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1.
N Z Med J ; 134(1529): 69-79, 2021 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-33582709

RESUMO

AIMS: This study aims to determine whether door-to-needle times (DNT) for reversal of anticoagulant-associated intracerebral haemorrhage (ICH) (1) have improved over time, (2) differ between warfarin and dabigatran and (3) are comparable to ischaemic stroke (IS) thrombolysis DNT, and (4) whether reversal is monitored. METHODS: Retrospective review of all warfarin- and dabigatran-associated ICH presenting to Christchurch Hospital over a 15-year period. DNT data from 2013-2018 were compared between warfarin-related ICH (WRICH), dabigatran-related ICH (DRICH) and IS thrombolysis. RESULTS: 172 WRICH were identified. Over time there were significant reductions in door-to-first-reversal-agent (r=-0.21, p=0.01), scan-to-first-reversal-agent (r=-0.27, p=0.001) and scan-to-prothrombin-complex-concentrate (PCC) (r=-0.33, p=0.001) times. In the 2013-2018 cohort, WRICH had significantly slower DNT, door-to-scan time and scan-to-needle time compared to DRICH and IS thrombolysis (all p<0.001). There was no statistical difference between DRICH and IS. Median DNT was 183 minutes for WRICH, 72 minutes for DRICH and 52 minutes for IS. Median time to repeat international normalised ratio was 231 minutes, and the median time to repeat thrombin clotting time was 825 minutes. CONCLUSION: Door-to-any-reversal-agent and scan-to-PCC times have improved over time, but they remain significantly longer than IS thrombolysis times. Monitoring of reversal is inadequate, particularly for WRICH receiving PCC.


Assuntos
Fatores de Coagulação Sanguínea/uso terapêutico , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/tratamento farmacológico , Terapia Trombolítica/métodos , Terapia Trombolítica/normas , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea/administração & dosagem , Dabigatrana/efeitos adversos , Feminino , Humanos , Coeficiente Internacional Normatizado , Hemorragias Intracranianas/diagnóstico , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Varfarina/efeitos adversos
2.
Medicine (Baltimore) ; 100(1): e23676, 2021 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-33429734

RESUMO

INTRODUCTION: Ischemic stroke caused by arterial occlusion is the cause of most strokes. The focus of treatment is rapid reperfusion through intravenous thrombolysis and intravascular thrombectomy. Two acute stroke management including prehospital thrombolysis and in hospital have been widely used clinically to treat ischemic stroke with satisfied efficacy. However, there is no systematic review comparing the effectiveness of these 2 therapies. The aim of this study is to compare the effect of prehospital thrombolysis versus in hospital for patients with ischemic stroke. METHODS AND ANALYSIS: The following electronic databases will be searched: Web of Science, PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), Wanfang Database, and Chinese Scientific Journal Database.The randomized controlled trials of prehospital thrombolysis versus in hospital for ischemic stroke will be searched in the databases from their inception to December 2020 by 2 researchers independently. Onset to therapy (OTT) duration and National Institute Health Stroke Scale (NIHSS) scores will be assessed as the primary outcomes; safety assessment including intracerebral hemorrhage (ICH) and mortality will be assessed as the secondary outcomes. The Review Manager 5.3 will be used for meta-analysis and the evidence level will be assessed by using the method for Grading of Recommendations Assessment, Development and evaluation Continuous outcomes will be presented as the weighted mean difference or standardized mean difference with 95% confidence interval (CI), whereas dichotomous data will be expressed as relative risk with 95% CI. If heterogeneity existed (P < .05), the random effect model was used. Otherwise, we will use the fixed effect model for calculation. ETHICS AND DISSEMINATION: Ethical approval is not required because no primary data are collected. This review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42020200708.


Assuntos
Protocolos Clínicos , Hospitais/normas , Unidades Móveis de Saúde/normas , Terapia Trombolítica/normas , Hospitais/estatística & dados numéricos , Humanos , Metanálise como Assunto , Unidades Móveis de Saúde/organização & administração , Unidades Móveis de Saúde/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Revisões Sistemáticas como Assunto , Terapia Trombolítica/métodos , Terapia Trombolítica/estatística & dados numéricos
3.
J Stroke Cerebrovasc Dis ; 29(11): 105181, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066945

RESUMO

COVID-19 pandemic has led to a change in the way we manage acute medical illnesses. This pandemic had a negative impact on stroke care worldwide. The World Stroke Organization (WSO) has raised concerns due to the lack of available care and compromised acute stroke services globally. The numbers of thrombolysis and thrombectomy therapies are declining. As well as, the rates and door-to treatment times for thrombolysis and thrombectomy therapies are increasing. The stroke units are being reallocated to serve COVID-19 patients, and stroke teams are being redeployed to COVID-19 centers. Covid 19 confirmed cases and deaths are rising day by day. This pandemic clearly threatened and threatening all stroke care achievements regionally. Managing stroke patients during this pandemic is even more challenging at our region. The Middle East and North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO) is the main stroke organization regionally. MENA-SINO urges the need to developing new strategies and recommendations for stroke care during this pandemic. This will require multiple channels of interventions and create a protective code stroke with fast triaging path. Developing and expanding the tele-stroke programs are urgently required. There is an urgent need for enhancing collaboration and cooperation between stroke expertise regionally and internationally. Integrating such measures will inevitably lead to an improvement and upgrading of the services to a satisfactory level.


Assuntos
Infecções por Coronavirus/terapia , Prestação Integrada de Cuidados de Saúde/normas , Pneumonia Viral/terapia , Acidente Vascular Cerebral/terapia , Trombectomia/normas , Terapia Trombolítica/normas , África do Norte/epidemiologia , Consenso , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Humanos , Oriente Médio/epidemiologia , Pandemias , Segurança do Paciente , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Padrões de Prática Médica/normas , Quarentena , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Telemedicina/normas , Fatores de Tempo , Resultado do Tratamento , Triagem/normas
5.
J Stroke Cerebrovasc Dis ; 29(9): 105012, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807427

RESUMO

BACKGROUND: Located on the Borneo Island, Sarawak is the largest state of Malaysia and has a population distinctive from Peninsular Malaysia. The ischaemic stroke data in Sarawak had not been reported despite the growing number of patients annually. We aimed to investigate patient characteristics, management, and outcomes of ischaemic stroke in Sarawak and benchmark the results with national and international published data. METHODS: We included ischaemic stroke cases admitted to Sarawak General Hospital between June 2013 and August 2018 from Malaysia National Stroke Registry. We performed descriptive analyses on patient demographics, cardiovascular risk factors, prior medications, smoking status, arrival time, thrombolysis rate, Get With The Guidelines (GWTG)-Stroke measures, and outcomes at discharge. We also numerically compared the results from Sarawak with the published data from selected national and international cohorts. RESULTS: We analysed 1435 ischaemic stroke cases. The mean age was 60.1±13.2 years old; 64.9% were male; median baseline National Institute of Health Stroke Scale was seven points. Hypertension was the most prevalent risk factor of ischaemic stroke; 12.7% had recurrent stroke; 13.7% were active smokers. The intravenous thrombolysis rate was 18.8%. We achieved 80-90% in three GWTG-Stroke performance measures and 90-98% in four additional quality measures in our ischaemic stroke management. At discharge, 57% had modified Rankin Scale of 0-2; 6.7% died during hospitalisation. When compared with selected national and international data, patients in Sarawak were the youngest; Sarawak had more male and more first-ever stroke. Thrombolysis rate in Sarawak was higher compared with most studies in the comparison. Functional outcome at discharge in Sarawak was better than national cohort but still lagging behind when compared with the developed countries. In-hospital mortality rate in Sarawak was slightly lower than the national data but higher when compared with other countries. CONCLUSION: Our study described characteristics, management, and outcomes of ischaemic stroke in Sarawak. We achieved high compliance with most of GTWG-Stroke performance and quality indicators. Sarawak had better outcomes than the national results on ischaemic stroke. However, there is still room for improvement when compared with other countries. Actions are needed to reduce the cardiovascular burdens for stroke prevention, enhance healthcare resources for stroke care, and improve intravenous thrombolysis treatment in Sarawak.


Assuntos
Benchmarking/normas , Isquemia Encefálica/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/normas , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Feminino , Disparidades em Assistência à Saúde/normas , Mortalidade Hospitalar , Humanos , Malásia/epidemiologia , Masculino , Pessoa de Meia-Idade , Alta do Paciente/normas , Padrões de Prática Médica/normas , Recidiva , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
6.
Stroke ; 51(8): 2339-2346, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32640947

RESUMO

BACKGROUND AND PURPOSE: Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes. METHODS: A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback. RESULTS: Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51-93) to 39.0 minutes (interquartile range, 27-58) for patients treated per guideline (P<0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% (P<0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3-55.8) to 53.6 days (interquartile range, 36.8-64.6) (P=0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% (P=0.0990). CONCLUSIONS: The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Medidas de Resultados Relatados pelo Paciente , Vigilância da População , Acidente Vascular Cerebral/tratamento farmacológico , Tempo para o Tratamento/normas , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Alberta/epidemiologia , Isquemia Encefálica/epidemiologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Vigilância da População/métodos , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica/normas , Terapia Trombolítica/tendências , Tempo para o Tratamento/tendências
7.
J Vasc Surg ; 72(3): 790-798, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32497747

RESUMO

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto , Síndrome do Desfiladeiro Torácico/diagnóstico , Triagem/normas , Consenso , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Descompressão Cirúrgica/normas , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Tratamento de Emergência/métodos , Tratamento de Emergência/normas , Humanos , Controle de Infecções/normas , Comunicação Interdisciplinar , Salvamento de Membro/métodos , Salvamento de Membro/normas , Seleção de Pacientes , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Telemedicina/normas , Síndrome do Desfiladeiro Torácico/etiologia , Síndrome do Desfiladeiro Torácico/terapia , Terapia Trombolítica/métodos , Terapia Trombolítica/normas , Tempo para o Tratamento/normas
8.
Medicine (Baltimore) ; 99(10): e19358, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32150076

RESUMO

INTRODUCTION: Intravenous thrombolysis is not suitable for patients undergoing oral anticoagulants therapy, with INR > 1.7 or PT > 15 s. We described a case of intravenous thrombolysis in a patient with INR 1.9. PATIENT CONCERNS: A 66-year-old female patient was diagnosed with acute appendicitis complicated with atrial fibrillation. Seven days after admission, the patient suffered mixed aphasia with right limb asthenia. The NIHSS score was 11 points. and early infarction and hemorrhagic manifestations were not found in the emergency head CT. Thirty minutes after the onset of symptoms, NIHSS of patient increased from 11 to 14, but the INR was 1.92. DIAGNOSIS: Acute ischemic stroke. INTERVENTIONS: The IT therapy was recommended and all the therapy related risks were explained to the patient's parents. Briefly, the patient was given rTPA 38.5 mg. In addition to intravenous thrombolysis, VitK1 40 mg was simultaneously administered. OUTCOME: The patient's symptoms of drowsiness were improved. After 24 hours, all symptoms were stabilized with NIHSS of 2 points, there was a slight language obstruction, and no hemorrhagic transformation in head CT. Three months later, the review showed MRS score of 0, and the patient could take care of herself in daily life. CONCLUSION: The clinical guidelines are still the main reference for guiding clinical practice, and the main thrombolytic standards and contraindications for treatment still need to be conformed. On this basis, for individualized patients, clinicians must accurately judge the cause of acute stroke, to make optimal choice, reduce disability and mortality, and improve quality of life of patients.


Assuntos
Segurança do Paciente/normas , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/normas , Varfarina/efeitos adversos , Idoso , Apendicite/complicações , Apendicite/cirurgia , Feminino , Fibrinolíticos/normas , Fibrinolíticos/uso terapêutico , Humanos , Coeficiente Internacional Normatizado/métodos , Complicações Pós-Operatórias/tratamento farmacológico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/métodos , Resultado do Tratamento , Varfarina/uso terapêutico
9.
J Neurointerv Surg ; 12(6): 574-578, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31653755

RESUMO

BACKGROUND: The intra-arterial treatment (IAT) of acute ischemic stroke (AIS) is now evidence-based and given the highest level of recommendation among eligible patients. Using a multi-state stroke registry, we studied the trend in IAT among patients with AIS over 11 years and its impact on the utilization of intravenous thrombolysis (IVT) within the same 11 years. METHODS: Using data from the Paul Coverdell National Acute Stroke Program (PCNASP), we studied trends in IVT and IAT for patients with AIS between 2008 and 2018. Trends over time were examined for rates of IVT only, IAT only, or a combination of IVT and IAT (IVT+IAT). Favorable outcome was defined as discharge to home. RESULTS: During the study period there were 595 677 patients (mean age 70.4 years, 50.4% women) from 646 participating hospitals with a clinical diagnosis of AIS in the PCNASP. Trends for IVT only, IAT only, and IVT+IAT all significantly increased over time (P<0.001). Total use of IVT and IAT increased from 7% in 2008 to 19.1% in 2018. The rate of patients discharged to home increased significantly over time among all treatment groups (P<0.001). CONCLUSION: In our large registry-based analysis, we observed a significant increase in the use of IAT for the treatment of AIS, with continued increases in the use of IVT. Concurrently, the percent of patients with favorable outcomes continued to increase.


Assuntos
Isquemia Encefálica/terapia , Infusões Intra-Arteriais/tendências , Injeções Intra-Arteriais/tendências , Melhoria de Qualidade/tendências , Sistema de Registros , Acidente Vascular Cerebral/terapia , Idoso , Isquemia Encefálica/epidemiologia , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Infusões Intra-Arteriais/normas , Infusões Intravenosas/normas , Infusões Intravenosas/tendências , Injeções Intra-Arteriais/normas , Injeções Intravenosas/normas , Injeções Intravenosas/tendências , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade/normas , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica/normas , Terapia Trombolítica/tendências , Resultado do Tratamento
10.
Am J Cardiol ; 125(1): 1-10, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31685213

RESUMO

The benefit-risk ratio of a pharmacoinvasive strategy (PI) in patients ≥70 years of age with ST-segment elevation myocardial infarction (STEMI) remains uncertain resulting in its limited use in this population. This study compared efficacy and safety of PI with primary percutaneous coronary intervention (pPCI). Data from 2,841 patients (mean age: 78.1 ± 5.6 years, female: 36.1%) included in a prospective multicenter registry, and who underwent either PI (n = 269) or pPCI (n = 2,572), were analyzed. The primary end point was in-hospital major adverse cardiovascular events (MACE) defined as the composite of all-cause mortality, nonfatal MI, stroke, and definite stent thrombosis. Secondary end points included all-cause death, major bleeding, net adverse clinical events, and the development of in-hospital Killip class III or IV heart failure. Propensity-score matching and conditional logistic regression were used to adjust for confounders. Within the matched cohort, rates of MACE was not statistically different between the PI (n = 247) and pPCI (n = 958) groups, (11.3% vs 9.0%, respectively, odds ratio 1.25, 95% confidence interval 0.81 to 1.94; p = 0.31). Secondary end points were comparable between groups at the exception of a lower rate of development of Killip class III or IV heart failure after PI. The rate of intracranial hemorrhage was significantly higher in the PI group (2.3% vs 0.0%, p = 0.03). In conclusion, the present study demonstrated no difference regarding in-hospital MACE following PI or pPCI in STEMI patients ≥70 years of age. An adequately-powered randomized trial is needed to precisely define the role of PI in this high-risk subgroup.


Assuntos
Intervenção Coronária Percutânea/normas , Guias de Prática Clínica como Assunto , Sistema de Registros , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Terapia Trombolítica/normas , Idoso , Idoso de 80 Anos ou mais , Causas de Morte/tendências , Feminino , Seguimentos , França/epidemiologia , Mortalidade Hospitalar/tendências , Humanos , Masculino , Intervenção Coronária Percutânea/métodos , Prognóstico , Estudos Prospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Taxa de Sobrevida/tendências , Terapia Trombolítica/métodos , Tempo para o Tratamento
11.
Neurol Med Chir (Tokyo) ; 59(12): 449-491, 2019 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-31801934
12.
Implement Sci ; 14(1): 98, 2019 11 27.
Artigo em Inglês | MEDLINE | ID: mdl-31771599

RESUMO

BACKGROUND: The Thrombolysis ImPlementation in Stroke (TIPS) trial tested the effect of a multicomponent, multidisciplinary, collaborative intervention designed to increase the rates of intravenous thrombolysis via a cluster randomized controlled trial at 20 Australian hospitals (ten intervention, ten control). This sub-study investigated changes in self-reported perceptions and practices of physicians and nurses working in acute stroke care at the participating hospitals. METHODS: A survey with 74 statements was administered during the pre- and post-intervention periods to staff at 19 of the 20 hospitals. An exploratory factor analysis identified the structure of the survey items and linear mixed modeling was applied to the final survey domain scores to explore the differences between groups over time. RESULT: The response rate was 45% for both the pre- (503 out of 1127 eligible staff from 19 hospitals) and post-intervention (414 out of 919 eligible staff from 18 hospitals) period. Four survey domains were identified: (1) hospital performance indicators, feedback, and training; (2) personal perceptions about thrombolysis evidence and implementation; (3) personal stroke skills and hospital stroke care policies; and (4) emergency and ambulance procedures. There was a significant pre- to post-intervention mean increase (0.21 95% CI 0.09; 0.34; p < 0.01) in scores relating to hospital performance indicators, feedback, and training; for the intervention hospitals compared to control hospitals. There was a corresponding increase in mean scores regarding perceptions about the thrombolysis evidence and implementation (0.21, 95% CI 0.06; 0.36; p < 0.05). Sub-group analysis indicated that the improvements were restricted to nurses' responses. CONCLUSION: TIPS resulted in changes in some aspects of nurses' perceptions relating to the evidence for intravenous thrombolysis and its implementation and hospital performance indicators, feedback, and training. However, there is a need to explore further strategies for influencing the views of physicians given limited statistical power in the physician sample. TRIAL REGISTRATION: ACTRN12613000939796, UTN: U1111-1145-6762.


Assuntos
Atitude do Pessoal de Saúde , Isquemia Encefálica/tratamento farmacológico , Capacitação em Serviço/organização & administração , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Adulto , Austrália , Feminino , Fidelidade a Diretrizes , Humanos , Capacitação em Serviço/normas , Masculino , Corpo Clínico Hospitalar , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem no Hospital , Percepção , Guias de Prática Clínica como Assunto/normas , Terapia Trombolítica/normas , Adulto Jovem
13.
J Emerg Med ; 57(4): 478-487, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31594741

RESUMO

BACKGROUND: Cardiac arrests are caused in most cases by thromboembolic diseases, such as acute myocardial infarction (AMI) and pulmonary embolism (PE). OBJECTIVE: We aimed to ascertain the associations of thrombolytic therapy with potential benefits among cardiac arrest patients during cardiopulmonary resuscitation (CPR). METHODS: We searched PubMed, Embase, and Cochrane databases for studies that evaluated systemic thrombolysis in cardiac arrest patients. The primary outcome was survival to hospital discharge, and secondary outcomes included return of spontaneous circulation (ROSC), 24-h survival rate, hospital admission rate, and bleeding complications. RESULTS: Nine studies with a total of 4384 cardiac arrest patients were pooled in the meta-analysis, including 1084 patients receiving systemic thrombolysis and 3300 patients receiving traditional treatments. Compared with conventional therapies, the use of systemic thrombolysis did not significantly improve survival to hospital discharge (13.5% vs. 10.8%; risk ratio [RR] 1.13; 95% confidence interval [CI] 0.92-1.39; p = 0.24, I2 = 35%), ROSC (50.9% vs. 44.3%; RR 1.29; 95% CI 1.00-1.66; p = 0.05, I2 = 73%), and 24-h survival (28.1% vs. 25.6%; RR 1.25; 95% CI 0.88-1.77; p = 0.22, I2 = 63%). We observed higher hospital admission rates for patients receiving systemic thrombolysis (43.4% vs. 30.6%; RR 1.53; 95% CI 1.04-2.24; p = 0.03, I2 = 87%). In addition, higher risk of bleeding was observed in the thrombolysis group (8.8% vs. 5.0%; RR 1.65; 95% CI 1.16-2.35; p = 0.005, I2 = 7%). CONCLUSIONS: Systemic thrombolysis during CPR did not improve hospital discharge rate, ROSC, and 24-h survival for cardiac arrest patients. Patients receiving thrombolytic therapy have a higher risk of bleeding. More high-quality studies are needed to confirm our results.


Assuntos
Parada Cardíaca/tratamento farmacológico , Prognóstico , Ressuscitação/instrumentação , Terapia Trombolítica/normas , Parada Cardíaca/epidemiologia , Parada Cardíaca/mortalidade , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Ressuscitação/métodos , Ressuscitação/normas , Análise de Sobrevida , Terapia Trombolítica/métodos
14.
Circulation ; 140(20): e774-e801, 2019 11 12.
Artigo em Inglês | MEDLINE | ID: mdl-31585051

RESUMO

Pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality. The technological landscape for management of acute intermediate- and high-risk PE is rapidly evolving. Two interventional devices using pharmacomechanical means to recanalize the pulmonary arteries have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. The purpose of this document is to clarify the current state of endovascular interventional therapy for acute PE and to provide considerations for evidence development for new devices that will define which patients with PE would derive the greatest net benefit from their use in various clinical settings. First, definitions and limitations of commonly used risk stratification tools for PE are reviewed. An adjudication of risks and benefits of available interventional therapies for PE follows. Next, considerations for optimal future evidence development in this field are presented in the context of the current US regulatory framework. Finally, the document concludes with a discussion of the pros and cons of the rapidly expanding PE response team model of care delivery.


Assuntos
Embolectomia/normas , Procedimentos Endovasculares/normas , Embolia Pulmonar/terapia , Terapia Trombolítica/normas , American Heart Association , Tomada de Decisão Clínica , Consenso , Técnicas de Apoio para a Decisão , Embolectomia/efeitos adversos , Embolectomia/instrumentação , Embolectomia/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Humanos , Seleção de Pacientes , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/instrumentação , Terapia Trombolítica/mortalidade , Resultado do Tratamento , Estados Unidos
15.
J Stroke Cerebrovasc Dis ; 28(12): 104423, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31606319

RESUMO

BACKGROUND: The Mission Protocol was implemented in 2017 to expedite stroke evaluation and reduce door-to-needle (DTN) times at Zuckerberg San Francisco General Hospital. The key system changes were team-based evaluation of suspected stroke patients at ambulance entrance by an Emergency Department (ED) physician, ED nurse, and neurologist and immediate emergency medical service (EMS) provider transport of patients to CT. METHODS: Patients were eligible for a Mission Protocol prehospital stroke activation if an EMS provider found a positive Cincinnati Prehospital Stroke Scale and a last known normal time within 6 hours. We retrospectively compared treatment metrics between the first year of Mission Protocol patients and patients from the year prior also brought in via ambulance with suspected stroke and a last known normal time within 6 hours. Median Door to CT and DTN times were compared using 2 sample Wilcoxon rank-sum (Mann-Whitney) tests. RESULTS: There were 236 patients in the Mission Protocol group and 112 in the comparison group. The Mission Protocol was associated with a 10 minutes faster median door to CT time (P < .00001), a 6 minutes faster median DTN time (P = .0046), a 22% increase in the proportion of patients treated within 45 minutes of arrival (84% versus 62%), and a 12% increase in the proportion of patients treated within 60 minutes (92% versus 80%). There were 8 stroke mimics treated in the Mission Protocol cohort compared to 2 in the comparison cohort. Symptomatic intracranial hemorrhage occurred in one Mission Protocol patient with an ischemic stroke. CONCLUSIONS: The EMS direct to CT based Mission Protocol was associated with faster median door to CT and DTN times. There was a 22% increase in the proportion of thrombolysis patients treated within 45 minutes or less. More stroke mimic patients received thrombolysis but symptomatic intracranial hemorrhage only occurred in 1 ischemic stroke patient.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Protocolos Clínicos/normas , Serviços Médicos de Emergência/normas , Fibrinolíticos/administração & dosagem , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/normas , Tempo para o Tratamento/normas , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Diagnóstico Diferencial , Serviço Hospitalar de Emergência/normas , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Tomografia Computadorizada por Raios X/normas , Resultado do Tratamento
16.
BMJ Open ; 9(9): e026496, 2019 09 04.
Artigo em Inglês | MEDLINE | ID: mdl-31488463

RESUMO

INTRODUCTION: The Lone Star Stroke Consortium Telestroke Registry (LeSteR) currently consisting of 3 academic hub centres and 27 partner spokes is a statewide initiative organised by leading academic health centres in the State of Texas to understand practice patterns of acute stroke management via telestroke (TS) in Texas, a state with one of the largest rural populations in the USA. METHODS AND ANALYSIS: All patients who had presumed stroke for whom a TS consultation has been obtained in the network are entered into a web-based, Health Insurance Portability and Accountability Act-compliant database from September 2013 to present. Spokes were enrolled into LeSteR in a staggered approach in two data collection phases: a retrospective phase and a prospective phase. Basic clinical, demographic data and relevant time metrics are collected in the retrospective phase. Starting 1 September 2015, additional outcome data including 90-day modified Rankin score, readmission and 90-day disposition are obtained by a standard phone interview. From the registry initiation to 31 December 2017, there are 8089 patients who had suspected stroke in the registry. Over 60% of patients enrolled after 1 September 2015 have reported outcome data. Enrolment is still active for this registry. ETHICS AND DISSEMINATION: LeSteR is a statewide TS registry organised by academic health centres that will provide significant insight regarding the impact of TS in the State of Texas. Findings from LeSteR will provide data that can be analysed to improve the allocation of healthcare resources using TS to treat stroke in a state with one of the largest rural populations.


Assuntos
Isquemia Encefálica/terapia , Sistema de Registros , Consulta Remota/normas , Acidente Vascular Cerebral/terapia , Telemedicina/métodos , Terapia Trombolítica/normas , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Fibrinolíticos/administração & dosagem , Humanos , Projetos de Pesquisa , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Texas , Fatores de Tempo , Tempo para o Tratamento/normas , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento , Comunicação por Videoconferência/normas , Fluxo de Trabalho
17.
J Stroke Cerebrovasc Dis ; 28(11): 104332, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31439524

RESUMO

INTRODUCTION: Telestroke has increased access to acute management of ischemic stroke in areas that lack stroke care expertise, yet delays persist in evaluation and treatment. We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligible for acute stroke therapies among community hospitals in our telestroke network, and explore demographic and spoke-related characteristics associated with delays. METHODS: From our telestroke registry, we identified suspected acute ischemic stroke patients who arrived within 6 hours of symptom onset and underwent video consultation at 1 of 17 community hospitals in our hub-and-spoke network. We compared time between patient arrival to telestroke alert (door-to-page-time) and to tissue plasminogen activator (tPA) administration for eligible patients (door-to-needle-time). We identified factors associated with prolonged metrics. RESULTS: Of 1020 cases between 9/2015 and 3/2017, 47% received tPA. Sixty percent had door-to-page-time more than 15 minutes (median 19.5; IQR, 11-34). Door-to-page-time more than 15 minutes was associated with an 8-fold increase in likelihood of door-to-needle-time more than 60 minutes. Patients with severe stroke experienced faster door-to-page-times. Hospitals with more beds had prolonged door-to-page-time. Full time in-house neurology presence, even when not covering emergent consultations, was associated with faster door-to-page-time over telestroke. Seventy-one percent of patients underwent CT brain prior to the telestroke physician alert; this scenario delayed door-to-page and door-to-needle times. CONCLUSIONS: Door-to-page-time varied considerably among spokes. Awaiting CT scan prior to alerting the telestroke consultant of a stroke code delayed metrics. Telestroke physician alert standards are needed, as are educational initiatives on acute ischemic stroke management and workflow.


Assuntos
Benchmarking/normas , Isquemia Encefálica/terapia , Prestação Integrada de Cuidados de Saúde/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Equipe de Assistência ao Paciente/normas , Padrões de Prática Médica/normas , Consulta Remota/normas , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/normas , Tempo para o Tratamento/normas , Administração Intravenosa , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Tomografia Computadorizada por Raios X/normas , Resultado do Tratamento , Comunicação por Videoconferência/normas , Fluxo de Trabalho
18.
Am J Cardiol ; 124(6): 879-885, 2019 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-31311662

RESUMO

Guidelines recommend oral anticoagulant (OAC) monotherapy without antiplatelet therapy (APT) in patients with nonvalvular atrial fibrillation (AF) with stable coronary artery disease (CAD) of >1 year after myocardial infarction or percutaneous coronary intervention. More evidences are required for the safety and efficacy of OAC monotherapy compared with OAC plus APT. PubMed, EMBASE, and Cochrane Database of Systematic Reviews were systematically searched up to February 2019. Nonrandomized studies and randomized clinical trials comparing OAC monotherapy with OAC plus single APT (SAPT) for patients with stable CAD and nonvalvular AF. The primary end point was major adverse cardiovascular events (composite of ischemic or thrombotic events) and secondary outcomes included major bleeding, stroke, all-cause death, and net adverse events (composite of ischemic, thrombotic, or bleeding events). From 6 trials, 8,855 patients were included. There was no significant difference in major adverse cardiovascular event in patients with AF treated using OAC plus SAPT compared with those treated with OAC monotherapy (hazard ratio [HR] 1.09; 95% confidence interval [CI] 0.92 to 1.29). OAC plus SAPT was associated with a significantly higher risk of major bleeding compared with OAC monotherapy (HR 1.61; 95% CI 1.38 to 1.87), as well as in terms of net adverse event (HR 1.21; 95% CI 1.02 to 1.43). There were no significant differences in rates of stroke and all-cause death. In conclusion, in this meta-analysis, OAC monotherapy and OAC plus SAPT treatment showed similar effectiveness, but OAC monotherapy was significantly associated with a lower risk of bleeding compared with OAC plus SAPT in patients with nonvalvular AF and stable CAD.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Doença da Artéria Coronariana/tratamento farmacológico , Guias de Prática Clínica como Assunto , Terapia Trombolítica/normas , Administração Oral , Fibrilação Atrial/complicações , Doença da Artéria Coronariana/complicações , Humanos , Resultado do Tratamento
19.
J Stroke Cerebrovasc Dis ; 28(9): 2488-2495, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31277995

RESUMO

BACKGROUND AND OBJECTIVE: Current standard practice guidelines recommend ICU admission for ischemic stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). More recently, the trend in stroke care is to broaden eligibility for IV thrombolysis. Two examples are a more liberal inclusion criteria known as SMART criteria (sIV-tPA), and the transfer of patients to comprehensive stroke centers (CSC). The present study characterizes ICU interventions in these patients. Understanding which stroke patients that require ICU-level care may allow for placement of patients in the appropriate level of care at hospital admission. METHODS: We performed a retrospective review of consecutive transfer and nontransfer sIV-tPA-treated patients admitted to the ICU at a CSC. We evaluated the frequency, timing, and nature of ICU interventions. RESULTS: Three hundred and thirty one patients were treated with sIV-tPA and 42% required ICU interventions during ICU admission. Of patients requiring ICU interventions, 98% had an ICU intervention performed in triage, prior to admission. National Institute of Health Stroke Scale score only had a moderate association to requirement of ICU interventions. Neither transferring patients to a CSC nor the number of standard IV-tPA contraindications increased ICU interventions. CONCLUSIONS: Liberalized IV-tPA administration did not increase ICU interventions. Nearly all patients that required ICU interventions declared this need in triage, prior to ICU admission. This timing of ICU intervention use during triage is highly sensitive for whether a patient will require ongoing ICU-level care during hospital admission. Identifying ICU intervention use in triage may allow for more effective placement of post-IV-tPA patients in the appropriate inpatient care setting, leading to better utilization of scarce ICU resources.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Unidades de Terapia Intensiva , Admissão do Paciente , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Triagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva/normas , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/normas , Seleção de Pacientes , Transferência de Pacientes , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/normas , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Triagem/normas
20.
J Thromb Thrombolysis ; 48(2): 203-208, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31214876

RESUMO

This meta-analysis was conducted to assess the safety and efficacy of sonothrombolysis along with intravenous recombinant tissue plasminogen activator, alteplase (IV rtPA), in the management of acute ischemic stroke. Electronic databases were searched under different meSH terms without the restriction of time and language. 1415 studies were analyzed and seven studies that matched the inclusion criteria were selected. Multiple safety and efficacy outcomes were extracted. Our pooled analysis demonstrated that there is no significant difference between sonothrombolysis group and control group in preventing mortality (RR 1.10 [0.81, 1.50]; p = 0.55; I2 = 0%) and intracranial hemorrhage (RR 1.11 [0.76, 1.63]; p = 0.59; i2 = 0%), however, among the efficacy outcomes; complete recanalization after 60-120 min was achieved more effectively in the sonothrombolysis group (RR 2.11 [1.48, 3.03]; p ≤ 0.0001; I2 = 0%). The rest of the efficacy outcomes like neurological improvement at 24 h (RR 1.20 [0.92, 1.57]; p = 0.18; I2 = 40%) and excellent functional outcome after 3 months (RR 1.19 [0.93, 1.52]; p = 0.17; I2 = 35%) showed no significant differences between the two groups. In subgroup analysis, we found that sonothrombolysis led to a better neurological improvement in patients who were less than 65 years of age (RR 1.20 [0.92, 1.57]; p = 0.05; I2 = 40%). Moreover, there were no significant differences in the following of the subgroups assessed: (a) microsphere or microbubble use, (b) Ultrasound frequency (2 MHz or < 2 MHz), (c) transcranial Doppler (TCD) duration (1 h or 2 h), (d) age (≤ 65 or > 65).


Assuntos
Isquemia Encefálica/terapia , Terapia Combinada/normas , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Terapia Combinada/efeitos adversos , Terapia Combinada/mortalidade , Humanos , Hemorragias Intracranianas/etiologia , Pessoa de Meia-Idade , Acidente Vascular Cerebral/mortalidade , Terapia Trombolítica/mortalidade , Terapia Trombolítica/normas , Resultado do Tratamento , Ultrassonografia
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