Blood-brain barrier integrity of stroke patients presenting in an extended time window.

BACKGROUND: Current guidelines limit thrombolytic treatment of stroke to those patients who present within 4.5 h to minimize the risk of hemorrhagic complications. Risk of hemorrhage increases with increasing blood-brain barrier (BBB) disruption. This study aimed to determine, in a cohort of patients presenting outside of an IV-tPA treatment window, whether disruption of the BBB is time dependent, and what proportion of patients could be safely treated. METHODS: We analyzed untreated stroke patients, seen between 2011 and 2015, who had MRI studies in the time window of 4 to 24 h from symptoms onset. Permeability of the BBB was measured within the ischemic tissue using an application of dynamic susceptibility contrast imaging. Patients were dichotomized into two groups based on a 20% threshold of BBB disruption and compared using logistic regression. RESULTS: Of the 222 patients included in the final analysis, over half, 129 (58%), had preserved BBB integrity below the 20% threshold. There was no relationship between time imaged after symptom onset and the amount of BBB disruption (p = 0.138) across the population; BBB disruption varied widely. CONCLUSIONS: Estimating BBB integrity may help to expand the treatment window for stroke patients by identifying those individuals for whom thrombolytic therapy can be considered.

Spontaneous Coronary Artery Dissection: A Comprehensive Overview.

Spontaneous coronary artery dissection is an underdiagnosed cause of acute coronary syndrome that primarily impacts young women. Spontaneous coronary artery dissection as a cause of acute coronary syndrome is not rare and should not be overlooked. Spontaneous coronary artery dissection should be considered on the list of differential diagnosis of any chest pain occurring in young women with few typical risk factors. The purposes of this article are to broaden the understanding and increase awareness of spontaneous coronary artery dissection, specifically its diagnosis and clinical outcomes.

Assessment Strategies Used by Nurse Educators To Evaluate Critical Thinking, Clinical Judgment or Clinical Reasoning In Undergraduate Nursing Students In Clinical Settings: A Scoping Review of The Literature.

BACKGROUND: Nursing students in Canada are typically enrolled in a four-year bachelor degree program that provides students with the necessary skills and knowledge to enter a highly demanding and challenging workforce. Strong critical thinking, clinical reasoning, and clinical judgment skills are essential skills for safe nursing practice. Therefore, educational institutes and their mentors are mandated to teach and assess these skills. In addition, nursing programs operate under an apprenticeship model, which entails the fulfillment of practical experience during which students are expected to develop and refine their skills in critical thinking, clinical reasoning, and clinical judgment. PURPOSE: The purpose of this scoping review of the literature is to assess the available evidence of how higher-level thinking, including critical thinking, clinical reasoning, and clinical judgment are evaluated in undergraduate nursing students in clinical settings. METHODS: The inclusion criteria consisted of quantitative research articles published in the last 10 years. Search databases accessed included CINAHL Plus (EBSCO), Medline, and PubMed. RESULTS: Seven articles that fit the inclusion criteria became the focus of this scoping review. Four tools to evaluate higher-thinking processes in clinical settings were located and scrutinized: Lasater Clinical Judgment Rubric (LCJR), Script Concordance Testing, and Yoon's Critical Thinking Disposition Instrument. Relevance to practice: The scoping review will provide direction and contextualize future studies that focus on the appraisal of nursing students' critical thinking, clinical reasoning, and clinical judgment in clinical settings.

Frequency of thrombolytic targets in stroke patients presenting in an extended time window.

OBJECTIVE: The objective of this study was to determine the proportion of stroke patients presenting in an extended time window who have a thrombolytic treatment target. BACKGROUND: Patients presenting up to 24 h after stroke onset have been found to have penumbral tissue on multimodal imaging. Stroke patients presenting in this extended time window without a large vessel occlusion (LVO) may benefit from reperfusion therapy using thrombolysis. METHODS: Patients seen at our institutions from 2011 through 2015 were reviewed to identify those who presented >4 h and <24 h from last seen normal (LSN) and did not receive acute treatment. Magnetic resonance imaging (MRI) scans were used to dichotomize patients using a diffusion-perfusion mismatch ratio of 1.2. RESULTS: During the study period, 3469 patients were evaluated by our stroke service, with 893 seen 4-24 h from LSN who were not treated. MRI was performed with diffusion and perfusion imaging in 439 patients, of whom 26 were excluded due to hemorrhage and 37 were excluded due to LVO. This left 376 patients who potentially could have been treated with thrombolysis in an extended time window and were included in the analysis. Of these, 156 (42%) demonstrated a mismatch ratio >1.2. Patients with a mismatch presented earlier (P = 0.012), were more likely to be female (P = 0.03), and had higher National Institutes of Health Stroke Scale (P < 0.001). CONCLUSIONS: Almost half of the patients presenting 4-24 h from LSN had a target for thrombolysis in our study. Multimodal imaging may be able to expand the population of treatable stroke patients given the results of recent clinical trials.

The Relationship Between Penumbral Tissue and Blood-Brain Barrier Disruption in Acute Stroke Patients Presenting in an Extended Time Window.

Background: Penumbral brain tissue identified with multimodal imaging can be salvaged with reperfusion in an extended time window. The risk of severe hemorrhagic complications after reperfusion therapy increases with worsening disruption of the blood-brain barrier (BBB). The relationship between penumbral tissue and BBB disruption has not been previously studied. Methods: Stroke patients presenting in an extended time window without a large vessel occlusion who underwent diffusion-perfusion MRI within 24 h of last-seen-normal were included. The volume of penumbral tissue was calculated using mismatch on MRI. Mean permeability derangement (MPD) of the BBB was measured within the ischemic lesion. A target profile (TP) for treatment was defined based on the EXTEND trial. Results: 222 patients were included with a median age of 73 and 55% women. The median NIHSS was 6, the mean core volume was 14 ml, the mean ischemic volume was 47 mL and the mean mismatch volume was 33 mL. Higher MPD was significantly associated with less mismatch volume (p = 0.001). A target profile was associated with lower MPD (OR 0.97; CI 0.96:0.99; p < 0.001). Of the 105 patients who had a TP, 31 (30%) had a MPD > 20% suggesting an increased risk of hemorrhage. Thus, 33% (74/222) of patients had a favorable profile for benefit and safety. Conclusions: Patients presenting in an extended time window with a favorable penumbral profile for treatment have less severe BBB disruption. Up to a third of patients who currently go untreated could be considered for enrollment in a clinical trial of thrombolysis in an extended time window.

Survival as medical registrar on call: remember the doughnut.

Life as a medical registrar presents many challenges and concern is growing that a downwards trend in recruitment to General Medicine is the direct result of a perception by junior doctors that the role of the medical registrar is excessively demanding and results in poor work-life balance. A solution-focused approach (SFA) can be used successfully to find a satisfying outcome for both registrar and patient in many of the situations encountered during an on-call, as well as carrying over benefits into life outside of work. We explore the origins of SFA and the ways in which it can be successfully applied to clinical medicine, providing case studies from the author's own experience to illustrate the principles of this way of thinking.