2 Minute Medicine Rewind February 8, 2016

Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services

With recent advances in stroke prevention and treatment, failure to recognize the signs of acute ischemic stroke in the emergency department leads to missed opportunities in improving outcomes. The purpose of this retrospective chart review was to examine the accuracy of diagnosis of acute ischemic stroke in the emergency department of an academic teaching hospital and a large community hospital over a 1-year period. A total of 465 patients were identified (280 from an academic hospital and 185 from a community hospital). Of the total number of strokes, a total of 103 strokes were initially misdiagnosed (i.e. 22% of strokes). Comparing the two sites, 22% were misdiagnosed at the academic hospital and 26% at the community hospital (p = 0.11). Of the misdiagnosed strokes, 33% would have been eligible for tPA given their presentation within the 3-hour time window. In addition, a potential 11% presented between 3-6 hours and would have been potential candidates for intervention with thrombectomy. Symptoms associated with greater odds of missed stroke diagnosis were: nausea/vomiting (odds ratio, 4.02; 95% confidence interval (CI), 1.60–10.1), dizziness (odds ratio, 1.99; 95% CI, 1.03–3.84), and a positive stroke history (odds ratio, 2.40; 95% CI, 1.30–4.42). Posterior strokes were more likely to be misdiagnosed initially compared to anterior strokes (37% vs 16%; p < 0.001). This study is a first step in helping both neurologists and emergency physicians recognize acute ischemic stroke symptoms that are more likely to lead to missed diagnoses, and future studies should look at different tools in the emergency department to help improve accuracy.

Efficacy, Acceptability, and Tolerability of Antipsychotics in Treatment-Resistant Schizophrenia A Network Meta-analysis

Clozapine is considered the standard approach to patients with treatment-resistant schizophrenia, however its use is often limited due to its wide side-effect profile. Recently, randomized clinical trials (RCTs) have been published analyzing the use of other antipsychotics for this specific patient population. The purpose of this meta-analysis was to integrate all the randomized evidence from the available antipsychotics used for treatment-resistant schizophrenia. The primary outcome was efficacy, which was measured by overall change in schizophrenia symptoms. Secondary outcomes included change in positive and negative symptoms of schizophrenia, categorical response to treatment, dropouts for any reason and for inefficacy of treatment, and important adverse events. The authors found 40 blinded RCTs with a total of 5172 patients which was included in the analysis. In the primary outcome olanzapine was more effective than quetiapine, haloperidol, and sertindole; clozapine was more effective than haloperidol and sertindole; risperidone was more effective than sertindole. A pattern of superiority for olanzapine, clozapine, and risperidone was seen in other efficacy outcomes as well, however there were inconsistent results and small effect sizes. The results of this study demonstrate that there is insufficient current evidence on the superiority of clozapine compared to other atypical antipsychotics for treatment-resistant schizophrenia.

Induction of labour at term with oral misoprostol versus a Foley catheter (PROBAAT-II): a multicentre randomised controlled non-inferiority trial

Compared to dinoprostone, both oral misoprostol and a Foley catheter are equally effective with less side-effects for induction of labour in women with an unfavorable cervix. The purpose of this randomized controlled trial was to directly compare oral misoprostol with a Foley catheter for induction of labour. The authors completed an open-label randomized non-inferiority trial in a total of 29 hospitals in the Netherlands over a 1-year period. The women were randomly assigned to either 50 μg oral misoprostol every four hours, or to a 30 mL transcervical Foley catheter. The inclusion criteria were women with a term singleton pregnancy, fetus in the cephalic presentation, an unfavorable cervix, intact membranes, and no previous caesarean section. The primary outcome were markers of asphyxia (pH ≤7.05 or 5-min Apgar score <7) or post-partum hemorrhage (defined as ≥1000 mL). The authors found no difference in the primary outcome between both groups. In the misoprostol group the primary outcome occurred in 113 of 924 participants (12.2%) compared to 106 of 921 participants (11.5%) in the Foley catheter group (adjusted relative risk 1.06, 90% CI 0.86–1.31). There was also no difference in the occurrence of caesarean section which occurred in 155 (16.8%) women in the misoprostol group compared to 185 (20.1%) in the Foley catheter group (relative risk 0.84, 95% CI 0.69–1.02, p=0.067). In terms of adverse events, there was no difference between the two groups. Overall the authors found that induction of labour with oral misoprostol or a Foley catheter had similar outcomes and safety profile.

Community health worker-based intervention for adherence to drugs and lifestyle change after acute coronary syndrome: a multicentre, open, randomised controlled trial

In patients with an acute coronary syndrome (ACS), adherence to medication and healthy lifestyles is often low. The purpose of this multicenter, open, randomized controlled trial was to assess whether trained community health workers could improve adherence to drugs, lifestyle changes, and clinical risk markers in patients who suffered an ACS. A total of 750 patients were randomly assigned to either to a community health worker-based intervention group, which consisted of four in-hospital and two home visits by community health workers educating patients on on healthy lifestyle and drugs, and measures to enhance adherence, or they were assigned to a standard care group with no community education. The primary outcome was adherence to medications for secondary prevention at 1 year. The secondary outcomes measured were lifestyle factors, which consisted of diet, exercise, tobacco and alcohol use, and clinical risk markers, which consisted of blood pressure, bodyweight, BMI, heart rate, and lipids. The authors found that adherence to prescribed secondary prevention drugs at one year was higher in the intervention group (97% vs 92%, odds ratio [OR] 2.62, 95% CI 1.32–5.19; p=0.006). The intervention group also had significantly greater adherence to smoking cessation (85% vs 52%, OR 5.46, 95% CI 3.03–9.86; p<0.0001), regular physical activity (89% vs 60%, OR 5.23, 95% CI 3.57–7.66; p<0.0001), and healthy diet (OR 2.47, 95% CI 1.88–3.25; p<0.0001). With respect to alcohol consumption, more patients in the intervention group stopped alcohol use at 1 year (87% vs 46%, OR 2.92, 95% CI 1.26–6.79; p =0.010). Clinical risk markers were also significantly lower in the intervention group compared to the control group, except for diastolic blood pressure and heart rate. Overall the results of this study provide evidence that community health worker-based interventions result in improved overall health of patients who suffered an ACS.

Incontinence and gait disturbance after intraventricular extension of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) with extension into the ventricles is a poorer prognostic sign. The authors hypothesized that in survivors of ICH, intraventricular hemorrhage (IVH) is associated with incontinence and gait disturbance. 307 ICH patients were analyzed from both The Genetic and Environmental Risk Factors for Hemorrhagic Stroke study and The Ethnic/Racial Variations of Intracerebral Hemorrhage study, both of which were prospective studies with 3-month follow-up. The authors found in The Genetic and Environmental Risk Factors for Hemorrhagic Stroke study that increasing IVH volume was associated with incontinence (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.10–2.06) and dysmobility (OR 1.58; 95% CI 1.17–2.15). The authors controlled for variables such as ICH location, initial ICH volume, age, baseline modified Rankin Scale score, sex, and admission Glasgow Coma Scale score. In The Ethnic/Racial Variations of Intracerebral Hemorrhage study, after controlling for the same variables, the authors also found that increasing IVH volume was associated with both incontinence (OR 1.42; 95% CI 1.27–1.60) and dysmobility (OR 1.40; 95% CI 1.24–1.57). This retrospective study provides evidence that IVH extension is a risk factor for long-term disability increasing the probability of developing incontinence and gait disturbance. These patients should be targeted early to prevent both the long-term clinical and economic impact of this disability.

Image: CC/Blausen

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