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Chan BPL, Wong LYH, Tan BYQ, Yeo LLL, Venketasubramanian N. Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review. J Cardiovasc Dev Dis 2024; 11:48. [PMID: 38392262 PMCID: PMC10889184 DOI: 10.3390/jcdd11020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.
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Affiliation(s)
- Bernard P L Chan
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Lily Y H Wong
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Leonard L L Yeo
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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2
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Sharma VK, Gopinathan A, Tan BYQ, Loh PH, Hung J, Tang D, Chua C, Chan ACY, Ong JJY, Chin A, Jing M, Goh Y, Sunny S, Keat CH, Ka Z, Pandya S, Wong LYH, Chen JT, Yeo LLL, Chan BPL, Teoh HL, Sinha AK. Enhanced external counter pulsation therapy in patients with symptomatic and severe intracranial steno-occlusive disease: a randomized clinical trial protocol. Front Neurol 2023; 14:1177500. [PMID: 37325226 PMCID: PMC10262049 DOI: 10.3389/fneur.2023.1177500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Intracranial stenosis is prevalent among Asians and constitutes a common cause of cerebral ischemia. While the best medical therapy carries stroke recurrence rates in excess of 10% per year, trials with intracranial stenting have been associated with unacceptable peri-procedural ischemic events. Cerebral ischemic events are strongly related to the severity of intracranial stenosis, which is high in patients with severe intracranial stenosis with poor vasodilatory reserve. Enhanced External Counter Pulsation (EECP) therapy is known to improve myocardial perfusion by facilitating the development of collateral blood vessels in the heart. In this randomized clinical trial, we evaluate whether EECP therapy may be useful in patients with severe stenosis of intracranial internal carotid (ICA) or middle cerebral artery (MCA). The review of literature, methods of evaluation, status of currently used therapeutic approaches, and trial protocol have been presented. Clinical trial registration ClinicalTrials.gov, Identifier: NCT03921827.
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Affiliation(s)
- Vijay K. Sharma
- Divisin of Neurology, National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Anil Gopinathan
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Benjamin Y. Q. Tan
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Poay Huan Loh
- Department of Cardiology, National University Hospital, Singapore, Singapore
| | - Jennifer Hung
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - David Tang
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Christopher Chua
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Amanda C. Y. Chan
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Jonathan J. Y. Ong
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Amanda Chin
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Mingxue Jing
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Yihui Goh
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Sibi Sunny
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Chin Howe Keat
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Zhang Ka
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Shivani Pandya
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Lily Y. H. Wong
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Jin Tao Chen
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Leonard L. L. Yeo
- Divisin of Neurology, National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bernard P. L. Chan
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Hock Luen Teoh
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Arvind K. Sinha
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
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Zheng Y, Lim MJR, Tan BYQ, Chan BPL, Paliwal P, Jonathan OJY, Bharatendu C, Chan ACY, Yeo LLL, Vijayan J, Hong CS, Chee YH, Wong LYH, Chen J, Chong VYF, Dong Y, Tan CH, Sunny S, Teoh HL, Sinha AK, Sharma VK. Role of plaque inflammation in symptomatic carotid stenosis. Front Neurol 2023; 14:1086465. [PMID: 36761341 PMCID: PMC9902904 DOI: 10.3389/fneur.2023.1086465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/09/2023] [Indexed: 01/25/2023] Open
Abstract
Objective Prior studies have shown that plaque inflammation on FDG-PET and the symptomatic carotid atheroma inflammation lumen-stenosis (SCAIL) score were associated with recurrent ischemic events, but the findings have thus far not been widely validated. Therefore, we aimed to validate the findings of prior studies. Methods A single-center prospective cohort study that recruited patients with (1) recent TIA or ischemic stroke within the past 30 days, (2) ipsilateral carotid artery stenosis of ≥50%, and (3) were not considered for early carotid revascularization. The (1) maximum standardized uptake value (SUVmax) of the symptomatic carotid plaque, (2) the SCAIL score, and (3) stenosis severity of the symptomatic carotid artery were measured for all patients. The outcomes were (1) a 90-day ipsilateral ischemic stroke and (2) a 90-day ipsilateral symptomatic TIA or major adverse cardiovascular event (MACE). Results Among the 131 patients included in the study, the commonest cardiovascular risk factor was hypertension (95 patients, 72.5%), followed by diabetes mellitus (77 patients, 58.8%) and being a current smoker (64 patients, 48.9%). The median (IQR) duration between the index cerebral ischemic event and recruitment to the study was 1 (0, 2.5) days. The median (IQR) duration between the index cerebral ischemic event and FDG-PET was 5 (4, 7) days. A total of 14 (10.7%) patients had a 90-day stroke, and 41 (31.3%) patients had a 90-day TIA or MACE. On comparison of the predictive performances of the SCAIL score and SUVmax, SUVmax was found to be superior to the SCAIL score for predicting both 90-day ipsilateral ischemic stroke (AUC: SCAIL = 0.79, SUVmax = 0.92; p < 0.001; 95% CI = 0.072, 0.229) and 90-day TIA or MACE (AUC: SCAIL = 0.76, SUVmax = 0.84; p = 0.009; 95% CI = 0.020, 0.143). Conclusion Plaque inflammation as quantified on FDG-PET may serve as a reliable biomarker for risk stratification among patients with ECAD and recent TIA or ischemic stroke. Future studies should evaluate whether patients with significant plaque inflammation as quantified on FDG-PET benefit from carotid revascularization and/or anti-inflammatory therapy.
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Affiliation(s)
- Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mervyn Jun Rui Lim
- Division of Neurosurgery, National University Health System, Singapore, Singapore
| | - Benjamin Yong-Qiang Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Division of Neurology, National University Health System, Singapore, Singapore
| | | | | | | | - Chandra Bharatendu
- Division of Neurology, National University Health System, Singapore, Singapore
| | | | | | - Joy Vijayan
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Chiew S. Hong
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Young Heng Chee
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Lily Y. H. Wong
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Jintao Chen
- Division of Neurology, National University Health System, Singapore, Singapore
| | | | - Yanhong Dong
- Alice Lee Centre for Nursing Studies, Singapore, Singapore
| | - Chi Hsien Tan
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Sibi Sunny
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Arvind Kumar Sinha
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Vijay Kumar Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Division of Neurology, National University Health System, Singapore, Singapore,*Correspondence: Vijay Kumar Sharma ✉
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Paliwal PR, Sharma AK, Komal Kumar RN, Wong LYH, Chan BPL, Teoh HL, Sharma VK. Effect of erroneous body-weight estimation on outcome of thrombolyzed stroke patients. J Thromb Thrombolysis 2021; 50:921-928. [PMID: 32337652 DOI: 10.1007/s11239-020-02118-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Intravenously administered tissue plasminogen activator (IV-tPA), dose determined by patients' body-weight, remains the only approved drug treatment for acute ischemic stroke (AIS). Since a shorter onset-to-treatment time results in better functional outcome, treatment is often initiated according to the estimated or last-known body-weight of the patient. This approach may result in underdosing or overdosing of tPA. In this multicenter retrospective study, we evaluated the extent of error in tPA dosing in our AIS cohort and its impact on functional outcome and symptomatic intracranial hemorrhage (SICH). Consecutive AIS patients, receiving IV-tPA, dose determined by the estimated body-weight, at three tertiary centers between January and December 2017 were included. Collected data included information about demographics, cardiovascular risk factors, stroke subtype and National Institute of Health Stroke Scale (NIHSS) score. Estimated and measured body-weights were recorded. Modified Rankin scale (mRS) of 2 or more defined unfavorable outcome. The study included 150 patients. Median age was 64 -years (IQR 55-75) with male preponderance (67%) and median NIHSS score of 9 points (IQR 6-17). Mean measured weight of our study population was 58 (SD 13) kg. Median difference between actual and estimated body-weight was 3 kg (IQR 1.5-6). Difference was more than 10% in 35 (23.3%) patients. Good functional outcome (mRS 0-1) was achieved by 74 (49.3%) patients and 10 (6.8%) developed SICH. NIHSS (OR 1.288; 95% CI 1.157-1.435, p < 0.001) and large artery atherosclerosis (OR 5.878; 95% CI 1.929-17.910, p = 0.002) were independent predictors of unfavorable functional outcome. Our finding of the statistically insignificant 2.5-fold increase in poor outcomes among patients where the estimated and actual weight differed by more than 10% should be interpreted with caution due to the limited sample size. Significant difference occurs between estimated and actual body-weight in a considerable proportion of thrombolysed AIS patients. However, this discrepancy does not affect functional outcome or the risk of SICH.
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Affiliation(s)
- Prakash R Paliwal
- Division of Neurology, National University Health System, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | | | - Lily Y H Wong
- Division of Neurology, National University Health System, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, National University Health System, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, National University Health System, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, National University Health System, Singapore, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Division of Neurology, National University Hospital, NUHS Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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Chew NWS, Ngiam JN, Tan BYQ, Tham SM, Tan CYS, Jing M, Sagayanathan R, Chen JT, Wong LYH, Ahmad A, Khan FA, Marmin M, Hassan FB, Sharon TML, Lim CH, Mohaini MIB, Danuaji R, Nguyen TH, Tsivgoulis G, Tsiodras S, Fragkou PC, Dimopoulou D, Sharma AK, Shah K, Patel B, Sharma S, Komalkumar RN, Meenakshi RV, Talati S, Teoh HL, Ho CS, Ho RC, Sharma VK. Asian-Pacific perspective on the psychological well-being of healthcare workers during the evolution of the COVID-19 pandemic. BJPsych Open 2020; 6:e116. [PMID: 33028449 PMCID: PMC7542327 DOI: 10.1192/bjo.2020.98] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has led to significant strain on front-line healthcare workers. AIMS In this multicentre study, we compared the psychological outcomes during the COVID-19 pandemic in various countries in the Asia-Pacific region and identified factors associated with adverse psychological outcomes. METHOD From 29 April to 4 June 2020, the study recruited healthcare workers from major healthcare institutions in five countries in the Asia-Pacific region. A self-administrated survey that collected information on prior medical conditions, presence of symptoms, and scores on the Depression Anxiety Stress Scales and the Impact of Events Scale-Revised were used. The prevalence of depression, anxiety, stress and post-traumatic stress disorder (PTSD) relating to COVID-19 was compared, and multivariable logistic regression identified independent factors associated with adverse psychological outcomes within each country. RESULTS A total of 1146 participants from India, Indonesia, Singapore, Malaysia and Vietnam were studied. Despite having the lowest volume of cases, Vietnam displayed the highest prevalence of PTSD. In contrast, Singapore reported the highest case volume, but had a lower prevalence of depression and anxiety. In the multivariable analysis, we found that non-medically trained personnel, the presence of physical symptoms and presence of prior medical conditions were independent predictors across the participating countries. CONCLUSIONS This study highlights that the varied prevalence of psychological adversity among healthcare workers is independent of the burden of COVID-19 cases within each country. Early psychological interventions may be beneficial for the vulnerable groups of healthcare workers with presence of physical symptoms, prior medical conditions and those who are not medically trained.
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Affiliation(s)
- Nicholas W S Chew
- Department of Medicine, National University Health System, Singapore
| | | | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore; and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore,Singapore
| | - Sai-Meng Tham
- Department of Medicine, National University Health System, Singapore
| | | | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | | | - Jin Tao Chen
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Lily Y H Wong
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Aftab Ahmad
- Department of Neurology, Ng Teng Fong General Hospital, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Singapore
| | - Maznah Marmin
- Department of Neurology, Ng Teng Fong General Hospital, Singapore
| | | | | | | | | | | | - Thang H Nguyen
- Cerebrovascular Disease Department, 115 People's Hospital, Vietnam
| | - Georgios Tsivgoulis
- Attikon University Hospital, National and Kapodistrian University of Athens, Greece
| | - Sotirios Tsiodras
- Attikon University Hospital, National and Kapodistrian University of Athens, Greece
| | - Paraskevi C Fragkou
- Attikon University Hospital, National and Kapodistrian University of Athens, Greece
| | - Dimitra Dimopoulou
- Attikon University Hospital, National and Kapodistrian University of Athens, Greece
| | | | | | | | | | | | | | - Shikha Talati
- Department of Psychiatry, Geetanjali Medical College and Hospital, India
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore; and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cyrus S Ho
- Department of Psychological Medicine, National University of Singapore, Singapore
| | - Roger C Ho
- Department of Psychological Medicine and Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore; and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, Zhang K, Chin HK, Ahmad A, Khan FA, Shanmugam GN, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH, Sagayanathan R, Chen JT, Ng AYY, Teoh HL, Ho CS, Ho RC, Sharma VK. Psychological Impact of the COVID-19 Pandemic on Health Care Workers in Singapore. Ann Intern Med 2020; 173:317-320. [PMID: 32251513 PMCID: PMC7143149 DOI: 10.7326/m20-1083] [Citation(s) in RCA: 705] [Impact Index Per Article: 176.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Benjamin Y Q Tan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore (B.Y.T., L.L.Y., V.K.S.)
| | - Nicholas W S Chew
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Grace K H Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore (G.K.L.)
| | - Mingxue Jing
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Yihui Goh
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Leonard L L Yeo
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore (B.Y.T., L.L.Y., V.K.S.)
| | - Ka Zhang
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Howe-Keat Chin
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Aftab Ahmad
- Ng Teng Fong General Hospital, Singapore (A.A., F.A.K., G.N.S.)
| | | | | | - Bernard P L Chan
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Sibi Sunny
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Bharatendu Chandra
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Jonathan J Y Ong
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Prakash R Paliwal
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Lily Y H Wong
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Renarebecca Sagayanathan
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Jin Tao Chen
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Alison Ying Ying Ng
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Hock Luen Teoh
- National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
| | - Cyrus S Ho
- National University of Singapore, Singapore (C.S.H.)
| | - Roger C Ho
- Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore (R.C.H.)
| | - Vijay K Sharma
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore (B.Y.T., L.L.Y., V.K.S.)
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7
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Chew NWS, Lee GKH, Tan BYQ, Jing M, Goh Y, Ngiam NJH, Yeo LLL, Ahmad A, Ahmed Khan F, Napolean Shanmugam G, Sharma AK, Komalkumar RN, Meenakshi PV, Shah K, Patel B, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH, Sagayanathan R, Chen JT, Ying Ng AY, Teoh HL, Tsivgoulis G, Ho CS, Ho RC, Sharma VK. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain Behav Immun 2020; 88:559-565. [PMID: 32330593 PMCID: PMC7172854 DOI: 10.1016/j.bbi.2020.04.049] [Citation(s) in RCA: 917] [Impact Index Per Article: 229.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/18/2020] [Accepted: 04/18/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Since the declaration of the coronavirus 2019 (COVID-19) outbreak as pandemic, there are reports on the increased prevalence of physical symptoms observed in the general population. We investigated the association between psychological outcomes and physical symptoms among healthcare workers. METHODS Healthcare workers from 5 major hospitals, involved in the care for COVID-19 patients, in Singapore and India were invited to participate in a study by performing a self-administered questionnaire within the period of February 19 to April 17, 2020. Healthcare workers included doctors, nurses, allied healthcare workers, administrators, clerical staff and maintenance workers. This questionnaire collected information on demographics, medical history, symptom prevalence in the past month, Depression Anxiety Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R) instrument. The prevalence of physical symptoms displayed by healthcare workers and the associations between physical symptoms and psychological outcomes of depression, anxiety, stress, and post-traumatic stress disorder (PTSD) were evaluated. RESULTS Out of the 906 healthcare workers who participated in the survey, 48 (5.3%) screened positive for moderate to very-severe depression, 79 (8.7%) for moderate to extremely-severe anxiety, 20 (2.2%) for moderate to extremely-severe stress, and 34 (3.8%) for moderate to severe levels of psychological distress. The commonest reported symptom was headache (32.3%), with a large number of participants (33.4%) reporting more than four symptoms. Participants who had experienced symptoms in the preceding month were more likely to be older, have pre-existing comorbidities and a positive screen for depression, anxiety, stress, and PTSD. After adjusting for age, gender and comorbidities, it was found that depression (OR 2.79, 95% CI 1.54-5.07, p = 0.001), anxiety (OR 2.18, 95% CI 1.36-3.48, p = 0.001), stress (OR 3.06, 95% CI 1.27-7.41, p = 0.13), and PTSD (OR 2.20, 95% CI 1.12-4.35, p = 0.023) remained significantly associated with the presence of physical symptoms experienced in the preceding month. Linear regression revealed that the presence of physical symptoms was associated with higher mean scores in the IES-R, DASS Anxiety, Stress and Depression subscales. CONCLUSIONS Our study demonstrates a significant association between the prevalence of physical symptoms and psychological outcomes among healthcare workers during the COVID-19 outbreak. We postulate that this association may be bi-directional, and that timely psychological interventions for healthcare workers with physical symptoms should be considered once an infection has been excluded.
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Affiliation(s)
- Nicholas W S Chew
- Department of Medicine, National University Health System, Singapore
| | - Grace K H Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Yihui Goh
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | | | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Aftab Ahmad
- Department of Neurology, Ng Teng Fong General Hospital, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Singapore
| | | | - Arvind K Sharma
- Department of Neurology, Zydus Hospital and BJ Hospital, Ahmedabad, India
| | - R N Komalkumar
- Department of Neurology, Yashoda Hospital, Secunderabad, India
| | | | - Kenam Shah
- Department of Neurology, Zydus Hospital and BJ Hospital, Ahmedabad, India
| | - Bhargesh Patel
- Department of Neurology, Zydus Hospital and BJ Hospital, Ahmedabad, India
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Sibi Sunny
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Bharatendu Chandra
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Jonathan J Y Ong
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Prakash R Paliwal
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Lily Y H Wong
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | | | - Jin Tao Chen
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Alison Ying Ying Ng
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece and The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Cyrus S Ho
- Department of Psychological Medicine, National University of Singapore, Singapore
| | - Roger C Ho
- Department of Psychological Medicine, National University of Singapore, Singapore; Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
| | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore.
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8
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Low SW, Teo K, Lwin S, Yeo LLL, Paliwal PR, Ahmad A, Sinha AK, Teoh HL, Wong LYH, Chong VF, Seet RCS, Chan BPL, Yeo TT, Chou N, Sharma VK. Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries. J Neurosurg 2015; 123:662-9. [PMID: 26023999 DOI: 10.3171/2014.11.jns141553] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Both the older and the recent extracranial-intracranial (EC-IC) bypass trials for symptomatic carotid occlusion failed to demonstrate a reduction in stroke recurrence. However, the role of superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in patients with symptomatic intracranial stenoocclusive disease has been rarely evaluated. The authors evaluated serial changes in various cerebral hemodynamic parameters in patients with severe stenoocclusive disease of the intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR), treated by STA-MCA bypass surgery or medical treatment. METHODS Patients with severe stenoocclusive disease of the intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using the breath-holding index (BHI). Patients with impaired BHI (< 0.69) were further evaluated with acetazolamide-challenge technitium-99m hexamethylpropyleneamine oxime ((99m)Tc HMPAO) SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4 ± 1 months and were followed up for cerebral ischemic events. RESULTS A total of 112 patients were included. This total included 73 men, and the mean age of the entire study population was 56 years (range 23-78 years). (99m)Tc HMPAO SPECT demonstrated impaired CVR in 77 patients (69%). Of these 77 patients, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenge (99m)Tc HMPAO SPECT repeated at 4 ± 1 months showed significant improvement in the STA-MCA bypass group. During a mean follow-up of 34 months (range 18-39 months), only 6 (13%) of 46 patients in the bypass group developed cerebral ischemic events, as compared with 14 (45%) of 31 patients receiving medical therapy (absolute risk reduction 32%, p = 0.008). CONCLUSIONS STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial stenoocclusive disease of the intracranial ICA or MCA results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.
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Affiliation(s)
| | | | | | | | | | | | - Arvind K Sinha
- Department of Diagnostic Imaging, National University Hospital System, Singapore; and
| | | | | | - Vincent F Chong
- Department of Diagnostic Imaging, National University Hospital System, Singapore; and
| | | | | | | | | | - Vijay K Sharma
- Division of Neurology, and.,YLL School of Medicine, National University of Singapore, Singapore
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9
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Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, Chan BPL. Recanalization therapies in acute ischemic stroke: pharmacological agents, devices, and combinations. Stroke Res Treat 2009; 2010. [PMID: 20798838 PMCID: PMC2925093 DOI: 10.4061/2010/672064] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Accepted: 11/02/2009] [Indexed: 11/24/2022] Open
Abstract
The primary aim of thrombolysis in acute ischemic stroke is recanalization of an occluded intracranial artery. Recanalization is an important predictor of stroke outcome as timely restoration of regional cerebral perfusion helps salvage threatened ischemic tissue. At present, intravenously administered tissue plasminogen activator (IV-TPA) remains the only FDA-approved therapeutic agent for the treatment of ischemic stroke within 3 hours of symptom onset. Recent studies have demonstrated safety as well as efficacy of IV-TPA even in an extended therapeutic window. However, the short therapeutic window, low rates of recanalization, and only modest benefits with IV-TPA have prompted a quest for alternative approaches to restore blood flow in an occluded artery in acute ischemic stroke. Although intra-arterial delivery of the thrombolytic agent seems effective, various logistic constraints limit its routine use and as yet no lytic agent have not received full regulatory approval for intra-arterial therapy. Mechanical devices and approaches can achieve higher rates of recanalization but their safety and efficacy still need to be established in larger clinical trials. The field of acute revascularization is rapidly evolving, and various combinations of pharmacologic agents, mechanical devices, and novel microbubble/ultrasound technologies are being tested in multiple clinical trials.
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Affiliation(s)
- Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074
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