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As if on cue, Monroe County's first mobile stroke unit raced to a call Tuesday morning within 30 minutes of going into service for the first time.

"Stroke is an epidemic in the community," said Dr. Tarun Bhalla, chief of stroke and cerebrovascular surgery at the UR Medicine Comprehensive Stroke Center.

As of midday Friday, the unit had made six runs.

Stroke is the third-leading cause of death in Monroe County. The county has a higher age-adjusted death rate from the condition than in New York as a whole, according to 2010-2014 data from the Monroe County Department of Public Health.

Next month, UR Medicine will begin operation of a Mobile Stroke Unit (MSU), a high-tech 'emergency room on wheels' that is designed to provide life-saving care to stroke victims. The $1 million unit will be operated in partnership with AMR as a community resource and represents a significant step forward for stroke care in the Rochester region.

While the MSU resembles an ambulance on the outside, inside it contains highly specialized staff, equipment, and medications used to diagnose and treat strokes. The unit is equipped with a portable CT scanner that is capable of imaging the patient's brain to detect the type of stroke they are experiencing. The scans and results from a mobile lab on the unit are wirelessly transmitted to UR Medicine stroke specialists at Strong Memorial Hospital, who will consult with the on board EMS staff via telemedicine and decide if they can begin treatment immediately on scene.

If it is determined that the patient is experiencing an ischemic stroke -- which account for approximately 90 percent of all strokes -- the MSU team can administer the drug tissue plasminogen activator (tPA) to attempt to break up the clot in the patient's brain. While en route to the hospital, UR Medicine specialists will continue to remotely monitor and assess the patient's symptoms.

"The UR Medicine Mobile Stroke Unit essentially brings the hospital to the patient," said neurosurgeon Tarun Bhalla, M.D., Ph.D., with the UR Medicine Comprehensive Stroke Center. "This unit will improve care and outcomes by shortening the gap between diagnosis and treatment and enable us to initiate care before the patient reaches the hospital."

It is estimated that 3,000 people in Monroe County suffer from a stroke every year. Stroke is the fifth leading cause of death and the number one cause of long-term disability in the U.S. However, if caught early, many stroke victims can make a full recovery.

"Ten years ago we realized there was an epidemic of stroke in our community which resulted in tremendous human suffering and health care costs," said Web Pilcher, M.D., Ph.D., chair of the UR Medicine Department of Neurosurgery. "We decided to embark on a long-term plan to provide the best stroke care in upstate New York. The Mobile Stroke Unit represents the next evolution in that effort and places Rochester among an elite list of communities with this cutting-edge technology."

The current best treatment for stroke is tPA. But in order to work properly, the drug must be given within four and half hours of the first stroke symptoms. Depending upon the circumstances, doctors may also elect to perform a minimally invasive endovascular surgical procedure that involves threading a catheter through the blood vessels and physically removing the obstruction in the brain. The capabilities provided by the MSU to diagnose, start treatment, and prepare hospital staff to receive the patient before they arrive at the emergency department will save lives and improve chances of recovery.

"In stroke care, time equals brain," said neurologist Curtis Benesch, M.D., M.P.H., with the UR Medicine Comprehensive Stroke Center. "The approximately 30 minutes that could be saved by the Mobile Stroke Unit by starting treatment before a stroke patient reaches the hospital could mean the difference between the recovery of function or a lifetime of impairment."

"Patients who receive tPA sooner are more likely to go home and retain the ability to walk and care for themselves," said Bob Holloway, M.D., M.P.H., chair of the UR Medicine Department of Neurology. "The Mobile Stroke Unit will improve outcomes for stroke victims in our community and, because people with less disability use fewer health care resources, lower costs in the long term."

The unit is owned by UR Medicine and will be operated by AMR. The MSU will be staffed by a UR Medicine nurse trained in stroke care and a CT technician, an AMR paramedic and emergency medical technician, and remotely by a stroke specialist at UR Medicine.

The construction and operating costs of the unit, which was custom built by Frazer Ltd. in Houston, are being funded by UR Medicine and philanthropy, including a lead gift from Elena Prokupets and support from the Del Monte family and other donors in the Rochester community.

"We are extremely grateful to Elena for her gift to the School of Medicine and Dentistry, which has made it possible to bring this life saving technology to Rochester," said Mark Taubman, M.D., CEO of the University of Rochester Medical Center. "Her generosity, along with the support of many others, has provided us the resources to invest in the infrastructure, technology, and clinical talent necessary to provide the most advanced stroke care to our community."

The MSU is part of a broader UR Medicine initiative to bring state-of-the-art stroke care to the region. This includes Strong Memorial Hospital's designation as the region's only Comprehensive Stroke Center by the Joint Commission, a certification that indicates that the hospital either meets or exceeds the highest standards of care required to provide timely, advanced, and coordinated care to patients with cerebrovascular disease, and the Neuromedicine Intensive Care Unit, a 12-bed ICU that provides care to critically ill patients with complex neurological life threating illnesses such as stroke. UR Medicine stroke specialists also provide 24/7 consultation services for emergency department personnel in several hospitals in the region via telemedicine.

Eight years ago, UR Medicine, in partnership with the Greater Rochester Health Foundation, created the Stroke Treatment Alliance of Rochester/New York (STAR-NY), to educate medical professionals and the broader community about stroke recognition and prevention.

A new study out today in the Journal of Neurology finds that pregabalin is not effective in controlling the chronic pain that sometimes develops following traumatic nerve injury. The results of the international study, which was driven by an effort to identify effective non-opioid pain medications, did show potential in relieving in pain that sometimes lingers after surgery.

"The unrelenting burning or stabbing symptoms due to nerve trauma are a leading reason why people seek treatment for chronic pain after a fall, car accident, or surgery," said John Markman, M.D., director of the Translational Pain Research Program in the University of Rochester Department of Neurosurgery and lead author of the study. "While these finding show that pregabalin is not effective in controlling the long-term pain for traumatic injury, it may provide relief for patients experience post-surgical pain."

Pregabalin, which is marketed by Pfizer under the name Lyrica, is approved to treat chronic pain associated with shingles, spinal cord injury, fibromyalgia, and diabetic peripheral neuropathy. However, it is also commonly prescribed as an "off label" treatment for chronic nerve injury syndromes that occur after motor vehicle accidents, falls, sports injuries, knee or hip replacement and surgeries such as hernia repair or mastectomy.

A previous eight-week study had shown that pregabalin reduced pain intensity better than placebo in these chronic, post-traumatic pain syndromes. These results led many doctors to prescribe this medication for long-term pain that does not resolve as expected.

Chronic postsurgical pain syndromes occur in approximately one or two out of every 10 surgical patients and the levels rated as intolerable after roughly one or two in every 100 operations. With 55 million surgeries performed in the U.S. every year, severe chronic pain impacts more than a million new people annually. Roughly one third of these patients are believed to have neuropathic pain or ongoing pain related to nerve injury.

These rates vary widely by type of surgery. The risks factors and underlying mechanisms of this type of chronic pain are not well understood, but because the types of symptoms patients describe like "burning", "unpleasant tingling," or "numbness" resemble other nerve pain syndromes like shingles pain. As a result, physicians trying to find useful non-opioid pain relievers have often turned to prescribing gabapentin or pregabalin.

The current study was conducted in 101 centers in in North America, Europe, Africa, and Asia and followed 539 individuals for three months. Study participants were randomized into two groups who either prescribed pregabalin or a placebo.

The study found that pregabalin was not effective in controlling pain for individuals with traumatic nerve injury. A retrospective analysis of a subgroup of study of participants, whose nerve pain was attributed to surgery, showed that the drug did provide better pain relief than placebo at 3 months.

"The possibility that there was pain relief for those patients who had a hernia repair, or breast surgery for cancer, or a joint replacement lays the groundwork for future studies in these post-surgical syndromes where there is so much need for non-opioid treatments," said Markman.

One major challenge is that different biological changes in the nerves and other tissues that cause pain to persist after healing from trauma vary from one patient to the next. Currently, there is no diagnostic method that allows doctors to readily identify the patients whose pain will respond to a particular type of pain treatment.

Despite employing new strategies to reduce placebo effects, the patients receiving placebo also had a steady lowering of their pain over the course of the study. The pattern of these placebo effects in longer studies has proved to be a major challenge to the development of new pain medications.

"Given the rising rates of surgery and shrinking reliance on opioids, it is critical that we understand how to study new drugs that work differently in patients like the ones included in this study," Markman added.

Additional co-authors of the study include Malca Resnick, Scott Greenberg, Ruoyong Yang, Joseph Scavocne, Ed Whalen, Gabriela Gregorian, Bruce Parsons, and Lloyd Knapp with Pfizer and Nathaniel Katz with Analgesic Solutions. Pfizer funded the trial, and was involved in its design as well as the data collection and analysis. The company also paid for medical writing assistance and editorial support in preparing the article for the journal. Markman has received consulting fees and research funding support from Pfizer.

If you're in the hospital or a doctor's office with a painful problem, you'll likely be asked to rate your pain on a scale of 0 to 10 – with 0 meaning no pain at all and 10 indicating the worst pain you can imagine. But many doctors and nurses say this rating system isn't working and they're trying a new approach.

The numeric pain scale may just be too simplistic, says Dr. John Markman, director of the Translational Pain Research Program at the University of Rochester School of Medicine and Dentistry. It can lead doctors to "treat by numbers," he says and as a result, patients may not be getting the most effective treatment for their pain.

Take the case of 33-year-old Adam Rosette, who was recently hospitalized for fibrous dysplasia, a bone disorder that made it nearly impossible for him to chew or even speak. After brain surgery to remove benign tumors related to the disorder, he was definitely in pain. But he was reluctant to label the pain too high.

"I don't think I ever answered higher than a '7' because an '8' would be, in my mind, like I'm missing half of my body or a limb," he recalls.

A series of awards from the American Heart Association (AHA) to a team of researchers at the University of Rochester Medical Center (URMC) will focus on the development of new treatments to thwart the damage in the brain caused by stroke.

One of the research projects brings together experts in stroke, cardiovascular biology, platelet biology, and peptide chemistry. Marc Halterman, M.D., Ph.D., with the URMC Center for Neurotherapeutics Discovery, Scott Cameron, M.D., Ph.D., and Craig Morrell, D.V.M., Ph.D., with the URMC Aab Cardiovascular Research Institute, and Bradley Nilsson, Ph.D., with the University of Rochester Department of Chemistry will focus on the role that platelets play in acute brain injury and inflammation during stroke.

Platelets serve an important role in protecting against blood loss and repairing injured blood vessels. However, during a stroke the inflammatory properties of platelets can interfere with the restoration of blood flow once the clot in the brain is removed, particularly in micro-vessels, which can lead to permanent damage of brain tissue.

The research team will build synthetic peptides that activate platelets to study the phenomenon -- which is called no-reflow -- in an effort to identify specific switches within platelets that can be turned off and limit the cells' inflammatory functions without blocking their ability to prevent bleeding.

Two AHA pre-doctoral fellowship awards Kathleen Gates and Jonathan Bartko in Halterman's lab will support research that examines the link between an immune system response triggered by stroke in the lungs that can exacerbate damage in the brain and investigate the cellular mechanisms that determine whether or not brain cells die following stroke.

A final AHA award to the Halterman lab will seek to identify new drug targets by focusing on specific proteins activated during stroke that are suspected to play an important role in determining the survival of neurons.

Collectively, the AHA Collaborative Sciences Award, Pre-Doctoral, and Innovation awards represent $1.09 million in funding.

The American Heart Association/American Stroke Association (AHA/ASA) has once again honored the UR Medicine Strong Memorial Hospital for having achieved the highest standard of care for stroke. This award identifies hospitals that provide care that can speed the recovery and reduce death and disability for stroke patients.

Strong Memorial Hospital has received the 2018 AHA/ASA Get With The Guidelines program's Stroke Gold Plus Quality Achievement Award. The hospital was also recognized for the Target: Stroke Honor Role Elite Plus designation, which identifies hospitals that have consistently and successfully reduced door-to-needle time -- the window of time between a stroke victim's arrival at the hospital, the diagnosis of an acute ischemic stroke, and the administration of the clot-busting drug tPA. If given intravenously in the first four and a half hours after the start of stroke symptoms, tPA has been shown to significantly reduce the effects of stroke and lessen the chance of permanent disability.

Wilmot's competitive seed-grant program aims to fund research projects that will generate preliminary data necessary to potentially apply for federal funding in the future. Thanks to financial support from two community organizations -- Adding Candles for a Cure and the Edelman Gardner Cancer Research Foundation -- four projects have received funding that started Jan. 1.

Mark Noble, Ph.D., Professor in the departments of Biomedical Genetics and Neuroscience, received a $50,000 grant for his project titled, "A biomarker for a novel glioblastoma (GBM) vulnerability." The co-investigators for this project are Kevin Walter, M.D., Mahlon Johnson, M.D., Ph.D., Nimish Mohile, M.D., and Peggy Auinger, M.S.

Bradford Mahon, Ph.D., Assistant Professor in the Departments of Neurology and Neurosurgery, received a $50,000 grant for his project seeking to demonstrate feasibility and preliminary efficacy of advanced MRI mapping in improving outcome in patients with glioblastoma. Kevin Walter, M.D., is the co-investigator for this project.

Congratulations to all Wilmot pilot grant recipients.

By Mark Michaud

Providers from across upstate New York are gathering tomorrow for UR Medicine’s 7^h annual Stroke Treatment Alliance of Rochester – New York (STAR-NY) Stroke Management Symposium. The meeting – which attracts more than 400 participants annually – will highlight pre-hospital care, new medical and surgical advances, a regional approach to stroke care, and recovery and prevention.

Participants in the conference, held at the Hyatt Regency in Rochester, attracts over 400 clinicians annually, include primary care physicians, internists, neurologists, neurosurgeons, emergency physicians, family physicians, radiologists, cardiologists, nurses, physician assistants, nurse practitioners and EMS personnel who care for patients with cerebrovascular disorders.

Topics that will be discussed include the challenges of stroke care in community and rural hospital settings, protocols to identify and transfer acute stroke patients, developing a regional approach to stroke care, advances in medical and surgical treatment technology, medical management of at-risk patients, and rehabilitation, with a focus on the adoption of new mobile technologies that can help physicians and EMS personnel diagnose start treatment for stroke patients before they reach the hospital.

The sessions will be led by neurology, and neurosurgery, and cardiothoracic surgery faculty from UR Medicine and Cayuga Medical Center, with a guest speaker from Memorial Hermann - Texas Medical Center who will describe efforts to improve pre-hospital stroke care through the use of advanced technologies.

For more information, visit: https://www.urmc.rochester.edu/stroke-treatment-alliance-rochester.aspx

John Markman, M.D.

The American Pain Society is the nation's leading organization of scientists, physicians, and allied professionals focused on increasing knowledge of pain and transforming clinical practice and policy to reduce pain-related suffering. Markman founded and directs the University's Neuromedicine Pain Management Center and Translational Pain Research Program. Together these programs were previously recognized as a Center of Excellence by the American Pain Society.

Congratulations Dr. Markman!