Prognostic Disclosure to Dying Adolescents Against Parental Wishes: A Point-Counter Point Debate.

An adolescent's last moment of life is an emotionally and medically complex time. Children may grapple with understanding the things happening to them and with grief of a future lost; caregivers struggle to simultaneously balance deep sorrow, hope, and love; and healthcare providers fight to maintain sound medical and ethical decision making. Increased discussion regarding adolescent end-of-life care is needed so that clinicians may better understand how to engage in ethically based medical management during these events. This holds particularly true in situations where potentially conflicting ideas exist between clinicians and family members. We describe the case of an acutely and terminally ill adolescent who remained cognitively intact but with rapidly advancing multiple organ failure and whose parents requested that he remain uninformed of his critical illness and prognosis.

Coexistent Sickle Cell Disease Has No Impact on the Safety or Outcome of Lytic Therapy in Acute Ischemic Stroke: Findings From Get With The Guidelines-Stroke.

BACKGROUND AND PURPOSE: The recommended treatment for ischemic stroke is tPA (tissue-type plasminogen activator). Although sickle cell disease (SCD) represents no known contraindication to tPA, National Heart Lung and Blood Institute of the National Institutes of Health recommended acute exchange transfusion for stroke in SCD, not tPA. Data on safety and outcomes of tPA in patients are needed to guide tPA use in SCD. METHODS: We matched patients from the American Heart Association and American Stroke Association Get With The Guidelines-Stroke registry with SCD to patients without SCD and compared usage, complications, and discharge outcomes after tPA. Multivariable logistic regression models using generalized estimating equations were used to assess outcomes. RESULTS: From 2 016 652 stroke patients admitted to Get With The Guidelines-Stroke sites in the United States, 832 SCD and 3328 non-SCD controls with no differences in admission National Institutes of Health Stroke Scale or blood pressure were identified. Neither the fraction receiving thrombolytic therapy (8.2% for SCD versus 9.4% non-SCD) nor symptomatic intracranial hemorrhage (4.9% of SCD versus 3.2% non-SCD; P=0.4502) was different. There was no difference in a prespecified set of outcome measures for those with SCD compared with controls. CONCLUSIONS: Coexistent SCD had no significant impact on the safety or outcome of thrombolytic therapy in acute ischemic stroke. Although the sample size is relatively small, these data suggest that adults with SCD and acute ischemic stroke should be treated with thrombolysis, if they otherwise qualify. Addition studies, however, should track the intracranial hemorrhage rate and provide information on other SCD-related care such as transfusion.

Racial differences in poststroke rehabilitation utilization and functional outcomes.

OBJECTIVE: To examine racial differences in poststroke rehabilitation utilization and functional outcomes. DESIGN: Observational follow-up study. SETTING: Designated stroke center. PARTICIPANTS: Stroke survivors (N=162; 106 whites and 56 blacks) surveyed at 1 year poststroke. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Twenty-question measure of activities of daily living (ADL) and instrumental activities of daily living (IADL) performance, life participation, and driving. One-year follow-up data collected from stroke survivors as part of the Stroke Education and Prevention-South Carolina Project were examined for racial disparities in rehabilitation utilization and functional outcomes. RESULTS: Analyses revealed no significant differences between blacks and whites for rehabilitation utilization. In multivariate comparisons controlling for stroke severity, blacks were less likely to report independence in overall functional performance and domain-specific measures of toileting, walking, transportation, laundry, and shopping. Blacks also reported less independence in driving at 1-year follow-up. CONCLUSIONS: Blacks were less likely to report independence in performing ADL and IADL at 1 year poststroke after controlling for stroke severity. Racial disparities were reported in ADL and IADL performance despite a lack of racial differences in rehabilitation utilization. Future studies are needed to further understand the reason for this disparity in reported functional independence.

Shared Decision-Making in Palliative Care: A Maternalistic Approach.

During goals of care conversations, palliative care clinicians help patients and families determine priorities of care and align medical care with those priorities. The style and methods of communicating with families and negotiating a care plan can range from paternalistic to entirely patient driven. In this paper, we describe a case in which the palliative care clinician approached decision-making using a paradigm that is intuitive to many clinicians and which seems conceptually sound, but which has not been fully explored in the bioethics literature. This paradigm, termed maternalism, allows the clinician to direct decision-making within a relationship such that best interests and autonomy are mutually reinforced, thus reflecting relational autonomy as opposed to individual autonomy. We explore whether this method is appropriate in this case and explain how it captures significant ethical features of the case that might be missed by other approaches.

Practical approach to management of intracranial atherosclerosis.

OPINION STATEMENT: Intracranial atherosclerosis (ICAS) is one of the most frequent causes of stroke worldwide and has a high incidence of recurrent stroke. The therapeutic approaches for treating this high-risk disease have been evolving over time. The most recent, evidence-based approach is to focus on aggressive medical management of vascular risk factors and includes short-term dual antiplatelet treatment for 90 days followed by antiplatelet monotherapy. The role of endovascular therapy in the treatment of ICAS has not been established and is currently reserved only for patients who have failed aggressive medical management with recurrent ischemic events. There are no currently recommended surgical options to treat ICAS; however, investigational treatments such as encephaloduroarteriosynagiosis (EDAS) may hold promise. Despite aggressive medical management with short-term dual antiplatelet therapy, there remains a subset of patients with severe ICAS who will have recurrence of ischemic events. Further research is needed to better identify this high-risk subset and develop novel treatments to prevent further stroke and death.

Comparison of endovascular treatment approaches for acute ischemic stroke: cost effectiveness, technical success, and clinical outcomes.

INTRODUCTION: The use of mechanical thrombectomy for the treatment of acute ischemic stroke has significantly advanced over the last 5 years. Few data are available comparing the cost and clinical and angiographic outcomes associated with available techniques. The aim of this study is to compare the cost and efficacy of current endovascular stroke therapies. METHODS: A single-center retrospective review was performed of the medical record and hospital financial database of all ischemic stroke cases admitted from 2009 to 2013. Three discrete treatment methodologies used during this time were compared: traditional Penumbra System (PS), stent retriever with local aspiration (SRLA) and A Direct Aspiration first Pass Technique (ADAPT). Statistical analyses of clinical and angiographic outcomes and costs for each group were performed. RESULTS: 222 patients (45% men) underwent mechanical thrombectomy. Successful revascularization was defined as Thrombolysis In Cerebral Infarction (TICI) 2b/3 flow, which was achieved in 79% of cases with PS, 83% of cases with SRLA, and 95% of cases with ADAPT. The average total cost of hospitalization for patients was $51,599 with PS, $54,700 with SRLA, and $33 ,11 with ADAPT (p<0.0001). Average times to recanalization were 88 min with PS, 47 min with SRLA, and 37 min with ADAPT (p<0.0001). Similar rates of good functional outcomes were seen in the three groups (PS 36% vs SRLA 43% vs ADAPT 47%; p=0.4). CONCLUSIONS: The ADAPT technique represents the most technically successful yet cost-effective approach to revascularization of large vessel intracranial occlusions.