A Young Adult with White Matter Changes and Recurrent Stroke Symptoms.

White matter changes on MRI can be a diagnostic puzzle as a large group of inflammatory, autoimmune, infectious, and neoplastic conditions can present in this way. An otherwise healthy 36-year-old male presented with his second episode of unilateral weakness, the first episode occurring five years previously. He did not have sensory or cerebellar symptoms with the current or previous episode. He reported that his grandfather, father, two of his aunts, and an uncle had multiple sclerosis (MS), dying in their 40s-50s from their disease. The MRI during his first hospitalization revealed acute ischemia as well as diffuse white matter hyperintensities. The current MRI revealed new ischemic changes as well as progression of the white matter hyperintensities with notable temporal lobe involvement. While small vessel disease and multiple sclerosis can present similarly, the history of stroke, lesion distribution, and family history suggested an alternative diagnosis. Due to high clinical suspicion, genetic testing was performed for CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) and confirmed the diagnosis. This case report describes the approach to the adult with white matter changes and describes the typical presentation and findings of CADASIL, the most common heritable cause of stroke and vascular dementia in adults.

Stroke Nurse Triage: Effects on Time Metrics at a Regional Stroke Center.

INTRODUCTION: Optimization of time metrics in the management of acute stroke is a priority. Nurses with special training in stroke management may contribute to enhanced delivery of care. This study analyzes the effects of initiating a nurse-led stroke triage program at a regional stroke center on time metrics of acute stroke. METHODS: In retrospective review, stroke metrics 25 months prior to the start of the triage program and 23 months after the start of the program were analyzed, including time from arrival to: emergency department assessment, neurologist assessment, head computed tomography (CT) scan, start of tissue plasminogen activator (tPA) administration, and puncture for mechanical thrombectomy. RESULTS: The study included 1,019 patients presenting with symptoms of acute stroke. Significant decrease was found between means for the time measures of arrival to emergency department (ED) physician assessment (pre-program: 6.2 minutes, post-program: 5.7 minutes, p= 0.0036), and CT start (pre-program: 21.3 minutes, post-program: 19.8 minutes, p= 0.0001). Time from arrival to ED physician assessment and CT start showed an increase in the proportion of cases meeting goal times: ED physician assessment increased from 82 percent to 84.4 percent of cases meeting the goal time (p= 0.3543), and CT start increased from 55.3 percent to 63.2 percent (p= 0.0481) of cases meeting the goal time. Significant increase was found between means for time from arrival to neurologist assessment (pre-program: 11.6 minutes, post-program: 17.1 minutes, p= 0.0015), and the proportion of cases meeting the goal time for arrival to neurologist assessment decreased (88.8 percent pre-program, 75.8 percent post-program). No significant differences were found for times from arrival to tPA administration and mechanical thrombectomy, or between Modified Rankin Scores (mRS) at discharge. CONCLUSIONS: Certain time-sensitive metrics of acute stroke care were improved after implementation of the stroke nurse triage program, particularly those related to immediate patient assessment within the ED. Time metrics related to the direct administration of stroke therapies were unaffected, indicating the need for recognition of additional factors affecting timely stroke management. Incorporating specially trained stroke nurses in acute stroke management may be an important component in efforts to improve time metrics of acute stroke.

The evolution of clinical outcomes in metastatic pancreatic adenocarcinoma: a 10-year experience at a tertiary referral center.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer mortality in the US. Recent studies have demonstrated survival benefits for FOLFIRINOX (5-FU, leucovorin, irinotecan, and oxaliplatin) and Gem/nab-P (gemcitabine/nab-paclitaxel) over gemcitabine. We aimed to evaluate the clinical outcomes of mPDAC before and after incorporating these newer regimens into the clinical practice. METHODS: A retrospective study of patients with mPDAC at our institution between 2009 and 2018, who were followed up until December 2019. Overall survival (OS) and progression-free survival (PFS) were calculated using Kaplan-Meier survival analysis. Univariate and multivariable Cox regression analyses were used to explore predictors of survival. RESULTS: A total of 394 patients with mPDAC were included: 122 (31%) were diagnosed 2009-2013 and 272 (69%) 2014-2018. In 2009-2013 cohort vs. 2014-2018 cohort, the median OS and PFS were similar (4 vs. 3.6 months, P = 0.5) and (2.3 vs. 2.5 months, P = 0.41), respectively. Age, ECOG-PS >1, serum albumin, neutrophil-to-lymphocyte ratio, and platelets-to-lymphocyte ratio were independent predictors of better OS. CONCLUSIONS: In this study of real-world data, the median OS and PFS for all patients with mPDAC were equivalent before and after incorporating newer treatment regimens into the clinical practice.