful recanalization, and avoiding endotrachaeal GA independent predictors of good clinical outcome.

Inter-rater agreement analysis of the Precise Diagnostic Score for suspected transient ischemic attack

Background

No definitive criteria are available to confirm the diagnosis of transient ischemic attack. Inter-rater agreement between physicians regarding the diagnosis of transient ischemic attack is low, even among vascular neurologists. We developed the Precise Diagnostic Score, a diagnostic score that consists of discrete and well-defined clinical and imaging parameters, and investigated inter-rater agreement in patients with suspected transient ischemic attack.

Methods

Fellowship-trained vascular neurologists, blinded to final diagnosis, independently reviewed retrospectively identical history, physical examination, routine diagnostic studies, and brain magnetic resonance imaging (diffusion and perfusion images) from consecutive patients with suspected transient ischemic attack. Each patient was rated using the 8-point Precise Diagnostic Score score, composed of a clinical score (0–4 points) and an imaging score (0–4 points). The composite Precise Diagnostic Score determines a Precise Diagnostic Score Likelihood of Brain Ischemia Scale: 0–1 = unlikely, 2 = possible, 3 = probable, 4–8 = very likely.

Results

Three raters reviewed data from 114 patients. Using Precise Diagnostic Score, all three raters scored a similar percentage of the clinical events as being “probable” or “very likely” caused by brain ischemia: 57, 55, and 58%. Agreement was high for both total Precise Diagnostic Score (intraclass correlation coefficient of 0.94) and for the Likelihood of Brain Ischemia Scale (agreement coefficient of 0.84).

Conclusions

Compared with prior studies, inter-rater agreement for the diagnosis of transient brain ischemia appears substantially improved with the Precise Diagnostic Score scoring system. This score is the first to include specific criteria to assess the clinical relevance of diffusion-weighted imaging and perfusion lesions and supports the added value of magnetic resonance imaging for assessing patients with suspected transient ischemic attack.

Abstract 28: Defining the Diagnosis of TIA: An Inter-rater Agreement Analysis of a New Precise Diagnostic Score (PREDISC)

Background: the “gold standard” for the diagnosis of transient ischemic attack (TIA) is typically the final diagnosis of a neurologist. However, inter-rater agreement between physicians for the diagnosis of TIA is low, even among vascular neurologist. We developed a diagnostic scoring scale (PREDISC), which features well defined clinical and imaging parameters and investigated inter-rater agreement in patients with suspected TIA. Methods:fellowship-trained vascular neurologists, blinded to patient’s final diagnosis or outcomes, independently reviewed the history, clinical examination and MRI (including DWI and perfusion imaging) findings of patients with suspected TIA who were referred to our institution's TIA program. Each patient’s clinical manifestation and MRI findings were rated using the PREDISC score, an 8-point scale composed of a clinical score (0-4 points) and an Imaging score (0-4 points). The imaging score includes specific criteria for DWI positivity (4 points) as well as criteria for assessment of clinically relevant perfusion lesions (maximum 3 points for patients who are DWI negative). The final PREDISC score for confirmation that the event was caused by brain ischemia is determined as: 0-1 = unlikely, 2= possible, 3= probable, 4-8 = very likely. We assessed global agreement between the raters. Results: Three raters reviewed data from 114 patients. Using PREDISC all 3 raters scored a similar percentage of the clinical events as being “probable” or “very likely” caused by brain ischemia: 57%, 55% and 58%. Agreement was high for both total PREDISC Score (Intraclass correlation coefficient [ICC] of 0.94) and for the 4-point scale of TIA likelihood of diagnosis (AC1 agreement coefficient of 0.84). Agreement was excellent both on the clinical and imaging sub scores (ICC 0.88 and 0.95). Conclusion:Based on comparison with prior studies, inter-rater agreement for the diagnosis of TIA appears to be substantially improved with the PREDISC structured scoring system. This scale is the first to include specific criteria to assess the clinical relevance of DWI and perfusion lesions and supports the added value of MRI for assessing patients with suspected TIA. The diagnostic value of PREDISC should be confirmed in a prospective multicenter trial.

TIA Triage in Emergency Department Using Acute MRI (TIA-TEAM): A Feasibility and Safety Study

Background

Positive diffusion weighted imaging (DWI) on MRI is associated with increased recurrent stroke risk in TIA patients. Acute MRI aids in TIA risk stratification and diagnosis.

Aim

To evaluate the feasibility and safety of TIA triage directly from the emergency department (ED) with acute MRI and neurological consultation.

Methods

Consecutive ED TIA patients assessed by a neurologist underwent acute MRI/MRA of head/neck per protocol and were hospitalized if positive DWI, symptomatic vessel stenosis, or per clinical judgment. Stroke neurologist adjudicated the final TIA diagnosis as definite, possible, or not a cerebrovascular event. Stroke recurrence rates were calculated at 7, 90, 365 days and compared with predicted stroke rates derived from historical DWI and ABCD2 score data.

Results

One hundred twenty-nine enrolled patients had a mean age of 69 years (±17) and median ABCD2 score of 3 (interquartile range [IQR] 3–4). During triage, 112 (87%) patients underwent acute MRI after a median of 16 h (IQR 10–23) from symptom onset. No patients experienced a recurrent event before imaging. Twenty-four (21%) had positive DWI and 8 (7%) had symptomatic vessel stenosis. Of the total cohort, 83 (64%) were discharged and 46 (36%) were hospitalized. By one-year follow-up, one patient in each group had experienced a stroke. Of 92 patients with MRI and index cerebrovascular event, recurrent stroke rates were 1·1% at 7 and 90 days. These were similar to predicted recurrence rates.

Conclusion

TIA triage in the ED using a protocol with neurological consultation and acute MRI is feasible and safe. The majority of patients were discharged without hospitalization and rates of recurrent stroke were not higher than predicted.

Abstract 133: Magnetic Resonance Imaging Based Transient Ischemic Attack Triage In The Emergency Department Is Feasible And Safe

Objective: To evaluate the safety and feasibility of a magnetic resonance imaging (MRI) based transient ischemic attack (TIA) triage pathway in the emergency department (ED). We hypothesized that an MRI based triage pathway in an academic setting would be feasible and associated with a low rate of stroke recurrence.

Methods: From January 2010 to May 2011, consecutive patients assessed in our institution’s ED for suspicion of TIA were evaluated by a neurologist and underwent MRI with diffusion weighted imaging (DWI) and MRA of the head and neck within 12 hours per radiology department convention. By protocol, the neurologist recommended admission for patients with restricted diffusion on MRI, symptomatic vessel stenosis, or per clinical judgment. Final diagnosis was adjudicated by the treating neurologist at the time of discharge as definite or possible transient cerebrovascular event, or a non-cerebrovascular event. Stroke recurrence was evaluated at 1 week, 3 months, and 1 year with a telephone interview.

Results: One hundred and twenty nine patients were enrolled with a mean age of 69 years (+/-16.8) and median ABCD 2 of 3 (IQR 3-4). Final diagnosis was definite transient cerebrovascular event in 77 (59.7%), possible in 21 (16.3%), and other in 31 (24%). At the time of triage, 112 (92%) patients underwent brain MRI in the ED after a median delay of 8.2 hours (IQR 4.8-14.7) from arrival and 15.7 hours (IQR 9.9-22.8) from symptom onset. No patients experienced a recurrent stroke before imaging. Twenty two (19.6%) patients had a positive DWI and 9 (8%) had a symptomatic vessel stenosis. All but two patients with a positive DWI or MRA were admitted. In total, 46 of the 129 (35.7%) patients were hospitalized and one (2.2%) had a recurrent stroke after 90 days. Of 83 patients discharged from the ED, one (1.2%) had a minor stroke at one week. This patient’s baseline MRI was DWI negative and MRA was without stenosis. Altogether, among 98 patients with a final diagnosis of possible or definite transient cerebrovascular event, the rate of recurrent stroke was 1.03% at 7 and 90 days, and 2.2% at one year.

Conclusion: Acute evaluation of TIA using an MRI based triage approach is feasible and associated with a low rate of recurrent stroke.

Abstract TP240: Simulation-Based Learning Improves Neurology Resident Training in Acute Stroke Care

Introduction: Acute “stroke codes” are stressful for the new neurology resident who must lead a multi-disciplinary team and quickly integrate information to make high risk time-sensitive decisions. While other disciplines have used simulation technology for years for cardiac arrest codes, neurology has just begun utilizing this resource.

Objective: To improve neurology trainees’ execution of a multi-disciplinary acute stroke code using simulation experience

Methods: We identified three learning objectives for the simulation experience: assess tissue plasminogen activator (tPA) eligibility, utilize appropriate order sets, and communicate effectively. Scripts for two emergent scenarios were developed: ischemic stroke requiring i.v. tPA and warfarin-associated intracranial hemorrhage requiring coagulopathy reversal. A standardized patient (SP) was trained. Neurology residents in their first week of training were the learners. Six residents attended a four-hour training session in the Simulation Center at Stanford University. Half of the trainees participated in the scenario while the others observed through live video. The SP acted the part in a fully-equipped, mock emergency room. Monitors, controlled remotely, displayed vital signs which changed to reflect interventions performed. Screens also displayed radiologic data. Trainees communicated with the stroke fellow and nursing regarding the plan of care and placed orders through an electronic medical record in training mode. Debriefing occurred after each scenario. Evaluations were completed and collected.

Results: Trainees had positive experiences and felt more comfortable with the stroke code after the training. On a 1-5 scale, learners rated quality of teaching (average 4.6); learning from the scenario (4.8); overall organization (4.2); facilities (5); and overall evaluation (4.6).

Conclusions: Simulation training offers a valuable opportunity to enhance neurology resident’s comfort in running stroke codes. Additional studies are required to measure long-term retention of acquired skills and training effect on systems and clinical outcomes.

Past, present, and future of endovascular stroke therapies

Endovascular therapy in the acute management of ischemic stroke has become more common with technologic advances, such as easier navigation into the intracranial circulation and improved treatment efficacy with the advent of revascularization devices. This select review outlines milestones in the application of endovascular therapy in acute ischemic stroke (AIS) and offers some insight into important factors influencing the future directions of endovascular AIS treatment. In particular, we discuss the evolution of endovascular devices for AIS and how ingenuity continues to offer novel treatments. With these advances, the future of endovascular AIS treatment is promising.

Leptin/adiponectin ratio in patients with coronary heart disease: comparing subjects with and without metabolic syndrome

BACKGROUND

Adiponectin and leptin are adipose tissue-derived hormones, shown to have opposing associations with the metabolic syndrome and coronary heart disease (CHD). This study evaluated the association between the leptin/adiponectin ratio and the components of the metabolic syndrome in a cohort with CHD. Methods and results This cross-sectional study included data from 105 subjects (men = 91), undergoing first-time elective coronary artery bypass grafting (CABG). Leptin and adiponectin concentrations were determined by enzyme-linked immunosorbent assay (ELISA). Association was found between the leptin/adiponectin ratio and homeostatic model assessment (HOMA) (r(s) = 0.34, P = 0.0006), fasting insulin concentrations (r(s) = 0.37, P = 0.0001), fasting glucose concentrations (r(s) = 0.24, P = 0.01), systolic blood pressure (r(s) = 0.20, P = 0.05), diastolic blood pressure (r(s) = 0.24, P = 0.02), waist circumference (r(s) = 0.55, P < 0.0001), body mass index (BMI) (r(s) = 0.55, P < 0.0001) and waist/hip ratio (r(s) = 0.38, P = 0.0001). A significant difference was found in ratios between those with and without insulin resistance (HOMA > 3 and HOMA ≤ 3) (P = 0.029) and those with and without metabolic syndrome, defined by the International Diabetes Federation, (P < 0.001). However, using receiver operating characteristic (ROC) analysis and assessment of area under curve (AUC), the leptin/adiponectin ratio did not perform significantly better than its components.

CONCLUSION

In patients with severe CHD, the leptin/adiponectin ratio was not found to be a robust tool to distinguish patients with and without insulin resistance and those with and without the metabolic syndrome.

A student-initiated and student-facilitated international health elective for preclinical medical students

INTRODUCTION

Global health education is becoming more important for developing well-rounded physicians and may encourage students toward a career in primary care. Many medical schools, however, lack adequate and structured opportunities for students beginning the curriculum.

METHODS

Second-year medical students initiated, designed, and facilitated a pass-fail international health elective, providing a curricular framework for preclinical medical students wishing to gain exposure to the clinical and cultural practices of a developing country.

RESULTS

All course participants (N=30) completed a post-travel questionnaire within one week of sharing their experiences. Screening reflection essays for common themes that fulfill university core competencies yielded specific global health learning outcomes, including analysis of health care determinants.

CONCLUSION

Medical students successfully implemented a sustainable global health curriculum for preclinical student peers. Financial constraints, language, and organizational burdens limit student participation. In future, long-term studies should analyze career impact and benefits to the host country.

Risk of hemorrhage in combined neuroform stenting and coil embolization of acutely ruptured intracranial aneurysms

SUMMARY

Stenting as adjuvant therapy for the coiling of acutely ruptured aneurysms remains controversial due to the necessity of anticoagulation and antiplatelet medications. We report our experience using the Neuroform stent in the management of 41 aneurysms in 40 patients over a period of three years. For aneurysms whose open surgical risk remains excessive with a morphology that would preclude complete embolization, the risks of stenting may be warranted.

Anatomic results and complications of stent-assisted coil embolization of intracranial aneurysms

SUMMARY

The purpose of this study was to evaluate and report our anatomic results and complications associated with stent-assisted coil embolization of intracranial aneurysms using the Neuroform stent. From September 2003 to August 2007, 127 consecutive patients (ruptured 50, 39.4%; unruptured 77, 60.6%) underwent 129 stent-assisted coil embolization procedures to treat 136 aneurysms at our institution. Anatomic results at follow-up, procedure-related complications, and morbidity/mortality were retrospectively reviewed. Stent deployment was successful in 128 out of 129 procedures (99.2%). Forty-seven patients presented with 53 procedure-related complications (37.0%, 47/127). Thromboembolic events (n=17, 13.4%) were the most common complications, followed by intraoperative rupture (n=8, 6.3%), coil herniation (n=5, 3.9%), and postoperative rupture (n=4, 3.1%). For thromboembolic events, acute intra-procedural instent thromboses were observed in two patients and subacute or delayed in-stent thromboses in three patients. Overall mortality rate was 16.5% (21/127) and procedure-related morbidity and mortality rates were 5.5% (7/127) and 8.7% (11/127) retrospectively. Patients with poor grade subarachnoid hemorrhage (Hunt and Hess grade IV or V; 25/127, 19.7%) exhibited 56% (14/25) overall mortality rate and 24% (6/25) procedure-related mortality rate. Immediate angiographic results showed complete occlusion in 31.7% of aneurysms, near-complete occlusion in 45.5%, and partial occlusion in 22.8%. Sixty nine patients in 70 procedures with 77 aneurysms underwent angiographic followup at six months or later. Mean follow-up period was 13.7 months (6 to 45 months). Complete occlusion was observed in 57 aneurysms (74.0%) and significant in-stent stenosis was not found. Thromboembolism and intra/postoperative aneurysm ruptures were the most common complications and the main causes of procedure-related morbidity and mortality. Patients with poor grade subarachnoid hemorrhage showed poor clinical outcomes. Since most complications were induced by stent manipulation and deployment, it is mandatory to utilize these devices selectively and cautiously. While the follow- up angiographic results are promising, further studies are essential to evaluate safety, efficacy, and durability of the Neuroform stent.

Radical surgery is not necessary following neoadjuvant chemotherapy in stage III-IV resectable, non-laryngeal head and neck cancer (NLHNC)

16501

Background: Traditionally, following neoadjuvant chemotherapy (NC), head and neck surgeons have insisted in performing radical surgery regardless of the response to NC. This prospective study evaluates the results of conservative surgery following NC in resectable stage III-IV non-laryngeal head and neck cancer (NLHNC). Methods: Between 1993 and 2003, 70 patients with NLHNC were treated with one of the following NC: Cisplatin and 5FU (17.1%); Cisplatin, 5FU, Leucovorin, and Taxotere (58.6%); Cisplatin, 5FU, and Taxol (24.3%). After three courses of NC, patients were reevaluated to determine the need for local therapy. Local excision or biopsy was performed for patients with near-complete pathological response (n-CPR) or patients with a complete pathological response (CPR). Radical surgery was reserved for patients with partial response (PPR). All patients received radiation to the primary and neck. Results: The median follow up was 35 months, median disease-free survival was 33.4 months and 3-year overall survival was 71.4% for the entire group. Thirty-five patients (50.0%) had a complete pathological response (CPR), 11 (15.7%) had a complete clinical response (CCR) and no pathological staging, 5 patients (7.1%) had a n-CPR, and 19 patients (27.1%) had a partial pathological response (PPR). Primary surgery is shown in the following table : At the time of the last follow up, 1/35 (2.9%) patients with CPR had a local recurrence (LR) at the primary and 5/11 (45.5%) patients with CCR and no pathological staging had a LR; in 3/6 (50%) patients with LR the primary was controlled with salvage surgery. Seven of eleven (63.6%) patients with PPR had a LR, only one achieved local control with salvage surgery. Conclusions: Complete pathological response at the primary site is a good predictor of long term local control in NLHNC. Radical surgery, is not necessary in non-laryngeal head and neck cancers following a complete pathological response at the primary site.

[Table: see text]

No significant financial relationships to disclose.

A long-term follow-up report on allogeneic stem cell transplantation for patients with primary refractory acute myelogenous leukemia: impact of cytogenetic characteristics on transplantation outcome

The prognosis of patients with primary refractory acute myelogenous leukemia (AML) is poor. Our initial report suggested that some patients could achieve durable remission after allogeneic stem cell transplantation (SCT). Herein, we update our initial experience and report further analysis of this group of patients to determine whether there are pre-SCT prognostic factors predictive of posttransplantation relapse and survival. We reviewed the records of 68 patients who consecutively underwent transplantation at the City of Hope Cancer Center with allogeneic SCT for primary refractory AML between July 1978 and August 2000. Potential factors associated with overall survival and disease-free survival were examined. With a median follow-up of 3 years, the 3-year cumulative probabilities of disease-free survival (DFS), overall survival (OS), and relapse rate for all 68 patients were 31% (95% confidence interval [CI], 20%-42%), 30% (95% CI, 18%-41%), and 51% (95% CI, 38%-65%), respectively. In multivariate analysis, the only variables associated with shortened OS and DFS included the use of an unrelated donor as the stem cell source (relative risk, 2.23 [OS] and 2.05 [DFS]; P =.0005 and.0014, respectively) and unfavorable cytogenetics before SCT (relative risk: 1.68 [OS] and 1.58 [DFS]; P =.0107 and.0038, respectively). Allogeneic SCT can cure approximately one third of patients with primary refractory AML. Cytogenetic characteristics before SCT correlate with transplantation outcome and posttransplantation relapse.

A study of radiotherapy modalities combined with continuous 5-FU infusion for locally advanced gastrointestinal malignancies

AIM

We describe the feasibility of combining infusional 5-fluorouracil (5-FU) with intraoperative radiation therapy (IORT).

METHODS

Patients with surgically resectable locally advanced gastrointestinal cancers were treated concurrently during surgery with IORT and a 72 h infusion of 5-FU. Patients without previous external beam radiation therapy (EBRT) were subsequently treated with EBRT (40-50Gy) concurrent with a 21-day continuous infusion of 5-FU. Pancreatic, gastric, duodenal, ampullary, recurrent colorectal, and recurrent anal cancer were included.

RESULTS

During IORT/5-FU, no chemotherapy-related grade III or IV hematologic or gastrointestinal toxicity was noted. Post-surgical recovery or wound healing was not affected. One of nine patients who received post-operative radiation required a treatment break. During follow-up, there were more complications in patients with pelvic tumours, especially those with previous radiation. Nine patients have had local and/or local regional recurrences, two of these in the IORT field.

CONCLUSIONS

Treatment with a combination of IORT and 5-FU followed by EBRT and 5-FU is feasible. However, long-term complications may be increased in previously irradiated recurrent pelvic tumours.

Reduced-intensity allogeneic stem cell transplantation for patients whose prior autologous stem cell transplantation for hematologic malignancy failed

Autologous hematopoietic stem cell transplantation (autoSCT) is an effective treatment for patients with various hematologic malignancies. Despite the significant improvement in the overall outcome, disease progression after transplantation remains the major cause of treatment failure. With longer follow-up, therapy-related myelodysplasia/acute myelogenous leukemia is becoming an important cause of treatment failure. The prognosis for these 2 groups of patients is very poor. Allogeneic hematopoietic stem cell transplantation (alloSCT) is a potential curative treatment for these patients. However, the outcome with conventional myeloablative alloSCT after failed autoSCT is typically poor because of high transplant-related mortality. In an attempt to reduce the treatment-related toxicity, we studied a reduced-intensity conditioning regimen followed by alloSCT for patients with progressive disease or therapy-related myelodysplasia/acute myelogenous leukemia after autoSCT. This report describes the outcomes of 28 patients with hematologic malignancies who received a reduced-intensity alloSCT after having treatment failure with a conventional autoSCT. Fourteen patients received a hematopoietic stem cell transplant from a related donor and 14 from an unrelated donor. The conditioning regimen consisted of low-dose (2 Gy) total body irradiation with or without fludarabine in 4 patients and the combination of melphalan (140 mg/m(2)) and fludarabine in 24. Cyclosporine and mycophenolate mofetil were used for posttransplantation immunosuppressive therapy, as well as graft-versus-host disease (GVHD) prophylaxis, in all patients. All patients engrafted and had >90% donor chimerism on day 100 after SCT. Currently, 13 patients (46%) are alive and disease free, 7 patients (25%) developed disease progression after alloSCT, and 8 (32%) died of nonrelapse causes. Day 100 mortality and nonrelapse mortality were 25% and 21%, respectively. With a median follow-up of 24 months for surviving patients, the 2-year probabilities of overall survival, event-free survival, and relapse rates were 56.5%, 41%, and 41.9%, respectively. Six patients (21%) developed grade III to IV acute GVHD. Among 21 evaluable patients, 15 (67%) developed chronic GVHD. We conclude that (1) reduced-intensity alloSCT is feasible and has an acceptable toxicity profile in patients who have previously received autoSCT and that (2) although follow-up was short, a durable remission may be achieved in some patients who would otherwise be expected to have a poor outcome.

Variations of dose and electrode spacing for rat breast cancer electrochemical treatment

Electrochemical treatment (EChT) with direct current delivered through implanted electrodes has been used for local control of solid tumors in humans. This study tested the hypothesis that rat breast cancer responses to EChT are dependent on electrode spacing and dose, and explored suitable parameters for treating breast cancers with EChT. Rat breast cancers were initiated by injecting 1 x 10(6) MTF-7 cells to the right mammary gland fat pad of Fisher 344 female rats. The rats were randomly divided into designated experimental groups when the tumors grew to approximately 2 x 2 x 2 cm. One hundred and thirty rats were used for a survival study and 129 for a pathology study. A 4-channel EChT machine was used to administer coulometric doses. The survival study indicated that local tumor control rate is less than 40% in the 40 coulomb (C) and 60 C groups and more than 70% in the 80 and 100 C groups. Sixty six rats died of primary tumors, including all 10 rats in the control group. Once a rat's primary tumor was controlled, no recurrence was found. The main reason for terminating the primary tumor-free rats (51) was lymph node metastasis. Thirteen tumor-free rats survived for more than 6 months. The pathology study showed a significant dose effect on EChT induced tumor necrosis. At 10, 20, 40, and 80 C, the fraction showing necrosis were 39.7, 52.3, 62, and 77.7%, respectively (P </= 0.001). Electrodes spacing was not an important factor within a given range. At 5, 10, and 15 mm spacing, the fraction showing the necrosis were 54.1, 60.4, and 59.2%, respectively (P = 0.552). The overlap rate of necroses was similar in the 5 and 10 mm groups (82.5 and 85%) and lower in the 15 mm group (65%). We conclude that the tumor responses to EChT, local control, survival rates, and necrosis percentages were significantly increased with increasing dose. The changes in electrode spacing (3, 5, and 10 mm) did not significantly affect the tumor responses to EChT within the same dose. For a diameter of 2.0-2.5 cm rat breast cancer, EChT should be applied with 5-10 mm spacing and a minimum dosage of 80 C.