Division of Medicine. Department of Neurology Staff

Transcription

1 Division of Medicine Department of Neurology Staff Néstor Gálvez-Jiménez, M.D., M.Sc., M.H.A., F.A.C.P., F.A.H.A., F.A.C.A. Tarannum S. Khan, M.D. Virgilio D. Salanga, M.D., M.S. Efrain D. Salgado, M.D. Adriana Rodriguez, M.D. 1

2 Introduction Established in 1986, the Department of Neurology at Cleveland Clinic Florida brings the tradition and care of the well-known Cleveland Clinic in Ohio. As the only Neurology service of its kind in Broward, West Palm and Collier counties, the department provides a multidisciplinary approach to the neurosciences, continuing neurological education and training of future neurologist and scientist. When education, training and state-of-the-art care meet the results are phenomenal for patients and society. of the Clinic in making various decisions. We are pleased to share our data and hope you will find it useful and informative. Nestor Galvez-Jimenez, M.D., M.Sc., M.H.S.A., F.A.C.P., Chairman, Department of Neurology We are pleased to provide our referring physicians and patients alike a quick overview of what services we provide and how we measure up to others. The Department of Neurology provides consultation in all areas of neurology but has exceeding expertise in stroke, neuromuscular diseases, headache medicine, movement disorders, epilepsy, and the dementias. Together with the Spine Institute, the neurology department actively cares, and diagnoses patients with degenerative spine disorders. With the Department of Neurosurgery innovative therapies such as Deep Brain Stimulation are offered. Brain tumors are address in a multidisciplinary fashion along with the Oncology, Radiotherapy and Neurosurgical departments. We believe reporting outcomes serves the needs of the referring physician, patients, donors and friends 2

3 Stroke Program Cleveland Clinic s Stroke Program only one of 12 such programs in the United States to receive the 2007 American Heart Association Get with the Guidelines-Stroke Annual Performance Achievement Award recognizing Cleveland Clinic s commitment and success in implementing higher standard of stroke care, according to nationally accepted standards and recommendations. guidelines of the American Heart and Stroke Association. Percent of ischemic stroke or TIA patients with atrial fibrillation who are discharged on anticoagulation therapy (warfarin/coumadin or heparin/heparinoids), unless an absolute or relative contraindication exists Time Period: Jan Dec 2006; Site: Cleveland Clinic Florida (13811) Cleveland Clinic has developed a comprehensive system for rapid diagnosis and treatment of stroke patients admitted to the emergency department. This includes being equipped 24 hours a day, seven days a week to provide brain imaging scans, having neurologists available to conduct patient evaluations, and using clot-busting medications when appropriate. According to the World Health Organization (WHO) stroke is the leading cause of neurological disability and death in the world. Many are due to embolic events from a diseased heart or arteries. During the period between January and December 2006, all such patients, treated at the Neurology Service of the Cleveland Clinic Hospital were discharged on preventative anticoagulation as required under the current Percent of acute ischemic stroke patients who arrive at the ED at CCF within 120 minutes (2 hours) of onset of stroke symptoms who receive IV t-pa within 180 minutes (3 hours) of onset of stroke symptoms. 3

4 Time Period: Q Q4 2006; Site: Cleveland Clinic Florida (13811) When compared to hospitals around the country, we are above the expected standard nationwide in the treatment of acute ischemic stroke and use of blood clothing busting or thrombolytic agents. Percent of patients at risk for DVT who received DVT prophylaxis by the 2nd hospital day. Time Period: Q Q4 2006; Site: Cleveland Clinic Florida (13811) When compared to all Florida hospitals, we were above the norm in 2006 on prevention for blood cloth formation in the legs. Treatment and prevention of abnormal cholesterol markers upon discharge continued to increase and were above the norm when compared to all Florida hospitals during

5 Neuromuscular Diseases The oldest of all programs within the department of neurology, the neuromuscular diseases program runs perhaps one of the busiest electrodiagnostic laboratories in Broward and West Palm Beach counties. In 2006 a total of 2493 studies were performed of which 1476 were specifically requested for the diagnosis or evaluation of patients suffering with neuromuscular diseases. All electrodiagnosticians are board certified or eligible in the field Percent of ischemic stroke or TIA patients with LDL>100 mg/dl OR on cholesterol reducer prior to admission who are discharged on cholesterolreducing drugs. Time Period: Q Q4 2006; Site: Cleveland Clinic Florida (13811) For the calendar year 2006, the stroke service treated: o Stroke/Transient ischemic attacks (TIA): 124. o Intracerebral hemorrhage (subarachnoid): 16. o The stroke service performed above the national and state norms in all recognized areas of prevention and acute treatment of ischemic stroke The number of electrodiagnostic studies continues to trend upwards, reaching nearly 1476 in (EDX: EMG/NCS, autonomic testing, pudendal nerve studies and SSEP (somatosensory evoked responses). 5

6 In 2006 over a thousand EMG/NCS were performed, 53 autonomic studies, 251 pudendal nerve testing and 167 SSEP evaluations degenerative spine related conditions such as radiculopathies are commonly encountered in the laboratory EMG Auton. Pud. SSEP Neurodiagnostic Laboratory The neurodiagnostic laboratory provides comprehensive state of the art neurodiagnostic evaluation for patients with a variety of neurological disorders, such as epilepsy, stroke, neuromuscular disorders, motor control, imbalance and vertigo, sensory complaints and multiple sclerosis. A sample of the most common diagnosis seen at the neuromuscular program: neuromuscular junction disorders such as myasthenia gravis, Lambert Eaton myasthenic syndrome; motor neuron diseases such as ALS, primary lateral sclerosis, post polyo syndrome; peripheral neuropathies and myopathies such as diabetic, toxic, inflammatory and other metabolic neuropathies; genetic disorders such as Charcot Marie Tooth disease, Dejerine Sottas and other HSM neuropathies. Compressive neuropathies such as carpal tunnel syndrome; ulnar neuropathies; Those performed at out laboratory include: Electroencephalography (EEG) Ambulatory EEG Visual Evoked Responses Somatosensory Evoked Responses Brainstem Evoked Responses Electrocochleography Transcranial Doppler Ultrasonography Autonomic Testing EMG/NCS (electromyography/nerve conduction studies) 6

7 Pudendal EMG Botulinum toxin therapy Research studies/procedures The numbers of procedures at the laboratory continue to steadily increase since 2003 as the graphs demonstrates. Between 2003 and 2006 over 8,775 procedures have been performed at the laboratory making this one of the busiest laboratories of its type in Broward, WPB and Collier counties. Many of these patients may have nerve and or muscle biopsies performed in cooperation with the neurosurgical or plastic surgery departments. Genetic testing is offered to those patients whose clinical history and examination support the need to perform such studies. Movement Disorders Program The Movement Disorders Program, established in 1996, is the only program of its type in Broward, West Palm Beach and Collier Counties offering a multidisciplinary approach to the diagnosis and treatment of patients with al types of conditions affecting motor control. A total of 1667 consultations for the evaluation and diagnosis of patients with abnormal motor control were performed in Most common conditions treated were: Parkinson s disease; Secondary forms of Parkinsonism such as PSP, OPCA, MSA; Mytochondrial cytopathies; Metabolic syndromes resulting in abnormal motor control such as Wilson s disease; Degenerative hereditary disorders such as Huntington disease. Cerebellar ataxias, Choreas, Tics, Tourrete syndrome, Restless Legs, Tremor Gait disorders and Falls and other associated condition were continuously assessed at the program during

8 Speech disturbances (dystonic/spastic) One of the largest dystonia clinic with botulinum toxin therapy and baclofen pumps in Broward and West Palm Beach is housed at the Movement Disorders Program of the Cleveland Clinic. Evaluation for both research studies on this condition, investigator initiated studies and patients undergoing deep brain stimulation for dystonia have all been performed at our center We performed our first Deep Brain Stimulation Surgery in 1998, then one of the few centers offering the procedure in the state of Florida. Since then this type of surgery has been performed in a very selected groups of patients suffering with Parkinson s disease, tremor and Dystonia. Expert evaluation for programming of patient with deep brain stimulators is offered along with patients with baclofen pumps for a variety of conditions such as cerebral palsy, dystonia, primary lateral sclerosis, post stroke spasticity and others. An active academic program over 68 scientific publications, book chapters and books have been written by the movement disorders staff. A fellowship program for the training of neurologist wishing to become expert in the field have been in placed since Over 1034 patients-injections have been administered over a 4-year period and the number of patients continues to grow. 8

9 Epilepsy Program The Epilepsy program within the Department of Neurology offers comprehensive diagnosis and treatment for those patients with seizures and epilepsy. The Epilepsy program actively collaborates with the renowned Epilepsy Center of the Cleveland Clinic in Cleveland, Ohio where patients requiring epilepsy surgery are referred. This allows Cleveland Clinic Florida physicians and patients access to cutting edge medical and surgical therapies for those patients in most need for such treatments. The epilepsy-monitoring unit, housed at the Cleveland Clinic Hospital, provides in-patient assessment for the diagnosis and treatment of patients with unusual epileptic syndromes or for those patients who present with a diagnostic dilemma EEG Amb EEG The numbers of electroencephalograms continued to steadily increase over four years, especially the numbers of ambulatory studies over the same time period. 9

10 Innovation In education, research and patient care. First report on the benefits of aspirin in combination with dypiridamole after 30 days in patients presenting with acute ischemic stroke. In 1987 among the first centers offering deep brain stimulation for patients with Parkinson s disease, tremor and dystonia in the state of Florida. First observational and therapeutic studies on the relationship of cervical dystonia and chronic daily headaches. First report on the benefits of botulinum toxin therapy for the treatment of headaches associated with cervical dystonia. First depiction on the benefits of topiramate for the treatment of essential tremor First account on the benefits of zonizamide for the treatment of essential tremor First comparison study on the benefits of pramipexole vs. ropinirole for the treatment of restless legs syndrome First neurology residency training program north of Miami-Dade but south of Gainesville, Florida with full accreditation from the American Council of Graduate Medical Education. First in offering education in the subspecialties of Cerebrovascular diseases; Neuromuscular disorders and Electrodiagnostic Medicine; and Movement Disorders north of Miami-Dade but south of Gainesville, Florida. The only neurodiagnostic laboratory dedicated for the assessment of patients with colorectal and genitourinary systems disorders as it relates to the peripheral and central nervous system. The only autonomic nervous system laboratory in Broward and West Palm Beach counties. Among the first reports on the use of electrodiagnostic studies in the diagnosis of severe constipation. Implantable deep brain electrodes (DBS) in a patient with familial tremors. 10

11 Publications BOOKS : Galvez-Jimenez N. Editor. The Scientific Basis for the Treatment of Parkinson s Disease. 2 nd edition. Parthenon Publishing Company/Martin Dunitz. London,UK Galvez-Jimenez N. Guest Editor. Neurologic Clinics of North America. Perioperative Management and Preoperative Assessment of Neurological Diseases. May Volume 22, Number 2. Elsevier Science/W.B. Saunders. Philadelphia, PA PEER REVIEWED PUBLICATIONS: Hanson MR, Galvez-Jimenez N. Management of dementia and acute confusional states in the perioperative period. Neurol Clin 2004; 22(2): Galvez-Jimenez N, Lang AE. The perioperative management of Parkinson s disease revisited. Neurol Clin 2004; 22(2): Galvez-Jimenez N, Lampuri C, Patino-Picirrillo R, Hargreave MJ, Hanson RM. Dystonia and headaches: clinical features and response to botulinum toxin therapy. Adv Neurol 2004; 94: Ondo WG, Gollomp S, Galvez-Jimenez N. A Pilot Study of Botulinum Toxin A for Headache in Cervical Dystonia. Headache 2005; 45: Chen DT, Worrall BB, Brown RD, et al. The Impact of Privacy Protections on Recruitment in a Multicenter Stroke Genetics Study. Neurology 2005; 64: The Huntington Study Group PHAROS Investigators. Nestor Galvez-Jimenez participant. At risk for Huntington Disease. The PHAROS (Prospective Huntington At Risk Observational Study) Cohort Enrolled. [The Huntington s study group/pharos investigator]. Arch Neurol. 2006;63: Prankrats N, Pauciulo MW, Elsaesser VE, et al. (Parkinson Study Group PROGENI investigators). Nestor Galvez-Jimenez participant. Mutations in the DJ-1 are rare in familial Parkinson disease. Neuroscience Letters 2006; 408: Prankrats N, Pauciulo ME, Elasesser VE, et al (Parkinson Study Group PROGENI investigators). Nestor Galvez-Jimenez participant. Mutations in LRRK2 other than G2019S are rare in North American-based sample of familial Parkinson s disease. Mov Disord 2006; 21(12): Prankrats N, Pauciulo MW, Elsaesser V, et al. and the Parkinson Study Group PROGENI Investigators. Nestor Galvez-Jimenez, participant. Mutations in DJ- 1 are rare in Familial Parkinson disease. Neurosci Lett 2006 Nov 20; 408(3): Prankrats N, Pauciulo MW, Elsaesser V, et al. and the Parkinson Study Group PROGENI Investigators. 11

12 Nestor Galvez-Jimenez, participant. Mutations in LRRK2 other than G2019S are rare in a North American-based sample of familial Parkinson disease. Mov Disord 2006 Dec; 21(12): Nichols WC, Marek DK, Pauciulo MW et al. and The Parkinson Study Group PROGENI Investigators. Nestor Galvez-Jimenez, participant. R1514Q substitution in Lrrk2 is not a pathogenic Parkinson s disease mutation. Mov Disord 2007 Feb; 22(2): The Mixed Lineage Kinase Inhibitor CEP-1347 Fails to Delay Disability in Early Parkinson s Disease. [The Parkinson Study Group PRECEPT Investigators]. Nestor Galvez-Jimenez participant. Neurology 2007; In Press. BOOK CHAPTERS Galvez-Jimenez N, Parkinson s disease. In Neurobiology of Disease. Sid Gilma (ed), Academy Press. Chaper 5 (Neurodegenerative Disorders. Gregor K. Wenning MD, PhD) pp Galvez-Jimenez N, Hargreave MJ. Psychogenic Hemifacial Spasm (Psych-HFS). Incidence and Clinical Features. In Hallett M, Fahn S, Jankovick J, Lang AE, Cloninger CR, Yodofsky ST. Psychogenic Movement Disorders. Neurology and Neuropyschiatry. Lippincott Williams and Wilkins Philadelphia Galvez-Jimenez N. Advances in the surgical treatment of Parkinson s disease: emphasis on pallidotomy and deep brain stimulation. In The Scientific Basis for the Treatment of Parkinson s Disease. Galvez-Jimenez (ed). Taylor and Francis Group. London Hanson MR, Galvez-Jimenez N, Dopamine agonist. In The Scientific Basis for the Treatment of Parkinson s Disease. Galvez-Jimenez (Ed), Taylor and Francis Group. London 2005 Galvez-Jimenez N. Psychogenic Tremor. In Handbook of Essential Tremor and Other Tremor Disorders. Kelly E. Lyons, Rajesh Pahwa (eds). Taylor and Francis Group. London Hanson MR, Galvez-Jimenez N. Neurological Examination of the Cervical Spine. The Cervical Spine, 4 th edition. Clark CR, Dvorak J, Benzel EC, Ullrich CG, Dormans JP, Garfin SR, Eismont F, Currier B, Herkowitz HN, Vaccaro A (eds.). Lippincott Williams & Wilkins. Chapter Galvez-Jimenez N, Khan T. Amyotrophic lateral sclerosis. UpToDate [electronic resource] Retrieved June 30, &type=A&selectedTitle=1~30 Sa D, Galvez-Jimenez N, AE Lang. Psychogenic Movement Disorders. In Movement Disorders Neurologic Principles and Practice. Ray Watts, 12

13 William Koller Ed. Second Edition. McGraw-Hill Galvez-Jimenez N. Pallidotomy. William Koller, Kelly Lyons Rajesh Pawa Editors. Handbook of Parkinson s Disease. Marcell Beker Galvez-Jimenez N, AE Lang. Perioperative management of Parkinson s Disease Revisited. In Galvez-Jimenez (Eds). Neurology Clinics Perioperative management and preoperative assessment of neurological diseases. (Vol 22) Hanson MR, Galvez-Jimenez N. Hanson MR. Management of Dementia and Acute Confusional States in the Perioperative Period. Perioperative management and Preoperative assessment of Neurological Diseases. Neurology Clinics In Galvez-Jimenez, Nestor (eds). Neurology Clinics (Vol 22.)

14 Excellence We strive to provide the best care possible one patient at a time. We ask our patients about their experience and satisfaction with the care received by our staff. Among 260 patients treated at our department, 80% reported very good to excellent care provided by the staff. In addition, over 90% will recommend our providers to others. Frequency (%) 100% 80% 60% 40% 20% 0% 2% Rating of Provider (N=260) 14% 84% Poor Good/Fair Excellent/Very Good We strive to provide the best care possible one patient at a time. We ask our patients about their experience and satisfaction with the care received by our staff. Among 260 patients treated at our department, 80% reported very good to excellent care provided by the staff. In addition, over 90% will recommend our providers to others. Frequency (%) 100% 80% 60% 40% 20% 0% Recommend Provider (N=249) Extremely and Very Likely Somewhat Likely Very Unlikely Rating Quality of Care (N=260) 100% Overall Quality (N=251) 84% Frequency (%) 100% 80% 60% 40% 20% 0% 3% 16% 81% Poor Good/Fair Excellent/Very Good Frequency (%) 80% 60% 40% 20% 0% 11% 5% (1-3) (4-6) (7-10) 14