National Institutes of Health Stroke Scale (NIHSS) scoring inconsistencies between neurologists and emergency room nurses

Background

Little is known about the consistency of initial NIHSS scores between neurologists and RNs in clinical practice.

Methods

A cohort study of patients with a code stroke was conducted at an urban academic Primary Stroke Center in the Midwest between January 1, 2018, and December 31, 2019 to determine consistency in National Institutes of Health Stroke Scale Scores (NIHSS) between neurologists and registered nurses (RNs).

Results

Among the 438 patients included in this study 65.3% (n = 286) of neurologist-RN NIHSS scoring pairs had congruent scores. One-in-three, (34.7%, n = 152) of neurologist-RN NIHSS scoring pairs had a clinically meaningful scoring difference of two points or greater. Higher NIHSS (p ≤ 0.01) and aphasia (p ≤ 0.01) were each associated with incongruent scoring between neurologist and emergency room RN pairs.

Conclusions

One-in-three initial NIHSS assessed by both a neurologist and RN had a clinically meaningful score difference between providers. More severe stroke, as indicated by a higher NIHSS was associated with scoring inconsistency between neurologist-RN pairs. Subjective scoring measures, especially those involving a patient having aphasia, was associated with greater score incongruency. Score differences may be attributed to differences in NIHSS training requirements between neurologists and RNs.

Abstract P167: Inconsistency in the Application of National Institutes of Health Stroke Scale Scores (NIHSS) Between Neurologist and Emergency Room Nurses During Acute Ischemic Stroke

Background: The National Institutes of Health Stroke Scale (NIHSS) score is the gold standard for assessing stroke severity. One 2006 study demonstrated research nurses had better interrater reliability in clinical trials than neurologists, but little is known about NIHSS score consistency between neurologists and registered nurses in clinical practice. Consistent baseline NIHSS scoring by neurologists and nurses is crucial to determine stroke acuity, deliver evidence-based treatment, and optimize patient outcomes. The purpose of this study was to determine whether a difference existed between healthcare providers’ NIHSS scores and determine factors affecting inconsistencies in scores.

Methods: A retrospective chart review of patients treated at a single Comprehensive Stroke Center safety net hospital compared the initial NIHSS scores given to the same patient by neurologists and emergency department nurses from January 2018 to December 2019. Of the 588 charts reviewed, 438 met inclusion criteria. Patients were divided into two cohorts based on score differences between neurologists and nurses: clinically meaningful score difference ≥2 (n= 152, 34.70%) and non-meaningful score difference <2 (n= 286, 65.30%,).

Results: Only two variables were significantly associated with greater score inconsistencies: higher NIHSS score (p = <.01) and patients presenting with aphasia (p =<.01). Clinically meaningful score inconsistencies were 44% more likely to occur in aphasic stroke patients.

Conclusions: Although overall NIHSS scores are similar between physicians and nurses, patients with aphasia and more severe strokes were more likely to be scored inconsistently. Neurologists and nurses have different training and certification requirements with nurses required to certify annually while neurologists are not. Implementing a policy that requires all providers to undergo the same training in specific areas of the NIHSS may eliminate disparity and ensure patients are given the interventions needed for best outcomes.

Abstract P834: Inconsistency in the Application of National Institutes of Health Stroke Scale Scores (NIHSS) Between Neurologist and Emergency Room Nurses During Acute Ischemic Stroke

Background: The National Institutes of Health Stroke Scale (NIHSS) score is the gold standard for assessing stroke severity. One 2006 study demonstrated research nurses had better interrater reliability in clinical trials than neurologists, but little is known about NIHSS score consistency between neurologists and registered nurses in clinical practice. Consistent baseline NIHSS scoring by neurologists and nurses is crucial to determine stroke acuity, deliver evidence-based treatment, and optimize patient outcomes. The purpose of this study was to determine whether a difference existed between healthcare providers’ NIHSS scores and determine factors affecting inconsistencies in scores.

Methods: A retrospective chart review of patients treated at a single Comprehensive Stroke Center safety net hospital compared the initial NIHSS scores given to the same patient by neurologists and emergency department nurses from January 2018 to December 2019. Of the 588 charts reviewed, 438 met inclusion criteria. Patients were divided into two cohorts based on score differences between neurologists and nurses: clinically meaningful score difference ≥2 (n= 152, 34.70%) and non-meaningful score difference <2 (n= 286, 65.30%,).

Results: Only two variables were significantly associated with greater score inconsistencies: higher NIHSS score (p = <.01) and patients presenting with aphasia (p =<.01). Clinically meaningful score inconsistencies were 44% more likely to occur in aphasic stroke patients.

Conclusions: Although overall NIHSS scores are similar between physicians and nurses, patients with aphasia and more severe strokes were more likely to be scored inconsistently. Neurologists and nurses have different training and certification requirements with nurses required to certify annually while neurologists are not. Implementing a policy that requires all providers to undergo the same training in specific areas of the NIHSS may eliminate disparity and ensure patients are given the interventions needed for best outcomes.

Nmp4/CIZ contributes to fluid shear stress induced MMP-13 gene induction in osteoblasts

The expression of matrix metalloproteinase-13 (MMP-13), involved in bone turnover, is elevated in stretched MC3T3-E1 osteoblast-like cells. Strain-mediated forces impact bone remodeling due in large part to the movement of fluid through the canalicular-lacunar network. The resulting fluid shear stress (FSS) over the surface membranes of bone cells initiates bone remodeling. Although the nuclear events mediating putative FSS-induced changes in osteoblast MMP-13 transcription are unknown, previous studies with bone cells suggest an overlap between osteoblast FSS- and PTH-induced signal response pathways. MMP-13 PTH response is regulated by a 110 bp 5' regulatory region, conserved across the mouse, rat, and human genes, that supports the binding of numerous transcription factors including Runx2, c-fos/c-jun, Ets-1, and nuclear matrix protein 4/cas interacting zinc finger protein (Nmp4/CIZ) a nucleocytoplasmic shuttling trans-acting protein that attenuates PTH-driven transcription. Nmp4/CIZ also binds p130(cas), an adaptor protein implicated in mechanotransduction. Here we sought to determine whether Nmp4/CIZ contributes to FSS-induced changes in MMP-13 transcription. FSS (12 dynes/cm(2), 3-5 h) increased MMP-13 promoter-reporter activity approximately two-fold in MC3T3-E1 osteoblast-like cells attended by a comparable increase in mRNA expression. This was accompanied by a decrease in Nmp4/CIZ binding to its cis-element within the PTH response region, the mutation of which abrogated the MMP-13 response to FSS. Interestingly, FSS enhanced Nmp4/CIZ promoter activity and induced p130(cas) nuclear translocation. We conclude that the PTH regulatory region of MMP-13 also contributes to FSS response and that Nmp4/CIZ plays similar but distinct roles in mediating hormone- and FSS-driven induction of MMP-13 in bone cells.

HMGB1 is a bone-active cytokine

High mobility group box 1 (HMGB1) is a chromatin protein that acts as an immunomodulatory cytokine upon active release from myeloid cells. HMGB1 is also an alarmin, an endogenous molecule released by dying cells that acts to initiate tissue repair. We have previously reported that osteoclasts and osteoblasts release HMGB1 and release by the latter is regulated by parathyroid hormone (PTH), an agent of bone remodeling. A recent study suggests that HMGB1 acts as a chemotactic agent to osteoclasts and osteoblasts during endochondral ossification. To explore the potential impact of HMGB1 in the bone microenvironment and its mechanism of release by osseous cells, we characterized the effects of recombinant protein (rHMGB1) on multiple murine bone cell preparations that together exhibit the various cell phenotypes present in bone. We also inquired whether apoptotic bone cells release HMGB1. rHMGB1 enhanced the RANKL/OPG steady state mRNA ratio and dramatically augmented the release of tumor necrosis factor-alpha (TNFalpha) and interleukin-6 (IL6) in osteoblastogenic bone marrow stromal cell (BMSC) cultures but not in the calvarial-derived MC3T3-E1 cells. Interestingly, rHMGB1 promoted GSK-3beta phosphorylation in MC3T3-E1 cells but not in BMSCs. Apoptotic bone cells released HMGB1, including MLO-Y4 osteocyte-like cells. MLO-Y4 release of HMGB1 was coincident with caspase-3 cleavage. Furthermore, the anti-apoptotic action of PTH on MC3T3-E1 cells correlated with the observed decrease in HMGB1 release. Our data suggest that apoptotic bone cells release HMGB1, that within the marrow HMGB1 is a bone resorption signal, and that intramembraneous and endochondral osteoblasts exhibit differential responses to this cytokine.

Who's listening? Experiences of women with breast cancer in communicating with physicians

The purpose of this qualitative study was to describe communication behaviors and attitudes of physicians that were most important to women living with breast cancer. Two focus group sessions were conducted, 1 month apart, involving 15 women who were members of a community-based breast cancer support group in Vancouver, British Columbia, Canada. Group dialogue was audiotaped, and notes were taken at each session by the coinvestigators, also members of the support group. Audiotapes, coinvestigators' written notes from the two focus group sessions, and the written homework assignments were used in the qualitative data analysis. Conceptual themes were identified and grouped to discern patterns within the data. The women were asked the following: (a) What were the most helpful things your doctor said or did at the time of your diagnosis? (b) What does a good intervention feel or look like? They were then asked to describe behaviors and attitudes they would like to influence in medical students who might later be communicating with women facing a diagnosis of breast cancer and to indicate which behaviors and attitudes they felt were most important. Women's positive experiences with physicians were characterized by communication based on active listening, awareness of the women's knowledge of their illness, honesty, and partnership. Physicians who showed interest in their patients as persons and who used touch to communicate caring were perceived as supportive communicators. Not surprisingly, there were similarities between the participants' positive experiences with their own physicians and the behaviors and attitudes desired in future physicians. Once again, "listening" was ranked as most important, followed by willingness to discern the individual patient's knowledge level.

An adult education model for training third-year medical students in use of the Physician Data Query (PDQ) System

BACKGROUND AND METHODS

An adult education model was developed to familiarize third-year medical students with the Physician Data Query (PDQ) system, a computerized, full-text database of state-of-the-art cancer information developed by the National Cancer Institute. The educational model was designed in collaboration with a medical librarian and was implemented within the context of a busy surgery clerkship using only modest resources that were readily available within the medical school.

RESULTS

During three years, 275 medical students participated in the exercise and evaluated both the PDQ system and the educational model. Overall, 87% of the students considered the PDQ system to be a valuable source of information, and 84% anticipated using PDQ after completing their surgical rotations. Ninety-six percent of the students agreed that the objectives of the exercise were met.

CONCLUSIONS

This article provides a description of the educational model and discusses the principles of adult education and andragogy on which it was developed. The importance of emphasizing the process of learning as well as the content is described relative to self-directed and life-long learning.

Metabolism and bioactivation of clozapine by human liver in vitro

The metabolism of clozapine by human liver has been investigated in vitro. Irreversible protein-binding and conjunction with model nucleophiles have been used as markers for bioactivation of clozapine, while stable metabolite formation has been assessed using radiometric HPLC. In all nine liver microsomal preparations investigated, clozapine was extensively metabolized to the stable products desmethylclozapine (range 19%-27.2%), N-oxide (1.5-20.5%) and three polar metabolites (0-20.8%), and was bioactivated to a protein-reactive metabolite (0.6-2.1%). The CYP2D6 genotype did not influence the capacity of the livers to form these metabolites. All metabolic pathways were inhibited by ketoconazole, indicating the involvement of the cytochrome P450 enzymes. Isozyme-selective inhibitor studies demonstrated that whereas demethylation was performed by CYP1A2, N-oxidation and chemically reactive metabolite formation were dependent upon multiple forms of P450. The N-oxide was readily reduced back to clozapine in the presence of NADPH, this conversion being inhibited by ascorbic acid. Glutathione (1 mM) decreased covalent binding by 70%. The amount of putative adduct formed in the presence of glutathione (13.4 +/- 0.9%) was much greater than the covalent binding (mean 1.1 +/- 0.2%). The bioactivation of clozapine was, like the N-oxidation of clozapine, a reversible process. In summary, our results indicate clozapine undergoes extensive metabolism by human liver to both stable and chemically reactive metabolites, the formation of which is catalyzed by the cytochrome P450 enzymes. The role of the reactive metabolite, which may be a free radical, in the pathogenesis of clozapine agranulocytosis and hepatotoxicity requires further study.

An investigation of the formation of cytotoxic, genotoxic, protein-reactive and stable metabolites from naphthalene by human liver microsomes

Chemically reactive epoxide metabolites have been implicated in various forms of drug and chemical toxicity. Naphthalene, which is metabolized to a 1,2-epoxide, has been used as a model compound in this study in order to investigate the effects of perturbation of detoxication mechanisms on the in vitro toxicity of epoxides in the presence of human liver microsomes. Naphthalene (100 microM) was metabolized to cytotoxic, protein-reactive and stable, but not genotoxic, metabolites by human liver microsomes. The metabolism-dependent cytotoxicity and covalent binding to protein of naphthalene were significantly higher in the presence of phenobarbitone-induced mouse liver microsomes than with human liver microsomes. The ratio of trans-1,2-dihydrodiol to 1-naphthol was 8.6 and 0.4 with the human and the induced mouse microsomes, respectively. The metabolism-dependent toxicity of naphthalene toward human peripheral mononuclear leucocytes was not affected by the glutathione transferase mu status of the co-incubated cells. Trichloropropene oxide (TCPO; 30 microM), an epoxide hydrolase inhibitor, increased the human liver microsomal-dependent cytotoxicity (19.6 +/- 0.9% vs 28.7 +/- 1.0%; P = 0.02) and covalent binding to protein (1.4 +/- 0.3% vs 2.8 +/- 0.2%; P = 0.03) of naphthalene (100 microM), and reversed the 1,2-dihydrodiol to 1-naphthol ratio from 6.6 (without TCPO) to 2.6, 0.6 and 0.1 at TCPO concentrations of 30, 100 and 500 microM, respectively. Increasing the human liver microsomal protein concentration reduced the cytotoxicity of naphthalene, while increasing its covalent binding to protein and the formation of the 1,2-dihydrodiol metabolite. Co-incubation with glutathione (5 mM) reduced the cytotoxicity and covalent binding to protein of naphthalene by 68 and 64%, respectively. Covalent binding to protein was also inhibited by gestodene, while stable metabolite formation was reduced by gestodene (250 microM) and enoxacin (250 microM). The study demonstrates that human liver cytochrome P450 enzymes metabolize naphthalene to a cytotoxic and protein-reactive, but not genotoxic, metabolite which is probably an epoxide. This is rapidly detoxified by microsomal epoxide hydrolase, the efficiency of which can be readily determined by measurement of the ratio of the stable metabolites, naphthalene 1,2-dihydrodiol and 1-naphthol.

MEDLINE on CD-ROM: end user searching in a medical school library

End users at the Medical College of Pennsylvania enjoyed searching CD-ROM versions of MEDLINE and judged such searches "extremely useful." To assess the effectiveness of their searches, a sample of 500 search statements from Compact Cambridge (CC) MEDLINE was examined. A high proportion of search statements (224, or 45 percent) retrieved no documents. Over one-third of search statements (185, or 37 percent) contained at least one error, which usually resulted in zero retrieval for that search statement. Searchers attempting to enter Medical Subject Headings were frequently defeated by the elaborate punctuation requirement of CC MEDLINE. "Missed opportunities" were evident in over three-fourths of search statements. One-on-one instruction and library classes may increase search success, but these measures reach a limited audience. Improvement in the search software itself is needed to help searchers improve the effectiveness of their searches.