Michael DeGeorgia

The Impact of Accreditation Council for Graduate Medical Education Duty Hours, the July Phenomenon, and Hospital Teaching Status on Stroke Outcomes

BACKGROUND Acute ischemic stroke (AIS) is common cause of hospital admission. The objective of this study was to determine the impact of the new Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations on AIS outcomes including inhospital mortality. METHODS Hospitalized patients with AIS were selected from the National Inpatient Sample database. Patients with AIS with a known mortality and hospital teaching status were included for the years 2000 through 2005. Inhospital mortality and predictors of mortality were stratified by the hospital teaching status. To determine the variability of mortality around the month of July (July phenomenon) the trend of mortality was determined in teaching hospitals stratified by the calendar month of each year. RESULTS In all, 377,266 patients were included in this analysis; 43.0% were admitted to teaching hospitals. Overall inhospital mortality was 10.8%, slightly higher in teaching hospitals (11.4% v 10.3%, P < .0001). The trend in AIS mortality showed a decline during the 6 years included in this study in both hospital types (P < .0001). Adjusted analysis showed decline in mortality in both hospital types after July 1, 2003: odds ratio (OR) 0.91 (95% confidence interval [CI] 0.87, 0.94) in teaching hospitals and OR 0.81 (95% CI 0.78, 0.84) in nonteaching hospitals. Predictors of AIS-associated hospital mortality were similar in both hospital types except for sepsis, which was another independent predictor of death in nonteaching hospitals (OR 1.58, 95% CI 1.30, 1.94). There was no significant change in AIS mortality when stratified by each calendar month within the years included in this study (P value = .25-.93). CONCLUSION There was no difference in AIS mortality after the implementation of the new ACGME duty hour standards. In addition, data support the lack of July phenomenon in neurology residency programs in regard to AIS mortality.

Craniectomy for acute ischemic stroke: How to apply the data to the bedside

Purpose of reviewMalignant hemispheric infarction is associated with a high mortality rate, approximately 80%, as a result of the development of intracranial pressure gradients, brain tissue shift, and herniation. By allowing the brain to swell outwards and equalizing pressure gradients, decompressive craniectomy appears to significantly reduce the mortality to approximately 20%. This review takes a comprehensive look at the evidence highlighting the benefits and limits of decompressive craniectomy in malignant cerebral infarction. Recent findingsThree recent European randomized trials have provided compelling evidence that decompressive hemicraniectomy for large hemispheric infarction is not only lifesaving, but also leads to improved functional outcome in patients 60 years of age or less when treated within 48 h of stroke onset. SummaryEarly decompressive hemicraniectomy (≤48 h) should be strongly considered in any patient 60 years old or less presenting with malignant hemispheric infarction. Further studies are needed to establish objective neuroimaging criteria for aggressive intervention, and to clarify the role of decompressive surgery in older patients (>60 years old) and perhaps, when delayed beyond 48 h.

Acute onset of upbeat nystagmus, exotropia, and internuclear ophthalmoplegia—A tell-tale of ponto-mesencephalic infarct

Two patients were assessed for acute onset of diplopia. Clinical examination revealed upbeat nystagmus, exotropia, and internuclear ophthalmoplegia (INO). Both patients had vascular risk factors; acute ischemic stroke affecting ponto-mesencephalic junction was suspected. Magnetic resonance imaging confirmed strategic location of the acute infarct affecting the medial longitudinal fasciculus, adjacent occulomotor nuclei, and paramedian tract. We propose that constellation of acute onset of upbeat nystagmus, INO, and exotropia in patients with vascular risk factors might be unequivocal manifestation of the ponto-mesencephalic stroke.

A Case of Neuro-Behcet’s Disease Presenting with Central Neurogenic Hyperventilation

Patient: Female, 46 Final Diagnosis: Central hyperventilation Symptoms: Hyperventilation Medication: — Clinical Procedure: None Specialty: Neurology Objective: Unusual clinical course Background: Behcet’s disease is a chronic inflammatory disorder usually characterized by the triad of oral ulcers, genital ulcers, and uveitis. Central to the pathogenesis of Behcet’s disease is an autoimmune vasculitis. Neurological involvement, so called “Neuro-Behcet’s disease”, occurs in 10–20% of patients, usually from a meningoencephalitis or venous thrombosis. Case Report: We report the case of a 46-year-old patient with Neuro-Behcet’s disease who presented with central neurogenic hyperventilation as a result of brainstem involvement from venulitis. Conclusions: To the best of our knowledge, central neurogenic hyperventilation has not previously been described in a patient with Neuro-Behcet’s disease.

Dr. Joseph Foley – Case Western Reserve's Living Legend (P04.005)

Background Dr. Joseph Foley, Professor Emeritus and former Chief of Neurology at Western Reserve University in Cleveland, Ohio, is a living legend. Raised in a strict Irish-Catholic household during the Great Depression, he was influenced early in life by colorful Boston politicians and a classic literary training. After earning scholarships to Holy Cross and Harvard Medical School, he treated the wounded on the beaches of Normandy. In 1948, Foley joined Derek Denny-Brown at Boston City Hospital and in 1951 became the Director of the Mallory Pathological Institute. Over the next decade, Foley described benign fasciculation syndrome (Denny-Brown-Foley Disease), the vascular supply of hypothalamus, and with Raymond Adams, coined the term “asterixis” and triphasic waves of hepatic encephalopathy. In 1961, Foley was recruited to Cleveland. Two years later he recruited his former resident Maurice Victor. In contrast to beurecratic chiefs of his time, Foley was constantly visible in wards and clinics, spreading humor, which earned him the reputation as the “silver tongued Irish doctor from Boston”. He could recite poetry of Homer, Yeats, and Joyce ad lib. He once said, “For an Irishman to be listening when he could be talking is a form of perversity”. Yet he set strict academic standards for his well-attired, well-spoken young doctors. From 1963-1965, he served as president of the AAN and from 1974-1975, president of the ANA, retiring in 1980. Joseph Foley, at age of 95, remains a cheerful personality, present at most conferences, and frequently seen at local coffee shops. During a Cleveland local radio interview, when asked of advice, Dr. Foley simply stated, “Make sure you continue to love people and behave in a way that you can be loved”. Dr. Foley lived by his own advice, and let love of humanity guide his practice in neurology and medicine. Disclosure: Dr. Shams has nothing to disclose. Dr. Ashraf has nothing to disclose. Dr. DeGeorgia has received personal compensation for activities with Osram Medical Incorporated as a consultant.