Emergent use of ticagrelor during endovascular reperfusion in large arterial occlusions.

OBJECTIVE: Given many emerging indications for endovascular interventions in ischemic strokes, a safe and effective adjuvant antiplatelet regimen for acute revascularization has become a subject of interest. Ticagrelor is a direct oral P2Y12 inhibitor that may achieve rapid platelet suppression than standard oral therapies. We report our experience of Ticagrelor use in revascularization of acute large arterial steno-occlusive disease, describing procedural post-procedure thrombotic events, major hemorrhages, and other clinical outcomes. METHODS: This was a single-center retrospective case series of large steno-occlusive disease requiring endovascular reperfusion with emergent adjuvant Ticagrelor, defined as 30 min of the procedure from skin puncture to closure of the arteriotomy. Major outcomes investigated were thromboembolism in the target artery, and symptomatic intracranial or extracranial major hemorrhages. Additional analyses were performed with respect to timing of the administration and use of rescue GPIIb/IIIa inhibitors if any. RESULTS: 73 consecutive patients were identified, presenting with severe ischemic stroke (median NIHSS 16) of large artery origin. 67% required stent placement (45% cervical carotid, 22% intracranial artery), 9.5% angioplasty and 23% mechanical thrombectomy only. Two experienced symptomatic in-stent occlusion, and 7 experienced major hemorrhages (9.5%) including 3 fatal symptomatic intracranial hemorrhages (4.1%). Among 19 subjects (26%) who received pretreatment with Ticagrelor, there were fewer GPIIb/IIIa administration, angioplasty and stenting, without yielding benefit in functional outcome or mortality. GPIIb/IIIa was administered as rescue therapy in 45 subjects (62%), which was found associated with increased bleeding compared to patients receiving Ticagrelor only, in whom no bleeding complications were recorded (16% vs. 0%; p = 0.03). CONCLUSION: We report our findings on Ticagrelor as an adjuvant antiplatelet therapy in ischemic stroke of large arterial origin requiring emergent revascularization. Effectiveness, safety, need for additional rescue treatment, and comparison to other commonly used oral antiplatelets should be investigated in future prospective studies.

Reliability of Field Assessment Stroke Triage for Emergency Destination Scale Use by Paramedics: Mobile Stroke Unit First-Year Experience.

Background and Purpose: Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale is a helpful tool to triage patients with stroke in the field. However, data on its reliability in the prehospital setting are lacking. We aim to test the reliability of FAST-ED scale when used by paramedics in a mobile stroke unit covering a metropolitan area. Methods: As part of standard operating mobile stroke unit procedures, paramedics initially evaluated patients. If the event characterized a stroke alert, the FAST-ED score was determined by the paramedic upon patient contact (in-person) and then independently by a vascular neurologist (VN) immediately after paramedic evaluation (remotely/telemedicine). This allowed testing of the interrater agreement of the FAST-ED scoring performance between on-site prehospital providers and remotely located VN. Results: Of a total of 238 patients transported in the first 15 months of the mobile stroke unit's activity, 173 were included in this study. Median age was 63 (interquartile range, 55.5­75) years and 52.6% were females. A final diagnosis of ischemic stroke was made in 71 (41%), transient ischemic attack in 26 (15%), intracranial hemorrhage in 15 (9%), whereas 61 (35%) patients were stroke mimics. The FAST-ED scores matched perfectly among paramedics and VN in 97 (56%) instances, while there was 0 to 1-point difference in 158 (91.3%), 0 to 2-point difference in 171 (98.8%), and 3 or more point difference in 2 (1.1%) patients. The intraclass correlation between VN and paramedic FAST-ED scores showed excellent reliability, intraclass correlation coefficient 0.94 (95% CI, 0.92­0.96; P<0.001). When VN recorded FAST-ED score ≥3, paramedics also scored FAST-ED≥3 in majority of instances (63/71 patients; 87.5%). A large vessel occlusion was identified in 16 (9.2%) patients; 13 occlusions were identified with a FAST-ED≥3 while 3 were missed. All of the latter patients had National Institutes of Health Stroke Scale score ≤5. Conclusions: We demonstrate excellent reliability of FAST-ED scale performed by paramedics when compared with VN, indicating that it can be accurately performed by paramedics in the prehospital setting.

Safety and Tolerability of Rapid Administration Undiluted Levetiracetam.

BACKGROUND/OBJECTIVE: Levetiracetam (LEV) is an antiepileptic drug used widely in patients with a favorable safety profile. Studies evaluating the safety and efficacy of intravenous (IV) LEV included volumes of at least 100 mL. Minimally diluted doses administered over 5-6 min were found to be both safe and effective. Given the complexities of admixing, this practice can be impractical and result in delays in antiepileptic therapy. This study aimed to retrospectively review the safety and tolerability of rapid administration of undiluted LEV doses ≤ 1000 mg. METHODS: This was a retrospective study evaluating adverse drug reactions associated with undiluted LEV from January 1, 2018-June 1, 2018. Patients were included if they received at least one dose of undiluted LEV and were ≥ 18 years old. Safety endpoints were reviewed and collected from the time administration until hospital discharge. Endpoints included injection site pain and discomfort, injection site erythema, extravasation, IV line replacement, and any documented adverse effect leading to IV LEV discontinuation. Descriptive statistics were used to analyze the data. RESULTS: A total of 199 patients were included in the study totaling 1626 doses of LEV. Most patients were administered LEV 1000 mg (60.8%), through a peripheral line (64.3%), and were prescribed LEV for seizure prophylaxis (58.3%). Patients received a mean of 8.1 ± 8 doses for a mean duration of therapy of 5 ± 4.5 days. About 98.5% of patients did not experience an adverse effect, whereas 1.5% of patients experienced agitation, delirium, confusion, and/or lethargy, which is well known to LEV therapy. CONCLUSIONS: Rapid administration of undiluted LEV doses ≤ 1000 mg were well tolerated with no concentration-related side effects. Further prospective research is needed to confirm this observation as well as the safety of higher doses.

Consumption of anthocyanin-rich cherry juice for 12 weeks improves memory and cognition in older adults with mild-to-moderate dementia.

PURPOSE: Dietary flavonoids, including anthocyanins, may positively influence cognition and may be beneficial for the prevention and treatment of dementia. We aimed to assess whether daily consumption of anthocyanin-rich cherry juice changed cognitive function in older adults with dementia. Blood pressure and anti-inflammatory effects were examined as secondary outcomes. METHODS: A 12-week randomised controlled trial assessed cognitive outcomes in older adults (+70 year) with mild-to-moderate dementia (n = 49) after consumption of 200 ml/day of either a cherry juice or a control juice with negligible anthocyanin content. Blood pressure and inflammatory markers (CRP and IL-6) were measured at 6 and 12 weeks. ANCOVA controlling for baseline and RMANOVA assessed change in cognition and blood pressure. RESULTS: Improvements in verbal fluency (p = 0.014), short-term memory (p = 0.014) and long-term memory (p ≤ 0.001) were found in the cherry juice group. A significant reduction in systolic (p = 0.038) blood pressure and a trend for diastolic (p = 0.160) blood pressure reduction was evident in the intervention group. Markers of inflammation (CRP and IL-6) were not altered. CONCLUSION: Inclusion of an anthocyanin-rich beverage may be a practical and feasible way to improve total anthocyanin consumption in older adults with mild-to-moderate dementia, with potential to improve specific cognitive outcomes.

Incorporation and Impact of a Clinical Pharmacist in a Hospital-Based Neurology Clinic Treating Patients with Multiple Sclerosis.

BACKGROUND: Clinical pharmacists are uniquely positioned to assist with the complexities of medication management for patients with multiple sclerosis (MS). The objective was to describe clinical pharmacy services provided, as well as provider satisfaction with and perceived impact of incorporating a clinical pharmacist in MS patient care. METHODS: The study consisted of a retrospective medical record review and a provider survey conducted in an outpatient neurology clinic at an academic medical center. Between April 2017 and June 2018, electronic medical records of patients with documented interventions by a pharmacist were reviewed to describe clinical pharmacy services provided to patients with MS. A voluntary, anonymous survey was distributed to neurology providers to evaluate provider satisfaction with and perceived impact of clinical pharmacist involvement in MS patient care. RESULTS: There were 64 patients identified with 378 documented interventions made by clinical pharmacists. Pharmacist interventions were mostly related to facilitating medication access (n = 208), pretreatment screening (n = 57), patient counseling (n = 51), and providing drug information (n = 43). All nine providers surveyed indicated that facilitating medication access, counseling patients, and managing drug interactions were moderately or very important clinical pharmacy services. Furthermore, all providers surveyed strongly agreed that pharmacist involvement decreased time to therapy initiation and provider time spent on medication management. CONCLUSIONS: Clinical pharmacists play an integral role in MS patient care, particularly with facilitating medication access. Prospective studies are needed to further evaluate the contribution of clinical pharmacists in MS patient care.

Smoking-Related Social Interactions as Experienced by Persons Who Smoked Long-term.

PURPOSE/AIMS: Smoking-related stigma is manifested in the everyday social interactions of persons who smoke and can result in low self-esteem, diminished self-efficacy, and resistance to smoking cessation. The purpose of this study was to describe smoking-related social interactions as experienced by persons with a history of long-term smoking. DESIGN: This study used a qualitative descriptive approach. METHODS: This study is part of a larger study designed to identify factors that influence lung cancer screening participation. Data were drawn from 39 qualitative interviews with persons from the parent study. All descriptions about smoking-related social interactions found in the narratives were extracted, coded, categorized, and summarized with content analytic techniques. RESULTS: Seven different types of social interactions were identified: (a) being looked down on for smoking, (b) being humiliated for smoking in public, (c) being banished while smoking, (d) being blamed for one's health problems, (e) not "really" being blamed for smoking, (f) being told "just quit," and (g) being worried about hurting others. CONCLUSIONS: Clinical nurse specialists should promote antismoking campaigns that are not stigmatizing, discuss health risks of smoking in a respectful manner, provide evidence-based cessation resources, improve communication with persons who smoke, and address stigma in programs to improve screening for smoking-related illnesses.