Today is Monday, Mar. 27, 2017

Department of

Neurology & Rehabilitation Medicine 

Curriculum/Schedule

Research Training Goals

Completion of coursework in clinical research methodology including biostatistics, epidemiology, population genetics, ethics, clinical trial design, outcome analysis and grant writing. Additional course work will depend upon direction in clinical research (e.g., master’s in molecular genetics, master’s in epidemiology and biostatistics).

Hands-on experience in ongoing clinical research projects including medical record abstraction, stroke phenotyping, radiographic film review and classification, outcome analyses, handling and storage of biological materials including DNA, RNA and proteins, HIPAA compliance, writing of informed consents and protocols, participation in conference calls and meetings for large number of ongoing clinical trials and studies directed by our stroke center, data analysis and critique and preparation of manuscripts.

In addition, fellows will have the opportunity to collaborate with a number of very well-funded and active laboratories involving genomic and protein expression of stroke in animals and humans, genotypic analysis, models of intracerebral hemorrhage and ischemic stroke, models of arterial vasospasm, ultrasound treatment of arterial clot and magnetic resonance imaging.

  • Active participation in weekly cerebrovascular research meetings.
  • Participation in conference calls and meetings related to ongoing clinical trials and genetic studies.
  • Submission of at least one first-author manuscripts by end of first year.
  • Development of independent research idea by end of first year.
  • Development of K-23 or National Fellowship Award specific aims by end of second year to be submitted during their first year of faculty at their new institution.   Other grant submissions to foundations, AHA and the AAN are highly encouraged.  Another option during the first two years is to become principal investigator of NINDS-funded study as the site PI.

Participation in Ongoing Research

In the first week of arrival, the fellows will meet with Dawn Kleindorfer, MD, for an overview of all ongoing research. This will include a discussion of all clinical trials, clinical research studies and basic science projects.

Within the first month, the fellows will meet for one hour with each training faculty to get a very in-depth review of ongoing research projects of each faculty trainer in the program.

In addition, the fellows will spend one hour with the lead study coordinator from every ongoing clinical research study. This will be to familiarize themselves with their colleagues as well as to understand the protocols. The fellows will receive a detailed protocol for all studies that will be placed into hand-held device (Palm or Windows-based system).

One of the main projects that the fellows will work on every week are the “Hemorrhagic and Ischemic Strokes among Blacks and Whites” and the “Genetic and Environmental Risk Factors for Hemorrhagic Stroke” studies. They will receive detailed training in reviewing these data forms that includes imaging reports and actual brain images in selected patients.

After this training, they will review and complete case report forms that contain a large amount of clinical information including testing as well the imaging reports and images. They will then phenotype potential cases that have been abstracted by the study nurses. This provides the fellows with an experience of a large number of stroke cases and helps them learn the key role of phenotyping in epidemiologic and genetic studies.

Stroke fellows will also participate in the large number of ongoing clinical stroke trials. This includes the evaluation and treatment of patients in our entire regional hospital system since at least some of the ongoing clinical trials and research studies are active at all area hospitals.

In addition, fellows are required to attend the weekly and monthly conferences regarding the studies that are coordinated by the University of Cincinnati.

This provides them with great practical experience of how such studies are managed as well as a large network of potential contacts for future projects and their career. 

By the midpoint of the first year, fellows are encouraged to identify potential research areas of long term interest. By the end of the first year, the fellows are strongly encouraged to develop a grant proposal to develop this research area. This is often done in the context of a grant writing course.

By the end of the second year (if on the two-year track), the fellow is expected to have a national fellowship or K-23 proposal project chosen and specific aims written. Another option is be to be principal investigator at our site of a NINDS-funded study. Realistically, K-23 submissions often occur in the first half of the third year.

Clinical Training Goals

  • The fellow's direct involvement with the evaluation and treatment of 35-50 ischemic stroke patients per year who receive intravenous tPA or who are treated as part of a research protocol within three hours of stroke onset; indirect involvement with  300 patients per year who are treated with recanalization therapy.
  • Participation in the evaluation and treatment of an additional 100 stroke patients per year in the emergency departments who are not treated with tPA.
  • Training in Transcranial Doppler techniques and interpretation.
  • Active participation in weekly clinical cerebrovascular conference in which patients with the entire range of medical and surgical cerebrovascular problems are presented and discussed in a multidisciplinary setting. Participants include neurologists, neurosurgeons, neuro-interventionalists, emergency physicians, neuro-intensivists,neuro-ophthamologists, research nurses, residents and medical students.
  • Management and diagnosis of stroke patients on the UC Medical Center inpatient service, including ordering and interpreting appropriate diagnostic tests, prevention of medical complications and participation in the patient’s rehabilitation plan.
  • Evaluation and treatment of stroke patients in the various outpatient settings, including the UC Medical Center  practice, and Daniel Drake Center for Post-Acute Care, among others, in conjunction with stroke attendings. This will include management of anti-thrombotic medications based on the latest scientific literature, diagnostic testing and enrolling patients in prevention clinical trials.

Regional Stroke Service/Acute Call

The primary focus of our stroke fellows is the acute assessment and subsequent management of stroke patients in the emergency departments of our regional hospitals.

Since 1988, we have been on call 24-hour a day, seven days a week for the Greater Cincinnati/Northern Kentucky region. We currently average approximately 10 telephone calls for potential stroke calls per day (4,000 calls per year).

Approximately one quarter of these calls require that the stroke physician go to the hospital to evaluate the patient in person or log into telemedicine to view the patient.

Currently, physicians who are on-call for the Acute Stroke Intervention Team include six stroke neurologists, 1-3 vascular neurology stroke fellow(s), seven emergency physicians, fourneuro-ICU fellows and three neuro-interventionalists (one vascular neurologist, one neuroradiologist and one endovascular neurosurgeon).

We average approximately 400 patients per year who are treated with thrombolytic medication within three hours of stroke onset at our 15 regional hospitals and 10+ telemedicine hospitals.

For the first two months, the fellows are not entered into the stroke call pool. They accompany the stroke attending on-call for all prospective cases during the day (except if otherwise in outpatient clinic) and are on-call two nights a week as well. They are also welcome and often attend stroke calls outside of their scheduled call times. They are responsible for evaluation of the patient and subsequent follow-up for the next 24 hours.  Patient logs are kept by the fellow for review with the program director.

At UC Medical Center, the stroke fellow will follow and be responsible for the care of the stroke patient working with the University Hospital Neurology service. At the other regional hospitals care of the stroke patient is transferred to the local neurologist or internist the following day with additional input offered as needed. 

All fellows obtain clinical privileges at the 17 hospitals that are part of their training experience. Each fellow is provided with a cellphone stipend to interact with the hospitals and to answer pages at any time.  The fellow is also provided a tablet device by UCMC, which can be used for telemedicine

The fellows are gradually given increasing responsibility to answer pages (to determine eligibility for tPA), evaluate the acute stroke patient and make clinical decisions regarding tPA use. The expectation is that they primarily observe at first but become independent stroke clinicians by the end of the two-month period. Thereafter, they are entered into the call pool and function independently in all aspects of acute stroke care.

The attendings that are not on-call are still available by page or phone at all times to assist the fellow with questions or concerns regarding difficult cases. The stroke faculty interacts directly with the stroke fellows on all stroke patients.

Inpatient Stroke Management

The stroke fellow is expected to manage all of the critically ill patients they have treated with tPA or other acute therapies for the first 24 hours at the regional hospitals, and the entire hospitalization at UC Medical Center. This will involve critical care management of acute stroke including blood pressure control, increased intracranial pressure/cerebral edema, intracranial hemorrhage and, occasionally, central line placement and ventilator management. 

Additional experience in critical care and neurosurgical diseases such as aneurysm/AVM management is required for an additional one month.

Also, for at least one to two months out of the year, the fellow will round daily on all the stroke patients admitted to the inpatient neurology service. On average, this will range from one to five patients per day. The fellow will take primary responsibility for decision-making regarding these patients, with backup from the attending. Fellows will be expected to teach residents and students at the bedside as well.

Specific training regarding neurological and medical complications after stroke will be taught through bedside teaching and didactic lectures by the stroke faculty.

Fellows are expected to order and interpret all appropriate imaging studies, and will receive training in this regard from the stroke and neuro-radiology faculty members of the stroke team. 

Outpatient Stroke Management

The neurology stroke fellow will also see stroke patients as outpatients in one of three locations. They will see new and complex cerebrovascular cases as well as patients who are evaluated as part of ongoing clinical research protocols. These clinics include:

  • General Stroke Clinic: This is usually for stroke patients recently discharged from UC Medical Center. Many of the prevention studies screen in this clinic. This clinic is staffed on a rotating basis with each of the seven stroke neurologists. 
  • Multi-Disciplinary Neuro-Intervention Clinic: Held in the neurosurgery department, these patients have all been referred for intervention, including intracranial aneurysms, AVMs, carotid stenosis etc. Dawn Kleindorfer, MD, is the neurologist, and Andrew Ringer, MD, is the neurosurgeon. All patients are seen by both disciplines; neurology’s role is to assess medical management.
  • Stroke Recovery Clinic: Staffed by Brett Kissela, MD, or Oluwole Awoskia, MD, these are more chronic stroke patients that are being evaluated for additional needs, including additional therapies and screening for the many stroke recovery trials that are ongoing. Also multidisciplinary, patients are seen by neurology, psychiatry and many different therapists.

Graduate-Level Coursework in Clinical Research

All formal coursework will be taken through the UC Department of Environmental Health's Division of Epidemiology and Biostatistics. In addition, a number of excellent clinical research seminars are also given at Cincinnati Children’s Hospital Medical Center.

Vascular neurology fellowship training includes, at a minimum, the following coursework:

  • Introduction to Biostatistics (fall quarter)
  • Introduction to Epidemiology (winter quarter)
  • Either Clinical Trial Design or Management of Field Studies in Epidemiology (spring quarter) in a two-year cycle
  • Ethics in Research
  • Grant-Writing Course in Winter Quarter

Fellows who stay a second year are encouraged to take advanced level courses in epidemiology and biostatistics, clinical trial design, human genetics and outcomes-analysis depending upon their research focus.  The second year schedule is more flexible depending on the focus of the fellow.

Daily Schedule for Stroke Fellows (does not include Stroke Call)

Monday
1:30–3:30 p.m.: Graduate level course work.


Tuesday
8–9 a.m.: Weekly clinical research conference. Acute stroke cases that are part of clinical trials are presented and discussed. Bi-monthly presentation by one of basic scientists on ongoing research for discussion and critique.

9–10 a.m.: Weekly clinical research conference dealing with all ongoing epidemiologic and genetic studies.

11 a.m.–Noon: Work on ongoing clinical research projects.

1–5 p.m.: Stroke recovery clinic at Daniel Drake Center for Post-Acute Care.


Wednesday
7:30–8 a.m.: Journal Club for Neurology Residents – Stroke fellows participate in articles related to cerebrovascular disease.

7:30–8 a.m.: Journal Club for Neurology Residents – Stroke fellows participate in articles related to cerebrovascular disease.

8–9 a.m.: Neurology Grand Rounds.

9 a.m.–1 p.m.: Work on ongoing clinical research projects or master’s level course work depending on quarter.

1:30–3:30 p.m.: Graduate level coursework.


Thursday
7:30–8:30 a.m.: Interdisciplinary neurovascular radiology conference with stroke physicians and nurses, vascular neurosurgery, endovascular neuroradiology. Review of cases from previous week.

7:30–8:30 a.m.: Interdisciplinary neurovascular radiology conference with stroke physicians and nurses, vascular neurosurgery, endovascular neuroradiology. Review of cases from previous week.

9 a.m.–5 p.m.: Work on ongoing clinical research.


Friday
7:30–8:30 a.m.: Neurology faculty meeting once per month.

Noon–1 p.m.: Didactic lecture series, fellows to attend stroke-related topics.

8 a.m.–Noon: Neuro-intervention Clinic (every other week).

1–5 p.m.: Stroke Clinic (every other week).