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1.
Eur J Neurol ; 30(3): 671-677, 2023 03.
Artigo em Inglês | MEDLINE | ID: mdl-36463490

RESUMO

BACKGROUND AND PURPOSE: Limited data guide the selection of patients with large vessel occlusion ischaemic stroke who may benefit from referral to a distant tertiary centre for mechanical thrombectomy (MT). We aimed to characterize this population, describe clinical outcomes and develop a screening system to identify patients most likely to benfit from delayed mechanical thrombectomy (MT). METHODS: We undertook a retrospective cohort analysis enrolling patients transferred from regional sites to one of two MT comprehensive stroke units with a time from non-contrast computed tomography (NCCT) of the brain to reperfusion of 4 h or more. We describe Alberta Stroke Programme Early Computed Tomography Score (ASPECTS), National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) in our patients and compare these patients to those in extended-time-window trials. Lastly, we developed and validated a scoring model to help clinicians identify appropriate patients based on variables associated with poor outcomes. RESULTS: We included 563 patients, 46% of whom received thrombolysis; the median (interquartile range [IQR]) ASPECTS was 8 (7-10) and the median (IQR) NIHSS score was 16 (11-20). The median (IQR) symptom to mechanical reperfusion time was 390 (300-580) min. Eight patients (1%) had a symptomatic haemorrhage. We achieved good clinical outcome (defined as mRS score ≤2) in 299 patients (54%). Age, diabetes, NIHSS score and ASPECTS were used to create a weighted scoring system with a validated area under the curve of 0.83 (95% confidence interval 0.74-0.92). CONCLUSION: Our study shows, in highly selected patients, that delayed MT many hours after baseline NCCT is associated with good clinical outcomes. However, older patients with diabetes, high NIHSS score and low ASPECTS may not benefit from transfer to a hub centre many hours away for MT in this model of care.


Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Estudos Retrospectivos , Trombectomia/métodos , Resultado do Tratamento , AVC Isquêmico/etiologia
2.
J Am Heart Assoc ; 13(14): e032321, 2024 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-38958146

RESUMO

BACKGROUND: Patient outcome after stroke is frequently assessed with clinical scales such as the modified Rankin Scale score (mRS). Days alive and out of hospital at 90 days (DAOH-90), which measures survival, time spent in hospital or rehabilitation settings, readmission and institutionalization, is an objective outcome measure that can be obtained from large administrative data sets without the need for patient contact. We aimed to assess the comparability of DAOH with mRS and its relationship with other prognostic variables after acute stroke reperfusion therapy. METHODS AND RESULTS: Consecutive patients with ischemic stroke treated with intravenous thrombolysis or endovascular thrombectomy were analyzed. DAOH-90 was calculated from a national minimum data set, a mandatory nationwide administrative database. mRS score at day 90 (mRS-90) was assessed with in-person or telephone interviews. The study included 1278 patients with ischemic stroke (714 male, median age 70 [59-79], median National Institutes of Health Stroke Scale score 14 [9-20]). Median DAOH-90 was 71 [29-84] and median mRS-90 score was 3 [2-5]. DAOH-90 was correlated with admission National Institutes of Health Stroke Scale score (Spearman rho -0.44, P<0.001) and Alberta Stroke Program Early CT [Computed Tomography] Score (Spearman rho 0.24, P<0.001). There was a strong association between mRS-90 and DAOH-90 (Spearman rho correlation -0.79, P<0.001). Area under receiver operating curve for predicting mRS score >0 was 0.86 (95% CI, 0.84-0.88), mRS score >1 was 0.88 (95% CI, 0.86-0.90) and mRS score >2 was 0.90 (95% CI, 0.89-0.92). CONCLUSIONS: In patients with stroke treated with reperfusion therapies, DAOH-90 shows reasonable comparability to the more established outcome measure of mRS-90. DAOH-90 can be readily obtained from administrative databases and therefore has the potential to be used in large-scale clinical trials and comparative effectiveness studies.


Assuntos
AVC Isquêmico , Trombectomia , Terapia Trombolítica , Humanos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , AVC Isquêmico/terapia , AVC Isquêmico/diagnóstico , Fatores de Tempo , Resultado do Tratamento , Fibrinolíticos/uso terapêutico , Procedimentos Endovasculares , Alta do Paciente , Acidente Vascular Cerebral/terapia , Acidente Vascular Cerebral/diagnóstico , Tempo de Internação/estatística & dados numéricos , Avaliação da Deficiência
3.
J Neurol Sci ; 460: 122987, 2024 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-38579412

RESUMO

Neuronal intranuclear inclusion disease, caused by a GGC repeat expansion in the 5'-untranslated region of NOTCH2NLC, is a rare neurodegenerative condition with highly variable clinical manifestations. In recent years, the number of reported cases have increased dramatically in East Asia. We report the first four genetically confirmed cases of neuronal intranuclear inclusion disease in New Zealand, all having Polynesian ancestry (three New Zealand Maori and one Cook Island Maori). Phenotypically, they resemble cases reported from recent large East Asian cohorts.


Assuntos
Corpos de Inclusão Intranuclear , Doenças Neurodegenerativas , Humanos , Nova Zelândia , Corpos de Inclusão Intranuclear/patologia , Corpos de Inclusão Intranuclear/genética , Doenças Neurodegenerativas/genética , Doenças Neurodegenerativas/patologia , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Receptor Notch2/genética
4.
JAMA Neurol ; 80(3): 233-243, 2023 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-36807495

RESUMO

Importance: International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective: To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants: This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures: Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures: The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results: Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance: In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.


Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Adulto , Humanos , Feminino , Idoso , Idoso de 80 Anos ou mais , Masculino , Hemorragia Cerebral/complicações , Fibrinolíticos/uso terapêutico , AVC Isquêmico/tratamento farmacológico , AVC Isquêmico/complicações , Terapia Trombolítica , Isquemia Encefálica/complicações , Estudos Retrospectivos , Acidente Vascular Cerebral/terapia , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/complicações , Anticoagulantes/uso terapêutico , Ingestão de Alimentos
5.
N Z Med J ; 135(1548): 13-18, 2022 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-35728126

RESUMO

AIM: Stroke clot retrieval (SCR) is now considered a standard of care for select stroke patients with proximal large vessel occlusion (LVO) of the anterior circulation. Here we present the experience of regional Taranaki patients transferred by air for SCR and compare this to metropolitan Auckland patients who were transferred by road. The aim is to present and compare process metrics and outcomes between the regional and metropolitan centres. METHODS: This is a retrospective analysis of consecutive patients with anterior LVO transferred to Auckland City Hospital (ACH) for SCR from Taranaki, Waitemata and Counties Manukau district health boards (DHBs) between November 2017 and December 2020. RESULTS: Thirty Taranaki patients were transferred for SCR, compared to 244 patients from Waitemata and Counties Manukau DHBs. Taranaki patients were seven years older and less ethnically diverse but similar in other characteristics. The proportion of patients with an independent Modified Rankin Scale (mRS) score between 0 and 2 at three months was the same as for the regional and metropolitan centres. CONCLUSIONS: In this real-world study, regional stroke patients can achieve similar SCR outcomes to metropolitan patients. Overcoming the post-code lottery for hyperacute stroke care can be achieved in a New Zealand setting.


Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Trombose , Humanos , Nova Zelândia , Estudos Retrospectivos , Acidente Vascular Cerebral/terapia , Trombectomia , Resultado do Tratamento
6.
J Health Organ Manag ; 29(7): 1065-79, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26556168

RESUMO

PURPOSE: The purpose of this paper is to establish the relationship between organisational culture and psychotropic medication use in residential care. DESIGN/METHODOLOGY/APPROACH: Cross-sectional analyses of staff and resident's record survey in residential aged care facilities in Auckland, New Zealand (NZ). The competing values framework categorised organisational culture as clan, hierarchical, market driven or adhocracy and was completed by all staff. The treatment culture tool categorised facilities as having resident centred or traditional culture and was completed by registered nursing staff and general practitioners (GP). Functional and behavioural characteristics of residents were established by staff report and health characteristics and medications used were ascertained from the health record. Multiple regression was used to test for associations between measures of culture with psychotropic medication use (anxiolytics, sedatives, major tranquillisers). FINDINGS: In total 199 staff, 27 GP and 527 residents participated from 14 facilities. On average 8.5 medications per resident were prescribed and 42 per cent of residents received psychotropic medication. Having a diagnosis of anxiety or depression (odds ratio (OR) 3.18, 95 per cent confidence interval (CI) 1.71, 5.91), followed by persistent wandering (OR 2.53, 95 per cent CI 1.59, 4.01) and being in a dementia unit (OR 2.45, 95 per cent CI 1.17, 5.12) were most strongly associated with psychotropic use. Controlling for resident- and facility-level factors, health care assistants' assignation of hierarchical organisational culture type was independently associated with psychotropic medication use, (OR 1.29, CI 1.08, 1.53) and a higher treatment culture score from the GP was associated with lower use of psychotropic medication (OR 0.95, CI 0.92, 0.98). ORIGINALITY/VALUE: Psychotropic medication use remains prevalent in residential care facilities in NZ. Interventions aimed at changing organisational culture towards a less hierarchical and more resident-centred culture may be another avenue to improve prescribing in residential aged care.


Assuntos
Instituição de Longa Permanência para Idosos , Casas de Saúde , Cultura Organizacional , Psicotrópicos/uso terapêutico , Idoso , Estudos Transversais , Humanos , Auditoria Médica , Nova Zelândia , Assistência Centrada no Paciente , Análise de Regressão
7.
Korean J Radiol ; 15(3): 370-5, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24843242

RESUMO

Periosteal osteosarcoma is an extremely rare chondroblastic osteosarcoma in the flat bone. There were authors reporting of two cases of periosteal osteosarcoma in the highly unusual sites. One of them arose from the rib, in a 17-year-old male, which appeared as a hypodense juxtacortical mass with periosteal reaction on CT. The other one arose from the scapula, in a 17-year-old female, which showed the intermediate signal intensity (SI) on T1-weighted image (WI), heterogeneous high SI on T2WI, and rim-enhancement on contrast-enhanced T1WI with cortical destruction on MRI.


Assuntos
Neoplasias Ósseas/diagnóstico por imagem , Osteossarcoma/diagnóstico por imagem , Costelas/diagnóstico por imagem , Escápula/diagnóstico por imagem , Adolescente , Meios de Contraste , Feminino , Humanos , Masculino , Radiografia
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