Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial Hemorrhage: Systematic Review and Meta-Analysis.

BACKGROUND: For patients with atrial fibrillation who survive an intracranial hemorrhage (ICrH), the decision to offer oral anticoagulation (OAC) is challenging and necessitates balancing risk of thromboembolic events with risk of recurrent ICrH. METHODS: This systematic review assesses the effectiveness and safety of OAC and/or antiplatelets in patients with atrial fibrillation with nontraumatic ICrH. Bibliographic databases CENTRAL, MEDLINE, EMBASE, and CINAHL were searched. Articles on adults with atrial fibrillation with spontaneous ICrH (intracerebral, subdural, and subarachnoid), receiving antithrombotic therapy for stroke prevention were eligible for inclusion. RESULTS: Twenty articles (50 470 participants) included 2 randomized controlled trials (n=304)' 8 observational studies, 8 cohort studies, and 2 studies that meta-analyzed individual-level data from observational studies. OAC therapy was associated with a significant reduction in thromboembolic events (summary relative risk [sRR], 0.51 [95% CI, 0.30-0.86], heterogeneity I2=2%; P=0.39, n=5 studies) and all-cause mortality (sRR, 0.52 [95% CI, 0.38-0.71], heterogeneity I2=0; P=0.44, n=3 studies). OAC therapy was not associated with an increased risk of recurrent ICrH (sRR, 1.44 [95% CI, 0.38-5.46], heterogeneity I2=70%, P=0.02, n=5 studies). Nonvitamin K antagonist OACs were more effective at reducing the risk of thromboembolic events (sRR, 0.65 [95% CI, 0.44-0.97], heterogeneity I2=72%, P=0.03, n=3 studies) and were associated with a lower risk of recurrent ICrH (sRR, 0.52 [95% CI, 0.40-0.67], heterogeneity I2=0%, P=0.43, n=3 studies) than warfarin. CONCLUSIONS: In nontraumatic ICrH survivors with atrial fibrillation, OAC therapy is associated with a reduced risk of thromboembolic events and all-cause mortality without significantly increasing risk of recurrent ICrH. This finding is primarily based on observational data, and further larger randomized controlled trials are needed to corroborate or refute these findings.

Antithrombotic therapy for stroke prevention in patients with atrial fibrillation who survive an intracerebral haemorrhage: results of an EHRA survey.

The aim of this survey is to provide a snapshot of current practice regarding antithrombotic therapy (ATT) in patients with atrial fibrillation (AF) comorbid with intracerebral haemorrhage (ICH). An online survey was distributed to members of the European Heart Rhythm Association. A total of 163 clinicians responded, mostly cardiologists or electrophysiologists (87.7%), predominantly working in University hospitals (61.3%). Most respondents (47.2%) had seen one to five patients with AF comorbid with ICH in the last 12 months. Among patients sustaining an ICH on oral anticoagulation (OAC), 84.3% respondents would consider some form of ATT post-ICH, with 73.2% preferring to switch from a vitamin-K antagonist (VKA) to a non-VKA oral anticoagulant (NOAC) and 37.2% preferring to switch from one NOAC to another. Most (36.6%) would restart OAC >30 days post-ICH. Among patients considered unable to take OAC, left atrial appendage occlusion procedure was the therapy of choice in 73.3% respondents. When deciding on ATT, respondents considered patient's CHA2DS2-VASc score, ICH type, demographics, risk factors, and patient adherence. The main reason for not restarting or commencing ATT was concern about recurrent ICH (80.8%). National or international clinical guidelines would be advantageous to support decision-making (84.3%). Other helpful resources reported were multidisciplinary team involvement (46.9%) and patient education (82%). In summary, most survey respondents would prescribe OAC therapy for patients with AF who have sustained an ICH on OAC and would restart OAC >30 days post-ICH. The risk of recurrent ICH was the main reason for not prescribing any ATT post-ICH.

Challenges in tuberculosis management in Peru and England.

Tuberculosis (TB) is a serious but preventable and largely treatable disease caused by the bacterium Mycobacterium tuberculosis. Although there is evidence that the UK incidence remains stable, rates of the disease, particularly in some London boroughs, remain high, earning it the unenviable title of the 'tuberculosis capital of Europe'. In March 2014 Public Health England published a consultation document on a collaborative strategy for tackling tuberculosis in England. This highlights a growing concern surrounding the issue. In the 1990s, Peru's tuberculosis epidemic saw the country listed among the Pan-American Health Organisation's top 23 countries of heaviest burden. Since then overall rates, although remaining significantly higher than those of the UK, have fallen dramatically. This article uses the observations of a BSc Nursing student undertaking an international elective in Peru to highlight some of the challenges faced by nurses in managing TB and draws parallels with those faced in the UK.

Understanding the palliative care needs of heart failure patients.

It is increasingly recognised that end-of-life care is suboptimal, especially for those with advanced non-malignant diseases. This study shows that individuals living with heart failure have a number of palliative care needs, including education, communication, symptom management and psychosocial needs. Clinicians struggled to discuss palliation with heart failure patients due to the unclear disease trajectory and cardiac-specific barriers to identifying palliation needs. Carers reported a need for greater social support and better guidance on best practice care. Furthermore, patients struggled to cope physically and psychologically with their reduced physical capabilities and were fearful of being a burden to their carers. Both patients and clinicians recognised a discontinuity between secondary and primary care, which has particular resonance in the context of the intention to relocate care nearer home.

Managing Uncertainty: Physicians' Decision Making for Stroke Prevention for Patients with Atrial Fibrillation and Intracerebral Hemorrhage.

BACKGROUND: Stroke prevention in patients with atrial fibrillation (AF) post-intracerebral hemorrhage (ICH) is an area of clinical equipoise. Little is known about the tools and processes that physicians use to make decisions regarding anticoagulation in this high-risk patient population. OBJECTIVE: To explore physicians' decision-making process regarding stroke prevention in patients with AF and a recent history of ICH. METHODS: Qualitative study, utilizing semistructured interviews and analyzed using Framework analysis. RESULTS: Twenty physicians from five European countries (Austria, France, Germany, Spain, United Kingdom) participated. The overarching theme "Managing uncertainty," addressed the process of making high-risk clinical decisions in the context of little available robust clinical evidence for best practice. Three subthemes were identified under the umbrella theme: (1) "Computing the risks," captured the challenge of balancing the risks of ischemic stroke with the risk of recurrent ICH in a complex patient population; (2) "Patient factors" highlighted the influence that physician-perceived patients' beliefs and previous experience of stroke had on physicians' decisions; and (3) "Making a decision" explored the process of reaching a final decision regarding initiation of OAC therapy or not. CONCLUSION: Physicians described the process of deciding on stroke prevention in patients with AF post-ICH as "challenging" due to considerable "clinical equipoise." Key factors that affected decision making were patient comorbidities, functional status, and patient willingness to engage with OAC therapy. Shared decision making was believed to be beneficial, but physicians believed that the ultimate responsibility to decide on stroke prevention lay with the clinician.

Challenges and facilitators in providing effective end of life care in intensive care units.

Caring for patients who are at the end of their lives is an essential aspect of practice in intensive care units (ICUs). While intensive care is one of the fastest-growing healthcare specialties as a result of technological and scientific advances, a significant proportion of patients admitted to an ICU in the UK will not survive their ICU stay. Therefore, it is important to examine ways to enhance practice in this area and the factors that might affect the care provided to patients and their families. AIM: To identify the challenges and facilitators that members of the ICU multidisciplinary team encounter in the delivery of end of life care to dying patients in ICUs. METHOD: A scoping literature review was undertaken. Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with full text, MEDLINE Complete and the EBSCOhost E-Journals Database were searched electronically to identify literature from April 2007 to April 2017, alongside hand-searching. Critical appraisal tools were used and thematic analysis was undertaken to analyse the data and identify themes. FINDINGS: Ten articles were included in the literature review, which identified various challenges and facilitators in providing effective end of life care in ICUs. The main themes identified were: communication, family involvement, personal factors and the ICU environment. CONCLUSION: All of the studies included in the literature review identified several important challenges related to communication, such as time constraints, disagreements among healthcare professionals, and a lack of knowledge among healthcare professionals about how to conduct challenging conversations with patients and families. Future developments in practice should consider the role of effective multidisciplinary team-working in end of life care.