Weekday Versus Weekend Presentation in the Acute Management of Ischemic Stroke Through Telemedicine.

A "weekend effect" resulting in higher mortality rates for patients with stroke admitted on weekends has been reported. We examine this phenomenon for patients with acute ischemic stroke (AIS) presenting to telestroke (TS) sites to determine its effect on stroke alert process times and outcomes. From October 2015 to June 2017, we reviewed patients with AIS receiving intravenous alteplase within our TS network. We compared patients presenting to TS sites on weekdays (Monday 07:00 to Friday 18:59) to those presenting on weekends (Friday 19:00 to Monday 06:59). We analyzed door-to-alert activation, alert activation-to-TS evaluation, door-to-imaging, and door-to-needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared. We identified 89 (54 weekday and 35 weekend) patients (mean age: 71.8 ± 13.3 years, 47.2% women) during the study period. Median door-to-alert activation (P = .01) and door-to-needle (P = .004) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door-to-imaging (P = .1) and alert activation-to-TS evaluation (P = .07) times. Rates of favorable outcome (P = .19) and death (P = .56) at 90 days did not differ. While there were no significant differences in outcomes, patients presenting on weekends had longer door-to-alert activation and door-to-needle times. Efforts to improve methods in efficiency of care on weekends should be considered.

Antimicrobial stewardship: Staff nurse knowledge and attitudes.

BACKGROUND: Registered nurses are uniquely qualified to augment antimicrobial stewardship (AS) processes. However, the role of nursing in AS needs further development. More information is needed regarding gaps in registered nurse knowledge, attitudes toward AS, and how infection preventionists can help. METHODS: An online descriptive survey was deployed to a convenience sample of approximately 2,000 nurses at the bedside. The survey included 15 questions addressing: (1) overall knowledge of AS; (2) antimicrobial delivery; (3) knowledge and attitudes regarding antimicrobial use; (4) antimicrobial resistance; and (5) antimicrobial resources and education. RESULTS: Three hundred sixteen staff nurses from 3 hospitals (15.8%) responded to the survey. Fifty-two percent of nurses were not familiar with the term "antimicrobial stewardship," although 39.6% of nurses indicated that an AS program was moderately or extremely important in their health care setting. Almost all nurses (95%) believed that they should be involved in AS interventions. DISCUSSION: These findings suggest gaps in nursing knowledge rearding AS. However, nurses believed AS programs were important and were eager to be involved. CONCLUSIONS: This study showed that many nurses are not aware of AS, or do not understand their role in contributing to AS endeavors. Infection preventionist education should focus on increasing staff nurse awareness and demonstrating how nurses can make specific AS interventions.

Endovascular aspiration to treat acute ischemic stroke caused by embolic carcinoma.

Although cardiac myxomas have been known to cause acute ischemic stroke and other cerebrovascular complications, intracranial embolization of metastatic tumor fragments is rare. This is likely because venous emboli generally cause pulmonary embolism. Pulmonary vein metastases and patent foramen ovales have previously shown to propagate intracranial embolic carcinomas, but these events are very uncommon, and are not well characterized. We report a rare case of large-cell, high-grade neuroendocrine lung cancer embolus occluding the basilar artery, which likely detached into the bloodstream from the lung after intruding into a pulmonary vein. The embolus was treated with endovascular aspiration, and achieved modified Thrombolysis In Cerebral Infarction 2c revascularization. After initial neurological recovery, the patient suffered respiratory arrest and support was withdrawn 48 h later. We discuss the tumor characteristics and implications for treatment of acute ischemic stroke in patients with cancer diagnoses.

Prevalence of atrial fibrillation with insertable cardiac monitors in cryptogenic stroke: A single-center experience.

BACKGROUND: The use of insertable cardiac monitors (ICM) has increased the rate of detection of atrial fibrillation (AF) among cryptogenic stroke (CS) patients. We describe a single-center experience for AF detection among CS patients receiving ICMs upon discharge after the index stroke event and attempt to identify predictors for AF detection. METHODS: From April 2014 to October 2017, patients receiving ICMs for CS who underwent >60 days of monitoring were reviewed. Chronic underlying medical illnesses, presence of left atrial enlargement (LAE) on echocardiography, and PR interval on admission electrocardiogram were assessed as predictors of AF detection. RESULTS: A total of 234 patients (median age 72 [61, 78] years, 45% women) met inclusion criteria and were followed for a median of 536 [282, 848] days. Among studied patients, 68 patients (29%) were found to have AF at a median of 94.5 [16, 239] days from ICM placement. CS patients with AF were significantly older (p < 0.001), and there was a significantly higher proportion of women (p = 0.003) when compared to CS patients without AF. Neither presence of LAE nor prolonged PR interval was predictive of AF detection. CONCLUSION: Almost one-third of CS patients monitored with an ICM were found to have previously undiagnosed AF. CS patients found to have AF were older and more commonly women. Prospective studies are needed to better identify predictors for early AF among the broader population of all CS patients.

Real-world treatment of large vessel occlusions: combined outcomes of directly presenting and transferred-in patients to a stroke center.

Background Stroke patients transferred in for endovascular treatment (ET) may have lower chances for favorable outcomes compared to those who presented directly to a ET-capable hospital. We describe our real-world experience of ET in AIS, especially among patients transferred in. Materials and methods AIS patients receiving ET from January 2015 to November 2016 were reviewed. We calculated median onset to groin puncture (OTP) and groin puncture to recanalization times (PTR), location of target vessel treated, rate of concurrent intravenous (IV) alteplase use, and rate of successful recanalization as defined by TICI ≥ 2b. Outcomes included discharge disposition to nursing home (NH) and 90-day modified Rankin Scale (mRS) scores. Results We identified 174 patients (50.6% women, mean age 69.5 ± 15.7 years, 49.4% transfer-ins) undergoing ET (20.5% terminal internal carotid artery, 47.7% M1, 17% M2, 9.2% basilar artery, 5.7% other). Median OTP and PTR times were 257 [158, 375] and 30 [22, 48] minutes, respectively. Rate of TICI ≥ 2b was 82.9%, and 55.7% received adjunctive IV alteplase. Rate of discharge to NH was 17.2% 90-day mRS ≤ 2 was 41.7%. Discharge to NH (P = 0.32) and 90-day mRS ≤ 2 (P = 0.75) were not significantly different between transferred in versus direct presentation patients. Conclusion High rates of favorable angiographic and clinical outcomes were found among AIS patients receiving ET in our single-center experience, particularly among transferred in patients. The establishment of a stroke network may help in the efficient transfer and assembly of appropriate resources for eligible patients that are transferred in for ET.

The Door to Needle Time Metric Can Be Achieved via Telestroke.

The administration of intravenous (IV) alteplase to patients with stroke via telestroke (TS) can be safe and effective. It remains unclear how quickly IV alteplase occurs during TS evaluations. We sought to compare door to needle times (DNTs) between patients receiving IV alteplase who present directly to our comprehensive stroke center (CSC) and those presenting to community hospitals in our TS network. Consecutive patients with acute ischemic stroke (AIS) who presented to emergency departments and received IV alteplase between August 2014 and June 2015 were identified at our CSC and TS network. Median DNTs with interquartile ranges were calculated in each cohort. During the study period, 117 patients with AIS (mean age 71 ± 15 years, 47% women) receiving IV alteplase were included in the analysis (65 CSC and 52 TS). Median DNT at our CSC was significantly shorter compared to TS sites (CSC: 43 [35-55] minutes vs TS: 54 [41-71] minutes, P < .01). The proportion of patients receiving IV alteplase ≤60 minutes of presentation was significantly higher at our CSC compared to our TS network (CSC 84.6% vs TS 63.5%, P = .02). Differences in favorable discharge to home were not significant (CSC 60% vs TS 46%, P = .14). Guideline-recommended DNTs ≤60 minutes can be achieved in community hospitals with TS guidance. Initiatives are required to better resemble DNTs found at stroke centers.

Thrombolytic treatment to stroke mimic patients via telestroke.

OBJECTIVE: The safety and outcomes of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) is similar to those presenting to stroke centers. Little is known on the accuracy of TS diagnosis among those receiving IVT. We sought to compare the rate of patients receiving IVT with diagnosis of ischemic stroke as opposed to stroke mimic (SM) in our TS network to those who presented to our comprehensive stroke center (CSC). MATERIALS AND METHODS: Consecutive patients receiving IVT between August 2014 and June 2015 were identified at our CSC and TS network. We compared rates of SM, post-IVT symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, and discharge destination. RESULTS: We evaluated 131 receiving IVT were included in the analysis. Rates of SM receiving IVT were similar (CSC 12% versus 7% TS, p=0.33). Four stroke patients experienced sICH or in-hospital mortality; neither were found among SM patients. Discharge destination was similar between stroke and SM patients (p=0.9). SM patients had higher diagnoses of migraine (p=0.05) and psychiatric illness (p<0.01). CONCLUSION: The accuracy of diagnosing stroke in IVT-eligible patients evaluated via TS is similar to evaluations at our CSC. Continued efforts should be made to minimize exposure of SM patients to IVT in both settings.

Diffuse idiopathic intracranial fusiform aneurysm development. Case report and literature review.

BACKGROUND: Fusiform intracranial aneurysms (FIAs) are uncommon lesions representing less than 15% of all intracranial aneurysms in most large series. Their etiology has been linked to a variety of causes including atherosclerosis, fibromuscular dysplasia, cystic medial necrosis, connective tissue disease, hypertension, diabetes, hyperlipidemia, infection, cardiac myxoma, oral contraceptive use, vasculitis, and lymphoproliferative disorders. The finding of numerous lesions in a single patient is distinctly uncommon. CASE DESCRIPTION: We describe the unique case of a 47-year-old female who developed multiple FIAs over a 6-year period without an obvious underlying pathology. The patient's medical history was significant for obesity, migraine headaches, insomnia, breast cancer, and chronic skin rash. Various diagnoses were explored including infectious etiologies, autoimmune vasculopathies, malignancy-related causes, connective tissue disorders, and underlying genetic conditions. However, all investigations, including aneurysm wall and skin biopsies were negative or deemed noncontributory toward making a definitive diagnosis. CONCLUSION: We report an unusual case of a patient with a normal cerebral angiogram developing numerous, FIAs without obvious underlying etiology over a 6-year period. Close clinical and radiological follow-up is recommended in this case because the natural history of the disease is unclear at this point. The literature regarding potential causes of multiple fusiform intracranial aneuryms is reviewed.

Implementing a stroke system of care in a rural hospital: a case report from Granite Falls.

Acute stroke is a leading cause of morbidity and mortality. Both time-sensitive treatment and telemedicine are being used to improve the care of stroke patients in rural areas. This article highlights the case of a 62-year-old male patient with sudden onset of right-sided hemiparesis and a family history of vascular disease and how he was treated at a rural hospital that was connected by telemedicine technology to an urban tertiary care center. It also reviews protocols for acute treatment of stroke and systems of stroke care in rural areas.

The clinical effectiveness of Movicol in children with severe constipation: an outcome audit.

This audit reviewed the clinical effectiveness of polyethylene glycol 3350 plus electrolytes (PEG+E, Movicol) in the management of severe paediatric constipation. A seven-day disimpaction regimen was initiated followed by a maintenance dose as appropriate. An information and support service was provided by the community children's nursing team (CCNT) at Darent Valley Hospital. Twenty-three parents completed questionnaires on their children's experiences with previous and current laxative treatments, bowel movement status, in-patient admissions or home visits required and the perceived value of the back up service. The mean age of children studied was 6.7 years. Prior to PEG+E treatment, 57 per cent of children were admitted to hospital and 26 per cent required home visits for constipation treatment. After treatment, no child needed either intervention. Thirty-nine percent of parents used the support service, of which 96 per cent rated the information it provided as adequate. When asked about their satisfaction with the control of their children's constipation, 96 per cent of parents were 'more than happy' after treatment with PEG+E. The treatment of severe paediatric constipation with PEG+E in conjunction with a support and advice service was both clinically and economically effective.

A community-based intervention for siblings and parents of children with chronic illness or disability: the ISEE study.

OBJECTIVE: Siblings of children with chronic illness or disability have been reported to have a 1.6 to 2.0 risk for behavioral and mental health problems. Our objective was to examine the effects of an intervention for siblings (age 7-15 years) of children with chronic illness or disability. METHOD: A randomized, three-group repeated-measures design was used: full intervention (n=79), partial intervention (n=71), and a waiting list control group (n=102). Outcomes were sibling knowledge about illness, behavior problems, social support, self-esteem, attitude, and mood measured over four postintervention periods. Covariates were family cohesion, maternal mood, socioeconomic status, and well sibling age. The full intervention included structured teaching and psychosocial sessions at a 5-day residential summer camp. The partial intervention included camp only. Treatment effects were estimated by using generalized estimating equation panel analyses. RESULTS: The full treatment group showed significant improvements on all six outcomes over most periods, the partial treatment group on three outcomes, and the control group on two outcomes. Improvements in outcomes ranged from 5% to 25% increases over baseline measures. CONCLUSIONS: A dose-response relationship to intervention was found. Treatment gains were sustained over a period of 12 months.

Interrelationships among variables affecting well siblings and mothers in families of children with a chronic illness or disability.

A structural equation model (SEM) examined interrelationships among psychosocial variables known to affect the health and development of well siblings and parents when a child with a chronic illness or disability is a member of the family. Using dyads of 252 well children and parents, socioeconomic status (SES) and family cohesion were associated with the parent-reported behavior of the well sibling. SES also influenced the mood of the mother that in turn influenced family cohesion. The well sibling's knowledge about the illness of the brother or sister, attitude toward the illness, mood, self-esteem, and feelings of social support were interrelated and related to the behavior of the well sibling. The SEM suggests that interventions may be directed at several points in these interactions including boosting knowledge levels of the well sibling, improving family cohesion, and assuring adequate "income" support to the family through income transfers or in-kind services.

Markers of increased risk of intracerebral hemorrhage after intravenous recombinant tissue plasminogen activator therapy for acute ischemic stroke in clinical practice: the Multicenter rt-PA Stroke Survey.

BACKGROUND: Intravenous recombinant tissue plasminogen activator (rtPA) is an effective therapy for acute ischemic stroke, but it is associated with risk of intracerebral hemorrhage (ICH). Our aim was to identify, in a large cohort of patients, readily available baseline factors that are associated with thrombolysis-related ICH. METHODS AND RESULTS: In a multicenter retrospective and prospective investigation of individual data from 1205 patients treated in routine clinical practice with intravenous rtPA within 3 hours of stroke symptom onset, 72 patients (6%) developed symptomatic ICH and 86 additional patients (7%) had asymptomatic ICH identified on a routine follow-up CT. In analyses based on clinical variables alone, the main attributes associated with ICH were a history of diabetes mellitus and cardiac disease, increasing stroke severity, advancing age, use of antiplatelet agents other than aspirin before stroke onset, and elevated pretreatment mean blood pressure. In additional analyses that incorporated baseline CT and laboratory findings (in a subset of patients), the main associations were early ischemic CT changes, in particular if exceeding one third of middle cerebral artery territory; increasing stroke severity; diabetes mellitus or elevated serum glucose; and lower platelet counts. Final independent attributes associated with parenchymatous hematoma, defined by purely radiologically based criteria, were similar to those of symptomatic ICH. CONCLUSIONS: Readily available factors can identify acute ischemic stroke patients at high and low risk for rtPA-related ICH. These factors require confirmation in a prospective cohort before clinical implementation.