Factors Contributing to Stroke Clinic Follow-Up "No Show": A Quality Improvement Project.

Objective Controlling modifiable risk factors provides a strong impact on secondary stroke prevention. Stroke outpatient follow-up (OPFU) provides a significant role in assuring these goals are met. However, in our institute in 2018, one out of four patients was not seen in the stroke clinic after their stroke. To increase this ratio, we instituted a performance improvement project (PIP) to determine factors that contribute to OPFU and offered rescheduling after their missed appointment. Methods The nurse scheduler called patients labeled as "no-show," asked for reasons for the missed appointment, and offered rescheduling accordingly. Other data were collected retrospectively. Results Of the 53 "no show" patients, most were females, single, Black, uninsured, and had a Modified Rankin Scale (MRS) of 0. Of the 30 patients who participated in the phone interview, a most common reason for "no show" was transportation. Fifteen out of 27 patients kept their rescheduled appointment, increasing patients seen in the clinic by 6.7%. Conclusion This PIP determined contributing factors on health care seeking practices of our stroke clinic patients allowing necessary improvements in our institute. Rescheduling increased the number of stroke patients seen in the stroke clinic. Our general neurology ambulatory department consequently adopted this process as well.

Predictors of Early Mortality for Mechanically Ventilated Spontaneous Intracerebral Hemorrhage Patients.

Introduction Spontaneous intracerebral hemorrhage (sICH) carries a high mortality burden. Limited data are available on early mortality (EM) and sICH. This study attempted to identify the independent predictors of EM and analyze the mortality characteristics for mechanically ventilated patients with sICHs at a tertiary care hospital over a period of five years. Methods An Institutional Review Board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPPA)-compliant retrospective analysis was performed on sICH patients admitted at the University of Mississippi Medical Center Neuroscience Intensive Care Unit between January 1, 2013, to December 31, 2017. Patients were divided into two cohorts: EM cohort (death within seven days of admission) versus survivor cohort (alive more than seven days after admission). Demographic, comorbidity, clinical, and radiographic data were collected for each patient. Outcomes were compared utilizing student t-test or Mann-Whitney U tests for continuous variables. Logistic regression analysis was performed to determine independent predictors of EM. Results A total of 204 mechanically ventilated patients with sICHs, with a mean age of 59.73 (SD ±14.30), mostly African American (137, 67%), were included in the study. The characteristics of the two cohorts were comparable except the EM cohort had a lower proportion of patients with hypertension and end-stage renal disease; lower median Glasgow Coma Score (GCS) on admission; lower proportion of surgical evacuation and external ventricular drain (EVD) placement; higher proportion of lobar hemorrhage, brainstem involvement, midline shift, hydrocephalus, intraventricular hemorrhage component, and right-sided intracerebral hemorrhage (ICH); higher median ICH score; and higher ICH volume compared to the survivor cohort. Overall, the mortality of mechanically ventilated sICH patients in this institution was 53% (N=109), with 47% (N=96) not surviving beyond seven days. Logistic regression analysis revealed that ICH volume and brainstem involvement increased the odds of EM, while a history of hypertension, surgical evacuation, and EVD placement decreased the odds of EM. Conclusions This study on mechanically ventilated sICH patients identified ICH volume and brainstem involvement as independent predictors of increased EM. History of hypertension, EVD placement, and surgical evacuation decreased its odds. Further studies should be conducted to explore potentially modifiable processes that can improve patient outcomes, most importantly EM, especially in this cohort of patients.

A Novel Dynamin 2 Mutation Causing Dominant Intermediate Charcot-Marie-Tooth Neuropathy: Case Report.

Dynamin 2 mutations are associated with Charcot-Marie-Tooth neuropathy. We report two siblings with a novel missense heterozygous point mutation (c.1609 G>A) in the highly conserved pleckstrin homology domain in exon 15 of Dynamin 2 presenting with progressive length-dependent sensorimotor polyneuropathy with mixed demyelinating and axonal features on electrodiagnostic studies. The previously unrecognized missense point mutation, which was inherited from their symptomatic but previously undiagnosed mother, was determined to be likely pathogenic based on a non-conservative amino acid substitution (p.Gly537Ser) that is predicted to damage secondary protein structure or function. This report emphasizes the importance of recognizing inherited neuropathies in clinical practice and evaluating suspected pathogenic gene variants initially classified to be of undetermined clinical significance in family cohorts. These cases add to the spectrum of pathogenic Dynamin 2 mutations associated with dominant-intermediate Charcot-Marie-Tooth neuropathy.

Association between recent cannabinoid use and acute ischemic stroke.

BACKGROUND: Studies that have analyzed the association between cannabis use and acute ischemic stroke (AIS) have provided conflicting results. In this study, we aim to determine the association of recent cannabis use detected through urine drug screen (UDS) among patients admitted with AIS. METHODS: A retrospective observational study was performed using the medical records database. All patients aged 18 years and older admitted from January 1, 2015, to December 31, 2017, who underwent urine toxicology testing on admission were included in the analysis. Multivariate logistic regression analysis was performed to analyze independent association between recent cannabis use and AIS. RESULTS: A total of 9,350 patients were determined to have undergone UDS during admission, and 18% (1,643) of this had a positive urine cannabis test. Unadjusted risk ratio showed a 50% decrease in risk of AIS among cannabis users (risk ratio = 0.505, 95% confidence interval [CI] 0.425-0.600). The effect was lost after adjusting for age, race, ethnicity, sickle cell disease, dyslipidemia, hypertension, obesity, diabetes mellitus, cigarette smoking, atrial fibrillation, and other cardiac conditions (odds ratio 1.038, 95% CI 0.773-1.394). CONCLUSION: This is one of the few studies analyzing the association of recent cannabis use and AIS using admission urine toxicology test independent of polysubstance use. Although our study has limitations, we did not find an independent association between recent cannabis use and the incidence of AIS. Further studies using urine toxicology tests with larger sample size and including dosage of cannabis exposure should be conducted.