Accuracy of the new ICD-9-CM code for "drip-and-ship" thrombolytic treatment in patients with ischemic stroke.

A new International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code, V45.88, was approved by the Centers for Medicare and Medicaid Services (CMS) on October 1, 2008. This code identifies patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated in one hospital's emergency department, followed by transfer within 24 hours to a comprehensive stroke center, a paradigm commonly referred to as "drip-and-ship." This study assessed the use and accuracy of the new V45.88 code for identifying ischemic stroke patients who meet the criteria for drip-and-ship at 2 advanced certified primary stroke centers. Consecutive patients over a 12-month period were identified by primary ICD-9-CM diagnosis codes related to ischemic stroke. The accuracy of V45.88 code utilization using administrative data provided by Health Information Management Services was assessed through a comparison with data collected in prospective stroke registries maintained at each hospital by a trained abstractor. Out of a total of 428 patients discharged from both hospitals with a diagnosis of ischemic stroke, 37 patients were given ICD-9-CM code V45.88. The internally validated data from the prospective stroke database demonstrated that a total of 40 patients met the criteria for drip-and-ship. A concurrent comparison found that 92% (sensitivity) of the patients treated with drip-and-ship were coded with V45.88. None of the non-drip-and-ship stroke cases received the V45.88 code (100% specificity). The new ICD-9-CM code for drip-and-ship appears to have high specificity and sensitivity, allowing effective data collection by the CMS.

The Benefit of Mirtazapine in the Treatment of Progressive Multifocal Leukoencephalopathy in a Young HIV-positive Patient: A Case Report.

Highly active antiretroviral therapy is well-established in the treatment of human immunodeficiency virus (HIV)-positive patients. Nonadherence with therapy regimens often leads to the occurrence of opportunistic infections that further complicate treatment and challenge the treating physician. We report a young HIV-positive patient who suffered from progressive multifocal leukoencephalopathy caused by the human John Cunningham virus and showed objective clinical improvement after adding mirtazapine to the treatment regimen, an observation that is supported by the emerging literature.

Reliability and validity of blood pressure measurement in the Secondary Prevention of Small Subcortical Strokes study.

RATIONALE: The Secondary Prevention of Small Subcortical Strokes study is a multicenter, international trial funded by the National Institutes of Health testing the role of lowering systolic blood pressure to <130 mmHg in the prevention of stroke recurrence and cognitive decline in patients with recent symptomatic small subcortical stroke. Reliable and unbiased blood pressure measurement is critical to successful completion of the trial. METHODS: We looked at the reliability and validity of both the device used for blood pressure measurement and observer performance during measurement to assess the quality of blood pressure determination in the study. The Colin 8800C blood pressure device was tested for performance to Association for the Advancement of Medical Instrumentation standards and for presence of skipped digits. Observer performance was tested by examining adherence to the Secondary Prevention of Small Subcortical Strokes protocol. RESULTS: The mean difference (in mmHg) between the Colin device and the average of the two observers was 3.9 (SD 6.7) and -2.1 (SD 6.1) for systolic and diastolic pressures respectively, thereby meeting Association for the Advancement of Medical Instrumentation requirements. No skipped digits were found between 82-230 and 40-120 mmHg for systolic and diastolic pressures, respectively. Observer performance was excellent with greater than 90% of patients having blood pressure measured consistently according to the protocol. CONCLUSIONS: Device and observer performance in Secondary Prevention of Small Subcortical Strokes is excellent. Interpretation of the Secondary Prevention of Small Subcortical Strokes data for the effect of lowering systolic blood pressure on patient outcomes will not likely be adversely affected by these factors. Accuracy will be monitored throughout the remainder of the trial to ensure that this high quality is maintained.

What's new in stroke? The top 10 for 2004/05.

During the past decade, stroke has emerged from the dark ages of therapeutic nihilism to the current dawn of treatment activism, fueled by an unprecedented amount of high-quality clinical research. Here, the choices for the "Top 10" studies of 2004/05 influencing the management of patients with stroke and threatened stroke are reviewed. Nine are randomized, clinical trials involving a total of 61,810 participants. Three studies involved intracerebral hemorrhage, an important stroke subtype in which few trials have previously been carried out. Three studies involved acute treatment of stroke, and their results emphasize that "time is brain," and minutes count, in management of acute ischemic and hemorrhagic stroke. The 10th study was a longitudinal cohort analysis of participants with atrial fibrillation pooled from six clinical trials that validated predictive schemes to identify those who benefit most from anticoagulation. The practical management implications of these studies refine and improve care of geriatric patients with cerebrovascular disease.

Avoiding central nervous system bleeding during antithrombotic therapy: recent data and ideas.

BACKGROUND: Approximately 7000 intracerebral hemorrhages (ICHs) annually in the US are caused by use of antithrombotic therapies. We review the incidence, risk factors, and predictors of ICH in patients receiving long-term anticoagulation or antiplatelet therapy. SUMMARY OF REVIEW: ICH rates range from 0.3% to 0.6% per year during oral anticoagulation in recent reports. Major risk factors are advanced patient age, elevated blood pressure, intensity of anticoagulation, and previous cerebral ischemia. Combining antiplatelet agents with anticoagulation and the combined use of aspirin plus clopidogrel appear to increase ICH risk. Modest blood pressure-lowering halves the frequency of ICH during antiplatelet therapy. CONCLUSIONS: ICH is an uncommon, but often fatal, complication of antithrombotic therapy that particularly afflicts patients with previous stroke. Recent data support that keeping international normalized ratio < or =3.0, control of hypertension, and avoiding the combination of aspirin with warfarin reduce its frequency.

Stroke Prevention: The Best Outcome after a Transient Ischemic Attack. Results from the Minnesota Stroke Registry and Opportunities to Improve Care.

A transient ischemic attack (TIA) is an opportunity for stroke prevention. We examined the care of 708 TIA patients entered into the Minnesota Stroke Registry (MSR) and analyzed the extent to which they were discharged on appropriate guideline-recommended secondary prevention treatments. We calculated the overall number of strokes prevented by multiple risk factor modifying treatments. Of the 708 TIA patients, 533 (75%) were discharged on antihypertensive treatment. Of 208 patients with an LDL-Cholesterol greater than 100 mg/dl, 131 (63%) patients were prescribed lipid-lowering medications. Anticoagulation treatment was prescribed in 76% (82 of 108) of patients diagnosed with atrial fibrillation during hospitalization. Anti-thrombotic therapy was prescribed in 94% (563 of 600) TIA patients without atrial fibrillation. We estimated that 104 strokes will be prevented over 5 years due to combining multiple treatments assuming a baseline stroke risk of 60% in atrial fibrillation patients and 17% in non-atrial fibrillation patients over 5 years.