In-Hospital Versus Out-of-Hospital Stroke Onset Comparison of Process Metrics in a Community Primary Stroke Center.

Objective: To examine in-hospital stroke onset metrics and outcomes, quality of care, and mortality compared with out-of-hospital stroke in a single community-based primary stroke center. Patients and Methods: Medical records of in-hospital stroke onset were compared with out-of-hospital stroke onset alert data between January 1, 2013 and December 31, 2019. Time-sensitive stroke process metric data were collected for each incident stroke alert. The primary focus of interest was the time-sensitive stroke quality metrics. Secondary focus pertained to thrombolysis treatment or complications, and mortality. Descriptive and univariable statistical analyses were applied. Kruskal-Wallis and χ2 tests were used to compare median values and categorical data between prespecified groups. The statistical significance was set at α=0.05. Results: The out-of-hospital group reported a more favorable response to time-sensitive stroke process metrics than the in-hospital group, as measured by median stroke team response time (15.0 vs 26.0 minutes; P≤.0001) and median head computed tomography scan completion time (12.0 vs 41.0 minutes; P=.0001). There was no difference in the stroke alert time between the 2 groups (14.0 vs 8.0 minutes; P=.089). Longer hospital length of stay (4 vs 3 days; P=.004) and increased hospital mortality (19.3% vs 7.4%; P=.0032) were observed for the in-hospital group. Conclusions: The key findings in this study were that time-sensitive stroke process metrics and stroke outcome measures were superior for the out-of-hospital groups compared with the in-hospital groups. Focusing on improving time-sensitive stroke process metrics may improve outcomes in the in-hospital stroke cohort.

Getting SET for Student Success: Foundations for a Student Education Team.

BACKGROUND: Family medicine clinical education poses logistic issues that we sought to address with the Student Education Team model. METHODS: The model combined team-based, patient-centered care with student experiences in a sustainable precepting model. Four learners successfully underwent precepting simultaneously. Schedulers booked patients in the team schedule, and the patients knew they would see a student and a faculty team member. RESULTS: The Student Education Team model increased the learner to preceptor ratio compared to traditional precepting models. Use of the team increased the number of learners completing rotations. The team schedule nearly eliminated patients refusing student involvement and enhanced throughput because patients saw the most readily available staff. DISCUSSION: The team offered clinicians and learners a model for incorporating learning into clinicians' schedules.

Case of fatal eastern equine encephalitis.

Eastern Equine Encephalitis (EEE) is a rare and very serious arbovirus that is transmitted to humans through the bite of infected mosquitoes. When symptomatic, patients with this condition are typically seriously ill and the fatality rate is high. We present a fatal case of EEE that exhibited classic symptoms and findings. Included are high quality MRI images that show the classic radiographic findings of this infection. In addition to confirmatory laboratory findings, the case report includes pathologic specimens from brain tissue obtained at autopsy. Perhaps due to climate change and human encroachment on mosquito habitat, there is a westward spread of EEE in the United States.

Verbal Amnesia Secondary to Unilateral Infarct of the Mediodorsal Thalamic Nucleus.

INTRODUCTION: The mediodorsal nucleus is a subcomponent of the thalamus hypothesized to have a role in memory pathways. Given the limited number of reported cases and associated images, its clinical significance has not yet been fully elucidated. CASE PRESENTATION: We report the case of a 53-year-old man who presented with verbal amnesia, including deficits of both recall and recognition. High-resolution magnetic resonance imaging demonstrated a well-defined infarct contained within the mediodorsal nucleus. DISCUSSION: Current literature reports a range of conclusions regarding the extent to which the mediodorsal nucleus is involved in memory pathways. Several case series have attempted to localize infarcts by combining neuropsychology testing with imaging but were constrained by dated imaging modalities often dispersed with impurities. CONCLUSION: Our case demonstrates that isolated lesions of the mediodorsal nucleus can lead to deficits in both recall and recognition and that high-resolution magnetic resonance imaging is necessary when a thalamic infarct is suspected.

In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience.

BACKGROUND AND PURPOSE: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. METHODS: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. RESULTS: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. CONCLUSION: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

Effect of a Statewide Controlled-Substance Monitoring Requirement on the Opioid Prescribing Practice for Treatment of Acute Pain.

BACKGROUND: The US government affirmed the opioid epidemic as a public health emergency in late 2017. Prior to that, as part of the Heroin, Opiate, Prevention, and Education (HOPE) Agenda, the state of Wisconsin enacted 2015 Wisconsin Act 266. This law, which went into effect April 1, 2017, requires prescribers to review data from the state's enhanced Prescription Drug Monitoring Program (ePDMP) before issuing an opioid prescription, in order to reduce inappropriate prescriptions and, ultimately, decrease opioid overuse. OBJECTIVE: To evaluate the effect of 2015 Wisconsin Act 266 on opioid prescriptions for acute pain in Mayo Clinic Health System sites in northwest Wisconsin. PATIENTS AND METHODS: This retrospective review included all eligible patients who were discharged from emergency or urgent care departments in the Mayo Clinic Health System at northwest Wisconsin sites during the study period. The quantity of opioids prescribed (measured in morphine milligram equivalents per patient encounter) and the total number of opioid prescriptions were compared for the periods May and June 2016 (prior to implementation of Act 266) versus May and June 2017 (post-implementation of Act 266). RESULTS: A 33% reduction occurred in the median opioid quantity prescribed per patient encounter in the post-implementation period vs the pre-implementation period (P <0.001). In addition, a 13% relative reduction occurred in the percentage of patient encounters that involved an opioid prescription (P <0.001). No difference was observed in opioid prescription agents between time periods, except for an increase in morphine prescriptions (P <0.001. CONCLUSION: The HOPE Agenda, specifically 2015 Wisconsin Act 266, appears to have had a positive effect on decreased opioid prescriptions for acute pain at Mayo Clinic Health System sites in northwest Wisconsin.

A Unique Pattern on Memory Testing in Dementia Screening Predicts Obstructive Sleep Apnea.

OBJECTIVES: The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is used to screen for dementia in many Wisconsin Alzheimer Institute memory care clinics. After observing a pattern of lower scores for immediate memory than for delayed memory (immediate memory < delayed memory) that seemed to predict obstructive sleep apnea in patients seen in our memory care clinic, we aimed to confirm the validity of this finding. METHODS: We retrospectively identified all patients seen in our memory care clinic from December 2011 through December 2014 who completed the RBANS. The frequency of obstructive sleep apnea was determined among those with the pattern of interest (immediate memory < delayed memory). RESULTS: Among 191 patients who met the inclusion criteria, 81 (42%) displayed the immediate memory < delayed memory pattern. Of these, 54 patients had been or were subsequently tested for obstructive sleep apnea; 35 (65%) were positive. In the positive group, the mean age was 74 years; 60% were women. CONCLUSIONS: Obstructive sleep apnea is a known risk factor for cognitive dysfunction. It is a potentially treatable cause of memory loss that can be clinically silent. This study shows that a unique pattern (immediate memory < delayed memory) on the RBANS commonly used at memory care clinics can identify a group of patients who can be evaluated and treated for this common and remediable condition.

Factors Affecting Physician Satisfaction and Wisconsin Medical Society Strategies to Drive Change.

Physicians' dissatisfaction in their work is increasing, which is affecting the stability of health care in America. The Wisconsin Medical Society (Society) surveyed 1016 Wisconsin physicians to determine the source of their dissatisfaction. The survey results indicate Wisconsin physicians are satisfied when it comes to practice environment, work-life balance, and income. In addition, they are extremely satisfied when it comes to rating their ability to provide high quality care, and they have identified some benefits related to the adoption of electronic health records. However, they are feeling burned out, very unsatisfied with the amount of time spent in direct patient care compared to indirect patient care, and that they are spending too much time on administrative and data entry tasks. In terms of future workforce, many physicians are either unsure or would not recommend the profession to a prospective medical student. Electronic health records serve as both a satisfier and dissatisfier and as a potential driver for future physician satisfaction interventions. Changes at the institutional, organizational, and individual levels potentially could address the identified dissatisfiers and build upon the satisfiers. The Society identifies 12 strategies to improve upon the physician experience.

Identification and treatment of bronchoconstriction induced by a vagus nerve stimulator employed for management of seizure disorder.

We evaluated a 63-year-old woman who developed dyspnea with a sensation of chest tightness that was temporally associated with discharges from a vagus nerve stimulator that had been implanted for the control of intractable seizures. Spirometry demonstrated the development of significant airflow obstruction associated with the firing of the stimulator. Adjustment of the stimulator settings resolved the discharge-associated bronchoconstrictive phenomenon. These findings highlight an important association between vagus nerve stimulators and dyspnea that should be considered in the differential diagnosis of patients with these devices who present with dyspnea and/or chest tightness. The relative importance of vagal stimulation to bronchoconstriction is suggested by the findings.

Sleep, sleepiness and school start times: a preliminary study.

BACKGROUND: High school students are reported to be excessively sleepy, resulting in decreased academic performance, increased psycho-social problems and increased risk of morbidity and mortality from accidents. Early school start times have been noted to contribute to this problem. This report attempts to confirm the relationship of early school start times with decreased sleep and increased sleepiness. METHODS: We examined sophomore and junior students in 2 local high schools with different start times and measured the amount of time slept and sleepiness. RESULTS: We found that students at the early start school reported reduced sleep time and more sleepiness than their counterparts at the later starting school. CONCLUSION: Early school start times are associated with student reports of less sleep and increased sleepiness. Further studies in larger groups are recommended in view of the potential significant impact of sleep deprivation in this age group.