Adcock, Amelia

Background: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. Hypothesis: Rates of tPA recommendation, accuracy of final diagnosis and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations. Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center during one year. Statistical analysis: Chi squared test. Results: 303 consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non stroke-trained neurologists, and 60% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine- trained, stroke neurology-trained and other neurology- trained provider groups respectively (p = .427). Accuracy of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group. Conclusion: Our results did not illustrate any statistically significant difference between care provided by an Emergency Medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.

Opsoclonus myoclonus syndrome (OMS) is an extremely rare neurological syndrome typically affecting as few as 1 in 10,000,000 people annually. OMS is characterized by the presence of involuntary, saccadic eye movements, as well as ataxia, including gait incoordination, rigidity, and tremor. The origin of OMS is unclear, but a significant percentage of OMS cases are indicative of an underlying malignancy, most commonly neuroblastoma and small cell lung cancer. Here we describe an adult patient with OMS, who was ultimately diagnosed with a small ductal adenocarcinoma of the pancreas. To our knowledge, this is the third published report of an association between OMS and pancreatic malignancy, and the only case where the pancreatic malignancy was detected prior to metastasis or autopsy at death. This case report highlights the importance of careful, aggressive malignancy screening with OMS, as the pancreatic duct cut-off sign may be overlooked if pancreatic malignancy is not suspected.

Introduction: A significant burden of acute ischemic stroke (AIS) can be decreased by timely administration of tissue plasminogen activator (tPA). Door-to-needle (DTN) time is a nationally reported quality measure for patients with AIS. In a majority of primary and comprehensive stroke centers, acute stroke care is provided by teams comprising of trainees (residents/fellows). Adaptive learning is a well-studied paradigm to improve the quality of medical education. Conceptually, this model consists of four parts starting with planning, and subsequently involving learning, assessing and adjusting. It is a learner driven process. Hypothesis: Utilizing the adaptive learning model will reduce DTN time in AIS patients who present to the emergency department of a rural, tertiary care medical center staffed by neurology residents. Methods: Successive patients who received IV tPA for AIS in the emergency department of our academic medical center between January 1, 2014 and December 31, 2016 were included in the study. During months 1-18 (pre-intervention) DTN times were not shared with residents. During months 19-36 of study (post-intervention), we utilized our monthly stroke meeting to share DTN times anonymously. Discussions were held and emphasis was placed on the processes which led to shorter DTN times. Residents assessed responses, planned changes, and made adjustments in real time. Descriptive statistics were used to analyze the data. Results: A total of 313 patients received IV tPA during the study period (150 pre-intervention, 171 post intervention period). After the implementation of the quality improvement initiative, mean and median DTN time significantly reduced from 54.7 minutes to 43.0 minutes (p<0.0001) and 52 minutes to 39 minutes (p<0.0001) respectively. Conclusions: Our study exemplifies the success of the adaptive learning model in the care of patients with acute ischemic stroke. Our quality intervention led to significantly reduced DTN times. Furthermore, this educational initiative provided residents with objective feedback about their performance - one of the requirements of the accredited council of graduate medical education (ACGME).