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Patel J, Bhaskar SMM. Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care. J Cardiovasc Dev Dis 2023; 10:458. [PMID: 37998516 PMCID: PMC10672610 DOI: 10.3390/jcdd10110458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/25/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023] Open
Abstract
Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab, Sydney 2150, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney 2170, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney 2150, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South Western Sydney Local Health District (SWSLHD), Sydney 2170, Australia
- Department of Neurology, National Cerebral and Cardiovascular Center (NCVC), Suita 564-8565, Osaka, Japan
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Manns K, Khan A, Carlson KV, Wagg A, Baverstock RJ, Trafford Crump R. The use of onabotulinumtoxinA to treat idiopathic overactive bladder in elderly patients is in need of study. Neurourol Urodyn 2021; 41:42-47. [PMID: 34618366 DOI: 10.1002/nau.24809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/04/2021] [Accepted: 08/12/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Injecting onabotulinumtoxinA (BoTN-A) into the bladder has been established as an effective treatment of overactive bladder (OAB) and well-tolerated by patients. However, there evidence suggests the efficacy and safety of this treatment may decrease with age due to increased comorbidities and frailty. This study's objective was to establish empirical evidence regarding age-related differences in outcomes related to BoTN-A for the treatment of idiopathic OAB. METHODS MEDLINE, EMBASE, and the Cochrane Central Registry for Controlled Trials were systematically searched. Results were restricted to randomized control trials of BoTN-A bladder injections for the treatment of idiopathic OAB. The resulting articles' abstracts were screened independently by two reviewers. Those passing the screen were reviewed in full. Articles were excluded if participants were <18 years old, diagnosed with neurogenic overactivity, or treated with both oral medications and BoTN-A; if the frequency and severity of OAB symptoms were not specified; or, if symptoms were not stratified by age. RESULTS The initial search resulted in 1572 articles; 166 were reviewed in full. None met all inclusion/exclusion criteria. However, 21 studies met all criteria except age stratification. Authors were contacted to obtain raw data to perform an independent age-based analysis, but sufficient data was not received. CONCLUSION While the initial systematic review did not generate the expected results, it did reveal that age-related outcomes of BoTN-A for the treatment of OAB are significantly under-studied. Given that the prevalence of OAB increases with age, this is an important knowledge gap. Our article explains the rationale for further study in this area.
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Affiliation(s)
- Kate Manns
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Asher Khan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kevin V Carlson
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - R Trafford Crump
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Silver JK, Flores LE, Mondriguez González A, Frontera WR. An Analysis of the Inclusion of Women, Older Individuals, and Racial/Ethnic Minorities in Rehabilitation Clinical Trials. Am J Phys Med Rehabil 2021; 100:546-554. [PMID: 33782277 DOI: 10.1097/phm.0000000000001750] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Our objective was to investigate whether women, people 65 yrs and older, or individuals who identify with racial and/or ethnic minority groups, were underrepresented among participants in rehabilitation clinical trials. DESIGN This is a cross-sectional study of completed rehabilitation clinical trials investigating the number and percentage of women, older adults, and racial and/or ethnic minorities enrolled in rehabilitation clinical trials between January 1, 2011, and January 1, 2020. Secondary outcome measures were inclusion by diagnostic group, as well as International Classification of Functioning, Disability and Health category, and intervention by diagnostic group. RESULTS Of the 108 studies meeting inclusion criteria, a majority (69%) were based in the United States. Stroke was the most frequent diagnostic group, followed by musculoskeletal conditions. Ninety-six percent of the United States-based trials included at least one female participant in their study, but among specific diagnostic groups, this ranged from 5% to 73%. Age information was reported inconsistently; however, of the trials reporting age, 100% of cardiac trials included older adults, whereas no spinal cord injury (SCI) trials included them. Among trials based in the United States reporting race, 70% of participants were White, followed by 20% Black or African American and 1% Asian. Among trials based in the United States reporting ethnicity, Hispanic or Latino participants were underrepresented overall and among each diagnostic group. CONCLUSIONS In this study, we found that among participants of rehabilitation clinical trials women, older individuals, and racial/ethnic minorities were generally underrepresented. In contrast, Black or African American participants were overrepresented with the exception of cardiac trials. An important finding was that many trials did not report age and/or race/ethnicity. Investigators should aim to include underrepresented populations and improve reporting.
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Affiliation(s)
- Julie K Silver
- From the Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts (JKS); Spaulding Rehabilitation Hospital, Charlestown, Massachusetts (JKS); Massachusetts General Hospital, Boston, Massachusetts (JKS); Brigham and Women's Hospital, Boston, Massachusetts (JKS); College of Allied Health Professions, University of Nebraska Medical Center, Omaha, Nebraska (LEF); Universidad Central del Caribe, Bayamón, Puerto Rico (AMG); Department of Physical Medicine, Rehabilitation and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico (WRF); and Department of Physiology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico (WRF)
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Kompanje EJO, van Dijck JTJM, Chalos V, van den Berg SA, Janssen PM, Nederkoorn PJ, van der Jagt M, Citerio G, Stocchetti N, Dippel DWJ, Peul WC. Informed consent procedures for emergency interventional research in patients with traumatic brain injury and ischaemic stroke. Lancet Neurol 2020; 19:1033-1042. [PMID: 33098755 DOI: 10.1016/s1474-4422(20)30276-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 11/30/2022]
Abstract
Health-care professionals and researchers have a legal and ethical responsibility to inform patients before carrying out diagnostic tests or treatment interventions as part of a clinical study. Interventional research in emergency situations can involve patients with some degree of acute cognitive impairment, as is regularly the case in traumatic brain injury and ischaemic stroke. These patients or their proxies are often unable to provide informed consent within narrow therapeutic time windows. International regulations and national laws are criticised for being inconclusive or restrictive in providing solutions. Currently accepted consent alternatives are deferred consent, exception from consent, or waiver of consent. However, these alternatives appear under-utilised despite being ethically permissible, socially acceptable, and regulatorily compliant. We anticipate that, when the requirements for medical urgency are properly balanced with legal and ethical conduct, the increased use of these alternatives has the potential to improve the efficiency and quality of future emergency interventional studies in patients with an inability to provide informed consent.
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Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care Adult, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Ethics and Philosophy of Medicine, Erasmus University, Rotterdam, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Vicky Chalos
- Department of Public Health, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Radiology and Nuclear Science, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Sophie A van den Berg
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Neurology, Amsterdam UMC, The Netherlands
| | - Paula M Janssen
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | | | - Mathieu van der Jagt
- Department of Intensive Care Adult, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
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Thompson DA, Iannaccone A, Ali RR, Arshavsky VY, Audo I, Bainbridge JWB, Besirli CG, Birch DG, Branham KE, Cideciyan AV, Daiger SP, Dalkara D, Duncan JL, Fahim AT, Flannery JG, Gattegna R, Heckenlively JR, Heon E, Jayasundera KT, Khan NW, Klassen H, Leroy BP, Molday RS, Musch DC, Pennesi ME, Petersen-Jones SM, Pierce EA, Rao RC, Reh TA, Sahel JA, Sharon D, Sieving PA, Strettoi E, Yang P, Zacks DN. Advancing Clinical Trials for Inherited Retinal Diseases: Recommendations from the Second Monaciano Symposium. Transl Vis Sci Technol 2020; 9:2. [PMID: 32832209 PMCID: PMC7414644 DOI: 10.1167/tvst.9.7.2] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/12/2020] [Indexed: 12/18/2022] Open
Abstract
Major advances in the study of inherited retinal diseases (IRDs) have placed efforts to develop treatments for these blinding conditions at the forefront of the emerging field of precision medicine. As a result, the growth of clinical trials for IRDs has increased rapidly over the past decade and is expected to further accelerate as more therapeutic possibilities emerge and qualified participants are identified. Although guided by established principles, these specialized trials, requiring analysis of novel outcome measures and endpoints in small patient populations, present multiple challenges relative to study design and ethical considerations. This position paper reviews recent accomplishments and existing challenges in clinical trials for IRDs and presents a set of recommendations aimed at rapidly advancing future progress. The goal is to stimulate discussions among researchers, funding agencies, industry, and policy makers that will further the design, conduct, and analysis of clinical trials needed to accelerate the approval of effective treatments for IRDs, while promoting advocacy and ensuring patient safety.
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Affiliation(s)
- Debra A Thompson
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alessandro Iannaccone
- Department of Ophthalmology, Duke Eye Center, Duke University Medical Center, Durham, NC, USA
| | - Robin R Ali
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA.,Institute of Ophthalmology, University College London, London, UK
| | - Vadim Y Arshavsky
- Department of Ophthalmology, Duke Eye Center, Duke University Medical Center, Durham, NC, USA
| | - Isabelle Audo
- Sorbonne Université, Institut de la Vision, INSERM, CNRS, Paris, France.,CHNO des Quinze-Vingts, INSERM-DGOS CIC 1423, Paris, France
| | | | - Cagri G Besirli
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Kari E Branham
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Artur V Cideciyan
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven P Daiger
- Human Genetics Center, School of Public Health, University of Texas Health Science Center Houston, Houston, TX, USA
| | - Deniz Dalkara
- Sorbonne Université, Institut de la Vision, INSERM, CNRS, Paris, France
| | - Jacque L Duncan
- Department of Ophthalmology, University of California-San Francisco, San Francisco, CA, USA
| | - Abigail T Fahim
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John G Flannery
- Helen Wills Neuroscience Institute, University of California-Berkeley, Berkeley, CA, USA
| | | | - John R Heckenlively
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Elise Heon
- Department of Ophthalmology and Vision Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
| | - K Thiran Jayasundera
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Naheed W Khan
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Henry Klassen
- Gavin Herbert Eye Institute, Stem Cell Research Center, University of California-Irvine, Irvine, CA, USA
| | - Bart P Leroy
- Department of Ophthalmology and Center Medical Genetics, Ghent University Hospital and University, Ghent, Belgium.,Division of Ophthalmology and Center for Cellular and Molecular Therapeutics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert S Molday
- Department of Biochemistry/Molecular Biology, University of British Columbia, Vancouver, British Columbia, Canada
| | - David C Musch
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark E Pennesi
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science Center, Portland, OR, USA
| | - Simon M Petersen-Jones
- Small Animal Clinical Sciences, Michigan State University, College of Veterinary Medicine, East Lansing, MI, USA
| | - Eric A Pierce
- Ocular Genomics Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Rajesh C Rao
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas A Reh
- Department of Biological Structure, University of Washington, Seattle, WA, USA
| | - Jose A Sahel
- Sorbonne Université, Institut de la Vision, INSERM, CNRS, Paris, France.,CHNO des Quinze-Vingts, INSERM-DGOS CIC 1423, Paris, France.,Fondation Ophtalmologique Rothschild, Paris, France.,Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dror Sharon
- Department of Ophthalmology, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Paul A Sieving
- Department of Ophthalmology and Center for Ocular Regenerative Therapy, University of California-Davis School of Medicine, Sacramento, CA, USA.,National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Enrica Strettoi
- Institute of Neuroscience, National Research Council (CNR), Pisa, Italy
| | - Paul Yang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science Center, Portland, OR, USA
| | - David N Zacks
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
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