Nirali Vora

All Publications

• Consensus Competencies for Post-Graduate Fellowship Training in Global Neurology. Neurology Schiess, N., Kulo, V., Anand, P., Bearden, D. R., Berkowitz, A. L., Birbeck, G. L., Cervantes-Arslanian, A., Chan, P., Chishimba, L. C., Chow, F. C., Elicer, I., Fleury, A., Kinikar, A., Kvalsund, M., Mateen, F. J., Mbonde, A. A., Meyer, A. L., O'Carroll, C. B., Ogunniyi, A., Patel, A. A., Rubenstein, M., Siddiqi, O. K., Spudich, S., Tackett, S. A., Thakur, K. T., Vora, N., Zunt, J., Saylor, D. R. 2023

  Abstract

  Use a modified Delphi approach to develop competencies for neurologists completing >1 year of advanced global neurology training.An expert panel of 19 US-based neurologists involved in global health was recruited from the American Academy of Neurology Global Health Section and the American Neurological Association International Outreach Committee. An extensive list of global health competencies was generated from review of global health curricula and adapted for global neurology training. Using a modified Delphi method, US-based neurologists participated in three rounds of voting on a survey with potential competencies rated on a 4-point Likert scale. A final group discussion was held to reach consensus. Proposed competencies were then subjected to a formal review from a group of seven neurologists from low- and middle-income countries (LMICs) with experience working with neurology trainees from high-income countries (HICs) who commented on potential gaps, feasibility, and local implementation challenges of the proposed competencies. This feedback was used to modify and finalize competencies.Three rounds of surveys, a conference call with US-based experts, and a semi-structured questionnaire and focus group discussion with LMIC experts were utilized to discuss and reach consensus on the final competencies. This resulted in a competency framework consisting of 47 competencies across eight domains: (1) Cultural Context, Social Determinants of Health and Access to Care; (2) Clinical and Teaching Skills and Neurological Medical Knowledge; (3) Team-Based Practice; (4) Developing Global Neurology Partnerships; (5) Ethics; (6) Approach to Clinical Care; (7) Community Neurological Health; (8) Health Care Systems and Multinational Health Care Organizations.These proposed competencies can serve as a foundation on which future global neurology training programs can be built and trainees evaluated. It may also serve as a model for global health training programs in other medical specialties as well as a framework to expand the number of neurologists from HICs trained in global neurology.

  View details for DOI 10.1212/WNL.0000000000207184

  View details for PubMedID 36997322

• Trends in Utilization of Magnetic Resonance Imaging for Stroke Patients With Cardiac Rhythm Devices. The Neurohospitalist Culbertson, C. J., Perino, A. C., Gardner, R. M., Balasubramanian, V., Vora, N. 2022; 12 (4): 624-631

  Abstract

  Magnetic resonance imaging (MRI) is safe for most patients with cardiovascular implantable electronic devices (CIEDs). However, patients presenting with acute ischemic stroke or transient ischemic attack (AIS/TIA) who have CIEDs may undergo MRI less frequently than patients without devices. We assessed contemporary use of MRI for patients with AIS/TIA and the effect of a recent coverage revision by the Center for Medicare and Medicaid Services (CMS) on MRI utilization.Using Optum® claims data from January 2012 to June 2019, we performed an interrupted time series analysis of MRI utilization during AIS/TIA hospitalizations with the April 2018 CMS coverage revision serving as the intervention. For patients treated after the coverage revision, we used multivariable logistic regression to determine the association between lack of CIED and MRI utilization for AIS/TIA.We identified 417,899 patient hospitalizations for AIS/TIA, of which 30,425 (7%) had a CIED present (CIED vs non-CIED patients: age 77.6 ± 9.8 vs 72.7 ± 12.3 years; 45.5% vs 54.3% female). From 2012 to 2019, annual MRI utilization increased from 3% to 20% for CIED patients and 58% to 66% for non-CIED patients. The CMS coverage revision was associated with a 4.2% absolute additional increase in MRI utilization for CIED patients. Non-CIED patients treated after the CMS coverage revision were substantially more likely than CIED patients to undergo MRI (adjusted OR 6.7, 95% CI: 6.3-7.1, P<.001).MRI utilization has increased for stroke patients with CIEDs but remains far lower than in similar patients without devices.

  View details for DOI 10.1177/19418744221115004

  View details for PubMedID 36147760

  View details for PubMedCentralID PMC9485690

• Early identification and treatment of women's cardiovascular risk factors prevents cardiovascular disease, saves lives, and protects future generations: Policy recommendations and take action plan utilizing policy levers CLINICAL CARDIOLOGY Ivey, S. L., Hanley, H., Taylor, C., Stock, E., Vora, N., Woo, J., Johnson, S., Merz, C., Right Care Womens Cardiovasc Writi 2022

  Abstract

  Cardiovascular diseases (CVD) including heart attacks, strokes, heart failure, and uncontrolled hypertension are leading causes of death among women of all ages. Despite efforts to increase awareness about CVD among women, over the past decade there has been stagnation in the reduction of CVD in women, and CVD among younger women and women of color has in fact increased. We recommend taking action using policy levers to address CVD in women including: (1) Promoting periodic screening for risk factors including blood pressure, lipids/cholesterol, diabetes for all women starting at 18-21 years, with calculated atherosclerotic CVD (ASCVD) risk score use among women 40 years or older. (2) Considering coronary artery calcium (CAC) screening for those with intermediate risk per current guidelines. (3) Enhancing Obstetrics and Gynecology and primary care physician education on reproductive age CVD risk markers, and that follow-up is needed, including extended postpartum follow-up. (4) Offering Health Coaching/motivational Interviewing to support behavior change. (5) Funding demonstration projects using different care models. (6) Creating a Stop High Blood Pressure consult line (for providers and patients) and providing other support resources with actions consumers can take, modeled after the California tobacco quit line. And (7) Requiring inclusion of adverse pregnancy outcomes in all Electronic Health Records, with reminder systems to follow-up on hypertension post-partum.

  View details for DOI 10.1002/clc.23921

  View details for Web of Science ID 000855725000001

  View details for PubMedID 36128629

• Reply to Letter to the Editor: Atypical Optic Neuritis After COVID-19 Vaccination: Response. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society Tugizova, M., Siegel, D. T., Huang, S., Su, E., Subramanian, P. S., Beres, S., Vora, N. 2022

  View details for DOI 10.1097/WNO.0000000000001596

  View details for PubMedID 35439209

• Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings. Stroke Prust, M. L., Saylor, D., Zimba, S., Sarfo, F. S., Shrestha, G. S., Berkowitz, A., Vora, N. 1800: STROKEAHA121037297

  Abstract

  Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.

  View details for DOI 10.1161/STROKEAHA.121.037297

  View details for PubMedID 35045720

• Case Series: Atypical Optic Neuritis After COVID-19 Vaccination. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society Tugizova, M., Siegel, D. T., Huang, S., Su, E., Subramanian, P. S., Beres, S., Vora, N. 2022

  View details for DOI 10.1097/WNO.0000000000001519

  View details for PubMedID 35020705

• Feasibility and safety of a rapid-access transient ischemic attack clinic. Journal of the American Association of Nurse Practitioners Hermanson, S., Vora, N., Blackmore, C. C., Williams, B., Isenberg, N. 2021

  Abstract

  BACKGROUND: In the United States, patients with transient ischemic attacks (TIAs) are commonly admitted to the hospital despite evidence that low-risk TIA patients achieve improved outcomes at lower costs at specialized rapid-access TIA clinics (RATCs).LOCAL PROBLEM: All patients experiencing TIAs at a hospital system in the Pacific Northwest were being admitted to the hospital. This project aimed to implement an RATC to relocate care for low-risk TIA patients, showing feasibility and safety.METHODS: Following implementation of the RATC, a retrospective chart review was performed. Outcomes included days to RATC; days to magnetic resonance imaging (MRI); final diagnosis; stroke-related admissions and deaths within 90 days of the RATC visit.INTERVENTIONS: From 2016 to 2018, implementation of an RATC included patient triage tools; multidisciplinary collaboration between departments; a direct scheduling pathway; and emphasis on stroke prevention.RESULTS: Ninety-nine patients were evaluated in the RATC, 69% (69/99) were referred from the emergency department. Sixty-six percent of patients were seen in the TIA clinic in 2 days or less, 19% at 3 days, and 15% at 4 days or more. Mean days to TIA clinic was 2.5 days (SD 2.4). Mean days (SD) to MRI was 2.1 days (SD 2.3). Forty-eight percent (48/99) had a final diagnosis of probable TIA, followed by 32% (32/99) who had other diagnoses; 15% (15/99) migraine variant; 4% (4/99) with stroke. Two percent (2/99) of patients had a stroke-related admission within 90 days, another 2% (2/99) died of non-stroke-related causes within 90 days of the RATC visit.CONCLUSIONS: Utilization of RATCs is feasible and safe. Nurse practitioners are integral in delivering this innovative, cost-effective model of care.

  View details for DOI 10.1097/JXX.0000000000000622

  View details for PubMedID 34107503

• The Most Effective Interventions for Resident Well-being during the COVID-19 Pandemic Chen, J., Dujari, S., Pavitt, S., Miller-Kuhlmann, R., Vora, N. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for Web of Science ID 000729283603315

• Trends in Utilization of Magnetic Resonance Imaging for Stroke Patients With Cardiac Rhythm Devices. Culbertson, C. J., Perino, A. C., Gardner, R. M., Balasubramanian, V., Vora, N. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for DOI 10.1161/str.52.suppl_1.P229

  View details for Web of Science ID 000670883500347

• Spontaneous intracerebral hemorrhage in West Africa A call to action NEUROLOGY Saylor, D., Vora, N. 2020; 94 (10): 417–18

  View details for Web of Science ID 000524504000013

• Spontaneous intracerebral hemorrhage in West Africa: A call to action. Neurology Saylor, D. n., Vora, N. n. 2020

  View details for DOI 10.1212/WNL.0000000000009054

  View details for PubMedID 32075890

• Time Course for Benefit and Risk of Clopidogrel and Aspirin after Acute Transient Ischemic Attack and Minor Ischemic Stroke: A Secondary Analysis from the POINT Randomized Trial. Circulation Johnston, S. C., Elm, J. J., Easton, J. D., Farrant, M., Barsan, W. G., Kim, A. S., Lindblad, A. S., Palesch, Y. Y., Zurita, K. G., Albers, G. W., Cucchiara, B. L., Kleindorfer, D. O., Lutsep, H. L., Pearson, C., Sethi, P., Vora, N., POINT and Neurological Emergencies Treatment Trials Network Investigators 2019

  Abstract

  BACKGROUND: In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial, the combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage compared to aspirin alone.METHODS: In a secondary analysis of POINT (N=4,881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models.RESULTS: Through 90 days, the rate of major ischemic events was initially high then decreased markedly, while the rate of major hemorrhage remained low but relatively constant throughout. Using a model-based approach, the optimal change-point for major ischemic events was 21 days (0-21 days HR 0.65 for clopidogrel-aspirin vs. aspirin, 95% CI 0.50-0.85, p=0.0015, compared to 22-90 days HR 1.38, 95% CI 0.81-2.35, p=0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset.CONCLUSIONS: The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of CHANCE, a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk TIA or minor ischemic stroke.CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov Unique Identifier: NCT00991029.

  View details for DOI 10.1161/CIRCULATIONAHA.119.040713

  View details for PubMedID 31238700

• NEUROLOGY RESIDENT EDUCATION WITH ACUTE STROKE SIMULATION IMPROVES CODE READINESS Legault, C., Vora, N. SAGE PUBLICATIONS LTD. 2018: 72

  View details for Web of Science ID 000448113301088

• Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial. The Lancet. Neurology Kasner, S. E., Swaminathan, B., Lavados, P., Sharma, M., Muir, K., Veltkamp, R., Ameriso, S. F., Endres, M., Lutsep, H., Messé, S. R., Spence, J. D., Nedeltechev, K., Perera, K., Santo, G., Olavarria, V., Lindgren, A., Bangdiwala, S., Shoamanesh, A., Berkowitz, S. D., Mundl, H., Connolly, S. J., Hart, R. G. 2018

  Abstract

  Patent foramen ovale (PFO) is a contributor to embolic stroke of undetermined source (ESUS). Subgroup analyses from previous studies suggest that anticoagulation could reduce recurrent stroke compared with antiplatelet therapy. We hypothesised that anticoagulant treatment with rivaroxaban, an oral factor Xa inhibitor, would reduce the risk of recurrent ischaemic stroke compared with aspirin among patients with PFO enrolled in the NAVIGATE ESUS trial.NAVIGATE ESUS was a double-blinded, randomised, phase 3 trial done at 459 centres in 31 countries that assessed the efficacy and safety of rivaroxaban versus aspirin for secondary stroke prevention in patients with ESUS. For this prespecified subgroup analysis, cohorts with and without PFO were defined on the basis of transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE). The primary efficacy outcome was time to recurrent ischaemic stroke between treatment groups. The primary safety outcome was major bleeding, according to the criteria of the International Society of Thrombosis and Haemostasis. The primary analyses were based on the intention-to-treat population. Additionally, we did a systematic review and random-effects meta-analysis of studies in which patients with cryptogenic stroke and PFO were randomly assigned to receive anticoagulant or antiplatelet therapy.Between Dec 23, 2014, and Sept 20, 2017, 7213 participants were enrolled and assigned to receive rivaroxaban (n=3609) or aspirin (n=3604). Patients were followed up for a mean of 11 months because of early trial termination. PFO was reported as present in 534 (7·4%) patients on the basis of either TTE or TOE. Patients with PFO assigned to receive aspirin had a recurrent ischaemic stroke rate of 4·8 events per 100 person-years compared with 2·6 events per 100 person-years in those treated with rivaroxaban. Among patients with known PFO, there was insufficient evidence to support a difference in risk of recurrent ischaemic stroke between rivaroxaban and aspirin (hazard ratio [HR] 0·54; 95% CI 0·22-1·36), and the risk was similar for those without known PFO (1·06; 0·84-1·33; pinteraction=0·18). The risks of major bleeding with rivaroxaban versus aspirin were similar in patients with PFO detected (HR 2·05; 95% CI 0·51-8·18) and in those without PFO detected (HR 2·82; 95% CI 1·69-4·70; pinteraction=0·68). The random-effects meta-analysis combined data from NAVIGATE ESUS with data from two previous trials (PICSS and CLOSE) and yielded a summary odds ratio of 0·48 (95% CI 0·24-0·96; p=0·04) for ischaemic stroke in favour of anticoagulation, without evidence of heterogeneity.Among patients with ESUS who have PFO, anticoagulation might reduce the risk of recurrent stroke by about half, although substantial imprecision remains. Dedicated trials of anticoagulation versus antiplatelet therapy or PFO closure, or both, are warranted.Bayer and Janssen.

  View details for DOI 10.1016/S1474-4422(18)30319-3

  View details for PubMedID 30274772

• Design and Implementation of a Novel Acute Stroke Code for the Extended Window of Endovascular Treatment Legault, C., Dujari, S., Shen, S. H., Wagner, A. M., Albers, G., Bernier, E., Callagy, P., Vora, N. LIPPINCOTT WILLIAMS & WILKINS. 2018

  View details for Web of Science ID 000453090803006

• Stroke Code Simulation Has Sustained Benefit on Neurology Resident Education and Preparedness for Stroke Call Legault, C., Vora, N. LIPPINCOTT WILLIAMS & WILKINS. 2018

  View details for Web of Science ID 000453090801454

• Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. The New England journal of medicine Johnston, S. C., Easton, J. D., Farrant, M. n., Barsan, W. n., Conwit, R. A., Elm, J. J., Kim, A. S., Lindblad, A. S., Palesch, Y. Y. 2018

  Abstract

  Background Combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack (TIA). A trial of combination antiplatelet therapy in a Chinese population has shown a reduction in the risk of recurrent stroke. We tested this combination in an international population. Methods In a randomized trial, we assigned patients with minor ischemic stroke or high-risk TIA to receive either clopidogrel at a loading dose of 600 mg on day 1, followed by 75 mg per day, plus aspirin (at a dose of 50 to 325 mg per day) or the same range of doses of aspirin alone. The dose of aspirin in each group was selected by the site investigator. The primary efficacy outcome in a time-to-event analysis was the risk of a composite of major ischemic events, which was defined as ischemic stroke, myocardial infarction, or death from an ischemic vascular event, at 90 days. Results A total of 4881 patients were enrolled at 269 international sites. The trial was halted after 84% of the anticipated number of patients had been enrolled because the data and safety monitoring board had determined that the combination of clopidogrel and aspirin was associated with both a lower risk of major ischemic events and a higher risk of major hemorrhage than aspirin alone at 90 days. Major ischemic events occurred in 121 of 2432 patients (5.0%) receiving clopidogrel plus aspirin and in 160 of 2449 patients (6.5%) receiving aspirin plus placebo (hazard ratio, 0.75; 95% confidence interval [CI], 0.59 to 0.95; P=0.02), with most events occurring during the first week after the initial event. Major hemorrhage occurred in 23 patients (0.9%) receiving clopidogrel plus aspirin and in 10 patients (0.4%) receiving aspirin plus placebo (hazard ratio, 2.32; 95% CI, 1.10 to 4.87; P=0.02). Conclusions In patients with minor ischemic stroke or high-risk TIA, those who received a combination of clopidogrel and aspirin had a lower risk of major ischemic events but a higher risk of major hemorrhage at 90 days than those who received aspirin alone. (Funded by the National Institute of Neurological Disorders and Stroke; POINT ClinicalTrials.gov number, NCT00991029 .).

  View details for PubMedID 29766750

• The Sound of Silence: How Much Noise Should We Make About Postablation Silent Strokes? CIRCULATION Zei, P. C., Vora, N. 2017; 135 (9): 878-880

  View details for DOI 10.1161/CIRCULATIONAHA.117.026982

  View details for Web of Science ID 000395549700015

  View details for PubMedID 28242639

• Inter-rater agreement analysis of the Precise Diagnostic Score for suspected transient ischemic attack. International journal of stroke Cereda, C. W., George, P. M., Inoue, M., Vora, N., Olivot, J., Schwartz, N., Lansberg, M. G., Kemp, S., Mlynash, M., Albers, G. W. 2016; 11 (1): 85-92

  Abstract

  No definitive criteria are available to confirm the diagnosis of transient ischemic attack. Inter-rater agreement between physicians regarding the diagnosis of transient ischemic attack is low, even among vascular neurologists. We developed the Precise Diagnostic Score, a diagnostic score that consists of discrete and well-defined clinical and imaging parameters, and investigated inter-rater agreement in patients with suspected transient ischemic attack.Fellowship-trained vascular neurologists, blinded to final diagnosis, independently reviewed retrospectively identical history, physical examination, routine diagnostic studies, and brain magnetic resonance imaging (diffusion and perfusion images) from consecutive patients with suspected transient ischemic attack. Each patient was rated using the 8-point Precise Diagnostic Score score, composed of a clinical score (0-4 points) and an imaging score (0-4 points). The composite Precise Diagnostic Score determines a Precise Diagnostic Score Likelihood of Brain Ischemia Scale: 0-1 = unlikely, 2 = possible, 3 = probable, 4-8 = very likely.Three raters reviewed data from 114 patients. Using Precise Diagnostic Score, all three raters scored a similar percentage of the clinical events as being "probable" or "very likely" caused by brain ischemia: 57, 55, and 58%. Agreement was high for both total Precise Diagnostic Score (intraclass correlation coefficient of 0.94) and for the Likelihood of Brain Ischemia Scale (agreement coefficient of 0.84).Compared with prior studies, inter-rater agreement for the diagnosis of transient brain ischemia appears substantially improved with the Precise Diagnostic Score scoring system. This score is the first to include specific criteria to assess the clinical relevance of diffusion-weighted imaging and perfusion lesions and supports the added value of magnetic resonance imaging for assessing patients with suspected transient ischemic attack.

  View details for DOI 10.1177/1747493015607507

  View details for PubMedID 26763024

• TIA triage in emergency department using acute MRI (TIA-TEAM): A feasibility and safety study. International journal of stroke Vora, N., Tung, C. E., Mlynash, M., Garcia, M., Kemp, S., Kleinman, J., Zaharchuk, G., Albers, G., Olivot, J. 2015; 10 (3): 343-347

  Abstract

  Positive diffusion weighted imaging (DWI) on MRI is associated with increased recurrent stroke risk in TIA patients. Acute MRI aids in TIA risk stratification and diagnosis.To evaluate the feasibility and safety of TIA triage directly from the emergency department (ED) with acute MRI and neurological consultation.Consecutive ED TIA patients assessed by a neurologist underwent acute MRI/MRA of head/neck per protocol and were hospitalized if positive DWI, symptomatic vessel stenosis, or per clinical judgment. Stroke neurologist adjudicated the final TIA diagnosis as definite, possible, or not a cerebrovascular event. Stroke recurrence rates were calculated at 7, 90, 365 days and compared with predicted stroke rates derived from historical DWI and ABCD(2) score data.One hundred twenty-nine enrolled patients had a mean age of 69 years (±17) and median ABCD(2) score of 3 (interquartile range [IQR] 3-4). During triage, 112 (87%) patients underwent acute MRI after a median of 16 h (IQR 10-23) from symptom onset. No patients experienced a recurrent event before imaging. Twenty-four (21%) had positive DWI and 8 (7%) had symptomatic vessel stenosis. Of the total cohort, 83 (64%) were discharged and 46 (36%) were hospitalized. By one-year follow-up, one patient in each group had experienced a stroke. Of 92 patients with MRI and index cerebrovascular event, recurrent stroke rates were 1·1% at 7 and 90 days. These were similar to predicted recurrence rates.TIA triage in the ED using a protocol with neurological consultation and acute MRI is feasible and safe. The majority of patients were discharged without hospitalization and rates of recurrent stroke were not higher than predicted.

  View details for DOI 10.1111/ijs.12390

  View details for PubMedID 25367837

• The global burden of neurologic diseases. Neurology Chin, J. H., Vora, N. 2014; 83 (4): 349-351

  View details for DOI 10.1212/WNL.0000000000000610

  View details for PubMedID 25049303

• A student-initiated and student-facilitated international health elective for preclinical medical students. Medical education online Vora, N., Chang, M., Pandya, H., Hasham, A., Lazarus, C. 2010; 15

  Abstract

  Global health education is becoming more important for developing well-rounded physicians and may encourage students toward a career in primary care. Many medical schools, however, lack adequate and structured opportunities for students beginning the curriculum.Second-year medical students initiated, designed, and facilitated a pass-fail international health elective, providing a curricular framework for preclinical medical students wishing to gain exposure to the clinical and cultural practices of a developing country.All course participants (N=30) completed a post-travel questionnaire within one week of sharing their experiences. Screening reflection essays for common themes that fulfill university core competencies yielded specific global health learning outcomes, including analysis of health care determinants.Medical students successfully implemented a sustainable global health curriculum for preclinical student peers. Financial constraints, language, and organizational burdens limit student participation. In future, long-term studies should analyze career impact and benefits to the host country.

  View details for DOI 10.3402/meo.v15i0.4896

  View details for PubMedID 20186283

• Decreasing Stroke Code to CT Time in Patients Presenting with Stroke Symptoms. Radiographics : a review publication of the Radiological Society of North America, Inc Kalnins, A. n., Mickelsen, L. J., Marsh, D. n., Zorich, C. n., Casal, S. n., Tai, W. A., Vora, N. n., Olalia, G. n., Wintermark, M. n., Larson, D. B. ; 37 (5): 1559–68

  Abstract

  Guided quality improvement (QI) programs present an effective means to streamline stroke code to computed tomography (CT) times in a comprehensive stroke center. Applying QI methods and a multidisciplinary team approach may decrease the stroke code to CT time in non-prenotified emergency department (ED) patients presenting with symptoms of stroke. The aim of this project was to decrease this time for non-prenotified stroke code patients from a baseline mean of 20 minutes to one less than 15 minutes during an 18-week period by applying QI methods in the context of a structured QI program. By reducing this time, it was expected that the door-to-CT time guideline of 25 minutes could be met more consistently. Through the structured QI program, we gained an understanding of the process that enabled us to effectively identify key drivers of performance to guide project interventions. As a result of these interventions, the stroke code to CT time for non-prenotified stroke code patients decreased to a mean of less than 14 minutes. This article reports these methods and results so that others can similarly improve the time it takes to perform nonenhanced CT studies in non-prenotified stroke code patients in the ED. (©)RSNA, 2017.

  View details for PubMedID 28820652