ICU Interventions in Ischemic Stroke Patients Treated Using Liberalized IV-tPA Criteria.

BACKGROUND AND OBJECTIVE: Current standard practice guidelines recommend ICU admission for ischemic stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). More recently, the trend in stroke care is to broaden eligibility for IV thrombolysis. Two examples are a more liberal inclusion criteria known as SMART criteria (sIV-tPA), and the transfer of patients to comprehensive stroke centers (CSC). The present study characterizes ICU interventions in these patients. Understanding which stroke patients that require ICU-level care may allow for placement of patients in the appropriate level of care at hospital admission. METHODS: We performed a retrospective review of consecutive transfer and nontransfer sIV-tPA-treated patients admitted to the ICU at a CSC. We evaluated the frequency, timing, and nature of ICU interventions. RESULTS: Three hundred and thirty one patients were treated with sIV-tPA and 42% required ICU interventions during ICU admission. Of patients requiring ICU interventions, 98% had an ICU intervention performed in triage, prior to admission. National Institute of Health Stroke Scale score only had a moderate association to requirement of ICU interventions. Neither transferring patients to a CSC nor the number of standard IV-tPA contraindications increased ICU interventions. CONCLUSIONS: Liberalized IV-tPA administration did not increase ICU interventions. Nearly all patients that required ICU interventions declared this need in triage, prior to ICU admission. This timing of ICU intervention use during triage is highly sensitive for whether a patient will require ongoing ICU-level care during hospital admission. Identifying ICU intervention use in triage may allow for more effective placement of post-IV-tPA patients in the appropriate inpatient care setting, leading to better utilization of scarce ICU resources.

Generalized Safety and Efficacy of Simplified Intravenous Thrombolysis Treatment (SMART) Criteria in Acute Ischemic Stroke: The MULTI SMART Study.

BACKGROUND: Common intravenous recombinant tissue plasminogen activator (IV rt-PA) exclusion criteria may substantially limit the use of thrombolysis. Preliminary data have shown that the SMART (Simplified Management of Acute stroke using Revised Treatment) criteria greatly expand patient eligibility by reducing thrombolysis exclusions, but they have not been assessed on a large scale. We evaluated the safety and efficacy of general adoption of SMART thrombolysis criteria to a large regional stroke network. METHODS: Retrospective analysis of consecutive patients who received IV thrombolysis within a regional stroke network was performed. Patients were divided into those receiving thrombolysis locally versus at an outside hospital. The primary outcome was modified Rankin Scale score (≤1) at discharge and the main safety outcome was symptomatic intracranial hemorrhage (sICH) rate. RESULTS: There were 539 consecutive patients, and 50.5% received thrombolysis at an outside facility. Ninety percent of the patients possessed common conventional IV rt-PA contraindications. There were no significant differences between local and network treated patients in favorable outcome (45.4% versus 37.4%; odds ratio [OR], .72; P > .09), mortality (9% versus 14%; OR, 1.6; P > .07), or sICH rate (2.6% versus 5.1%; OR, 2.0; P = .13). Multivariate analysis showed no association between receiving IV rt-PA at an outlying spoke hospital and higher rate of sICH or worse outcome at discharge. CONCLUSIONS: Generalized application of SMART criteria is safe and effective. Widespread application of these criteria could substantially increase the proportion of patients who might qualify for treatment.

Racial and mental illness stereotypes and discrimination: an identity-based analysis of the Virginia Tech and Columbine shootings.

The Virginia Tech and Columbine High shootings are 2 of the deadliest school massacres in the United States. The present study investigates in a nationally representative sample how White Americans' causal attributions of these shooting moderate their attitudes toward the shooter's race. White Americans shown a vignette based on the Virginia Tech shooting were more likely to espouse negative beliefs about Korean American men and distance themselves from this group the more they believed that the shooter's race caused the shooting. Among those who were shown a vignette based on the Columbine High shooting, believing that mental illness caused the shooting was associated with weaker negative beliefs about White American men. White Americans in a third condition who were given the Virginia Tech vignette and prompted to subtype the shooter according to his race were less likely to possess negative beliefs about Korean American men the more they believed that mental illness caused the shooting. There was no evidence for the ultimate attribution error. Theoretical accounts based on the stereotype and in-group-out-group bias literature are presented. The current findings have important implications for media depictions of minority group behavior and intergroup relations.

Systemic augmentation of alphaB-crystallin provides therapeutic benefit twelve hours post-stroke onset via immune modulation.

Tissue plasminogen activator is the only treatment option for stroke victims; however, it has to be administered within 4.5 h after symptom onset, making its use very limited. This report describes a unique target for effective treatment of stroke, even 12 h after onset, by the administration of αB-crystallin (Cryab), an endogenous immunomodulatory neuroprotectant. In Cryab(-/-) mice, there was increased lesion size and diminished neurologic function after stroke compared with wild-type mice. Increased plasma Cryab was detected after experimental stroke in mice and after stroke in human patients. Administration of Cryab even 12 h after experimental stroke reduced both stroke volume and inflammatory cytokines associated with stroke pathology. Cryab is an endogenous anti-inflammatory and neuroprotectant molecule produced after stroke, whose beneficial properties can be augmented when administered therapeutically after stroke.

Reduced clopidogrel metabolism in a multiethnic population: prevalence and rates of recurrent cerebrovascular events.

BACKGROUND: Concern has recently been raised over the possibility of a reduced efficacy of clopidogrel because of genetic variations in cytochrome P450, family 2, subfamily C, polypeptide 19 (CYP2C19) metabolism. A black box warning from the US Food and Drug Administration recommends that all patients be tested. It has been estimated that approximately 3% (range 2-14%) of the population are poor metabolizers, but few data are available for cerebrovascular patients. The objective of this study is to evaluate the frequency and effects of variability in CYP2C19 metabolism in patients with cerebrovascular disease. METHODS: A retrospective review of all patients with stroke and transient ischemic attack (TIA) tested for the clopidogrel CYP2C19 genotype was performed, with a collection of data including race/ethnicity, CYP2C19 status, and the presence of recurrent vascular events. RESULTS: A total of 53 cerebrovascular patients were tested, consisting of 5.7% poor (n = 3), 26.4% intermediate (n = 14), 62.3% extensive (n = 33), 3.8% indeterminate (n = 2), and 1.9% "mixed ultra rapid and poor" (n = 1) metabolizers. Only 10 of 38 white patients (26.3%; 95% confidence interval [CI] 0.14-0.42) were intermediate or poor metabolizers, compared with 7 of 15 (46.7%; 95% CI 0.25-0.70) nonwhites. Of 43 patients treated with clopidogrel, 3 of 27 extensive metabolizers (11.1%; 95% CI 0.04-0.28) had recurrent cerebrovascular events compared with 33.3% of intermediate metabolizers (4/12; 95% CI 0.14-0.61) and 50% of poor metabolizers (1/2; 95% CI 0.09-0.90). CONCLUSIONS: These data suggest that the proportion of poor/intermediate clopidogrel metabolizers in cerebrovascular patients is comparable to cardiovascular studies and these patients may have an increased risk of recurrent cerebrovascular events. Routine CYP2C19 testing may be warranted.

Evaluation of care management for the uninsured.

BACKGROUND: In 2008, Kern Medical Center established a Care Management Program (CMP) for low-income adults identified as frequent users of hospital services. Frequent users are defined as having 4 or more emergency department (ED) visits or admissions, 3 or more admissions, or 2 or more admissions and 1 ED visit within 1 year. The CMP helps patients access primary care and medical and social resources. OBJECTIVE: To determine whether the CMP reduces ED visits and hospitalizations among frequent users. METHOD: Between August 2007 and January 2010, a retrospective analysis was conducted using Kern Medical Center encounter data. ED visits and inpatient visits were compared pre- and postenrollment for care managed patients (n = 98). The analysis included a comparison group (n = 160) of frequent users matched on the basis of race and age. Multivariate analyses were performed to evaluate the difference in utilization between groups, and to adjust for potential group differences. RESULTS: There was a reduction in the median number of ED visits per year from 6.0 ± 5.0 (median ± interquartile range) pre-enrollment to 1.7 ± 3.3 [corrected] postenrollment (P < 0.0001). The difference in inpatient admissions pre- and postenrollment was 0.0 ± 1.0 (P < 0.0001). After adjusting for multiple factors, multivariate analysis demonstrated that care managed patients had a 32% lower risk of visiting the ED than the comparison group (P < 0.0001). There was no difference in inpatient admissions between groups. CONCLUSIONS: CMP that helps patients navigate the health care system and access social and medical resources show significant promise in reducing ED utilization.

Feeling distressed from making decisions: Assessors' need to be right.

Our research posits that decision-making is particularly distressing for individuals with high assessment tendencies. Assessment involves truth concerns about making the "right" decision. We hypothesize that people with high assessment experience greater distress during decision-making because of their concerns about making a wrong decision. In four studies of chronic assessment conducted across four different decision contexts, we found assessment to be positively associated with distress, with this relation being mediated by concerns with being wrong. A meta-analysis of these results provided support for the robustness of this positive association. Finally, a fifth experimental study that induced assessment found the same association with distress. Moreover, an implicit measure of truth concerns mediated this positive association. Given the prevalence of decision-making activities in everyday life, our findings about how truth concerns can cause distress have important implications for the psychological well-being of assessment-oriented individuals. (PsycINFO Database Record

Correlations between compulsory drug abstinence treatments and HIV risk behaviors among injection drug users in a border city of South China.

Compulsory drug abstinence treatments (CAT) provided by the public security system have been one of the predominant methods of addressing drug abuse and HIV risks in China. This study assessed the association between CAT and HIV risk behaviors by surveying a community sample of 613 injection drug users (IDUs) at a city located in South China. The data indicated that the great majority of the participants (89.6%) had received the institutionalized treatments an average of 4.5 times. The study found that the number of compulsory drug abstinence treatments increased IDUs' HIV/AIDS knowledge. However, other HIV-related outcomes were not encouraging. The study found that the number of compulsory drug abstinence treatments was not related to an increase in condom use. Furthermore, the frequency of compulsory drug abstinence treatments was not related to needle/syringe sharing, but was positively associated with cooker/cotton/rinse water sharing and drug solution sharing. The number of compulsory drug abstinence treatments was positively associated with HIV status. In general, this study found little support that CAT has accomplished its goal in reducing HIV risks among injection drug users in the sample. Policy implications for reforming CAT are suggested.

Reliability and validity of the SmartDiet Canadian version questionnaire.

Measuring the outcomes of nutrition interventions in health promotion settings can be a challenge. Nutrition screening tools are often used to measure dietary patterns and nutrition intervention outcomes, but these tools may lack quantitative scoring methods. Using the SmartDiet questionnaire from Oslo, Norway, as a model, the SmartDiet Canadian Version questionnaire was developed to assess fiber and fat intake. The purpose of this study was to assess the reliability and validity of this new questionnaire. In 2007, 54 volunteer subjects (63% men, mean age 68.3+/-9.7 years) were recruited from the Cardiac Rehabilitation Program at Vancouver General Hospital, Vancouver, BC, Canada. Test-retest reliability was assessed by having subjects complete the questionnaire at recruitment and 1 month later. Intraclass correlation coefficients of reliability (ICC) for both fiber and fat intake were calculated. For fiber scores the ICC was 0.66 (95% confidence interval 0.48, 0.79) and for fat scores the intraclass correlation coefficient was 0.74 (95% confidence interval 0.59, 0.84). Validity was assessed by correlating the completed questionnaire at recruitment with a 3-day food diary. The daily fat and fiber scores from the questionnaire were correlated with the corresponding average daily fat and fiber scores from the 3-day food diary by means of the Spearman correlation coefficient. For fiber scores, Spearman rho was 0.53 (P<0.001), and for fat scores it was 0.48 (P<0.001). The SmartDiet Canadian Version questionnaire is a reliable and valid tool for assessing the daily fiber and fat intake of cardiac rehabilitation clients.

Assessment of the quality of cost analysis literature in physical therapy.

BACKGROUND: Policy makers, payers, and other stakeholders increasingly call for greater evidence of the cost-effectiveness of health care interventions. OBJECTIVE: The purposes of this study were to identify and rate the quality of cost analysis literature in physical therapy and to report summary information on the findings from the reviewed studies. DESIGN: This study was a targeted literature review and rating of relevant studies published in the last decade using a quality evaluation tool for economic studies. MEASUREMENTS: The Quality of Health Economic Studies (QHES) instrument was used to obtain quality scores. RESULTS: Ninety-five in-scope studies were identified and rated using the QHES instrument. The average quality score was 82.2 (SD=15.8), and 81 of the studies received a score of 70 or higher, placing them in the "good" to "excellent" quality range. Investigators in nearly two thirds of the studies found the physical therapy intervention under investigation to be cost-effective. LIMITATIONS: The small number of studies meeting the inclusion criteria was a limitation of the study. CONCLUSIONS: The quality of the literature regarding the cost-effectiveness of physical therapy is very good, although the magnitude of this body of literature is small. Greater awareness of the strengths and limitations of cost analyses in physical therapy should provide guidance for conducting high-quality cost-effectiveness studies as demand increases for demonstrations of the value of physical therapy.