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Doeppner TR, Olbricht L, Maxhuni T, Alhaj Omar O, Sachs UJ, Juenemann MB, Huttner HB, Gerner ST. Urine-based point-of-care testing for factor-Xa-inhibitors in acute ischemic stroke patients: a feasibility study. Front Neurol 2023; 14:1330421. [PMID: 38162451 PMCID: PMC10756232 DOI: 10.3389/fneur.2023.1330421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Direct oral anticoagulants (DOACs) have become widely used in clinical practice for preventing thromboembolic events. Point-of-care testing methods, particularly those based on urine samples, offer a promising approach for rapid and accurate assessment of DOAC presence. This pilot study aims to evaluate the utility of a urine-based DOAC dipstick test as a point-of-care tool for identifying DOAB presence in acute ischemic stroke (AIS) or transient ischemic attack (TIA) patients. Patients and methods This prospective pilot study included patients with AIS/TIA eligible for DOAC-measurement. After exclusion of 3 patients, 23 patients with DOAC-intake (DOAC group; factor-Xa-inhibitors; n = 23) and 21 patients without DOAC-intake (control-group) remained for analyses. The urine-based DOAC dipstick test and parallel blood-based specific DOAC-level assessment were performed in all patients. Time-intervals of sampling urine/blood sampling and result of DOAC-test were recorded to analyze a potential time benefit based on dipstick evaluation. Results The urine-based DOAC dipstick test demonstrated high sensitivity (100%) and specificity (100%), correctly identifying all patients with anticoagulatory activity due to DOAC intake (i.e., anti-Xalevel ≥30 ng/mL). Moreover, the visual readout of the test provided semiquantitative information on drug-specific anti-Xa levels, showing a sensitivity of 83% and specificity of 93% to detect anti-Xa levels ≥120 ng/mL. The dipstick test exhibited a median time-benefit of 2:25 h compared to standard blood-based DOAC-level testing. Discussion The results of this pilot study underline the efficacy of urine-based point-of-care testing as a rapid and reliable method for assessing DOAC presence in patients with acute ischemic stroke. Conclusion The value of this tool for clinical decision-making in stroke management needs to be established in future trials.Clinical Trial Registration: Clinicaltrails.org identifier [NCT06037200].
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Affiliation(s)
- Thorsten R. Doeppner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
- Department of Neurology, University of Göttingen, Göttingen, Germany
| | - Linus Olbricht
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Toska Maxhuni
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Omar Alhaj Omar
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Ulrich J. Sachs
- Division of Haemostaseology, University Hospital Giessen, Giessen, Germany
| | | | - Hagen B. Huttner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
| | - Stefan T. Gerner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
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Trongnit S, Reesukumal K, Kost GJ, Nilanont Y, Pratumvinit B. Reducing Laboratory Turnaround Time in Patients With Acute Stroke and the Lack of Impact on Time to Reperfusion Therapy. Arch Pathol Lab Med 2023; 147:87-93. [PMID: 35486488 DOI: 10.5858/arpa.2021-0444-oa] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/31/2022]
Abstract
CONTEXT.— Timely reperfusion improves the recovery of patients with acute ischemic stroke. Laboratory results are crucial to guide treatment decisions in patients when abnormal laboratory tests are suspected. OBJECTIVE.— To implement a new laboratory workflow for acute stroke patients and compare laboratory turnaround time (TAT) preimplementation and postimplementation. DESIGN.— We conducted a retrospective pre-post intervention study of patients with suspected acute stroke during the 4-month periods before and after the implementation of a new laboratory workflow process. The improvement process included relocating the specimen registration site, laboratory notification before specimen arrival, a color-coding system on tubes, timing at all processes, and eliminating the smear review if platelets were normal. TATs of the laboratory and door-to-clinical intervention times before and after the improvement process were compared. RESULTS.— Postintervention, median specimen transportation time decreased from 11 (interquartile range [IQR], 8.4-16.4) to 9 minutes (IQR, 6.3-12.8), P < .001. The intralaboratory and total TATs of complete blood cell count, coagulation tests, and creatinine significantly decreased (P < .001 for all). Blood drawn-to-laboratory reported time decreased from 43 (IQR, 36.0-51.5) to 33 minutes (IQR, 29.2-35.8, P < .001). However, door-to-needle time for thrombolysis and door-to-puncture time and door-to-recanalization time for mechanical thrombectomy were not statistically different (P = .11, .69, and .50, respectively). CONCLUSIONS.— The new laboratory workflow significantly decreased transportation time, TAT of individual tests, and the blood drawn-to-laboratory reported time. However, the time to treatment of acute ischemic stroke patients was not different between preimplementation and postimplementation.
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Affiliation(s)
- Sasipong Trongnit
- From the Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (Trongnit, Reesukumal, Kost, Pratumvinit).,The Department of Pathology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand (Trongnit)
| | - Kanit Reesukumal
- From the Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (Trongnit, Reesukumal, Kost, Pratumvinit)
| | - Gerald J Kost
- From the Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (Trongnit, Reesukumal, Kost, Pratumvinit).,The Point-of-Care Testing Center for Teaching and Research (POCT•CTR), Pathology and Laboratory Medicine, School of Medicine, University of California, Davis (Kost)
| | - Yongchai Nilanont
- The Siriraj Stroke Center, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (Nilanont)
| | - Busadee Pratumvinit
- From the Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (Trongnit, Reesukumal, Kost, Pratumvinit).,The Point-of-Care Testing Center for Teaching and Research (POCT•CTR), Pathology and Laboratory Medicine, School of Medicine, University of California, Davis (Kost)
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Rajsic S, Breitkopf R, Bachler M, Treml B. Diagnostic Modalities in Critical Care: Point-of-Care Approach. Diagnostics (Basel) 2021; 11:diagnostics11122202. [PMID: 34943438 PMCID: PMC8700511 DOI: 10.3390/diagnostics11122202] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 02/07/2023] Open
Abstract
The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.
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Affiliation(s)
- Sasa Rajsic
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
| | - Robert Breitkopf
- Transplant Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria;
| | - Mirjam Bachler
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
| | - Benedikt Treml
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
- Correspondence:
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Siller T, Chandratheva A, Bücke P, Werring DJ, Seiffge D. Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option? Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00695-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients.
Recent Findings
Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients.
Summary
IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified.
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Seiffge DJ, Meinel T, Purrucker JC, Kaesmacher J, Fischer U, Wilson D, Wu TY. Recanalisation therapies for acute ischaemic stroke in patients on direct oral anticoagulants. J Neurol Neurosurg Psychiatry 2021; 92:534-541. [PMID: 33542084 PMCID: PMC8053326 DOI: 10.1136/jnnp-2020-325456] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/12/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
Direct oral anticoagulants (DOACs) have emerged as primary therapeutic option for stroke prevention in patients with atrial fibrillation. However, patients may have ischaemic stroke despite DOAC therapy and there is uncertainty whether those patients can safely receive intravenous thrombolysis or mechanical thrombectomy. In this review, we summarise and discuss current knowledge about different approaches to select patient. Time since last DOAC intake-as a surrogate for anticoagulant activity-is easy to use but limited by interindividual variability of drug pharmacokinetics and long cut-offs (>48 hours). Measuring anticoagulant activity using drug-specific coagulation assays showed promising safety results. Large proportion of patients at low anticoagulant activity seem to be potentially treatable but there remains uncertainty about exact safe cut-off values and limited assay availability. The use of specific reversal agents (ie, idarucizumab or andexanet alfa) prior to thrombolysis is a new emerging option with first data reporting safety but issues including health economics need to be elucidated. Mechanical thrombectomy appears to be safe without any specific selection criteria applied. In patients on DOAC therapy with large vessel occlusion, decision for intravenous thrombolysis should not delay thrombectomy (eg, direct thrombectomy or immediate transfer to a thrombectomy-capable centre recommended). Precision medicine using a tailored approach combining clinicoradiological information (ie, penumbra and vessel status), anticoagulant activity and use of specific reversal agents only if necessary seems a reasonable choice.
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Affiliation(s)
- David J Seiffge
- Stroke Research Center, Queen Square Institute of Neurology, London, UK .,Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | | | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric RadiologyUniversity Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Duncan Wilson
- Stroke Research Center, Queen Square Institute of Neurology, London, UK.,Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Teddy Y Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
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6
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Härtig F, Birschmann I, Peter A, Ebner M, Spencer C, Gramlich M, Richter H, Kuhn J, Lehmann R, Blumenstock G, Zuern CS, Ziemann U, Poli S. Specific Point-of-Care Testing of Coagulation in Patients Treated with Dabigatran. Thromb Haemost 2021; 121:782-791. [PMID: 33469905 PMCID: PMC8180376 DOI: 10.1055/s-0040-1721775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND PURPOSE Accurate and rapid assessment of coagulation status is necessary to guide thrombolysis or reversal of anticoagulation in stroke patients, but commercially available point-of-care (POC) assays are not suited for coagulation testing in patients treated with direct oral anticoagulants (DOACs). We aimed to evaluate the direct thrombin monitoring (DTM) test card by Helena Laboratories (Texas, United States) for anti-IIa-specific POC coagulation testing, hypothesizing that its POC-ecarin clotting time (POC-ECT) accurately reflects dabigatran plasma concentrations. METHODS A prospective single-center diagnostic study (ClinicalTrials.gov-identifier: NCT02825394) was conducted enrolling patients receiving a first dose of dabigatran and patients already on dabigatran treatment. Blood samples were collected before drug intake and 0.5, 1, 2, 8, and 12 hours after intake. POC-ECT was performed using whole blood (WB), citrated blood (CB), and citrated plasma (CP). Dabigatran plasma concentrations were determined by mass spectrometry. RESULTS In total, 240 blood samples from 40 patients contained 0 to 275 ng/mL of dabigatran. POC-ECT with WB/CB/CP ranged from 20 to 186/184/316 seconds. Pearson's correlation coefficient showed a strong correlation between dabigatran concentrations and POC-ECT with WB/CB/CP (R2 = 0.78/0.90/0.92). Dabigatran concentrations >30 and >50 ng/mL (thresholds for thrombolysis, surgery, and reversal therapy according to clinical guidelines) were detected by POC-ECT with WB/CB/CP (>36/35/45 and >43/45/59 seconds) with 95/97/97 and 96/98/97% sensitivity, and 81/87/94 and 74/60/91% specificity. CONCLUSION This first study evaluating DOAC-specific POC coagulation testing revealed an excellent correlation of POC-ECT with actual dabigatran concentrations. Detecting clinically relevant dabigatran levels with high sensitivity/specificity, the DTM assay represents a suitable diagnostic tool in acute stroke, hemorrhage, and urgent surgery.
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Affiliation(s)
- Florian Härtig
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Andreas Peter
- German Centre for Diabetes Research (DZD), Neuherberg, Germany.,Institute for Diabetes Research and Metabolic Diseases, Helmholtz Centre Munich, University of Tübingen, Tübingen, Germany.,Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, Tübingen, Germany
| | - Matthias Ebner
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Hospital, Charité, Berlin, Germany
| | - Charlotte Spencer
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | | | - Hardy Richter
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Rainer Lehmann
- German Centre for Diabetes Research (DZD), Neuherberg, Germany.,Institute for Diabetes Research and Metabolic Diseases, Helmholtz Centre Munich, University of Tübingen, Tübingen, Germany.,Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, Tübingen, Germany
| | - Gunnar Blumenstock
- Department of Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Christine S Zuern
- Department of Cardiology, University Hospital Tübingen, Germany.,Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
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Harpaz D, Seet RCS, Marks RS, Tok AIY. Blood-Based Biomarkers Are Associated with Different Ischemic Stroke Mechanisms and Enable Rapid Classification between Cardioembolic and Atherosclerosis Etiologies. Diagnostics (Basel) 2020; 10:E804. [PMID: 33050269 PMCID: PMC7600601 DOI: 10.3390/diagnostics10100804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 12/22/2022] Open
Abstract
Stroke is a top leading cause of death, which occurs due to interference in the blood flow of the brain. Ischemic stroke (blockage) accounts for most cases (87%) and is further subtyped into cardioembolic, atherosclerosis, lacunar, other causes, and cryptogenic strokes. The main value of subtyping ischemic stroke patients is for a better therapeutic decision-making process. The current classification methods are complex and time-consuming (hours to days). Specific blood-based biomarker measurements have promising potential to improve ischemic stroke mechanism classification. Over the past decades, the hypothesis that different blood-based biomarkers are associated with different ischemic stroke mechanisms is increasingly investigated. This review presents the recent studies that investigated blood-based biomarker characteristics differentiation between ischemic stroke mechanisms. Different blood-based biomarkers are specifically discussed (b-type natriuretic peptide, d-dimer, c-reactive protein, tumor necrosis factor-α, interleukin-6, interleukin-1β, neutrophil-lymphocyte ratio, total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein and apolipoprotein A), as well as the different cut-off values that may be useful in specific classifications for cardioembolic and atherosclerosis etiologies. Lastly, the structure of a point-of-care biosensor device is presented, as a measuring tool on-site. The information presented in this review will hopefully contribute to the major efforts to improve the care for stroke patients.
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Affiliation(s)
- Dorin Harpaz
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Raymond C. S. Seet
- Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore;
| | - Robert S. Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Alfred I. Y. Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
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Fiabilidad del coagulómetro portátil en pacientes con ictus isquémico agudo tratados con fibrinólisis intravenosa. Neurologia 2020; 35:155-159. [DOI: 10.1016/j.nrl.2017.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 07/06/2017] [Accepted: 07/09/2017] [Indexed: 11/17/2022] Open
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Guisado-Alonso D, Fayos-Vidal F, Martí-Fàbregas J, Prats-Sánchez L, Marín-Bueno R, Martínez-Domeño A, Delgado-Mederos R, Camps-Renom P. Reliability of point-of-care coagulometer measurements in patients with acute ischaemic stroke receiving intravenous fibrinolysis. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2017.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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10
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Imbalanced Regional Development of Acute Ischemic Stroke Care in Emergency Departments in China. Emerg Med Int 2019; 2019:3747910. [PMID: 31467718 PMCID: PMC6701302 DOI: 10.1155/2019/3747910] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/28/2019] [Accepted: 07/15/2019] [Indexed: 11/17/2022] Open
Abstract
Objective Most patients of acute ischemic stroke (AIS) receive treatments in the department of emergency in China. We aimed to examine the status of AIS diagnosis and treatment and the impact of green pathway operation in different regions of China. Methods In this nationwide survey, information regarding the emergency care of AIS was collected from 451 hospitals in different regions of China, by interviewing 484 physicians from these hospitals. Structured questionnaire was used to explore the status of AIS care and impact of the green pathway. Results 445 hospitals from 18 provinces, 4 municipalities, and 3 ethnic autonomous regions in China were included in the present study. Overall, the proportion of door-to-needle time (DNT) less than 60 min was 66.08% in the enrolled hospitals (n = 298). Stratified by regions, the results suggested that hospitals located in East regions had shorter DNT time (P=0.036), and more proportion of rtPA (P < 0.001) than those in West regions. Further analysis suggested that hospitals with a green channel were more likely to shorten DNT and improve the proportion of rtPA (P < 0.01). Conclusion Considerable regional differences were observed in terms of DNT time and thrombolysis rates in the departments of emergency in China. Further studies are required to confirm the regional differences in AIS care in China.
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11
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Ischemic Stroke in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.011] [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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12
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Wool GD. Benefits and Pitfalls of Point-of-Care Coagulation Testing for Anticoagulation Management: An ACLPS Critical Review. Am J Clin Pathol 2019; 151:1-17. [PMID: 30215666 DOI: 10.1093/ajcp/aqy087] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objectives Point-of-care (POC) testing is generally less precise and has higher reagent costs per test than laboratory-based assays. However, POC hemostasis testing can offer significant advantages in particular situations: patient-managed warfarin therapy as well as rapid turnaround time heparin management for intraoperative patients. Of note, POC hemostasis testing is generally approved for the purposes of anticoagulation monitoring and is inferior to laboratory coagulation testing for the diagnosis of congenital or acquired coagulopathy. Methods The frequently used POC coagulation instruments for POC international normalized ratio and activated clotting time are reviewed, as well as their typical performance relative to central laboratory testing (where available). Results Several cases are discussed that highlight the benefits, as well as pitfalls, of POC coagulation testing. Conclusions POC coagulation testing for anticoagulation monitoring offers advantages in particular situations. Clear policies and protocols must be developed to guide proper use of POC versus central laboratory hemostasis testing.
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Affiliation(s)
- Geoffrey D Wool
- The Department of Pathology, University of Chicago, Chicago, IL
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13
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Steiner T, Köhrmann M, Schellinger PD, Tsivgoulis G. Non-Vitamin K Oral Anticoagulants Associated Bleeding and Its Antidotes. J Stroke 2018; 20:292-301. [PMID: 30309225 PMCID: PMC6186922 DOI: 10.5853/jos.2018.02250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/12/2018] [Indexed: 01/12/2023] Open
Abstract
Oral anticoagulant-associated intracerebral hemorrhage (OAC-ICH) accounts for nearly 20% of all ICH. The number of patients with an indication for oral anticoagulant therapy (OAT) increases with increasing age. OAT became less complicate with the introduction of non-vitamin K oral anticoagulants (NOAC) OAT because of easier handling, favorable risk-benefit profile, reduced rates of ICH compared to vitamin K antagonists and no need for routine coagulation testing. Consequently, despite a better safety profile of NOAC the number of patients with OAC-ICH will increase. The mortality and complication rates of OAC-ICH are high and therefore they are the most feared complication of OAT. Immediate normalization of coagulation is the main goal and therefore knowledge of pharmacodynamics and coagulation status is essential. Laboratory measurements of anticoagulant activity in NOAC patients is challenging as specific tests are not widely available. More accessible tests such as the prothrombin time and activated partial thromboplastin time have important limitations. In dabigatran-associated ICH 5 g Idarucizumab should be administered. In rivaroxaban and apixaban-associated ICHs administration of andexanet alpha should be considered. Prothrombin complex concentrate may be considered if andexanet alpha is not available or in case of an ICH associated with edoxaban.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Peter D Schellinger
- Department of Neurology, Essen University Hospital, Essen, Germany.,Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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14
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Han JH, Jang S, Choi MO, Yoon MJ, Lim SB, Kook JR, Kang DW, Kwon SU, Kim JS, Jeon SB. Point-of-care coagulation testing for reducing in-hospital delay in thrombolysis. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918799938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The confirmation of prothrombin time international normalized ratio by a central laboratory often delays intravenous thrombolysis in patients with acute ischemic stroke. Objectives: We investigated the feasibility, reliability, and usefulness of point-of-care determination of prothrombin time international normalized ratio for stroke thrombolysis. Methods: Among 312 patients with ischemic stroke, 202 who arrived at the emergency room within 4.5 h of stroke onset were enrolled in the study. Patients with lost orders for point-of-care testing for the prothrombin time international normalized ratio or central laboratory testing for the prothrombin time international normalized ratio (n = 47) were excluded. We compared international normalized ratio values and the time interval from arrival to the report of test results (door-to-international normalized ratio time) between point-of-care testing for the prothrombin time international normalized ratio and central laboratory testing for the prothrombin time international normalized ratio. In patients who underwent thrombolysis, we compared the time interval from arrival to thrombolysis (door-to-needle time) between the current study population and historic cohort at our center. Results: In the 155 patients included in the study, the median door-to-international normalized ratio time was 9.0 min (interquartile range, 5.0–12.0 min) for point-of-care testing for the prothrombin time international normalized ratio and 46.0 min (interquartile range, 38.0–55.0 min) for central laboratory testing for the prothrombin time international normalized ratio (p < 0.001). The intraclass correlation coefficient between point-of-care testing for the prothrombin time international normalized ratio and central laboratory testing for the prothrombin time international normalized ratio was 0.975 (95% confidence interval: 0.966–0.982). Forty-nine of the 155 patients underwent intravenous thrombolysis. The door-to-needle time was significantly decreased after implementation of point-of-care testing for the prothrombin time international normalized ratio (median, 23.0 min; interquartile range, 16.0–29.8 vs median, 46.0 min; interquartile range, 33.5–50.5 min). Conclusion: Utilization of point-of-care testing for the prothrombin time international normalized ratio was feasible in the management of patients with acute ischemic stroke. Point-of-care testing for the prothrombin time international normalized ratio was quick and reliable and had a pivotal role in expediting thrombolysis.
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Affiliation(s)
- Jung Hee Han
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Ok Choi
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Jeong Yoon
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Bok Lim
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ran Kook
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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15
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Diener HC, Aisenberg J, Ansell J, Atar D, Breithardt G, Eikelboom J, Ezekowitz MD, Granger CB, Halperin JL, Hohnloser SH, Hylek EM, Kirchhof P, Lane DA, Verheugt FWA, Veltkamp R, Lip GYH. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 2. Eur Heart J 2018; 38:860-868. [PMID: 26848150 DOI: 10.1093/eurheartj/ehw069] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/09/2015] [Indexed: 12/11/2022] Open
Abstract
The choice of oral anticoagulant (OAC) for patients with atrial fibrillation (AF) may be influenced by individual clinical features or by patterns of risk factors and comorbidities. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. non-vitamin K oral anticoagulants (NOACs) for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In addition, we discuss the timing of initiation of anticoagulation. In the second of a two-part review, we discuss the use of NOAC for stroke prevention in the following subgroups of patients with AF: (vii) secondary stroke prevention in patients after stroke or transient ischaemic attack (TIA), (viii) patients with acute stroke requiring thrombolysis or thrombectomy, (ix) those initiating or restarting OAC treatment after stroke or TIA, (x) those with renal impairment on dialysis, (xi) the elderly, (xii) those at high risk of gastrointestinal bleeding, and (xiii) those with hypertension. In addition, we discuss adherence and compliance. Finally, we present a summary of treatment suggestions. In specific subgroups of patients with AF, evidence supports the use of particular NOACs and/or particular doses of anticoagulant. The appropriate choice of treatment for these subgroups will help to promote optimal clinical outcomes.
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Affiliation(s)
| | | | - Jack Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, USA
| | - Dan Atar
- Division of Medicine, Oslo University Hospital, Ullevål and University of Oslo, Norway
| | - Günter Breithardt
- Division of Rhythmology, Department of Cardiovascular Medicine, Hospital of the University Münster, Münster, Germany
| | - John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael D Ezekowitz
- Cardiovascular Research Foundation, New York, NY, USA.,Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA.,Lankenau Medical Center, Wynnewood, PA, USA
| | | | - Jonathan L Halperin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J. W. Goethe University, Frankfurt, Germany
| | - Elaine M Hylek
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, UK.,Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
| | - Deirdre A Lane
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | | | | | - Gregory Y H Lip
- University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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16
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Zenlander R, von Euler M, Antovic J, Berglund A. Point-of-care versus central laboratory testing of INR in acute stroke. Acta Neurol Scand 2018; 137:252-255. [PMID: 29068041 DOI: 10.1111/ane.12860] [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] [Accepted: 10/06/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Effective anticoagulant therapy is a contraindication to thrombolysis, which is an effective treatment of ischemic stroke if given within 4.5 hours of symptom onset. INR above 1.7 is generally considered a contraindication for thrombolysis. Rapid measurement of INR in warfarin-treated patients is therefore of major importance in order to be able to decide on thrombolysis or not. We asked whether INR measured on a point-of-care instrument would be as good as a central laboratory instrument. MATERIAL AND METHODS A total of 529 consecutive patients who arrived at the emergency department at a large urban teaching hospital with stroke symptoms were enrolled in the study. INR was measured with a CoaguChek and a Sysmex instrument. Basic clinical information such as age, sex, and diagnosis (if available) was recorded. INR from the instruments was compared using linear regression and Bland-Altman plot. RESULTS Of 529 patients, 459 had INR results from both instruments. Among these, 3 patients were excluded as outliers. The rest (n = 456) showed good correlation between the methods (R2 = 0.97). In the current setting, CoaguChek was in median 63 minutes faster than Sysmex. CONCLUSION Our results indicate that point-of-care testing is a safe mean to rapidly acquire a patient's INR value in acute clinical situations.
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Affiliation(s)
- R. Zenlander
- Department of Clinical Chemistry Karolinska University Hospital Stockholm Sweden
| | - M. von Euler
- Department of Clinical Pharmacology Karolinska University Hospital Stockholm Sweden
- Department of Clinical Science and Education Karolinska Institutet Stockholm Sweden
- Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | - J. Antovic
- Department of Clinical Chemistry Karolinska University Hospital Stockholm Sweden
- Department of Coagulation Research Institute for Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - A. Berglund
- Department of Clinical Science and Education Karolinska Institutet Stockholm Sweden
- Department of Internal Medicine Section of Neurology Södersjukhuset Stockholm Sweden
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17
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Kobayashi A, Czlonkowska A, Ford GA, Fonseca AC, Luijckx GJ, Korv J, de la Ossa NP, Price C, Russell D, Tsiskaridze A, Messmer-Wullen M, De Keyser J. European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre-hospital management of stroke. Eur J Neurol 2018; 25:425-433. [PMID: 29218822 DOI: 10.1111/ene.13539] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/01/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE The reduction of delay between onset and hospital arrival and adequate pre-hospital care of persons with acute stroke are important for improving the chances of a favourable outcome. The objective is to recommend evidence-based practices for the management of patients with suspected stroke in the pre-hospital setting. METHODS The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to define the key clinical questions. An expert panel then reviewed the literature, established the quality of the evidence, and made recommendations. RESULTS Despite very low quality of evidence educational campaigns to increase the awareness of immediately calling emergency medical services are strongly recommended. Moderate quality evidence was found to support strong recommendations for the training of emergency medical personnel in recognizing the symptoms of a stroke and in implementation of a pre-hospital 'code stroke' including highest priority dispatch, pre-hospital notification and rapid transfer to the closest 'stroke-ready' centre. Insufficient evidence was found to recommend a pre-hospital stroke scale to predict large vessel occlusion. Despite the very low quality of evidence, restoring normoxia in patients with hypoxia is recommended, and blood pressure lowering drugs and treating hyperglycaemia with insulin should be avoided. There is insufficient evidence to recommend the routine use of mobile stroke units delivering intravenous thrombolysis at the scene. Because only feasibility studies have been reported, no recommendations can be provided for pre-hospital telemedicine during ambulance transport. CONCLUSIONS These guidelines inform on the contemporary approach to patients with suspected stroke in the pre-hospital setting. Further studies, preferably randomized controlled trials, are required to examine the impact of particular interventions on quality parameters and outcome.
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Affiliation(s)
- A Kobayashi
- Institute of Psychiatry and Neurology, Interventional Stroke and Cerebrovascular Diseases Treatment Centre, Warsaw, Poland.,Department of Neuroradiology, Institute of Psychiatry and Neurology, Warsaw, Poland.,Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - A Czlonkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - G A Ford
- Division of Medical Sciences, Oxford University, Oxford, UK
| | - A C Fonseca
- Department of Neurology, Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - G J Luijckx
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J Korv
- Department of Neurology, Estonia Department of Neurology and Neurosurgery, Neurology Clinic, Tartu University Hospital, University of Tartu, Tartu, Estonia
| | - N Pérez de la Ossa
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - C Price
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - D Russell
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - A Tsiskaridze
- Department of Neurology, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia
| | - M Messmer-Wullen
- Austrian Stroke Selfhelp Association, Lochau, Austria.,European Federation of Neurological Associations (EFNA) and Stroke Alliance for Europe (SAFE), Brussels, Belgium
| | - J De Keyser
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Neurology, Centre for Neurosciences, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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18
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Dolscheid-Pommerich RC, Dolscheid S, Eichhorn L, Stoffel-Wagner B, Graeff I. Thrombolysis in stroke patients: Comparability of point-of-care versus central laboratory international normalized ratio. PLoS One 2018; 13:e0190867. [PMID: 29320558 PMCID: PMC5761884 DOI: 10.1371/journal.pone.0190867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 12/21/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In acute stroke patients, thrombolysis is one gold standard therapy option within the first four hours after the ischemic event. A contraindication for thrombolysis is an International Normalized Ratio (INR) value >1.7. Since time is brain, rapid and reliable INR results are fundamental. Aim was to compare INR values determined by central laboratory (CL) analyzer and Point-of-Care Testing(POCT)-device and to evaluate the quality of POCT performance in cases of potential therapeutic thrombolysis at a certified stroke unit. METHODS In 153 patients INR measurements using POCT-devices (HEMOCHRON Signature Elite®) were compared to INR measurements (BCS®XP) performed at the central laboratory. Outlier evaluation was performed regarding the critical thrombolysis cut-off. RESULTS Overall, we demonstrated a significant correlation (r = 0.809, p<0.0001) between both measurement methods. Mean value of the absolute difference between CL-INR and POCT-INR measurements was 0.23. In 95.4% of these cases, no differences regarding the critical cut-off (INR 1.7) were observed. POCT-INR values tended to be higher than the CL-INR values (p = 0.01). In 4.6% cases, a different value regarding thrombolysis cut-off was found. All patients were >75 years. CONCLUSIONS POCT-INR measurements based on our POCT concept are suitable to determine INR values in critical stroke patients. Nevertheless, outlier evaluation is mandatory.
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Affiliation(s)
| | - Sarah Dolscheid
- Department of Rehabilitation and Special Education, University of Cologne, Köln, Germany
| | - Lars Eichhorn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Birgit Stoffel-Wagner
- Department of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | - Ingo Graeff
- Center Clinician Scientist, Emergency Department, University Hospital Bonn, Bonn, Germany
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19
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Abstract
PURPOSE OF REVIEW An increasing number of patients are receiving oral anticoagulants. Since non-vitamin K antagonist oral anticoagulants (NOACs) were approved, primary prevention of ischemic stroke has become simpler. However, managing ischemic stroke and intracerebral hemorrhage while on oral anticoagulation (OAC) has become more complex. This review covers the latest developments in managing ischemic and hemorrhagic stroke in patients receiving vitamin K antagonists (VKA) and NOACs. RECENT FINDINGS Testing coagulation in patients with acute ischemic stroke and receiving NOACs is complex, and observational data challenge guideline recommendations. Initial registry and cohort data support the safety of endovascular therapy despite OAC. In intracerebral hemorrhage, rapid reversal of VKA can be achieved better with prothrombin complex concentrates than with fresh frozen plasma. Furthermore, rapid reversal seems to be associated with less hematoma expansion and better functional outcome. In addition, new evidence strongly supports resuming OAC after intracerebral hemorrhage. The unfavorable properties of NOAC-related intracerebral hemorrhage are similar to those associated with VKA. SUMMARY Translation of recent findings might improve both outcome in acute ischemic and hemorrhagic stroke in patients on oral anticoagulants and help refine clinical management. Data from randomized clinical trials are scarce.
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20
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Weber JE, Audebert HJ. [Appropriate treatment of acute stroke at all times and in all places : Organizational concepts and new approaches]. Internist (Berl) 2017; 58:1213-1219. [PMID: 28840255 DOI: 10.1007/s00108-017-0305-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Stroke is one of the most common neurological diseases in acute care. The introduction of new organizational concepts in the rescue chain and in acute inpatient services can significantly reduce time to treatment and patients can receive specific therapeutic options that have been shown to improve acute stroke prognosis. This review provides an overview of organizational structures that lead to improved medical care and outlines the evidence-based therapeutic options. This is intended to give the reader a decision support on provision of specific treatment in acute ischemic stroke. The almost simultaneous proof of effectiveness of mechanical thrombectomy for targeted patient populations in five randomized trials has challenged the organization of stroke care. This provides a good example of how an optimized interplay within the rescue chain from emergency services via community hospitals to referral centers with intervention facilities can ensure access to this novel treatment for as many patients as possible. For the limited time span between onset of symptoms and start of treatment, creative but nevertheless well-standardized concepts have emerged that lead to measurable therapeutic success. It has become an urgent challenge to create sustainable regional infrastructures that allow access to appropriate treatment for all patients.
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Affiliation(s)
- J E Weber
- Klinik für Neurologie mit experimenteller Neurologie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.
| | - H J Audebert
- Klinik für Neurologie mit experimenteller Neurologie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Centrum für Schlaganfallforschung Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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21
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Harpaz D, Eltzov E, Seet RCS, Marks RS, Tok AIY. Point-of-Care-Testing in Acute Stroke Management: An Unmet Need Ripe for Technological Harvest. BIOSENSORS 2017; 7:E30. [PMID: 28771209 PMCID: PMC5618036 DOI: 10.3390/bios7030030] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 12/20/2022]
Abstract
Stroke, the second highest leading cause of death, is caused by an abrupt interruption of blood to the brain. Supply of blood needs to be promptly restored to salvage brain tissues from irreversible neuronal death. Existing assessment of stroke patients is based largely on detailed clinical evaluation that is complemented by neuroimaging methods. However, emerging data point to the potential use of blood-derived biomarkers in aiding clinical decision-making especially in the diagnosis of ischemic stroke, triaging patients for acute reperfusion therapies, and in informing stroke mechanisms and prognosis. The demand for newer techniques to deliver individualized information on-site for incorporation into a time-sensitive work-flow has become greater. In this review, we examine the roles of a portable and easy to use point-of-care-test (POCT) in shortening the time-to-treatment, classifying stroke subtypes and improving patient's outcome. We first examine the conventional stroke management workflow, then highlight situations where a bedside biomarker assessment might aid clinical decision-making. A novel stroke POCT approach is presented, which combines the use of quantitative and multiplex POCT platforms for the detection of specific stroke biomarkers, as well as data-mining tools to drive analytical processes. Further work is needed in the development of POCTs to fulfill an unmet need in acute stroke management.
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Affiliation(s)
- Dorin Harpaz
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
| | - Evgeni Eltzov
- Agriculture Research Organization (ARO), Volcani Centre, Rishon LeTsiyon 15159, Israel.
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore.
| | - Robert S Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- The National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- The Ilse Katz Centre for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
| | - Alfred I Y Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
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22
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A high-urgency stroke code reduces in-hospital delays in acute ischemic stroke: a single-centre experience. Neurol Sci 2017; 38:1671-1676. [DOI: 10.1007/s10072-017-3046-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 06/21/2017] [Indexed: 12/29/2022]
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23
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Point-of-care testing for emergency assessment of coagulation in patients treated with direct oral anticoagulants. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:32. [PMID: 28196509 PMCID: PMC5309971 DOI: 10.1186/s13054-017-1619-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 01/27/2017] [Indexed: 01/24/2023]
Abstract
Background Point-of-care testing (POCT) of coagulation has been proven to be of great value in accelerating emergency treatment. Specific POCT for direct oral anticoagulants (DOAC) is not available, but the effects of DOAC on established POCT have been described. We aimed to determine the diagnostic accuracy of Hemochron® Signature coagulation POCT to qualitatively rule out relevant concentrations of apixaban, rivaroxaban, and dabigatran in real-life patients. Methods We enrolled 68 patients receiving apixaban, rivaroxaban, or dabigatran and obtained blood samples at six pre-specified time points. Coagulation testing was performed using prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), and activated clotting time (ACT+ and ACT-low range) POCT cards. For comparison, laboratory-based assays of diluted thrombin time (Hemoclot) and anti-Xa activity were conducted. DOAC concentrations were determined by liquid chromatography-tandem mass spectrometry. Results Four hundred and three samples were collected. POCT results of PT/INR and ACT+ correlated with both rivaroxaban and dabigatran concentrations. Insufficient correlation was found for apixaban. Rivaroxaban concentrations at <30 and <100 ng/mL were detected with >95% specificity at PT/INR POCT ≤1.0 and ≤1.1 and ACT+ POCT ≤120 and ≤130 s. Dabigatran concentrations at <30 and <50 ng/mL were detected with >95% specificity at PT/INR POCT ≤1.1 and ≤1.2 and ACT+ POCT ≤100 s. Conclusions Hemochron® Signature POCT can be a fast and reliable alternative for guiding emergency treatment during rivaroxaban and dabigatran therapy. It allows the rapid identification of a relevant fraction of patients that can be treated immediately without the need to await the results of much slower laboratory-based coagulation tests. Trial registration Unique identifier, NCT02371070. Retrospectively registered on 18 February 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1619-z) contains supplementary material, which is available to authorized users.
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24
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Coagulation Testing in Acute Ischemic Stroke Patients Taking Non–Vitamin K Antagonist Oral Anticoagulants. Stroke 2017; 48:152-158. [DOI: 10.1161/strokeaha.116.014963] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/19/2016] [Accepted: 11/08/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In patients who present with acute ischemic stroke while on treatment with non–vitamin K antagonist oral anticoagulants (NOACs), coagulation testing is necessary to confirm the eligibility for thrombolytic therapy. We evaluated the current use of coagulation testing in routine clinical practice in patients who were on NOAC treatment at the time of acute ischemic stroke.
Methods—
Prospective multicenter observational RASUNOA registry (Registry of Acute Stroke Under New Oral Anticoagulants; February 2012–2015). Results of locally performed nonspecific (international normalized ratio, activated partial thromboplastin time, and thrombin time) and specific (antifactor Xa tests, hemoclot assay) coagulation tests were documented. The implications of test results for thrombolysis decision-making were explored.
Results—
In the 290 patients enrolled, nonspecific coagulation tests were performed in ≥95% and specific coagulation tests in 26.9% of patients. Normal values of activated partial thromboplastin time and international normalized ratio did not reliably rule out peak drug levels at the time of the diagnostic tests (false-negative rates 11%–44% [95% confidence interval 1%–69%]). Twelve percent of patients apparently failed to take the prescribed NOAC prior to the acute event. Only 5.7% (9/159) of patients in the 4.5-hour time window received thrombolysis, and NOAC treatment was documented as main reason for not administering thrombolysis in 52.7% (79/150) of patients.
Conclusions—
NOAC treatment currently poses a significant barrier to thrombolysis in ischemic stroke. Because nonspecific coagulation test results within normal range have a high false-negative rate for detection of relevant drug concentrations, rapid drug-specific tests for thrombolysis decision-making should be established.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01850797.
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25
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Feasibility of rapid measurement of Rivaroxaban plasma levels in patients with acute stroke. J Thromb Thrombolysis 2016; 43:112-116. [DOI: 10.1007/s11239-016-1431-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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26
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Hsieh FI, Jeng JS, Chern CM, Lee TH, Tang SC, Tsai LK, Liao HH, Chang H, LaBresh KA, Lin HJ, Chiou HY, Chiu HC, Lien LM. Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke. PLoS One 2016; 11:e0160426. [PMID: 27487190 PMCID: PMC4972387 DOI: 10.1371/journal.pone.0160426] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/19/2016] [Indexed: 11/22/2022] Open
Abstract
In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010–2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006–08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States.
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Affiliation(s)
- Fang-I Hsieh
- School of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Ming Chern
- Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Linkou, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsun-Hsiang Liao
- Taiwan Joint Commission on Hospital Accreditation, Taipei, Taiwan
| | - Hang Chang
- Taiwan Joint Commission on Hospital Accreditation, Taipei, Taiwan
| | | | - Hung-Jung Lin
- Taiwan Joint Commission on Hospital Accreditation, Taipei, Taiwan
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Hung-Yi Chiou
- School of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Hou-Chang Chiu
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- College of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Drouet L, Bal dit Sollier C, Steiner T, Purrucker J. Measuring non-vitamin K antagonist oral anticoagulant levels: When is it appropriate and which methods should be used? Int J Stroke 2016; 11:748-58. [DOI: 10.1177/1747493016659671] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/27/2016] [Indexed: 12/26/2022]
Abstract
Background Although the need for an emergency intervention may merit laboratory measurement of non-vitamin K antagonist oral anticoagulant (NOAC) concentration or anticoagulant activity, NOACs are not supposed to require routine monitoring due to their stable pharmacological profiles compared with warfarin. Aims To examine situations where NOAC measurement may be useful and to provide information about methodologies available to measure NOAC-related anticoagulation activity. Summary of review The routine coagulation tests, including prothrombin time, thrombin time, activated partial thromboplastin time, and international normalized ratio, have variable sensitivities to NOACs. Tests have been developed for use with specific NOACs, e.g. diluted thrombin time or chromogenic factor Xa assays. In emergency situations, such as severe bleeding, stroke, or a requirement for urgent surgery or procedures, there may be a need to assess anticoagulant activity to guide clinical decision making. In cases where neutralization of the anticoagulant effect is warranted, specific reversal agents are likely to become invaluable medical tools. Evidence to date suggests that dosing decisions for NOACs based on clinical features (e.g. age or renal function) can help optimize the benefit–risk balance without assessment of anticoagulant activity in non-emergency routine situations. Conclusions Regular monitoring of NOAC levels does not provide benefits and cannot be recommended at present. In some specific circumstances, e.g. severe bleeding, before urgent surgery, or before thrombolysis, measurement may be beneficial to assess whether a patient is actively anticoagulated. The availability of NOAC-specific reversal agents may change management practices in emergencies.
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Affiliation(s)
- Ludovic Drouet
- Hôpital Lariboisière, Paris, France and Paris VII University, Paris, France
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Effective management of patients with acute ischemic stroke based on lean production on thrombolytic flow optimization. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2016; 39:987-996. [PMID: 27094731 DOI: 10.1007/s13246-016-0442-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
Abstract
The efficacy of thrombolytic therapy for acute ischemic stroke (AIS) decreases when the administration of tissue plasminogen activator (tPA) is delayed. Derived from Toyota Production System, lean production aims to create top-quality products with high-efficiency procedures, a concept that easily applies to emergency medicine. In this study, we aimed to determine whether applying lean principles to flow optimization could hasten the initiation of thrombolysis. A multidisciplinary team (Stroke Team) was organized to implement an ongoing, continuous loop of lean production that contained the following steps: decomposition, recognition, intervention, reengineering and assessment. The door-to-needle time (DNT) and the percentage of patients with DNT ≤ 60 min before and after the adoption of lean principles were used to evaluate the efficiency of our flow optimization. Thirteen patients with AIS in the pre-lean period and 43 patients with AIS in the lean period (23 in lean period I and 20 patients in lean period II) were consecutively enrolled in our study. After flow optimization, we reduced DNT from 90 to 47 min (p < 0.001¤). In addition, the percentage of patients treated ≤60 min after hospital arrival increased from 38.46 to 75.0 % (p = 0.015¤). Adjusted analysis of covariance confirmed a significant influence of optimization on delay of tPA administration (p < 0.001). The patients were more likely to have a good prognosis (mRS ≤ 2 at 90 days) after the flow optimization (30.77-75.00 %, p = 0.012¤). Our study may offer an effective approach for optimizing the thrombolytic flow in the management of AIS.
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Huang Q, Ma QF, Feng J, Cheng WY, Jia JP, Song HQ, Chang H, Wu J. Factors Associated with In-Hospital Delay in Intravenous Thrombolysis for Acute Ischemic Stroke: Lessons from China. PLoS One 2015; 10:e0143145. [PMID: 26575839 PMCID: PMC4648585 DOI: 10.1371/journal.pone.0143145] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/30/2015] [Indexed: 11/19/2022] Open
Abstract
In-hospital delay reduces the benefit of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS), while factors affecting in-hospital delay are less well known in Chinese. We are aiming at determining the specific factors associated with in-hospital delay through a hospital based cohort. In-hospital delay was defined as door-to-needle time (DTN) ≥60min (standard delay criteria) or ≥75% percentile of all DTNs (severe delay criteria). Demographic data, time intervals [onset-to-door time (OTD), DTN, door-to-examination time (DTE), door-to-imaging time (DTI), door-to-laboratory time (DTL) and final-test-to-needle time (FTN, the time interval between the time obtaining the result of the last screening test and the needle time)], medical history and additional variables were calculated using Mann-Whitney U or Pearson Chi-Square tests for group comparison, and multivariate linear regression analysis was performed to identify independent variables of in-hospital delay. A total of 202 IVT cases were enrolled. The median age was 61 years and 25.2% were female. The cutoff points for the upper quartile of DTN (severe delay criteria) was 135min.When compared with the reference group without in-hospital delay, older age, shorter OTD and less referral were found in the standard delay group and male sex, presence with transient ischemic attacks or rapidly improving symptom, and with multi-model CT imaging were more frequent in the severe delay group. In the multivariate linear regression analysis, FTN (P<0.001) and DTL (P = 0.002) were significantly associated with standard delay; while DTE (P = 0.005), DTI (P = 0.033), DTL (P<0.001), and FTN (P<0.001) were positively associated with severe delay. There was not a significant change in the trend of DTNs during the study period (P = 0.054). In-hospital delay was due to multifactors in China, in which time delays of decision-making process and laboratory tests contributed the most. Efforts aiming at reducing the delay should be focused on the optimization for the items of screening tests and improvement of the pathway organization.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qing-feng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Juan Feng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei-yang Cheng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian-ping Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hai-qing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hong Chang
- Department of Nursing, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- * E-mail:
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30
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Härtig F, Purrucker J, Hametner C, Poli S. [From stroke to reperfusion : How can we be faster?]. Med Klin Intensivmed Notfmed 2015; 111:703-707. [PMID: 26459456 DOI: 10.1007/s00063-015-0092-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/01/2015] [Accepted: 08/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND During the last two decades major efforts in clinical research have led to the establishment of intravenous thrombolysis as the first line acute therapy for ischemic stroke. More recently, data from successful phase III trials have provided proof of the efficiency of mechanical recanalization in acute stroke. The fact that the efficiency of the available therapies can be increased through faster delivery is well documented; however, many institutions dealing with the emergency care of stroke patients lack organizational or infrastructural arrangements to optimize time efficiency in the diagnostic and therapeutic workup. CONCLUSION Many of these arrangements have been well evaluated, can be implemented at reasonable costs and have been proven to increase the beneficial effects of thrombolytic therapy.
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Affiliation(s)
- F Härtig
- Abteilung Neurologie mit Schwerpunkt neurovaskuläre Erkrankungen, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72070, Tübingen, Deutschland
| | - J Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - C Hametner
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - S Poli
- Abteilung Neurologie mit Schwerpunkt neurovaskuläre Erkrankungen, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72070, Tübingen, Deutschland.
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Abstract
OPINION STATEMENT The acute treatment of major ischemic stroke has been revolutionized by strong and consistent evidence from multiple randomized trials. Endovascular treatment by mechanical thrombectomy will be increasingly chosen as an adjunctive or alternative to intravenous thrombolysis. To apply this form of stroke treatment is associated with the challenge of optimal periinterventional treatment. The patient has to be identified, counselled, prepared, monitored, cardiovascularly stabilized, possibly sedated and ventilated, and postprocedurally treated in the optimal way. However, most aspects of periinterventional treatment have as yet not been clarified and require prospective research. Among these, the question of general anesthesia vs conscious sedation has received most attention and may be the most crucial one. Based on a great amount of retrospective data, it appears reasonable to start the intervention under conscious sedation of the non-intubated patient with standby measures for emergent intubation, until prospective randomized trials have clarified that issue. Periinterventional management will significantly affect the success of recanalization.
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Affiliation(s)
- Julian Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Ebner M, Peter A, Spencer C, Härtig F, Birschmann I, Kuhn J, Wolf M, Winter N, Russo F, Zuern CS, Blumenstock G, Ziemann U, Poli S. Point-of-Care Testing of Coagulation in Patients Treated With Non-Vitamin K Antagonist Oral Anticoagulants. Stroke 2015; 46:2741-7. [PMID: 26272385 DOI: 10.1161/strokeaha.115.010148] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/17/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Specific coagulation assays for non-vitamin K antagonist oral anticoagulants (NOAC) are relatively slow and often lack availability. Although specific point-of-care tests (POCT) are currently not available, NOAC are known to affect established coagulation POCT. This study aimed at determining the diagnostic accuracy of the CoaguChek POCT to rule out relevant concentrations of rivaroxaban, apixaban, and dabigatran in real-life patients. METHODS We consecutively enrolled 60 ischemic stroke patients newly started on NOAC treatment and obtained blood samples at 6 prespecified time points. Samples were tested using the CoaguChek POCT, laboratory-based coagulation assays (prothrombin time and activated partial thromboplastin time, anti-Xa test and Hemoclot), and liquid chromatography-tandem mass spectrometry for direct determination of NOAC concentrations. RESULTS Three hundred fifty-six blood samples were collected. The CoaguChek POCT strongly correlated (r=0.82 P<0.001) with rivaroxaban concentrations but did not accurately detect dabigatran or apixaban. If used to estimate the presence of low rivaroxaban concentrations, POCT was superior to predictions based on normal prothrombin time and activated partial thromboplastin time values even if sensitive reagents were used. POCT-results≤1.0 predicted rivaroxaban concentrations<32 and <100 ng/mL with a specificity of 90% and 96%, respectively. CONCLUSIONS If anti-Xa test is not available, we propose the use of the CoaguChek POCT to guide thrombolysis decisions after individual risk assessment in rivaroxaban-treated patients having acute ischemic stroke. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02371044.
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Affiliation(s)
- Matthias Ebner
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Andreas Peter
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Charlotte Spencer
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Florian Härtig
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Ingvild Birschmann
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Joachim Kuhn
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Martin Wolf
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Natalie Winter
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Francesca Russo
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Christine S Zuern
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Gunnar Blumenstock
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Ulf Ziemann
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.)
| | - Sven Poli
- From the Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., C.S., F.H., M.W., N.W., F.R., U.Z., S.P.), Division of Clinical Chemistry and Pathobiochemistry, Department of Internal Medicine IV (A.P.), Department of Cardiology and Cardiovascular Medicine (C.S.Z.), and Department of Clinical Epidemiology and Applied Biometry (G.B.), University of Tübingen, Tübingen, Germany; and Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.).
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Beynon C, Erk AG, Potzy A, Mohr S, Popp E. Point of care coagulometry in prehospital emergency care: an observational study. Scand J Trauma Resusc Emerg Med 2015; 23:58. [PMID: 26260487 PMCID: PMC4542099 DOI: 10.1186/s13049-015-0139-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/31/2015] [Indexed: 11/16/2022] Open
Abstract
Background Haemostatic impairment can have a crucial impact on the outcome of emergency patients, especially in cases of concomitant antithrombotic drug treatment. In this prospective observational study we used a point of care (POC) coagulometer in a prehospital physician-based emergency medical system in order to test its validity and potential value in the treatment of emergency patients. Methods During a study period of 12 months, patients could be included if venous access was mandatory for further treatment. The POC device CoaguChek® was used to assess international normalized ratio (INR) after ambulance arrival at the scene. Results were compared with in-hospital central laboratory assessment of INR. The gain of time was analysed as well as the potential value of POC testing through a questionnaire completed by the responsible prehospital emergency physician. Results A total of 103 patients were included in this study. POC INR results were highly correlated with results of conventional assessment of INR (Bland-Altman-bias: 0.014). Using a cutoff value of INR >1.3, the device’s sensitivity to detect coagulopathy was 100 % with a specificity of 98.7 %. The median gain of time was 69 min. Treating emergency physicians considered the value of prehospital POC INR testing ‘high’ in 9 % and ‘medium’ in 21 % of all patients. In patients with tracer diagnosis ‘neurology’, the value of prehospital INR assessment was considered ‘high’ or ‘medium’ (63 %) significantly more often than in patients with non-neurological tracer diagnoses (24 %). Conclusions Assessment of INR through a POC coagulometer is feasible in prehospital emergency care and provides valuable information on haemostatic parameters in patients. Questionnaire results suggest that POC INR testing may present a valuable technique in selected patients. Whether this information translates into an improved management of respective patients has to be evaluated in further studies.
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Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Angelina G Erk
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Anna Potzy
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Stefan Mohr
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Erik Popp
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Bruch TP, Mendes DC, Pedrozo JC, Figueiredo L, Nóvak EM, Zétola VF, Lange MC. Is point-of-care accurate for indicating thrombolysis in anticoagulated patients on oral anticoagulation treatments? ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:487-9. [PMID: 25054978 DOI: 10.1590/0004-282x20140075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 05/06/2014] [Indexed: 11/22/2022]
Abstract
UNLABELLED The use of oral anticoagulation treatment (OAT) in patients with an international normalized ratio (INR) higher than 1.7 is a contraindication to thrombolysis in acute ischemic stroke. The aim of the present study is to compare the use of point-of-care (POC) coagulometers to the standard coagulation analysis (SCA) procedure of the INR as a decision-making test for use with patients taking OAT. METHOD Eighty patients on chronic OAT underwent a POC and an SCA during a regular outpatient evaluation. RESULTS When comparing the abilities of the POC test and the SCA test to identify adequate levels for thrombolysis (≤1.7), the POC had a sensitivity of 96.6% (95%CI 88.4-99.1) and a specificity of 60.0% (95%CI 38.6-78). POC overestimated INR levels by 0.51 points compared to the SCA test. CONCLUSION POC has a high sensitivity compared to the SCA test for the identification of patients within the cut-off point for thrombolysis.
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Affiliation(s)
- Tatiana P Bruch
- Divisão de Neurologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Danielle C Mendes
- Divisão de Neurologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Jeff C Pedrozo
- Divisão de Neurologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Lívia Figueiredo
- Divisão de Neurologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Edison M Nóvak
- Divisão de Neurologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Viviane F Zétola
- Divisão de Neurologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Marcos C Lange
- Divisão de Neurologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
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Beynon C, Unterberg AW, Sakowitz OW. Point of care coagulation testing in neurosurgery. J Clin Neurosci 2014; 22:252-7. [PMID: 25439750 DOI: 10.1016/j.jocn.2014.07.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/13/2014] [Accepted: 07/28/2014] [Indexed: 11/19/2022]
Abstract
Impaired haemostasis represents a major risk factor for bleeding complications in neurosurgical patients. Coagulopathy commonly occurs after (brain) trauma and major haemorrhage or originates from antithrombotic medication. Point of care (POC) devices for bedside assessment of haemostatic parameters are increasingly used in various medical specialties. Results can be instantly implemented into treatment modalities as results are delivered within a very short period. POC coagulation testing has also shown beneficial effects in the treatment of neurosurgical patients. Identification of hyperfibrinolysis is achieved through viscoelastic testing of haemostasis and bedside coagulometry hastens the management of anticoagulated patients in need of urgent neurosurgical procedures. Results of POC testing of platelet function have been correlated with patient outcomes after traumatic brain injury and furthermore, quantification of antiplatelet medication effects on platelet activity is made possible through the use of these devices. Further studies are needed to characterise the potential of POC testing of platelet function. Antiplatelet medication plays an important role in regard to haemorrhagic and thromboembolic risks. Therefore, POC testing of platelet activity may improve treatment modalities in patients undergoing neurosurgical procedures as well as neurointerventional procedures (such as intracranial stent placement). In this article we summarise the available data of POC testing in neurosurgical patients and discuss the potential of these devices in this field. POC technologies have improved patient care in various medical fields and in our view it is likely that this will also apply to the field of neurosurgery.
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Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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Nusa D, Harvey I, Almansouri AY, Wright S, Neeman T, Ahmad O, Hughes AR, Lueck CJ. Assessment of point-of-care measurement of international normalised ratio using the CoaguChek XS Plus system in the setting of acute ischaemic stroke. Intern Med J 2014; 43:1205-9. [PMID: 23906088 DOI: 10.1111/imj.12255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/24/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Thrombolysis with alteplase (recombinant tissue plasminogen activator) is accepted hyperacute therapy for acute ischaemic stroke. Clotting must be normal before this can be administered safely. Laboratory testing of international normalised ratio (INR) takes 30-60 min, which can significantly delay administration of recombinant tissue plasminogen activator. Previous studies have suggested that point-of-care testing is useful in patients presenting with stroke and improves door-to-needle time. We performed a prospective study of point-of-care testing in patients presenting with acute ischaemic stroke. METHODS Fifty patients were entered into the study to compare point-of-care testing using the CoaguChek XS system with laboratory testing of INR. RESULTS Point-of-care testing correlated well with laboratory levels (R = 0.93, P < 0.0001). The standard deviation of difference between the two was 0.115. Overall, point-of-care testing tended to underestimate INR slightly, meaning that an INR value of 1.1 or less was required to be 95% certain that the laboratory value was 1.3 or below. Simultaneous testing using blood from a syringe was more consistent with laboratory results than testing capillary blood through finger prick. CONCLUSION Point-of-care INR testing correlates well with laboratory values. The results in this study mostly relate to values in the normal range. We suggest that it can be used to try to shorten door-to-needle time.
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Affiliation(s)
- D Nusa
- Department of Neurology, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
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Tai YJ, Yan B. Minimising time to treatment: targeted strategies to minimise time to thrombolysis for acute ischaemic stroke. Intern Med J 2014; 43:1176-82. [PMID: 23734983 DOI: 10.1111/imj.12204] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 05/22/2013] [Indexed: 12/01/2022]
Abstract
Time to thrombolysis is a critical determinant of favourable outcomes in acute ischaemic stroke. It is not infrequent that patient outcomes are compromised due to out-of-hospital and in-hospital time delays. On the other hand, time delays could be minimised through the identification of barriers and the implementation of targeted solutions. This review outlines the different strategies in minimising treatment delays and offers recommendations. Literature search in PubMed, Medline and EBSCO Host was conducted to identify studies that are relevant to reduction of time to treatment from January 1995 to December 2012. Strategies to reduce time to thrombolysis are categorised into pre-hospital strategies, in-hospital strategies and post-treatment decision strategies. Proposed pre-hospital strategies include public education on stroke symptoms awareness, prioritising stroke by emergency medical services, increasing ease of access to medical records, pre-hospital notification, and mobile computed tomography scanning. In-hospital strategies include a streamlined code stroke system, computed tomography scanner co-location with emergency department, 24/7 availability of stroke physicians, point-of-care laboratory testing and access to expert neuroimaging interpretation. Post-decision strategies include increasing availability of intravenous thrombolysis and simplification of informed consent procurement. Time to thrombolysis delays is multifactorial. Effective reduction of time delays for acute ischaemic stroke requires the correct identification of and targeted strategies to overcome time barriers.
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Affiliation(s)
- Y J Tai
- Department of Medicine, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Chen CH, Tang SC, Tsai LK, Hsieh MJ, Yeh SJ, Huang KY, Jeng JS. Stroke code improves intravenous thrombolysis administration in acute ischemic stroke. PLoS One 2014; 9:e104862. [PMID: 25111200 PMCID: PMC4128738 DOI: 10.1371/journal.pone.0104862] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/12/2014] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Timely intravenous (IV) thrombolysis for acute ischemic stroke is associated with better clinical outcomes. Acute stroke care implemented with “Stroke Code” (SC) may increase IV tissue plasminogen activator (tPA) administration. The present study aimed to investigate the impact of SC on thrombolysis. Methods The study period was divided into the “pre-SC era” (January 2006 to July 2010) and “SC era” (August 2010 to July 2013). Demographics, critical times (stroke symptom onset, presentation to the emergency department, neuroimaging, thrombolysis), stroke severity, and clinical outcomes were recorded and compared between the two eras. Results During the study period, 5957 patients with acute ischemic stroke were admitted; of these, 1301 (21.8%) arrived at the emergency department within 3 h of stroke onset and 307 (5.2%) received IV-tPA. The number and frequency of IV-tPA treatments for patients with an onset-to-door time of <3 h increased from the pre-SC era (n = 91, 13.9%) to the SC era (n = 216, 33.3%) (P<0.001). SC also improved the efficiency of IV-tPA administration; the median door-to-needle time decreased (88 to 51 min, P<0.001) and the percentage of door-to-needle times ≤60 min increased (14.3% to 71.3%, P<0.001). The SC era group tended to have more patients with good outcome (modified Rankin Scale ≤2) at discharge (49.5 vs. 39.6%, P = 0.11), with no difference in symptomatic hemorrhage events or in-hospital mortality. Conclusion The SC protocol increases the percentage of acute ischemic stroke patients receiving IV-tPA and decreases door-to-needle time.
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Affiliation(s)
- Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Division of Neurology, Department of Internal Medicine, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Yu Huang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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Conforto AB. Potential impact of point-of-care INR testing on intravenous thrombolysis. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:485-6. [DOI: 10.1590/0004-282x20140114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 06/09/2014] [Indexed: 11/22/2022]
Affiliation(s)
- Adriana Bastos Conforto
- Universidade de São Paulo, Brazil; Hospital Israelita Albert Einstein, Brazil; Cleveland Clinic, United States
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Ploen R, Sun L, Zhou W, Heitmeier S, Zorn M, Jenetzky E, Veltkamp R. Rivaroxaban does not increase hemorrhage after thrombolysis in experimental ischemic stroke. J Cereb Blood Flow Metab 2014; 34:495-501. [PMID: 24346690 PMCID: PMC3948130 DOI: 10.1038/jcbfm.2013.226] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 10/21/2013] [Accepted: 11/15/2013] [Indexed: 12/30/2022]
Abstract
The management of acute ischemic stroke during anticoagulation with a novel oral anticoagulant (NOAC) is challenging because intravenous thrombolysis is contraindicated because of a putative increased risk of intracerebral hemorrhagic complications. We examined the risk of secondary postischemic hemorrhage after thrombolysis in rodents pretreated with rivaroxaban or warfarin. Mice were pretreated with either rivaroxaban (30 mg/kg), warfarin (target international normalized ratio 2 to 3) or vehicle. After 2 or 3 hours, middle cerebral artery occlusion (MCAO), mice received 9 mg/kg recombinant tissue plasminogen activator. Twenty-four hours after MCAO, secondary hemorrhage was quantified using a macroscopic hemorrhage score and hemoglobin spectrophotometry. Blood-brain barrier (BBB) permeability was measured by Evans Blue spectrofluorometry. To increase the validity of our findings, experiments were also performed using a thromboembolic model in anticoagulated rats. Infarct size did not differ among groups. Pretreatment with warfarin led to significantly more secondary hemorrhage compared with rivaroxaban and nonanticoagulated controls after 2- and 3-hour ischemia in mice as well as in rats. Blood-brain barrier permeability was significantly higher in the warfarin group compared with rivaroxaban and control. Thus, rivaroxaban in contrast to warfarin does not increase secondary hemorrhage after thrombolysis in experimental cerebral ischemia. Less effects of rivaroxaban on postischemic BBB permeability may account for this difference.
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Affiliation(s)
- Robert Ploen
- Department of Neurology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Li Sun
- Department of Neurology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Wei Zhou
- Department of Neurology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Markus Zorn
- Department of Internal Medicine I, Ruprecht-Karls-University, Heidelberg, Germany
| | - Ekkehart Jenetzky
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Roland Veltkamp
- Department of Neurology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
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Ferrari J, Knoflach M, Seyfang L, Lang W. Differences in process management and in-hospital delays in treatment with iv thrombolysis. PLoS One 2013; 8:e75378. [PMID: 24069406 PMCID: PMC3771907 DOI: 10.1371/journal.pone.0075378] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Accepted: 08/13/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Rapid initiation of intravenous thrombolysis improves patient's outcome in acute stroke. We analyzed inter-center variability and factors that influence the door-to-needle time with a special focus on process measurements in all Austrian stroke units. METHODS Case level data of patients receiving intravenous thrombolysis in the Austrian Stroke Unit Registry were enriched with information of a structured questionnaire on center specific process measures of all Austrian stroke units. Influence of case and center specific variables was determined by LASSO procedure. RESULTS Center specific median door-to-needle time ranged between 30 and 78 minutes. Between April 2004 and November 2012, 6246 of 57991 patients treated in Austrian stroke units with acute ischemic stroke received intravenous thrombolysis. An onset-to-door time >120 minutes, patients with total anterior circulation stroke, recent year of admission, patient transportation with ambulance crew and emergency physician, the use of point of care tests reduced the door-to-needle time, whereas onset-to-door ≤ 60 minutes, unknown onset-to-door, patients with an NIHSS ≤ 4 or posterior circulation stroke, initial admission to a general emergency department, a distant radiology department, primary imaging modality other than plain CT and waiting for the lab results were associated with an increase in door-to-needle time. Case level and center specific factors could explain the inter center variability of door-to-needle times in 31 of 34 stroke units in Austria. CONCLUSIONS In light of our results it seems crucial that every single stroke center documents and critically reviews possibilities of optimizing practice strategies in acute stroke care.
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Affiliation(s)
- Julia Ferrari
- Department of Neurology, Hospital Barmherzige Brueder, Vienna, Austria
| | - Michael Knoflach
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Leonhard Seyfang
- Department for Clinical Neurosciences and Preventive Medicine, Danube University, Krems, Austria
| | - Wilfried Lang
- Department of Neurology, Hospital Barmherzige Brueder, Vienna, Austria
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Diener HC, Foerch C, Riess H, Röther J, Schroth G, Weber R. Treatment of acute ischaemic stroke with thrombolysis or thrombectomy in patients receiving anti-thrombotic treatment. Lancet Neurol 2013; 12:677-88. [DOI: 10.1016/s1474-4422(13)70101-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Steiner T, Böhm M, Dichgans M, Diener HC, Ell C, Endres M, Epple C, Grond M, Laufs U, Nickenig G, Riess H, Röther J, Schellinger PD, Spannagl M, Veltkamp R. Recommendations for the emergency management of complications associated with the new direct oral anticoagulants (DOACs), apixaban, dabigatran and rivaroxaban. Clin Res Cardiol 2013; 102:399-412. [PMID: 23669868 DOI: 10.1007/s00392-013-0560-7] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 03/21/2013] [Indexed: 02/07/2023]
Abstract
Dabigatran, apixaban, and rivaroxaban have been approved for primary and secondary stroke prevention in patients with atrial fibrillation. However, questions have arisen about how to manage emergency situations, such as when thrombolysis would be required for acute ischemic stroke or for the managing intracranial or gastrointestinal bleedings. We summarize the current literature and provide recommendations for the management of these situations. Peak plasma levels of the direct oral anticoagulants (DOACs) apixaban, dabigatran, or rivaroxaban are observed about 2-4 h after intake. Elimination of dabigatran is mainly dependent on renal function. Consequently, if renal function is impaired, there is a risk of drug accumulation that is highest for dabigatran followed by rivaroxaban and then apixaban and thus dosing recommendations are different. To date, no bedside tests are available that reliably assess the anticoagulatory effect of DOACs, nor are specific antidotes available. We recommend performing the following tests if DOAC intake is unknown: dabigatran-associated bleeding risk is minimized or can be neglected if thrombin time, Hemoclot test, or Ecarin clotting time is normal. Apixaban and rivaroxaban effects can be ruled out if findings from the anti-factor Xa activity test are normal. High plasma levels of DOAC are also mostly excluded if PTT and PTZ are normal four or more hours after DOAC intake. However, normal values of global coagulation tests are not sufficient if thrombolysis is indicated for treating acute stroke. The decision for or against thrombolysis is an individual decision; in these cases, thrombolysis use is off-label. In case of bleeding, prothrombin complex concentrates seems to be the most plausible treatment. For severe gastrointestinal bleeding with life-threatening blood loss, the bleeding source needs to be identified and treated by invasive measures. Use of procoagulant drugs (antifibrinolytics) might also be considered. However, there is very limited clinical experience with these products in conjunction with DOAC.
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Affiliation(s)
- T Steiner
- Neurologische Klinik, Klinikum Frankfurt Höchst, Frankfurt am Main, Germany.
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Laborde CM, Mourino-Alvarez L, Akerstrom F, Padial LR, Vivanco F, Gil-Dones F, Barderas MG. Potential blood biomarkers for stroke. Expert Rev Proteomics 2013; 9:437-49. [PMID: 22967080 DOI: 10.1586/epr.12.33] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Stroke is one of the most common causes of death worldwide and a major cause of acquired disability in adults. Despite advances in research during the last decade, prevention and treatment strategies still suffer from significant limitations, and therefore new theoretical and technical approaches are required. Technological advances in the proteomic and metabolomic areas, during recent years, have permitted a more effective search for novel biomarkers and therapeutic targets that may allow for effective risk stratification and early diagnosis with subsequent rapid treatment. This review provides a comprehensive overview of the latest candidate proteins and metabolites proposed as new potential biomarkers in stroke.
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Affiliation(s)
- Carlos M Laborde
- Laboratory of Vascular Pathophysiology, Hospital Nacional de Paraplejicos, SESCAM, Toledo, Spain
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Rizos T, Horstmann S, Jenetzky E, Spindler M, Gumbinger C, Möhlenbruch M, Ringleb P, Hacke W, Veltkamp R. Oral anticoagulants--a frequent challenge for the emergency management of acute ischemic stroke. Cerebrovasc Dis 2012; 34:411-8. [PMID: 23221347 DOI: 10.1159/000343655] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 09/19/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The emergency management of patients with acute ischemic stroke (IS) using oral anticoagulants (OAC) represents a great challenge. Effective anticoagulation predisposes to bleeding and represents a contraindication for systemic thrombolysis. However, patients on OAC can receive intravenous thrombolysis with recombinant tissue-type plasminogen activator if the international normalized ratio (INR) does not exceed 1.7, but data regarding the risk of hemorrhagic complications are highly controversial. Neurointerventional recanalization of intracranial artery occlusion represents an alternative option in OAC patients with acute IS. The proportion of OAC users among consecutive patients who suffer from acute IS or transient ichemic attacks (TIA) is unknown. METHODS A prospective observational study, consecutively enrolling all patients with IS or TIA admitted to our neurological emergency room (ER), was performed between August 2009 and February 2011. Basic demographic variables, present use of OAC, severity of stroke, cardiovascular risk factors, INR values and the symptom onset to presentation time were recorded. In IS patients on OAC presenting within 4.5 h after symptom onset, management was analyzed. In thrombolysed IS patients, bleeding events were documented. Outcome was assessed after 3 months. RESULTS During the study period, 12,237 patients were admitted to our neurological ER. IS or TIA were diagnosed in 2,074 (16.9%). Complete data were available for 1,914 of these subjects (92.3%); 53.8% were male (median age: 72 years). 69.7% suffered IS, 30.3% TIA. OAC were being used by 8.7% of all patients. OAC patients were older than non-OAC patients (78 vs. 72 years, p < 0.001). Subtherapeutic INR values (<2.0) were found in 67.3% of OAC patients with IS. 54.8% of all OAC IS patients presented at the ER within ≤4.5 h after the event (57/104). An INR ≤1.7 - compatible with systemic thrombolysis - was present in 33/57 patients (57.9%). Recanalization therapy was performed in 21/57 patients (36.8%). No difference in symptomatic or fatal intracerebral bleedings between thrombolysed patients with and without prior OAC use was observed (p = 0.720 and 0.135, respectively). Multivariable analysis of predictors of the 3-month outcome in IS patients revealed that prior medication with OAC was neither associated with an unfavorable clinical outcome after 3 months in the whole population of stroke patients (p = 0.235) nor in patients in whom recanalization approaches were used (n = 306; p = 0.271). CONCLUSIONS Oral anticoagulation represents a frequent challenge for the emergency manangement of IS. A considerable proportion of anticoagulated IS patients appears to be eligible for thrombolysis. Establishing standardized treatment procedures in these patients is warranted.
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Affiliation(s)
- Timolaos Rizos
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Nanduri S, Tayal AH, Hegde GG, Shang J, Venkat A. An analysis of discrepancy between point-of-care and central laboratory international normalized ratio testing in ED patients with cerebrovascular disease. Am J Emerg Med 2012; 30:2025-9. [DOI: 10.1016/j.ajem.2012.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 03/31/2012] [Accepted: 04/01/2012] [Indexed: 11/16/2022] Open
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Diagnostic et prise en charge de la coagulopathie post-traumatique. Transfus Clin Biol 2012; 19:165-73. [DOI: 10.1016/j.tracli.2012.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 07/21/2012] [Indexed: 11/21/2022]
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Evaluation of the i-STAT point-of-care capillary whole blood prothrombin time and international normalized ratio: Comparison to the Tcoag MDAII coagulation analyzer in the central laboratory. Clin Chim Acta 2012; 413:955-9. [DOI: 10.1016/j.cca.2012.01.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 12/27/2011] [Accepted: 01/30/2012] [Indexed: 11/20/2022]
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POINT-OF-CARE HEMATOLOGY AND COAGULATION TESTING IN PRIMARY, RURAL EMERGENCY, AND DISASTER CARE SCENARIOS. POINT OF CARE 2012; 11:140-145. [PMID: 23843728 DOI: 10.1097/poc.0b013e31825a9d3a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The purpose of this article is to review current principles and criteria for obtaining Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) waiver, identify existing point-of-care (POC) coagulation and hematology technologies, and analyze regulatory challenges regarding CLIA-waiver for those and future devices. CLIA '88 documentation requires tests performed by laboratories with a Certificate of Waiver to be so simple that the likelihood of erroneous results by the user is negligible, or poses no unreasonable risk of harm to the patient if performed incorrectly as determined by the Secretary of Health and Human Services. "Simple" means that the test uses unprocessed samples, has a direct read-out of test results, does not have specifications for user training, and includes instructions for confirmatory testing when advisable. Currently the CLIA-waived hematology and coagulation POC devices only test for hemoglobin (Hb), hematocrit (Hct), and prothrombin time/international normalized ratio (PT/INR). The problem with these devices is the lack of multiplexing. POC coagulation and hematology devices face challenges for obtaining a waiver. These challenges include the lack of clinical needs assessment, miniturized assays that correct for interfering substances, and assays simple enough to be combined in a multiplex platform. Several scenarios demonstrate how POC coagulation or hematology devices can improve crisis care. Industry should perform needs assessment on clinicians and emergency responders to determine which analytes to incorporate on multiplex POC coagulation and hematology devices, and produce devices that address confounding factors.
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