Pratik Bhattacharya

Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology

Objective: To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy. Methods: Review of practice models and published literature on primary studies of the efficacy of neurology telemedicine. Results: Teleneurology is of greatest benefit to populations with restricted access to general and subspecialty neurologic care in rural areas, those with limited mobility, and those deployed by the military. Through the use of real-time audio-visual interaction, imaging, and store-and-forward systems, a greater proportion of neurologists are able to meet the demand for specialty care in underserved communities, decrease the response time for acute stroke assessment, and expand the collaboration between primary care physicians, neurologists, and other disciplines. The American Stroke Association has developed a defined policy on teleneurology, and the American Academy of Neurology and federal health care policy are beginning to follow suit. Conclusions: Teleneurology is an effective tool for the rapid evaluation of patients in remote locations requiring neurologic care. These underserved locations include geographically isolated rural areas as well as urban cores with insufficient available neurology specialists. With this technology, neurologists will be better able to meet the burgeoning demand for access to neurologic care in an era of declining availability. An increase in physician awareness and support at the federal and state level is necessary to facilitate expansion of telemedicine into further areas of neurology.

Clinical Profiles, Complications, and Disability in Cocaine-Related Ischemic Stroke

Cocaine use is associated with ischemic stroke through unique mechanisms, including reversible vasospasm, drug-induced arteritis, enhanced platelet aggregation, cardioembolism, and hypertensive surges. To date, no study has described disability in patients with cocaine-related ischemic stroke. The present study compared risk factors, comorbidities, complications, laboratory findings, medications, and outcomes in patients with cocaine-related (n = 41) and non-cocaine-related (n = 221) ischemic stroke (n = 147) and transient ischemic attack (n = 115) in 3 academic hospitals. The patients with cocaine-related stroke were younger (mean age, 51.9 years vs 59.1 years; P = .0008) and more likely to be smokers (95% vs 62.9%; P < .004). The prevalence of arrhythmias was significantly higher in the patients with cocaine-related stroke, and that of diabetes was significantly higher in those with non-cocaine-related strokes. The prevalence of hypertension and lipid profiles were similar in the 2 groups; however, those with cocaine-related stroke were less likely to receive statins. Antiplatelet use was similar in the 2 groups. Survivors of both groups had similar modified Rankin scores and lengths of hospital stay. In the older urban population, smoking and cocaine use may coexist with other cerebrovascular risk factors, and cocaine-related strokes have similar morbidities and mortality as non-cocaine-related strokes. Moreover, because the patients with cocaine-related stroke is younger, they have an earlier morbidity. New strategies for effective stroke prevention interventions are needed in this subgroup.

Are Racial Disparities in Stroke Care Still Prevalent in Certified Stroke Centers

Racial differences in stroke risk and risk factor prevalence are well established. The present study explored racial differences in the delivery of care to patients with acute stroke between Joint Commission (JC)-certified hospitals and noncertified hospitals. A retrospective chart review was conducted in patients sustaining ischemic stroke admitted to 5 JC-certified centers and 5 noncertified hospitals. Demographic data, risk factors, utilization of acute stroke therapies, and compliance with core measures were recorded. Racial disparities were investigated in the entire group as well as for JC-certified and noncertified hospitals separately. A total of 574 patients (25.1% African Americans) were included. African Americans were significantly younger and more likely to have previous stroke, whereas Caucasians were more likely to have coronary disease and atrial fibrillation. There were no racial differences in other risk factors or baseline functions. Median National Institutes of Health Stroke Scale scores were similar in African Americans and Caucasians, as were proportions receiving intravenous tissue plasminogen activator (tPA) therapy (2.1% in African Americans, 3.5% in Caucasians; P = .40) and intervention (4.2% in African Americans, 6.8% in Caucasians; P = .26). Caucasians were more likely to arrive by emergency medical services (65.5% vs 51.5%; P = .004), to be evaluated by a stroke team (19.1% vs 7.7%; P = .001), and to have a documented National Institutes of Health Stroke Scale score (40.2% vs 29.9%; P = .03). African Americans often did not receive intravenous tPA because of a delay in arrival. African Americans performed better on virtually all stroke care variables in JC-certified centers. JC certification reduced disparity in certain variables, including tPA and deep venous thrombosis prophylaxis administration. Important racial disparities exist in the delivery of several acute stroke care variables. Efforts must be focused on eliminating disparities in prehospital delays. Guideline-based care tendered at JC-certified centers might help narrow disparities in acute stroke care delivery.

Why do ischemic stroke and transient ischemic attack patients get readmitted

OBJECTIVE Readmission is an important indicator for the quality of healthcare services. The authors examined the reasons for 30-day readmission among urban stroke patients, and their clinical consequences. METHODS Consecutive patients admitted to a JCAHO certified primary stroke center with ischemic stroke or transient ischemic attacks (TIA) were included. Demographics, TOAST mechanism, risk factors, treatments administered and discharge destination were collected. Charts were reviewed for readmissions up to 30 days from discharge. Reasons for readmission and outcomes in terms of disability and discharge destination were determined. RESULTS Two hundred sixty-five patients (50.9% male; 79.6%African American; mean age 60.9 years) were included. There were 205(77.4%) strokes and 60(22.6%) TIAs. Thirteen (5%) patients died during their first admission. Of the remaining 252 patients, 25 (9.9%) were readmitted within 30 days. The reason for readmission was neurological in 8/25 patients (32%; 3 ischemic strokes, 1 hemorrhagic stroke and 4 TIAs); and non-neurological in 17/25 patients (68%). The frequent non-neurological reasons were infections (6/25), electrolyte disturbances (3/25) and trauma related to falls (2/25). Patients with coronary artery disease were more likely to be readmitted (45.5% vs. 14.7%; p=0.001) An NIH stroke scale ≥10 predicted readmission (50.0% vs. 25.4% for NIHSS<10; p value 0.02). Patients discharged home or to acute rehabilitation units were less likely to be readmitted than those discharged to subacute rehabilitation units or nursing homes (8.2% vs. 23.8%; p value=0.01). INTERPRETATION Disabling strokes are more likely to be readmitted. The reason is often non-neurological, and sometimes preventable. Physicians should review cases that return within 30 days and determine best practices that prevent readmission.

Safety considerations in the epilepsy monitoring unit for psychogenic nonepileptic seizures

Injury occurs in epilepsy monitoring units (EMUs) to patients with epileptic seizures (ES); however, there are limited data regarding the safety concerns of patients with psychogenic nonepileptic seizures (PNES) being monitored in EMUs. We reviewed EMU records from 116 PNES and compared them to 170 ES. Three falls (2.6%) occurred in PNES without injury compared to 6 falls (3.5%) in ES with 1 injury, a facial hematoma. Of the 9 total falls, 8 patients were ambulatory during their events. Several adverse incidents occurred for both groups. Of the PNES without staff response, 30 of 39 were due to PNES being less than 60s in duration, and 16 of 39 involved lack of push-button activation to alert the staff. For the ES group, 57 of 101 were due to electrographic seizures without seizure detection software or push-button activation. Similar safety protocols should be administered while monitoring these patients regardless of seizure type.

Gender based differences in acute stroke care in Michigan hospitals

BACKGROUND We sought to examine whether gender-based differences in acute stroke care occur in both Joint Commission (JC) certified and noncertified hospitals. METHODS 602 charts of patients with ischemic stroke were reviewed from five JC certified and five noncertified hospitals for gender differences in the prehospital factors, emergency department evaluation, in-hospital stroke care, discharge outcome and use of secondary prevention measures. RESULTS More women arrived via ambulance (63.1% women vs. 53.9% men, p=0.025) while more men came by self-transportation (42.6% vs. 30%, p=0.0016). There was no difference by gender for evaluation for thrombolytics (89.4% men vs. 85.9% women) or intravenous t-PA administered (3.5% men vs. 2.5% women, p=0.82). More patients in JC certified centers were evaluated for thrombolysis than in noncertified centers. Delay in arrival was the commonest reason for not getting thrombolysis in both groups. More men than women had mild/resolving symptoms, had more interventional procedures, and better discharge outcome. More men were discharged on antithrombotics. Even after adjusting for age, gender differences were significant for arrival by ambulance, self transportation, mild/resolving symptoms, interventional procedures performed and marginally for good discharge outcome. CONCLUSION There were significant gender differences in delivery of acute stroke care in Michigan hospitals even after adjustment for age differences. In spite of milder symptoms and less usage of emergency services, men received more aggressive stroke care with a tendency towards better discharge outcome. Going to a JC certified center was a better predictor of consideration for thrombolytics than gender.

Automated Data Mining: An Innovative and Efficient Web-Based Approach to Maintaining Resident Case Logs

BACKGROUND Use of resident case logs has been considered by the Residency Review Committee for Neurology of the Accreditation Council for Graduate Medical Education (ACGME). OBJECTIVE This study explores the effectiveness of a data-mining program for creating resident logs and compares the results to a manual data-entry system. Other potential applications of data mining to enhancing resident education are also explored. DESIGN/METHODS Patient notes dictated by residents were extracted from the Hospital Information System and analyzed using an unstructured mining program. History, examination and ICD codes were obtained and compared to the existing manual log. The automated data History, examination, and ICD codes were gathered for a 30-day period and compared to manual case logs. RESULTS The automated method extracted all resident dictations with the dates of encounter and transcription. The automated data-miner processed information from all 19 residents, while only 4 residents logged manually. The manual method identified only broad categories of diseases; the major categories were stroke or vascular disorder 53 (27.6%), epilepsy 28 (14.7%), and pain syndromes 26 (13.5%). In the automated method, epilepsy 114 (21.1%), cerebral atherosclerosis 114 (21.1%), and headache 105 (19.4%) were the most frequent primary diagnoses, and headache 89 (16.5%), seizures 94 (17.4%), and low back pain 47 (9%) were the most common chief complaints. More detailed patient information such as tobacco use 227 (42%), alcohol use 205 (38%), and drug use 38 (7%) were extracted by the data-mining method. CONCLUSIONS Manual case logs are time-consuming, provide limited information, and may be unpopular with residents. Data mining is a time-effective tool that may aid in the assessment of resident experience or the ACGME core competencies or in resident clinical research. More study of this method in larger numbers of residency programs is needed.

Role of Non-High-Density Lipoprotein Cholesterol in Predicting Cerebrovascular Events in Patients Following Myocardial Infarction

Although there appears to be a role for statins in reducing cerebrovascular events, the exact role of different lipid fractions in the etiopathogenesis of cerebrovascular disease (CVD) is not well understood. A secondary analysis of data collected for the placebo arm (n = 2,078) of the Cholesterol and Recurrent Events (CARE) trial was performed. The CARE trial was a placebo-controlled trial aimed at testing the effect of pravastatin on patients after myocardial infarction. Patients with histories of CVD were excluded from the study. A Cox proportional-hazards model was used to evaluate the association between plausible risk factors (including lipid fractions) and risk for first incident CVD in patients after myocardial infarction. At the end of 5 years, 123 patients (6%) had incident CVD after myocardial infarction (76 with stroke and 47 with transient ischemic attack). Baseline non-high-density lipoprotein (HDL) cholesterol level emerged as the only significant lipid risk factor that predicted CVD; low-density lipoprotein cholesterol and HDL cholesterol were not significant. The adjusted hazard ratios (adjusted for age, gender, hypertension, diabetes mellitus, and smoking) for CVD were 1.28 (95% confidence interval [CI] 1.06 to 1.53) for non-HDL cholesterol, 1.14 (95% CI 0.96 to 1.37) for low-density lipoprotein cholesterol, and 0.90 (95% CI 0.75 to 1.09) for HDL cholesterol (per unit SD change of lipid fractions). This relation held true regardless of the level of triglycerides. After adjustment for age and gender, the hazard ratio for the highest natural quartile of non-HDL was 1.76 (95% CI 1.05 to 2.54), compared to 1.36 (95% CI 0.89 to 1.90) for low-density lipoprotein cholesterol. In conclusion, non-HDL cholesterol is the strongest predictor among the lipid risk factors of incident CVD in patients with established coronary heart disease.

Early use of MRI improves diagnostic accuracy in young adults with stroke

OBJECTIVES The misdiagnosis of acute ischemic stroke in young adults is a significant problem since patients may have many decades of potential disability. Also, proven therapies for acute stroke may not be administered if there is an initial misdiagnosis. We assessed the hypothesis that early use of MRI, arrival by ambulance, and presentation to a Primary Stroke Center (PSC) would be associated with a reduced rate of misdiagnosis. METHODS A prospective database of young adults (ages 16-49 years) with ischemic stroke (final diagnosis provided by vascular neurologists) was reviewed. We collected information on several variables, including age, race, arrival by ambulance, whether brain MRI was performed within 48 h, and initial presentation to a PSC. Variables were tested against emergency department (ED) misdiagnosis using univariate and multivariate methods. RESULTS 77 patients with a mean age of 37.9 years were reviewed. 48.3% of patients arrived by ambulance, 53.2% had a brain MRI within 48 h, and 23.4% initially presented to a PSC. The overall rate of ED misdiagnosis was 14.5%. In multivariate testing, performance of MRI within 48 h (p=0.023) was associated with a lower rate of misdiagnosis and age <35 years was linked with greater likelihood of misdiagnosis (p=0.047). CONCLUSIONS Early performance of MRI leads to greater accuracy of stroke diagnosis in young adults presenting to the ED. Patients less than age 35 years have a greater risk of misdiagnosis. ED physicians and neurologists should consider early use of MRI in young adults with stroke-like deficits and diagnostic uncertainty.

Early Access to a Neurologist Reduces the Rate of Missed Diagnosis in Young Strokes

BACKGROUND We hypothesized that the presence of an in-house neurologist or a neurology or emergency medicine (EM) residency is associated with a lower rate of missed stroke diagnosis and a greater use of thrombolytic therapy. METHODS The outpatient Young Stroke registry from our academic medical center was reviewed. Patients 16 to 50 years of age who presented with ischemic stroke were included. Information on presentation, acute therapy, and missed diagnosis was obtained. The presence of an EM or neurology residency at the presenting hospital was recorded. We also assessed whether hospital teaching status in these fields affected missed diagnosis rates, the use of thrombolysis, or stroke intervention. RESULTS Ninety-three patients were included. Thirteen patients were misdiagnosed. In hospitals with and without a neurology residency, the missed diagnosis rate was 6.3% versus 18.0%, respectively (P=.21). Two patients were misdiagnosed in hospitals with a neurology residency, but neither had neurology consultations in the emergency department. If these cases are removed from our analysis, the rate of missed diagnosis with and without a neurology residency is 0% versus 20.6%, respectively (P=.008). Acute stroke therapy was administered in 17.9% of patients seen with an EM residency, compared to 2.7% without an EM residency (P=.046). With and without a neurology residency, acute stroke therapy was administered in 25% versus 8.2% of cases, respectively (P=.055). CONCLUSIONS Young adults with ischemic stroke seen at hospitals with a neurology residency had a lower missed diagnosis rate. The presence of an EM resident or a neurology teaching program was associated with a greater use of acute stroke therapies. These results support initiatives to triage young adults with suspected acute stroke to hospitals with access to neurologic expertise in the emergency department.