Andre Kumar earned his MD degree from Tulane University in New Orleans, Louisiana. He completed his residency and chief residency in internal medicine at Stanford University. He is currently a Clinical Assistant Professor in the Stanford Division of Hospital Medicine.
Dr. Kumar currently serves as co-president of the Society of Hospital Medicine (SHM) Bay Area Chapter and is the director of the medicine consult/procedure service. His professional interests include point-of-care ultrasound and clinical research in the era of COVID-19. He is a course instructor for the SHM ultrasound certification program. He is the lead investigator for a multicenter trial related to ultrasound and COVID-19 (https://clinicaltrials.gov/ct2/show/NCT04384055). He is also an investigator for the National Institutes of Health ACTT and ACTIV trials for COVID-19 treatment. A full list of his publications on Pubmed can be found here: https://www.ncbi.nlm.nih.gov/pubmed/?term=andre+kumar
In addition to ultrasound, Dr. Kumar is passionate about medical education and improving physician training. He earned a Master's in Education from Stanford University (2019) and is a 2019-2020 fellow for the Rathmann Medical Education Fellowship. His educational interests include educational technology, curriculum design, and leveraging educational outcomes research to improve curricula. As a resident, he developed the Stanford Hospitalist Advanced Practice and Education (SHAPE) Program, which was the first resident-run hospitalist training track in the country. He currently serves as the director for the SHAPE Program, as well as co-director for the Advanced Clinical Skills course in the Stanford School of Medicine.
- Internal Medicine
- Hospital Medicine
Clinical Assistant Professor, Medicine
Clinical Assistant Professor, Division of General Medical Disciplines (2018 - Present)
Director, Medicine Consult Service (2018 - Present)
Course Co-Director, Advanced Clinical Skills (2017 - Present)
Chief Resident, Stanford Internal Medicine Residency Program (2016 - 2017)
Director, SHAPE Program (2014 - Present)
Honors & Awards
David A Rytand Clinical Teaching Award, Stanford University Department of Medicine (2018)
Henry J. Kaiser Foundation Award for Excellence in Teaching, Stanford University School of Medicine (2018)
Award for Humanism & Excellence in Teaching, Arnold P. Gold Foundation (2017)
Resident Teacher of the Year, Stanford Internal Medicine Residency Program (2016)
Resident Teacher of the Year, Stanford Internal Medicine Residency Program (2015)
Johns Hopkins National Housestaff Research Award, Johns Hopkins School of Medicine (2015)
Julian Wolfsohn Award, Stanford Internal Medicine Residency Program (2014)
Medical Jeopardy 1st Place, California ACP Chapter (2015)
C. Thorpe Ray Internal Medicine Society Award, Tulane University School of Medicine (2013)
Harold C. Cummins Award, Tulane University School of Medicine (2013)
Boards, Advisory Committees, Professional Organizations
President, Society of Hospital Medicine Bay Area Chapter (2019 - Present)
Residency: Stanford University Internal Medicine Residency (2016) CA
Medical Education: Tulane University School of Medicine Registrar (2013) LA
Master of Education, Stanford University, Education (2019)
Board Certification: American Board of Internal Medicine, Internal Medicine (2016)
Chief Residency, Stanford University, Internal Medicine
Residency, Stanford University, Internal Medicine
BS, University of Nevada, Biology
Interobserver agreement of lung ultrasound findings of COVID-19.
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
BACKGROUND: Lung ultrasound (LUS) has received considerable interest in the clinical evaluation of patients with COVID-19. Previously described LUS manifestations for COVID-19 include B-lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID-19 is unknown.METHODS: This study was conducted between March and June 2020. Nine physicians (hospitalists: n = 4; emergency medicine: n = 5) from 3 medical centers independently evaluated n = 20 LUS scans (n = 180 independent observations) collected from patients with COVID-19, diagnosed via RT-PCR. These studies were randomly selected from an image database consisting of COVID-19 patients evaluated in the emergency department with portable ultrasound devices. Physicians were blinded to any patient information or previous LUS interpretation. Kappa values (kappa) were used to calculate IRR.RESULTS: There was substantial IRR on the following items: normal LUS scan (kappa = 0.79 [95% CI: 0.72-0.87]), presence of B-lines (kappa = 0.79 [95% CI: 0.72-0.87]), ≥3 B-lines observed (kappa = 0.72 [95% CI: 0.64-0.79]). Moderate IRR was observed for the presence of any consolidation (kappa = 0.57 [95% CI: 0.50-0.64]), subpleural consolidation (kappa = 0.49 [95% CI: 0.42-0.56]), and presence of effusion (kappa = 0.49 [95% CI: 0.41-0.56]). Fair IRR was observed for pleural thickening (kappa = 0.23 [95% CI: 0.15-0.30]).DISCUSSION: Many LUS manifestations for COVID-19 appear to have moderate to substantial IRR across providers from multiple specialties utilizing differing portable devices. The most reliable LUS findings with COVID-19 may include the presence/count of B-lines or determining if a scan is normal. Clinical protocols for LUS with COVID-19 may require additional observers for the confirmation of less reliable findings such as consolidations.
View details for DOI 10.1002/jum.15620
View details for PubMedID 33426734
Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial.
Journal of hospital medicine
2020; 15 (2): e1–e6
BACKGROUND: Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage.OBJECTIVE: This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS.METHODS: Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures.RESULTS: Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores.CONCLUSIONS: Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.
View details for DOI 10.12788/jhm.3351
View details for PubMedID 32118565
Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments.
Journal of general internal medicine
Point-of-care ultrasonography (POCUS) has the potential to transform healthcare delivery through its diagnostic expediency. Trainee competency with POCUS is now mandated for emergency medicine through the Accreditation Council for Graduate Medical Education (ACGME), and its use is expanding into other medical specialties, including internal medicine. However, a key question remains: how does one define "competency" with this emerging technology? As our trainees become more acquainted with POCUS, it is vital to develop validated methodology for defining and measuring competency amongst inexperienced users. As a framework, the assessment of competency should include evaluations that assess the acquisition and application of POCUS-related knowledge, demonstration of technical skill (e.g., proper probe selection, positioning, and image optimization), and effective integration into routine clinical practice. These assessments can be performed across a variety of settings, including web-based applications, simulators, standardized patients, and real clinical encounters. Several validated assessments regarding POCUS competency have recently been developed, including the Rapid Assessment of Competency in Echocardiography (RACE) or the Assessment of Competency in Thoracic Sonography (ACTS). However, these assessments focus mainly on technical skill and do not expand upon other areas of this framework, which represents a growing need. In this review, we explore the different methodologies for evaluating competency with POCUS as well as discuss current progress in the field of measuring trainee knowledge and technical skill.
View details for PubMedID 30924088
Duty-Hour Flexibility Trial in Internal Medicine
NEW ENGLAND JOURNAL OF MEDICINE
2018; 379 (3): 300
View details for Web of Science ID 000439063900020
To Cure Sometimes, to Relieve Often, to Comfort Always.
JAMA internal medicine
2016; 176 (6): 731–32
View details for PubMedID 27110667
OrderRex clinical user testing: a randomized trial of recommender system decision support on simulated cases.
Journal of the American Medical Informatics Association : JAMIA
OBJECTIVE: To assess usability and usefulness of a machine learning-based order recommender system applied to simulated clinical cases.MATERIALS AND METHODS: 43 physicians entered orders for 5 simulated clinical cases using a clinical order entry interface with or without access to a previously developed automated order recommender system. Cases were randomly allocated to the recommender system in a 3:2 ratio. A panel of clinicians scored whether the orders placed were clinically appropriate. Our primary outcome included the difference in clinical appropriateness scores. Secondary outcomes included total number of orders, case time, and survey responses.RESULTS: Clinical appropriateness scores per order were comparable for cases randomized to the order recommender system (mean difference -0.11 order per score, 95% CI: [-0.41, 0.20]). Physicians using the recommender placed more orders (median 16 vs 15 orders, incidence rate ratio 1.09, 95%CI: [1.01-1.17]). Case times were comparable with the recommender system. Order suggestions generated from the recommender system were more likely to match physician needs than standard manual search options. Physicians used recommender suggestions in 98% of available cases. Approximately 95% of participants agreed the system would be useful for their workflows.DISCUSSION: User testing with a simulated electronic medical record interface can assess the value of machine learning and clinical decision support tools for clinician usability and acceptance before live deployments.CONCLUSIONS: Clinicians can use and accept machine learned clinical order recommendations integrated into an electronic order entry interface in a simulated setting. The clinical appropriateness of orders entered was comparable even when supported by automated recommendations.
View details for DOI 10.1093/jamia/ocaa190
View details for PubMedID 33106874
Physician Usage and Acceptance of a Machine Learning Recommender System for Simulated Clinical Order Entry.
AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science
2020; 2020: 89–97
Clinical decision support tools that automatically disseminate patterns of clinical orders have the potential to improve patient care by reducing errors of omission and streamlining physician workflows. However, it is unknown if physicians will accept such tools or how their behavior will be affected. In this randomized controlled study, we exposed 34 licensed physicians to a clinical order entry interface and five simulated emergency cases, with randomized availability of a previously developed clinical order recommender system. With the recommender available, physicians spent similar time per case (6.7 minutes), but placed more total orders (17.1 vs. 15.8). The recommender demonstrated superior recall (59% vs 41%) and precision (25% vs 17%) compared to manual search results, and was positively received by physicians recognizing workflow benefits. Further studies must assess the potential clinical impact towards a future where electronic health records automatically anticipate clinical needs.
View details for PubMedID 32477627
- Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments JOURNAL OF GENERAL INTERNAL MEDICINE 2019; 34 (6): 1025–31
- CMS Billing Guidelines and Student Documentation: a New Era or New Burden? JOURNAL OF GENERAL INTERNAL MEDICINE 2019; 34 (4): 634–35
Thrombophilia testing in the inpatient setting: impact of an educational intervention.
BMC medical informatics and decision making
2019; 19 (1): 167
Thrombophilia testing is frequently ordered in the inpatient setting despite its limited impact on clinical decision-making and unreliable results in the setting of acute thrombosis or ongoing anticoagulation. We sought to determine the effect of an educational intervention in reducing inappropriate thrombophilia testing for hospitalized patients.During the 2014 academic year, we implemented an educational intervention with a phase implementation design for Internal Medicine interns at Stanford University Hospital. The educational session covering epidemiology, appropriate thrombophilia evaluation and clinical rationale behind these recommendations. Their ordering behavior was compared with a contemporaneous control (non-medicine and private services) and a historical control (interns from prior academic year). From the analyzed data, we determined the proportion of inappropriate thrombophilia testing of each group. Logistic generalized estimating equations were used to estimate odds ratios for inappropriate thrombophilia testing associated with the intervention.Of 2151 orders included, 934 were deemed inappropriate (43.4%). The two intervention groups placed 147 orders. A pooled analysis of ordering practices by intervention groups revealed a trend toward reduction of inappropriate ordering (p = 0.053). By the end of the study, the intervention groups had significantly lower rates of inappropriate testing compared to historical or contemporaneous controls.A brief educational intervention was associated with a trend toward reduction in inappropriate thrombophilia testing. These findings suggest that focused education on thrombophilia testing can positively impact inpatient ordering practices.
View details for DOI 10.1186/s12911-019-0889-6
View details for PubMedID 31429747
The Role of Technology in the Bedside Encounter.
The Medical clinics of North America
2018; 102 (3): 443–51
Technology has the potential to both distract and reconnect providers with their patients. The widespread adoption of electronic medical records in recent years pulls physicians away from time at the bedside. However, when used in conjunction with patients, technology has the potential to bring patients and physicians together. The increasing use of point-of-care ultrasound by physicians is changing the bedside encounter by allowing for real-time diagnosis with the treating physician. It is a powerful example of the way technology can be a force for refocusing on the bedside encounter.
View details for PubMedID 29650066
A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback.
Postgraduate medical journal
Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).We successfully implemented a novel high value care curriculum that specifically targets intern physicians.
View details for PubMedID 28663352
Magnitude of Potentially Inappropriate Thrombophilia Testing in the Inpatient Hospital Setting.
Journal of hospital medicine
2017; 12 (9): 735–38
Laboratory costs of thrombophilia testing exceed an estimated $650 million (in US dollars) annually. Quantifying the prevalence and financial impact of potentially inappropriate testing in the inpatient hospital setting represents an integral component of the effort to reduce healthcare expenditures. We conducted a retrospective analysis of our electronic medical record to evaluate 2 years' worth of inpatient thrombophilia testing measured against preformulated appropriateness criteria. Cost data were obtained from the Centers for Medicare and Medicaid Services 2016 Clinical Laboratory Fee Schedule. Of the 1817 orders analyzed, 777 (42.7%) were potentially inappropriate, with an associated cost of $40,422. The tests most frequently inappropriately ordered were Factor V Leiden, prothrombin gene mutation, protein C and S activity levels, antithrombin activity levels, and the lupus anticoagulant. Potentially inappropriate thrombophilia testing is common and costly. These data demonstrate a need for institution-wide changes in order to reduce unnecessary expenditures and improve patient care.
View details for PubMedID 28914278
The Illness of Present Histories.
Academic medicine : journal of the Association of American Medical Colleges
2017; 92 (4): 434–35
View details for PubMedID 28350609
A resident-created hospitalist curriculum for internal medicine housestaff.
Journal of hospital medicine
2016; 11 (9): 646-649
The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.
View details for DOI 10.1002/jhm.2590
View details for PubMedID 27079160
- Incidence and financial impact of inappropriate thrombophilia testing in the inpatient hospital setting: a retrospective analysis. Blood 2016; 128: 2330
- Troubleshooting the NIHSS: question-and-answer session with one of the designers INTERNATIONAL JOURNAL OF STROKE 2015; 10 (8): 1284-1286
Preparing to take the USMLE Step 1: a survey on medical students' self-reported study habits
POSTGRADUATE MEDICAL JOURNAL
2015; 91 (1075): 257-261
The USA Medical Licensing Examination Step 1 is a computerised multiple-choice examination that tests the basic biomedical sciences. It is administered after the second year in a traditional four-year MD programme. Most Step 1 scores fall between 140 and 260, with a mean (SD) of 227 (22). Step 1 scores are an important selection criterion for residency choice. Little is known about which study habits are associated with a higher score.To identify which self-reported study habits correlate with a higher Step 1 score.A survey regarding Step 1 study habits was sent to third year medical students at Tulane University School of Medicine every year between 2009 and 2011. The survey was sent approximately 3 months after the examination.256 out of 475 students (54%) responded. The mean (SD) Step 1 score was 229.5 (22.1). Students who estimated studying more than 8-11 h per day had higher scores (p<0.05), but there was no added benefit with additional study time. Those who reported studying <40 days achieved higher scores (p<0.05). Those who estimated completing >2000 practice questions also obtained higher scores (p<0.01). Students who reported studying in a group, spending the majority of study time on practice questions or taking >40 preparation days did not achieve higher scores.Certain self-reported study habits may correlate with a higher Step 1 score compared with others. Given the importance of achieving a high Step 1 score on residency choice, it is important to further identify which characteristics may lead to a higher score.
View details for DOI 10.1136/postgradmedj-2014-133081
View details for Web of Science ID 000355010900004
View details for PubMedID 25910497
Persistent Leukocytosis-Is this a Persistent Problem for Patients with Acute Ischemic Stroke?
JOURNAL OF STROKE & CEREBROVASCULAR DISEASES
2014; 23 (7): 1939-1943
In the setting of acute ischemic stroke (AIS), leukocytosis has been shown to be an indicator of inflammatory response. Although leukocytosis on admission has been shown to correlate with initial stroke severity in AIS patients, no work has been done to assess if there are differences in transient or persistent leukocytosis in patients without infection. The objective of this study is to determine the clinical significance of persistent versus transient leukocytosis during the early phase of AIS.Patients who presented with AIS to our center within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified by chart review. Patients were included if they had leukocytosis on admission (defined as white blood cell count >11,000/μL based on laboratory reference range values). A logistic regression model was used to evaluate persistent leukocytosis (leukocytosis 48 hours after admission) as a predictor of several outcome measures, including good functional outcome (discharge modified Rankin Scale score of 0-2). Marginal effects were used to estimate the probability of poor functional outcome.Of the 438 patients screened, 49 had leukocytosis on admission and of those 24 (49%) had persistent leukocytosis. NIHSS score correlated significantly with persistence of leukocytosis (r = .306; P = .0044). More people with transient leukocytosis (leukocytosis lasting <48 hours) had a good functional outcome (44% versus 16%; P = .006). After adjusting for baseline NIHSS score, persistent leukocytosis was not a significant independent predictor of good functional outcome, but showed an association (OR, 2.5; 95% CI, .562-10.7; P = .2322). Persistent leukocytosis after adjusting for age and NIHSS score at admission is associated with a poor functional outcome, but it is not statistically significant (OR, 2.43; 95% CI, .59-9.87; P = .2151). After controlling for age and NIHSS score on admission, for patients with persistent leukocytosis, the probability of having poor functional outcome at discharge was increased by 16 percentage points.Persistent leukocytosis is associated with higher baseline NIHSS scores. Persistent leukocytosis is tightly linked with baseline stroke severity and is associated with poor patient outcomes. Our study found that patients with persistent leukocytosis are more likely to present with severe strokes and maintain a high NIHSS score at 24 hours after admission, unlike patients without leukocytosis or patients with transient leukocytosis. Furthermore, it appears that persistent leukocytosis outside the setting of an infection negatively impacts the short-term functional outcome of AIS patients. Identifying patients with persistent leukocytosis could help to prognosticate and target patients that may benefit from future anti-inflammatory interventions.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2014.02.004
View details for Web of Science ID 000341484400028
View details for PubMedID 24784010
Infections Present on Admission Compared with Hospital-Acquired Infections in Acute Ischemic Stroke Patients
JOURNAL OF STROKE & CEREBROVASCULAR DISEASES
2013; 22 (8): E582-E589
To date, few studies have assessed the influence of infections present on admission (POA) compared with hospital-acquired infections (HAIs) on neurologic deterioration (ND) and other outcome measures in acute ischemic stroke (AIS).Patients admitted with AIS to our stroke center (July 2010 to December 2010) were retrospectively assessed. The following infections were assessed: urinary tract infection, pneumonia, and bacteremia. Additional chart review was performed to determine whether the infection was POA or HAI. We assessed the relationship between infections in ischemic stroke patients and several outcome measures including ND and poor functional outcome. A mediation analysis was performed to assess the indirect effects of HAI, ND, and poor functional outcome.Of the 334 patients included in this study, 77 had any type of infection (23 POA). After adjusting for age, National Institutes of Health Stroke Scale at baseline, glucose on admission, and intravenous tissue plasminogen activator, HAI remained a significant predictor of ND (odds ratio [OR]=8.8, 95% confidence interval [CI]: 4.2-18.7, P<.0001) and poor functional outcome (OR=41.7, 95% CI: 5.2-337.9, P=.005), whereas infections POA were no longer associated with ND or poor functional outcome. In an adjusted analysis, we found that 57% of the effect from HAI infections on poor functional outcome is because of mediation through ND (P<.0001).Our data suggests that HAI in AIS patients increases the odds of experiencing ND and subsequently increases the odds of being discharged with significant disability. This mediated effect suggests a preventable cause of ND that can thereby decrease the odds of poor functional outcomes after an AIS.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2013.07.020
View details for Web of Science ID 000327719000048
View details for PubMedID 23954599
Leukocytosis in Patients with Neurologic Deterioration after Acute Ischemic Stroke is Associated with Poor Outcomes
JOURNAL OF STROKE & CEREBROVASCULAR DISEASES
2013; 22 (7): E111-E117
Neurologic deterioration (ND) after acute ischemic stroke (AIS) has been shown to result in poor outcomes. ND is thought to arise from penumbral excitotoxic cell death caused in part by leukocytic infiltration. Elevated admission peripheral leukocyte levels are associated with poor outcomes in stroke patients who suffer ND, but little is known about the dynamic changes that occur in leukocyte counts around the time of ND. We sought to determine if peripheral leukocyte levels in the days surrounding ND are correlated with poor outcomes.Patients with AIS who presented to our center within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified by chart review and screened for ND (defined as an increase in National Institutes of Health Stroke Scale score ≥ 2 within a 24-hour period). Patients were excluded for steroid use during hospitalization or in the month before admission and infection within the 48 hours before or after ND. Demographics, daily leukocyte counts, and poor functional outcome (modified Rankin Scale score 3-6) were investigated.Ninety-six of the 292 (33%) patients screened had ND. The mean age was 69.5 years; 62.5% were male and 65.6% were black. Patients with a poor functional outcome had significantly higher leukocyte and neutrophil levels 1 day before ND (P = .048 and P = .026, respectively), and on the day of ND (P = .013 and P = .007, respectively), compared to patients with good functional outcome.Leukocytosis at the time of ND correlates with poor functional outcomes and may represent a marker of greater cerebral damage through increased parenchymal inflammation.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.08.008
View details for Web of Science ID 000325874200018
View details for PubMedID 23031742
Identification of Modifiable and Nonmodifiable Risk Factors for Neurologic Deterioration after Acute Ischemic Stroke
JOURNAL OF STROKE & CEREBROVASCULAR DISEASES
2013; 22 (7): E207-E213
Neurologic deterioration (ND) after ischemic stroke has been shown to impact short-term functional outcome and is associated with in-hospital mortality.Patients with acute ischemic stroke who presented between July 2008 and December 2010 were identified and excluded for in-hospital stroke, presentation >48 hours since last seen normal, or unknown time of last seen normal. Clinical and laboratory data, National Institutes of Health Stroke Scale (NIHSS) scores, and episodes of ND (increase in NIHSS score ≥ 2 within a 24-hour period) were investigated.Of the 596 patients screened, 366 were included (median age 65 years; 42.1% female; 65.3% black). Of these, 35.0% experienced ND. Patients with ND were older (69 v 62 years; P < .0001), had more severe strokes (median admission NIHSS score 12 v 5; P < .0001), carotid artery stenosis (27.0% v 16.8%; P = .0275), and coronary artery disease (26.0% v 16.4%; P = .0282) compared to patients without ND. Patients with ND had higher serum glucose on admission than patients without ND (125.5 v 114 mg/dL; P = .0036). After adjusting for crude variables associated with ND, age >65 years, and baseline NIHSS score >14 remained significant independent predictors of ND. In a logistic regression analysis adjusting for age and serum glucose, each 1-point increase in admission NIHSS score was associated with a 7% increase in the odds of ND (odds ratio 1.07; 95% confidence interval 1.04-1.10; P < .0001).Older patients and patients with more severe strokes are more likely to experience ND. Initial stroke severity was the only significant, independent, and modifiable risk factor for ND, amenable to recanalization and reperfusion.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.11.006
View details for Web of Science ID 000325874200031
View details for PubMedID 23246190
What Change in the National Institutes of Health Stroke Scale Should Define Neurologic Deterioration in Acute Ischemic Stroke?
JOURNAL OF STROKE & CEREBROVASCULAR DISEASES
2013; 22 (5): 675-682
Neurologic deterioration (ND) occurs in one-third of patients with stroke. However, the true incidence of ND and risk for adverse outcomes remains unknown because no standardized definition of ND exists. Our study compared the prognostic value of a range of definitions for ND in patients with acute ischemic stroke (AIS).All patients who presented to our center with AIS within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified. Patient demographics, National Institutes of Health Stroke Scale (NIHSS) scores, etiologies of ND, and outcome measures were compared between patients according to a range of ND definitions using receiver operating characteristic analyses.Three hundred forty-seven patients were included. The 2 definitions of ND with the highest sensitivity and specificity for several outcome measures were tested against each other: an increase in the NIHSS score by ≥2 or ≥4 points in a 24-hour period. More than one third (36.9%) of patients experienced ≥2-point ND versus 17.3% with ≥4-point ND. Patients who experienced ND by either definition had prolonged hospitalization (P < .001), poorer functional outcome (discharge modified Rankin Scale score >2; P < .001), and higher discharge NIHSS score (P < .001) compared to patients without ND. Compared to patients without ND, a ≥2-point ND was associated with a 3-fold risk of death (odds ratio 3.120; 95% confidence interval 1.231-7.905; P < .0165) after adjusting for admission NIHSS score, serum glucose, and age.A ≥2-point ND is a sensitive indicator of poor outcome and in-hospital mortality. An accepted definition of ND is needed to systematically study and compare results across trials for ND in patients with stroke.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.04.012
View details for Web of Science ID 000321550000014
View details for PubMedID 22727922