John Booss

Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition

Background and Purpose— To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease. Summary of Review— A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors. Conclusions— There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

Smallpox and smallpox vaccination Neurological implications

Compulsory vaccination was discontinued in the U.S. in 1972; the world was declared free of smallpox infection in 1980. Since that time, no new smallpox infections have been recognized, and only limited numbers of military and laboratory personnel have been vaccinated. As a result, the majority of the U.S. and the world population have no or diminished immunity to smallpox. Widespread vaccination, beginning with the military and health care workers, is now being undertaken. Public health strategies for immunizing the general population include preexposure voluntary vaccination, case surveillance with ring vaccination, and mass vaccination at the time of attack. Cutaneous complications of vaccination occur in immunosuppressed subjects and in those with atopic dermatitis. Among the most serious complications is postvaccinal encephalomyelitis (PVEM). A related condition, postvaccinial encephalopathy (PVE), may be seen in children less than two years of age. There are no markers to predict who will develop PVEM. In the past, mortality was high, ranging from 10 to 50%. The neuropathology of PVEM suggested an immune-mediated attack on the CNS, but the target of the immune response is unknown. Comprehensive programs are needed for surveillance and confirming case definitions for neurologic complications. Multi-institutional controlled trials of antiviral and immune modulating therapy of PVEM should be considered. Neurologists should be actively involved in the planning process for vaccination programs and in the treatment of neurologic complications.

Idiopathic CSF pleocytosis in relapsing polychondritis

The association of relapsing polychondritis with CSF pleocytosis is reported for the first time. Three cases are described in which infectious etiologies of the pleocytosis were excluded by appropriate cultures and serologic studies. We suggest that the finding of CSF pleocytosis in relapsing polychondritis does not merit empiric antimicrobial therapy in the absence of demonstrated infection.

Cerebrospinal Fluid IgG Level in Herpes Simplex Encephalitis

Elevated levels of immunoglobulin G (IgG) in the cerebrospinal fluid (CSF) were associated with elevated herpes antibody in the CSF in a case of herpes simplex encephalitis. The case was also characterized by a prolonged course and a difficult virus isolation.

Herpes simplex encephalitis: analysis of a cluster of cases by restriction endonuclease mapping of virus isolates.

In December 1979, there were three deaths from culture-proven herpes encephalitis in 3 weeks in the New Haven area, and a nurse caring for one of these patients developed a herpetic lesion on her nose. The three brain isolates, the isolate from the nurse, and several epidemiologically unrelated strains were analyzed by restriction endonuclease mapping. All were determined to be distinct strains of herpes simplex virus. The possibility that a single strain of virus caused this cluster of cases was therefore examined directly and disproved.

Change in the department of veterans affairs : What should be done?

Health care in the Department of Veterans Affairs is undergoing the most dramatic change since the era following World War II. The Congress has supported the Undersecretary for Health in his guidance of this change. Traditional hospital-based, specialty-focused care has given way to outpatient and primary care focused health care. Administrative authority has been shifted to 22 Veterans Integrated Service Networks (VISNs). Research goals are being reoriented, and neurology resident allocation is being reduced. VA neurologists and neurology chairs must organize strong service lines in their own VA facilities and in their networks to provide care for veterans with neurologic diseases. VA neurologists must also emphasize their role in principal care and increase their involvement in outcomes research.