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Schuster L, Essig F, Daneshkhah N, Herm J, Hellwig S, Endres M, Dirnagl U, Hoffmann F, Michalski D, Pfeilschifter W, Urbanek C, Petzold GC, Rizos T, Kraft A, Haeusler KG. Ability of patients with acute ischemic stroke to recall given information on intravenous thrombolysis: Results of a prospective multicenter study. Eur Stroke J 2023; 8:241-250. [PMID: 37021170 PMCID: PMC10069168 DOI: 10.1177/23969873221143856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/20/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction: Intravenous thrombolysis (IVT) is an on label treatment for selected patients with acute ischemic stroke (AIS). As major bleeding or allergic shock may occur, the need to ensure patients’ informed consent for IVT is a matter of debate. Patients and methods: Prospective investigator-initiated multi-center observational study to assess the ability of AIS patients to recall information, provided by a physician during a standardized educational talk (SET) on IVT use. The recall of 20 pre-defined items was assessed in AIS after 60–90 min ( n = 93) or 23–25 h ( n = 40) after SET. About 40 patients with subacute stroke, 40 non-stroke patients, and 23 relatives of AIS patients served as controls, and were surveyed 60–90 min after SET. Results: Within 60–90 min after SET, AIS patients (median age 70 years, 31% female, median NIHSS score on admission 3 points) who were considered capable to provide informed consent recalled 55% (IQR 40%–66.7%) of the provided SET items. In multivariable linear regression analysis recapitulation by AIS patients was associated with their educational level (β = 6.497, p < 0.001), self-reported excitement level (β = 1.879, p = 0.011) and NIHSS score on admission (β = −1.186, p = 0.001). Patients with subacute stroke (70 years, 40% female, median NIHSS = 2) recalled 70% (IQR 55.7%–83.6%), non-stroke patients (75 years, 40% female) 70% (IQR 60%–78.7%), and AIS relatives (58 years, 83% female) 70% (IQR 60%–85%). Compared to subacute stroke patients, AIS patients less often recalled the frequency of IVT-related bleeding (21% vs 43%), allergic shock (15% vs 39%), and bleeding-related morbidity and mortality (44% vs 78%). AIS patients recalled 50% (IQR 42.3%–67.5%) of the provided items 23–25 h after SET. Conclusion: AIS patients eligible for IVT remember about half of all SET-items after 60–90 min or 23–25 h, respectively. The fact that the recapitulation of IVT-associated risks is particularly poor should be given special consideration.
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Affiliation(s)
- Luzie Schuster
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Fabian Essig
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Naeimeh Daneshkhah
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Juliane Herm
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
| | - Simon Hellwig
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany
| | - Ulrich Dirnagl
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- QUEST Center, Berlin Institute of Health (BIH), Berlin, Germany
| | - Frank Hoffmann
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Germany
| | | | - Waltraud Pfeilschifter
- Department of Neurology, University of Frankfurt, Frankfurt/Main, Germany
- Department of Neurology, Hospital Lüneburg, Lüneburg, Germany
| | - Christian Urbanek
- Department of Neurology, Hospital Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University of Bonn, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Timolaos Rizos
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Andrea Kraft
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Germany
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2
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Law ZK, Appleton JP, Scutt P, Roberts I, Al-Shahi Salman R, England TJ, Werring DJ, Robinson T, Krishnan K, Dineen RA, Laska AC, Lyrer PA, Egea-Guerrero JJ, Karlinski M, Christensen H, Roffe C, Bereczki D, Ozturk S, Thanabalan J, Collins R, Beridze M, Ciccone A, Duley L, Shone A, Bath PM, Sprigg N. Brief Consent Methods Enable Rapid Enrollment in Acute Stroke Trial: Results From the TICH-2 Randomized Controlled Trial. Stroke 2022; 53:1141-1148. [PMID: 34847710 PMCID: PMC7612544 DOI: 10.1161/strokeaha.121.035191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/26/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Seeking consent rapidly in acute stroke trials is crucial as interventions are time sensitive. We explored the association between consent pathways and time to enrollment in the TICH-2 (Tranexamic Acid in Intracerebral Haemorrhage-2) randomized controlled trial. METHODS Consent was provided by patients or by a relative or an independent doctor in incapacitated patients, using a 1-stage (full written consent) or 2-stage (initial brief consent followed by full written consent post-randomization) approach. The computed tomography-to-randomization time according to consent pathways was compared using the Kruskal-Wallis test. Multivariable logistic regression was performed to identify variables associated with onset-to-randomization time of ≤3 hours. RESULTS Of 2325 patients, 817 (35%) gave self-consent using 1-stage (557; 68%) or 2-stage consent (260; 32%). For 1507 (65%), consent was provided by a relative (1 stage, 996 [66%]; 2 stage, 323 [21%]) or a doctor (all 2-stage, 188 [12%]). One patient did not record prerandomization consent, with written consent obtained subsequently. The median (interquartile range) computed tomography-to-randomization time was 55 (38-93) minutes for doctor consent, 55 (37-95) minutes for 2-stage patient, 69 (43-110) minutes for 2-stage relative, 75 (48-124) minutes for 1-stage patient, and 90 (56-155) minutes for 1-stage relative consents (P<0.001). Two-stage consent was associated with onset-to-randomization time of ≤3 hours compared with 1-stage consent (adjusted odds ratio, 1.9 [95% CI, 1.5-2.4]). Doctor consent increased the odds (adjusted odds ratio, 2.3 [1.5-3.5]) while relative consent reduced the odds of randomization ≤3 hours (adjusted odds ratio, 0.10 [0.03-0.34]) compared with patient consent. Only 2 of 771 patients (0.3%) in the 2-stage pathways withdrew consent when full consent was sought later. Two-stage consent process did not result in higher withdrawal rates or loss to follow-up. CONCLUSIONS The use of initial brief consent was associated with shorter times to enrollment, while maintaining good participant retention. Seeking written consent from relatives was associated with significant delays. REGISTRATION URL: https://www.isrctn.com; Unique identifier: ISRCTN93732214.
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Affiliation(s)
- Zhe Kang Law
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
- Department of Medicine (Z.K.L.), National University of Malaysia
| | - Jason P. Appleton
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
- Stroke, University Hospitals Birmingham NHS Foundation Trust, United Kingdom (J.P.A.)
| | - Polly Scutt
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, United Kingdom (I.R.)
| | | | - Timothy J. England
- Vascular Medicine, Division of Medical Sciences and GEM, Royal Derby Hospital Centre (T.J.E.), University of Nottingham, United Kingdom
| | - David J. Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, United Kingdom (T.R.)
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (K.K., P.M.B., N.S.)
| | - Robert A. Dineen
- Radiological Sciences (R.A.D.), University of Nottingham, United Kingdom
- NIHR Nottingham Biomedical Research Centre, United Kingdom (R.A.D.)
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Karolinska Institute Danderyd Hospital, Sweden (A.C.L.)
| | - Philippe A. Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland (P.A.L.)
| | | | | | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Denmark (H.C.)
| | - Christine Roffe
- Stroke Research, School of Medicine, Keele University, Newcastle-Under-Lyme, United Kingdom (C.R.)
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary (D.B.)
| | - Serefnur Ozturk
- Selcuk University Faculty of Medicine, Department of Neurology, Konya, Turkey (S.O.)
| | - Jegan Thanabalan
- Department of Surgery, Division of Neurosurgery (J.T.), National University of Malaysia
| | - Ronan Collins
- Age Related Health Care/Stroke-Service, Tallaght University Hospital, Dublin, Republic of Ireland (R.C.)
| | - Maia Beridze
- The First University Clinic of Tbilisi State Medical University, GA (M.B.)
| | - Alfonso Ciccone
- Neurology and Stroke Unit, Poma Hospital, ASST di Mantova, Mantua, Italy (A.C.)
| | - Lelia Duley
- Nottingham Clinical Trials Unit (L.D.), University of Nottingham, United Kingdom
| | - Angela Shone
- Research and Innovation (A.S.), University of Nottingham, United Kingdom
| | - Philip M. Bath
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (K.K., P.M.B., N.S.)
| | - Nikola Sprigg
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (K.K., P.M.B., N.S.)
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3
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Appelros P, Svensson E, Heidenreich K, Svantesson M. Ethical issues in stroke thrombolysis revisited. Acta Neurol Scand 2021; 144:611-615. [PMID: 34725820 DOI: 10.1111/ane.13530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Peter Appelros
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Elisabeth Svensson
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Kaja Heidenreich
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Mia Svantesson
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
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4
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Sabau M, Bungau S, Buhas CL, Carp G, Daina LG, Judea-Pusta CT, Buhas BA, Jurca CM, Daina CM, Tit DM. Legal medicine implications in fibrinolytic therapy of acute ischemic stroke. BMC Med Ethics 2019; 20:70. [PMID: 31610781 PMCID: PMC6792206 DOI: 10.1186/s12910-019-0412-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 09/26/2019] [Indexed: 01/01/2023] Open
Abstract
Background Before the advent of fibrinolytic therapy as a gold standard method of care for cases of acute ischemic stroke in Romania, issues regarding legal medicine aspects involved in this area of medical expertise were already presented and, in the majority of cases, the doctors seem to be unprepared for these situations. Main text The present research illustrates some of the cases in which these aspects were involved, that adressed a clinical center having 6 years of professional experience in the application of fibrinolytic treatment for stroke. The following cases report either situations in which the afore mentioned therapy was not rightfully administrated or legal aspects regarding the obtainment of informed consent. Conclusion Obtaining informed consent is a mandatory procedure, which takes time, to the detriment of application of fibrinolytic treatment.
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Affiliation(s)
- Monica Sabau
- County Clinical Emergency Hospital, Oradea, Romania.,Faculty of Medicine and Pharmacy, Department of Psycho-Neurosciences and Rehabilitation, University of Oradea, Oradea, Romania
| | - Simona Bungau
- Faculty of Medicine and Pharmacy, Department of Pharmacy, University of Oradea, Oradea, Bihor, Romania
| | - Camelia Liana Buhas
- Faculty of Medicine and Pharmacy, Department of Morphological Disciplines, University of Oradea, 50 Clujului St., 410060, Oradea, Bihor, Romania. .,Bihor County Forensic Service, 50 Clujului St, 410060, Oradea, Bihor, Romania.
| | - Gheorghe Carp
- County Clinical Emergency Hospital, Oradea, Romania.,Faculty of Medicine and Pharmacy, Department of Surgical Disciplines, University of Oradea, Oradea, Romania
| | - Lucia-Georgeta Daina
- County Clinical Emergency Hospital, Oradea, Romania.,Faculty of Medicine and Pharmacy, Department of Psycho-Neurosciences and Rehabilitation, University of Oradea, Oradea, Romania
| | - Claudia Teodora Judea-Pusta
- Faculty of Medicine and Pharmacy, Department of Morphological Disciplines, University of Oradea, 50 Clujului St., 410060, Oradea, Bihor, Romania.,Bihor County Forensic Service, 50 Clujului St, 410060, Oradea, Bihor, Romania
| | | | - Claudia Maria Jurca
- Faculty of Medicine and Pharmacy, Department of Preclinical Disciplines, University of Oradea, Oradea, Romania.,Department of Genetics, Municipal Clinical Hospital, Dr. Gavril Curteanu, Oradea, Romania
| | - Cristian Marius Daina
- County Clinical Emergency Hospital, Oradea, Romania.,Faculty of Medicine and Pharmacy, Department of Psycho-Neurosciences and Rehabilitation, University of Oradea, Oradea, Romania
| | - Delia Mirela Tit
- Faculty of Medicine and Pharmacy, Department of Pharmacy, University of Oradea, Oradea, Bihor, Romania
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5
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Ethical Considerations in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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6
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Gong J, Zhang Y, Gao H, Wei W, Lv J, Liu H, Huang Y. Choices Regarding Thrombolysis Are Modified by the Way to Transfer the Messages. Front Neurol 2017; 8:589. [PMID: 29167657 PMCID: PMC5683066 DOI: 10.3389/fneur.2017.00589] [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] [Received: 10/14/2016] [Accepted: 10/20/2017] [Indexed: 12/04/2022] Open
Abstract
Although thrombolysis is the most effective medical treatment for acute ischemic stroke, many stroke patients eligible for thrombolysis miss this treatment as a result of delay or refusal by the patients and/or their proxies. To explore the influences of prognostic information for different intervals from stroke onset to the start of thrombolytic treatment (OTT) and other factors on the preferences of patients/proxies regarding thrombolytic therapy, a cross-sectional, discrete-choice experiment was performed between August 2013 and September 2014. A total of 613 Chinese inpatients or their immediate family members were consecutively recruited at the Department of Neurology. After random assignment to a negative-framing group or a positive-framing group, the subjects completed a series of surveys, including nine items about thrombolysis. Latent class analysis (LCA) was used to examine participants’ preference paradigms for thrombolysis and to categorize the participants into different subgroups. Subsequently, regression analyses were conducted to explore predictors of categorization of the participants into each subgroup and to construct a thrombolytic decision-making model. LCA revealed an optimal 3-subgroup model including a consent to thrombolysis subgroup and objection to thrombolysis subgroups 1 and 2. Multiple regression analysis demonstrated that compared with assignment to the consent to thrombolysis subgroup, assignment to objection to thrombolysis subgroup 1 or 2 could be predicted by different factors. χ2 tests indicated effects of framing and other factors on participants’ choices regarding thrombolysis. Choices regarding thrombolysis were modified by not only prognostic information for different OTT intervals but also message framing, presentation format, and sociodemographic characteristics. To facilitate consent to thrombolysis, physicians should convey prognostic information to patients/proxies on the basis of patient OTT interval and should order the presentation of therapies according to the classification of patients/proxies. Individualized decision-making (IDM) might be an optimal strategy to increase the selection of thrombolysis, which providing important reference points for IDM in other clinical domains.
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Affiliation(s)
- Jingjing Gong
- Department of Neurology, PLA Army General Hospital, Beijing, China
| | - Yan Zhang
- Center of Psychology, Air Force Aviation Medicine Research Institute, Beijing, China
| | - Hongyan Gao
- Department of Medical Administration, PLA Army General Hospital, Beijing, China
| | - Wei Wei
- Department of Neurology, PLA Army General Hospital, Beijing, China
| | - Jing Lv
- Department of Psychology, PLA General Hospital, Beijing, China
| | - Hongyun Liu
- School of Psychology, Beijing Normal University, Beijing, China
| | - Yonghua Huang
- Department of Neurology, PLA Army General Hospital, Beijing, China
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7
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Li H, Wu Y, Suo G, Shen F, Zhen Y, Chen X, Lv H. Profiling neuron-autonomous lncRNA changes upon ischemia/reperfusion injury. Biochem Biophys Res Commun 2017; 495:104-109. [PMID: 29101036 DOI: 10.1016/j.bbrc.2017.10.157] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 10/29/2017] [Indexed: 11/18/2022]
Abstract
Extensive changes of neuronal transcriptome occur post ischemic stroke and during the following reperfusion. Although numerous studies focused on transcriptome changes of mRNAs associated with ischemic stroke, little is known about whether and how long non-coding RNAs (lncRNAs), which play critical roles in cellular homeostasis, are involved in this process. In this study, we performed high throughput screening to analyze expression changes of lncRNAs in primarily cultured hippocampal neurons under an oxygen-glucose deprivation/reperfusion (OGD/R) condition at 0 h, 6 h, 12 h, and 18 h, respectively. Knock down of one validated lncRNAs (Tnxa-ps1) promoted neuronal survival by inhibiting apoptosis. Coding non-coding co-expression network analysis revealed that the expression of Tnxa-ps1 was highly correlated with changes of a particular group of genes, many of which are associated with neural protection. Finally, we showed that down-regulation of Tnxa-ps1 reversed the expression changes of four mRNAs post OGD/R, revealing a regulatory effect between Tnxa-ps1 and selected genes. Together, our data revealed possible participation of lncRNAs in the pathophysiology of OGD/R and thereby provided new insights into the studies of potential therapeutic targets for ischemic stroke.
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Affiliation(s)
- Haiying Li
- Department of Cardiology, Children's Hospital of Soochow University, Suzhou, Jiangsu 215025, PR China; Department of Pediatrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, PR China
| | - Youjia Wu
- Department of Pediatrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, PR China
| | - Guihai Suo
- Department of Pediatrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, PR China
| | - Feifei Shen
- Department of Pediatrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, PR China
| | - Yuqin Zhen
- Department of Pediatrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, PR China
| | - Xia Chen
- Basic Medical Research Center, Medical School, Nantong University, Nantong, Jiangsu 226001, PR China.
| | - Haitao Lv
- Department of Cardiology, Children's Hospital of Soochow University, Suzhou, Jiangsu 215025, PR China.
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8
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Shi J, Chen X, Li H, Wu Y, Wang S, Shi W, Chen J, Ni Y. Neuron-autonomous transcriptome changes upon ischemia/reperfusion injury. Sci Rep 2017; 7:5800. [PMID: 28724924 PMCID: PMC5517505 DOI: 10.1038/s41598-017-05342-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 05/30/2017] [Indexed: 01/22/2023] Open
Abstract
Ischemic stroke and the following reperfusion, an acute therapeutic intervention, can cause irreversible brain damages. However, the underlying pathological mechanisms are still under investigation. To obtain a comprehensive, real-time view of the cell-autonomous mechanisms involved in ischemic stroke and reperfusion, we applied the next-generation sequencing (NGS) technology to characterize the temporal changes in gene expression profiles using primarily cultured hippocampal neurons under an oxygen-glucose deprivation/reperfusion (OGD/R) condition. We first identified the differentially expressed genes (DEGs) between normal cultured neurons, neurons with OGD, and neurons with OGD followed by reperfusion for 6 h, 12 h, and 18 h, respectively. We then performed bioinformatics analyses, including gene ontological (GO) and pathway analysis and co-expression network analysis to screen for novel key pathways and genes involved in the pathology of OGD/R. After we confirmed the changes of selected key genes in hippocampal cultures with OGD/R, we further validated their expression changes in an in vivo ischemic stroke model (MCAO). Finally, we demonstrated that prevention of the up-regulation of a key gene (Itga5) associated with OGD/R promoted hippocampal neuronal survival. Our research thereby provided novel insights into the molecular mechanisms in ischemic stroke pathophysiology and potential targets for therapeutic intervention after ischemic stroke.
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Affiliation(s)
- Jinlong Shi
- Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and Department of Neurosurgery, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Xia Chen
- Basic Medical Research Center, Medical School, Nantong University, 19 Qixiu Road, Nantong, 226001, Jiangsu, China.
| | - Haiying Li
- Department of Pediatrics, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Youjia Wu
- Department of Pediatrics, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Shouyan Wang
- Basic Medical Research Center, Medical School, Nantong University, 19 Qixiu Road, Nantong, 226001, Jiangsu, China
| | - Wei Shi
- Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and Department of Neurosurgery, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Jian Chen
- Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and Department of Neurosurgery, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Yaohui Ni
- Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and Department of Neurology, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China.
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9
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Shen B, Liu Q, Gu Y, Wang Y, Zhang Z. Efficacy and Safety Evaluation on Arterial Thrombolysis in Treating Acute Cerebral Infarction. Cell Biochem Biophys 2017; 73:297-304. [PMID: 27352315 DOI: 10.1007/s12013-015-0577-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The objective of this study was to evaluate the efficacy and safety of intra-arterial thrombolysis in treating acute cerebral infarction and further discuss the indications of acute cerebral infarction treatment, in order to enhance the therapeutic effects of arterial thrombolysis. The data of 164 patients with acute cerebral infarction who accepted intra-arterial thrombolysis treatment by using rt-PA or reteplase between 2009 and 2014 at the Department of Neurology of our hospital, were collected, including patients' medical history, characteristics of the onset procedure, intervals between onset and intra-arterial thrombolysis, bleeding or death, and the changing process of patient's main neurologic function after the treatment. The neurological functions including muscle strength, speech, and level of consciousness were chosen for evaluation. Through a review of cerebral angiography, we collected the digital subtraction angiography (DSA) morphological changes of blood vessels before and after arterial thrombolysis to evaluate whether those blood vessels had been reperfused. Thereafter, we analyzed and statistically processed above-mentioned data. The mean time of arterial thrombolysis was 5.7 h. DSA results were as follows: 22 patients had complete internal carotid artery (ICA) occlusion; 49 patients middle cerebral artery's (MCA's) Ml or M2 segment occlusion; 6 patients anterior cerebral artery (ACA) occlusion; 58 patients reperfusion after thrombolysis, and the recanalization rate was 76 %. Based on vertebral-basilar artery (VBA) system, 18 patients had complete occlusion, 11 patients had reperfusion after thrombolysis, and the recanalization rate was 61 %. A total of 63 patients had severe stenosis, and they had significantly improved after thrombolysis. The clinical symptoms of patients were improved: 79 out of 164 patients with paralysis had partially recovered their limb muscle strength after operation, while 33 patients had completely recovered, and there was no recovery at all of the muscle strength in 4 patients after operation. In total, 59 out of 63 patients with aphasia had improved their language function, while 19 patients with disturbance of consciousness turned for the better after arterial thrombolysis. Only one patient experienced the cerebral hemorrhage, and 14 cases had gingival bleeding, oral mucosa bleeding, and urethrorrhagia. The overall effective rates of intra-arterial thrombolysis in treating the acute cerebral infarction by reteplase had no significant differences compared to those by rt-PA, and there were no hemorrhagic complications. It is safe and effective if the arterial thrombolysis using reteplase is performed within a few hours after acute cerebral infarction onset because reteplase has a higher clinical efficacy and lower hemorrhagic transformation, which suggests that it may become a new feasible option for clinical arterial thrombolysis.
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Affiliation(s)
- Baozhong Shen
- Department of Medical Imaging, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, 150001, Heilongjiang, People's Republic of China
| | - Qingan Liu
- Department of Neurology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, 150001, Heilongjiang, People's Republic of China
| | - Yingli Gu
- Department of Neurology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, 150001, Heilongjiang, People's Republic of China
| | - Yan Wang
- Department of Neurology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, 150001, Heilongjiang, People's Republic of China
| | - Zhuobo Zhang
- Department of Neurology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, 150001, Heilongjiang, People's Republic of China.
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10
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Flatharta TÓ, Khan A, Walsh T, O'Donnell M, O'Keefe ST. Advance preferences regarding thrombolysis in patients at risk for stroke: a cross-sectional study. QJM 2015; 108:27-31. [PMID: 24996769 DOI: 10.1093/qjmed/hcu142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND It is difficult to obtain informed consent for thrombolysis in stroke patients given the emergency setting, the need for a speedy decision and the effects of neurological deficits. AIM To determine the advance preferences for thrombolysis of patients at risk for stroke following discussion of the potential risks and benefits. DESIGN Cross-sectional survey. METHODS Data on benefits and risks of thrombolysis within 3 h and between 3 and 4.5 h after stroke were presented orally, in writing and pictorially to patients attending geriatric and stroke services in a teaching hospital with specified stroke risk factors and preferences for thrombolysis were recorded. RESULTS Of the 121 participants, 108 (89.3%; 95% confidence interval [CI] 82.4-93.7) would opt for thrombolysis within the 3-h period and 100 (82.6%; 95% CI 74.9-88.4) within the 3- to 4.5-h period after acute stroke (P = 0.04, McNemar's test for correlated proportions). Previous stroke or transient ischaemic attack was more common among those who agreed to thrombolysis (54.1% vs. 30.4%, P = 0.04) and those who opted for thrombolysis were significantly more likely to agree to have their preferences recorded and used in the event of a stroke than those who refused thrombolysis (88.8% vs. 30.4%, P = 0.002). CONCLUSION Advance discussion of the potential risks and benefits of thrombolysis in at-risk patients may improve decision making if thrombolysis is being considered and the patient can no longer make a decision.
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Affiliation(s)
- T Ó Flatharta
- From the Department of Medicine, National University of Ireland-Galway, Department of Geriatric Medicine, Galway University Hospitals and National University of Ireland, Galway, HRB Clinical Research Facility, Galway, Ireland
| | - A Khan
- From the Department of Medicine, National University of Ireland-Galway, Department of Geriatric Medicine, Galway University Hospitals and National University of Ireland, Galway, HRB Clinical Research Facility, Galway, Ireland
| | - T Walsh
- From the Department of Medicine, National University of Ireland-Galway, Department of Geriatric Medicine, Galway University Hospitals and National University of Ireland, Galway, HRB Clinical Research Facility, Galway, Ireland
| | - M O'Donnell
- From the Department of Medicine, National University of Ireland-Galway, Department of Geriatric Medicine, Galway University Hospitals and National University of Ireland, Galway, HRB Clinical Research Facility, Galway, Ireland
| | - S T O'Keefe
- From the Department of Medicine, National University of Ireland-Galway, Department of Geriatric Medicine, Galway University Hospitals and National University of Ireland, Galway, HRB Clinical Research Facility, Galway, Ireland
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De Brún A, Flynn D, Joyce K, Ternent L, Price C, Rodgers H, Ford GA, Lancsar E, Rudd M, Thomson RG. Understanding clinicians' decisions to offer intravenous thrombolytic treatment to patients with acute ischaemic stroke: a protocol for a discrete choice experiment. BMJ Open 2014; 4:e005612. [PMID: 25009137 PMCID: PMC4091456 DOI: 10.1136/bmjopen-2014-005612] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Intravenous thrombolysis is an effective emergency treatment for acute ischaemic stroke for patients meeting specific criteria. Approximately 12% of eligible patients in England, Wales and Northern Ireland received thrombolysis in the first quarter of 2013, yet as many as 15% are eligible to receive treatment. Suboptimal use of thrombolysis may have been largely attributable to structural factors; however, with the widespread implementation of 24/7 hyper acute stroke services, continuing variation is likely to reflect differences in clinical decision-making, in particular the influence of ambiguous areas within the guidelines, licensing criteria and research evidence. Clinicians' perceptions about thrombolysis may now exert a greater influence on treatment rates than structural/service factors. This research seeks to elucidate factors influencing thrombolysis decision-making by using patient vignettes to identify (1) patient-related and clinician-related factors that may help to explain variation in treatment and (2) associated trade-offs in decision-making based on the interplay of critical factors. METHODS/ANALYSIS A discrete choice experiment (DCE) will be conducted to better understand how clinicians make decisions about whether or not to offer thrombolysis to patients with acute ischaemic stroke. To inform the design, exploratory work will be undertaken to ensure that (1) all potentially influential factors are considered for inclusion; and (2) to gain insights into the 'grey areas' of patient factors. A fractional factorial design will be used to combine levels of patient factors in vignettes, which will be presented to clinicians to allow estimation of the variable effects on decisions to offer thrombolysis. ETHICS AND DISSEMINATION Ethical approval for this study was obtained from the Newcastle University Research Ethics Committee. The results will be disseminated in peer review publications and at national conferences. Findings will be translated into continuing professional development activities and will support implementation of a computerised decision aid for thrombolysis (COMPASS) in acute stroke care.
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Affiliation(s)
- Aoife De Brún
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Kerry Joyce
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Helen Rodgers
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Emily Lancsar
- Centre for Health Economics, Monash University, Clayton, Melbourne, Victoria, Australia
| | - Matthew Rudd
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Richard G Thomson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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12
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Rincon F, Lee K. Ethical considerations in consenting critically ill patients for bedside clinical care and research. J Intensive Care Med 2013; 30:141-50. [PMID: 24019298 DOI: 10.1177/0885066613503279] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Care of critically ill patients, as in any other field, demands the exercise of ethical principles related to respect of patient's autonomy, beneficence, nonmaleficence, and distributive justice. Professional duty and the common law require doctors to obtain consent before giving treatment or for requesting participation in clinical research. A procedure or research study must be adequately explained, and the patient must have the capacity to consent. If a patient does not have decision-making capacity, treatment must be given using alternative forms of consent or using principles of implied consent in emergency or life-threatening situations. In the case of clinical research, informed consent must always be sought. Exemptions to this rule are morally justified in circumstances related to research in life-threatening conditions or life-saving interventions in which the investigator departs from sound principles of equipoise. This usually implies the imposition of safeguards such as consultation with the community in which the study were to take place, oversight in patient screening and recruitment process by institutional review boards, special study designs, retrospective and prospective consent processes, and independent safety monitoring.
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Affiliation(s)
- Fred Rincon
- Divisions of Critical Care and Neurotrauma, Department of Neurology and Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kiwon Lee
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA
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13
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Flynn D, Ford GA, Stobbart L, Rodgers H, Murtagh MJ, Thomson RG. A review of decision support, risk communication and patient information tools for thrombolytic treatment in acute stroke: lessons for tool developers. BMC Health Serv Res 2013; 13:225. [PMID: 23777368 PMCID: PMC3734197 DOI: 10.1186/1472-6963-13-225] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 06/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tools to support clinical or patient decision-making in the treatment/management of a health condition are used in a range of clinical settings for numerous preference-sensitive healthcare decisions. Their impact in clinical practice is largely dependent on their quality across a range of domains. We critically analysed currently available tools to support decision making or patient understanding in the treatment of acute ischaemic stroke with intravenous thrombolysis, as an exemplar to provide clinicians/researchers with practical guidance on development, evaluation and implementation of such tools for other preference-sensitive treatment options/decisions in different clinical contexts. METHODS Tools were identified from bibliographic databases, Internet searches and a survey of UK and North American stroke networks. Two reviewers critically analysed tools to establish: information on benefits/risks of thrombolysis included in tools, and the methods used to convey probabilistic information (verbal descriptors, numerical and graphical); adherence to guidance on presenting outcome probabilities (IPDASi probabilities items) and information content (Picker Institute Checklist); readability (Fog Index); and the extent that tools had comprehensive development processes. RESULTS Nine tools of 26 identified included information on a full range of benefits/risks of thrombolysis. Verbal descriptors, frequencies and percentages were used to convey probabilistic information in 20, 19 and 18 tools respectively, whilst nine used graphical methods. Shortcomings in presentation of outcome probabilities (e.g. omitting outcomes without treatment) were identified. Patient information tools had an aggregate median Fog index score of 10. None of the tools had comprehensive development processes. CONCLUSIONS Tools to support decision making or patient understanding in the treatment of acute stroke with thrombolysis have been sub-optimally developed. Development of tools should utilise mixed methods and strategies to meaningfully involve clinicians, patients and their relatives in an iterative design process; include evidence-based methods to augment interpretability of textual and probabilistic information (e.g. graphical displays showing natural frequencies) on the full range of outcome states associated with available options; and address patients with different levels of health literacy. Implementation of tools will be enhanced when mechanisms are in place to periodically assess the relevance of tools and where necessary, update the mode of delivery, form and information content.
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Affiliation(s)
- Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Gary A Ford
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, UK
| | - Lynne Stobbart
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Helen Rodgers
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, UK
| | | | - Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
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Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, Boccardi E. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013; 368:904-13. [PMID: 23387822 PMCID: PMC3708480 DOI: 10.1056/nejmoa1213701] [Citation(s) in RCA: 930] [Impact Index Per Article: 84.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In patients with ischemic stroke, endovascular treatment results in a higher rate of recanalization of the affected cerebral artery than systemic intravenous thrombolytic therapy. However, comparison of the clinical efficacy of the two approaches is needed. METHODS We randomly assigned 362 patients with acute ischemic stroke, within 4.5 hours after onset, to endovascular therapy (intraarterial thrombolysis with recombinant tissue plasminogen activator [t-PA], mechanical clot disruption or retrieval, or a combination of these approaches) or intravenous t-PA. Treatments were to be given as soon as possible after randomization. The primary outcome was survival free of disability (defined as a modified Rankin score of 0 or 1 on a scale of 0 to 6, with 0 indicating no symptoms, 1 no clinically significant disability despite symptoms, and 6 death) at 3 months. RESULTS A total of 181 patients were assigned to receive endovascular therapy, and 181 intravenous t-PA. The median time from stroke onset to the start of treatment was 3.75 hours for endovascular therapy and 2.75 hours for intravenous t-PA (P<0.001). At 3 months, 55 patients in the endovascular-therapy group (30.4%) and 63 in the intravenous t-PA group (34.8%) were alive without disability (odds ratio adjusted for age, sex, stroke severity, and atrial fibrillation status at baseline, 0.71; 95% confidence interval, 0.44 to 1.14; P=0.16). Fatal or nonfatal symptomatic intracranial hemorrhage within 7 days occurred in 6% of the patients in each group, and there were no significant differences between groups in the rates of other serious adverse events or the case fatality rate. CONCLUSIONS The results of this trial in patients with acute ischemic stroke indicate that endovascular therapy is not superior to standard treatment with intravenous t-PA. (Funded by the Italian Medicines Agency, ClinicalTrials.gov number, NCT00640367.).
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Affiliation(s)
- Alfonso Ciccone
- Stroke Unit and Department of Neurology, Niguarda Ca' Granda Hospital, Milan, Italy.
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15
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Murtagh MJ, Burges Watson DL, Jenkings KN, Lie MLS, Mackintosh JE, Ford GA, Thomson RG. Situationally-sensitive knowledge translation and relational decision making in hyperacute stroke: a qualitative study. PLoS One 2012; 7:e37066. [PMID: 22675477 PMCID: PMC3365903 DOI: 10.1371/journal.pone.0037066] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 04/17/2012] [Indexed: 12/11/2022] Open
Abstract
Stroke is a leading cause of disability. Early treatment of acute ischaemic stroke with rtPA reduces the risk of longer term dependency but carries an increased risk of causing immediate bleeding complications. To understand the challenges of knowledge translation and decision making about treatment with rtPA in hyperacute stroke and hence to inform development of appropriate decision support we interviewed patients, their family and health professionals. The emergency setting and the symptomatic effects of hyper-acute stroke shaped the form, content and manner of knowledge translation to support decision making. Decision making about rtPA in hyperacute stroke presented three conundrums for patients, family and clinicians. 1) How to allow time for reflection in a severely time-limited setting. 2) How to facilitate knowledge translation regarding important treatment risks and benefits when patient and family capacity is blunted by the effects and shock of stroke. 3) How to ensure patient and family views are taken into account when the situation produces reliance on the expertise of clinicians. Strategies adopted to meet these conundrums were fourfold: face to face communication; shaping decisions; incremental provision of information; and communication tailored to the individual patient. Relational forms of interaction were understood to engender trust and allay anxiety. Shaping decisions with patients was understood as an expression of confidence by clinicians that helped alleviate anxiety and offered hope and reassurance to patients and their family experiencing the shock of the stroke event. Neutral presentations of information and treatment options promoted uncertainty and contributed to anxiety. ‘Drip feeding’ information created moments for reflection: clinicians literally made time. Tailoring information to the particular patient and family situation allowed clinicians to account for social and emotional contexts. The principal responses to the challenges of decision making about rtPA in hyperacute stroke were relational decision support and situationally-sensitive knowledge translation.
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Affiliation(s)
- Madeleine J Murtagh
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom.
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16
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Burges Watson DL, Sanoff R, Mackintosh JE, Saver JL, Ford GA, Price C, Starkman S, Eckstein M, Conwit R, Grace A, Murtagh MJ. Evidence from the scene: paramedic perspectives on involvement in out-of-hospital research. Ann Emerg Med 2012; 60:641-50. [PMID: 22387089 DOI: 10.1016/j.annemergmed.2011.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 11/21/2011] [Accepted: 12/05/2011] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE In the context of calls to develop better systems for out-of-hospital clinical research, we seek to understand paramedics' perceptions of involvement in research and the barriers and facilitators to that involvement. METHODS This was a qualitative study using semistructured focus groups with 58 United Kingdom paramedics and interviews with 30 US firefighter-paramedics. The study focused on out-of-hospital research (trials of out-of-hospital treatment for stroke), whereby paramedics identified potential study subjects or obtained consent and administered study treatment in the field. Data were analyzed with a thematic and discourse approach. RESULTS Three key themes emerged as significant facilitators and barriers to paramedic involvement in research: patient benefit, professional identity and responsibility, and time. Paramedics showed willingness and capacity to engage in research but also some reticence because of the perceived sacrifice of autonomy and challenge to their identity. Paramedics work in a time-sensitive environment and were concerned that research would increase time taken in the field. CONCLUSION Awareness of these perspectives will help with development of out-of-hospital research protocols and potentially facilitate greater participation.
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Rincon F. Emergency Management of Acute Ischemic Stroke in Incapacitated Patients Who Have No Surrogate Decision Makers. Continuum (Minneap Minn) 2011; 17:1335-9. [DOI: 10.1212/01.con.0000410040.49724.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Huang P, Khor GT, Chen CH, Lin RT, Liu CK. Eligibility and rate of treatment for recombinant tissue plasminogen activator in acute ischemic stroke using different criteria. Acad Emerg Med 2011; 18:273-8. [PMID: 21401790 DOI: 10.1111/j.1553-2712.2011.01006.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The rate of recombinant tissue plasminogen activator (rtPA) use for stroke is low among the Chinese-Taiwanese. The study objective was to determine if less restrictive exclusion criteria for rtPA would increase eligibility and the rate of treatment. METHODS This retrospective before-and-after study was conducted from 2006 to 2009. The authors compared stroke patients treated under the old rtPA exclusion criteria (January 2006 to December 2008) with those treated with less restrictive rtPA exclusion criteria (January to December 2009). Rates of eligibility and treatment and reasons for exclusion from rtPA between the two phases were assessed. RESULTS Of 461 eligible patients during the study period, 333 were evaluated by the old criteria and 128 were evaluated by the less restrictive criteria. Minor or improving stroke was the primary exclusion reason in both groups (194/333, 58% vs. 70/128, 55%). Eligibility for rtPA was increased in the less restrictive criteria (35/127, 27%, 95% confidence interval [CI] = 20% to 36%) compared to the old criteria (40/333, 12%, 95% CI = 8.7% to 16%; p = 0.0001). Fewer patients were excluded due to old age in the less restrictive criteria (0/128, 0%) compared to the old criteria (37/333, 11%; p = 0.0001). The rate of consent refusal increased in the less restrictive criteria (27/128, 21%, 95% CI = 14% to 29%) compared to the old criteria (23/333, 6.9%, 95% CI = 4.4% to 10%; p < 0.0001). Rate of rtPA treatment was unchanged between the less restrictive criteria (8/128, 6.3%, 95% CI = 2.7% to 12%) and the old criteria (17/333, 5.1%, 95% CI = 3% to 8%; p = 0.63). CONCLUSIONS Increasing eligibility for rtPA does not increase the rate of treatment, possibly due to the high symptomatic intracerebral hemorrhage rate among Chinese-Taiwanese, which is a major concern among emergency physicians (EPs), neurologists, and patients. Dealing with perceived safety issues of rtPA is crucial before the rate of treatment can be increased.
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Affiliation(s)
- Poyin Huang
- Department of Neurology, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abstract
The requirement that doctors obtain valid consent from patients before providing medical treatment has long been ingrained in both legal doctrine and medical ethics. We summarize the foundations of the informed consent doctrine and discuss the recent evolution in thinking about consent and medical decision making. We show how consent has evolved from physicians merely providing patients information to shared decision making between patients and physicians. We then address three specific examples of situations common in neurological practice that pose challenges in obtaining valid consent: the administration of intravenous tPA following ischemic stroke, consideration of carotid endarterectomy for carotid artery stenosis, and implementation of do-not-resuscitate orders.
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Affiliation(s)
- Emily B Rubin
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Sandercock P, Lindley R, Wardlaw J, Dennis M, Lewis S, Venables G, Kobayashi A, Czlonkowska A, Berge E, Slot KB, Murray V, Peeters A, Hankey G, Matz K, Brainin M, Ricci S, Celani MG, Righetti E, Cantisani T, Gubitz G, Phillips S, Arauz A, Prasad K, Correia M, Lyrer P. Third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke. Trials 2008; 9:37. [PMID: 18559104 PMCID: PMC2442584 DOI: 10.1186/1745-6215-9-37] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 06/17/2008] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Intravenous recombinant tissue plasminogen activator (rt-PA) is approved for use in selected patients with ischaemic stroke within 3 hours of symptom onset. IST-3 seeks to determine whether a wider range of patients may benefit. DESIGN International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rt-PA in acute ischaemic stroke. Suitable patients must be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracerebral haemorrhage. With 1000 patients, the trial can detect a 7% absolute difference in the primary outcome. With 3500 patients, it can detect a 4.0% absolute benefit & with 6000, (mostly treated between 3 & 6 hours), it can detect a 3% benefit. TRIAL PROCEDURES: Patients are entered into the trial by telephoning a fast, secure computerised central randomisation system or via a secure web interface. Repeat brain imaging must be performed at 24-48 hours. The scans are reviewed 'blind' by expert readers. The primary measure of outcome is the proportion of patients alive and independent (Modified Rankin 0-2) at six months (assessed via a postal questionnaire mailed directly to the patient). Secondary outcomes include: events within 7 days (death, recurrent stroke, symptomatic intracranial haemorrhage), outcome at six months (death, functional status, EuroQol). TRIAL REGISTRATION ISRCTN25765518.
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Affiliation(s)
- Peter Sandercock
- The IST-3 Co-ordinating Centre, Neurosciences Trials Unit, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK
| | - Richard Lindley
- The University of Sydney, Discipline of Medicine, Westmead Hospital (C24), The University of Sydney NSW 2006, Australia
| | - Joanna Wardlaw
- The IST-3 Co-ordinating Centre, Neurosciences Trials Unit, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK
| | - Martin Dennis
- The IST-3 Co-ordinating Centre, Neurosciences Trials Unit, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK
| | - Steff Lewis
- The IST-3 Co-ordinating Centre, Neurosciences Trials Unit, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK
| | - Graham Venables
- Neurology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
| | - Adam Kobayashi
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego Str 9, 02-957 Warsaw, Poland
| | - Anna Czlonkowska
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, ul.Krakowskie Przedmiescie 26/28, 00-927 Warsaw, Poland
| | - Eivind Berge
- Department of Internal Medicine, Ullevaal University Hospital, NO-0407 Oslo, Norway
| | - Karsten Bruins Slot
- Department of Internal Medicine, Ullevaal University Hospital, NO-0407 Oslo, Norway
| | - Veronica Murray
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, SE-182 88 Stockholm, Sweden
| | - Andre Peeters
- Service de neurologie, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Bruxelles, Belgium
| | - Graeme Hankey
- Royal Perth Hospital, Wellington Street, GPO Box X2213, Perth, Western Australia, 6001, Australia
| | - Karl Matz
- Landesklinikum Donauregion Tulln, Neurologische Abteilung, Alter Ziegelweg 10, 3430 Tulln, Austria
| | - Michael Brainin
- Landesklinikum Donauregion Tulln, Neurologische Abteilung, Alter Ziegelweg 10, 3430 Tulln, Austria
| | - Stefano Ricci
- Ospedale Beato Giacoma Villa, Citta della Pieve, 06062-Perugia, Italy
| | | | - Enrico Righetti
- Ospedale Beato Giacoma Villa, Citta della Pieve, 06062-Perugia, Italy
| | - Teresa Cantisani
- S C di Neurofisiopatologia, Azienda Ospedaliera di Perugia, Italy
| | - Gord Gubitz
- Division of Neurology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax Infirmary, 1796 Summer Street, Halifax, Nova Scotia B3H 3A7, Canada
| | - Steve Phillips
- Division of Neurology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax Infirmary, 1796 Summer Street, Halifax, Nova Scotia B3H 3A7, Canada
| | - Antonio Arauz
- Instituto Nacional de Neurologia, Insurgentes sur 3877, La Fama, 14269 Mexico DF, Mexico
| | - Kameshwar Prasad
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Manuel Correia
- Neurology Department, Hospital Geral de Santo Antonio, Largo Prof Abel Salazar, 4050 Porto, Portugal
| | - Phillippe Lyrer
- Department of Neurology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
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Hurley JC. Hazards of thrombolytic therapy for stroke: the real-world experience. Intern Med J 2007; 37:348-9; author reply 349-50. [PMID: 17504292 DOI: 10.1111/j.1445-5994.2007.01348.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kane I, Lindley R, Lewis S, Sandercock P. Impact of Stroke Syndrome and Stroke Severity on the Process of Consent in the Third International Stroke Trial. Cerebrovasc Dis 2006; 21:348-52. [PMID: 16490945 DOI: 10.1159/000091541] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Accepted: 11/12/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Obtaining informed consent for a patient's participation in a randomized trial of treatment for use in a medical emergency may be achieved in a variety of ways. We sought to assess the process of consent and to evaluate the influence of the patient's neurological deficit on the method used to obtain consent in the first 300 patients recruited into the Third International Stroke Trial (IST-3). METHODS IST-3 is the first large-scale randomized controlled trial of intravenous thrombolysis in acute ischaemic stroke. The clinician could use one of four procedures to recruit the patient: written consent, witnessed consent, assent, or a waiver of consent. The patient's neurological deficits were recorded at baseline. We analysed the relationship between the neurological deficits at baseline and the consent procedure. RESULTS The method of consent used was written consent in 71 subjects (24%), witnessed verbal consent in 30 subjects (10%), assent by a relative in 197 subjects (66%), and waiver of consent in 2 subjects (1%). Patients with severe neurological deficits (as measured either by their stroke syndrome or their lower predicted probability of being alive and independent at 6 months) were more likely to be recruited by assent. Patients able to give written consent had less severe strokes. CONCLUSIONS Patients with non-lacunar hemispheric stroke syndromes or with a more severe neurological deficit were less likely to give written consent. Excluding such patients from acute stroke treatment trials would eliminate many otherwise eligible subjects, who have a poor predicted outcome without treatment and yet might benefit from acute treatments such as thrombolysis. Flexible consent procedures developed for IST-3 have made it feasible to recruit the target population.
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Affiliation(s)
- Ingrid Kane
- Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK, and Western Clinical School, University of Sydney, Australia.
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Sivakumar C, Palumbo V, Hill MD, Buchan AM. Informed consent for thrombolytic therapy in acute ischemic stroke. Stroke 2005; 36:528-9; author reply 528-9. [PMID: 15738575 DOI: 10.1161/01.str.0000154854.92922.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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