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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Shahjouei S, Li J, Koza E, Abedi V, Sadr AV, Chen Q, Mowla A, Griffin P, Ranta A, Zand R. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2136644. [PMID: 34985520 PMCID: PMC8733831 DOI: 10.1001/jamanetworkopen.2021.36644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome. OBJECTIVE To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting. DATA SOURCES MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020. STUDY SELECTION Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer. DATA EXTRACTION AND SYNTHESIS The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models. MAIN OUTCOMES AND MEASURES Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days). RESULTS The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.
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Affiliation(s)
- Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
- Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Alireza Vafaei Sadr
- Department de Physique Theorique and Center for Astroparticle Physics, University Geneva, Geneva, Switzerland
| | - Qiushi Chen
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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Lim A, Singhal S, Lavallee P, Amarenco P, Rothwell PM, Albers G, Sharma M, Brown R, Ranta A, Maddula M, Kleinig T, Dawson J, Elkind MSV, Guarino M, Coutts SB, Clissold B, Ma H, Phan T. An International Report on the Adaptations of Rapid Transient Ischaemic Attack Pathways During the COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2020; 29:105228. [PMID: 33066882 PMCID: PMC7434484 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/30/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This report aims to describe changes that centres providing transient ischaemic attack (TIA) pathway services have made to stay operational in response to the SARS-CoV-2 pandemic. METHODS An international cross-sectional description of the adaptions of TIA pathways between 30th March and 6th May 2020. Experience was reported from 18 centres with rapid TIA pathways in seven countries (Australia, France, UK, Canada, USA, New Zealand, Italy, Canada) from three continents. RESULTS All pathways remained active (n = 18). Sixteen (89%) had TIA clinics. Six of these clinics (38%) continued to provide in-person assessment while the majority (63%) used telehealth exclusively. Of these, three reported PPE use and three did not. Five centres with clinics (31%) had adopted a different vascular imaging strategy. CONCLUSION The COVID pandemic has led TIA clinics around the world to adapt and move to the use of telemedicine for outpatient clinic review and modified investigation pathways. Despite the pandemic, all have remained operational.
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Affiliation(s)
- Andy Lim
- Department of Emergency Medicine, Monash Medical Centre, Melbourne, Australia; School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Shaloo Singhal
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology, Monash Medical Centre, Melbourne, Australia
| | - Philippa Lavallee
- Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France
| | - Pierre Amarenco
- Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences. Level 6, West Wing, John Radcliffe Hospital, Oxford, United Kingdom
| | - Gregory Albers
- Department of Neurology and Stanford Stroke Center, Stanford Medical Center, Palo Alto, CA, USA
| | - Mukul Sharma
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
| | - Robert Brown
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital and University of Otago, Wellington
| | - Mohana Maddula
- Tauranga Hospital, Bay of Plenty District Health Board, Tauranga, New Zealand
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Interaziendale Clinica Neurologica Metropolitana (NeuroMet), Neurologia AOU S.Orsola, Malpighi, Bologna, Italy
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Benjamin Clissold
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology, Monash Medical Centre, Melbourne, Australia
| | - Henry Ma
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology, Monash Medical Centre, Melbourne, Australia
| | - Thanh Phan
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology, Monash Medical Centre, Melbourne, Australia.
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Chang BP, Rostanski S, Willey J, Miller EC, Shapiro S, Mehendale R, Kummer B, Navi BB, Elkind MSV. Safety and Feasibility of a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Stroke: The Rapid Access Vascular Evaluation-Neurology (RAVEN) Approach. Ann Emerg Med 2019; 74:562-571. [PMID: 31326206 PMCID: PMC6756973 DOI: 10.1016/j.annemergmed.2019.05.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/23/2019] [Accepted: 05/10/2019] [Indexed: 01/01/2023]
Abstract
STUDY OBJECTIVE Although most transient ischemic attack and minor stroke patients in US emergency departments (EDs) are admitted, experience in other countries suggests that timely outpatient evaluation of transient ischemic attack and minor stroke can be safe. We assess the feasibility and safety of a rapid outpatient stroke clinic for transient ischemic attack and minor stroke: Rapid Access Vascular Evaluation-Neurology (RAVEN). METHODS Transient ischemic attack and minor stroke patients presenting to the ED with a National Institutes of Health Stroke Scale score of 5 or less and nondisabling deficit were assessed for potential discharge to RAVEN with a protocol incorporating social and medical criteria. Outpatient evaluation by a vascular neurologist, including vessel imaging, was performed within 24 hours at the RAVEN clinic. Participants were evaluated for compliance with clinic attendance and 90-day recurrent transient ischemic attack and minor stroke and hospitalization rates. RESULTS Between December 2016 and June 2018, 162 transient ischemic attack and minor stroke patients were discharged to RAVEN. One hundred fifty-four patients (95.1%) appeared as scheduled and 101 (66%) had a final diagnosis of transient ischemic attack and minor stroke. Two patients (1.3%) required hospitalization (one for worsening symptoms and another for intracranial arterial stenosis caused by zoster) at RAVEN evaluation. Among the 101 patients with confirmed transient ischemic attack and minor stroke, 18 (19.1%) had returned to an ED or been admitted at 90 days. Five were noted to have had recurrent neurologic symptoms diagnosed as transient ischemic attack (4.9%), whereas one had a recurrent stroke (0.9%). No individuals with transient ischemic attack and minor stroke died, and none received thrombolytics or thrombectomy, during the interval period. These 90-day outcomes were similar to historical published data on transient ischemic attack and minor stroke. CONCLUSION Rapid outpatient management appears a feasible and safe strategy for transient ischemic attack and minor stroke patients evaluated in the ED, with recurrent stroke and transient ischemic attack rates comparable to historical published data.
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Affiliation(s)
- Bernard P Chang
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY.
| | - Sara Rostanski
- Department of Neurology, New York University Medical Center, New York, NY
| | - Joshua Willey
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Eliza C Miller
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Steven Shapiro
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Rachel Mehendale
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Benjamin Kummer
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Mitchell S V Elkind
- Department of Neurology, Columbia University Irving Medical Center, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Incidence of acute cerebral infarction or space occupying lesion among patients with isolated dizziness and the role of D-dimer. PLoS One 2019; 14:e0214661. [PMID: 30921431 PMCID: PMC6438525 DOI: 10.1371/journal.pone.0214661] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022] Open
Abstract
Background To determine the incidence of acute cerebral infarction or space occupying lesion (SOL) among patients with isolated vertigo or dizziness (IVD) and to evaluate the role of cerebellar function test (CFT) and D-dimer to discriminate ACI/SOL and non-ACI/SOL. Methods A retrospective study of consecutive emergency department (ED) patients with IVD during one year was conducted. ACI was based on the diffusion-weighted magnetic resonance imaging (DW-MRI), and SOL was based on the concurrent MRI sequences. A sensitivity analysis of CFT and D-dimer was also performed. Results Among the 468 patients enrolled, 13 patients (2.8%) had ACI, 11 at cerebellum, 1 at occipital lobe, and 1 at centrum semiovale. Twenty-five patients (5.3%) had SOL. Aneurysm is most frequent (n = 7), followed by meningioma (n = 4) and venous anomaly (n = 4). In total, ACI/SOL was found in 8.1% (n = 38). Abnormal findings in finger-to-nose (FN), heel-to-shin (HTS), and rapid alternative movement (RAM) tests were significantly higher in ACI or ACI/SOL group, while gait disturbance, tandem gait abnormality, and Romberg’s test were not. CFT sensitivities were low for ACI as well as for ACI/SOL, but specificities were high for ACI and ACI/SOL. D-dimer level showed a sensitivity of 100% at >0.18 mg/L for ACI and >0.15 mg/L for ACI/SOL. However, specificity was low at corresponding D-dimer level. Among the subgroup (n = 411) who did not show any abnormality in CFT, 9 patients (2.2%) had ACI, and 33 patients (8.0%) had ACI/SOL. Conclusion The present study reports a clinically significant incidence of ACI/SOL among ED patients with IVD. D-dimer showed high sensitive and low specificity, while CFT showed low sensitivity and high specificity.
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Chang BP, Rostanski S, Willey J, Kummer B, Miller E, Elkind M. Can I Send This Patient with Stroke Home? Strategies Managing Transient Ischemic Attack and Minor Stroke in the Emergency Department. J Emerg Med 2018; 54:636-644. [PMID: 29321107 PMCID: PMC6446571 DOI: 10.1016/j.jemermed.2017.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 11/05/2017] [Accepted: 12/01/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND While transient ischemic attack and minor stroke (TIAMS) are common conditions evaluated in the emergency department (ED), there is controversy regarding the most effective and efficient strategies for managing them in the ED. Some patients are discharged after evaluation in the ED and cared for in the outpatient setting, while others remain in an observation unit without being admitted or discharged, and others experience prolonged and potentially costly inpatient admissions. OBJECTIVE OF THE REVIEW The goal of this clinical review was to summarize and present recommendations regarding the disposition of TIAMS patients in the ED (e.g., admission vs. discharge). DISCUSSION An estimated 250,000 to 300,000 TIA events occur each year in the United States, with an estimated near-term risk of subsequent stroke ranging from 3.5% to 10% at 2 days, rising to 17% by 90 days. While popular and easy to use, reliance solely on risk-stratification tools, such as the ABCD2, should not be used to determine whether TIAMS patients can be discharged safely. Additional vascular imaging and advanced brain imaging may improve prediction of short-term neurologic risk. We also review various disposition strategies (e.g., inpatient vs. outpatient/ED observation units) with regard to their association with neurologic outcomes, such as 30-day or 90-day stroke recurrence or new stroke, in addition to other outcomes, such as hospital length of stay and health care costs. CONCLUSIONS Discharge from the ED for rapid outpatient follow-up may be a safe and effective strategy for some forms of minor stroke without disabling deficit and TIA patients after careful evaluation and initial ED workup. Future research on such strategies has the potential to improve neurologic and overall patient outcomes and reduce hospital costs and ED length of stay.
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Affiliation(s)
- Bernard P Chang
- Department of Emergency Medicine, Columbia University Medical Center, New York, New York
| | - Sara Rostanski
- Department of Neurology, New York University, New York, New York
| | - Joshua Willey
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Benjamin Kummer
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Eliza Miller
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Mitchell Elkind
- Department of Neurology, Columbia University Medical Center, New York, New York
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Crowfoot G, van der Riet P, Maguire J. Real-life experiences of people with transient ischaemic attack or minor stroke: A qualitative literature review. J Clin Nurs 2018; 27:1381-1398. [PMID: 29569286 DOI: 10.1111/jocn.14271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To explore and present findings of qualitative studies exploring real-life experiences of people with transient ischaemic attack or minor stroke. BACKGROUND Transient ischaemic attack and minor stroke significantly increase the risk of stroke. Primarily, literature has examined healthcare pathways, patient outcomes and models of care through quantitative methodologies. Several studies have explored patient experiences using qualitative approaches. However, these findings have not been systematically collated or critically appraised to better understand the experiences of this population. DESIGN A literature review of the qualitative evidence. METHOD A systematic literature search was conducted in CINAHL, MEDLINE, EMBASE and PsycINFO between January 2005-October 2016 to identify qualitative studies that explored real-life experiences of people with transient ischaemic attack or minor stroke. The relevant EQUATOR guidelines were followed. Findings of relevant studies were critically appraised and collated using a thematic approach. RESULTS The search retrieved 709 articles. Twelve articles were included after critical review. Three themes emerged including recognition, awareness and action; the vulnerable self; and social and personal life change. Participants experienced ongoing vulnerability and change in their personal and social lives. Specifically, people believed that their condition did not reflect their physical appearance and led to their needs being unmet by health professionals. CONCLUSIONS This is the first review of the literature to collate the thoughts, perspectives and experiences of people living with transient ischaemic attack or minor stroke. They reveal a complex, life-altering experience characterised by vulnerability, instability and change. Education that assists clinicians to connect with these experiences may alleviate the patient-reported disconnection with health professionals. RELEVANCE TO CLINICAL PRACTICE Physical and psychosocial dysfunctions were consistently reported to be overlooked or undetected by clinicians. Educating clinicians might enable them to better understand patient experiences, improve therapeutic interactions and meet the needs of this population.
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Affiliation(s)
- Gary Crowfoot
- School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia.,Priority Research Centre for Stroke and Brain Injury, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Pamela van der Riet
- School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Jane Maguire
- Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
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Jarhult SJ, Howell ML, Barnaure-Nachbar I, Chang Y, White BA, Amatangelo M, Brown DF, Singhal AB, Schwamm LH, Silverman SB, Goldstein JN. Implementation of a Rapid, Protocol-based TIA Management Pathway. West J Emerg Med 2018; 19:216-223. [PMID: 29560046 PMCID: PMC5851491 DOI: 10.5811/westjem.2017.9.35341] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Our goal was to assess whether use of a standardized clinical protocol improves efficiency for patients who present to the emergency department (ED) with symptoms of transient ischemic attack (TIA). METHODS We performed a structured, retrospective, cohort study at a large, urban, tertiary care academic center. In July 2012 this hospital implemented a standardized protocol for patients with suspected TIA. The protocol selected high-risk patients for admission and low/intermediate-risk patients to an ED observation unit for workup. Recommended workup included brain imaging, vascular imaging, cardiac monitoring, and observation. Patients were included if clinical providers determined the need for workup for TIA. We included consecutive patients presenting during a six-month period prior to protocol implementation, and those presenting between 6-12 months after implementation. Outcomes included ED length of stay (LOS), hospital LOS, use of neuroimaging, and 90-day risk of stroke or TIA. RESULTS From 01/2012 to 06/2012, 130 patients were evaluated for TIA symptoms in the ED, and from 01/2013 to 06/2013, 150 patients. The final diagnosis was TIA or stroke in 45% before vs. 41% after (p=0.18). Following the intervention, the inpatient admission rate decreased from 62% to 24% (p<0.001), median ED LOS decreased by 1.2 hours (5.7 to 4.9 hours, p=0.027), and median total hospital LOS from 29.4 hours to 23.1 hours (p=0.019). The proportion of patients receiving head computed tomography (CT) went from 68% to 58% (p=0.087); brain magnetic resonance (MR) imaging from 83% to 88%, (p=0.44) neck CT angiography from 32% to 22% (p=0.039); and neck MR angiography from 61% to 72% (p=0.046). Ninety-day stroke or recurrent TIA among those with final diagnosis of TIA was 3% for both periods. CONCLUSION Implementation of a TIA protocol significantly reduced ED LOS and total hospital LOS.
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Affiliation(s)
- Susann J. Jarhult
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
- Uppsala University, Department of Medical Sciences, Uppsala, Sweden
| | - Melissa L. Howell
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | | | - Yuchiao Chang
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
| | - Benjamin A. White
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Mary Amatangelo
- Brigham and Women’s Hospital, Department of Neurology, Boston, Massachusetts
| | - David F. Brown
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Aneesh B. Singhal
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Lee H. Schwamm
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Scott B. Silverman
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Joshua N. Goldstein
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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10
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Chang BP, Wira C, Miller J, Akhter M, Barth BE, Willey J, Nentwich L, Madsen T. Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department. Acad Emerg Med 2018; 25:54-64. [PMID: 28646558 PMCID: PMC6415947 DOI: 10.1111/acem.13243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting. METHODS A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors. RESULTS Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals. CONCLUSION Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.
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Affiliation(s)
- Bernard P. Chang
- Department of Emergency Medicine, Columbia University Medical Center
| | - Charles Wira
- Department of Emergency Medicine, Yale-New Haven Medical Center
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Medical Center
| | - Murtaza Akhter
- Department of Emergency Medicine, University of Arizona College of Medicine–Phoenix, Maricopa Integrated Health System, Phoenix, AZ
| | - Bradley E. Barth
- Department of Emergency Medicine, University of Kansas Medical Center
| | - Joshua Willey
- Department of Neurology, Stroke Service, Columbia University Medical Center
| | | | - Tracy Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
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Adjemian R, Moradi Zirkohi A, Coombs R, Mickan S, Vaillancourt C. Are emergency department clinical pathway interventions adequately described, and are they delivered as intended? A systematic review. INTERNATIONAL JOURNAL OF CARE COORDINATION 2017. [DOI: 10.1177/2053434517732507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction The accurate reproduction of clinical interventions and the evaluation of provider adherence in research publications improve the evaluation and implementation of research findings into clinical practice. We sought to examine the proportion of clinical pathway publications in an emergency department setting that adequately reported the following: (1) the exact reproduction of the clinical pathway that was implemented in the study, (2) the adherence to and correct execution of the clinical pathway intervention, and (3) the presence of a pre-implementation education phase. Methods We performed a descriptive systematic review of the literature from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. Validated clinical pathway criteria were used to identify relevant publications. Two reviewers independently collected data using a piloted data abstraction tool. Risk of bias was assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Tool and the Newcastle-Ottawa Scale. Results We identified 5947 publications, 44 of which met our inclusion criteria. The formal clinical pathway was fully reproduced in 27 (61%) publications, partially reproduced in 9 (21%), and not reproduced in 8 (18%). Only 14 (32%) studies reported whether at least one decision step was executed correctly. The presence of a pre-implementation education phase was reported in 33 (75%) studies. Conclusion The underreporting of intervention elements may present a barrier to both the evaluation and accurate replication of clinical pathway interventions. These finding may be useful for the elaboration of complex intervention reporting guidelines, improved reporting in future clinical pathway publications, and improved knowledge translation and exchange of clinical pathway interventions.
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Affiliation(s)
- Raffi Adjemian
- Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, Oxford, UK
- Department of Family Medicine, McGill University, Quebec, Canada
| | | | - Robin Coombs
- Department of Family Medicine, McGill University, Quebec, Canada
| | - Sharon Mickan
- Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Gold Coast Health, Griffith University, Gold Coast, Australia
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Adjemian R, Zirkohi AM, Coombs R, Mickan S, Vaillancourt C. Validation of descriptive clinical pathway criteria in the systematic identification of publications in emergency medicine. INTERNATIONAL JOURNAL OF CARE COORDINATION 2017. [DOI: 10.1177/2053434517707971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Heterogeneity in both the definition and terminology of clinical pathways presents a challenge to the systematic identification of primary studies for review purposes. Recently developed clinical pathway identification criteria may facilitate both the identification and assessment of clinical pathway studies. The goal of this publication is the validation of these five criteria in a descriptive systematic review of actively implemented clinical pathway studies in the emergency department setting. The main outcome measure is the inter-rater agreement of investigators using the clinical pathway criteria. Methods We performed a systematic literature search from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. We identified relevant publications using the above-mentioned clinical pathway criteria. Two reviewers independently collected data using a piloted data abstraction tool. Results We identified 5947 publications, with 472 potentially relevant full text publications retrieved. Of these, 357 did not meet preliminary study inclusion criteria, leaving 115 publications where the clinical pathway criteria were applied. Ultimately, 44 publications were included. The inter-rater agreement of the criteria was very good (κ = 0.81, 95% Confidence Interval = 0.70–0.92). The vast majority of studies were excluded because the intervention did not meet the criterion of being multidisciplinary in nature. Conclusion These criteria are a useful instrument to reliably identify clinical pathway publications for systematic review purposes in an emergency department setting. Future modification of these criteria may improve their usefulness. Particular attention should be placed on clarifying what is meant by multidisciplinary involvement within the context of clinical pathway interventions, with specific emphasis placed on delineating the level of involvement of each discipline and their decision-making responsibility.
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Affiliation(s)
| | | | | | - Sharon Mickan
- University of Oxford, UK
- Griffith University, Australia
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Long B, Koyfman A. Best Clinical Practice: Controversies in Transient Ischemic Attack Evaluation and Disposition in the Emergency Department. J Emerg Med 2017; 52:299-310. [DOI: 10.1016/j.jemermed.2016.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 02/07/2023]
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14
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Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department. Ann Emerg Med 2016; 68:354-370.e29. [DOI: 10.1016/j.annemergmed.2016.06.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Yakhkind A, McTaggart RA, Jayaraman MV, Siket MS, Silver B, Yaghi S. Minor Stroke and Transient Ischemic Attack: Research and Practice. Front Neurol 2016; 7:86. [PMID: 27375548 PMCID: PMC4901037 DOI: 10.3389/fneur.2016.00086] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/23/2016] [Indexed: 12/29/2022] Open
Abstract
A majority of patients with ischemic stroke present with mild deficits for which aggressive management is not often pursued. Comprehensive work-up and appropriate intervention for minor strokes and transient ischemic attacks (TIAs) point toward better patient outcomes, lower costs, and fewer cases of disability. Imaging is a key modality to guide treatment and predict stroke recurrence. Patients with large vessel occlusions have been found to suffer worse outcomes and could benefit from intervention. Whether intravenous thrombolytic therapy decreases disability in minor stroke patients and whether acute endovascular intervention improves functional outcomes in patients with minor stroke and known large vessel occlusion remain controversial. Studies are ongoing to determine ideal antiplatelet therapy for stroke and TIA, while ongoing statin therapy, surgical management for patients with carotid stenosis, and anticoagulation for patients with atrial fibrillation have all been proven to decrease the rate of stroke recurrence and improve outcomes. This review summarizes the current evidence and discusses the standard of care for patients with minor stroke and TIA.
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Affiliation(s)
- Aleksandra Yakhkind
- Department of Neurology, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Ryan A McTaggart
- Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Mahesh V Jayaraman
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Matthew S Siket
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Brian Silver
- Department of Neurology, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University , Providence, RI , USA
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Cafardi SG, Pines JM, Deb P, Powers CA, Shrank WH. Increased observation services in Medicare beneficiaries with chest pain. Am J Emerg Med 2015; 34:16-9. [PMID: 26490388 DOI: 10.1016/j.ajem.2015.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION We examined trends in the use of observation services and the relationship between index service type (observation services, emergency department [ED] visits, inpatient stays) and both clinical outcomes and Medicare payments. METHODS We created a yearly cohort panel of Medicare beneficiaries with chest pain. We evaluate the relationships between index service type and 30-day clinical outcomes using a multinomial logit model and between index service type and Medicare payments using generalized linear models. RESULTS In 2009, 24% of patients with chest pain received observation services; this rose to 29% in 2011. Conversely, 20% were treated as hospital inpatients in 2009; this fell to 16% in 2011. In the adjusted analysis, the risk of 30-day return to the hospital was 7% less (95% confidence interval, 5%-8%) for those receiving observation services as compared with inpatients. Average Medicare payments ranged from $3032 for beneficiaries initially treated in the ED to $3885 for those initially treated in observation to $6545 for those initially treated as inpatients. DISCUSSION Patients treated in observation are less likely than those treated in the ED or as inpatients to have an adverse event within 30 days. Adjusted Medicare payments, including the index stay and the subsequent 30 days, were substantially less for those treated in observation as compared with those treated as inpatients, but more than for those treated and released from the ED. Higher rates of observation service use do not appear to be negatively affecting patient outcomes and may lower costs relative to inpatient treatment.
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Affiliation(s)
- Susannah G Cafardi
- Research and Rapid-Cycle Evaluation Group, Centers for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, MD.
| | - Jesse M Pines
- Department of Emergency Medicine, The George Washington University, Washington, DC; Department of Health Policy, The George Washington University, Washington, DC
| | - Partha Deb
- Department of Economics, Hunter College, New York, NY; Centers for Medicare & Medicaid Services, Center for Medicare & Medicaid Innovation, Baltimore, MD
| | - Christopher A Powers
- Office of Information Products and Data Analytics, Center for Medicare & Medicaid Services, Baltimore, MD
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Prabhakar AM, Misono AS, Harvey HB, Yun BJ, Saini S, Oklu R. Imaging utilization from the ED: no difference between observation and admitted patients. Am J Emerg Med 2015; 33:1076-9. [PMID: 25957145 DOI: 10.1016/j.ajem.2015.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/11/2015] [Accepted: 04/15/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES This study aims to determine the use of diagnostic imaging in emergency department (ED) observation units, particularly relative to inpatients admitted from the ED. STUDY DESIGN Retrospective, descriptive analysis. METHODS Our database of ED patients was retrospectively reviewed to identify patients managed in the observation unit or admitted to inpatient services. In February 2014, we randomly selected 105 ED observation patients and 108 patients admitted to inpatient services from the ED. Electronic medical records were reviewed to assess diagnosis as well as type and quantity of imaging tests obtained. RESULTS Eighty (76%) ED observation patients underwent imaging tests (radiographs, 39%; computed tomography, 25%; magnetic resonance imaging (MRI), 24%; ultrasound, 8%; other, 4%); 85 inpatients (79%) underwent imaging tests while in the ED (radiographs, 52%; computed tomography, 30%; MRI, 8%; ultrasound, 9%; other, 1%). There was no significant difference in overall imaging use between ED observation patients and inpatients, but ED observation patients were more likely to undergo MRI (P=.0243). The most common presenting diagnoses to the ED observation unit were neurologic complaints (25%), abdominal pain (17%), and cardiac symptoms (16%). CONCLUSION There is no difference in the overall use of imaging in patients transferred to the ED observation unit vs those directly admitted from the ED. However, because ED observation unit patients tend to be accountable for a higher proportion of their health care bill, the impact of imaging in these patients is likely substantive.
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Affiliation(s)
- Anand M Prabhakar
- Division of Cardiovascular Imaging and Emergency Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Alexander S Misono
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - H Benjamin Harvey
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sanjay Saini
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Rahmi Oklu
- Division of Vascular Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Gulli G, Peron E, Ricci G, Formaglio E, Micheletti N, Tomelleri G, Moretto G. Yield of ultra-rapid carotid ultrasound and stroke specialist assessment in patients with TIA and minor stroke: an Italian TIA service audit. Neurol Sci 2014; 35:1969-75. [DOI: 10.1007/s10072-014-1875-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/27/2014] [Indexed: 10/24/2022]
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Vora N, Tung CE, Mlynash M, Garcia M, Kemp S, Kleinman J, Zaharchuk G, Albers G, Olivot JM. TIA Triage in Emergency Department Using Acute MRI (TIA-TEAM): A Feasibility and Safety Study. Int J Stroke 2014; 10:343-7. [DOI: 10.1111/ijs.12390] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 09/08/2014] [Indexed: 11/30/2022]
Abstract
Background Positive diffusion weighted imaging (DWI) on MRI is associated with increased recurrent stroke risk in TIA patients. Acute MRI aids in TIA risk stratification and diagnosis. Aim To evaluate the feasibility and safety of TIA triage directly from the emergency department (ED) with acute MRI and neurological consultation. Methods Consecutive ED TIA patients assessed by a neurologist underwent acute MRI/MRA of head/neck per protocol and were hospitalized if positive DWI, symptomatic vessel stenosis, or per clinical judgment. Stroke neurologist adjudicated the final TIA diagnosis as definite, possible, or not a cerebrovascular event. Stroke recurrence rates were calculated at 7, 90, 365 days and compared with predicted stroke rates derived from historical DWI and ABCD2 score data. Results One hundred twenty-nine enrolled patients had a mean age of 69 years (±17) and median ABCD2 score of 3 (interquartile range [IQR] 3–4). During triage, 112 (87%) patients underwent acute MRI after a median of 16 h (IQR 10–23) from symptom onset. No patients experienced a recurrent event before imaging. Twenty-four (21%) had positive DWI and 8 (7%) had symptomatic vessel stenosis. Of the total cohort, 83 (64%) were discharged and 46 (36%) were hospitalized. By one-year follow-up, one patient in each group had experienced a stroke. Of 92 patients with MRI and index cerebrovascular event, recurrent stroke rates were 1·1% at 7 and 90 days. These were similar to predicted recurrence rates. Conclusion TIA triage in the ED using a protocol with neurological consultation and acute MRI is feasible and safe. The majority of patients were discharged without hospitalization and rates of recurrent stroke were not higher than predicted.
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Affiliation(s)
- Nirali Vora
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, USA
| | - Christie E. Tung
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, USA
| | - Madelleine Garcia
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, USA
| | - Stephanie Kemp
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, USA
| | - Jonathan Kleinman
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Greg Zaharchuk
- Department of Radiology, Stanford School of Medicine, Stanford, CA, USA
| | - Gregory Albers
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, USA
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Oostema JA, Delano M, Bhatt A, Brown MD. Incorporating diffusion-weighted magnetic resonance imaging into an observation unit transient ischemic attack pathway: a prospective study. Neurohospitalist 2014; 4:66-73. [PMID: 24707334 DOI: 10.1177/1941874413519804] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE National guidelines advocate for early, aggressive transient ischemic attack (TIA) evaluations and recommend diffusion-weighted magnetic resonance imaging (MRI) for brain imaging. The purpose of this study is to examine clinician compliance, the yield of MRI, and patient-centered clinical outcomes following implementation of an emergency department observation unit (EDOU) clinical pathway incorporating routine MRI into the acute evaluation of patients with TIA. METHODS This is a prospective observational study of patients with TIA admitted from the ED. Patients with low-risk TIA were transferred to an EDOU for diagnostic testing including MRI; high-risk patients were directed to hospital admission. Clinical variables, diagnostic tests, and treatment were recorded for all patients. The primary clinical outcome was the rate of stroke or recurrent TIA, determined through telephone follow-up and medical record review at 7 and 30 days. RESULTS A total of 116 patients with TIA were enrolled. In all, 92 (79.3%) patients were transferred to the EDOU, of whom 69 (59.5%) were discharged without hospitalization. Compliance with the EDOU pathway was 83 (91.2%) of 92. Magnetic resonance imaging demonstrated acute infarct in 16 (15.7%) of 102 patients. Stroke (n = 2) or TIA (n = 3) occurred in 5 patients with TIA (4.3%, 95% confidence interval: 1.6%-10.0%) within 30 days; no strokes occurred after discharge. CONCLUSIONS Implementation of a TIA clinical pathway incorporating MRI effectively encouraged guideline-compliant diagnostic testing; however, patient-important outcomes appear similar to diagnostic protocols without routine MRI. Further study is needed to assess the benefits and costs associated with routinely incorporating MRI into TIA evaluation.
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Affiliation(s)
- J Adam Oostema
- Department of Emergency Medicine, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Mark Delano
- Department of Radiology, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Archit Bhatt
- Providence Stroke Center, Providence Brain and Spine Institute, Portland, OR, USA
| | - Michael D Brown
- Department of Emergency Medicine, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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Measuring comorbidity in cardiovascular research: a systematic review. Nurs Res Pract 2013; 2013:563246. [PMID: 23956853 PMCID: PMC3730163 DOI: 10.1155/2013/563246] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 06/24/2013] [Indexed: 11/18/2022] Open
Abstract
Background. Everything known about the roles, relationships, and repercussions of comorbidity in cardiovascular disease is shaped by how comorbidity is currently measured. Objectives. To critically examine how comorbidity is measured in randomized controlled trials or clinical trials and prospective observational studies in acute myocardial infarction (AMI), heart failure (HF), or stroke. Design. Systematic review of studies of hospitalized adults from MEDLINE CINAHL, PsychINFO, and ISI Web of Science Social Science databases. At least two reviewers screened and extracted all data. Results. From 1432 reviewed abstracts, 26 studies were included (AMI n = 8, HF n = 11, stroke n = 7). Five studies used an instrument to measure comorbidity while the remaining used the presence or absence of an unsubstantiated list of individual diseases. Comorbidity data were obtained from 1-4 different sources with 35% of studies not reporting the source. A year-by-year analysis showed no changes in measurement. Conclusions. The measurement of comorbidity remains limited to a list of conditions without stated rationale or standards increasing the likelihood that the true impact is underestimated.
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Griffiths D, Sturm J, Heard R, Reyneke E, Whyte S, Clarke T, O'Brien W, Crimmins D. Can lower risk patients presenting with transient ischaemic attack be safely managed as outpatients? J Clin Neurosci 2013; 21:47-50. [PMID: 23683740 DOI: 10.1016/j.jocn.2013.02.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 02/05/2013] [Accepted: 02/10/2013] [Indexed: 12/01/2022]
Abstract
This study aimed to examine outcome in low risk transient ischaemic attack (TIA) patients presenting to emergency departments (ED) in a regional Australian setting discharged on antiplatelet therapy with expedited neurology review. All patients presenting to Gosford or Wyong Hospital ED with TIA, for whom faxed referrals to the neurology department were received between October 2008 and July 2010, were included in this prospective cohort study. Classification of low risk was based on an age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score <4 and the absence of high risk features, including known carotid disease, crescendo TIA, or atrial fibrillation. Patients with ABCD2 scores > or =4 or with high risk features were discussed with the neurologist on call (a decision regarding discharge or admission was then made at the neurologist's discretion). Patients were investigated with a brain CT scan and/or CT angiography, routine pathology, and an electrocardiogram. All discharged patients were commenced on antiplatelet therapy and asked to follow up with their local medical officer within 7 days. The patients were contacted by the neurology department to arrange follow-up. Our primary outcome was the number of subsequent strokes occurring within 90 days. Of 200 discharged patients for whom referrals were received, three patients had a stroke within 90 days. None of these would have been prevented through hospitalisation. In conclusion, medical assessment, expedited investigation with immediate commencement of secondary prevention and outpatient neurology review may be a reasonable alternative to admission for low risk patients presenting to the ED with TIA.
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Affiliation(s)
- D Griffiths
- Department of Neurology, Royal North Shore Hospital, Pacific Hwy, St Leonards, NSW 2065, Australia.
| | - J Sturm
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - R Heard
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - E Reyneke
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - S Whyte
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - T Clarke
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - W O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - D Crimmins
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
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Montassier E, Lim TX, Goffinet N, Guillon B, Segard J, Martinage A, Potel G, Le Conte P. Results of an outpatient transient ischemic attack evaluation: a 90-day follow-up study. J Emerg Med 2013; 44:970-5. [PMID: 23478183 DOI: 10.1016/j.jemermed.2012.09.145] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/10/2012] [Accepted: 09/05/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Transient ischemic attack (TIA) is common and precedes 15% of strokes. TIA should be managed as a time-sensitive illness to prevent a subsequent stroke. However, management of TIA is heterogeneous, with little consensus about its optimal assessment. OBJECTIVE The objective of this study was to determine the outcome of patients with TIA evaluated in the Emergency Department (ED) and managed as outpatients within a 90-day period after discharge. METHODS All patients with symptoms of TIA admitted to the ED were eligible for inclusion. Patients were evaluated by an Emergency Physician who followed a decision algorithm used in the selection of patients for discharge. The main outcome variable was the occurrence of stroke during the 90 days after discharge from the ED. RESULTS During a 1-year period, a total of 118 patients were evaluated for TIA in the ED, representing 1.4% of ED medical admissions: 56 (47.5%) were hospitalized and 62 (52.5%) were discharged and enrolled in the outpatient TIA management. Two (3.2%) of the discharged patients could not be contacted for follow-up. Among the patients managed as outpatients, one (1.7%) presented with an ischemic stroke and 3 (5%) experienced a subsequent TIA within a period of 90 days after discharge from the ED. The rate of stroke predicted from the ABCD2 score was 9.7% at 90 days. CONCLUSION The results of our study suggest that outpatient management of TIA, as described in our institution's guidelines, may be a safe and effective strategy, but further confirmatory studies should be performed.
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Abstract
An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.
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Affiliation(s)
- Mark G. Moseley
- Associate Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Miles P. Hawley
- Assistant Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Jeffrey M. Caterino
- Associate Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
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Ross MA, Aurora T, Graff L, Suri P, O'Malley R, Ojo A, Bohan S, Clark C. State of the art: emergency department observation units. Crit Pathw Cardiol 2012; 11:128-38. [PMID: 22825533 DOI: 10.1097/hpc.0b013e31825def28] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. These benefits have been proven for health systems as a whole and for several acute conditions including chest pain, asthma, syncope, transient ischemic attack, atrial fibrillation, heart failure, abdominal pain, and more. Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.
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Affiliation(s)
- Michael A Ross
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Sanders LM, Srikanth VK, Jolley DJ, Sundararajan V, Psihogios H, Wong K, Ramsay D, Phan TG. Monash Transient Ischemic Attack Triaging Treatment. Stroke 2012; 43:2936-41. [DOI: 10.1161/strokeaha.112.664060] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lauren M. Sanders
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Velandai K. Srikanth
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Damien J. Jolley
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Vijaya Sundararajan
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Helen Psihogios
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Kitty Wong
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - David Ramsay
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Thanh G. Phan
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
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Impact of an Emergency Department Observation Unit Transient Ischemic Attack Protocol on Length of Stay and Cost. J Stroke Cerebrovasc Dis 2012; 21:673-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2011.02.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 02/25/2011] [Accepted: 02/27/2011] [Indexed: 11/17/2022] Open
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Panagos PD. Transient ischemic attack (TIA): the initial diagnostic and therapeutic dilemma. Am J Emerg Med 2012; 30:794-9. [DOI: 10.1016/j.ajem.2011.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 03/01/2011] [Indexed: 02/01/2023] Open
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Caterino JM, Hoover EM, Moseley MG. Effect of advanced age and vital signs on admission from an ED observation unit. Am J Emerg Med 2012; 31:1-7. [PMID: 22386358 DOI: 10.1016/j.ajem.2012.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 01/05/2012] [Accepted: 01/05/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVES The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. METHODS We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol. RESULTS Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14,000/mm(3) or greater (OR, 11.35; 95% CI, 3.42-37.72). CONCLUSIONS Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion.
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Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA.
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Torres Macho J, Peña Lillo G, Pérez Martínez D, González Mansilla A, Gámez Díez S, Mateo Alvarez S, García de Casasola G. Outcomes of Atherothrombotic Transient Ischemic Attack and Minor Stroke in an Emergency Department: Results of an Outpatient Management Program. Ann Emerg Med 2011; 57:510-6. [DOI: 10.1016/j.annemergmed.2010.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 06/24/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
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Stead LG, Suravaram S, Bellolio MF, Enduri S, Rabinstein A, Gilmore RM, Bhagra A, Manivannan V, Decker WW. An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack. Ann Emerg Med 2011; 57:46-51. [PMID: 20855130 PMCID: PMC3030982 DOI: 10.1016/j.annemergmed.2010.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 05/17/2010] [Accepted: 07/01/2010] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack. METHODS This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days. RESULTS The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days. CONCLUSION The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.
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Affiliation(s)
- Latha G Stead
- Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Wasserman J, Perry J, Dowlatshahi D, Stotts G, Stiell I, Sutherland J, Symington C, Sharma M. Stratified, Urgent Care for Transient Ischemic Attack Results in Low Stroke Rates. Stroke 2010; 41:2601-5. [DOI: 10.1161/strokeaha.110.586842] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jason Wasserman
- From the Divisions of Neurology (J.W., D.D., G.S., M.S.) and Emergency Medicine (J.P., I.S., J.S., C.S.), Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.W., J.P., D.D., G.S., I.S., J.S., C.S., M.S.), University of Ottawa, Ottawa, Ontario, Canada
| | - Jeff Perry
- From the Divisions of Neurology (J.W., D.D., G.S., M.S.) and Emergency Medicine (J.P., I.S., J.S., C.S.), Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.W., J.P., D.D., G.S., I.S., J.S., C.S., M.S.), University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- From the Divisions of Neurology (J.W., D.D., G.S., M.S.) and Emergency Medicine (J.P., I.S., J.S., C.S.), Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.W., J.P., D.D., G.S., I.S., J.S., C.S., M.S.), University of Ottawa, Ottawa, Ontario, Canada
| | - Grant Stotts
- From the Divisions of Neurology (J.W., D.D., G.S., M.S.) and Emergency Medicine (J.P., I.S., J.S., C.S.), Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.W., J.P., D.D., G.S., I.S., J.S., C.S., M.S.), University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- From the Divisions of Neurology (J.W., D.D., G.S., M.S.) and Emergency Medicine (J.P., I.S., J.S., C.S.), Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.W., J.P., D.D., G.S., I.S., J.S., C.S., M.S.), University of Ottawa, Ottawa, Ontario, Canada
| | - Jane Sutherland
- From the Divisions of Neurology (J.W., D.D., G.S., M.S.) and Emergency Medicine (J.P., I.S., J.S., C.S.), Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.W., J.P., D.D., G.S., I.S., J.S., C.S., M.S.), University of Ottawa, Ottawa, Ontario, Canada
| | - Cheryl Symington
- From the Divisions of Neurology (J.W., D.D., G.S., M.S.) and Emergency Medicine (J.P., I.S., J.S., C.S.), Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.W., J.P., D.D., G.S., I.S., J.S., C.S., M.S.), University of Ottawa, Ottawa, Ontario, Canada
| | - Mukul Sharma
- From the Divisions of Neurology (J.W., D.D., G.S., M.S.) and Emergency Medicine (J.P., I.S., J.S., C.S.), Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.W., J.P., D.D., G.S., I.S., J.S., C.S., M.S.), University of Ottawa, Ottawa, Ontario, Canada
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Urgent neurology consultation from the ED for transient ischemic attack. Am J Emerg Med 2010; 29:601-8. [PMID: 20825839 DOI: 10.1016/j.ajem.2009.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 12/17/2009] [Accepted: 12/29/2009] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the association between urgent neurology consultation and outcomes for patients with transient ischemic attack (TIA). METHODS In a secondary analysis of data from 1707 emergency department patients with transient ischemic attack from March 1997 to May 1998, we compared presentation, management, and outcomes by neurology consultation status using generalized estimating equations to adjust for ABCD(2) score and clustering by facility and survival analysis for outcomes. RESULTS Consultation was obtained f28% of patients. Median ABCD(2) scores were comparable, but consultation was associated with hospital admission (odds ratio, 1.35 [1.02-1.78], P = .04) and use of antithrombotics (odds ratio, 1.88 [1.20-2.93], P = .005). The cumulative stroke risk was significantly lower within 1 week (5.3% versus 7.5%, P = .02) but not at 90 days (9.9% versus 11.0%, P = .21). CONCLUSIONS Consultation was not targeted to high-risk patients but was associated with some quality of care measures and improved early outcomes; however, improvement in 90-day outcomes was not established.
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Fothergill A, Christianson TJH, Brown RD, Rabinstein AA. Validation and refinement of the ABCD2 score: a population-based analysis. Stroke 2009; 40:2669-73. [PMID: 19520983 DOI: 10.1161/strokeaha.109.553446] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Transient ischemic attacks are a frequent diagnosis in the emergency department setting, yet expert opinion as to the proper follow-up and need for hospitalization differs widely. Recently, an effort has been made to risk-stratify patients presenting with transient ischemic attacks through scoring systems such as the ABCD and ABCD2 scales. The aim of our study was to independently validate these scores using a population-based cohort. METHODS Using the data from the Rochester Stroke and Transient Ischemic Attack Registry and resources of the Rochester Epidemiology Project, medical records of all residents of Rochester, Minn, with a diagnosis of incident transient ischemic attack from 1985 through 1994 were examined (N=284). Patients were scored on the ABCD and ABCD2 scales and new scores were created by adding hyperglycemia and a history of hypertension. The end points of stroke and death were collected previously and were verified through the Rochester Epidemiology Project data. RESULTS Although our study did find that scores >4 had a statistically significant predictive value for future stroke, a substantial proportion of strokes within 7 days (9 of 36 cases [25%]) occurred in patients with low or intermediate risk scores (< or =4) on the ABCD2 scale. Including history of hypertension and hyperglycemia on presentation increased the sensitivity of the score to identify patients who had a stroke within 7 days. CONCLUSIONS Reliance on the ABCD and ABCD2 scores misses some patients who will have a stroke within 7 days of a transient ischemic attack. Adding hyperglycemia and a history of hypertension to the predictive model could be useful, but the value of these additions need to be evaluated further.
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Affiliation(s)
- Amy Fothergill
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Lanzino G, Rabinstein AA, Brown RD. Treatment of carotid artery stenosis: medical therapy, surgery, or stenting? Mayo Clin Proc 2009; 84:362-87; quiz 367-8. [PMID: 19339655 PMCID: PMC2665982 DOI: 10.1016/s0025-6196(11)60546-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
With the aging of the general population and the availability of noninvasive imaging studies, carotid artery stenosis is a disease commonly seen in general medical practice. Differentiation between symptomatic and asymptomatic disease is critical to the treatment course because the natural history differs markedly between them. Antiplatelet therapy and aggressive treatment of vascular risk factors are the mainstays of medical therapy. Class I evidence shows that carotid endarterectomy (CEA) is effective in preventing ipsilateral ischemic events in patients with symptomatic moderate- and high-grade stenosis. The procedure is also effective in selected patients with asymptomatic stenosis, but the benefit is marginal. In the past decade, carotid angioplasty and stenting has been proposed as a valid alternative to CEA. Currently, it is unclear whether carotid angioplasty and stenting is as safe as CEA in patients with carotid artery stenosis who need invasive treatment. Large clinical trials are under way to answer this question.
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Affiliation(s)
- Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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