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Zhao Y, Li Q, Niu J, Guo E, Zhao C, Zhang J, Liu X, Wang L, Rao L, Chen X, Yang K. Neutrophil Membrane-Camouflaged Polyprodrug Nanomedicine for Inflammation Suppression in Ischemic Stroke Therapy. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2311803. [PMID: 38519052 DOI: 10.1002/adma.202311803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/17/2024] [Indexed: 03/24/2024]
Abstract
Neuroinflammation has emerged as a major concern in ischemic stroke therapy because it exacebates neurological dysfunction and suppresses neurological recovery after ischemia/reperfusion. Fingolimod hydrochloride (FTY720) is an FDA-approved anti-inflammatory drug which exhibits potential neuroprotective effects in ischemic brain parenchyma. However, delivering a sufficient amount of FTY720 through the blood-brain barrier into brain lesions without inducing severe cardiovascular side effects remains challenging. Here, a neutrophil membrane-camouflaged polyprodrug nanomedicine that can migrate into ischemic brain tissues and in situ release FTY720 in response to elevated levels of reactive oxygen species. This nanomedicine delivers 15.2-fold more FTY720 into the ischemic brain and significantly reduces the risk of cardiotoxicity and infection compared with intravenously administered free drug. In addition, single-cell RNA-sequencing analysis identifies that the nanomedicine attenuates poststroke inflammation by reprogramming microglia toward anti-inflammatory phenotypes, which is realized via modulating Cebpb-regulated activation of NLRP3 inflammasomes and secretion of CXCL2 chemokine. This study offers new insights into the design and fabrication of polyprodrug nanomedicines for effective suppression of inflammation in ischemic stroke therapy.
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Affiliation(s)
- Ya Zhao
- School of Life Science and Technology, Harbin Institute of Technology, Harbin, Heilongjiang, 150080, P. R. China
| | - Qian Li
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, 150081, P. R. China
| | - Jingyan Niu
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, 150081, P. R. China
| | - Erliang Guo
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, P. R. China
| | - Chenchen Zhao
- Institute of Biomedical Health Technology and Engineering, Shenzhen Bay Laboratory, Shenzhen, Guangdong, 518132, P. R. China
| | - Jian Zhang
- Biofunctional Experiment Teaching Center, Harbin Medical University, Harbin, Heilongjiang, 150081, P. R. China
| | - Xue Liu
- Department of Pharmacology, Harbin Medical University, Harbin, Heilongjiang, 150081, P. R. China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, 150081, P. R. China
| | - Lang Rao
- Institute of Biomedical Health Technology and Engineering, Shenzhen Bay Laboratory, Shenzhen, Guangdong, 518132, P. R. China
| | - Xiaoyuan Chen
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering and Biomedical Engineering, Yong Loo Lin School of Medicine and College of Design and Engineering, National University of Singapore, Singapore, 119074, Singapore
- Clinical Imaging Research Centre, Centre for Translational Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117599, Singapore
- Nanomedicine Translational Research Program, NUS Center for Nanomedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117597, Singapore
- Institute of Molecular and Cell Biology, Agency for Science Technology and Research (A*STAR), 61 Biopolis Drive, Proteos, Singapore, 138673, Singapore
| | - Kuikun Yang
- School of Life Science and Technology, Harbin Institute of Technology, Harbin, Heilongjiang, 150080, P. R. China
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Kyyak S, Jari A, Heimes D, Heider J, Kämmerer PW. Platelet-rich fibrin ensures hemostasis after single-tooth removal under factor Xa inhibitors - a clinical prospective randomized split-mouth study. Clin Oral Investig 2023; 27:7275-7283. [PMID: 37864605 PMCID: PMC10713775 DOI: 10.1007/s00784-023-05317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/08/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVES In this prospective, double-blinded, randomized split-mouth study, the local hemostatic effect of platelet-rich fibrin (PRF) inserted into the extraction socket in patients taking factor Xa (FXa) inhibitors (apixaban, rivaroxaban, edoxaban) was compared to a hemostatic gelatine sponge (GS) as the "therapeutic gold standard" without withdrawal of oral anticoagulant therapy. MATERIALS AND METHODS Single-tooth extraction was conducted under local anesthesia in n = 21 patients using a split-mouth design (42 teeth). Using a double-blind approach, the extraction socket on one side of the jaw was filled with PRF and on the other with a GS. Bleeding was assessed immediately after surgery, in 30 min, 1 h, 1.5 h, and on follow-up appointments in 24 h and on the 7th day. RESULTS In 67% of cases, mild postoperative oozing could be stopped 30-90 min after tooth extraction via gauze pressure without any delayed bleeding. Concerning bleeding events, there was no difference among the PRF and GS groups and no significant difference among rivaroxaban, apixaban, and edoxaban (all p > 0.15). CONCLUSION PRF and GS are reliable hemostatic methods in postextraction sockets of patients taking FXa inhibitors. CLINICAL RELEVANCE Consequently, there is no need to discontinue FXa inhibitors because of a single-tooth removal, eliminating the risk of thrombus formation.
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Affiliation(s)
- Solomiya Kyyak
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany.
| | - Ali Jari
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Diana Heimes
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Julia Heider
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Peer W Kämmerer
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
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Zhang Y, Li Q, Li H. A commentary on 'Incidence, prevention, risk factors, and prediction of venous thromboembolism in Chinese patients after colorectal cancer surgery: a prospective, multicenter cohort study'. Int J Surg 2023; 109:4359-4360. [PMID: 37678280 PMCID: PMC10720777 DOI: 10.1097/js9.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 09/09/2023]
Affiliation(s)
- Yongjing Zhang
- Department of Nursing, Fenyang College of Shanxi Medical University, Shanxi
| | - Qiuping Li
- Department of Nursing, School of Medicine of Jiangnan University, Jiangsu, People’s Republic of China
| | - Hongmei Li
- Department of Nursing, Fenyang College of Shanxi Medical University, Shanxi
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Lin W, Zhao XY, Cheng JW, Li LT, Jiang Q, Zhang YX, Han F. Signaling pathways in brain ischemia: Mechanisms and therapeutic implications. Pharmacol Ther 2023; 251:108541. [PMID: 37783348 DOI: 10.1016/j.pharmthera.2023.108541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023]
Abstract
Ischemic stroke occurs when the arteries supplying blood to the brain are narrowed or blocked, inducing damage to brain tissue due to a lack of blood supply. One effective way to reduce brain damage and alleviate symptoms is to reopen blocked blood vessels in a timely manner and reduce neuronal damage. To achieve this, researchers have focused on identifying key cellular signaling pathways that can be targeted with drugs. These pathways include oxidative/nitrosative stress, excitatory amino acids and their receptors, inflammatory signaling molecules, metabolic pathways, ion channels, and other molecular events involved in stroke pathology. However, evidence suggests that solely focusing on protecting neurons may not yield satisfactory clinical results. Instead, researchers should consider the multifactorial and complex mechanisms underlying stroke pathology, including the interactions between different components of the neurovascular unit. Such an approach is more representative of the actual pathological process observed in clinical settings. This review summarizes recent research on the multiple molecular mechanisms and drug targets in ischemic stroke, as well as recent advances in novel therapeutic strategies. Finally, we discuss the challenges and future prospects of new strategies based on the biological characteristics of stroke.
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Affiliation(s)
- Wen Lin
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, China; International Joint Laboratory for Drug Target of Critical Illnesses, Key Laboratory of Cardiovascular and Cerebrovascular Medicine, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Xiang-Yu Zhao
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, China; International Joint Laboratory for Drug Target of Critical Illnesses, Key Laboratory of Cardiovascular and Cerebrovascular Medicine, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Jia-Wen Cheng
- Department of Physiology, School of Basic Medical Sciences, Nanjing Medical University, Nanjing 211166, China
| | - Li-Tao Li
- Department of Neurology, Hebei General Hospital, Shijiazhuang 050051, Hebei, China
| | - Quan Jiang
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY 14853, USA
| | - Yi-Xuan Zhang
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, China; International Joint Laboratory for Drug Target of Critical Illnesses, Key Laboratory of Cardiovascular and Cerebrovascular Medicine, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China; Gusu School, Nanjing Medical University, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215002, China.
| | - Feng Han
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, China; International Joint Laboratory for Drug Target of Critical Illnesses, Key Laboratory of Cardiovascular and Cerebrovascular Medicine, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China; Gusu School, Nanjing Medical University, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215002, China; Institute of Brain Science, the Affiliated Brain Hospital of Nanjing Medical University, Nanjing 211166, China.
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Sheehan OC, Dhamoon MS, Bettger JP, Huang J, Liu C, Rhodes JD, Clay OJ, Roth DL. Racial differences in persistence to secondary prevention medication regimens after ischemic stroke. ETHNICITY & HEALTH 2022; 27:1671-1683. [PMID: 34196573 DOI: 10.1080/13557858.2021.1943321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 06/08/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Prior stroke is one of the biggest risk factors for future stroke events. Effective secondary prevention medication regimens can dramatically reduce recurrent stroke risk. Guidelines recommend the use of antithrombotic, antihypertensive and lipid-lowering medications after stroke. Medication adherence is known to be better in the presence of a caregiver but long-term adherence after stroke is unknown and disparities may persist. METHODS We examined the effects of race and sex on baseline prescription and maintenance of secondary prevention regimens in the presence of a caregiver using the Caring for Adults Recovering from the Effects of Stroke (CARES) study, an ancillary study of the national REasons for Geographic and Racial Differences in Stroke (REGARDS). RESULTS Incident ischemic stroke survivors (N = 172; 36% Black) with family caregivers had medications recorded at hospital discharge and on average 9.8 months later during a home visit. At discharge, antithrombotic prescription (95.9%), lipid-lowering medications (78.8%) and antihypertensives (89.9%) were common and there were no race or sex differences in discharge prescription rates. One year later, medication persistence had fallen to 86.6% for antithrombotics (p = 0.002) and 69.8% for lipid lowering (p = 0.008) but increased to 93.0% for antihypertensives (p = 0.30). Blacks were more likely to have discontinued antithrombotics than Whites (18.3% v 7.7%, p = 0.04). No significant differences in persistence were seen with age, sex, income, depression, or cognitive impairment. CONCLUSIONS Medication persistence was high in this sample, likely due to the presence of a caregiver. In our cohort, despite similar prescription rates at the time of hospital discharge, Black stroke survivors were more than twice as likely to stop antithrombotics than Whites. The effect of changes in patterns of medication usage on health outcomes in Black stroke survivors warrants continued investigation.
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Affiliation(s)
- Orla C Sheehan
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Jin Huang
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, USA
| | - Chelsea Liu
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, USA
| | - J David Rhodes
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Olivio J Clay
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David L Roth
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, USA
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Guo PC, Li N, Zhong HM, Zhao GF. Clinical effectiveness of a pneumatic compression device combined with low-molecular-weight heparin for the prevention of deep vein thrombosis in trauma patients: A single-center retrospective cohort study. World J Emerg Med 2022; 13:189-195. [PMID: 35646216 PMCID: PMC9108905 DOI: 10.5847/wjem.j.1920-8642.2022.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/10/2022] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND To investigate the clinical effectiveness of a pneumatic compression device (PCD) combined with low-molecular-weight heparin (LMWH) for the prevention and treatment of deep vein thrombosis (DVT) in trauma patients. METHODS This study retrospectively analyzed 286 patients with mild craniocerebral injury and clavicular fractures admitted to our department from January 2016 to February 2020. Patients treated with only LMWH served as the control group, and patients treated with a PCD combined with LMWH as the observation group. The incidence of DVT, postoperative changes in the visual analogue scale (VAS) score, and coagulation function were observed and compared between the two groups. Excluding the influence of other single factors, binary logistic regression analysis was used to evaluate the use of a PCD in the patient's postoperative coagulation function. RESULTS After excluding 34 patients who did not meet the inclusion criteria, 252 patients were were included. The incidence of DVT in the observation group was significantly lower than that in the control group (5.6% vs. 15.1%, χ2=4.605, P<0.05). The postoperative VAS scores of the two groups were lower than those before surgery (P<0.05). The coagulation function of the observation group was significantly higher than that of the control group, with a better combined anticoagulant effect (P<0.05). There were no significant differences between the two groups in preoperative or postoperative Glasgow Coma Scale scores, intraoperative blood loss, postoperative infection rate, or length of hospital stay (P>0.05). According to logistic regression analysis, the postoperative risk of DVT in patients who received LMWH alone was 1.764 times that of patients who received LMWH+PCD (P<0.05). The area under the receiver operating characteristic (AUROC) curve of partial thromboplastin time (APTT) and platelet (PLT) were greater than 0.5, indicating that they were the influence indicators of adding PCD to prevent DVT. Excluding the influence of other variables, LMWH+PCD effectively improved the coagulation function of patients. CONCLUSIONS Compared with LMWH alone, LMWH+PCD could improve blood rheology and coagulation function in patients with traumatic brain injury and clavicular fracture, reduce the incidence of DVT, shorten the length of hospital stay, and improve the clinical effectiveness of treatment.
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Affiliation(s)
- Peng-chao Guo
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Nan Li
- Plastic Surgery Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Hui-ming Zhong
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Guang-feng Zhao
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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7
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Mishra NK, Liebeskind DS. Artificial Intelligence in Stroke. Artif Intell Med 2022. [DOI: 10.1007/978-3-030-64573-1_197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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8
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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Dagonnier M, Donnan GA, Davis SM, Dewey HM, Howells DW. Acute Stroke Biomarkers: Are We There Yet? Front Neurol 2021; 12:619721. [PMID: 33633673 PMCID: PMC7902038 DOI: 10.3389/fneur.2021.619721] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Distinguishing between stroke subtypes and knowing the time of stroke onset are critical in clinical practice. Thrombolysis and thrombectomy are very effective treatments in selected patients with acute ischemic stroke. Neuroimaging helps decide who should be treated and how they should be treated but is expensive, not always available and can have contraindications. These limitations contribute to the under use of these reperfusion therapies. Aim: An alternative approach in acute stroke diagnosis is to identify blood biomarkers which reflect the body's response to the damage caused by the different types of stroke. Specific blood biomarkers capable of differentiating ischemic from hemorrhagic stroke and mimics, identifying large vessel occlusion and capable of predicting stroke onset time would expedite diagnosis and increase eligibility for reperfusion therapies. Summary of Review: To date, measurements of candidate biomarkers have usually occurred beyond the time window for thrombolysis. Nevertheless, some candidate markers of brain tissue damage, particularly the highly abundant glial structural proteins like GFAP and S100β and the matrix protein MMP-9 offer promising results. Grouping of biomarkers in panels can offer additional specificity and sensitivity for ischemic stroke diagnosis. Unbiased “omics” approaches have great potential for biomarker identification because of greater gene, protein, and metabolite coverage but seem unlikely to be the detection methodology of choice because of their inherent cost. Conclusion: To date, despite the evolution of the techniques used in their evaluation, no individual candidate or multimarker panel has proven to have adequate performance for use in an acute clinical setting where decisions about an individual patient are being made. Timing of biomarker measurement, particularly early when decision making is most important, requires urgent and systematic study.
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Affiliation(s)
- Marie Dagonnier
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Department of Neurology, Ambroise Paré Hospital, Mons, Belgium
| | - Geoffrey A Donnan
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Melbourne Brain Centre at the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Helen M Dewey
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - David W Howells
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Faculty of Health, School of Medicine, University of Tasmania, Hobart, TAS, Australia
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Camm AJ, Atar D. Use of Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention across the Stroke Spectrum: Progress and Prospects. Thromb Haemost 2021; 121:716-730. [PMID: 33412613 DOI: 10.1055/s-0040-1721665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Multiple randomized controlled trials and many real-world evidence studies have consistently shown that non-vitamin K antagonist oral anticoagulants (NOACs) are preferable to vitamin K antagonists for thromboembolic stroke prevention in the majority of patients with atrial fibrillation (AF). However, their role in the management of patients with AF and comorbidities, as well as in other patient populations with a high risk of stroke, such as patients with prior embolic stroke of undetermined source (ESUS) and those with atherosclerosis, is less clear. There is now increasing evidence suggesting that NOACs have a beneficial effect in the prevention of stroke in patients with AF and comorbidities, such as renal impairment and diabetes. In addition, while studies investigating the efficacy and safety of NOACs for the prevention of secondary stroke in patients with a history of ESUS demonstrated neutral results, subanalyses suggested potential benefits in certain subgroups of patients with ESUS. One NOAC, rivaroxaban, has also recently been found to be effective in reducing the risk of stroke in patients with chronic cardiovascular disease including coronary artery disease and peripheral artery disease, further broadening the patient groups that may benefit from NOACs. In this article, we will review recent evidence for the use of NOACs across the stroke spectrum in detail, and discuss the progress and future prospects in the different stroke areas.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,University of Oslo, Oslo, Norway
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11
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Artificial Intelligence in Stroke. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-58080-3_197-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Gattellari M, Hayen A, Leung DYC, Zwar NA, Worthington JM. Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial. BMC FAMILY PRACTICE 2020; 21:102. [PMID: 32513116 PMCID: PMC7281948 DOI: 10.1186/s12875-020-01175-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
Background Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration ANZCTRN12611000076976 Retrospectively registered.
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Affiliation(s)
- Melina Gattellari
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia. .,Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, New South Wales, 2170, Australia.
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney, 15 Broadway, Ultimo, New South Wales, 2007, Australia
| | - Dominic Y C Leung
- South Western Sydney Clinical School UNSW, Liverpool, Australia.,Department of Cardiology, Liverpool Health Service, Sydney South West Local Health District, Clinical Services Building, Elizabeth Street, Liverpool (Sydney), New South Wales, 2170, Australia
| | - Nicholas A Zwar
- Faculty of Health, Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - John M Worthington
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia.,South Western Sydney Clinical School UNSW, Liverpool, Australia
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13
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Livesay S, Fried H, Gagnon D, Karanja N, Lele A, Moheet A, Olm-Shipman C, Taccone F, Tirschwell D, Wright W, Claude Hemphill Iii J. Clinical Performance Measures for Neurocritical Care: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 2020; 32:5-79. [PMID: 31758427 DOI: 10.1007/s12028-019-00846-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care. METHODS The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form. RESULTS A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care. CONCLUSIONS This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.
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Affiliation(s)
- Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA.
| | | | - David Gagnon
- Maine Medical Center Department of Pharmacy, Portland, ME, USA
| | - Navaz Karanja
- Departments of Neurosciences and Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Abhijit Lele
- Department of Anesthesiology and Pain Medicine, Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Asma Moheet
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | - Casey Olm-Shipman
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Fabio Taccone
- Department of Intensive Care of Hospital Erasme, Brussels, Belgium
| | - David Tirschwell
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Wendy Wright
- Departments of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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14
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Serhan A, Aerts JL, Boddeke EW, Kooijman R. Neuroprotection by Insulin-like Growth Factor-1 in Rats with Ischemic Stroke is Associated with Microglial Changes and a Reduction in Neuroinflammation. Neuroscience 2020; 426:101-114. [DOI: 10.1016/j.neuroscience.2019.11.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 11/13/2019] [Accepted: 11/15/2019] [Indexed: 01/27/2023]
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15
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Guillaumin J, Gibson RMB, Goy-Thollot I, Bonagura JD. Thrombolysis with tissue plasminogen activator (TPA) in feline acute aortic thromboembolism: a retrospective study of 16 cases. J Feline Med Surg 2019; 21:340-346. [PMID: 29807505 PMCID: PMC10814639 DOI: 10.1177/1098612x18778157] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Thrombolytic therapy is a treatment of choice for people with acute ischemic events, but is uncommonly administered for feline aortic thromboembolism (FATE). This study reports selected clinical data and outcomes of acute FATE treated with tissue plasminogen activator (TPA). A reference group treated with current standard of care (SOC) was analyzed for comparison. METHODS This was a retrospective study of FATE in two academic hospitals. TPA-treated cats with two or more limbs (n = 16) affected were compared with a SOC-treated group with two or more limbs affected (n = 38). A limb score based on motor function and pulse quality was calculated for each group. RESULTS Limb score and proportion of congestive heart failure at admission was similar in both groups. Time from FATE to admission was shorter in the TPA group, with a median of 3 h (range 0-6 h) vs 6 h (range 0-48 h; P = 0.0004). The most common regimen received for TPA was 1 mg/kg over 1 h. Other treatments were similar to those of the SOC group and included analgesia, thromboprophylaxis and furosemide. Documented complications for TPA-treated cats included reperfusion injury (5/10) and acute kidney injury (AKI; 3/10). Discharge proportion rate was 44% (TPA) vs 29% (SOC; P = 0.351). There were no differences in short-term survival rate (56.2% vs 39.5%; P = 0.369), clinical improvement (56.2% vs 31%; P = 0.122), rates of reperfusion injury (50% vs 50%; P = 1.00) or AKI (30% vs 27%; P = 1.00) between the TPA-treated and SOC groups, respectively. CONCLUSIONS AND RELEVANCE Survival and complication rates of TPA-treated cats and SOC-treated cats for acute FATE were similar.
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Affiliation(s)
- Julien Guillaumin
- Department of Clinical Sciences, The Ohio State University, Columbus, OH, USA
| | - Ryan MB Gibson
- Veterinary Medical Center, The Ohio State University, Columbus, OH, USA
| | | | - John D Bonagura
- Department of Clinical Sciences, The Ohio State University, Columbus, OH, USA
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16
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A Review of Antiplatelet Activity of Traditional Medicinal Herbs on Integrative Medicine Studies. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:7125162. [PMID: 30719065 PMCID: PMC6335729 DOI: 10.1155/2019/7125162] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/27/2018] [Indexed: 12/13/2022]
Abstract
Thrombotic events mainly occurred by platelet activation and aggregation. The vascular occlusion causes serious disease states such as unstable angina, ischemic stroke, and heart attack. Due to the pervading of thrombotic diseases, new antiplatelet drugs are necessary for preventing and treating arterial thrombosis without adverse side effects. Traditional medicinal herbs have been used for the treatment of human ailments for a long time. The clinically useful and safe products from traditional medicinal herbs were identified and developed in numerous pharmacological approaches. A complementary system of traditional medicinal herbs is a good candidate for pharmacotherapy. However, it still has a limitation in its function and efficacy. Thus, it is necessary to study the mode of action of traditional medicinal herbs as alternative therapeutic agents. In this review, we focused on our current understanding of the regulatory mechanisms of traditional medicinal herbs in antiplatelet activity and antithrombotic effect of traditional medicinal herbs on platelet function.
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Yu Z, Shan P, Yang X, Lou XJ. Comparison of efficiency and safety of rivaroxaban, apixaban and enoxaparin for thromboprophylaxis after arthroplastic surgery: a meta-analysis. Biosci Rep 2018; 38:BSR20180423. [PMID: 30341244 PMCID: PMC6239253 DOI: 10.1042/bsr20180423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 09/20/2018] [Accepted: 10/14/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of rivaroxaban, apixaban and enoxaparin for thromboprophylaxis after arthroplastic surgery. METHODS We conducted a meta-analysis containing a wide range of randomized controlled trials about efficiency and safety of rivaroxaban, apixaban and enoxaparin for thromboprophylaxis after arthroplastic surgery in the recent decade from January 2006 to June 2018. The present study separately analyzed the following key components: the different efficiency and safety for rivaroxaban and enoxaparin; apixaban and enoxaparin; and enoxaparin and other new developed anticoagulants. RESULTS Sixteen studies containing 58885 patients were included. In results of efficacy outcomes, total events occurred in 4.89% patients of rivaroxaban group and 9.55% patients of the control group; however, no significant difference was observed in apixaban groups of their efficacy outcomes. Primary events didn't show significant difference when comparing apixaban with the control or comparing enoxaparin with the control. In analysis of safety outcomes, bleeding events occurred in 3.41% patients of rivaroxaban group compared with 2.84% patients of the control groups; bleeding events in apixaban groups were 4.09% compared with the control groups 4.64%. Bleeding events occurred in 3.51% patients of enoxaparin group, slightly lower than 5.82% of the control group. CONCLUSION Direct oral anticoagulant, rivaroxaban might have better efficacy outcomes in thromboprophylaxis after arthroplastic surgery; however, apixaban showed no significantly different efficacy outcomes compared with enoxaparin, and enoxaparin may have equal or even better safety outcomes compared with direct oral anticoagulants.
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Affiliation(s)
- Zhi Yu
- Department of Vascular Surgery, Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, China
| | - Ping Shan
- Department of Vascular Surgery, Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, China
| | - Xiaoxia Yang
- Department of Vascular Surgery, Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, China
| | - Xin-Jiang Lou
- Department of Vascular Surgery, Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, China
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18
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Dagonnier M, Wilson WJ, Favaloro JM, Rewell SSJ, Lockett LJ, Sastra SA, Jeffreys AL, Dewey HM, Donnan GA, Howells DW. Hyperacute changes in blood mRNA expression profiles of rats after middle cerebral artery occlusion: Towards a stroke time signature. PLoS One 2018; 13:e0206321. [PMID: 30439964 PMCID: PMC6237327 DOI: 10.1371/journal.pone.0206321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023] Open
Abstract
Stroke evolution is a highly dynamic but variable disease which makes clinical decision making difficult. Biomarker discovery programs intended to aid clinical decision making have however largely ignored the rapidity of stroke evolution. We have used gene array technology to determine blood mRNA expression changes over the first day after stroke in rats. Blood samples were collected from 8 male spontaneously hypertensive rats at 0, 1, 2, 3, 6 and 24h post stroke induction by middle cerebral artery occlusion. RNA was extracted from whole blood stabilized in PAXgene tubes and mRNA expression was detected by oligonucleotide Affymetrix microarray. Using a pairwise comparison model, 1932 genes were identified to vary significantly over time (p≤0.5x10-7) within 24h after stroke. Some of the top20 most changed genes are already known to be relevant to the ischemic stroke physiopathology (e.g. Il-1R, Nos2, Prok2). Cluster analysis showed multiple stereotyped and time dependent profiles of gene expression. Direction and rate of change of expression for some profiles varied dramatically during these 24h. Profiles with potential clinical utility including hyper acute or acute transient upregulation (with expression peaking from 2 to 6h after stroke and normalisation by 24h) were identified. We found that blood gene expression varies rapidly and stereotypically after stroke in rats. Previous researchers have often missed the optimum time for biomarker measurement. Temporally overlapping profiles have the potential to provide a biological “stroke clock” able to tell the clinician how far an individual stroke has evolved.
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Affiliation(s)
- Marie Dagonnier
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, Australia
- * E-mail:
| | - William John Wilson
- The Commonwealth Scientific and Industrial Research Organisation (CSIRO), Sydney, Australia
| | - Jenny Margaret Favaloro
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, Australia
| | - Sarah Susan Jane Rewell
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, Australia
| | - Linda Jane Lockett
- The Commonwealth Scientific and Industrial Research Organisation (CSIRO), Sydney, Australia
| | - Stephen Andrew Sastra
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, Australia
| | - Amy Lucienne Jeffreys
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, Australia
| | - Helen Margaret Dewey
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, Australia
| | - Geoffrey Alan Donnan
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, Australia
| | - David William Howells
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, Australia
- School of Medicine, Faculty of Health, University of Tasmania, Hobart, Australia
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Abstract
Antiplatelet agents used to treat neurovascular disease include aspirin; P2Y12 receptor antagonists clopidogrel, prasugrel, and ticagrelor; ADP antagonist ticlopidine; phosphodiesterase inhibitor dipyridamole; and glycoprotein IIb/IIIa inhibitors abciximab, eptifibatide, and tirofiban. Numerous studies have been performed evaluating their efficacy in stroke, extracranial carotid artery disease and dissection, intracranial atherosclerotic disease, and moyamoya disease. The rapid technological advancements in endovascular neurosurgical devices have also made antiplatelet therapy a necessary part of treating intracranial aneurysms. This article presents the relevant data supporting the use of antiplatelet agents in vascular neurosurgery and recommendations based on the described studies.
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Affiliation(s)
- Amanda S Zakeri
- Department of Neurological Surgery, Ohio State University Medical Center, N-1014 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, Ohio State University Medical Center, N-1014 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
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20
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Surasarang SH, Sahakijpijarn S, Florova G, Komissarov AA, Nelson CL, Perenlei E, Fukuda S, Wolfson MR, Shaffer TH, Idell S, Williams RO. Nebulization of Single-Chain Tissue-Type and Single-Chain Urokinase Plasminogen Activator for Treatment of Inhalational Smoke-Induced Acute Lung Injury. J Drug Deliv Sci Technol 2018; 48:19-27. [PMID: 30123328 DOI: 10.1016/j.jddst.2018.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Single-chain tissue-type plasminogen activator (sctPA) and single-chain urokinase plasminogen activator (scuPA) have attracted interest as enzymes for the treatment of inhalational smoke-induced acute lung injury (ISALI). In this study, the pulmonary delivery of commercial human sctPA and lyophilized scuPA and their reconstituted solution forms were demonstrated using vibrating mesh nebulizers (Aeroneb® Pro (active) and EZ Breathe® (passive)). Both the Aeroneb® Pro and EZ Breathe® vibrating mesh nebulizers produced atomized droplets of protein solution of similar size of less than about 5 μm, which is appropriate for pulmonary delivery. Enzymatic activities of scuPA and of sctPA were determined after nebulization and both remained stable (88.0% and 93.9%). Additionally, the enzymatic activities of sctPA and tcuPA were not significantly affected by excipients, lyophilization or reconstitution conditions. The results of these studies support further development of inhaled formulations of fibrinolysins for delivery to the lungs following smoke-induced acute pulmonary injury.
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Affiliation(s)
- Soraya Hengsawas Surasarang
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Sawittree Sahakijpijarn
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Galina Florova
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Andrey A Komissarov
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Christina L Nelson
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Enkhbaatar Perenlei
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Satoshi Fukuda
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Marla R Wolfson
- Lewis Katz School of Medicine at Temple University, Departments of Physiology, Thoracic Medicine and Surgery, Pediatrics, Philadelphia, PA, USA
| | - Thomas H Shaffer
- Lewis Katz School of Medicine at Temple University, Departments of Physiology, Thoracic Medicine and Surgery, Pediatrics, Philadelphia, PA, USA.,Jefferson Medical College/Thomas Jefferson University, Department of Pediatrics, Philadelphia, PA, USA
| | - Steven Idell
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Robert O Williams
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
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21
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Koyano Y, Nakagami G, Minematsu T, Sanada H. Reliability of the skin blotting method when used on the elderly. Int Wound J 2018; 15:807-813. [PMID: 29897658 DOI: 10.1111/iwj.12931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 03/19/2018] [Indexed: 12/01/2022] Open
Abstract
The aim of this study was to compare protein secretion on intact skin of extremities and verify the relationship between the marker proteins on abdominal skin and systemic factors using skin blotting. A cross-sectional study was conducted among elderly patients aged 65 years and older (N = 73) at a long-term medical facility in Japan. Skin blotting was performed on the right and left forearms, right and left lower legs, and abdomen. Pearson's correlations and Bland-Altman plots were utilised for comparing the protein secretion from the skin between the right or left forearms or lower legs. Multiple regression analysis was applied to determine the relationship between intensity levels of 3 proteins on the abdominal skin and the systemic factors. Bland-Altman plots demonstrated that there was no significant difference between right and left secretion levels on the forearms and lower legs among 3 proteins. Multiple regression analysis showed that age and antiplatelet use was positively associated with decreased collagen type IV and increased matrix metalloproteinase 2 levels, respectively. Our findings suggested that collecting samples from either the right or the left skin would be sufficient if skin properties between arms and legs are evaluated using skin blotting.
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Affiliation(s)
- Yuiko Koyano
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Gojiro Nakagami
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeo Minematsu
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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22
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DeZorzi C, Fernandez-Ruiz R, Gupta S, Harris K. Cerebral amyloid angiopathy mimicking central nervous system metastases: a case report. J Med Case Rep 2018; 12:133. [PMID: 29754590 PMCID: PMC5950108 DOI: 10.1186/s13256-018-1655-6] [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: 07/21/2017] [Accepted: 03/18/2018] [Indexed: 11/21/2022] Open
Abstract
Background This case describes an unusual presentation of an intracranial hemorrhage first thought to be metastatic disease on computed tomography and magnetic resonance imaging. The healthcare team completed an exhaustive search for a primary malignancy that was negative. Final diagnosis on brain biopsy showed intercranial hemorrhage secondary to cerebral amyloid angiopathy. With an increasing number of elderly patients and the rising cost of health care, this case can serve as a reminder to clinicians about their own responsibilities in limiting the cost of health care. Case presentation This is a case report about a 72-year-old white woman with an intracranial hemorrhage secondary to cerebral amyloid angiopathy. The brain lesions on computed tomography/magnetic resonance imaging mimicked a metastatic process until a brain biopsy could give a definitive diagnosis that was completely unexpected. Cerebral amyloid angiopathy is a rare cause of intracerebral hemorrhage and this diagnosis is important to consider in older patients on anticoagulation. Conclusions Cerebral amyloid angiopathy is a rare diagnosis but should be considered in elderly patients on anticoagulation presenting with imaging findings consistent with intracerebral hemorrhage. While metastatic disease is a more common cause of intracerebral hemorrhage, cerebral amyloid angiopathy should remain in the differential diagnosis. This case report serves as a teaching point to clinicians in cases involving an older patient on anticoagulation.
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Affiliation(s)
- Christopher DeZorzi
- University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52242, USA.
| | - Ruth Fernandez-Ruiz
- University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Sarika Gupta
- University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Katherine Harris
- University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52242, USA
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Zhang JJ, Liu X. Aspirin plus dipyridamole has the highest surface under the cumulative ranking curves (SUCRA) values in terms of mortality, intracranial hemorrhage, and adverse event rate among 7 drug therapies in the treatment of cerebral infarction. Medicine (Baltimore) 2018; 97:e0123. [PMID: 29595635 PMCID: PMC5895377 DOI: 10.1097/md.0000000000010123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The standardization for the clinical use of drug therapy for cerebral infarction (CI) has not yet determined in some aspects. In this paper, we discussed the efficacies of different drug therapies (aspirin, aspirin plus dipyridamole, aspirin plus clopidogrel, aspirin plus warfarin, cilostazol, warfarin, and ticlopidine) for CI. METHODS We searched databases of PubMed and Cochrane Library from the inception to April, 2017, randomized controlled trials (RCTs) met the inclusion and exclusion criteria were enrolled in this study. The network meta-analysis integrated evidences of direct and indirect comparisons to assess odd ratios (OR) and surface under the cumulative ranking curves (SUCRA) value. RESULTS Thirteen eligible RCTs including 7 drug therapies were included into this network meta-analysis. The network meta-analysis results showed that CI patients who received aspirin plus dipyridamole presented lower mortality when compared with those received aspirin plus clopidogrel (OR = 0.46, 95% CI = 0.18-0.99), indicating aspirin plus dipyridamole therapy had better efficacy for CI. As for intracranial hemorrhage (ICH), stroke recurrence, and adverse event (AE) rate, there were no significant differences of efficacy among 7 drug therapies. Besides, SUCRA values demonstrated that in the 7 drug therapies, aspirin plus dipyridamole therapy was more effective than others (mortality: 80.67%; ICH: 76.6%; AE rate: 90.2%). CONCLUSIONS Our findings revealed that aspirin plus dipyridamole therapy might be the optimum one for patients with CI, which could help to improve the survival of CI patients.
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Dagonnier M, Cooke IR, Faou P, Sidon TK, Dewey HM, Donnan GA, Howells DW. Discovery and Longitudinal Evaluation of Candidate Biomarkers for Ischaemic Stroke by Mass Spectrometry-Based Proteomics. Biomark Insights 2017; 12:1177271917749216. [PMID: 29308009 PMCID: PMC5751906 DOI: 10.1177/1177271917749216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 10/11/2017] [Indexed: 01/17/2023] Open
Abstract
Application of acute therapies such as thrombolysis for ischaemic stroke (IS) is constrained because of diagnostic uncertainty and the dynamic nature of stroke biology. To investigate changes in blood proteins after stroke and as a result of thrombolysis treatment we performed label-free quantitative proteomics on serum samples using high-resolution mass spectrometry and long high-performance liquid chromatography gradient (5 hours) combined with a 50-cm column to optimise the peptide separation. We identified (false discovery rate [FDR]: 1%) and quantified a total of 574 protein groups from a total of 92 samples from 30 patients. Ten patients were treated by thrombolysis as part of a randomised placebo-controlled trial and up to 5 samples were collected from each individual at different time points after stroke. We identified 26 proteins differently expressed by treatment group (FDR: 5%) and significant changes of expression over time for 23 proteins (FDR: 10%). Molecules such as fibrinogen and C-reactive protein showed expression profiles with a high-potential clinical utility in the acute stroke setting. Protein expression profiles vary acutely in the blood after stroke and have the potential to allow the construction of a stroke clock and to have an impact on IS treatment decision making.
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Affiliation(s)
- Marie Dagonnier
- Stroke Department, The Florey Institute of Neuroscience & Mental Health and Melbourne Brain Centre, Melbourne, VIC, Australia
| | - Ira Robin Cooke
- La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia.,Life Sciences Computation Centre, Victorian Life Sciences Computation Initiative, La Trobe University, Melbourne, VIC, Australia
| | - Pierre Faou
- La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
| | - Tara Kate Sidon
- Stroke Department, The Florey Institute of Neuroscience & Mental Health and Melbourne Brain Centre, Melbourne, VIC, Australia
| | - Helen Margaret Dewey
- Stroke Department, The Florey Institute of Neuroscience & Mental Health and Melbourne Brain Centre, Melbourne, VIC, Australia
| | - Geoffrey Alan Donnan
- Stroke Department, The Florey Institute of Neuroscience & Mental Health and Melbourne Brain Centre, Melbourne, VIC, Australia
| | - David William Howells
- Stroke Department, The Florey Institute of Neuroscience & Mental Health and Melbourne Brain Centre, Melbourne, VIC, Australia.,School of Medicine, Faculty of Health, University of Tasmania, Hobart, TAS, Australia
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25
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Esmon C, Turpie A. Venous and arterial thrombosis – pathogenesis and the rationale for anticoagulation. Thromb Haemost 2017; 105:586-96. [DOI: 10.1160/th10-10-0683] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 12/27/2010] [Indexed: 01/31/2023]
Abstract
SummaryThromboembolic disorders are major causes of morbidity and mortality. It is well-recognised that the pathogenesis is different for arterial and venous thrombosis; however, both involve coagulation activation. Anticoagulants are used for the prevention and treatment of a wide variety of thromboembolic and related conditions. Agents with anti-inflammatory properties in addition to anticoagulation may be particularly beneficial. Traditional anticoagulants, although effective, are associated with certain limitations. Understanding the pathological processes associated with thrombosis and the rational target for anticoagulation is essential, not only for the development of safer and more effective agents, but also for better clinical management of patients who require anticoagulation therapy. In recent years, new oral agents that target single enzymes of the coagulation cascade have been developed – some of those are in advanced stages of clinical development. Based on scientific rationale, both factor Xa and thrombin are viable targets for effective anticoagulation.
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Renjen PN, Chaudhari D. Re-initiation of oral-anticoagulants in survivors of hemorrhagic stroke. APOLLO MEDICINE 2017. [DOI: 10.1016/j.apme.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Abstract
Patients affected by cardiovascular disease (CVD) are treated with antiplatelet agents (AA) and/or anticoagulant drugs, which are fundamental in the management of stroke, coronary atherosclerotic disease, peripheral vascular disease and atrial fibrillation. CVD is the most important cause of death in chronic renal failure (CRF). Death rates from myocardial infarction (MI) and from all other cardiac causes exceed those for the general population. Incidence of MI in CRF is triple that in the general population. Moreover, mortality is seven- to eight-fold higher in patients requiring chronic hemodialysis compared to the general population, and approximately 40% of deaths in this population are attributable to coronary artery disease (CAD). For these reasons, AA are widely used in patients affected by CRF. Current data do not support a protective effect of antiplatelet administration in hemodialytic patients as primary prevention of cardiovascular mortality. Different results have been obtained concerning secondary prevention of CVD. The Cooperative Cardiovascular Project demonstrated that dialysis patients treated with aspirin following MI had a 43% lower mortality. Another study reported that the use of aspirin and beta-blockers following MI was associated with lower mortality in CRF patients. However, aspirin plus clopidogrel seems to increase the hemorrhagic risk without a significant reduction in cardiovascular mortality and there are insufficient data to support the use of new AA drugs in hemodialytic patients. In conclusion, since CRF patients are one of the groups at highest risk for atherosclerotic events, it could be reasonable to use aspirin in HD patients. However, the bleeding risk in HD patients needs to be strongly evaluated, especially before starting dual AA treatment.
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28
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Aspirin, stroke and drug-drug interactions. Vascul Pharmacol 2016; 87:14-22. [DOI: 10.1016/j.vph.2016.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/06/2016] [Accepted: 10/14/2016] [Indexed: 12/29/2022]
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29
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Chang Y, Kim YJ, Song TJ. Management of Oral Anti-Thrombotic Agents Associated Intracerebral Hemorrhage. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160082] [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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30
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Liu Z, Moorin R, Worthington J, Tofler G, Bartlett M, Khan R, Zuo Y. Using Large-Scale Linkage Data to Evaluate the Effectiveness of a National Educational Program on Antithrombotic Prescribing and Associated Stroke Prevention in Primary Care. J Am Heart Assoc 2016; 5:JAHA.116.003729. [PMID: 27737875 PMCID: PMC5121477 DOI: 10.1161/jaha.116.003729] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The National Prescribing Service (NPS) MedicineWise Stroke Prevention Program, which was implemented nationally in 2009-2010 in Australia, sought to improve antithrombotic prescribing in stroke prevention using dedicated interventions that target general practitioners. This study evaluated the impact of the NPS MedicineWise Stroke Prevention Program on antithrombotic prescribing and primary stroke hospitalizations. METHOD AND RESULTS This population-based time series study used administrative health data linked to 45 and Up Study participants with a high risk of cardiovascular disease (CVD) to assess the possible impact of the NPS MedicineWise program on first-time aspirin prescriptions and primary stroke-related hospitalizations. Time series analysis showed that the NPS MedicineWise program was significantly associated with increased first-time prescribing of aspirin (P=0.03) and decreased hospitalizations for primary ischemic stroke (P=0.03) in the at-risk study population (n=90 023). First-time aspirin prescription was correlated with a reduction in the rate of hospitalization for primary stroke (P=0.02). Following intervention, the number of first-time aspirin prescriptions increased by 19.8% (95% confidence interval, 1.6-38.0), while the number of first-time stroke hospitalizations decreased by 17.3% (95% confidence interval, 1.8-30.0). CONCLUSIONS Consistent with NPS MedicineWise program messages for the high-risk CVD population, the NPS MedicineWise Stroke Prevention Program (2009) was associated with increased initiation of aspirin and a reduced rate of hospitalization for primary stroke. The findings suggest that the provision of evidence-based multifaceted large-scale educational programs in primary care can be effective in changing prescriber behavior and positively impacting patient health outcomes.
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Affiliation(s)
- Zhixin Liu
- NPS MedicineWise, Sydney, New South Wales, Australia
| | - Rachael Moorin
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - John Worthington
- Ingham Institute, South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Geoffrey Tofler
- Royal North Shore Hospital, University of Sydney, New South Wales, Australia
| | | | - Rabia Khan
- NPS MedicineWise, Sydney, New South Wales, Australia
| | - Yeqin Zuo
- NPS MedicineWise, Sydney, New South Wales, Australia
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Razouki Z, Burgess JF, Ozonoff A, Zhao S, Berlowitz D, Rose AJ. Improving Anticoagulation Measurement Novel Warfarin Composite Measure. Circ Cardiovasc Qual Outcomes 2016; 8:600-7. [PMID: 26420820 DOI: 10.1161/circoutcomes.115.001789] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percent time in therapeutic range (TTR) and international normalized ratio (INR) variability both measure warfarin control and are associated with outcomes independently. Here, we examine the advantages of a warfarin composite measure (WCM), which summarizes the 2 when measuring patient outcomes. We also examine how the measure chosen would affect anticoagulation clinic performance rankings. METHODS AND RESULTS We constructed WCM using an equally weighted method, adding standardized TTR to standardized log-transformed INR variability using 103 897 warfarin-experienced patients from 100 anticoagulation clinics. We examined the association of WCM with ischemic stroke, major bleeding, and fatal bleeding, using a subset of patients with atrial fibrillation (n=40 404). We divided patients into quintiles based on their level of control for TTR, log INR variability, and WCM. We calculated the hazard ratios for ischemic stroke, major bleeding, and fatal bleeding stratified by these quintiles. WCM hazard ratios for stroke and fatal bleeding showed the largest difference between excellent control and poorest control quintile compared with TTR and log INR variability, but not for major bleeding. In addition, we compared site rankings obtained using each of our 3 performance measures. Kappa scores for identifying outlier and nonoutlier clinics between WCM and its components were moderate (κ=0.56 for TTR and κ=0.62 for log INR variability) but was weak between TTR and log INR variability (κ=0.13). CONCLUSIONS WCM produces the largest range of risk for warfarin complications, widening the floor ceiling effects that limit the use of TTR and INR variability as separate measures. Anticoagulation clinics ranking changed considerably according to the anticoagulation measure that was selected.
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Pandya A, Eggman AA, Kamel H, Gupta A, Schackman BR, Sanelli PC. Modeling the Cost Effectiveness of Neuroimaging-Based Treatment of Acute Wake-Up Stroke. PLoS One 2016; 11:e0148106. [PMID: 26840397 PMCID: PMC4740488 DOI: 10.1371/journal.pone.0148106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 01/13/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Thrombolytic treatment (tissue-type plasminogen activator [tPA]) is only recommended for acute ischemic stroke patients with stroke onset time <4.5 hours. tPA is not recommended when stroke onset time is unknown. Diffusion-weighted MRI (DWI) and fluid attenuated inversion recovery (FLAIR) MRI mismatch information has been found to approximate stroke onset time with some accuracy. Therefore, we developed a micro-simulation model to project health outcomes and costs of MRI-based treatment decisions versus no treatment for acute wake-up stroke patients. METHODS AND FINDINGS The model assigned simulated patients a true stroke onset time from a specified probability distribution. DWI-FLAIR mismatch estimated stroke onset <4.5 hours with sensitivity and specificity of 0.62 and 0.78, respectively. Modified Rankin Scale (mRS) scores reflected tPA treatment effectiveness accounting for patients' true stroke onset time. Discounted lifetime costs and benefits (quality-adjusted life years [QALYs]) were projected for each strategy. Incremental cost-effectiveness ratios (ICERs) were calculated for the MRI-based strategy in base-case and sensitivity analyses. With no treatment, 45.1% of simulated patients experienced a good stroke outcome (mRS score 0-1). Under the MRI-based strategy, in which 17.0% of all patients received tPA despite stroke onset times >4.5 hours, 46.3% experienced a good stroke outcome. Lifetime discounted QALYs and costs were 5.312 and $88,247 for the no treatment strategy and 5.342 and $90,869 for the MRI-based strategy, resulting in an ICER of $88,000/QALY. Results were sensitive to variations in patient- and provider-specific factors such as sleep duration, hospital travel and door-to-needle times, as well as onset probability distribution, MRI specificity, and mRS utility values. CONCLUSIONS Our model-based findings suggest that an MRI-based treatment strategy for this population could be cost-effective and quantifies the impact that patient- and provider-specific factors, such as sleep duration, hospital travel and door-to-needle times, could have on the optimal decision for wake-up stroke patients.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, United States of America
- * E-mail:
| | - Ashley A. Eggman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Hooman Kamel
- Department of Neurology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
| | - Ajay Gupta
- Department of Radiology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Pina C. Sanelli
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
- Department of Radiology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
- Department of Radiology, North Shore–LIJ Health System, Manhasset, NY, United States of America
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Greer DM, Homma S, Furie KL. Cardiac Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00032-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Propensity of Withania somnifera to Attenuate Behavioural, Biochemical, and Histological Alterations in Experimental Model of Stroke. Cell Mol Neurobiol 2015; 36:1123-38. [DOI: 10.1007/s10571-015-0305-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 11/11/2015] [Indexed: 12/19/2022]
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Tsai MS, Chuang PY, Huang CH, Shih SR, Chang WT, Chen NC, Yu PH, Cheng HJ, Tang CH, Chen WJ. Better adherence to antithyroid drug is associated with decreased risk of stroke in hyperthyroidism patients. Int J Clin Pract 2015; 69:1473-85. [PMID: 26299643 DOI: 10.1111/ijcp.12724] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND An increased risk for ischaemic stroke has been reported in young hyperthyroidism patients independent of atrial fibrillation (AF). However, whether the use of antithyroid drugs in hyperthyroidism patients can reduce the occurrence of ischaemic stroke remains unclear. METHODS A total of 36,510 newly diagnosed hyperthyroidism patients during 2003-2006 were identified from the Taiwan National Health Insurance Research database. Each patient was individually tracked for 5 years from their index date (beginning the antithyroid drugs) to identify those who suffered from new episode of ischaemic stroke. Medication possession ratio (MPR) was used to represent the antithyroid drug compliance. The association between the MPR and the risk of stroke was examined. RESULTS The stroke incidence rates for hyperthyroidism patients with age < 45 years and age ≥ 45 years were 0.42 and 3.76 per 1000 person-years, respectively. The patients aged < 45 years with MPR < 0.2 (adjusted hazard ratio, HR, 2.30; 95% CI, 1.13-4.70; p = 0.02) and 0.2 ≤ MPR < 0.4 (adjusted HR, 2.24; 95% CI, 1.06-4.72; p = 0.035) had a significantly increased risk of ischaemic stroke as compared to those with ≥ 0.6. In patients of the age ≥ 45 years, only the patients with MPR < 0.2 (adjusted HR, 1.44; 95% CI, 1.03-2.01; p = 0.036) had a significantly higher risk of ischaemic stroke as compared to those with MPR ≥ 0.6. In hyperthyroidism patients without AF, good antithyroid drugs compliance also reduced the incidence of stroke significantly (adjusted HR, range: 1.52-1.61; p = 0.02); but not in hyperthyroidism with AF. CONCLUSION Hyperthyroidism patients with good antithyroid drug compliance had a lower risk of ischaemic stroke than patients with poor compliance.
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Affiliation(s)
- M-S Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - P-Y Chuang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - C-H Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - S-R Shih
- Department of Internal Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - W-T Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - N-C Chen
- Department of Emergency Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan County, Taiwan
| | - P-H Yu
- Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan
| | - H-J Cheng
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - C-H Tang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - W-J Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Department of Emergency Medicine, Lotung Poh-Ai Hospital, Yilan County, Taiwan
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Ongen G, Demir M, Molinas N, Ince B, Ongen Z. Evaluation of the Practice Pattern of Medical Patients’ VTE Prophylaxis With a Standard Risk Assessment Model Form. Clin Appl Thromb Hemost 2015; 21:412-9. [DOI: 10.1177/1076029613505765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hospitalized acutely ill patients face high risk for venous thromboembolism (VTE) unless appropriate thromboprophylaxis is applied. This study aimed to determine VTE prophylaxis practices for inpatients in Turkey and to evaluate the impact of physicians’ training via a modified “Standard Medical Patients’ VTE Risk Assessment Model (MERAM).” A total of 607 inpatients included in this national multicenter noninterventional observational registry were evaluated in terms of demographics, VTE risk, and preventive measures at 2 consecutive cross-sectional visits. Physicians were asked to complete a questionnaire on current VTE method risk assessment and other models including MERAM. The VTE prophylaxis rates significantly increased from 49.4% to 62.4% between visits ( P < .05). The lack of risk evaluation decreased from 74.6% to 19.5% ( P < .001). Percentage of physicians using prophylaxis and use of MERAM increased between visits. Physician training proved effective for providing general “awareness” of VTE prophylaxis and led to higher rates of risk assessment model-based appropriate VTE prophylaxis.
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Affiliation(s)
- Gul Ongen
- Department of Chest Medicine, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Muzaffer Demir
- Department of Hematology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Nil Molinas
- Department of Oncology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Birsen Ince
- Department of Neurology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Zeki Ongen
- Department of Cardiology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
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Sugie M, Kamiya Y, Iizuka N, Murakami H, Kawamura M, Ichikawa H. Revisiting Clinical Utility of Chest Radiography and Electrocardiogram to Determine Ischemic Stroke Subtypes: Special Reference on Vascular Pedicle Width and Maximal P-Wave Duration. Eur Neurol 2015; 73:342-50. [PMID: 26021430 DOI: 10.1159/000382127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/05/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUNDS It is often difficult to diagnose stroke subtypes at admission, particularly in sinus rhythm cases. Vascular pedicle width (VPW) on chest X-ray (CXR) and maximal P-wave duration (P-max) on electrocardiogram (ECG) are again realized as useful parameters reflecting intravascular volume and atrial conduction status, respectively. We investigated the utility of VPW and P-max as a tool for differentiating ischemic stroke subtypes. METHODS We studied 343 acute stroke patients showing sinus rhythm on admission. Dividing the patients into cardioembolic (CE) stroke (n = 57) and non-CE (n = 286) groups, we compared clinical backgrounds including VPW on CXR, and P-max in lead II and premature atrial contraction (PAC) on 12-leads ECG. Then, we investigated the independent factors for CE. RESULTS Independent factors associated with CE were VPW (≥59.3 mm) (p < 0.001; odds ratio (OR), 10.12; 95% confidence interval (CI), 4.13-24.8), P-max in lead II (≥120 ms) (p < 0.001; OR, 8.61; 95% CI, 3.96-18.7), PAC (p = 0.002; OR, 7.35; 95% CI, 2.14-25.3) and D-dimer level (≥1.11 µg/ml) (p = 0.016; OR, 2.57; 95% CI, 1.20-5.51). CONCLUSIONS VPW, P-max, PAC and D-dimer are useful parameters for diagnosing CE stroke in patients with sinus rhythm at admission.
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Affiliation(s)
- Masayuki Sugie
- Department of Neurology, Showa University Fujigaoka Hospital, Yokohama, Japan
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Scullen TA, Monlezun DJ, Siegler JE, George AJ, Schwickrath M, El Khoury R, Cho MC, Martin-Schild S. Cryptogenic Stroke: Clinical Consideration of a Heterogeneous Ischemic Subtype. J Stroke Cerebrovasc Dis 2015; 24:993-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.12.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/15/2014] [Accepted: 12/18/2014] [Indexed: 11/17/2022] Open
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High on-treatment platelet reactivity in patients with ischemic cerebrovascular disease: assessment of prevalence and stability over time using four platelet function tests. Blood Coagul Fibrinolysis 2015; 25:604-11. [PMID: 24717421 DOI: 10.1097/mbc.0000000000000118] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
High on-treatment platelet reactivity (HTPR), referred to as a higher than expected platelet reactivity in patients under antiplatelet therapy, could influence outcome in cerebrovascular disease (CVD), but its prevalence and its stability over time is uncertain. Platelet reactivity was assessed in 18 patients with ischemic stroke/transient ischemic attack (TIA) 7 days (D7) and 90 days (D90) after prescription of clopidogrel, using four methods: light transmission aggregometry with 5 μmol/l ADP (LTA-ADP), vasodilator-stimulated phosphoprotein (VASP), Verify Now P2Y12 and platelet function analyzer (PFA) P2Y. HTPR was defined as LTA-ADP more than 46%; PFA-100-P2Y closure time less than 106 s; VerifyNow P2Y12, PRU greater than 235, VASP, PRI greater than 50%. Patients displayed, both at D7 and D90, a marked inhibition of platelet reactivity towards ADP in all tests as compared with reference levels. Correlations between the results obtained with all the tests at D7 and D90 and between measurements on each day in each test were low-to-moderate. The prevalence of HTPR for all the tests was 40% at D7 and 42% at D90. There was a moderate degree of agreement (k statistic < 0.5) between tests with regard to categorizing patients as HTPR/No-HTPR (D7 and D90). The on-clopidogrel platelet reactivity phenotype, HTPR/No-HTPR, remained stable in 55-72% of patients, depending on the test. A high prevalence of HTPR is found among CVD patients treated with clopidogrel and this platelet reactivity phenotype remains over time. There is poor agreement between the different platelet function tests for categorizing the platelet reactivity phenotype in these patients. The new PFA-100 P2Y equals other platelet function assays for evaluating HTPR in CVD.
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Marecos C, Gunny R, Robinson R, Ganesan V. Are children with acute arterial ischaemic stroke eligible for hyperacute thrombolysis? A retrospective audit from a tertiary UK centre. Dev Med Child Neurol 2015; 57:181-6. [PMID: 25223401 DOI: 10.1111/dmcn.12588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2014] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to evaluate the number of children with acute arterial ischaemic stroke (AIS) who would have been eligible for hyperacute thrombolysis in the authors' unit (Great Ormond Street Hospital, London, UK) and to identify barriers to this treatment. METHOD We compared the characteristics of children with a diagnosis of acute AIS, identified from neuroimaging databases, seen at our centre between January 2006 and December 2011. The criteria for hyperacute thrombolysis were predefined by us: age ≥8y; imaging-confirmed diagnosis of acute AIS and arrival at our centre within 6 hours of symptom onset; occluded major artery on computed tomography (CT) or magnetic resonance angiography; no contraindications. Factors that precluded therapy were examined. RESULTS Of a total of 107 children with acute AIS identified on MRI (n=64; 33 females, 31 males; median age 4y, range 1mo-17y) or CT databases (n=43; 14 females, 29 males; median age 1y, range 1mo-15y), none would have been eligible for hyperacute thrombolysis. The major barriers to this were (1) delayed diagnosis, (2) delayed transfer to the tertiary centre, (3) age, and (4) medical comorbidities. Of 107 children, three (2.8%) would have been eligible for thrombolysis if diagnosis and transfer had occurred in a timely manner. An additional 11 children (10.3%) would have been eligible if the age criterion was 28 days or more and if diagnosis and transfer had occurred promptly. INTERPRETATION Although hyperacute thrombolysis is, as yet, an unproven treatment in childhood AIS, at least a subset of patients could potentially benefit. This audit has identified that clinical factors preclude treatment in a high percentage of children. Furthermore, in our specialist unit, without an emergency department, we identified major logistic barriers that will need to be addressed to enable access to hyperacute therapies. These results could inform future trial design and service delivery.
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Affiliation(s)
- Clara Marecos
- Neurology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Zorowitz RD. Stroke Rehabilitation Quality Indicators: Raising the Bar in the Inpatient Rehabilitation Facility. Top Stroke Rehabil 2015; 17:294-304. [DOI: 10.1310/tsr1704-294] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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PérezRodon J, FranciscoPascual J, RivasGándara N, RocaLuque I, Bellera N, MoyaMitjans À. Cryptogenic Stroke And Role Of Loop Recorder. J Atr Fibrillation 2014; 7:1178. [PMID: 27957141 DOI: 10.4022/jafib.1178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/12/2014] [Accepted: 12/21/2014] [Indexed: 12/29/2022]
Abstract
Ischemic stroke is an important cause of morbidity and mortality when untreated. Identifying atrial fibrillation is important because atrial fibrillation ischemic related strokes are associated with an increased risk of disability and death compared with strokes of other etiologies and tend to recur without anticoagulation. However, atrial fibrillation detection can be difficult when it is asymptomatic and paroxistic and may be the underlying cause of some cryptogenic strokes or strokes of unknown origin. In this review, the different methods of cardiac monitoring to detect atrial fibrillation in patients with cryptogenic stroke are summarized, with a focus on loop recorder monitoring.
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Affiliation(s)
- Jordi PérezRodon
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Jaume FranciscoPascual
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Nuria RivasGándara
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Ivo RocaLuque
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Neus Bellera
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Àngel MoyaMitjans
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
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Abstract
Symptomatic extracranial internal carotid artery stenosis poses a high short-time risk of ischemic cerebral stroke, as high as 20% to 30% in the first three months. Timely performed carotid endarterectomy (CEA) has been shown to be highly effective in reducing this risk although, in recent years, there has been great interest in replacing this procedure with less invasive carotid angioplasty and stenting (CAS). In this update we review recent studies and provide recommendations regarding the indications, methods and timing of surgical intervention as well as the anaesthetic management of CEA, and we report on recently published randomized controlled trials comparing CEA to CAS. We also provide recommendations regarding the sometime neglected but important medical management of patients undergoing carotid intervention, including antithrombotic and antihypertension therapy, lipid lowering agents, assistance with smoking cessation, and diabetes control.
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Lago A, Parkhutik V, Tembl JI, Vallés J, Santos MT, Moscardó A. Assessment of Platelet Function in Acute Ischemic Stroke Patients Previously Treated with Aspirin. J Stroke Cerebrovasc Dis 2014; 23:2794-2799. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 05/29/2014] [Accepted: 07/02/2014] [Indexed: 11/25/2022] Open
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Thaler DE, Ruthazer R, Weimar C, Serena J, Mattle HP, Nedeltchev K, Mono ML, Di Angelantonio E, Elkind MSV, Di Tullio MR, Homma S, Michel P, Meier B, Furlan AJ, Lutz JS, Kent DM. Determinants of antithrombotic choice for patent foramen ovale in cryptogenic stroke. Neurology 2014; 83:1954-7. [PMID: 25339209 DOI: 10.1212/wnl.0000000000001007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE We examined the influence of clinical, radiologic, and echocardiographic characteristics on antithrombotic choice in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), hypothesizing that features suggestive of paradoxical embolism might lead to greater use of anticoagulation. METHODS The Risk of Paradoxical Embolism Study combined 12 databases to create the largest dataset of patients with CS and known PFO status. We used generalized linear mixed models with a random effect of component study to explore whether anticoagulation was preferentially selected based on the following: (1) younger age and absence of vascular risk factors, (2) "high-risk" echocardiographic features, and (3) neuroradiologic findings. RESULTS A total of 1,132 patients with CS and PFO treated with anticoagulation or antiplatelets were included. Overall, 438 participants (39%) were treated with anticoagulation with a range (by database) of 22% to 54%. Treatment choice was not influenced by age or vascular risk factors. However, neuroradiologic findings (superficial or multiple infarcts) and high-risk echocardiographic features (large shunts, shunt at rest, and septal hypermobility) were predictors of anticoagulation use. CONCLUSION Both antithrombotic regimens are widely used for secondary stroke prevention in patients with CS and PFO. Radiologic and echocardiographic features were strongly associated with treatment choice, whereas conventional vascular risk factors were not. Prior observational studies are likely to be biased by confounding by indication.
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Affiliation(s)
- David E Thaler
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH.
| | - Robin Ruthazer
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Christian Weimar
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Joaquín Serena
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Heinrich P Mattle
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Krassen Nedeltchev
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Marie-Luise Mono
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Emanuele Di Angelantonio
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Mitchell S V Elkind
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Marco R Di Tullio
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Shunichi Homma
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Patrik Michel
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Bernhard Meier
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Anthony J Furlan
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - Jennifer S Lutz
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
| | - David M Kent
- From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH
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Kaminski-Hartenthaler A, Meerpohl JJ, Gartlehner G, Kien C, Langer G, Wipplinger J, Schünemann HJ. [GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2014; 108:413-20. [PMID: 25444300 DOI: 10.1016/j.zefq.2014.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article describes the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to classifying the direction and strength of recommendations. The strength of a recommendation, separated into strong and weak, is defined as the extent to which one can be confident that the desirable effects of an intervention outweigh its undesirable effects. Alternative terms for a weak recommendation include conditional, discretionary, or qualified. The strength of a recommendation has specific implications for patients, the public, clinicians, and policy makers. Occasionally, guideline developers may choose to make "only-in-research" recommendations. Although panels may choose not to make recommendations, this choice leaves those looking for answers from guidelines without the guidance they are seeking. GRADE therefore encourages panels to, wherever possible, offer recommendations.
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Affiliation(s)
| | - Joerg J Meerpohl
- Deutsches Cochrane Zentrum, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Gerald Gartlehner
- Donau-Universität Krems, Department für Evidenzbasierte Medizin und Klinische Epidemiologie, Krems, Österreich
| | - Christina Kien
- Donau-Universität Krems, Department für Evidenzbasierte Medizin und Klinische Epidemiologie, Krems, Österreich
| | - Gero Langer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Jörg Wipplinger
- Donau-Universität Krems, Department für Evidenzbasierte Medizin und Klinische Epidemiologie, Krems, Österreich
| | - Holger J Schünemann
- Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, Hamilton, Kanada
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Abstract
Acute ischemic stroke is the fourth leading cause of death and the leading cause of disability in the United States. Stroke is a medical emergency. The development of stroke systems of care has changed the way practitioners view and treat this devastating disease. Ample evidence has shown that patients presenting early and receiving intravenous thrombolytic therapy have the best chance for significant improvement in functional outcome, particularly if they are transported to specialized stroke centers. Early detection and management of medical and neurologic complications is key at preventing further brain damage in patients with acute ischemic stroke.
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Affiliation(s)
- Nelson J Maldonado
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Syed O Kazmi
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Jose Ignacio Suarez
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA.
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Cho JK, Han JH, Park SW, Kim KS. Deep vein thrombosis after spine operation in prone position with subclavian venous catheterization: a case report. Korean J Anesthesiol 2014; 67:61-5. [PMID: 25097742 PMCID: PMC4121498 DOI: 10.4097/kjae.2014.67.1.61] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 07/11/2013] [Accepted: 07/11/2013] [Indexed: 12/20/2022] Open
Abstract
We experienced a case of deep vein thrombosis after spine surgery in the prone position with a central venous catheter (CVC). Posterior lumbar interbody fusion was performed on a 73-year-old female patient who was diagnosed with spinal stenosis. Accordingly, in the operation room under general anesthesia, two-lumen CVC were inserted into the left subclavian vein. The surgery was performed in the prone position with a Wilson frame. On the next day, there was a sudden occurrence of severe edema in the patient's left arm. By ultrasonography and computed tomography scanning, extensive deep vein thrombosis was observed in the left subclavian vein. The existence of a factor affecting blood flow such as the prone position may increase the risk of thrombus formation. Therefore, careful perioperative evaluation should be implemented.
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Affiliation(s)
- Jae Kyung Cho
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin Hee Han
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Sung Wook Park
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Keon Sik Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
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Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O'Donnell MJ, Sacco RL, Connolly SJ. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13:429-38. [PMID: 24646875 DOI: 10.1016/s1474-4422(13)70310-7] [Citation(s) in RCA: 1080] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cryptogenic (of unknown cause) ischaemic strokes are now thought to comprise about 25% of all ischaemic strokes. Advances in imaging techniques and improved understanding of stroke pathophysiology have prompted a reassessment of cryptogenic stroke. There is persuasive evidence that most cryptogenic strokes are thromboembolic. The thrombus is thought to originate from any of several well established potential embolic sources, including minor-risk or covert cardiac sources, veins via paradoxical embolism, and non-occlusive atherosclerotic plaques in the aortic arch, cervical, or cerebral arteries. Accordingly, we propose that embolic strokes of undetermined source are a therapeutically relevant entity, which are defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources, with a clear indication for anticoagulation. Because emboli consist mainly of thrombus, anticoagulants are likely to reduce recurrent brain ischaemia more effectively than are antiplatelet drugs. Randomised trials testing direct-acting oral anticoagulants for secondary prevention of embolic strokes of undetermined source are warranted.
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Affiliation(s)
- Robert G Hart
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
| | | | | | - J Donald Easton
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | | | | | - Ralph L Sacco
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada
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