Diagnostic Summary Research Articles

Late Changes in Refraction, Pachymetry, Visual Acuity, and Corneal Topography After Penetrating Keratoplasty

To analyze the late changes in refraction, corneal topography, and pachymetry after penetrating keratoplasty. We have retrospectively analyzed data of 64 eyes of 56 patients with a clear corneal graft and no other ocular diseases. The eyes were examined soon and several years after all sutures were removed, at 19.5 +/- 3.1 months and 76.8 +/- 25.2 months, respectively, after keratoplasty. All eyes were examined using the EyeSys 2000 videokeratograph and the Tomey SP2000 ultrasonic pachymeter. Corneal surface regularity was studied using the indices provided by the Holladay Diagnostic Summary (ie, asphericity coefficient Q; corneal uniformity index CU; predicted corneal acuity PCA). Irregular astigmatism was quantified using semimeridian data from videokeratographs (refractive power symmetry index). Visual acuity increased by an average of 0.35 +/- 0.93 lines (P = 0.002) between the 2 examinations, whereas no significant changes in refraction and videokeratoscopy (ie, power, indices, and irregular astigmatism) were observed (P > or = 0.08). Central corneal thickness significantly increased from 542 +/- 31 microm to 572 +/- 38 microm (P < 0.001). Change in BSCVA did not significantly correlate with the change in refraction, in topographic indices, or in irregular astigmatism (rs < or = 0.13; P > or = 0.16). Late after penetrating keratoplasty, best corrected visual acuity shows a small but statistically significant improvement, whereas refraction and corneal surface regularity are stable. This late improvement in visual acuity is not explained by current techniques.

Premature ejaculation: presentation and associations. An audit of patients attending a sexual problems clinic

The diagnostic register and case summaries of all male and female patients who attended the clinic on account of one or more sexual symptoms or relationship problems between 1 January 1992 and 31 December 1997 were reviewed. The index symptom or problem was considered the complaint that caused the patient most concern. When patients or couples were experiencing more than one sexual problem, the concomitant problems were tabulated against the index symptom. During this period, 1,056 (440 men and 616 women) patients with sexual symptoms were seen and 131 couples attended primarily with relationship problems. Overall, 18.2% of men referred to the clinic with sexual problems had premature ejaculation (PE), but this was the index symptom in only 11.6% of men. There was a high occurrence of PE in the partners of women presenting with sexual symptoms. Among couples presenting with relationship dissatisfaction or conflict, 18.3% of the male partners had ongoing PE.

Topographic corneal changes in patients with vernal keratoconjunctivitis

To carry out a case-control clinical study in patients with vernal keratoconjunctivitis, aiming at information about the anterior corneal curvature and visual performance using a quantitative corneal descriptor analyzer (Holladay Diagnostic Summary). We examined 342 eyes of 171 patients divided into 2 groups. Group 1 with 142 eyes of 71 patients with a clinical diagnosis of vernal keratoconjunctivitis (cases) and Group 2 with 200 eyes of 100 patients (controls) from the Department of Ophthalmology/"Santa Casa" of São Paulo. Patients were submitted to a complete examination and corneal topography with a quantitative corneal surface contour descriptor (Holladay Diagnostic Summary). Clinical and topographic criteria were established to diagnose keratoconus in both groups. The frequency of patients with a clinical diagnosis of keratoconus associated with vernal keratoconjunctivitis in Group 1 was 9.85% (7 patients). According to topographic criteria, the frequency in Group 1 was 22.53% (16 patients). In Group 2, no patient presented biomicroscopic, refratometric or topographic characteristics of keratoconus. All studied topographic variables, including corneal asphericity, presented statistical significance (p<0.05) between the two groups. Results of this study suggested high frequency of patients with keratoconus associated with vernal keratoconjunctivitis. Visual performance is compromised by aberrations and changes in corneal asphericity and other topographic variables.

Is Proton Pump Inhibitor Testing an Effective Approach to Diagnose Gastroesophageal Reflux Disease in Patients With Noncardiac Chest Pain?

Gastroesophageal reflux disease (GERD) is common in patients with noncardiac chest pain (NCCP). Results of studies evaluating the accuracy of a proton pump inhibitor (PPI) treatment as a diagnostic test for GERD-related NCCP have varied. We evaluated the overall accuracy of this modality. We searched the PubMed, MEDLINE, EMBASE, CINAHL, and Cochrane databases to May 2004 and included randomized, placebo-controlled studies evaluating the accuracy of findings from PPI testing in the diagnosis of GERD in patients with NCCP. The GERD diagnosis was confirmed by results of endoscopy and/or 24-hour esophageal pH monitoring. A summary diagnostic odds ratio and summary receiver operating characteristic curve analysis were used to estimate the overall accuracy and to explore any contributing factors. Six studies met the inclusion criteria. The overall sensitivity and specificity of a PPI test were 80% (95% confidence interval [CI], 71%-87%) and 74% (95% CI, 64%-83%), respectively, compared with 19% (95% CI, 12%-29%) and 77% (95% CI, 62%-87%), respectively, in the placebo group. The PPI test showed a significant higher discriminative power, with a summary diagnostic odds ratio of 19.35 (95% CI, 8.54-43.84) compared with 0.61 (95% CI, 0.20-1.86) in the placebo group. The impact of the prevalence of GERD and treatment duration on the accuracy of the test could not be determined because of the lack of an adequate number of studies. The use of PPI treatment as a diagnostic test for detecting GERD in patients with NCCP has an acceptable sensitivity and specificity and could be used as an initial approach by primary care physicians to detect GERD in selected patients with NCCP.

Corneal Topography in Involutional Ectropion of the Lower Eyelid

The shape and position of the eyelids affect corneal topography. This study evaluated preoperative and postoperative corneal topography in involutional ectropion of the lower eyelid. Eighteen patients with unilateral involutional lower eyelid ectropion underwent ophthalmic examinations and corneal topography before surgical correction and at the 6-month postoperative interval. Corneal topographies were evaluated with the Holladay Diagnostic Summary package. The fellow eyes served as controls. Parameters evaluated included the regularity of astigmatism (RA), steep refractive power (SRP), flat refractive power (FRP), and total astigmatism (TA). Preoperatively, RA was found significantly decreased in the eyes with ectropion compared with the fellow eyes, whereas differences in other parameters were statistically nonsignificant. Postoperatively, RA was significantly increased, whereas SRP was significantly reduced. The percentage of eyes with with-the-rule astigmatism (WTRA) was increased postoperatively, although astigmatic axis changes were not systematic. Postoperative topographic changes may be related to either restoration of symmetry in the upper and lower lid apposition on the cornea or to rearrangement of the tear film. Further research will be required to assess whether corneal topographic findings could be used as an index of the severity of eyelid laxity and to evaluate the effects of topographic changes on corneal and total optical aberrations.

R2WinBUGS: A Package for RunningWinBUGSfromR

The R2WinBUGS package provides convenient functions to call WinBUGS from R. It automatically writes the data and scripts in a format readable by WinBUGS for processing in batch mode, which is possible since version 1.4. After the WinBUGS process has finished, it is possible either to read the resulting data into R by the package itself—which gives a compact graphical summary of inference and convergence diagnostics—or to use the facilities of the coda package for further analyses of the output. Examples are given to demonstrate the usage of this package.

Corneal Topography in Corneal Refractive Therapy (CRT)

To evaluate visual outcome and corneal shape change during the first month of wearing corneal refractive therapy (CRT) reshaping contact lenses to correct myopia in otherwise healthy eyes. Twenty-nine eyes were fit with Paragon CRT contact lenses, which were worn nightly. Before and after CRT fitting, uncorrected visual acuity was measured, and corneal topography was performed and evaluated with the Holladay Diagnostic Summary EyeSys 2000 Videokeratoscope. To evaluate the visual outcome, refractive yield (achieved/attempted correction) was calculated and accounted for distance or monovision. Uncorrected visual acuity improved in all patients. In 1 month, refractive yield was 96.7%. Corneal uniformity index and predicted corneal acuity index were maintained, and the Q value changed from -0.08 to +0.38 (P < 0.05). CRT lenses are effective in improving visual acuity. They significantly changed the corneal from prolate to oblate while maintaining corneal quality.

Intraocular lens power calculation after incisional and thermal keratorefractive surgery

To evaluate the efficacy of corneal topography in determining the central corneal refractive power in intraocular lens (IOL) power calculations after incisional and thermal keratorefractive surgery. Oregon Eye Institute, Eugene, Oregon, USA. This retrospective review comprised 20 eyes (14 patients) that had cataract extraction with IOL implantation or refractive lens exchange after radial keratotomy, hexagonal keratotomy, or laser thermal keratoplasty. The effective refractive power (EffRP) of the Holladay Diagnostic Summary on the EyeSys Corneal Analysis System was used to determine the central corneal refractive power, which was input into the Holladay 2 IOL calculation formula. Eighty percent of eyes achieved a postoperative spherical equivalent refraction within +/-0.50 diopter of emmetropia. The use of the EffRP increases the likelihood of an acceptable refractive outcome after cataract or refractive lens exchange surgery in eyes with a history of keratorefractive surgery.

Diagnosis and exploration of massively univariate neuroimaging models

The goal of this work is to establish the validity of neuroimaging models and inferences through diagnosis and exploratory data analysis. While model diagnosis and exploration are integral parts of any statistical modeling enterprise, these aspects have been mostly neglected in functional neuroimaging. We present methods that make diagnosis and exploration of neuroimaging data feasible. We use three- and one-dimensional summaries that characterize the model fit and the four-dimensional residuals. The statistical tools are diagnostic summary statistics with tractable null distributions and the dynamic graphical tools which allow the exploration of multiple summaries in both spatial and temporal/interscan aspects, with the ability to quickly jump to spatiotemporal detail. We apply our methods to a fMRI data set, demonstrating their ability to localize subtle artifacts and to discover systematic experimental variation not captured by the model.

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency associated with bilateral keratoconus

To report a clinical association between congenital adrenal hyperplasia and keratoconus. Observational case report. Two 25-year-old dizygotic female twins were retrospectively studied. Clinical history, hormonal serologic profile, complete ophthalmologic examination, and Holladay Diagnostic Summary variables were evaluated. In the course of a 15-month follow-up period, a progression of the corneal disease was observed. In both twins a diagnosis of nonclassical congenital adrenal hyperplasia, due to 21-hydroxylase deficiency, was established when they were 21 years old. In one subject, the computed corneal topographic analyses diagnosed an asymmetric keratoconus in both eyes. A progressive form of fruste central keratoconus was also documented in her sister. Congenital adrenal hyperplasia may be associated with keratoconus. An abnormal steroidogenic pathway, affecting the normal development of the cornea, could induce stromal abnormalities that lead to corneal ectasia.

Corneal topographic changes after retinal detachment surgery.

To evaluate the changes in corneal topography after scleral buckling surgery for retinal detachment. Twenty-one eyes of 21 patients with the diagnosis of retinal detachment were included in this prospective study. Scleral buckling surgery was performed on all patients. The corneal topography of each was measured before surgery and at 1 week and 1 and 6 months after surgery by computer-assisted videokeratoscopy using the EyeSys 2000 Corneal Analysis System. Changes in corneal videokeratographies were analyzed using the Holladay Diagnostic Summary (HDS) software package. A statistically significant central corneal steepening (average, 1.8 diopter) was noted 1 week after surgery. The total and irregular astigmatic components both revealed a significant but transient increase in the first postoperative month. All these topographic changes persisted for as long as 6 months but returned to preoperative values afterward. Scleral buckling was found to induce transient changes in corneal topography producing both myopia and corneal astigmatism. Videokeratography is helpful for documenting such corneal changes after scleral buckling surgery for retinal detachment.

Corneal asphericity after hyperopic laser in situ keratomileusis

To analyze corneal asphericity after hyperopic laser in situ keratomileusis (LASIK) and its relationship to the clinical outcomes. Corneal and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA. In a retrospective case series, 23 patients (33 eyes) with hyperopia or hyperopic astigmatism who had LASIK were evaluated. A computer program (Holladay Diagnostic Summary, EyeSys Laboratories) was used to analyze corneal asphericity (Q) before and after LASIK. Corneal asphericity was evaluated to determine the association with the postoperative refractive error, best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), achieved refractive correction, mean corneal power (K), refractive yield (achieved/attempted correction), and keratometric yield (change in keratometry/attempted correction). After hyperopic LASIK, all corneas exhibited increased negative central Q. The postoperative corneal radius of curvature, BSCVA, and refractive and keratometric yields were not significantly correlated with the preoperative Q values. The asphericity change, Delta Q, was highly correlated with the achieved correction (r = 0.747, P <.0001). The postoperative Q value correlated well with the preoperative value (r = 0.534, P <.05) and the achieved correction (r = 0.601, P <.05) but not with the Delta Q. Neither the postoperative Q nor the Delta Q was correlated with the spherical equivalent, K, BSCVA, or UCVA. Asphericity may be a useful quantitative descriptor of the corneal optical contour after hyperopic LASIK. Negative central Q increased after hyperopic LASIK, especially when greater degrees of refractive correction were attempted.

Topographic changes in corneal asphericity and effective optical zone after laser in situ keratomileusis

To determine the relationship between the spherical refractive change after myopic excimer laser surgery and the effective optical zone (EOZ) and corneal asphericity determined by corneal topography. Baylor College of Medicine, Houston, Texas, USA. Preoperative and postoperative topographies along with refractions were evaluated in all patients who had had laser in situ keratomileusis since January 1999 and had at least 6 months of follow-up. The VISX Smoothscan S2 excimer laser and the Hansatome microkeratome (Bausch & Lomb) were used in all cases. Because optical zones are oval with astigmatic treatments with the VISX laser, only patients with spherical refractions and treatments were included. Thirty-nine cases met the criteria; their treatments ranged from -1.50 to -18.00 diopters (D). The preoperative and postoperative corneal asphericities (Q-values) were taken directly from the Holladay Diagnostic Summary Report on the EyeSys 2000, version 4.0. The mean diameter of the optical zone was measured on the local radius of curvature map using the outer edge of the yellow zone, which corresponds to 2 color changes or approximately 0.50 D steepening from the mean central radius (green). The EOZ decreased as the amount of treatment increased. The decrease was slightly nonlinear, decreasing slightly more rapidly at higher treatments. For an "intended" 6.0 mm optical zone, the nominal EOZs from the least-squares second-order polynomial regression were 6.0 mm for -1.5 D, 5.4 mm for -5.0 D, 4.6 mm for -10.0 D, 3.8 mm for -15.0 D, and 3.2 mm for -18.0 D. The least-squares second-order polynomial regression yielded a standard error of the estimate (SEE) of +/- 0.22 mm (R(2) = 0.90). The asphericity increased nonlinearly in a positive direction (oblate) with the amount of treatment, indicating greater amounts of correction produced progressively more oblate corneal surfaces. The least-squares second-order polynomial regression yielded an SEE of +/- 0.42 (R(2) = 0.55). The EOZ decreased and the Q-value increased with the amount of myopic excimer laser treatment. The optical zone was approximately 4.3 mm with a spherical treatment of -12.0 D. These findings may explain the clinical studies that indicate high myopic treatments (above -12.0 D) are associated with poor visual outcomes.

Topographic analysis of corneal regularity after penetrating keratoplasty.

To evaluate the accuracy of the Holladay Diagnostic Summary of the EyeSys Corneal Analysis System in predicting the corneal visual acuity potential in patients who have undergone penetrating keratoplasty (PKP). Astigmatism patterns, refractive and topographic astigmatism, best spectacle-corrected visual acuity (BSCVA), and hard contact lens (HCL) visual acuity of 54 patients were analyzed 3 months after PKP and compared with the Potential Corneal Acuity (PCA) value predicted by the Holladay Diagnostic Summary. Qualitative patterns of astigmatism (p = 0.01) and refractive (p = 0.002) and topographic (p = 0.0002) astigmatism were significantly correlated with PCA values. Using HCL visual acuities to correct the BSCVA (HCL-corrected BSCVA) for noncorneal causes of reduced vision, we found that the PCA values of 48.1% of the patients were within one line of the HCL-corrected BSCVA; 81.5% were within two lines; and 93.0% were within three lines. The Holladay PCA measurement may be useful in the postoperative evaluation of the optical quality of the central corneal surface in patients who have undergone PKP.

Wood and Bark Anatomy of Myricaceae: Relationships, Generic Definitions, and Ecological Interpretations

Wood anatomy of the single species of Canacomyrica (hitherto not studied) shows that it belongs in Myricaceae, although it differs from other genera in several respects (axial parenchyma grouped in bands or columns as well as diffuse; Heterogeneous Type I rays; more numerous bars per perforation plate). The latter two features are primitive for the family. The four genera (Canacomyrica. Comptonia, Morella, and Myrica s.s.) differ from each other not only by qualitative features but by quantitative features (feature means in genera mostly non- overl apping). Wood of Comptonia and Myri ca s.s. lacks chambered crystals in axial parenchyma and ray crystals. Wood of Myrica s.s. has tracheids in latewood but fiber-tracheids in earl ywood. Diagnostic generic summaries are presented. Features of Myricaceae such as scalarifom perforation plates, presence of (true) tracheids , ray types , chambered encapsulated crystals in axial parenchyma, and bark anatomy correspond with character states and expressions in Betulaceae, Casuarinaceae, Corylaceae, Juglandaceae (including Rhoipteleaceae), Ticodendraceae and, to a lesser extent, Fagaceae and Nothofagaceae. This grouping of families can be found as Fagales in recent DNA trees. The predominance of tracheids in basal Fagales such as Myricaceae and Ticodendraceae suggests that origin of vasicentric tracheids which occur in combination with libriform fibers in Fagaceae is the product of tracheid dimorphism. Low imperforate tracheid length to vessel element length ratios (FN ratios) in Myricaceae are a probable indication of wood primitiveness. Quantitative vessel features of Myricaceae, as combined in Mesomorphy Ratio values, characterize wood of Myricaceae as a whole, but at the species level such values correspond to respective habitats; notably high vessel density in Comptonia may represent greater conductive safety appropriate to relatively dry habitats.

Fuentes de error en clínica

The clinical setting is everything that contact us with the patient's reality, including physical, instrumental and laboratory exploration, and we use it for diagnostic and treatment purposes. Diagnosis is the synthesis by which physicians conclude an elaborated analysis of subjective and objective data, obtained by physical exam and technology. This procedure involves data collection about the patient and his disease, the results of various tests and laboratory findings, the interpretation of the data and a diagnostic summary. Medical errors may be derived from insufficiency in any of these phases. It is evident that technology will never replace the intellectual data recollection, analysis and reasoning that is the physician's art. This contribution underlines some of the defects frequently observed in clinical practice that may cause medical errors.

Lessons Learned in the Process of Stroke Quality Management: Revised tools and strategies in a follow-up study

P229 Objectives Written care protocols and quality improvement efforts have recently been included in published guidelines on care of the ischemic stroke patient. We describe revisions to the quality management process that resulted in increased protocol use at a 469-bed medical school affiliate private hospital. Methods An earlier clinical pathway for ischemic stroke was ineffectively implemented as shown by pathway use in less than half of appropriate cases. A multidisciplinary team addressed barriers identified in that early experience to modify strategies in the development of a new set of quality management tools (QMT) for ischemic stroke. The revised QMT included: standing orders, clinical pathway, NIH Stroke Scale flow sheet, diagnostic summary form, and variance tracking tool. QMT use rates were calculated by medical record abstraction during a 3-month pilot study and physician and nurse usage rates determined. Factors contributing to QMT usage were analyzed. Results Twenty-eight ischemic stroke patients were admitted to the pilot unit during the study. Usage rates for components of the QMT driven by physicians were: standing orders 93%; IV tPA standing orders 100%; and diagnostic summary form 46%. Nurse related QMT usage was: clinical pathway 96%; NIH Stroke Scale flow sheet 75%; and variance tracking tool 75%. Key strategies that contributed to improved implementation were: 1) early involvement and continuous communication between the expanded multidisciplinary team, staff nurses and physicians 2) empowerment of nurses through NIH Stroke Scale training 3) perception of mutual accountability between nurses and physicians through use of QMT documents 4) clearly defined administrative directives. Conclusion Effective implementation of quality management protocols for ischemic stroke requires active participation of related disciplines at working levels, clear administrative support, and mutual accountability of physicians and nurses. Continuous critical appraisal of the process can afford eventual strategic solutions.

Surgical Therapy of Juxtapapillary Tumors

Tumors of the papilla of Vater represent a pathophysiological entity. We propose a precise definition of these tumors and give a summary of diagnostics and therapy as well as a review of the literature. The most accurate definition includes all tumors originating within one cm of the papilla, regardless of their histology. We therefore use the term of "juxtapapillary tumors". Early symptoms are itching, jaundice, sometimes pain and cholangitis/cholecystitis. The first diagnostic means are sonography, CT-scan, ERCP and angiography. The therapeutic options range from pure palliation by stenting or bypass surgery with the specific option of transduodenal local tumor excision to the curative intention of a radical pylorus preserving duodenopancreatectomy (Whipple resection). Prognostic factors include growth pattern, histology, stage and lymph node involvement of the tumor. Another, new method with prognostic value seems to be the DNA-fingerprinting. A literature review of the different therapeutic modalities shows the following results: After stenting, the median survival is 10 months. The median 5-year survival after local excision and radical resection lies between 30-50%, with huge differences according to tumor stage. With a strict definition, more precise guide-lines concerning the therapy of such tumors seem adequate. These depend on tumor stage and dignity, general health condition of the patient and experience of the institution. Considering the low perioperative mortality of radical resection (actually below 5%), there will be increasing indications for this option in the future. But nevertheless, there are good palliative alternatives for selected cases.

Selective zonal ablations with excimer laser for correction of irregular astigmatism induced by refractive surgery

To demonstrate the safety and efficacy of selective zonal ablations with excimer laser for the correction of irregular astigmatism induced by refractive surgery. Thirty-one eyes of 26 patients. Retrospective and noncomparative case series. The authors reviewed the medical results of the two series of consecutive cases of irregular astigmatism induced by refractive surgery. One group showed a topography map with a defined pattern: decentered ablation, decentered steep central island, central irregularity, and peripheral irregularity. The other group showed an irregular astigmatism without defined pattern. Selective zonal ablation was performed with a broad-beam excimer laser. Laser ablations were adjusted according to the Munnerlyn formula. A phototherapeutic keratectomy (PTK) mode was used in all cases without using viscous masking solution. Uncorrected visual acuity, best spectacle-corrected visual acuity (BCVA), and Holladay diagnostic summary (Eye Sys 2.000) were considered before and after surgery to obtain the qualitative and quantitative characteristics of the visual acuity and corneal topography. The corneal uniformity index (CUI) was used to evaluate the corneal surface changes induced by the selective zonal ablations in the correction of irregular astigmatism. It proved to be a useful tool in the understanding of astigmatic changes when it is not possible to apply the vector analysis. In group 1, the irregular astigmatism was significantly improved in 96.4% of cases. The CUI was improved from 58+/-0.3% to 87+/-0.8%, P < 0.005 (Student's t-test). The improvement of the BCVA was from 20/40+/-20/100 to 20/25+/-20/100, P < 0.005 (Student's t-test). The results obtained in group 2 were not clinically significant in terms of improvement of CUI and BCVA. Using the corneal topographic map as a guide, selective zonal ablations with excimer laser can be used to create a more regular corneal surface, when a defined pattern of topographic irregularities can be defined.

Lessons Learned in the Process of Stroke Quality Management: Revised tools and strategies in a follow-up study

P229 Objectives Written care protocols and quality improvement efforts have recently been included in published guidelines on care of the ischemic stroke patient. We describe revisions to the quality management process that resulted in increased protocol use at a 469-bed medical school affiliate private hospital. Methods An earlier clinical pathway for ischemic stroke was ineffectively implemented as shown by pathway use in less than half of appropriate cases. A multidisciplinary team addressed barriers identified in that early experience to modify strategies in the development of a new set of quality management tools (QMT) for ischemic stroke. The revised QMT included: standing orders, clinical pathway, NIH Stroke Scale flow sheet, diagnostic summary form, and variance tracking tool. QMT use rates were calculated by medical record abstraction during a 3-month pilot study and physician and nurse usage rates determined. Factors contributing to QMT usage were analyzed. Results Twenty-eight ischemic stroke patients were admitted to the pilot unit during the study. Usage rates for components of the QMT driven by physicians were: standing orders 93%; IV tPA standing orders 100%; and diagnostic summary form 46%. Nurse related QMT usage was: clinical pathway 96%; NIH Stroke Scale flow sheet 75%; and variance tracking tool 75%. Key strategies that contributed to improved implementation were: 1) early involvement and continuous communication between the expanded multidisciplinary team, staff nurses and physicians 2) empowerment of nurses through NIH Stroke Scale training 3) perception of mutual accountability between nurses and physicians through use of QMT documents 4) clearly defined administrative directives. Conclusion Effective implementation of quality management protocols for ischemic stroke requires active participation of related disciplines at working levels, clear administrative support, and mutual accountability of physicians and nurses. Continuous critical appraisal of the process can afford eventual strategic solutions.