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Background: Early detection of dysphagia is critical to reducing hospital complications and length of stay in patients with various types of strokes. The aim of this study was to develop and evaluate the DePaul Hospital Swallow Screener (DHSS) tool to assess for dysphagia in patients with stroke.Methods: This prospective observational study investigated patients admitted to a comprehensive stroke center. The DHSS is composed of a questionnaire containing 8 nonswallow items and a water swallow test. All patients admitted under a standard stroke protocol are screened by the nursing staff using the DHSS and then objectively evaluated by a speech-language pathologist using the Mann Assessment of Swallowing Ability (MASA). Validity measures and reliability through Cohen's κ-coefficient with associated 95% confidence intervals were calculated.Results: A total of 224 patients completed the DHSS and had at least 1 MASA score. The overall Content Validity Index score for the DHSS was .92. Compared with the MASA dysphagia cutoff value, the DHSS had a specificity of 93% and a sensitivity of 69%, and compared with the MASA aspiration risk cutoff value, the DHSS had a specificity of 90% and a sensitivity of 70%. Stratified analysis for those with any documented stroke (ischemic or hemorrhagic) compared with those admitted with transient ischemic attack or no stroke yielded similar sensitivity and specificity in both dysphagia and aspiration risk.Conclusion: The DHSS is a valid and reliable swallow screening tool with moderate agreement, high specificity, and reliable predictive values when compared with the MASA. [ABSTRACT FROM AUTHOR]

Background: Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes. Methods: Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed. Results: One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS (P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital (P = .02). Conclusion: The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the practical application of International Pediatrics Multiple Sclerosis study group definitions in children with inflammatory demyelination of the central nervous system and to identify predictors of multiple sclerosis. Methods: Baseline data on 123 children with a first episode of acute central nervous system demyelination were collected. The initial diagnosis according to the International Pediatrics Multiple Sclerosis study group was recorded and compared with final diagnosis. Results: Forty-seven (38.2%) children met International Pediatrics Multiple Sclerosis study group criteria for acute disseminated encephalomyelitis and 67 (54.4%) had clinically isolated syndrome at the initial presentation. Four (3.2%) had the diagnosis of neuromyelitis optica and five (4%) did not meet any specific diagnosis per the study group criteria. Clinical follow-up was available on 118 of 123 children (95.9%), with a median of 61.5 months (quartile range 23, 110 months). Conversion from clinically isolated syndrome to multiple sclerosis occurred in 26 of 67 children (38.8%); acute disseminated encephalomyelitis to multiple sclerosis occurred in 4 of 47 children (8.5%). Adjusted multivariate logistic regression analysis for an outcome of future development of multiple sclerosis showed the following predictors: female gender (odds ratio 12.44; 95% confidence interval 1.03-149.3); initial diagnosis of monofocal brain stem or hemispheric dysfunction (odds ratio 24.57; 95% confidence interval 3.06-196.78); and Callen magnetic resonance imaging criteria if met (odds ratio 122.45; 95% confidence interval 16.57-904.57). Conclusion: International Pediatrics Multiple Sclerosis study group criteria affirm that children with initial clinically isolated syndrome are more likely to develop future multiple sclerosis compared with those with an acute disseminated encephalomyelitis initial diagnosis. In addition, female gender, brain stem or hemispheric involvement, and Callen magnetic resonance imaging criteria predict the diagnosis of multiple sclerosis. [Copyright &y& Elsevier]

Abstract: Background: Thrombolysis for acute ischemic stroke (AIS) in children is yet to be proven efficacious, and there is limited information about its safety in large pediatric samples. Here we evaluate the safety outcomes associated with thrombolysis in children as well as the trend of hospital utilization over the past decade in the United States. Methods: A cohort of children with acute ischemic stroke was identified from the Kids' Inpatient Database for the years 1998-2009. Acute ischemic stroke was identified by the International Classification of Diseases-9 clinical classification software codes (109 and 110). Multivariate logistic regression analyses were used to assess covariates associated with outcomes of hospital mortality and intracerebral hemorrhage. The Cochran-Armitage test was employed for linear trend of discrete variables. Results: In this analysis, 9257 children were admitted with the diagnosis of acute ischemic stroke; only 67 (0.7%) received thrombolysis. Thrombolysis-treated children were older than the rest of the cohort (13.1 ± 7.3 vs 8.18 ± 7.5; P < 0.0001) and they had a longer hospital stay (median 11 vs 6 days; P < 0.0001). Gender, race, and family income approximated by postal code were similar among the treated and untreated children. Unadjusted analysis showed higher hospital mortality (10.45% vs 6.14%; P = 0.06) and intracerebral hemorrhage (2.99% vs 0.77%; P = 0.08) in the thrombolysis group. Adjusted analysis showed that intracerebral hemorrhage is predictive of a higher hospital mortality (odds ratio 3.43; 95% confidence interval 1.89-6.22), whereas thrombolysis was not (odds ratio 1.78; 95% confidence interval 0.86-3.64). The overall rate of thrombolysis per 3 years intervals had increased from 5.2 to 9.7 per 1000 children with acute ischemic stroke (P = 0.02). This increase was mainly seen in non-children hospitals (P = 0.01). Conclusion: Thrombolysis for acute ischemic stroke is infrequently used in children. There is a trend toward higher risks of intracerebral hemorrhage and hospital mortality, although these risks are as low as those reported in adult population. The hospitals’ utilization of thrombolysis in children has increased during the study period. [Copyright &y& Elsevier]

The relationship between age and vasospasm caused by subarachnoid hemorrhage (SAH) is controversial. We evaluated this relationship in a contemporary sample from a single institution. In a retrospective study design, we included patients with SAH caused by ruptured intracranial aneurysms. All patients underwent an evaluation that included head imaging, cerebral angiography, and treatment for the underlying aneurysm. Vasospasm was classified as absent, any vasospasm, or symptomatic vasospasm. Age was classified into 2 categories with a cutoff of 50 years, and also was stratified by decade. All patients had received preventative and therapeutic measures for vasospasm. Logistic regression analysis was used to assess the association between age and the occurrence of vasospasm. A total of 108 patients were included in this analysis, 67 of whom were age ≥50 years. The older patients had a higher incidence of vascular risk factors, and the younger patients had a higher incidence of smoking and illicit substance abuse. The mean age of the patients with any vasospasm (n = 41) was 48.51 ± 11.23 years, compared with 59.67 ± 13.30 years in those without vasospasm (P < .0001). Adjusted analysis found a greater risk of vasospasm in the younger patients compared with the older patients (odds ratio, 5.83; 95% confidence interval, 2.41-14.12 for any vasospasm; odds ratio, 2.66; 95% confidence interval, 1.008-7.052 for symptomatic vasospasm). This risk of vasospasm decreased with advanced age (P < .0001). Our findings suggest that patients age <50 years are at 5-fold greater risk of any vasospasm compared with older patients, and that age-adjusted prevention protocols may need to be considered. [ABSTRACT FROM AUTHOR]

Hemicraniectomy is a surgical procedure performed to prevent cerebral herniation and death in patients who have sustained a massive ischemic stroke in the anterior circulation territory. Information on in-hospital mortality in patients with large ischemic stroke treated with hemicraniectomy outside randomized trials is lacking. We sought to identify in-hospital mortality associated with hemicraniectomy in a large US sample. We selected our cohort from the National Inpatient Sample database for the years 2000 through 2006 using the clinical classification software codes for acute ischemic stroke (AIS) and arterial occlusion, and identified those patients treated with thrombolysis or hemicraniectomy by the procedure codes. A multivariate logistic regression model was used for adjusted analysis. Among 502,231 patients with AIS, 252 (0.05%) underwent hemicraniectomy, and 7526 (1.5%) were treated with thrombolysis. Compared with the nonsurgical group, patients treated with hemicraniectomy were younger (mean age, 55.6 vs 71.5 years) and had lower Charlson Comorbidity Index scores (92.8% vs 76.0%). The mortality rate was higher in the hemicraniectomy group (32.1% vs 10.8%; adjusted odds ratio [OR] = 3.91; 95% confidence interval [CI] = 2.97-5.16). In patients treated with thrombolysis, mortality was higher in the hemicraniectomy group compared with the nonsurgical group (35.3% vs 13.1%; P = .01). The rate of hospital utilization of hemicraniectomy varied between 0.04% and 0.06% among all stroke admissions; the trend did not change significantly over the 7-year study period (P = .06). The mortality rate in hemicraniectomy-treated patients was significantly lower than in historical cohorts however, hemicraniectomy remains associated with high in-hospital mortality. The rate of utilization of hemicraniectomy for AIS in US hospitals has remained essentially unchanged. [ABSTRACT FROM AUTHOR]

Percutaneous endoscopic gastrostomy (PEG) tubes are commonly needed for early nutrition in patients with acute ischemic stroke. We evaluated the relationship between the NIH Stroke Scale (NIHSS) score and the need for PEG tube placement. Patients with acute ischemic stroke were included in this study. We collected information on patient demographics, stroke severity as indicated by the NIHSS, and risk factors for vascular disease. We ascertained the swallowing evaluation and PEG tube placement during the same hospitalization. A hierarchical optimal classification tree was determined for the best predictors. A total of 187 patients (mean age, 67.2 years) were included, only 33 (17.6%) of whom had a PEG tube placed during the course of hospitalization. Those who had the PEG were slightly older (73.8 vs 65.8 years), had severe stroke (median NIHSS score, 18 vs 4), and a longer hospital stay (median 12 vs 4 days). Independent predictors for PEG placement included bulbar symptoms at onset, higher NIHSS score, stroke in the middle cerebral artery distribution, and aspiration pneumonia. Hierarchical analysis showed that patients with aspiration pneumonia and NIHSS score ≥12 had the highest likelihood (relative risk [RR] = 4.67; P < .0001) of requiring a PEG tube. In the absence of pneumonia, NIHSS score ≥16 yielded a moderate likelihood of requiring PEG (RR = 1.80; P < .0001). Our findings indicate that the presence of pneumonia and high NIHSS score are the best predictors for requiring PEG tube insertion in patients with ischemic stroke. These findings may have benefits in terms of early decision making, shorter hospitalization, and possible cost savings. [ABSTRACT FROM AUTHOR]

Background: Acute ischemic stroke (AIS) is common cause of hospital admission. The objective of this study was to determine the impact of the new Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations on AIS outcomes including inhospital mortality. Methods: Hospitalized patients with AIS were selected from the National Inpatient Sample database. Patients with AIS with a known mortality and hospital teaching status were included for the years 2000 through 2005. Inhospital mortality and predictors of mortality were stratified by the hospital teaching status. To determine the variability of mortality around the month of July (July phenomenon) the trend of mortality was determined in teaching hospitals stratified by the calendar month of each year. Results: In all, 377,266 patients were included in this analysis; 43.0% were admitted to teaching hospitals. Overall inhospital mortality was 10.8%, slightly higher in teaching hospitals (11.4% v 10.3%, P < .0001). The trend in AIS mortality showed a decline during the 6 years included in this study in both hospital types (P < .0001). Adjusted analysis showed decline in mortality in both hospital types after July 1, 2003: odds ratio (OR) 0.91 (95% confidence interval [CI] 0.87, 0.94) in teaching hospitals and OR 0.81 (95% CI 0.78, 0.84) in nonteaching hospitals. Predictors of AIS-associated hospital mortality were similar in both hospital types except for sepsis, which was another independent predictor of death in nonteaching hospitals (OR 1.58, 95% CI 1.30, 1.94). There was no significant change in AIS mortality when stratified by each calendar month within the years included in this study (P value = .25-.93). Conclusion: There was no difference in AIS mortality after the implementation of the new ACGME duty hour standards. In addition, data support the lack of July phenomenon in neurology residency programs in regard to AIS mortality. [Copyright &y& Elsevier]

Abstract: Disorders of the autonomic nervous system, or dysautonomias, affect a large segment of the population, especially women, and represent a diagnostic challenge. Identification of biomarkers for autonomic disorders, and the subsequent development of screening methods, would benefit diagnosis and symptom management. We studied the effect of sera from fifteen well-characterized dysautonomia patients (mean age 49±16 years, 10 females, 5 males) and ten control subjects (mean age 31±14 years, 5 females, 5 males) on the proliferation of cultured Schwann cells and activity of mitogen-activated protein kinases (MAPKs) in these cells. We correlated characteristics of patients with the effects on cell proliferation and signaling. Overall, we observed a significant increase in proliferation when Schwann cells were incubated with sera from female dysautonomia patients when compared to control subjects and male patients. Interestingly, removal of IgGs significantly reduced the proliferative effect of patient sera. We also observed significant activation of p38 MAPK following incubation with both male and female patient sera. These results suggest that patient sera contain factors that contribute to aberrant Schwann cell proliferation and signaling and may ultimately lead to autonomic nerve dysfunction. Our observations represent a promising first step in the identification of dysautonomia biomarkers. [Copyright &y& Elsevier]