19 COMPARATIVE COST ANALYSIS OF ALTEPLASE VERSUS TENECTEPLASE FOR ISCHAEMIC STROKE IN A SINGLE CENTRE TERTIARY HOSPITAL

Background

Stroke thombolysis has been a proven effective treatment for acute stroke since 1995. Since then Alteplase has been the standard thrombolytic agent used in the hyperacute stroke patient, the dose being decided by body weight (0.9mg/kg). 10% of the dose is given as a bolus, and the remaining 90% given as an infusion. As the dose is weight based, more than one vial of Alteplase can be required.

Tenecteplase is a more recent thrombolytic agent, and the 2017 large multi-centre randomised control trial NOR-TEST 2 indicated that Tenecteplase is similarly effective compared to Alteplase. Tenecteplase is given entirely as a bolus dose, with a maximum dose of 40mg administered, equivalent to one vial. A single of vial of Alteplase (Actilyse) costs €536, and a single vial of Tenecteplase (Metalyse) costs €986. Our study was set up to compare potential costs of the two treatments based on our patient cohort.

Methods

We retrospectively looked at patients given Alteplase for acute ischaemic stroke in our institution in the year 2019 (n=29). We recorded the weight of the patient, and the number of vials used to administer the appropriate dose of Alteplase. We calculated the cost of the number of vials of Alteplase used over the year, and compared that to the cost of Tenectaplase, if that were to be used instead.

Results

Over the course of the calendar year, 29 patients received Alteplase. All 29 patients had a requirement for two vials of Alteplase based on their admission weight, at a total cost of €31,088 over the year 2019. The cost of Tenectaplase for the same patient cohort would have been €28,594, with a potential cost saving of €2,494.

Conclusion

Based on our acute ischaemic stroke patient cohort for the year 2019, there is a potential cost saving benefit in a move towards using Tenecteplase instead of Alteplase.

154 ANALYSIS OF ELIGIBILITY FOR THROMBOLYSIS IN ISCHAEMIC STROKE PRESENTATIONS IN A UNIVERSITY TEACHING HOSPITAL IN 2021

Background

Since the National Institute of Neurological Disorders and Stroke (NINDS) tissue-type Plasminogen Activator (tPA) trial was published in 1995, thrombolysis has been a mainstay of treatment for ischaemic stroke presenting within the appropriate age-adjusted timeframe, in the absence of contraindications. In the Irish National Audit of Stroke (INAS) National Report 2020, a nationwide thrombolysis rate of 10.6% (Range of 4-22%) was achieved. Aims: (1) This study was designed to compare this centre’s rate in 2021; (2) Identifying any missed potentially suitable presentations.

Methods

A retrospective chart review of 2021 stroke presentations in this centre was performed using medical admission notes and electronic emergency department records. Excluding haemorrhagic causes, we looked at the presenting National Institutes of Health Stroke Scale (NIHSS), the presenting timeframe and any contraindications of thrombolysis therapy, in order to identify any potentially missed eligible presentations. We also compared the percentage of thrombolysed patients in this centre to the national average.

Results

Of the 425 stroke presentations, 74 (17.4%) were excluded as intra-cerebral haemorrhages. Of the remaining 351 presentations, 32 (9.1%) underwent thrombolysis therapy. 225 (64.1%) were not eligible for therapy due to a low or recovering NIHSS (score 0-4). A further 72 (20.5%) with a NIHSS>5, were outside of the window of thrombolysis therapy. Of the remaining presentations, 13 (3.7%) were unsuitable due to anticoagulation use. The final 9 presentations (2.6%) were unsuitable due to other contraindications (previous intracranial haemorrhage, baseline modified Rankin ≥ 4). 18 (5.1%) of non-thrombolysed presentations had no contraindications to thrombolysis therapy aside from late presentation (excluding wake-up events).

Conclusion

While this centre’s thrombolysis percentage is lower than the national average in 2020, a review of presentations suggests no eligible candidates were missed. Therefore, variations in thrombolysis rates across Irish hospitals may reflect case mix variations rather than decision variations.

128 TO BLEED OR NOT TO BLEED: THE INTRACEREBRAL HAEMORRHAGE MANAGEMENT QUESTION

Background

Intracerebral Haemorhage (ICH) accounts for 9-27 per cent of all strokes. There are high rates of early case fatality and poor functional outcome. Clear guidelines and pathways exist around the management of ischaemic stroke. Pathways for the haemorrhagic stroke patient are lacking. Good evidence exists for early Blood Pressure (BP) management, reversal of Oral Anti-Coagulation (OAC) and admission to a Hyper-Acute Stroke Unit (HASU) in terms of improving outcomes.

Methods

A retrospective cohort analysis was performed, looking at all the presentations with ICH over one calendar year. The factors measured included time to CT Brain, BP at presentation, documented target systolic BP of under 140mmHg, time to treatment of hypertension, number on OAC, OAC reversal, time to OAC reversal, admission to HASU. The findings were compared to standards outlined in the European Stroke Organisation and American Heart Association’s ICH management guidance.

Results

76 patients were include (40 female). Mean age was 73, age range 34-93. median age 77. 44 were hypertensive on admission (20 info unavailable [u/a]). Of the 44, 34 had a documented target BP under 140mmHg (12 = n/a, 20 u/a). Time to treatment of hypertension was within 60 minutes for 3 patients. Of those that were hypertensive, 57 per cent were 75 or younger. 16 were on an OAC, of which 11 were appropriately reversed (3 u/a). Of the 11, 2 were reversed within 90 mins (7 u/a). Of those on an OAC, 75 per cent were over 75. 32 were admitted to HASU within 72h (all of these made it within 24h), (10 did not reach HASU, 3 reached HASU bed after 72h, 31 u/a).

Conclusion

Management of ICH is variable and suboptimal. Our goal is to produce a written pathway which will be incorporated into our hyperacute stroke document, with a plan to re-audit.

79 SIMULATION-BASED MEDICAL EDUCATION: A ‘HIP’ WAY TO LEARN ABOUT ORTHO-GERIATRICS!

Background

Simulation-based medical education (SBME) is emerging as a key method of medical education, particularly in the setting of the COVID-19 pandemic. As part of a simulation development competition (SimStars) run by the National Doctors Training and Planning Unit and the South–South West Hospital Group, we brought together an inter-disciplinary team to develop a simulation scenario on hip fracture.

Methods

Our development team consisted of members of the Geriatric Medicine and Orthopaedic Departments. We developed a scenario that can be adapted to suit the needs of learners in orthopaedics, medicine, or nursing. We ran the simulation on a medical ward with one candidate and four facilitators from the Geriatric Medicine Department. The candidate (medical SHO) was presented with a patient (facilitator one), who had sustained a hip fracture following a fall. The candidate was directed to elicit a falls and bone health history, screen for delirium, and suggest further investigations and management. Subsequently, feedback was sought from all participants.

Results

The simulation took twenty minutes, debriefing took fifteen minutes. All considered, the simulation an enjoyable and feasible method for teaching and learning, and a novel way to promote team-building. The candidate felt competent in some areas, reporting that the scenario provided positive reinforcement. She reported feeling supported in identifying areas for further learning. The facilitators also considered this method a useful way to highlight a candidate’s learning needs and direct further teaching. The candidate requested further SBME-based sessions.

Conclusion

This SBME session in Ortho-Geriatrics was well-received by the candidate and facilitators. All participants enjoyed teaching and learning through this medium. Areas of high competency were reinforced and areas for future learning were identified. Further SBME was requested across more topics and for simulation training to be brought in as part of formal training.

Inflammatory cytokines, high-sensitivity C-reactive protein, and risk of one-year vascular events, death, and poor functional outcome after stroke and transient ischemic attack

Background

Inflammation driven by pro-inflammatory cytokines is a new therapeutic target in coronary disease. Few data exist on the association of key upstream cytokines and post-stroke recurrence. In a prospective cohort study, we investigated the association between pivotal cytokines, high-sensitivity C-reactive protein (hsCRP) and one-year outcomes.

Methods

BIO-STROKETIA is a multi-center prospective cohort study of non-severe ischemic stroke (modified Rankin score ≤ 3) and transient ischemic attack. Controls were patients with transient symptoms attending transient ischemic attack clinics with non-ischemic final diagnosis. Exclusion criteria were severe stroke, infection, and other pro-inflammatory disease; hsCRP and cytokines (interleukin (IL) 6, IL-1β, IL-8, IL-10, IL-12, interferon-γ (IFN-γ), tumor-necrosis factor-α (TNF-α)) were measured. The primary outcome was one-year recurrent stroke/coronary events (fatal and non-fatal).

Results

In this study, 680 patients (439 stroke, 241 transient ischemic attack) and 68 controls were included. IL-6, IL-1β, IL-8, IFN-γ, TNF-α, and hsCRP were higher in stroke/transient ischemic attack cases (p ≤ 0.01 for all). On multivariable Cox regression, IL-6, IL-8, and hsCRP independently predicted one-year recurrent vascular events (adjusted hazard ratios (aHR) per-quartile increase IL-6 1.31, confidence interval (CI) 1.02–1.68, p = 0.03; IL-8 1.47, CI 1.15–1.89, p = 0.002; hsCRP 1.28, CI 1.01–1.62, p = 0.04). IL-6 (aHR 1.98, CI 1.26–3.14, p = 0.003) and hsCRP (aHR 1.81, CI 1.20–2.74, p = 0.005) independently predicted one-year fatality. IL-6 and hsCRP (adjusted odds ratio per-unit increase 1.02, CI 1.01–1.04) predicted poor functional outcome, with a trend for IL-1β (p = 0.054).

Conclusion

Baseline inflammatory cytokines independently predicted late recurrence, supporting a rationale for randomized trials of anti-inflammatory agents for prevention after stroke and suggesting that targeted therapy to high-risk patients with high baseline inflammation may be beneficial.

Assessment and management of transient ischaemic attack — the role of the TIA clinic

BACKGROUND

As the risk of early stroke following transient ischaemic attack (TIA) is increasingly recognised, the management of patients presenting with symptoms suggestive of TIA presents a clinical challenge.

METHODS

Analysis of prospectively collected data on patients referred to a TIA clinic in St. Vincent's University Hospital, between January 2003 and July 2004.

RESULTS

One-hundred-and-seventeen (117) patients (mean age 75.5 years) were assessed. The majority (79%) were referred from Accident and Emergency and 61% were seen within one week of referral. Seventy-two patients (62%) had a final diagnosis of cerebrovascular disease (56 TIA, 16 completed strokes), of whom five (7%) and four (5.5%) had severe (> 70%) and moderate (> 50%) symptomatic carotid artery stenosis, respectively, whilst seven patients (10%) had newly diagnosed atrial fibrillation, five of whom were anticoagulated. Non-cerebrovascular diagnoses were made in twenty-seven patients (24%).

CONCLUSION

A TIA clinic, in co-ordination with Accident and Emergency Services, provides a safe and efficient alternative to hospital admission for patients with TIA symptoms and a low early stroke risk.

Stroke in the very old

Prospective data on 614 consecutive stroke admissions was analysed. 262 (43%) were >80 years. 165 (63.5) were female. In the patients >80 years compared to patients <80 years, mortality was higher, 71 (27%/) v 33 (9%) and length of stay was longer (28.2 +/- 32.5 days v 24.4 +/- 27.5 days). More older patients (>80 years) were discharged to extended nursing care, 71 (27%) v 33 (9.3%), whilst less older patients were discharged home, 87 (33%) v 234 (66%). Prior to their stroke 65 (25%) and 39 (15%) of patients >80 years were dependent in activities of daily living or living in extended nursing care respectively, compared to 24 (6.8%) and 15 (4.2%) of patients <80 years. Existing or new onset atrial fibrillation was present in 118 (45%) of patients > or =80 years, compared to 76 (21.5%) in patients <80 years. Stroke in patient's > or =80 years occurs in over 40% of stroke admissions to our hospital and is associated with increased mortality and poor outcome. Stroke services must be developed to optimise stroke prevention and improve the poor outcome in this rapidly increasing population.

What happens to stroke patients after hospital discharge?

Of 231 stroke patients discharged from hospital, 34 patients (14.7%) had died when reviewed 6 months later. Of 195 survivors, 115 (58%) were independent and living in the community. The remaining 80 (42%) patients were dependent. The majority of dependent patients were in institutional care but 29 (36%) were residing in the community of whom a substantial number were not receiving physiotherapy, occupational therapy or day care. Patients who were dependent in nursing homes were less likely to have received physiotherapy (48% versus 70%) or occupational therapy (28% versus 60%) compared to disabled patients in hospital based extended nursing care. 45 patients (24%) had been re-admitted to hospital although only 48% of patients had been reviewed in hospital outpatients since discharge. 64% of patients were on anti-thrombotic treatment. This survey suggests that 6 months after hospital discharge, most stroke patients are still alive and living in the community. Many of the dependent survivors have ongoing unmet medical and rehabilitation needs.

Telling the truth about cancer: views of elderly patients and their relatives

The aim of this study was to compare the attitudes of elderly patients and their relatives towards telling the truth about cancer. 120 patients were asked if they would wish to be told about bad news, such as cancer, which might emerge during the admission. Matched relatives were asked if such information should be disclosed to the patient. Of the 120 patients, 99 (83%) wanted to be told the truth; 66 relatives (55%) relatives wanted their next of kin informed. There was agreement in 73 (61%) pairs. The kappa statistic was 0.16 (95% confidence interval -0.03 to 0.35), which indicates poor agreement. We conclude that most elderly people wish to be informed of a diagnosis of cancer. Patient preferences cannot be predicted by talking to relatives.