Continuous updating of individual headache forecasting models using Bayesian methods.

OBJECTIVE: To illustrate the benefits of deploying individual headache forecasting models using continuous updating with Bayesian methods. BACKGROUND: The ability to reliably forecast headache attacks within an individual over time would enhance the study of attacks and allow preemptive treatment. However, deploying a suitable forecasting model in a clinical setting will likely involve several unique challenges related to heterogeneity in the predictor weights, limited or sparse data, and the need for a quick "warm-up." The use of Bayesian methods offers solutions to each of these specific challenges. METHODS: This was a post hoc analysis of a cohort study of individuals with episodic migraine attacks. Individuals completed daily diaries that allowed the estimation of several forecasting models, each using different types of ancillary information incorporated into formal prior probability distributions. An in silico analysis was conducted that mimicked the deployment of these models in a clinical-like setting where the parameters of the models were continuously updated and evaluated each day using root mean square error (RMSE). RESULTS: Individuals (N = 95) were followed for 50 days and contributed 3359 days of nonmissing diary data. During the observation period, there were 1293/3359 (38.5%) days with a headache attack. Self-reported baseline headache frequency was associated with the corresponding predicted probability of future attacks, r = 0.15-0.39. At Day 25, the correlation between baseline information and predicted attack likelihood was r = 0.29 (95% CI: 0.09-0.47). Additionally, the use of prior probability distributions for model parameters improved the model fit, especially early in the deployment of the models (e.g., Day 5 RMSE 0.45 vs. 0.43). Models using informative prior probability distributions outperformed the models estimated without this information during the first 42 days of observation, although performance became more similar as more data were collected. CONCLUSIONS: This analysis demonstrates the value of Bayesian methods in using additional available information to improve forecasting model performance, especially early in the deployment of a forecasting model. To obtain the full value of such models or to apply any model in clinical settings, a model with adequate discrimination and calibration will be needed.

Forecasting Individual Headache Attacks Using Perceived Stress: Development of a Multivariable Prediction Model for Persons With Episodic Migraine.

OBJECTIVE: To develop and validate a prediction model that forecasts future migraine attacks for an individual headache sufferer. BACKGROUND: Many headache patients and physicians believe that precipitants of headache can be identified and avoided or managed to reduce the frequency of headache attacks. Of the numerous candidate triggers, perceived stress has received considerable attention for its association with the onset of headache in episodic and chronic headache sufferers. However, no evidence is available to support forecasting headache attacks within individuals using any of the candidate headache triggers. METHODS: This longitudinal cohort with forecasting model development study enrolled 100 participants with episodic migraine with or without aura, and N = 95 contributed 4626 days of electronic diary data and were included in the analysis. Individual headache forecasts were derived from current headache state and current levels of stress using several aspects of the Daily Stress Inventory, a measure of daily hassles that is completed at the end of each day. The primary outcome measure was the presence/absence of any headache attack (head pain > 0 on a numerical rating scale of 0-10) over the next 24 h period. RESULTS: After removing missing data (n = 431 days), participants in the study experienced a headache attack on 1613/4195 (38.5%) days. A generalized linear mixed-effects forecast model using either the frequency of stressful events or the perceived intensity of these events fit the data well. This simple forecasting model possessed promising predictive utility with an AUC of 0.73 (95% CI 0.71-0.75) in the training sample and an AUC of 0.65 (95% CI 0.6-0.67) in a leave-one-out validation sample. This forecasting model had a Brier score of 0.202 and possessed good calibration between forecasted probabilities and observed frequencies but had only low levels of resolution (ie, sharpness). CONCLUSIONS: This study demonstrates that future headache attacks can be forecasted for a diverse group of individuals over time. Future work will enhance prediction through improvements in the assessment of stress as well as the development of other candidate domains to use in the models.

Clinical, hemispheric, and autonomic changes associated with use of closed-loop, allostatic neurotechnology by a case series of individuals with self-reported symptoms of post-traumatic stress.

BACKGROUND: The objective of this pilot study was to explore the use of a closed-loop, allostatic, acoustic stimulation neurotechnology for individuals with self-reported symptoms of post-traumatic stress, as a potential means to impact symptomatology, temporal lobe high frequency asymmetry, heart rate variability (HRV), and baroreflex sensitivity (BRS). METHODS: From a cohort of individuals participating in a naturalistic study to evaluate use of allostatic neurotechnology for diverse clinical conditions, a subset was identified who reported high scores on the Posttraumatic Stress Disorder Checklist (PCL). The intervention entailed a series of sessions wherein brain electrical activity was monitored noninvasively at high spectral resolutions, with software algorithms translating selected brain frequencies into acoustic stimuli (audible tones) that were delivered back to the user in real time, to support auto-calibration of neural oscillations. Participants completed symptom inventories before and after the intervention, and a subset underwent short-term blood pressure recordings for HRV and BRS. Changes in temporal lobe high frequency asymmetry were analyzed from baseline assessment through the first four sessions, and for the last four sessions. RESULTS: Nineteen individuals (mean age 47, 11 women) were enrolled, and the majority also reported symptom scores that exceeded inventory thresholds for depression. They undertook a median of 16 sessions over 16.5 days, and 18 completed the number of sessions recommended. After the intervention, 89% of the completers reported clinically significant decreases in post-traumatic stress symptoms, indicated by a change of at least 10 points on the PCL. At a group level, individuals with either rightward (n = 7) or leftward (n = 7) dominant baseline asymmetry in temporal lobe high frequency (23-36 Hz) activity demonstrated statistically significant reductions in their asymmetry scores over the course of their first four sessions. For 12 individuals who underwent short-term blood pressure recordings, there were statistically significant increases in HRV in the time domain and BRS (Sequence Up). There were no adverse events. CONCLUSION: Closed-loop, allostatic neurotechnology for auto-calibration of neural oscillations appears promising as an innovative therapeutic strategy for individuals with symptoms of post-traumatic stress. TRIALS REGISTRATION: ClinicalTrials.gov #NCT02709369 , retrospectively registered on March 4, 2016.

Use of an allostatic neurotechnology by adolescents with postural orthostatic tachycardia syndrome (POTS) is associated with improvements in heart rate variability and changes in temporal lobe electrical activity.

Autonomic dysregulation and heterogeneous symptoms characterize postural orthostatic tachycardia syndrome (POTS). This study evaluated the effect of high-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM(®)), a noninvasive, allostatic neurotechnology for relaxation and auto-calibration of neural oscillations, on heart rate variability, brain asymmetry, and autonomic symptoms, in adolescents with POTS. Seven subjects with POTS (three males, ages 15-18) underwent a median of 14 (10-16) HIRREM sessions over 13 (8-17) days. Autonomic function was assessed from 10-min continuous heart rate and blood pressure recordings, pre- and post-HIRREM. One-minute epochs of temporal high-frequency (23-36 Hz) brain electrical activity data (T3 and T4, eyes closed) were analyzed from baseline HIRREM assessment and subsequent sessions. Subjects rated autonomic symptoms before and after HIRREM. Four of seven were on fludrocortisone, which was stopped before or during their sessions. Heart rate variability in the time domain (standard deviation of the beat-to-beat interval) increased post-HIRREM (mean increase 51%, range 10-143, p = 0.03), as did baroreflex sensitivity (mean increase in high-frequency alpha 65%, range -6 to 180, p = 0.05). Baseline temporal electrical asymmetry negatively correlated with change in asymmetry from assessment to the final HIRREM session (p = 0.01). Summed high-frequency amplitudes at left and right temporal lobes decreased a median of 3.8 µV (p = 0.02). There was a trend for improvements in self-reported symptoms related to the autonomic nervous system. Use of HIRREM was associated with reduced sympathetic bias in autonomic cardiovascular regulation, greater symmetry and reduced amplitudes in temporal lobe high-frequency electrical activity, and a trend for reduced autonomic symptoms. Data suggest the potential for allostatic neurotechnology to facilitate increased flexibility in autonomic cardiovascular regulation, possibly through more balanced activity at regions of the neocortex responsible for autonomic management. Clinical trial registry "Tilt Table with Suspected postural orthostatic tachycardia syndrome (POTS) Subjects," Protocol Record: WFUBAHA01.

Intersocietal Accreditation Commission Accreditation Status of Outpatient Cerebrovascular Testing Facilities Among Medicare Beneficiaries: The VALUE Study.

OBJECTIVES: Accreditation of cerebrovascular ultrasound laboratories by the Intersocietal Accreditation Commission (IAC) and equivalent organizations is supported by the Joint Commission certification of stroke centers. Limited information exists on the accreditation status and geographic distribution of cerebrovascular testing facilities in the United States. Our study objectives were to identify the proportion of IAC-accredited outpatient cerebrovascular testing facilities used by Medicare beneficiaries, describe their geographic distribution, and identify variations in cerebrovascular testing procedure types and volumes by accreditation status. METHODS: As part of the VALUE (Vascular Accreditation, Location, and Utilization Evaluation) Study, we examined the proportion of IAC-accredited facilities that conducted cerebrovascular testing in a 5% Centers for Medicare and Medicaid Services random Outpatient Limited Data Set in 2011 and investigated their geographic distribution using geocoding. RESULTS: Among 7327 outpatient facilities billing Medicare for cerebrovascular testing, only 22% (1640) were IAC accredited. The proportion of IAC-accredited cerebrovascular testing facilities varied by region (χ(2)[3] = 177.1; P < .0001), with 29%, 15%, 13%, and 10% located in the Northeast, South, Midwest, and West, respectively. However, of the total number of cerebrovascular outpatient procedures conducted in 2011 (38,555), 40% (15,410) were conducted in IAC-accredited facilities. Most cerebrovascular testing procedures were carotid duplex, with 40% of them conducted in IAC-accredited facilities. CONCLUSIONS: The proportion of facilities conducting outpatient cerebrovascular testing accredited by the IAC is low and varies by region. The growing number of certified stroke centers should be accompanied by more accredited outpatient vascular testing facilities, which could potentially improve the quality of stroke care.

Accreditation status and geographic location of outpatient vascular testing facilities among Medicare beneficiaries: the VALUE (Vascular Accreditation, Location & Utilization Evaluation) study.

OBJECTIVE: There is limited information on the accreditation status and geographic distribution of vascular testing facilities in the US. The Centers for Medicare & Medicaid Services (CMS) provide reimbursement to facilities regardless of accreditation status. The aims were to: (1) identify the proportion of Intersocietal Accreditation Commission (IAC) accredited vascular testing facilities in a 5% random national sample of Medicare beneficiaries receiving outpatient vascular testing services; (2) describe the geographic distribution of these facilities. METHODS: The VALUE (Vascular Accreditation, Location & Utilization Evaluation) Study examines the proportion of IAC accredited facilities providing vascular testing procedures nationally, and the geographic distribution and utilization of these facilities. The data set containing all facilities that billed Medicare for outpatient vascular testing services in 2011 (5% CMS Outpatient Limited Data Set (LDS) file) was examined, and locations of outpatient vascular testing facilities were obtained from the 2011 CMS/Medicare Provider of Services (POS) file. RESULTS: Of 13,462 total vascular testing facilities billing Medicare for vascular testing procedures in a 5% random Outpatient LDS for the US in 2011, 13% (n=1730) of facilities were IAC accredited. The percentage of IAC accredited vascular testing facilities in the LDS file varied significantly by US region, p<0.0001: 26%, 12%, 11%, and 7% for the Northeast, South, Midwest, and Western regions, respectively. CONCLUSIONS: Findings suggest that the proportion of outpatient vascular testing facilities that are IAC accredited is low and varies by region. Increasing the number of accredited vascular testing facilities to improve test quality is a hypothesis that should be tested in future research.

Randomized, controlled clinical trial of acoustic stimulation to reduce postconcussive symptoms.

OBJECTIVE: Effective interventions are needed to address postconcussive symptoms. We report the results of randomized, sham-controlled trial of Cereset Research™ Standard Operating Procedures (CR-SOP), a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology previously shown to improve insomnia. METHODS: Military service members, veterans, or their spouses with persistent symptoms (Neurobehavioral Symptom Inventory [NSI] Score ≥23) after mTBI 3 months to 10 years ago, were randomized to receive 10 sessions of engineered tones linked to brainwaves (LB, intervention), or random engineered tones not linked to brainwaves (NL, sham control). The primary outcome was change in NSI, with secondary outcomes of heart rate variability and self-report measures of sleep, mood, and anxiety. RESULTS: Participants (n = 106, 22% female, mean age 37.1, 2.8 deployments, 3.8 TBIs) were randomized 1:1 to LB or NL, with no significant differences between groups at baseline. Among all study participants, the NSI declined from baseline 41.0 to 27.2 after (P < 0.0001), with gains largely sustained at 3 months (31.2) and 6 months (28.4). However, there were no significant differences between the LB (NSI declined from 39.9 at baseline to 28.2 post-intervention, 31.5 at 3 months, and 29.4 at 6 months) and NL (NSI declined from 41.5 at baseline to 26.2, 29.9, and 27.3, respectively. Similar patterns were observed for the PCL5 and PHQ-9 and there was no difference in HRV between groups. INTERPRETATION: Ten hours of acoustic stimulation while resting in a zero-gravity chair improves postconcussive symptoms. However, linking tones to brain electrical activity did not reduce symptoms more than random tones. REGISTRATION: ClinicalTrials.gov - NCT03649958.

Targeting telestroke: benchmarking time performance in telestroke consultations.

OBJECTIVE: To describe the length of time physicians spend completing telestroke consultations and examine factors associated with that period. METHODS: This is a retrospective review of data from telestroke software. Clinical data obtained between July 2010 and February 2011 from 8 hub and 24 spoke hospitals were abstracted for 235 consecutive consultations and linked to time metadata generated by software interaction. Consult length was defined as the time logged on to the robot and was exclusive of any telephone interaction or documentation time. Response time was defined as patient arrival to physician log-on. RESULTS: Mean consult length for 203 complete, time-stamped cases was 14.5 minutes. There was no independent association between consult length and age, diagnosis, time of arrival from symptom onset, neurological exam findings, known recombinant tissue plasminogen activator (r-tPA) contraindications, and absence of vascular risk factors. Mean consult length was statistically longer in r-tPA-recommended cases (20.0 versus 15.3 minutes; P = .04). Mean response time was 76.3 minutes. CONCLUSIONS: The relatively short consult length suggests a workflow model in which acute stroke care is largely completed before telestroke consultation with a specialist rendering an expert opinion on previously gathered data performed off-line. The findings for prolonged response times indicate an area for improvement. Future workflow models for telestroke consultation will need to be reconsidered to optimize quality of care and clinical efficiency.

Evaluation of the transverse venous sinus with transcranial color-coded duplex.

BACKGROUND AND PURPOSE: Ultrasound-derived diagnosis of transverse venous sinus stenosis (TVSS) may have a promise given recent exploration of its role in pathophysiology of intracranial hypertension and availability of interventions like venous stenting. We investigated transverse venous sinus (TVS) insonation using transcranial color-coded duplex (TCCD) to establish normative values, inform on inherent physiological variability, and other measures to allow future studies on testing the construct validity of TCCD venous in diagnosing TVSS. METHODS: An institutional review board-approved prospective observational study evaluated 20 healthy volunteers to define TCCD-based measures for the TVS. Comparatively, the basal vein of Rosenthal, deep middle cerebral veins, and internal jugular veins were insonated. We report on physiological variability including the intrasubject, intersubject, and side-to-side variability; gradient of TVS velocities on each side from medial to lateral insonation; and the relationship between TVS and other insonated venous structures. RESULTS: Fifteen out of 20 subjects had the TVS insonated bilaterally, and five had unilaterally (four right, one left). TVS velocities had comparable intrasubject variability to other intracranial veins insonated and lower velocity-based variability than the pulsatility index. There was significant side-side variability in TVS-derived measures without discernible patterns. Insonating TVS from medial to lateral revealed a gradient with a bimodal peak in ultrasound-derived velocities. We did not find discernible relationships between TVS and other veins for TCCD-derived measures. CONCLUSIONS: These results can inform future studies validating the normative values in a larger sample and help explore the role of TCCD venous in the diagnosis of venous sinus stenosis.

Cereset Research Standard Operating Procedures for Insomnia: A Randomized, Controlled Clinical Trial.

Background: Interventions for insomnia that also address autonomic dysfunction are needed. Objective: We evaluate Cereset Research™ Standard Operating Procedures (CR-SOP) in a pilot randomized, controlled trial. CR-SOP is a less operator-dependent, more generalizable innovation of HIRREM®, a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology demonstrated to improve insomnia and autonomic function. Methods: Adults with Insomnia Severity Index (ISI) scores of ≥8 were randomized to receive ten sessions of CR-SOP, with tones linked to brainwaves (LB, intervention), or a sham condition of random tones not linked to brainwaves (NL, control). Measures were collected at enrollment and 0-14 days and 4-6 weeks post-allocated intervention. The primary outcome was differential change in ISI from baseline to 4-6 weeks post-intervention. Secondary self-report measures assessed sleep quality65 and behavioral outcomes. Ten-minute recordings of heart rate and blood pressure were collected to analyze autonomic function (heart rate variability [HRV] and baroreflex sensitivity). Results: Of 22 randomized, 20 participants completed the allocated condition. Intention to treat analysis of change from baseline to the 4-6 week outcome demonstrated mean ISI score reduction of 4.69 points among controls (SE 1.40). In the intervention group, there was an additional 2.58 point reduction in ISI score (SE 2.13; total reduction of 7.27, P = .24). Sleep quality and some measures of autonomic function improved significantly among the intervention group compared to control. Conclusions: This pilot study compared use of a standardized, allostatic, acoustic neurotechnology intervention with a sham, active control condition. The magnitude of change in insomnia severity was clinically relevant and similar to the findings in a prior, fully powered trial, but the differential improvement observed was not statistically significant. Significant improvements were demonstrated in sleep quality and some autonomic function measures.

Coexistent extra- and intracranial stenosis, cervical atherosclerosis, and abnormal ankle brachial index in acute ischemic stroke.

BACKGROUND: There are limited data regarding abnormal ankle brachial index (ABI) with coexistent extracranial carotid stenosis (ECS), intracranial stenosis (ICS), and nonstenotic cervical atherosclerosis (CAS) in stroke, especially in Asia. METHODS: We studied the prevalence of ECS, ICS, CAS, and combined ECS and ICS in 756 Thai patients with acute ischemic stroke and correlated sites of atherosclerosis with stroke risk factors and abnormal ABI. RESULTS: The prevalence of ECS was 8.8%, ICS 52.6%, CAS 36.0%, abnormal ABI 18.8%, combined ECS and ICS 4.6%, combined ECS and abnormal ABI 2.8%, combined ICS and abnormal ABI 10.6%, and combined ECS, ICS, and abnormal ABI 1.6%. The prevalence of ECS, CAS, and combined ECS and ICS was higher in abnormal ABI compared to normal ABI (14.8% v 7.5% [P = .006]; 46.5% v 33.5% [P = .004], and 8.4% v 3.7% [P = .016], respectively). ECS was significantly correlated with history of coronary artery disease (CAD) and abnormal ABI; ICS with male gender, no alcohol use, and no atrial fibrillation; CAS with age ≥ 60 years, history of CAD and abnormal ABI; and combined ECS and ICS with history of CAD. CONCLUSIONS: The frequency of atherosclerosis, especially ICS, was high. Cervicocerebral atherosclerosis was higher in abnormal ABI. This suggests that ischemic stroke patients should be screened for ECS, CAS, ICS, and abnormal ABI, especially in specific subsets (age ≥ 60 years, male gender, and history of CAD). The improved identification of vascular lesions could allow for a more optimal choice of antithrombotics, neurointervention, and more aggressive control of risk factors, potentially improving prevention of disease progression and a decrease in recurrent vascular events.

Prevalence and association between risk factors, stroke subtypes, and abnormal ankle brachial index in acute ischemic stroke.

BACKGROUND: Abnormal ankle brachial index (ABI) identifies a stroke subgroup with high risk of subsequent stroke and other vascular events. There are few data regarding the prevalence of abnormal ABI in ischemic stroke in Asian countries. METHODS: We evaluated the prevalence of abnormal ABI in 747 Thai patients with ischemic stroke or transient ischemic attack and assessed the correlation of abnormal ABI with stroke risk factors and stroke subtypes. RESULTS: The prevalence of abnormal ABI (≤0.9) in ischemic stroke patients was 18.1%. Abnormal ABI in ischemic stroke patients was significantly correlated with female gender (odds ratio [OR], 1.61; confidence interval [CI], 1.09-2.40; P = .017), age ≥ 60 years (OR, 3.54; CI, 2.14-5.85; P < .001), and previous ischemic events, including coronary artery disease (OR, 2.55; CI, 1.47-4.43; P = .001), cerebrovascular disease (OR, 2.15; CI, 1.37-3.55; P = .002), and atrial fibrillation (OR, 1.71; CI, 1.03-2.82; P = .036). There was a significant difference in the prevalence of abnormal ABI among stroke subtypes (P < .001), which tended to be more frequent in those with large artery disease (20.4%), cardioembolic stroke (29.2%), and undetermined etiology (20.6%). CONCLUSIONS: An ABI examination should be considered in patients with ischemic stroke to facilitate the early detection and treatment of asymptomatic peripheral arterial disease and identification of excess risk for subsequent stroke or other vascular events.

Telestroke to improve acute stroke care in North Carolina.

Effective, albeit time-limited, treatment is available for acute ischemic stroke but is underutilized in North Carolina. There is a mismatch between stroke resources and expertise and the services available at many hospitals where patients seek initial care. Video telecommunications can improve access to stroke expertise and to potentially life-saving therapies.

Holistic approach to treatment of intractable central neuropathic itch.

Central neuropathic itch can be a lifelong debilitating condition and treatment challenge. We report a patient with a traumatic brain injury with severe intractable pruritus who failed extensive pharmacologic and nonpharmacologic treatment but responded to a holistic approach using healing touch. We discuss the complexity of this type of neuropathic itch and present a holistic approach as an adjunct to therapy in reducing itch intensity. This case presentation along with the literature discussed suggests a therapeutic strategy for the management of complicated central neuropathic itch.

Enhancing the effectiveness of community stroke risk screening: a randomized controlled trial.

Stroke risk factors are routinely assessed in community screening programs; however, the rate of patient follow-up for health care once risk factors are identified is known to be low. This study was conducted to test the effectiveness of a brief behavioral telephonic intervention in an ongoing community stroke prevention screening program on health care seeking for stroke risk. A total of 227 participants with 2 or more stroke risk factors were randomly allocated to either an attention control arm or a behavioral intervention arm. The control group received standard information on risk and advice, whereas the intervention group received a brief Health Belief Model telephonic intervention designed to motivate care-seeking. The effect of treatment on the participants who completed a health care visit for stroke risk concerns was assessed using logistic regression. Cox survival analysis was used to compare time to physician visit between the 2 groups. Participants in the intervention arm were 1.85 times more likely to visit a primary care physician than controls. At 3 months, 69.2% of subjects in the intervention arm and 52.9% of those in the controls arm reported a new primary care visit after screening (P = .02), with 56.0% in the intervention arm and 38.4% in the control arm reporting a primary care visit specifically to discuss the stroke screening results (P < .01). Our data indicate that the brief, low-cost, motivational intervention effectively promoted adherence to screening advice and merits further testing.

Cerebral hemodynamics in peritoneal dialysis versus intermittent hemodialysis: A transcranial Doppler pilot study.

This study evaluated intradialytic cerebral hemodynamics measured by transcranial Doppler (TCD) in intermittent hemodialysis (iHD) versus nightly peritoneal dialysis (NIPD). Intradialytic TCD was serially performed in chronic dialysis patients receiving iHD (n = 10) and NIPD (n = 10). A linear mixed model was used to model mean flow velocity (MFV), pulsatility index (PI), and mean arterial pressure (MAP) as functions of time and treatment group. Intradialytic cerebral volatility (IDCV) was calculated using the coefficient of variation (CV) and mean absolute value of change (AVC) of each patient's MFV, PI, and MAP values over time. Mixed model analyses found no significant difference between MFV, PI, and MAP treatment groups in change over time, though volatility differed significantly. Mean CV values for MFV, PI, and MAP were higher in iHD than NIPD (MFV 0.22 vs. 0.10, p = 0.005; PI 0.14 vs. 0.08, p = 0.003; MAP 0.057 vs. 0.032, p = 0.009). AVC values were similarly higher in iHD compared to NIPD (MFV 8.26 vs. 4.43, p = 0.04; PI 0.17 vs. 0.084, p < 0.001; MAP 6.05 vs. 2.9, p = 0.003). PI, MFV, and MAP were more stable in NIPD than iHD, as measured by intradialytic TCD monitoring. This study identifies IDCV as a unique TCD metric for intradialytic cerebral hemodynamics.

Effects of an Allostatic Closed-Loop Neurotechnology (HIRREM) on Brain Functional Connectivity Laterality in Military-Related Traumatic Stress.

BACKGROUND AND PURPOSE: Brain asymmetries are reported in posttraumatic stress disorder, but many aspects of laterality and traumatic stress remain underexplored. This study explores lateralization changes in resting state brain network functional connectivity in a cohort with symptoms of military-related traumatic stress, associated with use of a closed-loop neurotechnology, HIRREM. METHODS: Eighteen participants (17 males, mean age 41 years [SD = 7]) received 19.5 (1.1) HIRREM sessions over 12 days. Whole brain resting magnetic resonance imaging was done pre- and post-HIRREM. Laterality of functional connectivity was assessed on a whole brain basis, and in six predefined networks or regions. Laterality of connectivity within networks or regions was assessed separately from laterality of connections between networks or regions. RESULTS: Before HIRREM, significant laterality effects of connection type (ipsilateral for either side, or contralateral in either direction) were observed for the whole brain, within networks or regions, and between networks or regions. Post-HIRREM, there were significant changes for within-network or within-region analysis in the motor network, and changes for between-network or between-region analyses for the salience network and the motor cortex. CONCLUSIONS: Among military service members and Veterans with symptoms of traumatic stress, asymmetries of network and brain region connectivity patterns were identified prior to usage of HIRREM. A variety of changes in lateralized patterns of brain connectivity were identified postintervention. These laterality findings may inform future studies of brain connectivity in traumatic stress disorders, with potential to point to mechanisms of action for successful intervention.

Rapid Implementation of Outpatient Teleneurology in Rural Appalachia: Barriers and Disparities.

OBJECTIVE: To describe rapid implementation of telehealth during the COVID-19 pandemic and assess for disparities in video visit implementation in the Appalachian region of the United States. METHODS: A retrospective cohort of consecutive patients seen in the first 4 weeks of telehealth implementation was identified from the Neurology Ambulatory Practice at a large academic medical center. Telehealth visits defaulted to video, and when unable, phone-only visits were scheduled. Patients were divided into 2 groups based on the telehealth visit type: video or phone only. Clinical variables were collected from the electronic medical record including age, sex, race, insurance status, indication for visit, and rural-urban status. Barriers to scheduling video visits were collected at the time of scheduling. Patient satisfaction was obtained by structured postvisit telephone call. RESULTS: Of 1,011 telehealth patient visits, 44% were video and 56% phone only. Patients who completed a video visit were younger (39.7 vs 48.4 years, p < 0.001), more likely to be female (63% vs 55%, p < 0.007), be White or Caucasian (p = 0.024), and not have Medicare or Medicaid insurance (p < 0.001). The most common barrier to scheduling video visits was technology limitations (46%). Although patients from rural and urban communities were equally likely to be scheduled for video visits, patients from rural communities were more likely to consider future telehealth visits (55% vs 42%, p = 0.05). CONCLUSION: Rapid implementation of ambulatory telemedicine defaulting to video visits successfully expanded video telehealth. Emerging disparities were revealed, as older, male, Black patients with Medicare or Medicaid insurance were less likely to complete video visits.

A multicenter evaluation of the ABCD2 score's accuracy for predicting early ischemic stroke in admitted patients with transient ischemic attack.

STUDY OBJECTIVE: We evaluate, in admitted patients with transient ischemic attack, the accuracy of the ABCD(2) (age [A], blood pressure [B], clinical features [weakness/speech disturbance] [C], transient ischemic attack duration [D], and diabetes history [D]) score in predicting ischemic stroke within 7 days. METHODS: At 16 North Carolina hospitals, we enrolled a prospective, nonconsecutive sample of admitted patients with transient ischemic attack and with no stroke history, presenting within 24 hours of transient ischemic attack symptom onset. We conducted a medical record review to determine ischemic stroke outcomes within 7 days. According to a modified Rankin Scale Score, strokes were classified as disabling (>2) or nondisabling (< or =2). RESULTS: During a 35-month period, we enrolled 1,667 patients, of whom 373 (23%) received a diagnosis of an ischemic stroke within 7 days. Eighteen percent (69/373) of all strokes were disabling. We were unable to calculate an ABCD(2) score in 613 patients (37%); however, our imputed analysis indicated this did not significantly alter results. The discriminatory power of the ABCD(2) score was modest for ischemic stroke in 7 days (c statistic 0.59), and fair for disabling ischemic stroke within 7 days (c statistic 0.71). Patients characterized as low risk according to ABCD(2) score (< or =3) were at low risk for experiencing a disabling stroke within 7 days, with a negative likelihood ratio of 0.16 (95% confidence interval [CI] 0.04 to 0.64) with missing values excluded and 0.34 (95% CI 0.15 to 0.76) when missing values were imputed. CONCLUSION: Our analysis suggests the best application of the ABCD(2) score may be to identify patients at low risk for an early disabling ischemic stroke. Further study of the ability to determine an ABCD(2) score in all patients is needed, along with validation in a large, consecutive population of patients with transient ischemic attack.

Transcranial Doppler Emboli Monitoring for Infective Endocarditis.

BACKGROUND AND PURPOSE: Ischemic stroke can occur in 20-55% of patients with infective endocarditis (IE) with 75% occurring during the first 2 weeks of treatment. CT or MRI brain can diagnose the sequelae of stroke but transcranial Doppler (TCD) can document active embolization. We undertook a retrospective review of our patient cohort and a systematic review of literature to assess the role of TCD in early diagnosis and management of ischemic stroke in IE. METHODS: Retrospective chart review and literature review. RESULTS: We found 89 patients with stroke caused by IE at our institution from December 2011 to April 2018. TCDs were obtained on 26 patients; 16 were abnormal for cerebrovascular abnormalities. Only 4 patients had 30-minute emboli monitoring performed, of which one revealed emboli. We found 3 studies investigating the role of TCDs in IE that showed promise in its use as a predictive tool in stroke risk stratification. CONCLUSIONS: Presence of embolization in the form of high-intensity transient signals (HITS) detected on TCDs can be used for early diagnosis of IE, assessing efficacy of antibiotic therapy, and stratification of stroke risk in IE. This can aid further research into testing preventative interventions for reducing stroke burden in IE such as earlier valvular surgery or vacuum-assisted vegetation extraction.