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Objectives: The primary objective of this study was to define the incidence, disability, and death associated with stroke in the Buffalo metropolitan area and Erie County. This area has the highest stroke rate in New York State and therefore represents an ideal site to develop a successful model for prevention and management of stroke. Design: A cross-sectional design to study all new and recurrent strokes that occurred in the calendar year 2000 in the geographical location of Buffalo metropolitan area and Erie County. Patients and Data Collected: A retrospective review of an estimated 5,000 patients with new stroke will be performed at regional hospitals and the coroner’s office to determine the stroke subtypes, cerebrovascular risk factors, diagnostic investigations, treatment provided, and outcome. The total population residing in Buffalo in the year 2000 is available through the recent census. The study will also evaluate the quality of care provided for stroke patients including effectiveness of primary and secondary stroke prevention measures within this geographical region. Conclusions: We believe that this information will assist in allocation of resources and implementation of steps to improve stroke prevention and treatment.

Performance Improvement (PI) in health care is defined as “combined and unceasing efforts of everyone - healthcare professionals, patients and their families, researchers, payers, planners and educators - to make the changes that will lead to better patient outcomes, better system performance and better professional development”.1 Emphasis on quality improvement with formal rotations in residency programmes is a recent phenomenon. Our Internal Medicine Training Program based at Sisters of Charity Hospital is a part of the State University of New York at Buffalo (SUNY Buffalo). We have a total of 37 medical residents each year. In 2006, we implemented a four-week rotation titled ‘Performance Improvement Rotation’ and focused on five specific areas: Core measures, Departmental peer review process, Clinical documentation, Patient safety goals and adverse event reporting. The four-week rotation, mandatory for the residents in second year of training, started with an orientation and concluded with a written examination with required performance at 75 percentile. While many programmes have their own curricula for patient safety rotations, in June 2012, the Accreditation Council for Graduate Medical Education (ACGME) established Clinical Learning Environment Review (CLER) as a component of the Next Accreditation System (NAS) in an attempt to focus on patient safety education and quality improvement in training programmes.2,3 ACGME is the body responsible for accrediting the majority of graduate medical training programmes for physicians in the United States. When ACGME established these CLER guidelines, we decided to evaluate and modify the existing curriculum. What was the curriculum? In the review of core measures, residents understood the Centers for Medicare & Medicaid Services (CMS) core measures.4 They performed chart review of patients admitted to the hospital. Core measures are specific clinical measures that, when viewed together, permit an assessment of the quality of care provided in a specific condition, for example, acute myocardial infarction. As a part of Peer Review Process, residents participated in a peer review module to identify and prevent patient safety deficiencies.5 To improve and standardize the documentation, the clinical documentation consultants discussed documentation requirements with chart review on the floors with the residents.6 Patient safety goals component of the rotation was diverse and included verbal order chart review, medication reconciliation, Do Not Use (DNU) abbreviations, patient identification guidelines as defined by Joint Commission on Accreditation of Healthcare Organizations (JCAHO)7 and look alike and sound alike medications. Adverse event reporting exercise had activities like participating in ‘Root Cause Analysis (RCA)’ of few patients.

Study Objective. To determine the proportion of patients in a large metropolitan population who developed ischemic stroke despite having received antiplatelet drug therapy, and their associated characteristics and in-hospital outcomes. Design. Retrospective, cross-sectional study. Setting. Eleven hospitals in western New York State. Patients. One thousand five hundred eighty-two patients with new or recurrent ischemic stroke who were admitted to one of the 11 study hospitals between January 1 and December 31, 2000, and for whom data were available regarding previous drug therapy. Measurements and Main Results. The proportion of patients taking antiplatelet drugs before the onset of stroke was determined. Demographic and clinical characteristics, stroke subtypes, in-hospital bleeding complications, mortality, and discharge drugs were compared between patients with and those without previous antiplatelet drug use. Previous use of antiplatelet drugs was observed in 642 (41%) of the 1582 patients admitted with ischemic stroke. The antiplatelet drugs were aspirin alone (494 patients), clopidogrel alone (70), aspirin and clopidogrel (36), aspirin in combination with other antiplatelet drugs (20), and others (22). Patients with previous use of antiplatelet drugs were older and more likely to have hypertension, diabetes mellitus, hyperlipidemia, and a history of cardiovascular disease. The proportion of patients with large-vessel disease was greater among patients with previous use of antiplatelet drugs. Patients with previous use of antiplatelet drugs were more likely to be discharged with aspirin, clopidogrel, and an aspirin-dipyridamole combination. Conclusion. The relatively high proportion of patients who developed ischemic stroke despite taking antiplatelet drugs observed in this regional hospital-based study mandates clinical trials specifically addressing therapeutic intervention for this group of patients.

DOI: http://dx.doi.org/10.5915/21-3-13366 The Tolosa-Hunt Syndrome (THS) refers to a painful recurrent ophthalmoplegia with or without associated sensory changes. Attacks may last days to weeks and are characterized by remission and periodic relapses. THS closely resembles pathologic process(es) around the cavernous sinus or the superior orbital fissure and must be differentiated from them. The case of a young female with THS is described below followed by a review of the literature.