Calculating the carbon footprint of a Geriatric Medicine clinic before and after COVID-19.

BACKGROUND: climate change is a health emergency. Central to addressing this is understanding the carbon footprint of our daily life and work, in order to reduce it effectively. The coronavirus disease of 2019 (COVID-19) pandemic has brought about rapid change to clinical practice, most notably in use of virtual clinics and personal protective equipment (PPE). AIM: to estimate the carbon footprint of a Geriatric Medicine clinic, including the effect of virtual consultation and PPE, in order to inform design of a service that addresses both the health of our patients and our environment. METHOD: data from the Greenhouse Gas Protocol, NHS Carbon Footprint Plus and UK Government were used to estimate the carbon emissions per consultation. Values were calculated for virtual and face-to-face contact and applied to actual clinics both before and during the COVID-19 pandemic. RESULTS: the carbon footprint of a face-to-face clinic consultation is 4.82 kgCO2e, most of which is patient travel, followed by staff travel and use of PPE. The footprint of a virtual consultation is 0.99 kgCO2e, most of which is staff travel, followed by data use.Using our hybrid model for a single session clinic reduced our annual carbon footprint by an estimated 200 kgCO2e, roughly equivalent to a surgical operation. DISCUSSION: the COVID-19 pandemic has made us deliver services differently. The environmental benefits seen of moving to a partially virtual clinic highlight the importance of thinking beyond reverting to 'business as usual'-instead deliberately retaining changes, which benefit the current and future health of our community.

improving interrater agreement about brain microbleeds: development of the Brain Observer MicroBleed Scale (BOMBS).

BACKGROUND AND PURPOSE: If the diagnostic and prognostic significance of brain microbleeds (BMBs) are to be investigated and used for these purposes in clinical practice, observer variation in BMB assessment must be minimized. METHODS: Two doctors used a pilot rating scale to describe the number and distribution of BMBs (round, low-signal lesions, <10 mm diameter on gradient echo MRI) among 264 adults with stroke or TIA. They were blinded to clinical data and their counterpart's ratings. Disagreements were adjudicated by a third observer, who informed the development of a new Brain Observer MicroBleed Scale (BOMBS), which was tested in a separate cohort of 156 adults with stroke. RESULTS: In the pilot study, agreement about the presence of >/=1 BMB in any location was moderate (kappa=0.44; 95% CI, 0.32-0.56), but agreement was worse in lobar locations (kappa=0.44; 95% CI, 0.30-0.58) than in deep (kappa=0.62; 95% CI, 0.48-0.76) or posterior fossa locations (kappa=0.66; 95% CI, 0.47-0.84). Using BOMBS, agreement about the presence of >/=1 BMB improved in any location (kappa=0.68; 95% CI, 0.49-0.86) and in lobar locations (kappa=0.78; 95% CI, 0.60-0.97). CONCLUSIONS: Interrater reliability concerning the presence of BMBs was moderate to good, and could be improved with the use of the BOMBS rating scale, which takes into account the main sources of interrater disagreement identified by our pilot scale.

Pseudoperipheral palsy due to cortical infarction.

We present two cases of isolated hand weakness that were initially thought to be due to lower motor neurone lesions until subsequent MRI confirmed strokes in both. Small strokes are important to identify in order to optimise secondary prevention.

Cerebral microbleeds are associated with lacunar stroke defined clinically and radiologically, independently of white matter lesions.

BACKGROUND AND PURPOSE: Associations among microbleeds, white matter lesions (WMLs), and small deep infarcts on imaging have been reported. Because many of these imaging infarcts were asymptomatic, the relationship of microbleeds to clinical lacunar stroke is unclear. An association between microbleeds and clinically defined lacunar stroke might suggest a common causal microangiopathy. METHODS: Patients with lacunar, partial anterior circulation or posterior circulation stroke syndromes and older healthy subjects underwent MRI. Microhemorrhages, infarcts, hemorrhages, and WMLs were coded blind to clinical details. A final clinicoradiologic stroke subtype diagnosis was assigned. RESULTS: Among 308 subjects (67 older healthy and 241 with stroke), 54 patients had microbleeds (17%). Microbleeds were twice as frequent in lacunar than cortical strokes (26% versus 13%, P=0.03) or healthy older subjects (9%) and associated with increasing WML scores (P<0.0001). Lacunar and cortical stroke subtypes and healthy older subjects had similar WML scores. CONCLUSIONS: Microbleeds are associated with lacunar stroke defined clinicoradiologically more than other stroke subtypes but not simply by association with WMLs. This suggests that microbleeds and lacunar stroke have a similar microvascular abnormality.

Immediate computed tomography scanning of acute stroke is cost-effective and improves quality of life.

BACKGROUND AND PURPOSE: Stroke is very common, but computed tomography (CT) scanning, an expensive and finite resource, is required to differentiate cerebral infarction, hemorrhage, and stroke mimics. We determined whether, and in what circumstances, CT is cost-effective in acute stroke. METHODS: We developed a decision tree representing acute stroke care pathways populated with data from multiple sources. We determined the effect of diagnostic information from CT scanning on functional outcome, length of stay, costs, and quality of life during 5 years for 13 alternative CT strategies (varying proportions and types of patients and rapidity of scanning). RESULTS: For 1000 patients aged 70 to 74 years, the policy "scan all strokes within 48 hours" cost 10,279,728 pounds sterling and achieved 1982.3 quality-adjusted life years (QALYs). The most cost-effective strategy was "scan all immediately" (9,993,676 pounds sterling and 1982.4 QALYs). The least cost-effective was "scan patients on anticoagulants and those in a life-threatening condition immediately and the rest within 14 days" (12,592,666 pounds sterling and 1931.8 QALYs). "Scan no patients" reduced QALYs (1904.2) and increased cost (10,544,000 pounds sterling). CONCLUSIONS: Immediate CT scanning is the most cost-effective strategy. For the majority of acute stroke patients, increasing independent survival by correct early diagnosis, ensuring appropriate subsequent treatment and management decisions, reduced costs of stroke and increased QALYs.

Stroke epidemiology studies have underestimated the frequency of intracerebral haemorrhage. A systematic review of imaging in epidemiological studies.

INTRODUCTION: Small primary intracerebral haemorrhages (PICHs) cause mild stroke symptoms and resolve rapidly on CT. Delays in imaging in stroke incidence studies may therefore have inadvertently led to an underestimate of the frequency of small PICHs. OBJECTIVE: To determine whether the rate and timing of CT in community-based stroke incidence studies was adequate to determine accurately the proportion of strokes due to PICH. METHODS: A systematic review of community-based stroke incidence studies that included details on pathological type of stroke, excluding subarachnoid haemorrhage. We extracted information on the proportions of patients scanned, the timing of scans, characteristics of patients that were less likely to be scanned, and the proportion of ischaemic, or haemorrhagic, or unknown strokes. RESULTS: In the 25 studies identified, scanning methods were poorly documented. When mentioned, the median proportion of patients scanned was 63 % (95 % confidence intervals (CI) 60 to 85 %) and mostly performed outside the time for reliable distinction of PICH from ischaemic stroke (median 18.5 days, 95 % CI 7 to 30 days). Patients particularly likely to miss scanning were older, those not admitted to hospital or who died early after stroke. CONCLUSION: The scanning strategy documentation, the proportion of patients scanned and the timing of scanning in stroke incidence studies has been suboptimal. The frequency of a primary intracerebral haemorrhage, and its distribution in different age groups of patients or severities of stroke, has been underestimated. Future incidence studies should adopt more rigorous scanning policies and describe these policies more precisely.

Long-term visibility of primary intracerebral hemorrhage on magnetic resonance imaging.

BACKGROUND: It is unclear whether primary intracerebral hemorrhage (PICH) remains detectable with magnetic resonance imaging (MRI) in the long term, or whether a gradient echo recalled (GRE) sequence is always necessary to detect it. METHODS: In a prospectively collected cohort of patients with stroke, we identified survivors of PICH able to undergo MRI at least 3 months after the original PICH. We compared several MRI sequences (spin echo (SE) T2, fast SE (FSE) T2 and proton density, fluid-attenuated inversion recovery, GRE) in a blinded fashion. The number of PICHs visible on each MRI sequence, and the presence of infarcts and microhemorrhages, were determined. RESULTS: In 26 patients imaged 3 years (median) after PICH, between 61% (fluid-attenuated inversion recovery) and 100% (GRE) of PICHs remained identifiable as definite PICH. On FSE T2, 3.4% of PICHs were missed. There were no specific patient features that determined which PICHs remained visible. A new PICH developed in 29% of patients between original presentation and the current study, and 38% had microhemorrhages. CONCLUSION: Although a FSE T2 sequence will identify most old PICHs, a GRE sequence is essential for definite identification. Recurrent PICH and microhemorrhages appear to be common.

Thrombolysis: attempting to reduce postcode prescribing in Scotland?

The literature is littered with reports presenting the proportion of patients admitted with ischaemic stroke receiving thrombolysis. This gives some measure of activity and the efficiency of prehospital and hospital triage. Some stroke centres have reported rates of thrombolysis as high as 20%, but without knowing the population that such services serve, these proportions do not indicate how well or equitably the treatment is being delivered. Here, we explore various metrics to monitor our efforts to provide equitable access to stroke thrombolysis in Lothian, a region in the South East of Scotland.

A telephone hotline for transient ischaemic attack and stroke: prospective audit of a model to improve rapid access to specialist stroke care.

PROBLEM: Patients with transient ischaemic attack or stroke benefit from early diagnosis, specialist assessment, and treatment with thrombolysis, and from stroke unit care and secondary prevention. The challenge with such patients is to minimise delays and ensure that treatment is appropriate, and to provide this care with the available resources. DESIGN: An ongoing prospective audit of a transient ischaemic attack and stroke clinic (1 January 2005 to 30 September 2009), as part of the Scottish Stroke Care Audit, and a three month targeted audit of immediate telephone access to a specialist stroke consultant (1 February 2009 to 30 April 2009). SETTING: Stroke and transient ischaemic attack services in Lothian, a region of Scotland with a population of 810,000. KEY MEASURES FOR IMPROVEMENT: Delays to assessment at a rapid access transient ischaemic attack and stroke clinic; delays to appropriate treatment. STRATEGY FOR CHANGE: In February 2007 we introduced a 24 hours a day, seven days a week hotline to a consultant, who provided immediate advice on diagnosis, investigation, and emergency treatment for patients with transient ischaemic attack or stroke, and suggested the most appropriate care pathway, which might include an early appointment in a transient ischaemic attack and stroke clinic. EFFECTS OF CHANGE: The introduction of the hotline was associated with an immediate and sustained reduction in delays to assessment (from 13 to three days) and treatment. The proportion of participants taking statins at the time of visiting the clinic increased from 40% before the introduction of the hotline to 60% after the hotline was in place. Also, the hotline contributed to a reduction in the delay from last event to carotid surgery, from 58 days to 21.5 days. A total of 376 calls were received during the three month audit. Of the 273 (88%) referrers who responded to our questionnaire, 257 (94%) were very satisfied with the advice given over the hotline. LESSONS LEARNT: Although associated with some disruption to the activities of the consultants, a 24 hours a day, seven days a week telephone hotline to a consultant is a feasible and effective means of reducing delays to specialist assessment and treatment of patients with transient ischaemic attack or stroke.

Antithrombotic therapy in patients with any form of intracranial haemorrhage: a systematic review of the available controlled studies.

Patients with intracranial haemorrhage may sometimes require antithrombotic drugs or be inadvertently given antithrombotic therapy. We systematically reviewed all published trials comparing any antithrombotic agent with control among patients with any form of intracranial haemorrhage. We extracted data on deaths, recurrent intracranial haemorrhage and functional outcome. There were 9 randomised trials of 5 different antithrombotic agents versus control in patients with subarachnoid haemorrhage (6 trials, n = 1,224) or with acute intracerebral haemorrhage (3 trials, n = 819). The overall odds ratio (OR) for death among patients with any intracranial haemorrhage given an antiplatelet agent (8 trials, 1,997 patients) was 0.85 (95% confidence interval, CI, 0.63-1.15), and for recurrent intracranial haemorrhage it was 1.00 (95% CI 0.73-1.37). The corresponding ORs for patients with intraparenchymal cerebral haemorrhage were 0.96 (0.62-1.5) and 1.02 (0.5-1.8), respectively, but 65% of these patients received only a few doses of antithrombotic treatment. The overall OR for death in patients with any intraparenchymal cerebral haemorrhage given heparin compared with control (3 trials, 819 patients, subcutaneous heparin) was 0.96 (95% CI 0.38-2.40), and for recurrent intracranial haemorrhage it was 2.00 (95% CI 0.86-4.70). There were no reliable data on the effects of antithrombotic agents on functional outcome. These scant data do not support reliable conclusions about the safety or otherwise of antithrombotic agents in patients with acute intracranial haemorrhage. Antithrombotic agents should be avoided where possible in patients with acute intracerebral haemorrhage.