Susan V. Brammer

OBJECTIVE: To investigate whether the location and extent of the CT hyperdense artery sign (HAS) at presentation affects response to IV alteplase in the randomized controlled Third International Stroke Trial (IST-3). METHODS: All prerandomization and follow-up (24-48 hours) CT brain scans in IST-3 were assessed for HAS presence, location, and extent by masked raters. We assessed whether HAS grew, persisted, shrank, or disappeared at follow-up, the association with 6-month functional outcome, and effect of alteplase. IST-3 is registered (ISRCTN25765518). RESULTS: HAS presence (vs absence) independently predicted poor 6-month outcome (increased Oxford Handicap Scale [OHS]) on adjusted ordinal regression analysis (odds ratio [OR] 0.66, p < 0.001). Outcome was worse in patients with more (vs less) extensive HAS (OR 0.61, p = 0.027) but not in proximal (vs distal) HAS (p = 0.420). Increasing age was associated with more HAS growth at follow-up (OR 1.01, p = 0.013). Treatment with alteplase increased HAS shrinkage/disappearance at follow-up (OR 0.77, p = 0.006). There was no significant difference in HAS shrinkage with alteplase in proximal (vs distal) or more (vs less) extensive HAS (p = 0.516 and p = 0.580, respectively). There was no interaction between presence vs absence of HAS and benefit of alteplase on 6-month OHS (p = 0.167). CONCLUSIONS: IV alteplase promotes measurable reduction in HAS regardless of HAS location or extent. Alteplase increased independence at 6 months in patients with and without HAS. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that for patients within 6 hours of ischemic stroke with a CT hyperdense artery sign, IV alteplase reduced intra-arterial hyperdense thrombus.

BACKGROUND: This article summarizes the experiences that a Midwest college of nursing had when telepsychiatry was introduced for psychiatric-mental health post-master’s nurse practitioner students to use in a clinical internship. AIMS: Implications for nurse practitioner educators will be identified, and recommendations for future research will be explored. METHOD: Described are the following: (1) policies and procedures the institution considered, (2) challenges that were encountered by faculty and students, and (3) strategies and limitations of these strategies defining best practice, what didactic content should be taught, and how clinical placements needed to be structured. RESULTS: Implications for nurse practitioner educators, practice, and research are identified. CONCLUSIONS: It is clear that telepsychiatry has an important role in the clinical education of psychiatric-mental health nurse practitioners. It is working well as a clinical internship option. The college of nursing is continuing to examine and address issues and is looking forward to enhancing the telepsychiatry experiences for students in the future.

INTRODUCTION: Health care providers (HCPs) who work primarily with Medicaid patients must be competent in identifying and addressing social determinants of health (SDH). A curricular gap exists between promoting an understanding of SDH and teaching HCPs how to recognize and increase empathy to manage them. The project aim was to develop two virtual reality simulations (VRSs) as innovative methods to teach HCPs to identify and manage SDH. A secondary aim was to decrease unconscious bias and increase empathy by experiencing SDH from their patients' perspective. METHODS: Scripts for two VRSs were created by two HCP educators and clinicians. Scripts were evaluated by experts using an index of content validity (CVI). An advisory panel critiqued the scripts for appropriateness for VRSs, adequacy of evidence-based practice, and use of VRS equipment and software. The panel participated in a focus group and completed a final evaluation. The VRSs then were pilot tested with five HCPs who assessed content and utility and participated in interviews. This led to iterative improvements. Qualitative data were analyzed using a content analysis approach. RESULTS: The VRS scripts demonstrated adequate content-related validity evidence with CVI scores of 0.81 and 0.75. The expert panel found the VRS easy to use, useful as an educational tool, while promoting empathy for patients. Overall, participants were satisfied with using the VRS as an educational experience. DISCUSSION: Through VRS technology, this project addresses a curricular gap in HCP training on SDH. VRS can be a useful tool to increase HCPs' understanding of SDH and, potentially, their empathy for patients.