Novel Use of a Nurse-Led Telemedicine Team in Acute Stroke: A Retrospective Review of the Impact on a Regional Health Care System.

INTRODUCTION: Despite the increasing incidence of acute ischemic stroke in the United States, many health care facilities remain unprepared to manage patients with acute stroke, including the administration of intravenous alteplase (recombinant tissue plasminogen activator [rTPA]). This has led to an opportunity for telemedicine systems to facilitate these evaluations and acute medical stroke treatment decisions. However, even telemedicine systems can fail to provide timely evaluation and management of the patient with acute stroke. The purpose of this retrospective study was to compare stroke outcome metrics pre- and postimplementation of a hybrid, local nurse-led "stroke-responder" telemedicine system. METHODS: A retrospective chart review was performed on 21 patients at a regional community hospital between the years of 2014 and 2016. Data were collected pre- and postimplementation of a local stroke-responder system. Outcomes obtained included door-to-alert time, door-to-computerized tomography (CT) time, door-to-rtPA order time, and door-to-rtPA bolus dose administration time. Outcomes were compared among years. RESULTS: Between 2014 and 2016, 21 charts were reviewed. Decreased mean times were observed for all metrics. The mean time for door-to-alert decreased from 21.19 to 5.84 minutes (P = 0.021), door-to-CT from 29.9 to 12.2 minutes (P = 0.022), door-to-rtPA order 88.4 to 53 minutes (P = 0.021), and door-to-rtPA administration from 106.94 to 64.65 minutes (P = 0.001). CONCLUSION: In an acute stroke telemedicine system, implementation of a local nurse-led "stroke responder" system resulted in significantly decreased acute stroke metrics for a community hospital within a regional hospital system.

Serum activity of angiotensin converting enzyme 2 is decreased in patients with acute ischemic stroke.

Levels of angiotensin converting enzyme 2 (ACE2), a cardio and neuro-protective carboxypeptidase, are dynamically altered after stroke in preclinical models. We sought to characterize the previously unexplored changes in serum ACE2 activity of stroke patients and the mechanism of these changes. Serum samples were obtained from patients during acute ischemic stroke (n=39), conditions mimicking stroke (stroke-alert, n=23), or from control participants (n=20). Enzyme activity levels were analyzed by fluorometric assay and correlated with clinical variables by regression analyses. Serum ACE2 activity was significantly lower in acute ischemic stroke as compared to both control and stroke-alert patients, followed by an increase to control levels at three days. Serum ACE2 activity significantly correlated with the presence of ischemic stroke after controlling for other factors (P=0.01). Additional associations with ACE2 activity included a positive correlation with systolic blood pressure at presentation in stroke-alert (R(2)=0.24, P=0.03), while stroke levels showed no correlation (R(2)=0.01, P=0.50). ACE2 sheddase activity was unchanged between groups. These dynamic changes in serum ACE2 activity in stroke, which concur with preclinical studies, are not likely to be driven primarily by acute changes in blood pressure or sheddase activity. These findings provide new insight for developing therapies targeting this protective system in ischemic stroke.

Identification of acoustically similar and dissimilar vowels in profoundly deaf adults who use hearing aids and/or cochlear implants: some preliminary findings.

PURPOSE: In this study, the authors examined the effects of aging and residual hearing on the identification of acoustically similar and dissimilar vowels in adults with postlingual deafness who use hearing aids (HAs) and/or cochlear implants (CIs). METHOD: The authors used two groups of acoustically similar and dissimilar vowels to assess vowel identification. Also, the Consonant-Nucleus-Consonant Word Recognition Test (Peterson & Lehiste, 1962) and sentences from the Hearing in Noise Test (Nilsson, Soli, & Sullivan, 1994) were administered. Forty CI recipients with postlingual deafness (ages 31-81 years) participated in the study. RESULTS: Acoustically similar vowels were more difficult to identify than acoustically dissimilar vowels. With increasing age, performance deteriorated when identifying acoustically similar vowels. Vowel identification was also affected by the use of a contralateral HA and the degree of residual hearing prior to implantation. Moderate correlations were found between speech perception and vowel identification performance. CONCLUSIONS: Identification performance was affected by the acoustic similarity of the vowels. Older adults experienced more difficulty identifying acoustically similar confusable vowels than did younger adults. The findings might lend support to the ease of language understanding model (Ronnberg, Rudner, Foo, & Lunner, 2008), which proposes that the quality and perceptual robustness of acoustic input affects speech perception.

Limbic, associative, and motor territories within the targets for deep brain stimulation: potential clinical implications.

The use of deep brain stimulation (DBS) has recently been expanding for the treatment of many neurologic disorders such as Parkinson disease, dystonia, essential tremor, Tourette's syndrome, cluster headache, epilepsy, depression, and obsessive compulsive disorder. The target structures for DBS include specific segregated territories within limbic, associative, or motor regions of very small subnuclei. In this review, we summarize current clinical techniques for DBS, the cognitive/mood/motor outcomes, and the relevant neuroanatomy with respect to functional territories within specific brain targets. Future development of new techniques and technology that may include a more direct visualization of "motor" territories within target structures may prove useful for avoiding side effects that may result from stimulation of associative and limbic regions. Alternatively, newer procedures may choose and specifically target non-motor territories for chronic electrical stimulation.

Deep brain stimulation of the internal segment of the globus pallidus in delayed runaway dyskinesia.

BACKGROUND: Dyskinesias that occur during a period without medication after embryonic cell transplantation have been commonly reported in double-blind trials; however, to date, they have not been reported in the few patients who participated in open-label pilot studies. DESIGN: Single case observation with preoperative and postoperative data, and intraoperative single-cell physiology. PATIENT: A patient who underwent embryonic cell transplantation in 1993 as part of the University of South Florida open-label study was referred for evaluation of intractable dyskinesia of the right arm. The dyskinesia was present during evaluation of the patient after a 12-hour period without medication and was clinically disabling. It was manifested as a severe groping movement of the hand. Intraoperative physiologic evaluation revealed decreased firing rates in the internal segment of the globus pallidus. RESULTS: Deep brain stimulation of the internal segment of the globus pallidus resulted in resolution of the dyskinesia. CONCLUSION: This case highlights the delayed development of runaway dyskinesia after a period without medication as an important potential long-term adverse effect of embryonic cell transplantation in patients with Parkinson disease.