A Scoping Review of mHealth Interventions for Secondary Prevention of Stroke: Implications for Policy and Practice.

Secondary prevention is a major priority for those living with stroke and may be improved through the use of mobile Health (mHealth) interventions. While evidence for the effectiveness of mHealth interventions for secondary prevention of stroke is growing, little attention has been given to the translation of these interventions into real-world use. In this review, we aimed to provide an update on the effectiveness of mHealth interventions for secondary prevention of stroke, and investigate their translation into real-world use. Four electronic databases and the gray literature were searched for randomized controlled trials of mHealth interventions for secondary prevention of stroke published between 2010 and 2023. Qualitative and mixed-methods evaluations of the trials were also included. Data were extracted regarding study design, population, mHealth technology involved, the intervention, and outcomes. Principal researchers from these trials were also contacted to obtain further translational information. From 1151 records, 13 randomized controlled trials and 4 evaluations were identified; sample sizes varied widely (median, 56; range, 24-4298). Short message service messages (9/13) and smartphone applications (6/13) were the main technologies used to deliver interventions. Primary outcomes of feasibility of the intervention were achieved in 4 trials, and primary outcomes of changes in risk factors, lifestyle behaviors, and adherence to medication improved in 6 trials. Only 1 trial had a hard end point (ie, stroke recurrence) as a primary outcome, and no significant differences were observed between groups. There was evidence for only 1 intervention being successfully translated into real-world use. Further evidence is required on the clinical effectiveness of mHealth interventions for preventing recurrent stroke, and the associated delivery costs and cost-effectiveness, before adoption into real-world settings.

Single-step Optimization in Triaging Large Vessel Occlusion Strokes: Identifying Factors to Improve Door-to-groin Time for Endovascular Therapy.

INTRODUCTION: Although acute stroke endovascular therapy (EVT) has dramatically improved outcomes in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO), access to EVT-capable centers remains limited, particularly in rural areas. Therefore, it is essential to optimize triage systems for EVT-eligible patients. One strategy may be the use of a telestroke network that typically consists of multiple spoke sites that receive a consultation to determine appropriateness of patient transfer to an EVT-capable hub site. Standardization of AIS protocols may be necessary to achieve target door-to-groin (DTG) times of less than 60 minutes in EVT-eligible patients upon hub arrival. Specifically, the decision to obtain vascular imaging at the transferring hub site vs delaying until arrival at the hub is controversial. The purpose of this study was to identify factors associated with reduced DTG time in LVO-AIS patients. METHODS: We performed a retrospective chart review for all patients treated over a 3.5-year period at our home hub institution. Patients were classified as telestroke transfers, non-telestroke transfers, and direct-to-hub presentations. We recorded demographic information, DTG time, reperfusion status, length of stay (LOS), functional status at discharge, seven-day mortality, and the site where vascular imaging- computed tomography angiography (CTA)-was obtained. We performed binary logistic regression to identify factors associated with DTG <60 minutes. RESULTS: In the sample of EVT-eligible patients (n = 383), CTA was performed at the spoke site prior to transfer to the hub institution in 53% of cases. Further, 59% of telestroke transfer cases received a CTA prior to transfer compared to only 40% of non-telestroke transfers (59 vs 40%, P = 0.01). A Door-to-groin time <60 minutes was achieved in 67% of transfer patients who received pre-transfer CTA compared to only 22% of transfer patients who received CTA upon hub arrival and 17% of patients who presented directly to the hub. Ultimately, transfer patients who received CTA prior to transfer were 7.2 times more likely to have a DTG <60 minutes compared to those who did not (OR 7.2, 95% confidence interval 3.5-14.7; P < 0.001). CONCLUSION: Pre-transfer computed tomography angiography was the only significant predictor of achieving target door-to-groin times of less than 60 minutes. Because DTG time has been well established as a predictor of clinical outcomes, including pre-transfer CTA in a standardized acute ischemic stroke protocol may prove beneficial. Our findings also illustrate the need to optimize direct-to-hub stroke alerts and telestroke relationships to minimize workflow disruptions, which became more apparent during the pandemic.

Analysis of Telestroke Usage in Rural Critical Access Emergency Departments.

Introduction: Telestroke is an effective strategy to increase appropriate stroke treatments among patients in resource-limited environments. Despite the well-documented benefits of telestroke, there is limited literature regarding its utilization. The purposes of this study are: (1) determine the percentage of potential stroke patients who generate a telestroke consult in rural critical access hospitals (CAHs) and (2) validate an electronic medical record (EMR)-derived report as a stroke screen. Methods: This retrospective chart review analyzed patients presenting between September 1, 2020 and February 1, 2021 to three CAHs. Visits with triage complaints suggesting acute ischemic stroke (AIS)/transient ischemic attack (TIA) were pooled for analysis using an EMR-derived report. Patients with confirmed AIS/TIA at discharge over this period were used to validate the EMR tool. Results: The EMR report pooled 252 possible AIS/TIA visits out of 12,685 emergency department visits for analysis. It had a specificity of 98.78% and sensitivity of 58.06%. Of the 252 visits, 12.7% met telestroke criteria and 38.89% received telestroke evaluation. Among these, a definite diagnosis of AIS/TIA was made in 92.86%. Of the remaining population who met criteria but didn't undergo consultation, 61.11% were diagnosed with AIS/TIA at discharge. Conclusion: This study provides novel characterization of stroke presentations and telestroke in rural CAHs. The EMR-derived report is a reasonable tool to concentrate potential AIS/TIA cases for review and resource allocation but is not sensitive enough to detect stroke as a stand-alone tool. The majority (56%) of eligible patients did not undergo telestroke consultation. Future studies are critical to further understand reasons contributing to this.

Incidence of Atrial Fibrillation in Large Vessel Occlusion and Large Embolic Stroke of Undetermined Source.

INTRODUCTION: Large vessel occlusion (LVO) stroke is a common presentation of acute ischemic stroke and is often unknown or cryptogenic in etiology. There is a strong association between atrial fibrillation (AF) and cryptogenic LVO stroke, making it a unique stroke subgroup. Therefore, we propose that any LVO stroke meeting the criteria for an embolic stroke of an undetermined source (ESUS) be classified as large ESUS (LESUS). The purpose of this retrospective cohort study was to report the etiology of anterior LVO strokes that underwent endovascular thrombectomy. METHODS: This was a single-center retrospective cohort study characterizing the etiology of acute anterior circulation LVO strokes that received emergent endovascular thrombectomy from 2011 to 2018. Patients with LESUS designation at hospital discharge were changed to cardioembolic etiology if AF was discovered during the two-year follow-up period.  Results: Overall, 155 (45%) of 307 patients in the study were found to have AF. New onset AF was discovered in 12 (23%) of 53 LESUS patients after hospitalization. Furthermore, eight (35%) of 23 LESUS patients who received extended cardiac monitoring were found to have AF. CONCLUSION: Nearly half the patients with LVO stroke who received endovascular thrombectomy were found to have AF. With the use of extended cardiac monitoring devices after hospitalization, AF is frequently discovered in patients with LESUS and may change the secondary stroke prevention strategy.

Neutrophil lymphocyte ratio (NLR) and systemic immune inflammatory index (SII) for the differential diagnosis of CT-negative mild acute ischemic stroke and transient ischemic attack.

Background: A number of acute ischemic stroke (AIS) cases may be misdiagnosed as transient ischemic attack (TIA), due to no infarct on initial computed tomography scan and/or mild deficits upon presentation. Several studies have found that the neutrophil-lymphocyte ratio (NLR) is an accurate differential diagnostic biomarker for AIS versus TIA; however, no study has evaluated the use of the NLR in differentiating CT negative AIS from TIA. Furthermore, the systemic immune-inflammation index (SII) is a relatively novel immune biomarker that has been shown to be positively correlated with AIS severity, poor functional outcomes and mortality. The purpose of this study is to determine if NLR or SII can be used as a diagnostic biomarker for the differential diagnosis of mild AIS with a negative CT upon admission and TIA. Methods: We performed a retrospective medical record review of patients diagnosed with either AIS or TIA. We collected peripheral white blood cell counts within 24 h of symptom onset and calculated the NLR and SII. Logistic regression was utilized to determine if NLR or SII are significant predictors of CT negative mild AIS. Results: CT negative mild AIS patients were 2 times as likely to have an NLR ≥ 2.71 compared to TIA patients, and CT negative mild AIS patients were 2.1 times as likely to have an SII ≥ 595 compared to TIA patients. Conclusion: NLR and SII are easily obtained biomarkers that can be used in early clinical decision making in cases of mild AIS with negative CT scan upon admission.

Spatiotemporal Correlation Analysis of Hydraulic Fracturing and Stroke in the United States.

Hydraulic fracturing or fracking has led to a rapid growth of oil and gas production in the United States, but the impact of fracking on public health is an important but underresearched topic. We designed a methodology to study spatiotemporal correlations between the risk of fracking and stroke mortality. An annualized loss expectancy (ALE) model is applied to quantify the risk of fracking. The geographically and temporally weighted regression (GTWR) model is used to analyze spatiotemporal correlations of stroke mortality, fracking ALE, and nine other socioeconomic- and health-related factors. The analysis shows that fracking ALE is moderately correlated with stroke mortality at ages over 65 in most states of fracking, in addition to cardiovascular disease and drug overdose being positively correlated with stroke mortality. Furthermore, the correlations between fracking ALE and stroke mortality in men appear to be higher than in women near the Marcellus Shale, including Ohio, Pennsylvania, West Virginia, and Virginia, while stroke mortality among women is concentrated in the Great Plains, including Montana, Wyoming, New Mexico, and Oklahoma. Lastly, within two kilometers of the fracking mining activity, the level of benzene in the air was found to be significantly correlated with the fracking activity in Colorado.

Trends in Use, Outcomes, and Disparities in Endovascular Thrombectomy in US Patients With Stroke Aged 80 Years and Older Compared With Younger Patients.

Importance: Patients aged 80 years and older were often excluded or underrepresented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis. Objective: To delineate temporal trends in EVT use, outcomes, and disparities among patients with acute ischemic stroke aged 80 years and older vs those younger than 80 years. Design, Setting, and Participants: A US nationwide retrospective cohort study using prospectively collected data was conducted in patients admitted with a primary diagnosis of acute ischemic stroke between April 1, 2012, and June 30, 2019. Data were obtained from hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, which is a stroke quality improvement registry, with data collected prospectively, sponsored by the American Heart Association/American Stroke Association. Data analysis was conducted from November 2, 2020, to June 25, 2021. Exposures: Potentially eligible for EVT based on arrival within 6 hours and National Institutes of Health Stroke Scale score greater than or equal to 6. Main Outcomes and Measures: Efficacy outcomes included discharge to home, independent ambulation at discharge, and functional independence (modified Rankin Scale score 0-2) at discharge. Safety outcomes included in-hospital mortality, combined in-hospital mortality or discharge to hospice, and symptomatic intracranial hemorrhage. Results: Among 302 965 patients with ischemic stroke meeting study criteria as potentially eligible for EVT admitted to 614 GWTG-Stroke hospitals, 14.0% (42 422) received EVT (21 634 women [51.0%]), including 10.7% (12 768 of 119 453) of patients aged 80 years and older (median [IQR] age, 85 [82-89] years) and 16.2% (29 654 of 183 512) of patients younger than 80 years (median [IQR] age, 65 [56-73] years). Among patients aged 80 years and older, EVT rates increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. By study end, the relative rate of EVT among eligible patients aged 80 years and older compared with those younger than 80 years increased from 0.49 (3.3% vs 6.7%) to 0.76 (20.8% vs 27.3%). Older patients had worse outcomes at discharge compared with younger patients, including discharge to home: 12.5% vs 31.1% (adjusted odds ratio [aOR], 0.43; 95% CI, 0.40-0.46), functional independence (modified Rankin Scale score 0-2): 10.9% vs 26.6% (aOR, 0.45; 95% CI, 0.41-0.49), and inpatient death or discharge to hospice, 34.5% vs 16.1% (aOR, 2.22; 95% CI, 2.09-2.36). Symptomatic intracranial hemorrhage rates did not differ significantly (6.9% vs 6.5%; aOR, 1.04; 95% CI, 0.94-1.14). Conclusions and Relevance: In this cohort study, use of EVT among individuals aged 80 years and older increased substantially from 2012 to 2019, although the rate remained lower than in younger patients. Although favorable functional outcomes at discharge were lower and combined mortality or discharge to hospice was higher in the older patients, the risk of symptomatic intracranial hemorrhage was not increased.

mHealth impact on secondary stroke prevention: a scoping review of randomized controlled trials among stroke survivors between 2010-2020.

Background: A fundamental gap between clinical prevention and self-management awareness heightens the risk for stroke recurrence in approximately one-fourth of the highest risk stroke survivors annually. Secondary stroke prevention has the potential to be promoted by mobile health (mHealth) applications for effective real-world adoption of vascular risk factor mitigation. This scoping review aims to evaluate the impact of mHealth interventions and their effectiveness to reduce recurrent stroke rates among stroke survivors in randomized controlled trials (RCTs). Methods: Scoping review in Ovid Medline, Cochrane Library, CINAHL, and Scopus for RCT literature employing mHealth among stroke populations published in English from 2010 to November 19, 2020. Small or pilot studies that included randomized design were included. Results: A total of 352 abstracts met inclusion criteria; 31 full-text articles were assessed and 18 unique RCTs involving 1,453 patients ultimately fulfilled criteria. Twelve of 18 met the pre-defined primary outcome measure, including 2 studies evaluating feasibility. Eight of 18 only addressed recovery from index stroke deficits. Most outcomes focused on self-reported functional status, mood, quality of life or compliance with intervention; primary outcome was an objective metric in 4/18 (blood pressure readings, step number, obstructive sleep apnea support compliance). Intervention duration 2-12 months, with a median 9 weeks. Conclusions: No high-quality evidence supporting mHealth applications to reduce recurrent stroke was found in this scoping review. Overall, most studies were relatively small, heterogenous, and employed subjective primary outcome measures. mHealth's potential as an effective tool for stroke stakeholders to reduce recurrent stroke rates has not been sufficiently demonstrated in this review. Future randomized studies are needed that explicitly evaluate stroke recurrence rate.

Can telemedicine address neurologic health disparities in rural Guatemala: a health promotor educational intervention study.

The global burden of neurologic disease is high and its impact manifests in health disparities observed in rural communities of limited resources like those surrounding San Lucas Tolimán, Guatemala. Telehealth may be one method to close these gaps by offering a virtual neurology curriculum. The goal of this project was to determine the pervasiveness of neurologic disease in San Lucas Tolimán and to increase interest and knowledge in neurology topics for local health promotors. A neurologic needs assessment was performed during the initial site visit. This information was subsequently used to create monthly health promotor neurology-based workshops and remote consultations delivered via a telehealth platform over the following year. The 29 health promotors were surveyed before and after the neurology course to measure self-reported knowledge of variable topics as well as their interest in neurology and how effective the remote lectures were. The needs assessment identified at least 68 different patients with neurologic diseases, the most common being headaches and seizures. The health promotors' knowledge of several neurologic diseases as well as their comfort level diagnosing a condition based on a description of neurologic symptoms significantly increased following the year-long neurology course. The lectures were convenient, easy to see and hear virtually, and increased the health promotors' interest in neurology. Telehealth is an acceptable and feasible method of delivering educational neurology topics relevant to rural communities. Future, longer-term studies are needed to determine if telehealth interventions such as these impact neurologic patient outcomes.

Although the global burden of neurologic disease remains high, rural communities throughout the world suffer from health disparities including inadequate resources and knowledge gaps. These barriers often prevent patients from receiving effective neurologic care. In collaboration with the health promoters in the rural communities surrounding San Lucas Tolimán, Guatemala, we designed a year-long educational curriculum addressing neurologic conditions and providing neurological consultations. The goal was to increase the health promoters' interest in and knowledge of clinical neurology. The delivery of virtual monthly lecture series with a telemedicine component offers a sustainable and feasible approach to achieving these goals.

Impact of Early Introduction to the Neurosciences on West Virginia High School Students via the Brain Bee.

BACKGROUND: The science, technology, engineering, and math (STEM) fields are often underrepresented due to lack of interest or exposure. The Brain Bee is a neuroscience competition for high school students meant to inspire future leaders in the neurosciences. A regional Brain Bee competition hosted in West Virginia was led by medical students and neurology residents with the goal of increasing high school student interest in the neurosciences. ACTIVITY: The West Virginia Brain Bee competition consisted of a neuroanatomy practical, a written exam, and a clinical assessment. Other fun neuroscience educational activities were also offered to students throughout the competition day. Students were surveyed before and after the competition day. RESULTS: Student interest in pursuing a neuroscience career increased (3.24 to 3.58, p = 0.043), and confidence in neuroscience knowledge increased (2.88 to 3.12, p = 0.036). Qualitative assessment revealed the importance of role models and a supportive environment for student learning. CONCLUSION: The West Virginia Brain Bee increased high school student interest in and confidence of neuroscience knowledge. This competition may be a meaningful way to connect high school students with potential mentors in the neurosciences and may also help foster an interest in pursuing a career in the neurosciences in the future.

A Case for the Non-Neurologist Telestroke Provider.

Introduction: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. We hypothesize that rates of tPA recommendation, sensitivity of final diagnosis, and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations. Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center over 1 year. Statistical analysis: Chi squared test. Results: Three hundred and three consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non-stroke-trained neurologists, and 59% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine-trained, stroke neurology-trained and other neurology- trained provider groups, respectively (p = 0.427). Sensitivity of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group. Discussion/Conclusion: Our results did not illustrate any statistically significant difference between care provided by an emergency medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore, may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.

Acute cerebellitis following SARS-CoV-2 infection: A case report and review of the literature.

Novel coronavirus disease (COVID-19) first described in Wuhan, China in December 2019, has rapidly spread across the world and become a global public health emergency. Literature on the neurological manifestations of COVID-19 is limited. We report a 24-year-old male, who presented with vertigo, dysarthria, and bradyphrenia 3 weeks after being diagnosed with COVID-19 on nasopharyngeal reverse transcription polymerase chain reaction. The patient was diagnosed with acute cerebellitis based on magnetic resonance imaging features and showed improvement posttreatment with intravenous methylprednisone for 5 days. The scope of this article is to highlight the importance of early identification of neurological symptoms and timely management as the outcomes may be catastrophic.

Muscle torques and joint accelerations provide more sensitive measures of poststroke movement deficits than joint angles.

The whole repertoire of complex human motion is enabled by forces applied by our muscles and controlled by the nervous system. The impact of stroke on the complex multijoint motor control is difficult to quantify in a meaningful way that informs about the underlying deficit in the active motor control and intersegmental coordination. We tested whether poststroke deficit can be quantified with high sensitivity using motion capture and inverse modeling of a broad range of reaching movements. Our hypothesis is that muscle moments estimated based on active joint torques provide a more sensitive measure of poststroke motor deficits than joint angles. The motion of 22 participants was captured while performing reaching movements in a center-out task, presented in virtual reality. We used inverse dynamic analysis to derive active joint torques that were the result of muscle contractions, termed muscle torques, that caused the recorded multijoint motion. We then applied a novel analysis to separate the component of muscle torque related to gravity compensation from that related to intersegmental dynamics. Our results show that muscle torques characterize individual reaching movements with higher information content than joint angles do. Moreover, muscle torques enable distinguishing the individual motor deficits caused by aging or stroke from the typical differences in reaching between healthy individuals. Similar results were obtained using metrics derived from joint accelerations. This novel quantitative assessment method may be used in conjunction with home-based gaming motion capture technology for remote monitoring of motor deficits and inform the development of evidence-based robotic therapy interventions.NEW & NOTEWORTHY Functional deficits seen in task performance have biomechanical underpinnings, seen only through the analysis of forces. Our study has shown that estimating muscle moments can quantify with high-sensitivity poststroke deficits in intersegmental coordination. An assessment developed based on this method could help quantify less observable deficits in mildly affected stroke patients. It may also bridge the gap between evidence from studies of constrained or robotically manipulated movements and research with functional and unconstrained movements.

Leukocyte Biomarkers for the Differential Diagnosis of Mild Acute Ischemic Stroke, Transient Ischemic Attack, and Stroke Mimic.

Introduction The differential diagnosis of transient ischemic attack (TIA) versus mild acute ischemic stroke (AIS) during the initial presentation to the emergency department is often difficult, as the diagnosis of both TIA and AIS relies on the presence of focal neurologic signs. As such, roughly 50% of patients with transient or mild neurologic deficits have an uncertain diagnosis prior to neuroimaging. Biomarkers, particularly leukocyte biomarkers, may be used by clinicians to diagnose mild AIS prior to neuroimaging, and this study is the first to describe the use of leukocyte biomarkers for the differentiation of mild AIS, TIA, and stroke mimic. Methods We performed a retrospective chart review of patients discharged from a local hospital with a discharge diagnosis of either TIA or AIS. Past medical history and complete blood cell count with differential upon admission were collected for all subjects. Statistical analyses were performed to compare immune cell parameters between the two groups. For all comparisons, logistic regression analysis was used to assess the effect of confounding variables, such as age, gender, and medical history for each study variable. Results Of all the immune parameters assessed in this study, the neutrophil percentage was the only significant biomarker that significantly differed between study groups. After adjustment for confounding variables using stepwise logistic regression, mild AIS patients were 5.3 times more likely than TIA cases to have a neutrophil percentage above the normal range. Conclusion Our results suggest that clinicians may utilize neutrophil percentage as an additional piece of information that may aid in their diagnosis of mild AIS versus TIA.

Relevance and Clinical Significance of Magnetic Resonance Imaging of Neurological Manifestations in COVID-19: A Systematic Review of Case Reports and Case Series.

We performed a systematic literature review of neuroimaging, predominantly focusing on magnetic resonance imaging (MRI) findings associated with neurological manifestations of coronavirus disease-2019 (COVID-19). We screened articles from PubMed, Google Scholar and Scopus, looking for reports that would potentially have neuroimaging findings in patients with COVID-19. Data analysis was performed with patient-based data based on the availability of clinical characteristics and outcomes for each individual patient from the studies. Chi square and Wilcoxon rank-sum tests were used to report COVID-19 severity and outcomes based on neurological imaging indicators and pathophysiology. A total of 171 patients with COVID-19 having neurological complications, from 134 studies, were identified in our review. The most common neuroimaging finding was ischemic stroke (62, 36.2%) cases, followed by CNS inflammatory disorder (44, 25.7%), and hemorrhagic stroke (41, 24.0%). Around 51% of all the fatal COVID-19 cases had an ischemic stroke. Among patients with ischemic stroke, the mean age of those who suffered from COVID-19 infection was 57.5 years (SD = 15.4) whereas it was 50.7 years (SD = 15.1) among those without stroke/other diagnosis. Fatality was more common in patients with ischemic stroke compared to those with other diagnosis (40% vs. 22%, p = 0.011). The most frequently published neuroimaging findings in patients with COVID-19 were ischemic stroke, CNS inflammatory disorder, and hemorrhagic disorder. In those studies, ischemic stroke was associated with fatality, and was more frequently seen in older patients. Based on our findings, early usage of MRI in COVID-19 patients may be recommended.

Value Utilization of Emergency Medical Services Air Transport in Acute Ischemic Stroke.

BACKGROUND: Determining whether a patient has a time-critical medical condition requiring helicopter Emergency Medical Services (HEMS) transportation is a challenge with acute ischemic stroke (AIS). Although HEMS is largely accepted as improving outcomes in time-sensitive conditions, overtriage of patients ineligible for acute stroke therapies places patients and providers at unnecessary risk and wastes limited health care resources. OBJECTIVE: We sought to identify how accurate our triage system was at identifying high-yield EMS transfers. A better triage system would decrease the volume of low flight value HEMS transfers. METHODS: We conducted a retrospective study during a 1-year period. Low flight value was defined by acute therapy eligibility and presenting medical status. RESULTS: Of 141 AIS patients transferred by HEMS, 23 (16%) were deemed of low flight value; 14 (61%) were outside the acute treatment time window for either intravenous tissue plasminogen activator or endovascular therapy (EVT); 5 patients (22%) were ineligible for EVT (National Institute of Health Stroke Scale < 6); 2 patients (9%) were ineligible for EVT (Modified Rankin Scale ≥ 3); and 2 patients (9%) were flown despite negative angiographic studies performed at transferring institution. Thirteen (57%) of the patients were interfacility transfers as opposed to direct HEMS transport from the field. CONCLUSIONS: HEMS transport for AIS patients plays a crucial role in delivering the best evidence-based care. However, a significant percent of patients did not meet criteria for its optimal utilization, most commonly due to expired treatment windows. Furthermore, low flight value transfers were initiated in spite of physician evaluation > 50% of the time. These results represent a unique opportunity to coordinate education and build effective triage paradigms across a system of stroke care.

Novel TMS for Stroke and Depression (NoTSAD): Accelerated Repetitive Transcranial Magnetic Stimulation as a Safe and Effective Treatment for Post-stroke Depression.

Background: Post-stroke depression (PSD) affects up to 50% of stroke survivors, reducing quality of life, and increasing adverse outcomes. Conventional therapies to treat PSD may not be effective for some patients. Repetitive transcranial magnetic stimulation (rTMS) is well-established as an effective treatment for Major Depressive Disorder (MDD) and some small trials have shown that rTMS may be effective for chronic PSD; however, no trials have evaluated an accelerated rTMS protocol in a subacute stroke population. We hypothesized that an accelerated rTMS protocol will be a safe and viable option to treat PSD symptoms. Methods: Patients (N = 6) with radiographic evidence of ischemic stroke within the last 2 weeks to 6 months with Hamilton Depression Rating Scale (HAMD-17) scores >7 were recruited for an open label study using an accelerated rTMS protocol as follows: High-frequency (20-Hz) rTMS at 110% resting motor threshold (RMT) was applied to the left dorsolateral prefrontal cortex (DLPFC) during five sessions per day over four consecutive days for a total of 20 sessions. Safety assessment and adverse events were documented based on the patients' responses following each day of stimulation. Before and after the 4-days neurostimulation protocol, outcome measures were obtained for the HAMD, modified Rankin Scale (mRS), functional independence measures (FIM), and National Institutes of Health Stroke Scales (NIHSS). These same measures were obtained at 3-months follow up. Results: HAMD significantly decreased (Wilcoxon p = 0.03) from M = 15.5 (2.81)-4.17 (0.98) following rTMS, a difference which persisted at the 3-months follow-up (p = 0.03). No statistically significant difference in FIM, mRS, or NIHSS were observed. No significant adverse events related to the treatment were observed and patients tolerated the stimulation protocol well overall. Conclusions: This pilot study indicates that an accelerated rTMS protocol is a safe and viable option, and may be an effective alternative or adjunctive therapy for patients suffering from PSD. Future randomized, controlled studies are needed to confirm these preliminary findings. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04093843.

Providing Oral Health Education to Adolescents with Peer-Assisted Learning.

There is a need to increase oral health knowledge, attitudes and behaviors in children to improve oral health. This research involves peer-assisted learning to determine if high school students can influence rural middle school students' oral health. The study sample consisted of middle school students. After completing pre-test, they were assigned to receive 1) didactic peer-assisted learning with professionally supervised and educated high school students (members of an after-school pipeline program for science, technology, engineering, mathematics, and health science); or, 2) teacher provided handouts/activity sheets. Both groups then completed a post test. The results of the Mann-Whitney U Tests showed that brushing and flossing failed to reach significant improvements between the pre-test and post-test for the handouts/activity sheets group (brushing, P=0.391; flossing, P=0.459). There was improvement within that group for oral health knowledge (P<.001). Brushing, flossing and oral health knowledge failed to reach significant improvement between the pre-test and post-test for the peer-assisted learning group (brushing, P=0.760; flossing, P=0.707; oral health knowledge, P= 0.154). In terms of oral health knowledge, there was no difference between the scores of the two groups on the pre-test (P-value = 0.980) nor on the post-test (P-value= 0.237). Near-peer assisted learning for oral hygiene knowledge, attitudes, and behaviors had similar outcomes as teacher provided handouts and activity sheets in a middle school setting.

Expanding Acute Stroke Care in Rural America: A Model for Statewide Success.

Background: The state of West Virginia (WV) is often seen as a health care desert with a scarcity of hospitals and resources. The prevalence of cerebrovascular disease and associated comorbidities are also some of the highest in the nation. Introduction: Ischemic stroke is a time-sensitive diagnosis. Prompt treatment in WV is difficult due to limited and isolated stroke-ready hospitals. Adoption of telestroke has helped to bypass these obstacles and improve access to care. Materials and Methods: Retrospective analyses; using data from the American Heart Association's Get With The Guidelines Stroke Data Registry, and other statewide agencies, we looked for trends in the volume of patients treated with intravenous-tissue plasminogen activator (tPA) in WV. We also reviewed data from West Virginia University's (WVU) telestroke database to assess trends in consult volumes and quality metrics. Results: Since the establishment of WVU telestroke, the total number of stroke patients receiving tPA across the state increased by 173% from 2015 (259 patients) to 2018 (448 patients) (p < 0.0001). Telestroke consults made up 24% (107/448) of total statewide tPA administrations for 2018. Between 2016 and 2018, the total symptomatic hemorrhage rate for tPA treated patients through telestroke was 1% (3/292). Telestroke also facilitated local care by avoiding patient transfer on average 65% of the time.Conclusion: Not only has telestroke increased the quantity of treated acute ischemic strokes, but it has also done so safely and effectively even in resource-poor areas. These findings demonstrate that telestroke is a useful tool for treating strokes, particularly those that happen far from stroke centers.