We hypothesized that dosing vancomycin to achieve trough concentrations of >15 mg/liter overdoses many adults compared to area under the concentration-time curve (AUC)-guided dosing. We conducted a 3-year, prospective study of vancomycin dosing, plasma concentrations, and outcomes. In year 1, nonstudy clinicians targeted trough concentrations of 10 to 20 mg/liter (infection dependent) and controlled dosing. In years 2 and 3, the study team controlled vancomycin dosing with BestDose Bayesian software to achieve a daily, steady-state AUC/MIC ratio of ≥400, with a maximum AUC value of 800 mg · h/liter, regardless of trough concentration. For Bayesian estimation of AUCs, we used trough samples in years 1 and 2 and optimally timed samples in year 3. We enrolled 252 adults who were ≥18 years old with ≥1 available vancomycin concentration. Only 19% of all trough concentrations were therapeutic versus 70% of AUCs ( < 0.0001). After enrollment, median trough concentrations by year were 14.4, 9.7, and 10.9 mg/liter ( = 0.005), with 36%, 7%, and 6% over 15 mg/liter ( < 0.0001). Bayesian AUC-guided dosing in years 2 and 3 was associated with fewer additional blood samples per subject (3.6, 2.0, and 2.4; = 0.003), shorter therapy durations (8.2, 5.4, and 4.7 days; = 0.03), and reduced nephrotoxicity (8%, 0%, and 2%; = 0.01). The median inpatient stay was 20 days among nephrotoxic patients versus 6 days ( = 0.002). There was no difference in efficacy by year, with 42% of patients having microbiologically proven infections. Compared to trough concentration targets, AUC-guided, Bayesian estimation-assisted vancomycin dosing was associated with decreased nephrotoxicity, reduced per-patient blood sampling, and shorter length of therapy, without compromising efficacy. These benefits have the potential for substantial cost savings. (This study has been registered at ClinicalTrials.gov under registration no. NCT01932034.).

Elevations in BP may foreshadow presentation of MMS in individuals with DS. This simple, low-cost screening measure may lead to early identification of at-risk patients in the medical home and prevent irreversible neurologic injury.

ObjectiveTo describe and assess the effectiveness of a neurology resident quality improvement curriculum focused on development of practical skills and project experience.MethodsWe designed and implemented a quality improvement curriculum composed of (1) a workshop series and (2) monthly resident-led Morbidity, Mortality, & Improvement conferences focused on case analysis and project development. Surveys were administered precurriculum and 18 months postcurriculum to assess the effect on self-assessed confidence with quality improvement skills, attitudes, and project participation. Scholarship in the form of posters, presentations, and manuscripts was tracked during the course of the study.ResultsPrecurriculum, 83% of neurology residents felt that instruction in quality improvement was important, but most rated their confidence level with various skills as low. Following implementation of the curriculum, residents were significantly more confident in analyzing a patient case (odds ratio, 95% confidence interval) (2.4, 1.9–3.1), proposing system changes (3.1, 2.3–3.9), writing a problem statement (9.9, 6.2–13.5), studying a process (3.1, 2.3–3.8), identifying resources (3.1, 2.3–3.8), identifying appropriate measures (2.5, 1.9–3.0), collaborating with other providers to make improvements (4.9, 3.5–6.4), and making changes in a system (3.1, 2.3–3.8). Project participation increased from the precurriculum baseline (7/18, 39%) to the postcurriculum period (17/22, 77%; p = 0.023). One hundred percent of residents surveyed rated the curriculum positively.ConclusionsOur multifaceted curriculum was associated with increased resident confidence with quality improvement skills and increased participation in improvement projects. With adequate faculty mentorship, this curriculum represents a novel template for preparing neurology residents for meeting the expectations of improvement in practice and offers scholarship opportunities.

Background The objective of the study was to assess the cost‐effectiveness of cilostazol (a selective phosphodiesterase 3 inhibitor) added to aspirin or clopidogrel for secondary stroke prevention in patients with noncardioembolic stroke. Methods and Results A Markov model decision tree was used to examine lifetime costs and quality‐adjusted life years (QALYs) of patients with noncardioembolic stroke treated with either aspirin or clopidogrel or with additional cilostazol 100 mg twice daily. Cohorts were followed until all patients died from competing risks or ischemic or hemorrhagic stroke. Probabilistic sensitivity analysis using Monte Carlo simulation was used to model 10 000 cohorts of 10 000 patients. The addition of cilostazol to aspirin or clopidogrel is strongly cost saving. In all 10 000 simulations, the cilostazol strategy resulted in lower health care costs compared with aspirin or clopidogrel alone (mean $13 488 cost savings per patient; SD, $8087) and resulted in higher QALYs (mean, 0.585 more QALYs per patient lifetime; SD, 0.290). This result remained robust across a variety of sensitivity analyses, varying cost inputs, and treatment effects. At a willingness‐to‐pay threshold of $50 000/QALY, average net monetary benefit from the addition of cilostazol was $42 743 per patient over their lifetime. Conclusions Based on the best available data, the addition of cilostazol to aspirin or clopidogrel for secondary prevention following noncardioembolic stroke results in significantly reduced health care costs and a gain in lifetime QALYs.

Introduction: Despite being an AHA Class 1 recommendation to achieve a blood pressure (BP) < 130/80 for secondary stroke prevention, only an estimated 20% of the general population can achieve this benchmark. Furthermore, it has been suggested that stroke patients may be at higher risk for an inability to achieve this goal. We aimed to examine real world clinic data to evaluate BP control among stroke patients. Methods: We conducted a population-based retrospective study using electronic health records collected during routine care at our institution for all adult patients 18 years or older with a diagnosis for stroke between January 2019 to November 2021. BP measurements were taken in an outpatient setting between 90 and 180 days from the index stroke. Descriptive statistics using R (R Core Team, 2022, r-project.org) were reported as the mean and standard deviation for continuous variables and frequencies and proportions for categorical variables. Results: Our review identified a total of 1,583 patients with a new diagnosis of acute ischemic stroke (AIS: 1,252; 79.1%) or intracerebral hemorrhage (ICH: 331; 20.9%). AIS patients were 45.7% female with a mean age of 68 years old, compared to 47.7% female and 59 years old for ICH patients. AIS patients had a higher proportion of secondary medical issues, including 34.7% with diabetes, 33.0% congestive heart failure, 19.2% cardiac disease, and 33.9% renal disease (compared to 22.2%, 16.1%, 8.8%, 19.2% respectively for ICH patients). In follow-up, only 11.7% of AIS patients were at goal (defined as a BP < 130/80) at 3 months, 17.3% at 6 months, 11.6% at 9 months, and 8.9% at 12 month follow-up. Conversely, ICH patients were slightly better controlled with 21.6%, 32.8%, 15.8%, and 12.2% controlled at 3, 6, 9, and 12 month follow-up respectively. Patients with stroke after March 2020 (post-COVID19 pandemic) had lower rates of blood pressure control compared to those diagnosed one year prior to the pandemic. Conclusion: Patients with AIS have lower rates of BP control compared to the general population, which was further amplified by the COVID19 pandemic. These results may suggest that stroke patients face unique barriers in BP management and highlight the need to perform targeted treatment for this especially vulnerable group.