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van Valburg MK, Termorshuizen F, Geerts BF, Abdo WF, van den Bergh WM, Brinkman S, Horn J, van Mook WNKA, Slooter AJC, Wermer MJH, Siegerink B, Arbous MS. Predicting 30-day mortality in intensive care unit patients with ischaemic stroke or intracerebral haemorrhage. Eur J Anaesthesiol 2024; 41:136-145. [PMID: 37962175 PMCID: PMC10763719 DOI: 10.1097/eja.0000000000001920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Stroke patients admitted to an intensive care unit (ICU) follow a particular survival pattern with a high short-term mortality, but if they survive the first 30 days, a relatively favourable subsequent survival is observed. OBJECTIVES The development and validation of two prognostic models predicting 30-day mortality for ICU patients with ischaemic stroke and for ICU patients with intracerebral haemorrhage (ICH), analysed separately, based on parameters readily available within 24 h after ICU admission, and with comparison with the existing Acute Physiology and Chronic Health Evaluation IV (APACHE-IV) model. DESIGN Observational cohort study. SETTING All 85 ICUs participating in the Dutch National Intensive Care Evaluation database. PATIENTS All adult patients with ischaemic stroke or ICH admitted to these ICUs between 2010 and 2019. MAIN OUTCOME MEASURES Models were developed using logistic regressions and compared with the existing APACHE-IV model. Predictive performance was assessed using ROC curves, calibration plots and Brier scores. RESULTS We enrolled 14 303 patients with stroke admitted to ICU: 8422 with ischaemic stroke and 5881 with ICH. Thirty-day mortality was 27% in patients with ischaemic stroke and 41% in patients with ICH. Important factors predicting 30-day mortality in both ischaemic stroke and ICH were age, lowest Glasgow Coma Scale (GCS) score in the first 24 h, acute physiological disturbance (measured using the Acute Physiology Score) and the application of mechanical ventilation. Both prognostic models showed high discrimination with an AUC 0.85 [95% confidence interval (CI), 0.84 to 0.87] for patients with ischaemic stroke and 0.85 (0.83 to 0.86) in ICH. Calibration plots and Brier scores indicated an overall good fit and good predictive performance. The APACHE-IV model predicting 30-day mortality showed similar performance with an AUC of 0.86 (95% CI, 0.85 to 0.87) in ischaemic stroke and 0.87 (0.86 to 0.89) in ICH. CONCLUSION We developed and validated two prognostic models for patients with ischaemic stroke and ICH separately with a high discrimination and good calibration to predict 30-day mortality within 24 h after ICU admission. TRIAL REGISTRATION Trial registration: Dutch Trial Registry ( https://www.trialregister.nl/ ); identifier: NTR7438.
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Affiliation(s)
- Mariëlle K van Valburg
- From the Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht (MKvV, AJCS), Department of Anaesthesiology, Intensive Care and Pain Medicine, Amphia Hospital, Breda (MKvV), National Intensive Care Evaluation Foundation, Amsterdam University Medical Center (FT, SB, MSA), Department of Medical Informatics, Amsterdam University Medical Center, Amsterdam (FT, SB), Healthplus.ai BV, Amsterdam (BFG), Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen (WFA), Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen (WMvdB), Department of Intensive Care, Amsterdam University Medical Center, Amsterdam (JH), Department of Intensive Care Medicine, and Academy for Postgraduate Training, Maastricht University Medical Center (WNKAvM), School of Health Professions Education, Maastricht University, Maastricht (WNKAvM), the UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS), Department of Neurology, Leiden University Medical Center, Leiden (MJHW), Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen (MJHW), Department of Clinical Epidemiology, Leiden University Medical Center (BS, MSA), Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands (MSA)
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Lin S, Xiao LD, Chamberlain D, Ullah S, Wang Y, Shen Y, Chen Z, Wu M. Nurse-led health coaching programme to improve hospital-to-home transitional care for stroke survivors: A randomised controlled trial. PATIENT EDUCATION AND COUNSELING 2022; 105:917-925. [PMID: 34294494 DOI: 10.1016/j.pec.2021.07.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate the effects of a nurse-led health coaching programme for stroke survivors and family caregivers in hospital-to-home transition care. METHODS A total of 140 dyads of stroke survivors and their family caregivers were recruited and randomly assigned to either the intervention group (received a 12-week nurse-led health coaching programme) or the usual care group. The primary outcome was self-efficacy, and secondary outcomes were quality of life (QoL), stroke-related knowledge, and caregiver-related burden. The outcomes were measured at baseline, 12 and 24 weeks. RESULTS Stroke survivors in the intervention group demonstrated a significant improvement in self-efficacy at 12 weeks (x̅: 24.9, 95%CI: 20.2-29.6, p < 0.001) and at 24 weeks (x̅: 23.9, 95%CI: 19.2-28.6, p < 0.001) compared to the usual care group. Findings also demonstrated significant increases in stroke survivors' QoL, stroke-related knowledge, and reduction in unplanned hospital readmissions and caregiver-related burden. There were no statistically significant changes in other outcomes between the two groups. CONCLUSION The nurse-led health coaching programme improved health outcomes for both stroke survivors and their caregivers. PRACTICE IMPACTION Findings from the study suggest that nurse-led health coaching should be incorporated into routine practice in hospital-to-home transitional care for stroke survivors and their caregivers.
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Affiliation(s)
- Shuanglan Lin
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Lily Dongxia Xiao
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.
| | - Diane Chamberlain
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Shahid Ullah
- College of Medicine and Public Health, Flinders University, Australia
| | - Yanjiang Wang
- Department of Neurology and Centre for Clinical Neuroscience, the Third Affiliated Hospital of Army Medical University, Chongqing, China
| | - Yingying Shen
- Department of Neurology and Centre for Clinical Neuroscience, the Third Affiliated Hospital of Army Medical University, Chongqing, China
| | - Zhenfang Chen
- Department of Neurology and Centre for Clinical Neuroscience, the First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Min Wu
- Department of Neurology and Centre for Clinical Neuroscience, the First Affiliated Hospital of Army Medical University, Chongqing, China
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Lettow I, Jensen M, Schlemm E, Boutitie F, Quandt F, Cheng B, Ebinger M, Endres M, Fiebach JB, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G. Serious Adverse Events and Their Impact on Functional Outcome in Acute Ischemic Stroke in the WAKE-UP Trial. Stroke 2021; 52:3768-3776. [PMID: 34433305 DOI: 10.1161/strokeaha.120.033425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE During the first days and weeks after an acute ischemic stroke, patients are prone to complications that can influence further treatment, recovery, and functional outcome. In clinical trials, severe complications are recorded as serious adverse events (SAE). We analyzed the effect of SAE on functional outcome and predictors of SAE in the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke). METHODS We performed a post hoc analysis of WAKE-UP, a multicenter, randomized, placebo-controlled clinical trial of magnetic resonance imaging-guided intravenous thrombolysis with alteplase in patients with acute ischemic stroke and unknown time of onset. Functional outcome was assessed by the modified Rankin Scale 90 days after the stroke. SAE were reported to a central safety desk and recorded and categorized by organ system using Medical Dictionary for Regulatory Activities terminology. We used logistic regression analysis to determine the effect of SAE on functional outcome and linear multiple regression analysis to identify baseline predictors of SAE. RESULTS Among 503 patients randomized, 199 SAE were reported for n=110 (22%) patients. Of those patients who did suffer a SAE, 20 (10%) had a fatal outcome. Patients suffering from at least one SAE had a lower odds of reaching a favorable outcome (modified Rankin Scale score of 0-1) at 90 days (adjusted odds ratio, 0.36 [95% CI, 0.21-0.61], P<0.001). Higher age (P=0.04) and male sex (P=0.01) were predictors for the occurrence of SAE. CONCLUSIONS SAEs were observed in about one in 5 patients, were more frequent in elderly and male patients and were associated with worse functional outcome. These results may help to assess the risk of SAE in future stroke trials and create awareness for severe complications after stroke in clinical practice. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01525290 and https://eudract.ema.europa.eu; Unique identifier: 2011-005906-32.
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Affiliation(s)
- Iris Lettow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, France (F.B.)
| | - Fanny Quandt
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Martin Ebinger
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Germany (M. Ebinger).,entrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany (M. Ebinger, M. Endres, J.B.F.)
| | - Matthias Endres
- entrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany (M. Ebinger, M. Endres, J.B.F.).,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (M. Endres)
| | - Jochen B Fiebach
- entrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany (M. Ebinger, M. Endres, J.B.F.)
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia (V.T.).,Austin Health, Department of Neurology, Australia (V.T.)
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (R.L.).,KU Leuven - University of Leuven, Department of Neurosciences, Experimental Neurology, Belgium (R.L.).,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Belgium (R.L.)
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, University Avenue, Glasgow G12 8QQ, United Kingdom (K.W.M.)
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, France (N.N.)
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, Italysa (S.P.)
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.)
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
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Ouyang M, Muñoz-Venturelli P, Billot L, Wang X, Song L, Arima H, Lavados PM, Hackett ML, Olavarría VV, Brunser A, Middleton S, Pontes-Neto OM, Lee TH, Watkins CL, Robinson T, Anderson CS. Low blood pressure and adverse outcomes in acute stroke: HeadPoST study explanations. J Hypertens 2021; 39:273-279. [PMID: 32897905 PMCID: PMC7810418 DOI: 10.1097/hjh.0000000000002649] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/13/2020] [Accepted: 08/15/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE As uncertainties exist over underlying causes, we aimed to define the characteristics and prognostic significance of low blood pressure (BP) early after the onset of acute stroke. METHODS Post hoc analyzes of the international Head Positioning in acute Stroke Trial (HeadPoST), a pragmatic cluster-crossover randomized trial of lying flat versus sitting up in stroke patients from nine countries during 2015-2016. Associations of baseline BP and death or dependency [modified Rankin scale (mRS) scores 3-6] and serious adverse events (SAEs) at 90 days were assessed in generalized linear mixed models with adjustment for multiple confounders. SBP and DBP was analysed as continuous measures fitted with a cubic spline, and as categorical measures with low (<10th percentile) and high (≥140 and ≥90 mmHg, respectively) levels compared with a normal range (≥10th percentile; 120-139 and 70-89 mmHg, respectively). RESULTS Among 11 083 patients (mean age 68 years, 39.9% women) with baseline BP values, 7.2 and 11.7% had low SBP (<120 mmHg) and DBP (<70 mmHg), respectively. Patients with low SBP were more likely to have preexisting cardiac and ischemic stroke and functional impairment, and to present earlier with more severe neurological impairment than other patients. Nonlinear 'J-shaped' relationships of BP and poor outcome were apparent: compared with normal SBP, those with low SBP had worse functional outcome (adjusted odds ratio 1.27, 95% confidence interval 1.02-1.58) and more SAEs, particularly cardiac events, with adjustment for potential confounders to minimize reverse causation. The findings were consistent for DBP and were stronger for ischemic rather than hemorrhagic stroke. CONCLUSION The prognostic significance of low BP on poor outcomes in acute stroke was not explained by reverse causality from preexisting cardiovascular disease, and propensity towards greater neurological deficits and cardiac events. These findings provide support for the hypothesis that low BP exacerbates cardiac and cerebral ischemia in acute ischemic stroke.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología and Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Hisatomi Arima
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Pablo M. Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología and Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Maree L. Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, UK
| | - Verónica V. Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología and Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Alejandro Brunser
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología and Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Sydney, Australia
| | - Octavio M. Pontes-Neto
- Stroke Service - Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto – SP, Brazil
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Caroline L. Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo
- Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia
- Heart Health Research Center, Beijing, China
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de Jonge JC, Woodhouse LJ, Reinink H, van der Worp HB, Bath PM. PRECIOUS: PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke-statistical analysis plan of a randomised, open, phase III, clinical trial with blinded outcome assessment. Trials 2020; 21:884. [PMID: 33106180 PMCID: PMC7586648 DOI: 10.1186/s13063-020-04717-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/31/2020] [Indexed: 12/01/2022] Open
Abstract
Rationale Aspiration, infections, and fever are common in the first days after stroke, especially in older patients. The occurrence of these complications has been associated with an increased risk of death or dependency. Aims and design PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke (PRECIOUS) is an international, multi-centre, 3 × 2 factorial, randomised, controlled, open-label clinical trial with blinded outcome assessment, which will assess whether prevention of aspiration, infections, or fever with metoclopramide, ceftriaxone, paracetamol, respectively, or any combination of these in the first 4 days after stroke onset improves functional outcome at 90 days in elderly patients with acute stroke. Discussion This statistical analysis plan provides a technical description of the statistical methodology and unpopulated tables and figures. The paper is written prior to data lock and unblinding of treatment allocation. Trial registration ISRCTN registry ISRCTN82217627. Registered on 22 September 2015. The trial was prospectively registered.
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Affiliation(s)
- Jeroen C de Jonge
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Hendrik Reinink
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Song J, Kim YS, Lee D, Kim H. Safety evaluation of root extract of Pueraria lobata and Scutellaria baicalensis in rats. BMC Complement Med Ther 2020; 20:226. [PMID: 32680504 PMCID: PMC7368675 DOI: 10.1186/s12906-020-02998-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/22/2020] [Indexed: 12/11/2022] Open
Abstract
Background The roots of Pueraria lobata and Scutellaria baicalensis, herbal medicines with a long history of widespread use, have been traditionally prescribed in combination to treat stroke, diabetes, and acute infectious diarrhea in East Asia. Nevertheless, toxicological data on these herbs and their combination are limited. This study investigated the acute and 13-week subchronic toxicity of root extract of P. lobata and S. baicalensis (HT047) for stroke treatment in male and female Sprague-Dawley rats. Methods In the acute toxicity study, HT047 was administered orally at a single dose of 5000 mg/kg. In the subchronic toxicity study, HT047 was administered orally at repeated daily doses of 800, 2000, and 5000 mg/kg/day for 13 weeks, followed by a 4-week recovery period. Results In the acute toxicity study, there were no deaths or toxicologically significant changes in clinical signs, body weight, and necropsy findings. In the subchronic toxicity study, HT047 at all doses caused no death and no treatment-related adverse effects on food consumption; organ weight; ophthalmologic, urinalysis, and hematological parameters; and necropsy findings of both rat sexes. There were some treatment-related alterations in clinical signs, body weight, and serum biochemistry and histopathological parameters; however, these changes were not considered toxicologically significant because they were resolved during the recovery period or resulted from the pharmacological effects of P. lobata and S. baicalensis. Conclusions The oral approximate lethal dose (the lowest dose that causes mortality) of HT047 was greater than 5000 mg/kg in male and female rats. The oral no-observed-adverse-effect level of HT047 was greater than 5000 mg/kg/day in rats of both sexes, and no target organs were identified. The present findings support the safety of an herbal extract of P. lobata and S. baicalensis as a therapeutic agent for stroke and further confirm the safety of the combined use of P. lobata and S. baicalensis in clinical practice.
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Affiliation(s)
- Jungbin Song
- Department of Herbal Pharmacology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Young-Sik Kim
- Department of Herbal Pharmacology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Donghun Lee
- Department of Herbal Pharmacology, College of Korean Medicine, Gachon University, 1342 Seongnamdae-ro, Sujeong-gu, Seongnam-si, Gyeonggi-do, 13120, Republic of Korea.
| | - Hocheol Kim
- Department of Herbal Pharmacology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea.
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Parkinson's disease and patient related outcomes in stroke: A matched cohort study. J Stroke Cerebrovasc Dis 2020; 29:104826. [PMID: 32402719 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/19/2020] [Accepted: 03/22/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To evaluate post-stroke outcomes in patients with Parkinson's disease (PD). METHODS A matched cohort study was performed. Stroke patients with PD and non-PD controls were extracted from the Thailand Universal Insurance Database. Logistic regressions were used to evaluate the association between PD and in-hospital outcomes (mortality and complications). The PD-associated long-term mortality was evaluated using Royston-Parmar models. RESULTS A total of 1967 patients with PD were identified between 2003 and 2015 and matched to controls (1:4) by age, sex, admission year, and stroke type. PD patients had decreased odds of in-hospital death: OR (95% CI) 0.66 (0.52 - 0.84) and 0.61 (0.43 - 0.85) after ischaemic and haemorrhagic strokes, respectively. PD was associated with a length-of-stay greater than median (4 days) after both stroke types: 1.37 (1.21 - 1.56) and 1.45 (1.05 - 2.00), respectively. Ischaemic stroke patients with PD also had increased odds of developing pneumonia, sepsis and AKI: 1.52 (1.2 - 1.83), 1.54 (1.16 - 2.05), and 1.33 (1.02 - 1.73). In haemorrhagic stroke patients, PD was associated with pneumonia: 1.89 (1.31 - 2.72). Survival analyses showed that PD was protective against death in the short term (HR=0.66; 95% CI 0.53-0.83 ischaemic, and HR=0.50; 95% CI 0.37 - 0.68 haemorrhagic stroke), but leads to an increased mortality risk approximately 1 and 3 months after ischaemic and haemorrhagic stroke, respectively. CONCLUSION PD is associated with a reduced mortality risk during the first 2-4 weeks post-admission but an increased risk thereafter, in addition to increased odds of in-hospital complications and prolonged hospitalisation.
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Godolphin PJ, Montgomery AA, Woodhouse LJ, Bereczki D, Berge E, Collins R, Díez-Tejedor E, Gommans J, Lees KR, Ozturk S, Phillips S, Pocock S, Prasad K, Szatmari S, Wang Y, Bath PM, Sprigg N. Central adjudication of serious adverse events did not affect trial's safety results: Data from the Efficacy of Nitric Oxide in Stroke (ENOS) trial. PLoS One 2018; 13:e0208142. [PMID: 30475912 PMCID: PMC6258247 DOI: 10.1371/journal.pone.0208142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 11/02/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Central adjudication of serious adverse events (SAEs) can be undertaken in clinical trials, especially for open-label studies where outcome assessment may be at risk of bias. This study explored the effect of central adjudication of SAEs on the safety results of the Efficacy of Nitric Oxide in Stroke (ENOS) Trial. METHODS ENOS assigned patients with acute stroke at random to receive either transdermal glyceryl trinitrate (GTN) or no GTN and to Stop or Continue previous antihypertensive treatment. SAEs were reported by local investigators who were not blinded to treatment allocation. Central adjudicators, blinded to treatment allocation, reviewed the investigators reports and used evidence available to confirm or re-categorise the classification of event, likely causality, diagnosis and expectedness of event. RESULTS Of 4011 patients enrolled in ENOS, 1473 SAEs were reported by local investigators; this was reduced to 1444 after the review by adjudicators, with 29 re-classified as not an SAE. There was fair agreement between investigators and adjudicators regarding likely causality, with 808 agreements and 644 disagreements (56% crude agreement, weighted kappa, κ = 0.31). Agreement increased upon dichotomisation of the causality categories, with 1432 agreements and 20 disagreements (99% crude agreement, kappa = 0.54). Repeating the main trial safety analysis with investigator reported events showed that adjudication had no effect on the main trial safety conclusions. CONCLUSIONS In a large trial, with many SAEs reported, central adjudication of these events did not affect trial conclusions. This suggests that adjudication of SAEs in a clinical trial where the intervention already has a well-established safety profile may not be necessary. Potential efficiency savings (financial, logistical) can be made through not adjudicating SAEs.
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Affiliation(s)
- Peter J. Godolphin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Exuperio Díez-Tejedor
- Department of Neurology, La Paz University Hospital–Autonoma University of Madrid, Madrid, Spain
| | | | | | | | - Stephen Phillips
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
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9
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Reinink H, de Jonge JC, Bath PM, van de Beek D, Berge E, Borregaard S, Ciccone A, Csiba L, Demotes J, Dippel DW, Kõrv J, Kurkowska-Jastrzebska I, Lees KR, Macleod MR, Ntaios G, Randall G, Thomalla G, van der Worp HB. PRECIOUS: PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke. Rationale and design of a randomised, open, phase III, clinical trial with blinded outcome assessment. Eur Stroke J 2018; 3:291-298. [PMID: 30246150 PMCID: PMC6120123 DOI: 10.1177/2396987318772687] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/28/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Elderly patients are at high risk of complications after stroke, such as infections and fever. The occurrence of these complications has been associated with an increased risk of death or dependency.Hypothesis: Prevention of aspiration, infections, or fever with metoclopramide, ceftriaxone, paracetamol, or any combination of these in the first four days after stroke onset will improve functional outcome at 90 days in elderly patients with acute stroke. DESIGN International, 3 × 2-factorial, randomised-controlled, open-label clinical trial with blinded outcome assessment (PROBE) in 3800 patients aged 66 years or older with acute ischaemic stroke or intracerebral haemorrhage and an NIHSS score ≥ 6. Patients will be randomly allocated to any combination of oral, rectal, or intravenous metoclopramide (10 mg thrice daily); intravenous ceftriaxone (2000 mg once daily); oral, rectal, or intravenous paracetamol (1000 mg four times daily); or usual care, started within 24 h after symptom onset and continued for four days or until complete recovery or discharge from hospital, if earlier.Outcome: The primary outcome measure is the score on the modified Rankin Scale at 90 days (± 14 days), as analysed with multiple regression.Summary: This trial will provide evidence for a simple, safe and generally available treatment strategy that may reduce the burden of death or disability in patients with stroke at very low costs.Planning: First patient included in May 2016; final follow-up of the last patient by April 2020.Registration: ISRCTN, ISRCTN82217627, https://doi.org/10.1186/ISRCTN82217627.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jeroen C de Jonge
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Alfonso Ciccone
- Department of Neurology and Stroke Unit, ASST di Mantova, Mantua, Italy
| | - Laszlo Csiba
- Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Jacques Demotes
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Diederik W Dippel
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | | | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Malcolm R Macleod
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - George Ntaios
- Department of Medicine, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Gary Randall
- Stroke Alliance for Europe (SAFE), Brussels, Belgium
| | - Götz Thomalla
- Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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10
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Lyden P, Hemmen T, Grotta J, Rapp K, Ernstrom K, Rzesiewicz T, Parker S, Concha M, Hussain S, Agarwal S, Meyer B, Jurf J, Altafullah I, Raman R. Results of the ICTuS 2 Trial (Intravascular Cooling in the Treatment of Stroke 2). Stroke 2016; 47:2888-2895. [PMID: 27834742 DOI: 10.1161/strokeaha.116.014200] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/13/2016] [Accepted: 10/05/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Therapeutic hypothermia is a potent neuroprotectant approved for cerebral protection after neonatal hypoxia-ischemia and cardiac arrest. Therapeutic hypothermia for acute ischemic stroke is safe and feasible in pilot trials. We designed a study protocol to provide safer, faster therapeutic hypothermia in stroke patients. METHODS Safety procedures and 4°C saline infusions for faster cooling were added to the ICTuS trial (Intravascular Cooling in the Treatment of Stroke) protocol. A femoral venous intravascular cooling catheter after intravenous recombinant tissue-type plasminogen activator in eligible patients provided 24 hours cooling followed by a 12-hour rewarm. Serial safety assessments and imaging were performed. The primary end point was 3-month modified Rankin score 0,1. RESULTS Of the intended 1600 subjects, 120 were enrolled before the study was stopped. Randomly, 63 were to receive hypothermia plus antishivering treatment and 57 normothermia. Compared with previous studies, cooling rates were improved with a cold saline bolus, without fluid overload. The intention-to-treat primary outcome of 90-day modified Rankin Score 0,1 occurred in 33% hypothermia and 38% normothermia subjects, odds ratio (95% confidence interval) of 0.81 (0.36-1.85). Serious adverse events occurred equally. Mortality was 15.9% hypothermia and 8.8% normothermia subjects, odds ratio (95% confidence interval) of 1.95 (0.56-7.79). Pneumonia occurred in 19% hypothermia versus 10.5% in normothermia subjects, odds ratio (95% confidence interval) of 1.99 (0.63-6.98). CONCLUSIONS Intravascular therapeutic hypothermia was confirmed to be safe and feasible in recombinant tissue-type plasminogen activator-treated acute ischemic stroke patients. Protocol changes designed to reduce pneumonia risk appeared to fail, although the sample is small. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01123161.
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Affiliation(s)
- Patrick Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.).
| | - Thomas Hemmen
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - James Grotta
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Karen Rapp
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Karin Ernstrom
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Teresa Rzesiewicz
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Stephanie Parker
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Mauricio Concha
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Syed Hussain
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Sachin Agarwal
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Brett Meyer
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Julie Jurf
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Irfan Altafullah
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Rema Raman
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
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Hesse K, MacIsaac RL, Abdul-Rahim AH, Lyden PD, Bluhmki E, Lees KR. Online Tool to Improve Stratification of Adverse Events in Stroke Clinical Trials. Stroke 2016; 47:882-5. [PMID: 26742798 DOI: 10.1161/strokeaha.115.011930] [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] [Received: 10/22/2015] [Accepted: 11/18/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Knowing characteristic adverse events (AEs) and their incidence among patients participating in acute stroke trials may assist interpretation of future studies. We aimed to develop an online tool to inform stroke trial safety. METHODS We identified relevant AEs from patients within the Virtual International Stroke Trials Archive (VISTA), using receiver operating characteristic principles. We modeled their incidence on patient age, baseline National Institutes of Health Stroke Scale, and comorbidities using binary logistic regression. Models with an R(2) >5% were deemed powerful enough to predict expected AE incidences and were included. The calculator was developed using programs R and Visual Studios. RESULTS Forty-eight of the most common AEs were identified and incorporated into the IschAEmic Stroke Calculator. The calculator, publicly available at http://www.vistacollaboration.org calculates the expected incidence of AEs or groups of AEs in a trial cohort and where possible compares them with the observed incidence. CONCLUSIONS The IschAEmic Stroke Calculator is an open access resource to support safety interpretation within acute stroke trials. Prediction of AEs with higher likelihood of occurrence may direct preventive clinical measures.
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Affiliation(s)
- Kerrick Hesse
- From the Medical School (K.H.), Institute of Cardiovascular and Medical Sciences (A.H.A.-R, K.R.L., R.L.M.), University of Glasgow, Glasgow, United Kingdom; Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.D.L.); and Department of Statistics, Boehringer Ingelheim, Bieberach, Germany (E.B.)
| | - Rachael L MacIsaac
- From the Medical School (K.H.), Institute of Cardiovascular and Medical Sciences (A.H.A.-R, K.R.L., R.L.M.), University of Glasgow, Glasgow, United Kingdom; Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.D.L.); and Department of Statistics, Boehringer Ingelheim, Bieberach, Germany (E.B.)
| | - Azmil H Abdul-Rahim
- From the Medical School (K.H.), Institute of Cardiovascular and Medical Sciences (A.H.A.-R, K.R.L., R.L.M.), University of Glasgow, Glasgow, United Kingdom; Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.D.L.); and Department of Statistics, Boehringer Ingelheim, Bieberach, Germany (E.B.).
| | - Patrick D Lyden
- From the Medical School (K.H.), Institute of Cardiovascular and Medical Sciences (A.H.A.-R, K.R.L., R.L.M.), University of Glasgow, Glasgow, United Kingdom; Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.D.L.); and Department of Statistics, Boehringer Ingelheim, Bieberach, Germany (E.B.)
| | - Erich Bluhmki
- From the Medical School (K.H.), Institute of Cardiovascular and Medical Sciences (A.H.A.-R, K.R.L., R.L.M.), University of Glasgow, Glasgow, United Kingdom; Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.D.L.); and Department of Statistics, Boehringer Ingelheim, Bieberach, Germany (E.B.)
| | - Kennedy R Lees
- From the Medical School (K.H.), Institute of Cardiovascular and Medical Sciences (A.H.A.-R, K.R.L., R.L.M.), University of Glasgow, Glasgow, United Kingdom; Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.D.L.); and Department of Statistics, Boehringer Ingelheim, Bieberach, Germany (E.B.)
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12
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Panagioti M, Stokes J, Esmail A, Coventry P, Cheraghi-Sohi S, Alam R, Bower P. Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0135947. [PMID: 26317435 PMCID: PMC4552710 DOI: 10.1371/journal.pone.0135947] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care. METHODS We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken. RESULTS Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low. CONCLUSIONS The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.
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Affiliation(s)
- Maria Panagioti
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
| | - Aneez Esmail
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
| | - Peter Coventry
- NIHR Collaboration for Leadership in Applied Health Research and Care—Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
| | - Rahul Alam
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
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Berge E, Ford GA, Bath PMW, Stapf C, van der Worp HB, Demotes J, Broderick J, Salman RAS, Lees KR. Regulation and Governance of Multinational Drug Trials in Stroke: Barriers and Possibilities. Int J Stroke 2015; 10:425-8. [DOI: 10.1111/ijs.12427] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/14/2014] [Indexed: 11/29/2022]
Abstract
Over the last 10 years, there has been stagnation in the number of multinational drug trials in stroke in Europe. One important cause of this is probably the increased burden of laws and regulations that came with the European Union Clinical Trials Directive. The main objective of research regulation and governance should be to protect research participants, their tissues, and data, but the approval systems are complex, regulation is variably interpreted and enforced, and the assessment of studies is often not proportionate to the risk of the research to participants. Such unnecessary barriers should be reduced by simplifying, centralizing, and harmonizing the application process, and by applying regulatory and governance requirements in a way that is proportionate to the potential harms to the patients. The traditional functions of a regulator (in setting, monitoring, and enforcing quality standards) could also be supplemented with an aim to actively help researchers achieve these standards, for example, by giving advice, and ultimately with an aim to facilitate and promote research, for example, by integrating research in everyday clinical practice. Research networks offer one way of integrating research and clinical practice across multiple centers, and can streamline research delivery by supporting researchers deal professionally and efficiently with the regulations and governance requirements.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Gary A. Ford
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Philip M. W. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Christian Stapf
- Department of Neurology, APHP – Hôpital Lariboisière and DHU NeuroVasc Paris – Sorbonne, Université Paris Diderot – Sorbonne Paris Cité, Paris, France
| | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - Jacques Demotes
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Joseph Broderick
- Department of Neurology, University of Cincinnati Neuroscience Institute, Cincinnati, OH, USA
| | - Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kennedy R. Lees
- Institute of Cardiovascular and Medical Sciences, University of Glascow, Glascow, UK
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