Impact and implementation of a sustainable regional telestroke network.

BACKGROUND: Telestroke uses videoconferencing technology to allow off-site experts to provide stroke thrombolysis decision support to less experienced front line clinicians. AIM: To assess the impact of a new telestroke service on thrombolysis rates and door-to-needle times in participating provincial hospitals and service resources to aid transition to a sustainable telestroke service. METHODS: This is a sequential comparison of 'pre' (December 2015 to May 2016) and 'post' (June 2016 to December 2016) implementation outcomes. The main outcomes were thrombolysis rate and door-to-needle time. All patient data were captured prospectively in a central database. Data captured and analysed also included technical problems, consumer and clinician feedback, and additional service resources required. RESULTS: Over the study period, 164 telestroke assessments were completed, including the 'hub' hospital. Among the participating provincial hospitals, 21 of 343 patients (6.1%) were thrombolysed in the 6-months prior to June 2016 and 50 of 318 patients (15.7%) during the 6-month following implementation of telestroke; odds ratio 2.86 (95% confidence interval 1.68-4.89); P = 0.0001. Overall, mean (standard deviation) regional hospital door-to-needle time reduced from 79.6 (31.4) to 62.7 (23.3) min (P = 0.015). Videoconferencing failure occurred in 4.8% of cases. Consumer and clinician feedback was positive. The main resource challenge was doubling of out-of-hours neurologist workload. CONCLUSION: Telestroke was associated with a significant increase in thrombolysis rate and reduction in door-to-needle time in provincial hospitals indicating improved patient care. Quantification of the extra neurologist workload allowed for a seamless transition to 'business as usual' using a novel annual subscription funding and service model.

International Telestroke: The First Five Cases.

Telestroke services can improve access to stroke thrombolysis. To address challenges of night time coverage we explored the feasibility of an international telestroke service between Scotland and New Zealand taking advantage of international time zone differences. After addressing medico-legal, governance, and technical issues we tested this international service model and here we present the first 5 cases. Based on our initial experience this new model of care appears feasible and has the potential to improve patient care through reduced doctor fatigue and improved access to expert care in regions where stroke specialist input is limited.

Utility of a primary care based transient ischaemic attack electronic decision support tool: a prospective sequential comparison.

BACKGROUND: Stroke is a major cause of death and disability worldwide. Reducing the incidence of stroke has the potential to not only improve health outcomes, but also lead to significant cost savings for health services. Transient ischaemic attacks (TIA) can herald an imminent stroke and following a TIA early initiation of best medical therapy significantly reduces the risk of subsequent stroke. To achieve time targets rapid access stroke specialist services have been promoted; however, a number of resource related barriers can impede specialist access and cause unnecessary time delays. Cross sector collaboration led to the development of a primary care based TIA/Stroke electronic decision support (EDS) tool. This study aimed to assess the impact of this tool on improving access and reducing management delays. METHODS: This is a prospective before (2009) versus after (2011) study of the effect on process of care following the implementation of EDS assisted TIA management in primary care. All patients presenting with TIA to secondary services were included. Outcomes assessed were TIA Guideline adherence and patient safety. RESULTS: Over the study period 266 patients presented for TIA assessment (130 in 2009 and 136 in 2011). Following EDS implementation the median delay to specialist assessment fell from 10 days in 2009 to three days in 2011 (HR 1.45; 95% CI 1.13-1.86; p=0.001), the number of patients achieving optimal medical therapy within 24 hours rose from 43% to 57% (RR 1.33; 95% CI 1.02-1.71; p=0.04), carotid and CT imaging were achieved significantly faster (HR 1.52 (1.02-2.26) p=0.003 and HR 1.34 (1.16-1.78 p=0.002) respectively), and there were no adverse events associated with EDS use. CONCLUSION: The availability of TIA/Stroke electronic decision support in the primary care setting was associated with reductions in management delays without compromising patient safety.

Incidence of motor neurone disease within MidCentral Region, New Zealand.

AIM: The aims of this observational study were firstly to calculate annual incidence of motor neurone disease (MND) within the midcentral region of New Zealand and secondly to characterise the demographics of this patient group, including age, sex, ethnicity and geographical distribution within the region. METHOD: Patients with a new diagnosis of MND over a five-year period (1 February 2013-31 January 2018) were identified via a clinical coding search of all outpatient and inpatient encounters. Records were then individually screened to confirm a new diagnosis of MND via both clinical (confirmation by a neurologist) and neurophysiological (needle electromyography) criteria. RESULTS: Twenty-five new diagnoses of MND were identified. The incidence was 2.9 per 100,000/year. Mean and median age at diagnosis were 69 and 72 respectively (range 38-84), and the male:female ratio was 13:12. Of the 25 identified cases, 21 (84%) were of European descent, two (8%) of Maori descent, and two of undetermined ethnicity. DISCUSSION: The findings from this study (incidence of 2.9/100,000) are in concordance with the higher incidence of MND found in other regions of New Zealand compared with other areas of the world. Further studies are warranted to investigate incidence in other regions, thereby building the foundations for the study of genetic and environmental factors.

Long-term amnesia: a review and detailed illustrative case study.

Long-term amnesia is a slowly developing form of anterograde amnesia accompanied by retrograde amnesia of variable severity (Kapur, 1996; 1997) often associated with damage to the anterior temporal neocortex and epileptic seizures. The precise neural and functional deficits that underlie this condition are unknown. A patient, JL, who has this condition following a closed-head injury, is described in detail. Her injury caused bilateral anterior temporal neocortex damage that was more extensive on the left and right-sided damage to the perirhinal and orbitofrontal cortices. The hippocampus appeared to be intact bilaterally. Epilepsy developed within two years of JL's injury. Apart from her memory impairments, JL's cognitive functions, including high-level visual perception, attention, semantic memory and executive functions were well preserved. Her memory also seemed well preserved for at least 30 minutes following encoding. The one exception was the patient's relatively greater impairment at difficult visual recognition tests for which verbalization may not have been an effective strategy. This problem may have been caused by JL's right-sided perirhinal and orbitofrontal cortex damage. Her recall and recognition was clearly impaired after a three-week delay. She also showed a retrograde amnesia, which appeared to be milder than her remote post-morbid memory deficit. JL's remote memory was preserved for information first encountered in either the pre- or post-morbid period provided the information had received sufficient rehearsal over long periods of time. Her long-term amnesia may have been caused by anterior temporal neocortex damage, possibly in association with her epileptic seizures. Whether the condition is heterogeneous, involves a deficit in slow consolidation, disruption of unconsolidated memories, or blockage of maintenance or disruption of insufficiently rehearsed memories whether or not these have been slowly consolidated is discussed.

Who should manage transient ischemic attacks? A comparison between stroke experts, generalists, and electronic decision support.

AIMS: Rapid expert management of transient ischemic attacks (TIA) has been shown to reduce the incidence of stroke, but is not always achievable. This study aims to demonstrate that TIA management by stroke experts is indeed more guideline adherent than that of generalists and that a TIA/stroke electronic decision support (EDS) tool closely mimics expert advice and improves guideline adherence. METHODS: 11 general practitioners (GPs), 12 general physicians, and 12 stroke specialists assessed and provided management plans for 7 hypothetical patients with potential TIAs. Responses were compared with the advice provided when patient data was entered into a TIA/stroke EDS programme. RESULTS: Diagnosis and medical management was highly consistent and guideline adherent amongst stroke experts. Diagnostic accuracy was lower in the GP and general physician groups (76% and 79% respectively) and only one-third of generalists initiated best medical therapy when indicated. The TIA/stroke EDS consistently agreed with expert diagnosis, investigations, and medical management and provided most comprehensive lifestyle advice. COCNLUSION: This study (a) confirms that stroke expert care achieves higher guideline adherence and (b) provides validation that the TIA/stroke EDS tool is able to mimic expert advice and can reliably apply best practice guidelines.

Safety and efficacy of stroke thrombolysis at a secondary provincial hospital in New Zealand.

AIMS: Stroke thrombolysis with alteplase is the most effective therapy for acute ischaemic stroke. Most trial data comes from tertiary centres. This study set out to assess safety and efficacy of thrombolysis at a secondary provincial centre in New Zealand. METHODS: A retrospective 3-year audit was performed to assess efficacy and safety of altepase at a secondary provincial hospital in New Zealand. RESULTS: Out of 27 patients receiving treatment 17 (62.3%) improved and 10 (37.0%) enjoyed essentially complete symptom resolution (mRS=0 or 1). There was one symptomatic intracranial haemorrhage (3.7%). CONCLUSION: Administration of intravenous alteplase for ischaemic stroke patients is effective and safe in the secondary provincial setting if local protocols are used, patient selection is stringent, and care is supervised by neurologists with training/experience in stroke care and thrombolysis. Aspects of thrombolysis-related management issues in this study population are discussed.

Safety and efficiency of non-contact first specialist assessment in neurology.

AIM: To investigate safety and efficiency of non-contact first specialist assessments (NCFSA) in neurology. METHODS: Out of a cohort of 1107 patients referred to a neurology clinic, a total of 222 (20%) was triaged into NCFSA and investigated with a 6 months observational study of safety and efficiency indicators. RESULTS: There were three (1.35%) adverse events (delay in diagnosis) recorded, one of which with actual detriment to the patient. After 6 months the rate of re-referrals was 11.26%, and inpatient admission rate 5.86%. CONCLUSIONS: There is a potential for NCFSAs to optimise the use of available resources in a neurology outpatient setting with low risk of delay in diagnosis.

Carotid endarterectomy: a Southern North Island regional consensus statement.

AIMS: The aim of this project was to employ interdepartmental and cross district health board collaboration to reach a regional consensus on the management of patients who may benefit from carotid endarterectomy. METHODS: All regional stroke physicians, neurologists, and vascular surgeons met to review relevant literature and local audits and to discuss best management strategies suited to the region. RESULTS: A consensus statement was agreed upon and is presented here along with a summary of the supporting scientific evidence. DISCUSSION: Regional interdisciplinary collaboration proved an effective way to reach a carotid endarterectomy management consensus across a wider geographical area that is served by a single vascular surgery department. This approach could serve as a model for other regional initiatives.

Segmental recording of cortical motor evoked potentials from thoracic paravertebral myotomes in complete spinal cord injury.

STUDY DESIGN: A study of thoracic paravertebral muscle motor-evoked potentials using transcranial magnetic stimulation in spinal cord injury patients and control participants. OBJECTIVES: To develop a method to study the level and density of corticospinal lesions in thoracic spinal cord injury. SUMMARY OF BACKGROUND DATA: Cervical and lumbar spinal cord injury, unlike thoracic spinal cord injury, can be quantified by recording muscle motor-evoked potentials from limb muscles. For thoracic spinal cord injury, the use of paravertebral muscles is limited by complex innervation patterns and the greater difficulty in obtaining muscle motor-evoked potentials. METHODS: In 10 patients with complete midthoracic spinal cord injury (T4-T7) and 10 age-matched control participants, muscle motor-evoked potentials were recorded from all thoracic paravertebral muscles using transcranial magnetic stimulation with a double-cone stimulating coil over the vertex. RESULTS: In control participants, muscle motor-evoked potential responses evoked in all myotomes had progressively increasing latency in a rostrocaudal direction. Threshold was comparable in all segments. The duration of muscle motor-evoked potentials was unrelated to the spinal level. In spinal cord injury, responses were elicited in all segments above a lesion and in a varying range of segments below the lesion. In comparison with control participants, threshold was lower above and higher below the lesion (P < 0.001) in patients with spinal cord injury. Latency was longer than normal both above and below the lesion (P < 0.001). Duration was not significantly different from that in control participants at any level. CONCLUSIONS: Paravertebral muscle motor-evoked potentials can be elicited below the level of a complete spinal cord injury. Possible reasons for this include the multisegmental innervation of these muscles and the long muscle fiber conduction. Stretch reflex activation elicited by contraction of muscles above the lesion is thought to be an unlikely mechanism because of the latency of the response. Although the presence or absence of muscle motor-evoked potentials does not appear to be a sensitive indicator of the level of thoracic spinal cord injury lesion, analysis of muscle motor-evoked potentials reveals abnormal patterns that may assist in defining lesions. Finally, lower threshold above the lesion suggests corticospinal hyperexcitability of this pathway as a result of central plasticity after spinal cord injury.