Co-morbid conditions in use of recombinant tissue plasminogen activator (rt-PA) for the treatment of acute ischaemic stroke.

BACKGROUND: The objective of this study was to characterize the comorbidities in a population of patients with an acute ischaemic stroke, comparing patients that received recombinant tissue plasminogen activator (rt-PA) to those that did not receive rt-PA. METHOD: In a retrospective sample of 663 patients admitted for acute ischaemic stroke, this study analysed the effects of co-morbid conditions in the use of rt-PA. It determined non-cerebrovascular risk factors (comorbidities) that differentiate patients who received rt-PA from those who did not receive rt-PA. RESULT: Patients with a history of carotid stenosis, CHF and previous strokes are significantly (p < 0.05) associated with high risk of not receiving rt-PA. A significant number of patients with a history of hypertension and smoking received rt-PA (p < 0.05). CONCLUSION: The findings indicate that certain risk factors including carotid stenosis, CHF and previous stroke history impact the treatment of patients with acute ischaemic stroke, specifically the decision to administer rt-PA. Treatment with rt-PA is dependent on stroke severity and onset to treatment time, but the findings suggest that rt-PA use may also depend on patient comorbidities.

Gender Differences in Exclusion Criteria for Recombinant Tissue-Type Plasminogen Activator.

BACKGROUND: Gender differences in the use of recombinant tissue-type plasminogen activator (r-tPA) in stroke are complicated. In this study, we investigated gender differences using r-tPA exclusion criterion in a stroke population. METHODS: We analyzed the data from ischemic stroke patients aged 18 years or older from the Greenville Health System stroke registry on r-tPA administration between January 2010 and December 2013. We identified exclusion criterion and used specific clinical factors to determine gender differences in stroke patients receiving r-tPA. RESULTS: Of the 633 patients who were eligible to receive r-tPA, less than half received r-tPA (n = 241) whereas 422 were not able to receive r-tPA. Of the 241 patients who received r-tPA, 49.4% were female and 50.6% were male. Of the 422 patients who did not receive r-tPA, more women (235) were excluded from r-tPA than men (187) (P < .05). There were no gender differences in warning signs and contraindications in female versus male stroke patients (P > .005). There were however gender differences in age group as more women (38%; n = 235) were more likely to be excluded if they are more than 80 years old than men (19%, n = 187). CONCLUSIONS: Within a large stroke population, exclusion criteria for r-tPA in women and men were similar with regard to race, initial National Institutes of Health Stroke Scale score, warning signs, and contraindications, but were different in the age group population exclusion criterion for intravenous r-tPA. We observed that intracerebral hemorrhage and match on computed tomography perfusion/magnetic resonance imaging or visible infarct greater than one third of the middle cerebral artery distribution were absolute criteria for exclusion.

Venous thrombosis with both heterozygous factor V Leiden (R507Q) and factor II (G20210A) mutations.

Both hereditary and acquired factors increase the risk of venous thromboembolism, thus the clinical management of affected patients involves evaluation of genetic factors that predispose to hypercoagulability. Factor V Leiden (R507Q) and factor II (prothrombin) mutation (G20210A) are the two most common inherited hypercoagulability disorders among populations of European origin. Both factor V Leiden and factor II mutation (G20210A) represent gain-of-function mutations: factor V Leiden causes resistance to activated protein C, and factor II mutation (G20210A) results in higher levels of plasma prothrombin. Herein, we present an uncommon case of combined factor V Leiden mutation (R507Q) and factor II mutation (G20210A), and discuss the prevalence and features of each entity, as well as their role in the clinical management of affected patients.

Developing the Neurology Diversity Officer: A Roadmap for Academic Neurology Departments.

Academic Neurology Departments must confront the challenges of developing a diverse workforce, reducing inequity and discrimination within academia, and providing neurologic care for an increasingly diverse society. A neurology diversity officer should have a specific role and associated title within a neurology department as well as a mandate to focus their efforts on issues of equity, diversity and inclusion that affect staff, trainees and faculty. This role is expansive and works across departmental missions but it has many challenges related to structural intolerance and cultural gaps. In this review, we describe the many challenges that diversity officers face and how they might confront them. We delineate the role and duties of the neurology diversity officer and provide a guide to departmental leaders on how to assess qualifications and evaluate progress. Finally, we describe the elements necessary for success. A neurology diversity officer should have the financial, administrative and emotional support of leadership in order for them to carry out their mission and to truly have a positive influence.

Reducing neurodisparity: Recommendations of the 2017 AAN Diversity Leadership Program.

Many advances in prevention, diagnosis, and treatment of neurologic disease have emerged in the last few decades, resulting in reduced mortality and decreased disability. However, these advances have not benefitted all populations equally. A growing body of evidence indicates that barriers to care fall along racial and ethnic lines, with persons from minority groups frequently having lower rates of evaluation, diagnosis, and intervention, and consequently experiencing worse neurologic outcomes than their white counterparts. The American Academy of Neurology (AAN) challenged its 2017 Diversity Leadership Program cohort to determine what the AAN can do to improve quality of care for racially and ethnically diverse patients with neurologic disorders. Developing a fuller understanding of the effect of disparities in neurologic care (neurodisparity) on patients is an important prerequisite for creating meaningful change. Clear insight into how bias and trust affect the doctor-patient relationship is also crucial to grasp the complexity of this issue. We propose that the AAN take a vital step toward achieving equity in neurologic care by enhancing health literacy, patient education, and shared decision-making with a focus on internet and social media. Moreover, by further strengthening its focus on health disparities research and training, the AAN can continue to inform the field and aid in the development of current and future leaders who will address neurodisparity. Ultimately, the goal of tackling neurodisparity is perfectly aligned with the mission of the AAN: to promote the highest-quality patient-centered neurologic care and enhance member career satisfaction.

Spinal cord infarction with multiple etiologic factors.

Spinal cord infarction is uncommon and usually presents with sudden onset of paralysis and sensory disturbances. A variety of causes are described, but rarely with multiple factors involved. We report a case of a 63-year-old man with a history of diabetes mellitus, hypertension, and osteoarthritis who presented with acute onset of chest pain, numbness, and weakness associated with episodic hypotension. He had incomplete tetraplegia and was areflexic without spasticity. Pain and temperature sensations were impaired below the C7 dermatome and absent below the T4 dermatome bilaterally. Proprioception and vibration sensations were diminished on the right below the C6 dermatome. Magnetic resonance imaging showed spinal cord infarction affecting C6-T3 segments, and severe cervical and lumbar spine degenerative changes. This case illustrates an unusual presenting symptom of spinal infarction, the need to identify multiple risk factors for spinal cord infarction, and the importance of optimal preventive therapy in patients at risk.