An updated review and meta-analysis of screening tools for stroke in the emergency room and prehospital setting.

BACKGROUND: Stroke screening tools should have good diagnostic performance for early diagnosis and a proper therapeutic plan. This paper describes and compares various diagnostic tools used to identify stroke in emergency departments and prehospital setting. METHODS: The meta-analysis was conducted according to the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines. The PubMed and Scopus databases were searched until December 31, 2021, for studies published on stroke screening tools. These tools' diagnostic performance (sensitivity and specificity) was pooled using a bivariate random-effects model whenever appropriate. RESULTS: Eleven screening tools for stroke were identified in 29 different studies. The various tools had a wide range of sensitivity and specificity in different studies. In the meta-analysis, the Cincinnati Pre-hospital Stroke Scale, Face Arm Speech Test, and Recognition of Stroke in the Emergency Room (ROSIER) had sensitivity (between 83 and 91%) but poor specificity (all below 64%). When comparing all the tools, ROSIER had the highest sensitivity 90.5%. Los Angeles Pre-hospital Stroke Screen performed best in terms of specificity 88.7% but had low sensitivity (73.9%). Melbourne Ambulance Stroke Screen had a balanced performance in terms of sensitivity (86%) and specificity (76%). Sensitivity analysis consisting of only prospective studies showed a similar range of sensitivity and specificity. CONCLUSION: All the stroke screening tools included in the review were comparable, but no clear superior screening tool could be identified. Simple screening tools like Cincinnati prehospital stroke scale (CPSS) have similar performance compared to more complex tools.

Lack of Sex Disparity in Oral Anticoagulation in Atrial Fibrillation Patients Presenting with Ischemic Stroke in a Rural Population.

Various studies on oral anticoagulants (OAC) use among atrial fibrillation (AF) patients have shown high rates of undertreatment and the presence of sex disparity. This study used the 'Geisinger Neuroscience Ischemic Stroke' (GNSIS) database to examine sex differences in OAC treatment among ischemic stroke patients with the pre-event diagnosis of AF in rural Pennsylvania between 2004 and 2019. We examined sex disparities in OAC undertreatment and associated risks based on age group and ischemic stroke year. A total of 1062 patients were included in the study and 1015 patients (96%) had CHA2DS2-VASc score ≥ 2, of which 549 (54.1%) were women. Undertreatment rates were not statistically significant between men and women in the overall cohort (50.0% vs. 54.5%, p = 0.18), and male sex was not found to be a significant factor in undertreatment (OR 0.82, 95% CI 0.62-1.09, p = 0.17). The result persisted even when patients were divided into four age groups and two groups based on the study time period. The undertreatment rates in both sex groups remained consistent following the introduction of novel oral anticoagulants. In conclusion, there was no evidence of sex disparity with respect to OAC treatment, even after stratifying the cohort by age and ischemic stroke year.

Adherence to anticoagulant guideline for atrial fibrillation: A large care gap among stroke patients in a rural population.

OBJECTIVE: This study aimed to investigate the prevalence and factors associated with oral anticoagulant undertreatment of atrial fibrillation (AF) among a cohort of rural patients with stroke outcomes and examine how undertreatment may influence a patient's one-year survival after stroke. METHODS: This retrospective cohort study examined ischemic stroke patients with pre-stroke AF diagnosis from September 2003 to May 2019 and divided them into proper treatment and undertreatment group. Analysis included chi-square test, variance analysis, Kruskal-Wallis test, logistic regression, Kaplan-Meier estimator, and Cox proportional-hazards model. RESULTS: Out of 1062 ischemic stroke patients with a pre-stroke AF diagnosis, 1015 patients had a CHA2DS2-VASc score ≥2, and 532 (52.4%) of those were undertreated. Median time from AF diagnosis to index stroke was significantly lower among undertreated patients (1.9 years vs. 3.6 years, p < 0.001). Other thromboembolism, excluding stroke, TIA, and myocardial infarction (OR 0.41, p < 0.001), the number of encounters per year (OR 0.90, p < 0.001), and the median time between AF diagnosis and stroke event (OR 0.86, p < 0.001) were negatively associated with undertreatment. Kaplan-Meier estimator showed no statistical difference in the one-year survival probability between groups (log-rank test, p = 0.29), while the Cox-Hazard model showed that age (HR 1.05, p < 0.001) and history of congestive heart failure (HR 1.88, p < 0.001) increased the risk of mortality. CONCLUSIONS: More than half of our rural stroke patients with a pre-index AF diagnosis were not on guideline-recommended treatment. The study highlights a large care gap and an opportunity to improve AF management.

Sonotherapy in the reduction of anxiety and postoperative pain in patients with regional anesthesia as a sole technique: randomized, controlled clinical trial.

OBJECTIVE: To determine if sonotherapy reduces the anxiety level and postoperative pain in adults undergoing outpatient orthopedic surgery under regional anesthesia. METHOD: A randomized, double-blind, placebo-controlled study in 80 adult patients undergoing orthopedic surgery, 40 received intervention with sonotherapy and 40 did not receive it. Pain, anxiety in the preoperative period, immediate postoperative, high, 24 and 48 hours later were measured. Hemodynamic parameters were measured in four moments. RESULTS: No significant differences were found between the two groups in the pain scales neither anxiety. A significant reduction of the systolic blood pressure was observed after the application of sonotherapy and in recovery. There was no difference in other hemodynamic variables such as heart rate, respiratory rate, arterial oxygen saturation or diastolic blood pressure between groups, however, the observed changes in some of them occurred faster in the intervention group. CONCLUSIONS: In adult patients undergoing outpatient orthopaedic surgery under regional anaesthesia, sound therapy is a novel strategy that significantly reduces systolic blood pressure, considered as an indicator of decreased anxiety. However, in our study, no difference could be demonstrated in terms of pain control or the need for additional sedation or analgesia.

OBJETIVO: Evaluar la eficacia de la sonoterapia en la diminución de la ansiedad y el dolor posoperatorio en adultos llevados a cirugía ambulatoria de ortopedia bajo anestesia regional. MÉTODO: estudio aleatorizado, doble ciego, controlado con placebo, en 80 pacientes adultos sometidos a cirugía ortopédica; 40 recibieron intervención con sonoterapia y 40 no la recibieron. Se midieron el dolor y la ansiedad en el preoperatorio, en el posoperatorio inmediato, al alta, y 24 y 48 horas después. Se midieron parámetros hemodinámicos en cuatro momentos. RESULTADOS: No se encontraron diferencias significativas entre ambos grupos en las escalas de dolor ni ansiedad. Se observó una reducción significativa de la presión arterial sistólica luego de la aplicación de la intervención y en recuperación. No se observaron diferencias en otras variables hemodinámicas entre los grupos, pero la reducción de algunas ocurre de forma más rápida en el grupo de intervención. CONCLUSIONES: En pacientes adultos llevados a cirugía ambulatoria de ortopedia bajo anestesia regional, la sonoterapia es una estrategia novedosa que reduce la presión arterial sistólica, y esto puede considerarse como un indicador de disminución de la ansiedad. En nuestro estudio no se pudo demostrar diferencia en términos de control del dolor ni de requerimiento de sedación o analgesia adicional.

Bloqueantes neuromusculares: en pro del uso adecuado / Neuromuscular blocking agents: an argument for their adequate use

Introducción. En el uso de bloqueantes musculares hay controversia: a favor está la necesidad de garantizar una adecuada intubación de manera rápida en los casos de urgencia y facilitar el campo quirúrgico al cirujano, además de otros beneficios reportados; en contra están los efectos adversos y los riesgos publicados. Objetivo. Promover la buena práctica médica en el uso de los bloqueantes musculares. Materiales y métodos. Revisión de la literatura científica disponible sobre el tema enfocada a indicaciones, riesgos, beneficios y monitoreo. Resultados. La indicación absoluta de bloqueante muscular es la intubación de secuencia rápida. Existen otros usos recomendados: intubación en cirugía electiva y ciertos tipos de cirugía y situaciones especiales (SDRA, TECAR, hipertensión intraabdominal, hipertensión intracraneana). Por otra parte, los bloqueantes pueden ser evitados en muchas anestesias generales. Lo más importante es conocer sus indicaciones y riesgos, y usarlos de manera adecuada. Conclusión. Hay situaciones en las que se puede evitar el uso de los bloqueantes, pero hay otras en las que son indispensables o están recomendados. Si van a ser usados, debe elegirse el bloqueanteideal para cada paciente, en el momento oportuno, con la dosis ajustada y siempre con el monitoreo apropiado.

Introduction. The debate regarding the use of muscle relaxants is still ongoing, with arguments against such as their adverse effects and published risks, and arguments in favor such as the need to ensure rapid and adequate intubation inemergency cases, the benefit of an easy surgical field for the surgeon, and other reported benefits. Objective. To review aspects associated with the adequate use of neuromuscular blocking agentsin anesthesia. Materials and methods. Narrative review of the scientific literature available on the subject thatfocused on indications, risks, benefits and monitoring. Results. The absolute indication of muscle relaxants is rapid-sequence intubation, but there areother situations where they are recommended: Intubation in elective surgery, certain types of specialsurgical procedures and situations (ARDS, electroconvulsive therapy, intra-abdominal hypertension, intracranial hypertension), and they may be avoided in many general anesthesia cases. Most important is to be aware of theirindications, risks and adequate use.