Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update on organizational stroke management.

AIM: Stroke is characterised by high morbidity, mortality and disability, which seriously affects the health and safety of the people. Stroke has become a serious public health problem in China. Organisational stroke management can significantly reduce the mortality and disability rates of patients with stroke. We provide this evidence-based guideline to present current and comprehensive recommendations for organisational stroke management. METHODS: A formal literature search of MEDLINE (1 January 1997 through 30 September 2019) was performed. Data were synthesised with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The Chinese Stroke Association's Levels of Evidence grading algorithm was used to grade each recommendation. RESULTS: Evidence-based guidelines are presented for the organisational management of patients presenting with stroke. The focus of the guideline was subdivided into prehospital first aid system of stroke, rapid diagnosis and treatment of emergency in stroke centre, organisational management of stroke unit and stroke clinic, construction of regional collaborative network among stroke centres and evaluation and continuous improvement of stroke medical quality. CONCLUSIONS: The guidelines offer an organisational stroke management model for patients with stroke which might help dramatically.

A Stroke Care Model at an Academic, Comprehensive Stroke Center During the 2020 COVID-19 Pandemic.

BACKGROUND AND PURPOSE: The COVID-19 pandemic has required the adaptation of hyperacute stroke care (including stroke code pathways) and hospital stroke management. There remains a need to provide rapid and comprehensive assessment to acute stroke patients while reducing the risk of COVID-19 exposure, protecting healthcare providers, and preserving personal protective equipment (PPE) supplies. While the COVID infection is typically not a primary cerebrovascular condition, the downstream effects of this pandemic force adjustments to stroke care pathways to maintain optimal stroke patient outcomes. METHODS: The University of California San Diego (UCSD) Health System encompasses two academic, Comprehensive Stroke Centers (CSCs). The UCSD Stroke Center reviewed the national COVID-19 crisis and implications on stroke care. All current resources for stroke care were identified and adapted to include COVID-19 screening. The adjusted model focused on comprehensive and rapid acute stroke treatment, reduction of exposure to the healthcare team, and preservation of PPE. AIMS: The adjusted pathways implement telestroke assessments as a specific option for all inpatient and outpatient encounters and accounts for when telemedicine systems are not available or functional. COVID screening is done on all stroke patients. We outline a model of hyperacute stroke evaluation in an adapted stroke code protocol and novel methods of stroke patient management. CONCLUSIONS: The overall goal of the model is to preserve patient access and outcomes while decreasing potential COVID-19 exposure to patients and healthcare providers. This model also serves to reduce the use of vital PPE. It is critical that stroke providers share best practices via academic and vetted social media platforms for rapid dissemination of tools and care models during the COVID-19 crisis.

Conversion to secondary progressive multiple sclerosis: Multistakeholder experiences and needs in Italy.

BACKGROUND: Conversion to secondary progressive multiple sclerosis (SPMS) is associated with a relatively poor prognosis, and SPMS is responsible for the majority of the social and economic costs associated with MS. Managing the Transition to SPMS (ManTra) is a mixed methods project conducted in Italy and Germany aimed to set up a user-led resource to empower and improve the quality of life of newly diagnosed SPMS patients. AIMS: To assess the experiences and the needs of Italian people who recently converted to SPMS, patient significant others (SOs), neurologists and other health professionals (HPs). METHODS: We conducted 15 personal semistructured interviews (PSIs) with SPMS patients who transitioned up to five years, and three focus group meetings (FGMs), one of SPMS SOs, one of neurologists, and one of other HPs. Participants were purposely selected from the three geographic areas of Italy, and varied in terms of gender, education and (for patients) disease severity. PSIs and FGMs were audiorecorded, transcribed and analyzed by two researchers using the framework analysis. RESULTS: One hundred sub-categories were identified, grouped into 13 categories and four themes: 'awareness of the transition', 'communication of the transition', 'dealing with symptoms worsening', and 'needs'. The major unmet needs were collected in four dimensions 'organization and management; 'empowerment training'; 'information'; and 'policies'. CONCLUSIONS: Two are the main findings: first, the widespread lack of awareness around the transition; second, the need to improve the quality of the care pathway in the Italian context. It was particularly stressed the need for a holistic and multidisciplinary approach (with patients and SOs as members of the team), the development of an ad hoc plan of follow up visits with easy access to MS specialists' consultation/treatment; specialized training for each stakeholders; more information on SPMS, daily management and changes at policy level.

New-onset seizure survey of epilepsy centers in the United States.

OBJECTIVES: Children presenting with new-onset seizures have variable access to resources and may not receive timely and adequate treatment. Some may experience adverse consequences when not evaluated in a timely manner by appropriate medical providers. Consequences can be especially severe for children under the age of two and for children who have psychiatric, cognitive, and behavioral comorbidities. There are no published data on how children with new-onset seizure are evaluated and treated across the US. Our goal was to gain insight into how different epilepsy centers across the country evaluate and treat children with new-onset seizures. METHODS: We conducted a survey of Epilepsy Centers in the US that are part of the Pediatric Epilepsy Research Consortium (PERC) and focused on children presenting with new-onset seizures; PERC is a group of pediatric epilepsy providers and researchers who participate in collaborative multicenter research in pediatric epilepsy with the goal of improving outcomes in children with pediatric epilepsy. The questionnaire was developed by the authors of this study. It was designed to provide a descriptive assessment of the consistency and variability in how patients with new-onset seizure are evaluated and treated at epilepsy sites across the country. The questionnaire was designed to assure all points of interest were explored. The questions were aimed at describing access to care, how care is delivered, whether centers prioritize based on clinical presentation and/or age, and availability of resources. The survey was sent to 80 epileptologists at 42 different Epilepsy Centers that are part of PERC. RESULTS: Respondents included 29 pediatric epileptologists representing 24 unique centers. In the cases where there were multiple respondents from each center, response of the most senior epileptologist was used. It is possible that the senior epileptologist may have not known about the center as much as a junior epileptologist, but this was used to establish consistencies among centers with multiple respondents. Results showed that 30% of centers had a dedicated new-onset seizure clinic. The median time for children to be seen was two to four weeks, and 12% reported that it takes more than five weeks until the patient is seen. There was a trend toward centers with new-onset seizure clinic having less wait times. Most centers identified lack of adequate care based on insurance coverage, resources, long wait times, and long travel times. SIGNIFICANCE: Most centers (70%) do not have a dedicated new-onset seizure clinic. Children presenting with new-onset seizures often do not receive timely and comprehensive care because of limitations in resources and lack of established standard of care. Standardizing care for patients presenting with new-onset seizures has not yet occurred in the US. Many centers do not have a screening process and employ staff other than physicians or nurses for screening and triaging patients. This study shows that having a neurologist or epileptologist in charge of triaging does not reduce wait times. This survey revealed that there is substantial variability in how these patients are evaluated. Although this study shows a trend for epilepsy centers with new-onset seizure clinic having less wait times, even when there is a new-onset seizure clinic, wait times can be greater than five weeks. Overall, however, a new-onset seizure clinic may be an effective way to improve access to timely and efficient care for these patients.

The World Federation of Neurology and the challenges in Environment Neurology.

Since its establishment the World Federation of Neurology (WFN) has manifested a keen interest in the environment and its relation to neurological diseases. Thus, in 2007 the WFN renamed the "Neurotoxicological Research Group" to "Environmental Neurology Research Group". In this short article, we review some recent events which illustrate the WFN involvement in Environmental Neurology as well its concerns about global health matters involving environmental issues.

Integrating palliative care into neurology services: what do the professionals say?

OBJECTIVES: Evaluations of new services for palliative care in non-cancer conditions are few. OPTCARE Neuro is a multicentre trial evaluating the effectiveness of short-term integrated palliative care (SIPC) for progressive long-term neurological conditions. Here, we present survey results describing the current levels of collaboration between neurology and palliative care services and exploring the views of professionals towards the new SIPC service. METHODS: Neurology and palliative care teams from six UK trial sites (London, Nottingham, Liverpool, Cardiff, Brighton and Chertsey) were approached via email to complete an online survey. The survey was launched in July 2015 and consisted of multiple choice or open comment questions with responses collected using online forms. RESULTS: 33 neurology and 26 palliative care professionals responded. Collaborations between the two specialties were reported as being 'good/excellent' by 36% of neurology and by 58% of palliative care professionals. However, nearly half (45%) of neurology compared with only 12% of palliative care professionals rated current levels as being 'poor/none'. Both professional groups felt that the new SIPC service would influence future collaborations for the better. However, they identified a number of barriers for the new SIPC service such as resources and clinician awareness. CONCLUSIONS: Our results demonstrate the opportunity to increase collaboration between neurology and palliative care services for people with progressive neurological conditions, and the acceptability of SIPC as a model to support this. TRIAL REGISTRATION NUMBER: ISRCTN18337380; Pre-results.

Review of the novelties from the 32nd ECTRIMS Congress, 2016, presented at the 9th Post-ECTRIMS Meeting (II). / Revision de las novedades del XXXII Congreso ECTRIMS 2016, presentadas en la IX Reunion Post-ECTRIMS (II).

For the ninth year in a row the Post-ECTRIMS Meeting has been held in Madrid (Spain) with the aim of presenting and discussing the hottest issues debated at the ECTRIMS Congress by renowned specialists in multiple sclerosis in our country. One outcome of this scientific activity, endorsed by the Spanish Neurology Society, is this review article, which is published in two parts. This second part reflects the current controversy over the management of multiple sclerosis, especially as regards the progressive forms and their differential diagnosis. The work presents the latest advances in remyelination, where the use of the micropillar technique in laboratory stands out, and in neuroprotection, which is reviewed through a study of the optic nerve. Anti-CD20 antibodies are a very promising development and we find ourselves before a new mechanism of action and therapeutic target in cells to which little attention has been paid to date. Another notable fact is the high correlation between the levels of neurofilaments in cerebrospinal fluid and in serum, which could make it possible to avoid the use of cerebrospinal fluid as a biological sample in future studies of biomarkers. The review also provides a preview of the advances in clinical research, which will converge in clinical practice in the future, thereby conditioning the steps that should be taken in the therapeutic management of multiple sclerosis.

TITLE: Revision de las novedades del XXXII Congreso ECTRIMS 2016, presentadas en la IX Reunion Post-ECTRIMS (II).Por noveno año consecutivo se ha celebrado en Madrid (España) la Reunion Post-ECTRIMS con el objetivo de presentar y discutir los temas mas debatidos en el congreso ECTRIMS de la mano de reconocidos especialistas en esclerosis multiple de nuestro pais. Fruto de esta reunion cientifica, avalada por la Sociedad Española de Neurologia, se genera este articulo de revision que sale publicado en dos partes. En esta segunda parte se pone de manifiesto la controversia actual en el manejo de la esclerosis multiple, especialmente en cuanto a formas progresivas y diagnostico diferencial se refiere. Se presentan los ultimos avances en remielinizacion, donde destaca el uso de la tecnica con micropilares en el laboratorio, y en neuroproteccion, la cual se revisa a traves del estudio del nervio optico. Los anticuerpos anti-CD20 ofrecen grandes expectativas, y estamos ante un nuevo mecanismo de accion y diana terapeutica en unas celulas a las que les habiamos prestado poca atencion hasta la fecha. Otro hecho destacable es la elevada correlacion entre los niveles de neurofilamentos en el liquido cefalorraquideo y el suero, que podria evitar el uso del liquido cefalorraquideo como muestra biologica en futuros estudios de biomarcadores. Tambien se anticipan los avances en investigacion clinica que en el futuro acabaran convergiendo en la practica clinica, condicionando los pasos que se deberan seguir en el abordaje terapeutico de la esclerosis multiple.

The Interdisciplinary Management of Brain Metastases.

BACKGROUND: 20-40% of patients with malignant tumors have one or more brain metastases in the course of their illness. Brain metastases are the first manifestation of cancer in 5-10%. Manifestations such as intracranial hypertension or focal neurologic deficits are seen in over 80% of patients with brain metastases. Uncertainty surrounds the treatment of patients with intracranial metastases, as the existing data are derived from trials with low levels of evidence. METHODS: This article is based on a selective literature review and on the authors' own experience of 100 consecutive patients who underwent surgery at the Department of Neurosurgery at Ruhr University Bochum (RUB), Germany. RESULTS: Multimodal treatment enables successful surgery for an increasing number of patients with brain metastases. The modalities and goals of treatment are established for each patient individually by an interdisciplinary tumor board. Drug therapy is usually indicated. Surgical resection followed by stereotactic radiotherapy prolongs mean survival by 3-6 months and lowers the risk of recurrence from 40% to 12.5%. In the authors' own experience, even seriously ill patients can benefit from the resection of brain metastases. The 30-day morbidity was 29%, accounted for mainly by medical complications such as pulmonary embolism, renal failure, and sepsis. CONCLUSION: Through the close interdisciplinary collaboration of neurosurgeons, radiation oncologists, and medical oncologists, the symptomatic state and the prognosis of patients with brain metastases can be improved. Longer overall survival implies that further studies will have to pay special attention to the toxicity of treatment.

[How to convince the head of department and managing director of the importance of specialised headache clinics]. / Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.

In spite that headache is, by far, the most frequent reason for neurological consultation and that the diagnosis and treatment of some patients with headache is difficult, the number of headache clinics is scarce in our country. In this paper the main arguments which should allow us, as neurologists, to defend the necessity of implementing headache clinics are reviewed. To get this aim we should first overcome our internal reluctances, which still make headache as scarcely appreciated within our specialty. The facts that more than a quarter of consultations to our Neurology Services are due to headache, that there are more than 200 different headaches, some of them actually invalidating, and the new therapeutic options for chronic patients, such as OnabotulinumtoxinA or neuromodulation techniques, oblige us to introduce specialised headache attendance in our current neurological offer. Even though there are no definite data, available results indicate that headache clinics are efficient in patients with chronic headaches, not only in terms of health benefit but also from an economical point of view.

TITLE: Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.A pesar de que la cefalea es, con diferencia, el principal motivo neurologico de consulta, y de la complejidad diagnostica y terapeutica de algunos pacientes, el numero de consultas monograficas de cefalea (CC) y de unidades de cefalea (UC) es muy reducido en nuestro pais. En este articulo pasaremos revista a los principales argumentos que nos permitan, como neurologos, defender la necesidad de la implementacion de una CC/UC, dependiendo de la poblacion que se debe atender, en todos nuestros servicios de neurologia. Para ello deberemos, en primer lugar, vencer las reticencias internas, que hacen que la cefalea sea aun poco apreciada y atractiva dentro de nuestra especialidad. El hecho de que la cefalea justifique mas de un cuarto de las consultas a un servicio de neurologia estandar de nuestro pais y de que existan mas de 200 cefaleas diferentes, algunas de ellas realmente invalidantes, y las nuevas opciones de tratamiento para pacientes cronicos, como la OnabotulinumtoxinA para la migraña cronica o las tecnicas de neuromodulacion, obligan a introducir dentro de nuestras carteras de servicios la asistencia especializada en cefaleas. Aunque no disponemos de datos incontrovertibles, existen ya datos suficientes en la literatura que indican que esta atencion es eficiente en pacientes con cefaleas cronicas no solo en terminos de salud, sino tambien desde el punto de vista economico.

[Positioning of headache units in the field of neurology: the importance of OnabotulinumtoxinA and other therapies in the treatment of headaches]. / Posicionamiento de las unidades de cefalea en el ambito de la neurologia: la importancia de la OnabotulinumtoxinA y otras terapias en el tratamiento de la cefalea.

Chronic migraine is a disease that affects 0.5-2.5% of the population, depending on the statistics that are analysed and the definition of chronic migraine that is used. It is extraordinarily disabling, since it does not allow the sufferer to carry out any of their scheduled personal, professional or social activities, and it has a great impact on the patients' quality of life, as measured on disability, quality of life and impact on daily activities scales. Yet, nowadays there are treatments that have proven to be effective in cases of chronic migraine, such as OnabotulinumtoxinA. It is a treatment that is well tolerated and with a high rate of efficacy. Yet it is not only a therapeutic tool, but in the world of headaches it has also opened up the doors to invasive treatments, to the learning of techniques and, in short, to placing headaches in referral units that are usually located in tertiary care hospitals. Furthermore, it has also helped to overcome the idea that patients with headache should be visited exclusively by primary care physicians or general neurologists. This is an opportunity to redefine the field of study and the care for headaches that must be seized. In the future, this is going to be complemented by novel treatments with neurostimulation and probably with monoclonal antibodies against the calcitonin gene-related peptide. A revolution has begun in our knowledge and capacity to act. It is our duty to give it the importance and usage it deserves both for our patients and for us as specialists.

TITLE: Posicionamiento de las unidades de cefalea en el ambito de la neurologia: la importancia de la OnabotulinumtoxinA y otras terapias en el tratamiento de la cefalea.La migraña cronica es una enfermedad que afecta al 0,5-2,5% de la poblacion segun las estadisticas que se analicen y la definicion de migraña cronica que se adopte. Es extraordinariamente incapacitante, ya que no permite realizar las actividades personales, profesionales o sociales programadas, y tiene un gran impacto sobre la calidad de vida de los pacientes, medido en escalas de discapacidad, calidad de vida e impacto en la actividad diaria. Sin embargo, actualmente se dispone de tratamientos que han demostrado eficacia en la migraña cronica, como la OnabotulinumtoxinA. Es un tratamiento bien tolerado y con una tasa de eficacia elevada. Pero no es solo una herramienta terapeutica, sino que ha abierto las puertas en el mundo de la cefalea a la realizacion de tratamientos invasivos, al aprendizaje de tecnicas y, en definitiva, a situar la cefalea en unidades de referencia ubicadas, habitualmente, en hospitales de tercer nivel. Ademas, ha ayudado a eliminar el concepto de que los pacientes con cefalea deben ser atendidos exclusivamente por medicos de atencion primaria o neurologos generales. Esta es una oportunidad que debe aprovecharse para redimensionar el campo del estudio y asistencia de la cefalea. En el futuro, esto va a complementarse con novedosos tratamientos con neuroestimulacion y, probablemente, con anticuerpos monoclonales contra el peptido relacionado con el gen de la calcitonina. Se ha iniciado una revolucion en nuestro conocimiento y capacidad de actuacion. Es nuestro deber darle la importancia y uso que se merecen tanto para nuestros pacientes como para nosotros como especialistas.

[Organisation of headache units from a multidisciplinary point of view]. / Organizacion de las unidades de cefalea desde un punto de vista multidisciplinar.

Headache units have come into being to respond to the need to address the treatment of patients with complex headaches in a multidisciplinary manner. Although headaches are one of the most prevalent medical pathologies, it is surprising how little is being done to foster the development of such units. Within the multidisciplinary organisation, the role of the neurologist with adequate training in this field is essential. He or she is the person responsible for receiving, directing, supervising and coordinating the treatment, together with other medical specialties. The basic core of the team should consist of a psychiatrist, psychologist and physiotherapist. Their joint coordinated action generates an objective improvement in the pain over and beyond that achieved with each isolated treatment.

TITLE: Organizacion de las unidades de cefalea desde un punto de vista multidisciplinar.Las unidades de cefaleas surgen ante la necesidad de abordar de forma multidisciplinar el tratamiento de pacientes con dolores de cabeza complejos. A pesar de que las cefaleas son una de las patologias medicas mas prevalentes, es llamativa la poca promocion que existe para su desarrollo. Dentro de la organizacion multidisciplinar, el papel del neurologo debidamente formado en este campo es crucial. Es la persona encargada de recibir, dirigir, supervisar y coordinar el tratamiento, junto con otras especialidades medicas. Se debe contar con la participacion del psiquiatra, del psicologo y del fisioterapeuta como nucleo basico. Su actuacion conjunta y coordinada genera de forma objetiva una mejoria del dolor frente a cada tratamiento de forma aislada.

[Creation and enhancement of headache units: the view of neurologists and heads of neurology departments]. / Creacion y potenciacion de las unidades de cefalea: vision de los neurologos y jefes de servicio de neurologia.

Headache is the most common reason for visiting in neurology. Almost a third of all patients surveyed in this specialty visit for this reason. The gradual increase in the complexity of the care afforded to patients with headaches requires neurologists to become more specialised and leads to the creation of specialised units where this more complex care can be implemented. The heads of the neurology department are responsible for structuring and coordinating the different care units. This article shows the findings of a survey carried out on a group of heads of neurology departments in order to determine the current state of headache units, that is, their opinion regarding the creation, functioning and development of headache units in Spanish hospitals, and the parameters of their efficacy and effectiveness.

TITLE: Creacion y potenciacion de las unidades de cefalea: vision de los neurologos y jefes de servicio de neurologia.La cefalea constituye el motivo de consulta mas frecuente en neurologia. Casi la tercera parte de pacientes consultados en esta especialidad lo hace por este motivo. El gradual incremento en la complejidad de asistencia a pacientes con cefalea hace necesaria una mayor especializacion por parte de los neurologos y propicia la creacion de unidades especializadas donde desarrollar esta actividad asistencial mas compleja. La estructuracion y coordinacion de las distintas unidades asistenciales corresponde a los jefes de servicio de neurologia. En este articulo se recogen los resultados de una encuesta realizado a un grupo de jefes de servicio de neurologia para conocer el estado actual de las unidades de cefalea: su opinion sobre la creacion, funcion y desarrollo de unidades de cefalea en los hospitales españoles, y los parametros de eficacia y eficiencia de estas.

Unidades de Desarrollo Infantil, Neuropediatría, Genética clínica y Dismorfología: Atención integrada como factor clave / Child Development, Neuropediatries, Clinieal Geneties and Dysmorphology Units: Comprehensive care as a key factor

En este capítulo describimos brevemente la práctica diaria en las Unidades de Desarrollo Infantil, Neuropediatría, Genética clínica, y Dismorfología. Enumeramos las situaciones de riesgo y patologías más frecuentemente atendidas, y hacemos especial hincapié en la creación de equipos multidisciplinares. Estos equipos son imprescindibles para el diagnóstico preconcepcional y prenatal. Un aspecto clave de nuestra actividad es la detección precoz y prevención de las discapacidades en la infancia. Se requiere para ello una atención coordinada entre los servicios y recursos para una intervención temprana, lo que ofrecemos a través de un proceso de atención integrada centrado en las necesidades de los niños y sus familias. Este proceso incluye en este momento también niños y niñas y sus familias con enfermedades poco frecuentes (AU)

In this chapter we describe briefly the daily practice in Units of Child Development, Pediatric Neurology, Clinical Genetics and Dysmorphology. We list the situations of risk and pathologies most often served, and we make special emphasis on the creation of multidisciplinary teams. These teams are essential for preconception and prenatal diagnosis. A key aspect of our activity is the early detection and prevention of disabilities in children. Resources and services coordination tasks are required for early intervention, what we offer through a process of integrated care centered on the needs of children and their families. This process also includes children and their families with rare diseases at this time (AU)

[Establishment of diagnosis and treatment patterns of holistic integrated medicine for neuro-ophthalmology].

Neuro-ophthalmology, as an interdisciplinary, covers at least three disciplines- ophthalmology, neurology and neurosurgery. With limited knowledge in each discipline, doctors often make misdiagnoses for neuro-ophthalmology diseases. Therefore, it is imperative to abandon the distinction between disciplines and combine all the knowledge to diagnose and treat patients in patterns of holistic integrated medicine in order to effectively improve the diagnosis and treatment of neuro-ophthalmology.

Lack of experience of intravenous thrombolysis for acute ischaemic stroke does not influence the proportion of patients treated.

OBJECTIVES: To determine the eligibility of patients with ischaemic stroke admitted to the 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland, for intravenous thrombolysis; to identify the major exclusions and assess whether organisational changes in the in-hospital stroke pathway and informative campaign in the local community and medical services can increase the number of patients treated; and to establish whether lack of previous experience with thrombolytic treatment or trials is predictive of the low proportion of patients treated. METHODS: A survey of the database of patients with stroke admitted during the first 30 months after the introduction of intravenous thrombolysis for acute ischaemic stroke was conducted to search for all eligible patients. This included patients admitted within 2 h of symptom onset (assuming a 1 h door-to-needle time), age <80 years, National Institute of Health Stroke Scale (NIHSS) Score of 5-22, seizures at onset, platelet count >100,000/ml, glycaemia 50-400 mg/dl and international normalised ratio (INR) <1.6. The number of eligible patients was compared with the number actually treated. RESULTS: 745 patients with acute ischaemic stroke were admitted during the study period. 18.4% were admitted within 2 h of symptom onset, 71% were aged <80 years, 55.4% had an NIHSS score between 5 and 22, 96.1% had INR <1.6, 98.9% had a platelet count >100,000/ml, 99.4% had blood glucose concentrations of 50-400 mg/dl and 97.4% had no seizures at onset. After adjusting for all inclusion criteria, 7.1% of the patients were found to be potentially eligible and 8.7% were actually treated (p = 0.25). Of the 65 treated patients, 63.1% were independent after 3 months, 16.9% died and none had a symptomatic intracranial haemorrhage. CONCLUSIONS: The proportion of patients with ischaemic stroke treated with intravenous thrombolysis in a previously inexperienced centre was not lower than in other centres and in countries where this treatment has been provided for a longer period of time. The number of patients treated was higher than that estimated mainly owing to organisational changes introduced in our centre, allowing treatment of those admitted between 2 and 3 h after symptom onset.

NICU-the "I" stands for integrated.

NICU stands for Neuro Integrated Care Unit. With the integration philosophy, from the time of admission the patients remain in the NICU even though their status and priority change, until they are ready for discharge home or discharge to a rehabilitation unit. This integration enhances patient satisfaction and decreases length of stay by providing consistent caregivers who have expertise in critical care nursing as well as neuroscience nursing. The interdisciplinary teamwork done in the NICU eliminates the fragmented process that can occur when patients are transferred to several units. The NICU is a unique design that works well in this community hospital.

Center of excellence for headache care: group model at Kaiser Permanente.

OBJECTIVE: To evaluate the effectiveness of a disease management model for primary headache by: (1) assessing improvement in patients' quality of life, (2) decreasing headache-related visits to primary care and emergency departments, and (3) maintaining high levels of patient and physician satisfaction. BACKGROUND: Patients with headache regularly seek health care but, in general, are dissatisfied with the care they receive. Patients with primary headaches utilize resources and cost health plans more than patients with other chronic diseases. Primary care visits are time restricted, prohibiting adequate headache evaluation and management. Practice guidelines are inconsistently followed, and access to headache specialists is limited. This headache management program implemented an alternative means of delivering care to manage large volumes of patients with headache. A multidisciplinary team approach coordinated by a neurologist, utilizing education and a nurse practitioner as the main provider of care, was the central process of the program. METHODS: This was a pilot study involving a prospective cohort with defined outcome measures. Inclusion criteria were adult patients with primary headaches. Patients initially attended an educational session instructed by a neurologist and a nurse practitioner. The patient was subsequently evaluated by the nurse practitioner who developed and coordinated a comprehensive individual treatment plan. The Migraine-Specific Quality of Life and the Medical Outcomes Study 36-Item Short Form Questionnaires were completed at baseline, at follow-up visits, and 6 months after completion of the program. Subjective patient assessment of improvement in their headaches, chart review for tabulation of headache-related visits, and primary care physician satisfaction surveys were measured. RESULTS: Both the Migraine-Specific questionnaire and the Short Form-36 measurements demonstrated a statistically significant improvement at 8 weeks, and this was maintained for 6 months after completing the program. At completion of the program, 92% of patients reported subjective improvement. Patient visits for headaches to primary care and emergency departments showed a significant decrease. High levels of satisfaction for primary care physicians were achieved. CONCLUSIONS: A disease management model using a multidisciplinary team improved individualized patient care. This model increased patient/provider rapport and communication through an educational class. It empowered the patient to take control of their health care by utilizing shared decision making. Patient satisfaction improved and overall health care utilization was reduced.