We explored the safety of intravenous thrombolysis (IVT) or intra-arterial treatment (IAT) in patients with ischemic stroke on non-vitamin K antagonist oral anticoagulants (NOACs, last intake <48 ...hours) in comparison with patients (1) taking vitamin K antagonists (VKAs) or (2) without previous anticoagulation (no-OAC).
This is a multicenter cohort pilot study. Primary outcome measures were (1) occurrence of intracranial hemorrhage (ICH) in 3 categories: any ICH (ICHany), symptomatic ICH according to the criteria of the European Cooperative Acute Stroke Study II (ECASS-II) (sICHECASS-II) and the National Institute of Neurological Disorders and Stroke (NINDS) thrombolysis trial (sICHNINDS); and (2) death (at 3 months). Cohorts were compared by using propensity score matching. Our NOAC cohort comprised 78 patients treated with IVT/IAT and the comparison groups of 441 VKA patients and 8938 no-OAC patients. The median time from last NOAC intake to IVT/IAT was 13 hours (interquartile range, 8-22 hours). In VKA patients, median pre-IVT/IAT international normalized ratio was 1.3 (interquartile range, 1.1-1.6). ICHany was observed in 18.4% NOAC patients versus 26.8% in VKA patients and 17.4% in no-OAC patients. sICHECASS-II and sICHNINDS occurred in 2.6%/3.9% NOAC patients, in comparison with 6.5%/9.3% of VKA patients and 5.0%/7.2% of no-OAC patients, respectively. At 3 months, 23.0% of NOAC patients in comparison with 26.9% of VKA patients and 13.9% of no-OAC patients had died. Propensity score matching revealed no statistically significant differences.
IVT/IAT in selected patients with ischemic stroke under NOAC treatment has a safety profile similar to both IVT/IAT in patients on subtherapeutic VKA treatment or in those without previous anticoagulation. However, further prospective studies are needed, including the impact of specific coagulation tests.
Current guidelines advocate to treat refractory status epilepticus (RSE) with continuously administered anesthetics to induce an artificial coma if first- and second-line antiseizure drugs have ...failed to stop seizure activity. A common surrogate for monitoring the depth of the artificial coma is the appearance of a burst-suppression pattern (BS) in the EEG. This review summarizes the current knowledge on the origin and neurophysiology of the BS phenomenon as well as the evidence from the literature for the presumed benefit of BS as therapy in adult patients with RSE.
Background and Aims: Cerebral small vessel disease (SVD) is an important cause for both ischemic stroke (IS) and intracranial hemorrhage (ICH). To date, knowledge on the impact of SVD on the clinical ...course in stroke patients treated with oral anticoagulation (OAC) for atrial fibrillation (AF) is limited.Methods: Registry-based prospective study of 320 patients (aged 78.2u00b19.2years) treated with anticoagulation following AF-stroke. Patients underwent standardized magnetic-resonance-imaging assessing measures of SVD, including cerebral microbleeds (CMBs) and white matter lesions (WMLs). Median follow-up was 754 days. Using adjusted logistic and Cox regression we assessed the association of imaging measures with clinical outcome including recurrent IS, ICH and death and assessed disability.Results: Recurrent IS was more common than ICH (22 versus 8, respectively). CMBs were related to an increased risk of the composite endpoint (IS, ICH, death: OR 2.05, 95%CI 1.27-3.31; p=0.003), as were WMLs (OR 2.00, 95%CI 1.23-3.27, p=0.005). This was also true in time-to-event analysis (CMBs: HR 9.17, 95%CI 1.39-3.52; p<0.001; WMLs: HR 7.05, 95%CI 1.20-3.17; p=0.007). Both measures were associated with an increased risk for recurrent IS (CMBs: HR 4.4, 95%CI 1.07-18.2; p=0.04; WMLs: HR 5.27, 95%CI 1.08-25.79, p=0.04) and ICH (CMBs: HR 2.43, 95%CI 1.04-5.69 ; p=0.04; WMLs: HR 2.57, 95%CI 1.11-5.98, p=0.03). Furthermore, confluent WMLs were associated with increased disability (OR 4.03; 95%CI 2.16-7.52; p<0.001) and mortality (HR 1.81, 95%CI 1.04-3.14, p=0.04).Conclusions: In AF-stroke patients treated with oral anticoagulation, SVD is associated with an unfavorable outcome. The presence of microbleeds indicated a risk higher for recurrent ischemic stroke than for intracranial hemorrhage.
It is timely and necessary to consider what Postgraduate Medical Training Programme outcomes are, how they are defined and revised over time, and how they can be used to align health professional ...performance with the healthcare needs of society. This article which addresses those issues, with specific reference to training in anaesthesiology, was prepared using a modified nominal group (or expert panel) approach.
Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS.
We conducted ...a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity.
We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12–4.02; P<0.001 and the presence of an emergency department in the treating hospital (OR=4.18; 95% CI, 2.22–7.89; P<0.001). Patients undergoing cancer surgery (OR=0.32; 95% CI, 0.22–0.46; P<0.001), obstetric procedures (OR=0.17; 95% CI, 0.08–0.32; P<0.001), and expedited surgery (OR=0.39; 95% CI, 0.27–0.56; P<0.001) were less likely to be cancelled.
A significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations.
PDF
