Abstract TP336: Influence of Aversion to Uncertainty in STROKE Care

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Yue Li ◽  
Lauren Crump ◽  
Mike Sharma ◽  
Ralph Sacco ◽  
Eric Smith ◽  
...  
Keyword(s):  
Oral Anticoagulants ◽  
Multivariable Analysis ◽  
Stroke Care ◽  
Treatment Preferences ◽  
Limited Information ◽  
Stroke Patients ◽  
Case Scenario ◽  
Online Questionnaire ◽  
Silent Cerebral Infarction ◽  
Practical Implications

Introduction: Physicians caring for patients with silent cerebral infarction (SCI) face several diagnostic and therapeutic challenges. In situations with limited information or lack of guidelines, clinical decisions may be influenced by aversion to uncertainty (AU) defined as a tendency to prefer known over unknown risks. Hypothesis: We hypothesize that physicians’ AU is associated with overutilization of diagnostic tests and influences therapeutic choices for patients with covert cerebrovascular disease. Methods: Participating physicians were practicing neurologists with expertise in stroke care identified from WSO, CSC, VasCog and SORCan. Those who agreed to participate were sent an online questionnaire. Participants randomly received 10 cases from a pool of 20 assessing perception of risk for later stroke and treatment preferences, with additional validated questions to quantitatively determine AU, and overconfidence. The questionnaire was completed online. A multivariable analysis was completed adjusting for age, years of experience, and annual volume of stroke patients. Results: Of 252 initial participants, 35 (13.9%) were excluded for incomplete responses. Of 217 remaining participants for the analysis, 50% of participants expressed that uncertainty was troublesome with their diagnosis. AU was associated with greater recommendation of oral anticoagulants for a case-scenario with atrial fibrillation, CHADS 4 and microbleeds (OR 3.26; 95%CI 1.30-8.19), and with ordering more investigations for an asymptomatic cortical infarction (OR 2.61; 95%CI 1.17-5.83). AU was also associated with recommending tPA or endovascular treatment for a 72 year old woman presented within 4 hours with an NIHSS 6-7 and asymptomatic microbleeds, but otherwise no other contraindication (OR 3.32; 95%CI 1.19-9.27). Conclusion: Aversion to uncertainty is common among practicing stroke neurologists. AU was associated with ordering more investigations and more appropriate recommendations for oral anticoagulation or revascularization when indicated. The present study has practical implications, as aversion to uncertainty may be associated with a more vigilant practice.

Abstract TMP37: Physicians’ Preferences in the Management of Silent Stroke: Results From a Worldwide Survey

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Lauren Crump ◽  
Yue Li ◽  
Mike Sharma ◽  
Ralph L Sacco ◽  
Eric E Smith ◽  
...  
Keyword(s):  
Mild Hypertension ◽  
Stroke Care ◽  
Treatment Preferences ◽  
Antithrombotic Treatment ◽  
Case Scenario ◽  
Cerebrovascular Lesions ◽  
Scientific Organizations ◽  
Wide Variability ◽  
Risk Patients ◽  
Silent Cerebral Infarction

Introduction: Patients with silent cerebral infarction (SCI) or microbleeds (MB) are at higher risk of developing a recurrent vascular event or suffering a hemorrhage as a consequence of thrombolysis or antithrombotic treatment. Additionally, the presence of occult cerebrovascular lesions on imaging may alter therapeutic or diagnostic recommendations. However, clinical guidelines are lacking. Hypothesis: We hypothesize that a wide variability in physician diagnostic and treatment preferences exist for individuals with SCI and MB. Methods: Respondents were practicing neurologists with expertise in stroke care identified from WSO, CSC, Vas-Cog and SORCan. Those who agreed to participate were sent a questionnaire which was completed online. Participants randomly received 10 cases from a pool of 20, assessing perception of risk for later stroke and treatment preferences, as well as demographic questions. Results: Among the 252 participants, 35 (13.9%) were excluded for incomplete responses. Of 217 participants included in this analysis, two thirds of participants would proceed with revascularization therapies (tPA: 40%, endovascular: 8%, combined: 22%) for a case scenario with acute global aphasia (NIHSS 6-7) and remote bilateral MB. Additionally, physicians would order an echocardiogram regardless of the location of the SCI (cortical SCI: 56%, lacunar SCI: 44%; p>0.05). In a case-scenario with mild hypertension and 4 deep microbleeds presented with difficulty with balance, almost half of respondents did not recommend antiplatelet drugs or statins (40.2%), and 20% recommended both antiplatelet and statins. NOACS were the most commonly recommended antithrombotic treatment in a case-scenario with atrial fibrillation (AF), SCI, and a remote lobar intracerebral hemorrhage (46.4%), followed by aspirin (20.9%), no treatment (17.3%). Conclusion: There is a wide variability in the management of SCI and MB among stroke experts. The present study highlights the need for further research in treatment efficacy, as well as recommendations from scientific organizations to guide clinicians in the management of high risk patients with SCI and MB.

scholarly journals New Perspectives in Stroke Management: Old Issues and New Pathways

2021 ◽  
Vol 11 (6) ◽  
pp. 767
Author(s):  
Fabio Pilato ◽  
Rosalinda Calandrelli ◽  
Fioravante Capone ◽  
Michele Alessiani ◽  
Mario Ferrante ◽  
...  
Keyword(s):  
Time Window ◽  
Enhanced Recovery ◽  
Current Knowledge ◽  
Oral Anticoagulants ◽  
Chronic Phase ◽  
Stroke Care ◽  
New Drugs ◽  
Stroke Patients ◽  
Social Burden ◽  
Novel Approaches

Stroke is a leading cause of disability and death worldwide and social burden is huge in terms of disabilities, mortality and healthcare costs. Recently, in an acute stroke setting, renewed interest in disease-modifying therapies and novel approaches has led to enhanced recovery and the reduction of long-term disabilities of patients who suffered a stroke. In the last few years, the basic principle “time is brain” was overcome and better results came through the implementation of novel neuroimaging tools in acute clinical practice, allowing one to extend acute treatments to patients who were previously excluded on the basis of only a temporal selection. Recent studies about thrombectomy have allowed the time window to be extended up to 24 h after symptoms onset using advanced neuroradiological tools, such as computer tomography perfusion (CTP) and magnetic resonance imaging (MRI) to select stroke patients. Moreover, a more effective acute management of stroke patients in dedicated wards (stroke units) and the use of new drugs for stroke prevention, such as novel oral anticoagulants (NOACs) for atrial fibrillation, have allowed for significant clinical improvements. In this editorial paper, we summarize the current knowledge about the main stroke-related advances and perspectives and their relevance in stroke care, highlighting recent developments in the definition, management, treatment, and prevention of acute and chronic complications of stroke. Then, we present some papers published in the Special Issue “Clinical Research on Ischemic Stroke: Novel Approaches in Acute and Chronic Phase”.

scholarly journals Impact of the COVID-19 lockdown on the adherence of stroke patients to direct oral anticoagulants: a secondary analysis from the MAAESTRO study

2021 ◽  
Author(s):  
Fine Dietrich ◽  
Alexandros A. Polymeris ◽  
Melina Verbeek ◽  
Stefan T. Engelter ◽  
Kurt E. Hersberger ◽  
...  
Keyword(s):  
Social Life ◽  
Electronic Monitoring ◽  
Negative Impact ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Secondary Analysis ◽  
Stroke Care ◽  
Stroke Patients ◽  
Oral Anticoagulant Treatment ◽  
Adherence Data

Abstract Background The negative impact of the COVID-19 outbreak on stroke care has been reported, but no data exist on the influence of the lockdown on medication adherence to antithrombotic treatment for stroke prevention. We present a comparison of electronic adherence data of stroke patients treated with direct oral anticoagulants (DOAC) prior to and during the COVID-19 lockdown in spring 2020 in Switzerland. Methods This is a secondary analysis using data from the ongoing MAAESTRO study, in which stroke patients with atrial fibrillation electronically monitor their adherence to DOAC treatment. Eligible patients for this analysis had at least four weeks of adherence data prior to and during the COVID-19 lockdown. Three adherence metrics (taking adherence, timing adherence, drug holidays) were calculated and compared descriptively. Results The analysis included eight patients (median age 81.5 years, IQR 74.8–84.5). Five patients had a pre-lockdown taking adherence over 90% (mean 96.8% ± 2.9), with no change during lockdown, high timing adherence in both periods and no drug holidays. The remaining three patients had pre-lockdown taking and timing adherence below 90%. Of those, two patients showed a moderate decline either in taking or timing adherence compared to pre-lockdown. One showed a substantial increase in taking and timing adherence during lockdown (both + 25.8%). Conclusion Our data suggest that a major disruption of social life (i.e., the imposed COVID-19 lockdown) is unlikely to relevantly affect the medication intake behaviour of patients with high pre-established adherence, but might have an impact in patients with previously suboptimal adherence. Trial registration number MAAESTRO: electronic Monitoring and improvement of Adherence to direct oral Anticoagulant treatment—a randomized crossover study of an Educational and reminder-based intervention in ischaemic STROke patients under polypharmacy, NCT03344146.

scholarly journals Evaluating the potential for pharmacists to prescribe oral anticoagulants for atrial fibrillation

2017 ◽  
Vol 151 (1) ◽  
pp. 51-61 ◽  
Author(s):  
Roopinder K. Sandhu ◽  
Lisa M. Guirguis ◽  
Tammy J. Bungard ◽  
Erik Youngson ◽  
Lisa Dolovich ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Prevention ◽  
Online Survey ◽  
Oral Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Multivariable Analysis ◽  
Case Scenario ◽  
Antithrombotic Agent ◽  
Major Barrier ◽  
Prevention Therapy

Background: Oral anticoagulant therapy (OAC) to prevent atrial fibrillation (AF)–related strokes remains poorly used. Alternate strategies, such as community pharmacist prescribing of OAC, should be explored. Methods: Approximately 400 pharmacists, half with additional prescribing authority (APA), randomly selected from the Alberta College of Pharmacists, were invited to participate in an online survey over a 6-week period. The survey consisted of demographics, case scenarios assessing appropriateness of OAC (based on the 2014 Canadian Cardiovascular Society AF guidelines) and perceived barriers to prescribing. Regression analysis was performed to determine predictors of knowledge. Results: A total of 35% (139/397) of pharmacists responded to the survey, and 57% of these had APA. Depending on the case scenario, 55% to 92% of pharmacists correctly identified patients eligible for stroke prevention therapy, but only about a half selected the appropriate antithrombotic agent; there was no difference in the knowledge according to APA status. In multivariable analysis, predictors significantly associated with guideline-concordant prescribing were having the pharmacist interact as part of an interprofessional team ( p = 0.04) and direct OAC (DOAC) self-efficacy (confidence in ability to extend, adapt, initiate or alter prescriptions; p = 0.02). Barriers to prescribing OAC for APA pharmacists included a lack of AF and DOAC knowledge and preference for consulting the physician first, but these same pharmacists also identified difficulty in contacting the physician as a major barrier. Interpretation and Conclusion: Community pharmacists can identify patients who would benefit from stroke prevention therapy in AF. However, physician collaboration and further training on AF and guidelines for prescribing OAC are needed.

Pre-Admission CHADS2 and CHA2DS2-VASc Scores on Early Neurological Worsening

2021 ◽  
pp. 1-8
Author(s):  
Ki-Woong Nam ◽  
Chi Kyung Kim ◽  
Sungwook Yu ◽  
Jong-Won Chung ◽  
Oh Young Bang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Stroke Risk ◽  
Multivariable Analysis ◽  
National Institutes Of Health ◽  
Risk Scores ◽  
Stroke Patients ◽  
Nihss Score ◽  
Early Neurological Deterioration ◽  
Close Relationship ◽  
The Relationship

<b><i>Background:</i></b> Stroke risk scores (CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc) not only predict the risk of stroke in atrial fibrillation (AF) patients, but have also been associated with prognosis after stroke. <b><i>Objective:</i></b> The aim of this study was to evaluate the relationship between stroke risk scores and early neurological deterioration (END) in ischemic stroke patients with AF. <b><i>Methods:</i></b> We included consecutive ischemic stroke patients with AF admitted between January 2013 and December 2015. CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc scores were calculated using the established scoring system. END was defined as an increase ≥2 on the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 on the motor NIHSS score within the first 72 h of admission. <b><i>Results:</i></b> A total of 2,099 ischemic stroke patients with AF were included. In multivariable analysis, CHA<sub>2</sub>DS<sub>2</sub>-VASc score (adjusted odds ratio [aOR] = 1.17, 95% confidence interval [CI] = 1.04–1.31) was significantly associated with END after adjusting for confounders. Initial NIHSS score, use of anticoagulants, and intracranial atherosclerosis (ICAS) were also found to be closely associated with END, independent of the CHA<sub>2</sub>DS<sub>2</sub>-VASc score. Multivariable analysis stratified by the presence of ICAS demonstrated that both CHA<sub>2</sub>DS<sub>2</sub>-VASc (aOR = 1.20, 95% CI = 1.04–1.38) and CHADS<sub>2</sub> scores (aOR = 1.24, 95% CI = 1.01–1.52) were closely related to END in only patients with ICAS. In patients without ICAS, neither of the risk scores were associated with END. <b><i>Conclusions:</i></b> High CHA<sub>2</sub>DS<sub>2</sub>-VASc score was associated with END in ischemic stroke patients with AF. This close relationship is more pronounced in patients with ICAS.

Abstract 12: Feasibility of Monitoring Covid-19 Related Stroke Patients Across a 14 Hospital Stroke System of Care

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Howard J Rho ◽  
Navdeep S Sangha
Keyword(s):  
Stroke Care ◽  
Stroke Patients ◽  
Specific Data ◽  
Related Data ◽  
Disease States ◽  
Hospital Systems ◽  
Pandemic Response ◽  
Relationship Of ◽  
The Relationship ◽  
Existing Data

Background: Identifying and tracking COVID-19 related data has been crucial to the pandemic response. Most hospital systems have created internal tracking databases specific to COVID-19 but separated from other disease specific data pools. Traditional methods for tracking and trending novel and specific data such as COVID-19 related strokes may require personnel with highly technical skills to abstract the data. We aimed to create a COVID-19 stroke dashboard which would easily auto-abstract and update data. Methods: A simple monitoring system was designed using PowerBI™ and Microsoft Suite™ products that model existing data sources without using other IT resources. Existing data queries from various sources were modeled into one report and the resulting data model was used to track and trend incidence of COVID-19 and its relationship to stroke care throughout a 14- hospital stroke system. Results: The report allowed region-wide identification and evaluation of several metrics, including: volume of code strokes, the volume of patients who had a stroke within two weeks before or after testing positive for COVID-19, the initial NIHSS, if alteplase was administered, reason for no alteplase administration, delay in alteplase administration and if related to COVID-19 and the relationship of COVID-19 cases to the volume of code strokes. It was found that the volume of code strokes significantly decreased during the time of the pandemic and was inversely related to the volume of COVID-19 positive cases being reported in a county. The tool also found that COVID-19 positive stroke patients increased as the overall COVID-19 hospital volume increased. Conclusion: Assessing the relationships between a novel disease and other disease states may lead to changes in hospital workflows and practices resulting into improved patient outcomes.

An evaluation of public policy student placements: outcomes of a Malta-based study

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Anne Marie Thake
Keyword(s):  
Public Policy ◽  
Tertiary Education ◽  
Real Life ◽  
Added Value ◽  
Academic Disciplines ◽  
Online Questionnaire ◽  
Content Type ◽  
Course Content ◽  
Mandatory Requirement ◽  
Practical Implications

PurposeThe purpose of this paper is to evaluate short-term, unpaid placements offered to students reading for a degree in public policy. They provide added value to their tertiary education experience. Elective placements were offered in 2012 and became a mandatory requirement for students reading for a three-year bachelor of commerce degree in public policy in 2018. To date, no research has been carried out on these placements and this may serve as a model for a post-evaluation assessment.Design/methodology/approachData were collected from students who undertook placements, embedded in the public policy undergraduate programme. A document analysis of selected student and placement provider's reports was carried out to complement the students' responses to an online questionnaire.FindingsPlacements are of value to students as they served as an introduction to the working world. They enable students to establish connections with the course content and carry out research. They were exposed to real-life situations, developing their knowledge, acquiring soft skills and learning new tools, sought after by employers. These placements were valued as a route to graduate employment tailor-made to the degree's requirements. Students were able to embark on a soul-searching, introspective discovery and journey which made them mature and shed light in the direction of future work prospects.Research limitations/implicationsPlacements give students the opportunity to gain insights into real-work environments and are able to link theories learnt in the class-room with real-life situations. Placements have positive implications on students adjusting to their work life easily after graduation. The limitations are that the sample size was small and that the reflective reports which were randomly selected may not have necessarily been representative of the full complement.Practical implicationsThe practical implications are that the placements system and process can easily be implemented and replicated in other academic disciplines and universities as a compulsory component of their studies.Social implicationsPlacements gave students the opportunity to reflect on their learning, develop non-technical skills and enhance their confidence levels. They were also able to network and communicate with different employees.Originality/valuePlacements provided exposure to relevant organisations and personal enrichment in terms of acquiring skills, autonomy and independence. Students with placement experience are also more likely to secure future employment, relevant to their undergraduate degree.

Abstract P256: Association Between Antidepressants Use and Intracerebral Hemorrhage: Florida Stroke Registry

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Mithilesh Siddu ◽  
Antonio Bustillo ◽  
Carolina M Gutierrez ◽  
Kefeng Wang ◽  
Hannah Gardener ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Oral Anticoagulants ◽  
Large Population ◽  
Multivariable Analysis ◽  
Population Based ◽  
Prior History ◽  
Stroke Registry ◽  
The Us ◽  
History Of ◽  
Antidepressant Use

Introduction: SSRIs, the most commonly prescribed antidepressants (AD) in the US, are linked to an increased intracerebral hemorrhage (ICH) risk possibly related to impaired platelet function. In the Florida Stroke Registry (FSR), we studied the proportion of cases presenting with ICH amongst AD users and the rate of SSRI prescription amongst stroke patients discharged on AD. Methods: From Jan 2010 to Dec 2019 we included 127,915 cases from FSR in whom information on AD use was available. Multivariable logistic regression was used to evaluate ICH proportions amongst AD and non-AD users and rates of prescribed SSRIs at discharge. Results: The rate of ICH amongst prior AD users (n=17,009, median age 74, IQR=19) and non-AD users (n=110,906, median age 72, IQR=21) were 11% and 14% respectively. Prior AD users were more likely to be female (17% vs. 10% male), non-Hispanic White (16% vs. 8% non-Hispanic Black vs. 12% Florida Hispanic vs. 6% Puerto Rican Hispanic), have hypertension (HTN) (14.% vs. 10%), diabetes mellitus (DM) (16% vs.12%), use oral anticoagulants (OAC) (17 % vs. 13%), antiplatelets (AP; 17% vs. 11%), and statins (17% vs. 10%) prior to hospital presentation. In multivariable analysis adjusting for age, race, prior history of HTN, DM, prior OAC, AP and statin use, AD users just as likely to present with spontaneous ICH as compared to non-AD users (OR=0.92, 95% CI 0.85, 1.01). A total of 3.4% of all ICH patients and 9% of those in whom AD information was available were discharged home on an AD (74 % SSRI, 24% other AD). Conclusion: In this large population-based study, we did not find an association between prior AD use and an increased rate of ICH. Importantly AD (mostly SSRIs) are commonly prescribed to patients with ICH in routine clinical practice. The association between types, duration, and safety of antidepressant use in ICH patients deserves further studies.

Abstract TMP63: Accuracy of Remote Video Cellphone Evaluation of Stroke Deficits Using California Brief Stroke Scale

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Latisha K Ali ◽  
Sidney Starkman ◽  
Gilda Avila ◽  
Neal M Rao ◽  
Rana Fiaz ◽  
...  
Keyword(s):  
Stroke Care ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Stroke Severity ◽  
Strongly Correlated ◽  
Mobile Video ◽  
Substantial Agreement ◽  
Stroke Patients ◽  
Item Scale ◽  
Score Evaluation

Background: Availability of 4G cellular network and video cellphone handsets may allow mobile videophone assessment to be employed in prehospital stroke care. The California Brief Stroke Scale (CABSS) is a 4 item scale designed as a mobile videophone test to evaluate a prehospital telemedicine instrument to rate stroke severity. Potential uses include identifying patients who are likely harboring persisting large vessel occlusions and to characterize baseline deficits prior to enrollment in prehospital trials. Methods: One bedside and one remote CABSS score were independently obtained on 15 ischemic stroke patients with persistent neurologic deficits. The bedside examination was performed by a stroke neurologist. The remote examination was performed by a second stroke neurologist through mobile video phone. A CABSS score of 1 or higher (scale 0-7) was an index of global stroke deficit severity. Kappa coefficients were calculated for concordance between bedside and remote scores. Results: The median National Institutes of Health Stroke Scale score was 6 (interquartile range IQR 4-10). On average the CABSS score evaluation took 25 seconds to perform. The median video CABSS was 2, (IQR1-3) and median bedside CABSS was 3, (IQR 1-3). Based on weighted K coefficients, cortical findings (aphasia, gaze deviation/hemineglect) displayed excellent agreement κ=1 (95% CI 1.0) and non-cortical findings (facial droop, arm drift) displayed substantial agreement κ =0.7 (95% CI 0.4-1.0). There was substantial agreement between bedside and remote methods for the total CABSS κ 0.68 (95% CI 0.44-0.92). The CABSS scores obtained by bedside and remote methods were strongly correlated (r= 0.85, P<0.0001). Conclusion: Our prospective study found that mobile videocell phone evaluation using CABSS is a feasible and reliable means of examining hyperacute stroke patients in the field. A physician can rapidly perform an audiovideo examination to increase the accuracy of prehospital identification of patients harboring persisting large vessel occlusions and characterize baseline deficits prior to enrollment in prehospital clinical trials to a clinically important degree.

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