Improving Acute In-Hospital Stroke Care by Reorganization of an In-Hospital Stroke Code Protocol.

BACKGROUND AND PURPOSE: Delays in recognition and assessment of in-hospital strokes (IHS) can lead to poor outcomes. The aim was to examine whether reorganized IHS code protocol can reduce treatment time. METHODS: IHS code protocol was developed, educational workshops were held for medical personnel. In the protocol, any medical personnel should directly consult a stroke neurologist before any diagnostic studies. Time intervals were compared between the pre- and post-implementation periods and between direct consultation with a stroke neurologist (DC group) and non-DC group in the post-implementation period. RESULTS: A total of 145 patients were included (pre, 42; post, 103). Time from recognition to stroke neurologist assessment (91 vs. 35 min, p = 0.002) and time from recognition to neuroimaging (123 vs. 74, p = 0.013) were significantly lower in the post-implementation period. Time from stroke neurologist assessment to groin puncture was significantly lower (135 vs. 81, p = 0.037). In the post-implementation period, DC group showed significant time savings from last known well (LKW) to recognition (93 vs. 260, p = 0.001), LKW to stroke neurologist assessment (145 vs. 378, p = 0.001), and recognition to stroke neurologist assessment (16 vs. 76, p < 0.001) compared with non-DC group. CONCLUSIONS: Reorganization of IHS code protocol reduced time from stroke recognition to assessment and treatment time. Reorganized IHS code and direct consultation with a stroke neurologist improved the initial response time.

Subcutaneous Heparin Therapy for Patients with Cancer-Associated Stroke.

BACKGROUND: Anticoagulation therapy, particularly subcutaneous heparin therapy, is recommended for cancer-associated thrombosis. However, not starting or discontinuing anticoagulation was not rare. The aim of the present study was to examine the practical issues related to anticoagulation therapy and effects of subcutaneous heparin therapy for cancer-associated stroke. METHODS: Patients with cancer-associated stroke in our stroke center between October 2014 and August 2017 who were diagnosed as having acute ischemic stroke based on diffusion-weighted imaging were retrospectively enrolled. Baseline clinical characteristics, heparin injection, reasons for no subcutaneous heparin therapy, and clinical outcomes were collected. RESULTS: A total of 59 patients with cancer-associated stroke (75 ± 10 years old, male 42%) were enrolled. Lung cancer was the most frequently observed cancer (n = 17, 29%), followed by gastric cancer (n = 8, 14%) and pancreatic cancer (n = 8, 14%). Of the 19 patients (32%) who underwent subcutaneous heparin therapy, it was discontinued in 9 (47%), mainly because of patients' medical conditions (deterioration of cancer or hemorrhagic complication). Ten patients with long-term subcutaneous heparin therapy did not have stroke recurrence. In contrast, among nine patients who discontinued subcutaneous heparin therapy, three (33%) had recurrence of ischemic stroke. Of the 40 patients without subcutaneous heparin therapy, the main reasons for no subcutaneous heparin therapy were the patients' medical conditions (n = 22, 55%). CONCLUSIONS: Although subcutaneous heparin therapy was given to only one third of cancer-associated stroke patients, long-term subcutaneous heparin therapy might prevent recurrence of cancer-associated stroke.

Predictable Value of Functional Independence Measure Differs between Anterior and Posterior Circulation Ischemic Strokes.

BACKGROUND: The functional independence measure (FIM) is a standard tool to provide a detailed evaluation of ADL of patients with disabilities. This study aimed to show the differences in FIM scores as an outcome predictor between patients with anterior circulation (AC) and posterior circulation (PC) strokes. METHODS: Consecutive patients with acute ischemic stroke hospitalized within 7 days after onset were investigated. Baseline NIHSS scores, 1st-FIM (< 72 h after -admission to stroke unit), 2nd-FIM (< 72 h before discharge), and modified Rankin Scale (mRS) scores were collected. Logistic regression analyses were used to identify predictors of a favorable outcome (mRS 0-2) at 3-month after stroke. RESULTS: Three hundred eighty-five patients (median age, 78 years; male, 59%; median length of stroke unit stay, 20 days) were included. The median baseline NIHSS, 1st- and 2nd-FIM scores were 4 (interquartile range 2-9), 65 (33-91), and 98 (54-122) respectively. Baseline NIHSS (3 vs. 4, p = 0.01) and mRS score at 3-month (1 vs. 2, p = 0.01) were lower, and 1st-FIM (75 vs. 64, p < 0.01) and 2nd-FIM (113 vs. 95, p = 0.01) were higher in 82 patients with PC than 303 patients with AC strokes. On multivariate logistic regression analysis, 2nd-FIM score was an independent predictor of favorable outcomes in both PC (OR 1.18, 95% CI 1.04-1.48, p < 0.01) and AC (OR 1.12, 95% CI 1.06-1.20, p < 0.01) strokes. The optimal cutoff scores of 2nd-FIM for predicting favorable outcome were 104 for PC (sensitivity 0.82, specificity 0.88) and 93 for AC (0.88-0.90) strokes. CONCLUSIONS: The differences in outcome predictability by FIM score between AC and PC strokes should be considered, although FIM scores at discharge from stroke unit were useful to predict a favorable outcome.

[Cilostazol was effective for capsular warning syndrome during anticoagulant therapy: a case report].

An 88-year-old woman with atrial fibrillation was admitted to our hospital due to the right hemiplegia and aphasia. MRA shows the left middle cerebral artery M2 occlusion. After intravenous rt-PA, her symptoms improved. She was diagnosed with cardioembolic stroke, and was treated with direct oral anticoagulation therapy. However, she had repeated stereotypical transient right hemiparesis a week after index stroke. Her symptoms were considered capsular warning syndrome (CWS). After cilostazol was administered, no further transient neurological deteriorations occurred. CWS can coexist with acute cardioembolic stroke, and cilostazol was effective.

[Burnout in Japanese neurologists: comparison of male and female physicians].

A questionnaire survey was conducted on 8,402 members of the Japanese Neurological Society to examine the current status and countermeasures for physician burnout, and 1,261 respondents (15.0%) responded. In this paper, we report the results of a comparison between male and female physicians. There was a significant difference in working and living conditions only for married people. It was confirmed that men work under stricter conditions in terms of working hours, and that the burden on women is heavier in the division of housework. Analysis using the Japanese Burnout Scale revealed no gender differences in overall scores, but as for factors related to burnout, in addition to factors common to both men and women, factors specific to men or women were clarified.

[Current and future strategies for burnout in Japanese neurologists].

To identify factors associated with burnout among Japanese physician and to use them in future measures, the Japanese Society of Neurology conducted a survey of neurologists on burnout using a web-based questionnaire in October 2019. A total of 1,261 respondents, 15.0% of the 8,402 members, responded to the survey. The mean of the subscales of the Japanese Burnout Scale was 2.86/5 points for emotional exhaustion, 2.21/5 points for depersonalization, and 3.17/5 points for lack of personal accomplishment. In addition, the burnout of our country's neurologists is not related to workloads such as working hours and the number of patients in charge, but also to a decreased meaningfulness and professional accomplishment. Therefore, it is necessary to take comprehensive measures to improve these issues at the individual, hospital, academic and national levels.

Does functional outcome in acute ischaemic stroke patients correlate with the amount of free-radical scavenger treatment? A retrospective study of edaravone therapy.

BACKGROUND: Edaravone is a free-radical scavenger that has been widely used for acute ischaemic stroke in Japan. However, the optimal total dosage of edaravone has not been established. OBJECTIVE: To clarify the relationship between the gain in functional recovery (rehabilitation gain) and the total amount of edaravone used for acute-phase therapy for cerebral infarction at a convalescent rehabilitation hospital. We also sought to determine if there were differences in outcome between stroke subtypes. METHODS: Medical records were retrospectively surveyed to identify patients who had received edaravone treatment for acute-phase cerebral infarction at Kawakita General Hospital, Tokyo, Japan, followed by recovery rehabilitation at Kawakita Rehabilitation Hospital, Tokyo, Japan, for > or = 30 days. Edaravone was initiated within 24 hours of stroke onset, and was administered as a 30 mg (1 ampoule) continuous intravenous infusion twice daily for up to 14 days. Patients were stratified into tertiles based on the total amount of edaravone used (measured in ampoules) during the acute phase (i.e. administration duration). Rehabilitation gain was defined as the change (increase) from convalescent rehabilitation hospital admission to discharge in the Functional Independence Measure-Motor (DeltaFIM-M) or Barthel Index (DeltaBI) score. RESULTS: Of the 72 enrolled patients, 21 belonged to the lower (short-term) tertile (0-14 ampoules), 27 to the middle (medium-term) tertile (15-23 ampoules) and 24 to the upper (long-term) tertile (24-33 ampoules) groups. There was no correlation between the total amount of edaravone used and the length of stay at an acute-phase hospital. However, a significant correlation was seen between the total amount of edaravone used and DeltaFIM-M (adjusted regression coefficient 0.81; p = 0.003) and DeltaBI (0.88; p = 0.005) score in patients with cardioembolic stroke; no significant correlation was seen in other stroke subtypes. Cardioembolic stroke patients also showed improvements in both FIM-M and BI score as the total amount of edaravone used increased. The difference between the short- and long-term group was 10.1 (95% CI 2.3, 17.8) for DeltaFIM-M score, and 12.0 (95% CI 2.8, 21.2) for DeltaBI score. Patients with atherothrombotic stroke showed a similar tendency with respect to DeltaBI score. CONCLUSION: Edaravone dose-dependently increases rehabilitation gain according to DeltaFIM-M and DeltaBI scores in patients with cardioembolic stroke, and a similar trend was also observed with respect to DeltaBI score in patients with atherothrombotic stroke. This suggests that the total amount of edaravone used is associated with its efficacy for rehabilitation gain.