1
|
Bako AT, Potter T, Pan AP, Tannous J, Britz G, Ziai WC, Awad I, Hanley D, Vahidy FS. Minimally Invasive Surgery With Thrombolysis for Intracerebral Hemorrhage Evacuation: Bayesian Reanalysis of a Randomized Controlled Trial. Neurology 2023; 101:e1614-e1622. [PMID: 37684058 PMCID: PMC10585679 DOI: 10.1212/wnl.0000000000207735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 06/20/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Bayesian analysis of randomized controlled trials (RCTs) can extend the value of trial data beyond interpretations based on conventional p value-based binary cutoffs. We conducted an exploratory post hoc Bayesian reanalysis of the minimally invasive surgery with thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE-3) trial and derived probabilities of potential intervention effect on functional and survival outcomes. METHODS MISTIE-3 was a multicenter phase 3 RCT designed to evaluate the efficacy and safety of the MISTIE intervention. Five hundred and six adults (18 years or older) with spontaneous, nontraumatic, supratentorial ICH of ≥30 mL were randomized to receive either the MISTIE intervention (n = 255) or standard medical care (n = 251). We provide Bayesian-derived estimates of the effect of the MISTIE intervention on achieving a good 365-day modified Rankin Scale score (mRS score 0-3) as relative risk (RR) and absolute risk difference (ARD), and the probabilities that these treatment effects are greater than prespecified thresholds. We used 2 sets of prior distributions: (1) reference priors, including minimally informative, enthusiastic, and skeptical priors, and (2) data-derived prior distribution, using a hierarchical random effects model. We additionally evaluated the potential effects of the MISTIE intervention on 180-day and 30-day mRS and 365-, 180-, and 30-day mortality using data-derived priors. RESULTS The Bayesian-derived probability that MISTIE intervention has any beneficial effect (RR >1) on achieving a good 365-day mRS score was 70% using minimally informative prior, 87% with enthusiastic prior, 68% with skeptical prior, and 73% with data-derived prior. However, these probabilities were ≤55% for RR >1.10 and 0% for RR >1.52 across a range of priors. The probabilities of achieving RR >1 for 180- and 30-day mRS scores are 65% and 80%, respectively. Furthermore, the probabilities of achieving RR <1 for 365-, 180-, and 30-day mortality are 93%, 98%, and 99%, respectively. DISCUSSION Our exploratory analyses indicate that across a range of priors, the Bayesian-derived probability of MISTIE intervention having any beneficial effect on 365-day mRS for patients with ICH is between 68% and 87%. These analyses do not change the frequentist-based interpretation of the trial. However, unlike the frequentist p values, which indirectly evaluate treatment effects and only provide an arbitrary binary cutoff (such as 0.05), the Bayesian framework directly estimates the probabilities of potential treatment effects. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov/ct2/show/NCT01827046. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that minimally invasive surgery (MIS) + recombinant tissue plasminogen activator (rt-PA) does not significantly improve functional outcome in patients with ICH. However, this study lacks the precision to exclude a potential benefit of MIS + rt-PA.
Collapse
Affiliation(s)
- Abdulaziz T Bako
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Thomas Potter
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Alan P Pan
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Jonika Tannous
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Gavin Britz
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Wendy C Ziai
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Issam Awad
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Daniel Hanley
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Farhaan S Vahidy
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL.
| |
Collapse
|
2
|
Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke 2023; 18:499-531. [PMID: 36725717 DOI: 10.1177/17474930231156753] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. AIMS To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). SUMMARY OF REVIEW Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. CONCLUSION The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
Collapse
Affiliation(s)
- Gillian E Mead
- Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.,Heart & Brain Lab, Western University, London, ON, Canada.,Robarts Research Institute, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laetitia Yperzeele
- Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.,Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - P N Sylaja
- Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kelvin Hill
- Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA
| | | |
Collapse
|
3
|
Zhang X, Liu J, Han H, Zhang P, Chen X, Yuan H, Chen M, Zhu Q, Liebeskind DS, Miao Z. Effectiveness and safety of the Trevo® Retriever for mechanical thrombectomy in Chinese patients with acute ischemic stroke: Trevo Retriever China Registry. Interv Neuroradiol 2023:15910199231151275. [PMID: 36703568 DOI: 10.1177/15910199231151275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND To quantify the effectiveness and safety of the Trevo® Retriever for endovascular treatment of acute ischemic stroke (AIS) patients in China. METHODS Trevo Retriever Registry (China) was a prospective, multicenter, non-comparative, open-label study of patients with AIS treated with the Trevo Retriever. The primary outcome was the proportion of patients achieving an expanded Thrombolysis in Cerebral Infarction (eTICI) score ≥2b at the end of endovascular treatment. Secondary outcomes included first-pass eTICI score ≥2b and 90-day modified Rankin Scale (mRS) score ≤2. RESULTS The Trevo Retriever Registry (China) enrolled and followed 201 patients (62.1 ± 12.5 years-old; 70.6% male) at 11 centers. The pre-procedure NIHSS score and ASPECTS were 16 (interquartile range (IQR), 13-21) and 7 (IQR, 6-9), respectively, and 188 (93.5%) patients had an mRS score of 0 prior to the stroke. The main stroke etiology was large artery atherosclerosis, accounting for 71.6% (144/201) of patients. Post-procedure eTICI ≥2b was 98.4% (187/190). First-pass eTICI ≥2b was 74.7% (136/182). The 90-day good outcome (mRS ≤2) rate was 73.6% (148/201). The 90-day all-cause mortality was 5.5% (11/201). Neurological deterioration at 24 h post-procedure was observed in 7.7% (15/195) patients. Embolism in a new territory was seen in one patient (0.5%). Two (1.0%) procedure-related adverse events (AEs) occurred, which were intra-procedure cerebral artery embolism. No Trevo related AEs occurred. CONCLUSIONS This real-world study of the Trevo Retriever in China demonstrated a high rate of revascularization and first-pass success that resulted in an overall high good function outcome rate and low mortality.
Collapse
Affiliation(s)
- Xuelei Zhang
- Department of Neurointerventional, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Jinchao Liu
- 117938Puyang Oilfield General Hospital, Puyang, China
| | - Hongxing Han
- Department of Neurology, 529858Linyi People's Hospital, Linyi, China
| | - Pinyuan Zhang
- Department of Neurosurgery (Cerebrovascular Disease), The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xianglin Chen
- Department of Cerebrovascular Disease, 534795Qingyuan People's Hospital, Qingyuan, China
| | - Haicheng Yuan
- Department of Neurology, Qingdao Central Hospital, Qingdao, China
| | - Maohua Chen
- Department of Neurosurgery, Wenzhou Central Hospital, Wenzhou, China
| | - Qiyi Zhu
- Department of Neurology, 529858Linyi People's Hospital, Linyi, China
| | - David S Liebeskind
- Department of Neurology and UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - Zhongrong Miao
- Department of Neurointerventional, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| |
Collapse
|
4
|
Ge B, Wei N, Mo Y, Qin G, Li H, Xu G. Hidden Telltale Signs in Hyperacute Ischemic Stroke Caused by Aortic Dissection: A Case Report and Post Hoc Analysis. Neurologist 2022; 27:350-353. [PMID: 34980835 PMCID: PMC9631774 DOI: 10.1097/nrl.0000000000000412] [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] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Rapid identification of hidden telltale signs in hyperacute ischemic stroke caused by aortic dissection (AD) is challenging, mainly owing to the narrow time window for bridging therapy. CASE REPORT A 63-year-old man was referred for sudden right-side weakness accompanied by a decreased level of consciousness for almost 1 hour and 37 minutes. He had a history of hypertension. His skin was clammy, and on physical examination, there was involuntary chest thumping in the left upper limb. Hyperacute cerebral infarction was considered after no bleeding was observed on emergency head computed tomography, and intravenous thrombolysis with alteplase was administered immediately after. The patient was then taken to the catheter room, ready for endovascular thrombectomy. Stanford type A AD was found by cerebral angiography before endovascular thrombectomy. The infusion of alteplase was stopped immediately during cerebral angiography, but the patient's blood pressure, heart rate, and blood oxygen were still declining progressively, and the degree of consciousness disturbance deepened. The patient died after the combined but failed rescue attempts of multiple departments. CONCLUSION Hyperacute ischemic stroke caused by AD often hides some telltale signs. Clinicians should master basic clinical skills to exclude AD by looking for these telltale signs hidden in hyperacute ischemic stroke to avoid the fatal consequences of intravenous thrombolysis and/or cerebral angiography within the narrow window of time.
Collapse
|
5
|
Fatovich DM, Milne WK. Thrombolysis with alteplase 3-4.5 hours after acute ischaemic stroke: trial reanalysis adjusted for baseline imbalances. BMJ Evid Based Med 2021; 26:e2. [PMID: 32788162 DOI: 10.1136/bmjebm-2020-111517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Daniel Michael Fatovich
- Emergency Medicine, Faculty of Health and Medical Sciences, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Wm Ken Milne
- Department of Medicine, Western University, London, Ontario, Canada
| |
Collapse
|
6
|
Gray M, Ernst J, Ashworth S, Patel R, Couperus K. Stroke or No Stroke: A Case Report of Bilingual Aphasia. Clin Pract Cases Emerg Med 2021; 5:325-327. [PMID: 34437039 PMCID: PMC8373183 DOI: 10.5811/cpcem.2021.4.51206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/06/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Bilingual aphasia is an atypical stroke presentation in the multilingual patient where an isolated aphasia occurs in one language while the other remains unaffected. Case Report A multilingual male presented to the emergency department with expressive aphasia to English but who was still able to speak fluently in French. Receptive English was preserved. While his National Institute of Health Stroke Scale score was technically zero, his pure aphasia component qualified him as an exception. He regained some repetitive English, so fibrinolyitic therapy was not initiated. Conclusion Bilingual aphasia is an indication for fibrinolysis given the impact that a pure aphasic stroke has on quality of life.
Collapse
Affiliation(s)
- Matthew Gray
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| | - Jacob Ernst
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| | - Simeon Ashworth
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| | - Ronak Patel
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| | - Kyle Couperus
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| |
Collapse
|
7
|
Klingman JG, Alexander JG, Vinson DR, Klingman LE, Nguyen‐Huynh MN. Potential accuracy of prehospital NIHSS-based triage for selection of candidates for acute endovascular stroke therapy. J Am Coll Emerg Physicians Open 2021; 2:e12441. [PMID: 33969354 PMCID: PMC8087906 DOI: 10.1002/emp2.12441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)-capable center is controversial. We sought to estimate the accuracy of field-based identification of potential EST candidates in a hypothetical best-of-all-worlds situation. METHODS In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility. RESULTS Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral. CONCLUSIONS Even if field-based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST-capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door-to-needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST-capable centers.
Collapse
Affiliation(s)
- Jeffrey G. Klingman
- Department of NeurologyKaiser Permanente, Northern CaliforniaWalnut CreekCaliforniaUSA
| | - Janet G. Alexander
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
| | - David R. Vinson
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
- Department of Emergency MedicineKaiser Permanente, Northern CaliforniaRosevilleCaliforniaUSA
| | | | - Mai N. Nguyen‐Huynh
- Department of NeurologyKaiser Permanente, Northern CaliforniaWalnut CreekCaliforniaUSA
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
| |
Collapse
|
8
|
Siket MS, Cadena R. Novel Treatments for Transient Ischemic Attack and Acute Ischemic Stroke. Emerg Med Clin North Am 2020; 39:227-242. [PMID: 33218660 DOI: 10.1016/j.emc.2020.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The treatment of acute ischemic stroke is one of the most rapidly evolving areas in medicine. Like all ischemic vascular emergencies, the priority is reperfusion before irreversible infarction. The central nervous system is sensitive to brief periods of hypoperfusion, making stroke a golden hour diagnosis. Although the phrase "time is brain" is relevant today, emerging treatment strategies use more specific markers for consideration of reperfusion than time alone. Innovations in early stroke detection and individualized patient selection for reperfusion therapies have equipped the emergency medicine clinician with more opportunities to help stroke patients and minimize the impact of this disease.
Collapse
Affiliation(s)
- Matthew S Siket
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine at the University of Vermont, 111 Colchester Avenue, EC2-216, Burlington, VT 05401, USA; Department of Neurological Sciences, Larner College of Medicine at the University of Vermont, 111 Colchester Avenue, EC2-216, Burlington, VT 05401, USA.
| | - Rhonda Cadena
- Division of Neurocritical Care, Department of Neurology, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA; Department of Neurosurgery, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA; Department of Emergency Medicine, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA
| |
Collapse
|
9
|
Garg R. Alteplase for Minor Stroke: The AAEM Clinical Practice Advisory is More Accurate Than Other National Guidelines. J Emerg Med 2020; 59:717-718. [PMID: 33248504 DOI: 10.1016/j.jemermed.2020.03.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/20/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Ravi Garg
- Department of Neurology, Division of Neurocritical Care, Stritch School of Medicine at Loyola University, Loyola University Medical Center, MacNeal Hospital, Maywood, Illinois
| |
Collapse
|
10
|
Alper BS, Foster G, Thabane L, Rae-Grant A, Malone-Moses M, Manheimer E. Thrombolysis with alteplase 3-4.5 hours after acute ischaemic stroke: trial reanalysis adjusted for baseline imbalances. BMJ Evid Based Med 2020; 25:168-171. [PMID: 32430395 PMCID: PMC7548536 DOI: 10.1136/bmjebm-2020-111386] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Alteplase is commonly recommended for acute ischaemic stroke within 4.5 hours after stroke onset. The Third European Cooperative Acute Stroke Study (ECASS III) is the only trial reporting statistically significant efficacy for clinical outcomes for alteplase use 3-4.5 hours after stroke onset. However, baseline imbalances in history of prior stroke and stroke severity score may confound this apparent finding of efficacy. We reanalysed the ECASS III trial data adjusting for baseline imbalances to determine the robustness or sensitivity of the efficacy estimates. DESIGN Reanalysis of randomised placebo-controlled trial. We obtained access to the ECASS III trial data and replicated the previously reported analyses to confirm our understanding of the data. We adjusted for baseline imbalances using multivariable analyses and stratified analyses and performed sensitivity analysis for missing data. SETTING Emergency care. PARTICIPANTS 821 adults with acute ischaemic stroke who could be treated 3-4.5 hours after symptom onset. INTERVENTIONS Intravenous alteplase (0.9 mg/kg of body weight) or placebo. MAIN OUTCOME MEASURES The original primary efficacy outcome was modified Rankin Scale (mRS) score 0 or 1 (ie, being alive without any disability) and the original secondary efficacy outcome was a global outcome based on a composite of functional end points, both at 90 days. Adjusted analyses were only reported for the primary efficacy outcome and the original study protocol did not specify methods for adjusted analyses. Our adjusted reanalysis included these outcomes, symptom-free status (mRS 0), dependence-free status (mRS 0-2), mortality (mRS 6) and change across the mRS 0-6 spectrum at 90 days; and mortality and symptomatic intracranial haemorrhage at 7 days. RESULTS We replicated previously reported unadjusted analyses but discovered they were based on a modified interpretation of the National Institutes of Health Stroke Scale (NIHSS) score. The secondary efficacy outcome was no longer significant using the original NIHSS score. Previously reported adjusted analyses could only be replicated with significant effects for the primary efficacy outcome by using statistical approaches not reported in the trial protocol or statistical analysis plan. In analyses adjusting for baseline imbalances, all efficacy outcomes were not significant, but increases in symptomatic intracranial haemorrhage remained significant. CONCLUSIONS Reanalysis of the ECASS III trial data with multiple approaches adjusting for baseline imbalances does not support any significant benefits and continues to support harms for the use of alteplase 3-4.5 hours after stroke onset. Clinicians, patients and policymakers should reconsider interpretations and decisions regarding management of acute ischaemic stroke that were based on ECASS III results. TRIAL REGISTRATION NUMBER NCT00153036.
Collapse
Affiliation(s)
- Brian Scott Alper
- Medical Knowledge Office, EBSCO Information Services, Ipswich, Massachusetts, USA
- Innovations and Evidence-Based Medicine Development, EBSCO Health, Ipswich, Massachusetts, USA
| | - Gary Foster
- Biostatistics, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Biostatistics, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Meghan Malone-Moses
- Innovations and Evidence-Based Medicine Development, EBSCO Health, Ipswich, Massachusetts, USA
| | - Eric Manheimer
- Innovations and Evidence-Based Medicine Development, EBSCO Health, Ipswich, Massachusetts, USA
| |
Collapse
|
11
|
Pawlukiewicz AJ, Long D, Mehta S. Large Vessel Occlusion Stroke Secondary to Acute Aortic Dissection. Cureus 2020; 12:e9278. [PMID: 32821621 PMCID: PMC7431306 DOI: 10.7759/cureus.9278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aortic dissection carries a high mortality of up to 40% at the time of initial dissection and an additional 1% per hour the dissection is untreated. Patients with acute aortic dissection most commonly present with chest or back pain. Less frequently, it manifests without pain with predominant neurologic symptoms secondary to an acute stroke. We present the case of a 53-year-old male presenting with acute onset aphasia and right-sided weakness. Incidentally, CT angiography of his neck revealed a carotid artery dissection, which was found an extension of a Stanford type A acute aortic dissection resulting in a large vessel occlusion stroke. The patient's concomitant pathologies resulted in uncertainty as to the priority of management between the interventional neurology and cardiothoracic surgery services, ultimately resulting in the transfer of the patient to an aorta specialist at an outside facility. This case highlights several areas of difficulty in the management of patients with presenting with both large vessel occlusion stroke and acute aortic dissection and the need for consideration of acute aortic dissection in patients presenting with symptoms consistent with large vessel occlusion stroke. Optimal blood pressure control is unknown, as is the ideal timing of aortic repair and the potential for endovascular therapy for large vessel occlusion stroke in the setting of acute aortic dissection. Emergency physicians must rapidly engage with neurology, interventional neurology, and cardiothoracic surgery to determine appropriate interventions and timing of operative repair. The emergency physician must consider acute aortic dissection in patients presenting with signs and symptoms concerning for large vessel occlusion stroke, even if they have no complaint of chest pain, as administration of thrombolytics in these patients may be deadly.
Collapse
Affiliation(s)
| | - Drew Long
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Sumeru Mehta
- Emergency Medicine, Greater San Antonio Emergency Physicians, San Antonio, USA
| |
Collapse
|
12
|
Shahsavarinia K, Ghavam Laleh Y, Moharramzadeh P, Pouraghaei M, Sadeghi-Hokmabadi E, Seifar F, Hajibonabi F, Khamnian Z, Farhoudi M, Mafi S. The predictive value of red cell distribution width for stroke severity and outcome. BMC Res Notes 2020; 13:288. [PMID: 32539809 PMCID: PMC7294627 DOI: 10.1186/s13104-020-05125-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 06/04/2020] [Indexed: 12/26/2022] Open
Abstract
Objectives In the present study, we sought to investigate the association between red cell distribution width (RDW) and stroke severity and outcome in patients who underwent anti-thrombolytic therapy with tissue plasminogen activator (tPA). Results In this prospective study, 282 stroke patients who underwent tPA injection were included. The categorization of RDW to < 12.9% and > 13% values revealed insignificant difference in stroke severity score, accounting for the mean 36-h NIHSS of 8.19 ± 8.2 in normal RDW values and 9.94 ± 8.28in higher RDW group (p = 0.64). In seventh day, NIHSS was 6.46 ± 7.28 in normal RDW group and was 8.52 ± 8.35 in increased RDW group (p = 0.058). Neither the 36-h, nor the seventh day and 3-month mRS demonstrated significant difference between those with normal and higher RDW values.
Collapse
Affiliation(s)
- Kavous Shahsavarinia
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Younes Ghavam Laleh
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Payman Moharramzadeh
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahboob Pouraghaei
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Fatemeh Seifar
- Stem Cell Research Center, Aging Research Institute, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, 5166/15731, Iran.
| | - Farid Hajibonabi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zhila Khamnian
- Department of Community and Family Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Farhoudi
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sara Mafi
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
13
|
Behdarvandy M, Karimian M, Atlasi MA, Azami Tameh A. Heat shock protein 27 as a neuroprotective biomarker and a suitable target for stem cell therapy and pharmacotherapy in ischemic stroke. Cell Biol Int 2019; 44:356-367. [PMID: 31502740 DOI: 10.1002/cbin.11237] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 09/08/2019] [Indexed: 12/12/2022]
Abstract
Ischemic stroke is a major common cause of death and long-term disability worldwide. Several pathophysiological events including excitotoxicity, oxidative/nitrative stress, inflammation, and apoptosis are involved in ischemic injuries. Recently, the molecular mechanisms involved in cerebral ischemia through a focus on a member of small heat shock proteins family, Hsp27, has been developed. Notably, following exposure to ischemia, Hsp27 expression in the brain could be increased rather than the normal condition and it may play an important role in neuroprotection after ischemic stroke. The neuroprotection effects of Hsp27 may arise from its anti-oxidant, anti-inflammatory, anti-apoptotic, and chaperonic properties. Moreover, some therapeutic strategies such as stem cell therapy and pharmacotherapy have been developed with Hsp27 targeting. In this review, we describe the function and structure of Hsp27 and its possible role in neuroprotection after ischemic stroke. Finally, we present current studies in stroke therapy, which focused on Hsp27 targeting.
Collapse
Affiliation(s)
- Marjan Behdarvandy
- Anatomical Sciences Research Center, Kashan University of Medical Sciences, Qotb-e Ravandi Blvd., 8715988141, Kashan, Iran
| | - Mohammad Karimian
- Anatomical Sciences Research Center, Kashan University of Medical Sciences, Qotb-e Ravandi Blvd., 8715988141, Kashan, Iran
| | - Mohammad Ali Atlasi
- Anatomical Sciences Research Center, Kashan University of Medical Sciences, Qotb-e Ravandi Blvd., 8715988141, Kashan, Iran
| | - Abolfazl Azami Tameh
- Anatomical Sciences Research Center, Kashan University of Medical Sciences, Qotb-e Ravandi Blvd., 8715988141, Kashan, Iran
| |
Collapse
|
14
|
Zwank MD. Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians. Ann Emerg Med 2019; 74:313-314. [DOI: 10.1016/j.annemergmed.2019.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Indexed: 10/26/2022]
|
15
|
Skolarus LE, O’Brien A, Meurer WJ, Fisher BJZ. Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics. Stroke 2019; 50:1595-1597. [PMID: 31084320 PMCID: PMC6538464 DOI: 10.1161/strokeaha.119.024653] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/12/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Lesli E. Skolarus
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI
- Department of Health Behavior of Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Alison O’Brien
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI
- Department of Health Behavior of Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - William J. Meurer
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Brian J. Zikmund Fisher
- Department of Health Behavior of Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| |
Collapse
|
16
|
Abstract
Acute ischemic stroke (AIS) is a medical emergency that requires prompt recognition and streamlined work-up to ensure that time-dependent therapies are initiated to achieve the best outcomes. This article discusses frequently missed AIS in the emergency department, the role of various imagining modalities in the work-up of AIS, updates on the use of intravenous thrombolytics and endovascular therapy for AIS, pearls on supportive care management of AIS, and prehospital and hospital process improvements to shorten door-to-needle time.
Collapse
Affiliation(s)
- Alfredo E Urdaneta
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Suite 350, Palo Alto, CA 94305, USA.
| | - Paulomi Bhalla
- Department of Neurology, Stanford Health Care - Valley Care, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94304, USA
| |
Collapse
|
17
|
Reynolds-Vaughn V, Riddle J, Brown J, Schiesel M, Wayant C, Vassar M. Evaluation of Spin in the Abstracts of Emergency Medicine Randomized Controlled Trials. Ann Emerg Med 2019; 75:423-431. [PMID: 31101371 DOI: 10.1016/j.annemergmed.2019.03.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 02/18/2019] [Accepted: 03/11/2019] [Indexed: 01/21/2023]
Abstract
STUDY OBJECTIVE We aim to investigate spin in emergency medicine abstracts, using a sample of randomized controlled trials from high-impact-factor journals with statistically nonsignificant primary endpoints. METHODS This study investigated spin in abstracts of emergency medicine randomized controlled trials from emergency medicine literature, with studies from 2013 to 2017 from the top 5 emergency medicine journals and general medical journals. Investigators screened records for inclusion and extracted data for spin. We considered evidence of spin if trial authors focused on statistically significant results, interpreted statistically nonsignificant results as equivalent or noninferior, used favorable rhetoric in the interpretation of nonsignificant results, or claimed benefit of an intervention despite statistically nonsignificant results. RESULTS Of 772 abstracts screened, 114 randomized controlled trials reported statistically nonsignificant primary endpoints. Spin was found in 50 of 114 abstracts (44.3%). Industry-funded trials were more likely to have evidence of spin in the abstract (unadjusted odds ratio 3.4; 95% confidence interval 1.1 to 11.9). In the abstracts' results, evidence of spin was most often due to authors' emphasizing a statistically significant subgroup analysis (n=9). In the abstracts' conclusions, spin was most often due to authors' claiming they accomplished an objective that was not a prespecified endpoint (n=14). CONCLUSION Spin was prevalent in the selected randomized controlled trial, emergency medicine abstracts. Authors most commonly incorporated spin into their reports by focusing on statistically significant results for secondary outcomes or subgroup analyses when the primary outcome was statistically nonsignificant. Spin was more common in studies that had some component of industry funding.
Collapse
Affiliation(s)
| | - Jonathan Riddle
- Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Jamin Brown
- Department of Emergency Medicine, Oklahoma State University Medical Center, Tulsa, OK
| | - Michael Schiesel
- Department of Emergency Medicine, Oklahoma State University Medical Center, Tulsa, OK
| | - Cole Wayant
- Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Matt Vassar
- Oklahoma State University Center for Health Sciences, Tulsa, OK
| |
Collapse
|
18
|
Skolarus LE, Neshewat GM, Evans L, Green M, Rehman N, Landis-Lewis Z, Schrader JW, Sales AE. Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study. BMC Health Serv Res 2019; 19:182. [PMID: 30894152 PMCID: PMC6425596 DOI: 10.1186/s12913-019-4012-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 03/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED). METHODS Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework. RESULTS We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework. CONCLUSIONS Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis.
Collapse
Affiliation(s)
- Lesli E. Skolarus
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
- School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Gina M. Neshewat
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Lacey Evans
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Molly Green
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
- School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Narmeen Rehman
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Zach Landis-Lewis
- Department of Learning Health Science, University of Michigan, Ann Arbor, USA
| | | | - Anne E. Sales
- Department of Learning Health Science, University of Michigan, Ann Arbor, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI USA
| |
Collapse
|
19
|
Zupon A, Rothenberg C, Couturier K, Tan TX, Siddiqui G, James M, Savage D, Melnick ER, Venkatesh AK. An appraisal of emergency medicine clinical practice guidelines: Do we agree? Int J Clin Pract 2019; 73:e13289. [PMID: 30372798 PMCID: PMC6351191 DOI: 10.1111/ijcp.13289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/08/2018] [Accepted: 10/24/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) have been published by the American College of Emergency Physicians (ACEP) since 1990 to advance evidence-based emergency care. ACEP clinical policies have drawn anecdotal criticism for bias, yet the overall quality of these guidelines has not previously been quantified. We sought to examine ACEP clinical policies using a recognised, validated appraisal instrument: Appraisal of Guidelines for Research & Evaluation (AGREE II). METHODS Systematic assessment of current ACEP clinical policies was conducted using the AGREE II instrument, which contains 23 appraisal items (scored on a 1-7 scale) in six domains and two overall assessments. Each policy was independently appraised by five trained appraisers. Primary outcomes were AGREE II ratings for each item, domain and "Overall Assessment," and scores were reported as standardised percentages from all five appraisers. Secondary analyses examined associations between AGREE II ratings and policy publication date, strength of underlying evidence and strength of recommendations. Additional analysis examined relationships between domain and "Overall Assessment" ratings. RESULTS Twenty guidelines published from April 2007 to November 2017 were included. Of the six domains, "Scope and Purpose" scored highest (mean 90%) and "Applicability" scored lowest (mean 35%). The four remaining domains ("Stakeholder Involvement," "Rigor of Development," "Clarity of Presentation" and "Editorial Independence") had mean scores of 53%-78%. The mean "Overall Assessment" rating was 69% and was not associated with policy publication date, strength of underlying evidence or strength of recommendations. We found positive associations between "Overall Assessment" ratings and two domains: "Rigor of Development" (r = 0.70) and "Clarity of Presentation" (r = 0.70). CONCLUSIONS Based on validated AGREE II criteria, ACEP clinical policies can be most improved by addressing their application in practice. ACEP clinical policies' overall quality did not improve over the assessed time period and is not explained by the quality of underlying evidence.
Collapse
Affiliation(s)
- Alyssa Zupon
- Yale University School of Medicine, New Haven, Connecticut
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Katherine Couturier
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ting-Xu Tan
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Gina Siddiqui
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew James
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Dan Savage
- Department of Emergency Medicine, University of California, San Francisco (UCSF) Fresno Medical Education Program, San Francisco, California
| | - Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- Yale New Haven Hospital, Center for Outcomes Research and Evaluation, New Haven, Connecticut
| |
Collapse
|
20
|
Financial relationships with industry among guideline authors for the management of acute ischemic stroke. Am J Emerg Med 2019; 37:921-923. [PMID: 30704949 DOI: 10.1016/j.ajem.2019.01.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/13/2019] [Accepted: 01/21/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To characterize the prevalence of industry relationships among authors of acute ischemic stroke (AIS) guidelines and its association with graded evidence. METHODS A cross-sectional study of five policy papers on AIS published by the American Heart Association (AHA)/American Stroke Association (ASA), American Academy of Emergency Physicians (AAEM), and American College of Emergency Physicians (ACEP). Financial conflicts of interest (FCOI) data were obtained using the Open Payments Database for the years 2013 through 2017. A search of publicly available information was done to determine post-guideline employment. We characterized the prevalence of FCOI, as well as employment with industry engaged in thrombolysis or neurointerventional treatment of AIS after guideline publication. RESULTS 76 unique authors were identified in 5 policy statements. The prevalence of FCOI among authors of AAEM, ACEP, and AHA/ASA guidelines was 0%, 0%, and 35%, respectively. Post-publication increase in FCOI was 0% for authors of the AAEM and ACEP guidelines, and a 300% increase for authors of the 2013 AHA/ASA guidelines with data unavailable to assess post-publication FCOI for authors of the 2018 AHA/ASA guidelines. 2 authors were found to engage in new industry employment following recommendation publication. Finally, 9% (n = 3) authors of the 2013/2018 AHA/ASA guidelines were employees of the Genentech Speakers Bureau. CONCLUSIONS Our results suggest an association between current Graded Evidence and FCOI of major academic societies for the management of AIS. Due to the bias inherent to such conflicts, future recommendation groups should take steps to insulate against FCOI both during and following guideline publication.
Collapse
|
21
|
A New Paradigm Shift in Acute Ischemic Stroke, Large Vessel Occlusions, and Endovascular Therapy. J Emerg Med 2018; 56:258-266. [PMID: 30528709 DOI: 10.1016/j.jemermed.2018.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/05/2018] [Accepted: 10/16/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND In the past three years, there have been several major studies published on the use of endovascular therapy (EVT) in large vessel occlusion (LVO) acute ischemic stroke. With multiple publications in such a short amount of time, it is difficult to keep up with the evolving landscape of ischemic stroke therapy. OBJECTIVE This narrative review discusses recent randomized controlled trials evaluating EVT and its effects on acute ischemic stroke management. DISCUSSION Ischemic stroke is the most common type of stroke overall, and recanalization is the predominant focus in stroke therapy to improve outcomes. Treatment first focused on systemic thrombolysis for ischemic stroke, followed by studies evaluating the use of thrombolysis with EVT. Early research did not find a benefit to EVT; however, recent studies using current devices and with narrow selection criteria demonstrate significant benefit to EVT in LVOs. In patients with LVOs and perfusion mismatches, reperfusion rates are higher with EVT compared with systemic thrombolysis alone. Recognition of patients with small infarct cores and large areas of ischemic but salvageable brain tissue up to 24 h after symptom onset stresses the need for advanced imaging to recognize the target group. CONCLUSIONS EVT technology for acute ischemic stroke has now become more efficient, minimizing complications and improving the efficacy of EVT. Several viable interventions for a small subgroup of patients with ischemic stroke up to 24 h after symptoms onset can significantly improve patient outcomes.
Collapse
|
22
|
The Results of Randomized Controlled Trials in Emergency Medicine Are Frequently Fragile. Ann Emerg Med 2018; 73:565-576. [PMID: 30551894 DOI: 10.1016/j.annemergmed.2018.10.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Randomized controlled trials govern evidence-based clinical practice, and it is therefore critical that their results be robust. We aim to investigate the fragility of randomized controlled trials in emergency medicine by determining how often significance would be nullified with small changes in outcomes using the fragility index. METHODS We conducted a methodological systematic review of randomized controlled trials in emergency medicine published in the top 10 general medicine journals and the top 10 emergency medicine journals. Inclusion criteria required that trials be emergency medicine studies structured with a 2-arm or 2-by-2 factorial design and report at least 1 statistically significant dichotomous outcome. RESULTS A total of 180 trials met inclusion criteria. The median fragility index across all trials in emergency medicine was 4 (interquartile range [IQR] 2 to 10) and the median sample size was 140 (IQR 69.5 to 286). For trials from general medicine journals (n=32), the median fragility index was 9 (IQR 4 to 16.5) and the median sample size was 415.5 (IQR 219.5 to 901); for trials from emergency medicine journals (n=148), the median fragility index was 4 (IQR 1 to 9) and the median sample size was 119 (IQR 60 to 227.25). One third of all trials (62/180) had a loss to follow-up that was greater than or equal to the fragility index. There was a modest correlation between fragility index and total number of events (r=0.36; 95% confidence interval [CI] 0.23 to 0.48) and a weak correlation between fragility index and total sample size (r=0.26; 95% CI 0.12 to 0.39). There was no correlation between fragility index and either P value (r=-0.14; 95% CI -0.28 to -0.006) or Science Citation Index (r=0.07; 95% CI -0.08 to 0.22). CONCLUSION The statistical significance of the results of randomized controlled trials in emergency medicine was often contingent on a small number of events. Until frequentist interpretation of clinical trials is replaced with Bayesian analysis, the fragility index may have utility as a tool to aid clinicians in assessing the robustness of randomized controlled trials in emergency medicine when considered in conjunction with the fragility quotient and other reported metrics.
Collapse
|
23
|
Nelson A, Kelly G, Byyny R, Dionne C, Preslaski C, Kaucher K. Tenecteplase utility in acute ischemic stroke patients: A clinical review of current evidence. Am J Emerg Med 2018; 37:344-348. [PMID: 30471930 DOI: 10.1016/j.ajem.2018.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/14/2018] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Acute ischemic stroke is a leading cause of disability in the United States. Treatment is aimed at reducing impact of cerebral clot burden and life-long disability. Traditional fibrinolytic treatment with recombinant tissue plasminogen activator (tPA) has shown to be effective but at high risk of major bleeding. Multiple studies have evaluated tenecteplase as an alternative to tPA. OBJECTIVE This review evaluates literature and utility of tenecteplase for treatment of acute ischemic stroke. DISCUSSION Tenecteplase is modified, third generation fibrinolytic with greater specificity for fibrin bound clots. Current data in acute myocardial infarction suggest decreased bleeding events compared to alteplase. Multiple trials have investigated superiority of tenecteplase compared to tPA for treatment of acute ischemic stroke. Current guidelines designate tenecteplase as an alternative treatment for mild acute ischemic stroke patients based on recent literature. CONCLUSION Recent emerging literature and limited recommendation guidance from governing medical societies leave many emergency medicine providers to weigh benefit versus risk of fibrinolytic therapy and tenecteplase's place in therapy. This review evaluates the available literature regarding tenecteplase and its utility in the treatment of acute ischemic stroke patients.
Collapse
Affiliation(s)
- Amelia Nelson
- Denver Health Medical Center, Department of Pharmacy, 777 Bannock ST. MC #0056, Denver, CO 80204, United States of America.
| | - Gregory Kelly
- Penn Medicine, University of Pennsylvania Health System, Department of Pharmacy, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Richard Byyny
- Denver Health Medical Center, Department of Emergency Medicine, 777 Bannock ST. MC #0108, Denver, CO 80204, United States of America.
| | - Catherine Dionne
- Denver Health Medical Center, Department of Pharmacy, 777 Bannock ST. MC #0056, Denver, CO 80204, United States of America.
| | - Candice Preslaski
- Denver Health Medical Center, Department of Pharmacy, 777 Bannock ST. MC #0056, Denver, CO 80204, United States of America.
| | - Kevin Kaucher
- Denver Health Medical Center, Department of Pharmacy, 777 Bannock ST. MC #0056, Denver, CO 80204, United States of America.
| |
Collapse
|
24
|
Guk J, Chae D, Son H, Yoo J, Heo JH, Park K. Model-based assessment of the benefits and risks of recombinant tissue plasminogen activator treatment in acute ischaemic stroke. Br J Clin Pharmacol 2018; 84:2586-2599. [PMID: 30003573 DOI: 10.1111/bcp.13715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 06/15/2018] [Accepted: 07/04/2018] [Indexed: 11/28/2022] Open
Abstract
AIMS Recombinant tissue plasminogen activator (rt-PA) is the only first-line agent approved by the US Food and Drug Administration to treat acute ischaemic stroke. However, it often causes the serious adverse event (AE) of haemorrhagic transformation. The present study developed a pharmacometric model for the rt-PA treatment effect and AE and, using the developed model, proposed a benefit-to-risk ratio assessment scheme as a supportive tool to optimize treatment outcome. METHODS The data from 336 acute ischaemic stroke patients were used. The treatment effect was assessed based on an improvement in National Institutes of Health Stroke Scale (NIHSS) scores, which were described using an item response theory (IRT)-based disease progression model. Treatment failure and AE probabilities, and their occurrence times, were described by incidence and time-to-event models. Using the developed model, benefit-to-risk ratios were simulated under various scenarios using the global benefit-to-risk trade-off ratio (GBR). RESULTS High initial NIHSS score and middle cerebral artery (MCA) stroke were risk factors for treatment failure, where the failure rate with MCA stroke was 2.87-fold higher than with non-MCA stroke. The haemorrhagic transformation time was associated with longitudinal changes in NIHSS scores. The benefit-to-risk ratio simulated was highest in minor stroke severity, with GBR >1 in all scenarios, and the ratio with non-MCA stroke was 2-3 fold higher than with MCA stroke. CONCLUSIONS The study demonstrated the feasibility of applying an IRT model to describing the time course of the rt-PA treatment effect and AE. Benefit-to-risk ratio analyses showed that the treatment was optimal in non-MCA stroke with minor stroke severity.
Collapse
Affiliation(s)
- Jinju Guk
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, South Korea.,Brain Korea 21 plus Project for Medical Science, Yonsei University, Seoul, South Korea
| | - Dongwoo Chae
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, South Korea.,Brain Korea 21 plus Project for Medical Science, Yonsei University, Seoul, South Korea
| | - Hankil Son
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, South Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University College of Medicine, Daegu, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyungsoo Park
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
25
|
Does Prestroke Antiplatelet Therapy Increase the Risk of Symptomatic Intracranial Hemorrhage in Patients Receiving Tissue Plasminogen Activator for Acute Ischemic Stroke? Ann Emerg Med 2018; 71:416-418. [DOI: 10.1016/j.annemergmed.2017.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
26
|
|
27
|
Vernooij RWM, Martínez García L, Florez ID, Hidalgo Armas L, Poorthuis MHF, Brouwers M, Alonso-Coello P. Updated clinical guidelines experience major reporting limitations. Implement Sci 2017; 12:120. [PMID: 29025429 PMCID: PMC5639761 DOI: 10.1186/s13012-017-0651-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 10/03/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The Checklist for the Reporting of Updated Guidelines (CheckUp) was recently developed. However, so far, no systematic assessment of the reporting of updated clinical guidelines (CGs) exists. We aimed to examine (1) the completeness of reporting the updating process in CGs and (2) the inter-observer reliability of CheckUp. METHODS We conducted a systematic assessment of the reporting of the updating process in a sample of updated CGs using CheckUp. We performed a systematic search to identify updated CGs published in 2015, developed by a professional society, reporting a systematic review of the evidence, and containing at least one recommendation. Three reviewers independently assessed the CGs with CheckUp (16 items). We calculated the median score per item, per domain, and overall, converting scores to a 10-point scale. Multiple linear regression analyses were used to identify differences according to country, type of organisation, scope, and health topic of updated CGs. We calculated the intraclass coefficient (ICC) and 95% confidence interval (95% CI) for domains and overall score. RESULTS We included in total 60 updated CGs. The median domain score on a 10-point scale for presentation was 5.8 (range 1.7 to 10), for editorial independence 8.3 (range 3.3 to 10), and for methodology 5.7 (range 0 to 10). The median overall score on a 10-point scale was 6.3 (range 3.1 to 10). Presentation and justification items at recommendation level (respectively reported by 27 and 38% of the CGs) and the methods used for the external review and implementing changes in practice were particularly poorly reported (both reported by 38% of the CGs). CGs developed by a European or international institution obtained a statistically significant higher overall score compared to North American or Asian institutions (p = 0.014). Finally, the agreement among the reviewers on the overall score was excellent (ICC 0.88, 95% CI 0.75 to 0.95). CONCLUSIONS The reporting of updated CGs varies considerably with significant room for improvement. We recommend using CheckUp to assess the updating process in updated CGs and as a blueprint to inform methods and reporting strategies in updating.
Collapse
Affiliation(s)
- Robin W M Vernooij
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Laura Martínez García
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Ivan Dario Florez
- Department of Health Research Methods, Evidence and Impact; McMaster University, Hamilton, Canada
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
| | - Laura Hidalgo Armas
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | | | - Melissa Brouwers
- Department of Health Research Methods, Evidence and Impact; McMaster University, Hamilton, Canada
- Department of Oncology, McMaster University, Hamilton, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| |
Collapse
|
28
|
Burton TM, Luby M, Nadareishvili Z, Benson RT, Lynch JK, Latour LL, Hsia AW. Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes. Neurology 2017; 89:343-348. [PMID: 28659427 DOI: 10.1212/wnl.0000000000004149] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/01/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine to what degree stroke mimics skew clinical outcomes and the potential effects of incorrect stroke diagnosis. METHODS This retrospective analysis of data from 2005 to 2014 included IV tissue plasminogen activator (tPA)-treated adults with clinical suspicion for acute ischemic stroke who were transferred or admitted directly to our 2 hub hospitals. Primary outcome measures compared CT-based spoke hospitals' and MRI-based hub hospitals' mimic rates, hemorrhagic transformation, follow-up modified Rankin Scale (mRS), and discharge disposition. Secondary outcomes were compared over time. RESULTS Of the 725 thrombolysis-treated patients, 29% were at spoke hospitals and 71% at hubs. Spoke hospital patients differed from hubs by age (mean 62 ± 15 vs 72 ± 15 years, p < 0.0001), risk factors (atrial fibrillation, 17% vs 32%, p < 0.0001; alcohol consumption, 9% vs 4%, p = 0.007; smoking, 23% vs 13%, p = 0.001), and mimics (16% vs 0.6%, p < 0.0001). Inclusion of mimics resulted in better outcomes for spokes vs hubs by mRS ≤1 (40% vs 27%, p = 0.002), parenchymal hematoma type 2 (3% vs 7%, p = 0.037), and discharge home (47% vs 37%, p = 0.01). Excluding mimics, there were no significant differences. Comparing epochs, spoke stroke mimic rate doubled (9%-20%, p = 0.03); hub rate was unchanged (0%-1%, p = 0.175). CONCLUSIONS Thrombolysis of stroke mimics is increasing at our CT-based spoke hospitals and not at our MRI-based hub hospitals. Caution should be used in interpreting clinical outcomes based on large stroke databases when stroke diagnosis at discharge is unclear. Inadvertent reporting of treated stroke mimics as strokes will artificially elevate overall favorable clinical outcomes with additional downstream costs to patients and the health care system.
Collapse
Affiliation(s)
- Tina M Burton
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Marie Luby
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Zurab Nadareishvili
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Richard T Benson
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - John K Lynch
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Lawrence L Latour
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Amie W Hsia
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD.
| |
Collapse
|
29
|
Wang Y, An FF, Chan M, Friedman B, Rodriguez EA, Tsien RY, Aras O, Ting R. 18F-positron-emitting/fluorescent labeled erythrocytes allow imaging of internal hemorrhage in a murine intracranial hemorrhage model. J Cereb Blood Flow Metab 2017; 37:776-786. [PMID: 28054494 PMCID: PMC5363488 DOI: 10.1177/0271678x16682510] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An agent for visualizing cells by positron emission tomography is described and used to label red blood cells. The labeled red blood cells are injected systemically so that intracranial hemorrhage can be visualized by positron emission tomography (PET). Red blood cells are labeled with 0.3 µg of a positron-emitting, fluorescent multimodal imaging probe, and used to non-invasively image cryolesion induced intracranial hemorrhage in a murine model (BALB/c, 2.36 × 108 cells, 100 µCi, <4 mm hemorrhage). Intracranial hemorrhage is confirmed by histology, fluorescence, bright-field, and PET ex vivo imaging. The low required activity, minimal mass, and high resolution of this technique make this strategy an attractive alternative for imaging intracranial hemorrhage. PET is one solution to a spectrum of issues that complicate single photon emission computed tomography (SPECT). For this reason, this application serves as a PET alternative to [99mTc]-agents, and SPECT technology that is used in 2 million annual medical procedures. PET contrast is also superior to gadolinium and iodide contrast angiography for its lack of clinical contraindications.
Collapse
Affiliation(s)
- Ye Wang
- 1 Department of Radiology, Molecular Imaging Innovations Institute (MI3), New York, USA
| | - Fei-Fei An
- 1 Department of Radiology, Molecular Imaging Innovations Institute (MI3), New York, USA
| | - Mark Chan
- 1 Department of Radiology, Molecular Imaging Innovations Institute (MI3), New York, USA
| | - Beth Friedman
- 2 Department of Pharmacology, University of California, La Jolla, USA
| | - Erik A Rodriguez
- 2 Department of Pharmacology, University of California, La Jolla, USA
| | - Roger Y Tsien
- 2 Department of Pharmacology, University of California, La Jolla, USA.,3 Howard Hughes Medical Institute, La Jolla, USA
| | - Omer Aras
- 4 Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Richard Ting
- 1 Department of Radiology, Molecular Imaging Innovations Institute (MI3), New York, USA
| |
Collapse
|
30
|
Miller JB, Merck LH, Wira CR, Meurer WJ, Schrock JW, Nomura JT, Siket MS, Madsen TE, Wright DW, Panagos PD, Lewandowski C. The Advanced Reperfusion Era: Implications for Emergency Systems of Ischemic Stroke Care. Ann Emerg Med 2017; 69:192-201. [DOI: 10.1016/j.annemergmed.2016.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/16/2016] [Accepted: 06/24/2016] [Indexed: 11/30/2022]
|
31
|
Misemer BS, Platts-Mills TF, Jones CW. Citation bias favoring positive clinical trials of thrombolytics for acute ischemic stroke: a cross-sectional analysis. Trials 2016; 17:473. [PMID: 27677444 PMCID: PMC5039798 DOI: 10.1186/s13063-016-1595-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/27/2016] [Indexed: 12/02/2022] Open
Abstract
Background Citation bias occurs when positive trials involving a medical intervention receive more citations than neutral or negative trials of similar quality. Several large clinical trials have studied the use of thrombolytic agents for the treatment of acute ischemic stroke with differing results, thereby presenting an opportunity to assess these trials for evidence of citation bias. We compared citation rates among positive, neutral, and negative trials of alteplase (tPA) and other thrombolytic agents for stroke. Methods We used a 2014 Cochrane Review of thrombolytic therapy for the treatment of acute stroke to identify non-pilot, English-language stroke trials published in MEDLINE-indexed journals comparing thrombolytic therapy with control. We classified trials as positive if there was a statistically significant primary outcome difference favoring the intervention, neutral if there was no difference in primary outcome, or negative for a significant primary outcome difference favoring the control group. Trials were also considered negative if safety concerns supported stopping the trial early. Using Scopus, we collected citation counts through 2015 and compared citation rates according to trial outcomes. Results Eight tPA trials met inclusion criteria: two were positive, four were neutral, and two were negative. The two positive trials received 9080 total citations, the four neutral trials received 4847 citations, and the two negative trials received 1096 citations. The mean annual per-trial citation rates were 333 citations per year for positive trials, 96 citations per year for neutral trials, and 35 citations per year for negative trials. Trials involving other thrombolytic agents were not cited as often, though as with tPA, positive trials were cited more frequently than neutral or negative trials. Conclusions Positive trials of tPA for ischemic stroke are cited approximately three times as often as neutral trials, and nearly 10 times as often as negative trials, indicating the presence of substantial citation bias. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1595-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Benjamin S Misemer
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, Suite 152, Camden, NJ, 08103, USA
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, 170 Manning Drive, CB#7594, Chapel Hill, NC, 27599, USA
| | - Christopher W Jones
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, Suite 152, Camden, NJ, 08103, USA.
| |
Collapse
|
32
|
Fatovich DM. Truth, thinking and thrombolysis. Emerg Med Australas 2016; 28:490-2. [DOI: 10.1111/1742-6723.12660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/25/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel M Fatovich
- Royal Perth Hospital, Department of Emergency Medicine; The University of Western Australia; Perth Western Australia Australia
| |
Collapse
|
33
|
Donaldson L, Fitzgerald E, Flower O, Delaney A. Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Emerg Med Australas 2016; 28:496-510. [DOI: 10.1111/1742-6723.12653] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 05/05/2016] [Accepted: 06/22/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Lachlan Donaldson
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital; Sydney New South Wales Australia
| | - Emily Fitzgerald
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital; Sydney New South Wales Australia
- Faculty of Health; University of Technology Sydney; Sydney New South Wales Australia
| | - Oliver Flower
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital; Sydney New South Wales Australia
- Northern Clinical School, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital; Sydney New South Wales Australia
- Northern Clinical School, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- ANZIC Research Centre, Department of Epidemiology and Preventative Medicine; Monash University; Melbourne Victoria Australia
| |
Collapse
|
34
|
Probst MA, Kanzaria HK, Frosch DL, Hess EP, Winkel G, Ngai KM, Richardson LD. Perceived Appropriateness of Shared Decision-making in the Emergency Department: A Survey Study. Acad Emerg Med 2016; 23:375-81. [PMID: 26806170 PMCID: PMC5308213 DOI: 10.1111/acem.12904] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/12/2015] [Accepted: 11/16/2015] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The objective was to describe perceptions of practicing emergency physicians (EPs) regarding the appropriateness and medicolegal implications of using shared decision-making (SDM) in the emergency department (ED). METHODS We conducted a cross-sectional survey of EPs at a large, national professional meeting to assess perceived appropriateness of SDM for different categories of ED management (e.g., diagnostic testing, treatment, disposition) and in common clinical scenarios (e.g., low-risk chest pain, syncope, minor head injury). A 21-item survey instrument was iteratively developed through review by content experts, cognitive testing, and pilot testing. Descriptive and multivariate analyses were conducted. RESULTS We approached 737 EPs; 709 (96%) completed the survey. Two-thirds (67.8%) of respondents were male; 51% practiced in an academic setting and 44% in the community. Of the seven management decision categories presented, SDM was reported to be most frequently appropriate for deciding on invasive procedures (71.5%), computed tomography (CT) scanning (56.7%), and post-ED disposition (56.3%). Among the specific clinical scenarios, use of thrombolytics for acute ischemic stroke was felt to be most frequently appropriate for SDM (83.4%), followed by lumbar puncture to rule out subarachnoid hemorrhage (73.8%) and CT head for pediatric minor head injury (69.9%). Most EPs (66.8%) felt that using and documenting SDM would decrease their medicolegal risk while a minority (14.2%) felt that it would increase their risk. CONCLUSIONS Acceptance of SDM among EPs appears to be strong across management categories (diagnostic testing, treatment, and disposition) and in a variety of clinical scenarios. SDM is perceived by most EPs to be medicolegally protective.
Collapse
Affiliation(s)
- Marc A Probst
- The Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hemal K Kanzaria
- The Department of Emergency Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Dominick L Frosch
- The Patient Care Program, Gordon and Betty Moore Foundation, Palo Alto, CA
- The Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Erik P Hess
- The Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Gary Winkel
- The Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ka Ming Ngai
- The Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lynne D Richardson
- The Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|