1
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Cheng Y, Zachariah J. Clinical Reasoning: A 54-Year-Old Woman With Progressive Headache and Neurologic Decline. Neurology 2024; 102:e209190. [PMID: 38330283 DOI: 10.1212/wnl.0000000000209190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/05/2024] [Indexed: 02/10/2024] Open
Abstract
A 54-year-old woman presented with headache and vasculopathy. She was treated for reversible cerebral vasoconstriction syndrome but continued to have clinicoradiographic decline with headache, seizures, systemic symptoms, and progression of vasculopathy on imaging. We present the diagnosis of a rare genetic disease with its various neurologic complications and systemic manifestations. Our case also illustrates the importance of differences in the metabolism of various antiseizure medications, recognition of which may avoid precipitating the disease.
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Affiliation(s)
- Yao Cheng
- From Corewell Health, Grand Rapids, MI
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2
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Cencer S, Tubergen T, Packard L, Gritters D, LaCroix H, Frye A, Wills N, Zachariah J, Wees N, Khan N, Min J, Dejesus M, Combs J, Khan M. Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis Is Safe and Reduces Length of Stay for Minor Stroke Patients. Neurohospitalist 2022; 12:504-507. [DOI: 10.1177/19418744211048014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The current standard of practice for patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator (tPA) requires critical monitoring for 24-hours post-treatment due to the risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of this standard 24-hour ICU monitoring period compared with a shorter 12-hour ICU monitoring period for minor stroke patients (NIHSS 0-5) treated with tPA only. Stroke mimics and those who underwent thrombectomy were excluded. The primary outcome was length of hospital stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and favorable functional outcome defined as modified Rankin scale (mRS) of 0-2 at 90 days. Of the 122 patients identified, 77 were in the 24-hour protocol and 45 were in 12-hour protocol. There was significant difference in length of hospital stay for the 24-hour ICU protocol (2.8 days) compared with the 12-hour ICU protocol (1.8 days) ( P < 0.001). Although not statistically significant, the 12-hour group had favorable rates of sICH, 30-day readmission rates, favorable discharge disposition and favorable functional outcome. Rates of DVT, PE and aspiration pneumonia were identical between the groups. Compared with 24-hour ICU monitoring, 12-hour ICU monitoring after thrombolysis for minor acute ischemic stroke was not associated with any increase in adverse outcomes. A randomized trial is needed to verify these findings.
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Affiliation(s)
- Samantha Cencer
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Tricia Tubergen
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Laurel Packard
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | | | - Hattie LaCroix
- Office of Research, Spectrum Health, Grand Rapids, MI, USA
| | - Angela Frye
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Nicole Wills
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Joseph Zachariah
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nabil Wees
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nadeem Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jiangyong Min
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Michelle Dejesus
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jordan Combs
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Muhib Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
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3
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Bhan C, Koehler TJ, Elisevich L, Singer J, Mazaris P, James E, Zachariah J, Combs J, Dejesus M, Tubergen T, Packard L, Min J, Wees N, Khan N, Mulderink T, Khan M. Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes. J Neuroimaging 2020; 30:315-320. [DOI: 10.1111/jon.12698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Chantal Bhan
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | | | | | - Justin Singer
- Michgan State University East Lansing MI
- Division of Neurosurgery, Neuroscience InstituteSpectrum Health Grand Rapids MI
| | - Paul Mazaris
- Michgan State University East Lansing MI
- University of Michigan Ann Arbor MI
| | - Elysia James
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Joseph Zachariah
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Jordan Combs
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Michelle Dejesus
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | | | - Laurel Packard
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
| | - Jiangyong Min
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Nabil Wees
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Nadeem Khan
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Todd Mulderink
- Department of RadiologySpectrum Health Grand Rapids MI
- Division of RadiologyMichigan State University Grand Rapids MI
- Advanced Radiology ServicesPC Grand Rapids MI
| | - Muhib Khan
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
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4
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Tubergen T, Packard L, Gritters D, LaCroix H, Goosen A, Wills N, Zachariah J, James E, Singer J, Wees N, Khan N, Min J, Khan M. Abstract WP448: Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis is Safe and Reduces Length of Stay for Minor Stroke Patients. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Acute Stroke Patients treated with intravenous tissue-type plasminogen activator (tPA) require intensive care unit (ICU) monitoring for 24 hours post-treatment due to risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of shorter ICU monitoring for minor stroke patients treated with tPA.
Methods:
Consecutive patients age >18 years with a diagnosis of ischemic stroke that received tPA only and who had an initial National Institute of Health Stroke Scale (NIHSS) 0-5 between 1/1/2017 and 3/30/2019 were included. Stroke mimics and those who underwent thrombectomy were excluded. Standard practice 24 hour ICU stay prior to 05/15/2018 was compared with 12 hour ICU stay after that date. The primary outcome was length of stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and modified rankin scale (mRS) at 90 days.
Results:
Of the 122 patients identified, 77 patients were in the 24-hour protocol and 45 were in 12-hour ICU stay protocol groups. There was significant difference in length of stay for the 24-hour ICU stay protocol (2.8 days) compared with the 12-hour ICU stay protocol (1.8 days) (
P
<.001). Compared with the 24-hour ICU stay, the rates of sICH (
p
= .65), DVT (
p
= NS), PE (
p
= NS), pneumonia (
p
= 1.00), favorable discharge disposition (
p
= .26), 30 day readmission (
p
=0.06) and 90 day mRS 0-2 (
p
= .37) were not different between the groups.
Conclusion:
Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with without any adverse outcomes. A randomized trial is needed to verify these findings.
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5
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Packard L, Tubergen T, LaCroix H, Gritters D, Ames N, Packard D, Wills N, Zachariah J, James E, Goosen A, Frye A, Wees N, Khan N, Min J, Singer J, Khan M. Abstract WP447: Early Mobilization After 12 Hours Post-Thrombolysis is Safe and Reduces Length of Stay in Minor Stroke Patients. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Bed rest of 24 hours post-thrombolysis is recommended for acute ischemic stroke patients. We sought to compare outcomes and in-hospital complications of 12- and 24-hour bed rest protocols following thrombolysis in minor stroke patients.
Methods:
Consecutive patients age >18 years with a diagnosis of ischemic stroke that received tPA only and who had an initial National Institute of Health Stroke Scale (NIHSS) 0-5 between 1/1/2017 and 3/30/2019 were included. Stroke mimics and patients who underwent mechanical thrombectomy were excluded. The standard practice bed rest order for the 24 hour protocol prior to 07/15/2017 was compared with the 12 hour bed rest order protocol after that date. The primary outcome was length of stay. Secondary outcome measures included symptomatic intracerebral hemorrhage (sICH), deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days and modified rankin scale (mRS) at 90 days.
Results:
Of the 106 patients identified, 36 patients were in the 24-hour protocol and 70 were in the 12-hour bed rest protocol group. There was significant difference for length of stay in the 24-hour bed rest protocol (2.9 days) compared with the 12-hour bed rest protocol (2.0 days) (p=0.032). Compared with the 24-hour bed rest group, the rates of sICH (p=NS), DVT (p=NS), PE (p=NS), pneumonia (p=NS), favorable discharge disposition (p=NS), 30 day readmission (p=0.NS) and 90 day mRS 0-2 (p=NS) were not different between the groups. Time to mobilization was significantly different between the two groups (24 hour group:2043.2 ± 680.1 minutes; 12 hour group:1221.0 ± 527.8) (p<0.0001).
Conclusion:
Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with significantly earlier patient mobilization and reduced length of stay without any adverse outcomes. A randomized trial is needed to verify these findings.
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6
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Martin H, Packard L, Gritters D, LaCroix H, Tubergen T, Zachariah J, James E, Combs J, Brazitis M, Zleik B, Wees N, Khan N, Min J, Singer J, Mazaris P, Khan M. Abstract WP459: Advanced Practice Providers versus Neurology Residents: Similar Stroke Code Quality Metrics and Functional Outcomes. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Advanced Practice Providers (APPs) are important members of stroke code teams. However, the impact of APP involvement on quality metrics and functional outcomes is unclear. We sought to evaluate if APPs perform similarly to neurology residents for stroke code quality metrics and functional outcome at 90 days.
Methods:
We retrospectively analyzed data of consecutive patients who underwent thrombectomy in a single center cohort. Demographics, National Institute of Health Stroke Scale (NIHSS), last known normal (LKN) to emergency department (ED) presentation time, ED door to skin puncture time, recanalization (mTICI IIb/III) rates, and modified rankin scale (mRS) at 90 days were compared between neurology residents and APPs. A multiple logistic regression was used to determine factors independently associated with a favorable mRS at 90 days.
Results:
A total of 172 patients were included in the study of which 80 (47%) were managed by neurology residents. Both groups (residents vs. APPs) were balanced for age (
p
=0.87), NIHSS (
p
=0.18), LKN to ED Door time (
p
=0.19), ED door to skin puncture time (
p
=0.08), recanalization rate (
p
=0.28), and favorable outcome (mRS 0-2) (
p
=0.27). The multiple logistic regression model found patients with recanalization were 8.9 times more likely to have a favorable outcome. Age and initial NIHSS were found to be negative predictors of mRS (Table 1). Resident or APP involvement in the stroke code process did not impact outcome (
p
=0.08).
Conclusion:
APPs achieve similar acute stroke code metrics and functional outcomes when compared to neurology residents. Further studies are needed to confirm our findings.
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Packard L, LaCroix H, Tubergen T, Huffman C, Raad B, Zachariah J, Combs J, Dejesus M, Sriram A, Singer J, Scureck R, Abdelhak T, Khan M. Abstract WP501: Stroke Code Quality Metrics and Functional outcomes: Advanced Practice Providers versus Neurology Residents. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Advanced Practice Providers (APPs) are important members of stroke code teams. However, the impact of APP involvement on quality metrics and functional outcomes is unclear. We sought to evaluate if APPs perform similarly to neurology residents for stroke code quality metrics and functional outcome at 90 days.
Methods:
We retrospectively analyzed data of consecutive patients who received thrombolysis (rtPA) and/or underwent thrombectomy in a single center cohort. Demographics, National Institute of Health Stroke Scale (NIHSS), Last known normal (LKN) to emergency department (ED) presentation time, ED door to rtPA time, ED door to skin puncture time, recanalization (mTICI IIb/III) rates and modified rankin scale (mRS) at 90 days were compared between neurology residents and advanced practice providers. Multiple logistic regression was used to determine factors independently associated with a favorable modified rankin scale (mRS) at 90 days.
Results:
A total of 96 patients were included in the study of which 44 (46%) were managed by neurology residents. Both groups (Residents vs. APPs) were balanced for age (p=0.17), NIHSS (p=0.73), LKN to ED Door time (p=0.17), ED door to tPA time (p=0.28), ED door to skin puncture time (p=0.22) and recanalization rate (p=0.93). Using multiple logistic regression, patients who were managed by neurology residents were 4.1 times more likely to have a favorable outcome (mRS 0-2) at 90 days. (Table)
Conclusion:
Advanced practice providers (APPs) achieve similar acute stroke code metrics as compared to neurology residents. However, functional outcomes are better in patients managed by neurology residents. Further studies are needed to confirm our findings.
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Bhan C, Khan M, Elisevich L, Koehler T, Singer J, Mazaris P, Deveshwar R, Raad B, Zachariah J, Combs J, Dejesus M, Scureck R, Tubergen T, Packard L, Min J, Mulderink T, Abdelhak T. Abstract WP2: Tissue Based Selection for Large Vessel Occlusion Thrombectomy Leads to Similar Functional Outcomes in Conventional (0-6 Hours) and Extended (>6 Hours) Window. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Recent trials have shown benefit of thrombectomy in carefully selected patients in the extended (>6 hours) window. However, it is not clear if the outcomes differ from those undergoing thrombectomy in the conventional (0-6 hours) window. We sought to evaluate if time to treatment modifies the effect of endovascular reperfusion in stroke patients with evidence of salvageable tissue on CT perfusion (CTP).
Methods:
We retrospectively analyzed data of consecutive patients who underwent thrombectomy in a single center cohort. Demographics, comorbidities, National Institute of Health Stroke Scale (NIHSS), vessel occlusion location, onset to skin puncture time, core infarct volume on initial CTP, recanalization (mTICI IIb/III) rates, final infarct volume and modified rankin scale (mRS) at 90 days were compared between patients who underwent thrombectomy in conventional (0-6 hours) and extended (>6 hour) window.
Results:
119 patients were studied of which 55% were female. Univariate analysis showed that the groups (Conventional vs. Extended) were balanced for age (p=0.37), NIHSS (p=0.35), vessel occlusion location (p=0.51), initial core infarct volume (p=0.64) and recanalization (mTICI IIb/III) rates (p=0.55). Final infarct volume (p=0.18) and favorable outcome (mRS 0-2) at 90 days (p=0.65) were similar. Shift analysis did not reveal any significant difference in 90 day outcome (p=0.34). (Figure) After adjustment; age (p=0.004) and final infarct volume (p<0.001) were predictive of favorable outcome.
Conclusion:
Tissue based selection with CTP for thrombectomy in large vessel occlusion stroke is independent of onset time for favorable functional outcome.
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9
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Tubergen T, LaCroix H, Packard L, Huffman C, Garcia A, Ames N, Newell D, Packard D, Raad B, Zachariah J, James E, Goosen A, Frye A, Abdelhak T, Silver B, Khan M. Abstract WP485: Early Mobilization After 12 Hours Post Thrombolysis is Feasible and Safe in Minor Stroke Patients. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Current guidelines recommend 24 hours of hospital bed rest after thrombolysis for acute ischemic stroke. We sought to compare outcomes and in-hospital complications of 12- and 24-hour bed rest protocols following thrombolysis in minor stroke patients.
Methods:
Consecutive patients age >18 years with a diagnosis of ischemic stroke with initial National Institute of Health Stroke Scale (NIHSS) 0-6 who received intravenous thrombolysis only from 1/1/2017 until 4/30/2018 were included. Standard practice bed rest order for 24 hour protocol prior to 07/15/2017 was compared with 12 hour bed rest order protocol after that date. Primary outcome was length of stay. Secondary outcome measures included symptomatic intracerebral hemorrhage (sICH), deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days and modified rankin scale (mRS) at 90 days.
Results:
77 patients were identified, 36 patients in the 24-hour protocol and 41 in 12-hour bed rest protocol groups. There was no significant difference for length of stay in the 24-hour bed rest protocol (2.8 days) compared with the 12-hour bed rest protocol (2.3 days) (p=0.37) (Table). Compared with the 24-hour bed rest group, the rates of sICH (p=1.00), DVT (p=NS), PE (p=NS), pneumonia (p=1.00), favorable discharge disposition (p=0.69), 30 day readmission (p=0.80) and 90 day mRS 0-2 (p=0.36) were also not different between the groups (Table). Time to mobilization was significantly different between the two groups (p<0.001) (Table).
Conclusion:
Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with significantly earlier patient mobilization without any adverse outcomes. A randomized trial is needed to verify these findings.
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10
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Khan M, Baird GL, Price T, Tubergen T, Kaskar O, De Jesus M, Zachariah J, Oostema A, Scurek R, Coleman RR, Sherman W, Hingtgen C, Abdelhak T, Smith B, Silver B. Stroke code simulation benefits advanced practice providers similar to neurology residents. Neurol Clin Pract 2018; 8:116-119. [PMID: 29708218 DOI: 10.1212/cpj.0000000000000435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/23/2018] [Indexed: 11/15/2022]
Abstract
Background Advanced practice providers (APPs) are important members of stroke teams. Stroke code simulations offer valuable experience in the evaluation and treatment of stroke patients without compromising patient care. We hypothesized that simulation training would increase APP confidence, comfort level, and preparedness in leading a stroke code similar to neurology residents. Methods This is a prospective quasi-experimental, pretest/posttest study. Nine APPs and 9 neurology residents participated in 3 standardized simulated cases to determine need for IV thrombolysis, thrombectomy, and blood pressure management for intracerebral hemorrhage. Emergency medicine physicians and neurologists were preceptors. APPs and residents completed a survey before and after the simulation. Generalized mixed modeling assuming a binomial distribution was used to evaluate change. Results On a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree), confidence in leading a stroke code increased from 2.4 to 4.2 (p < 0.05) among APPs. APPs reported improved comfort level in rapidly assessing a stroke patient for thrombolytics (3.1-4.2; p < 0.05), making the decision to give thrombolytics (2.8 vs 4.2; p < 0.05), and assessing a patient for embolectomy (2.4-4.0; p < 0.05). There was no difference in the improvement observed in all the survey questions as compared to neurology residents. Conclusion Simulation training is a beneficial part of medical education for APPs and should be considered in addition to traditional didactics and clinical training. Further research is needed to determine whether simulation education of APPs results in improved treatment times and outcomes of acute stroke patients.
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Affiliation(s)
- Muhib Khan
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Grayson L Baird
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Theresa Price
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Tricia Tubergen
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Omran Kaskar
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Michelle De Jesus
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Joseph Zachariah
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Adam Oostema
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Raymond Scurek
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Robert R Coleman
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Wendy Sherman
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Cynthia Hingtgen
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Tamer Abdelhak
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Brien Smith
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
| | - Brian Silver
- Division of Neurology, Neuroscience Institute (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Department of Accreditation and Regulations (TP), and Nursing Administration (TT), Spectrum Health, Grand Rapids; Department of Emergency Medicine (AO) and Department of Clinical Neuroscience, College of Human Medicine (MK, OK, MDJ, JZ, RRC, WS, CH, TA, B Smith), Michigan State University, East Lansing; Lifespan Biostatistics Core (GLB), Rhode Island Hospital; Department of Diagnostic Imaging (GLB), Warren Alpert School of Medicine, Brown University, Providence, RI; Emergency Care Specialists (RS), Grand Rapids, MI; and Department of Neurology (B Silver), University of Massachusetts Medical School, Worcester
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11
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Khan M, Baird G, Price T, Tubergen T, Kaskar O, De Jesus M, Oostema A, Scurek R, Zachariah J, Coleman R, Sherman W, Abdelhak T, Smith B. Abstract TP224: Stroke Code Simulation Training Benefits Advanced Practice Providers Similar to Neurology Residents. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Neurology led Stroke Teams are becoming imperative in recent care models of acute stroke management. Advanced Practice Providers (APP) are important members of these stroke teams. Code Stroke simulations allow (APP) to gain valuable experience in the evaluation and treatment of a potential stroke patient without compromising patient care. We hypothesized that simulation training would increase advanced practice provider confidence, comfort level and preparedness in leading a Code Stroke similar to neurology residents.
Methods:
Nine advanced practice providers and nine neurology residents each took turns leading a Code Stroke simulation to determine need for intravenous thrombolysis, thrombectomy and blood pressure management on three cases with standardized patients. Emergency medicine physicians and neurologists were preceptors and gave feedback. APPs and residents completed a survey before and after the simulation. Generalized mixed modeling assuming a binomial distribution was used to evaluate change.
Results:
On a 5-point Likert scale (1 - Strongly disagree and 5 - Strongly agree), confidence in leading a Code Stroke significantly increased from (2.8 to 4.5, p<0.01) comfort level in rapidly assessing a stroke patient for thrombolytics increased (3.0 vs. 4.3 p<0.001), making the decision to give thrombolytics increased (2.7 vs. 4.3, p<0.01) and assessing a patient for embolectomy increased (2.6 vs. 4.3, p<0.01); these results held for both APP and residents.
Conclusion:
Simulation training is a beneficial part of medical education for advanced practice providers and should be considered in addition to traditional didactics and clinical training.
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Affiliation(s)
- Muhib Khan
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI
| | - Grayson Baird
- Lifespan Biostatistics Core, Lifespan Hosp System, Providence, RI
| | - Theresa Price
- Neuroscience Institute, Spectrum Health, Grand Rapid, MI
| | | | - Omran Kaskar
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI
| | | | - Adam Oostema
- Emergency Medicine, Michigan State Univ, Grand Rapids, MI
| | | | | | - Robert Coleman
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI
| | - Wendy Sherman
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI
| | - Tamer Abdelhak
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI
| | - Brien Smith
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI
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Abstract
Electroencephalogram (EEG) reactivity has been increasingly utilized in prognostication after cardiac arrest. Recent studies have demonstrated a false-positive rate of 0% in predicting poor outcome with a nonreactive EEG. The reemergence of reactivity after an initial nonreactive EEG has been noted in cases of drug intoxication, rewarming after hypothermia, and after discontinuing sedation. This is the first case describing the reemergence of EEG reactivity without the confounding factors listed above. We describe a case of resuscitated cardiac arrest with initial EEG demonstrating a lack of reactivity. A repeat EEG completed 3 days later revealed a reemergence of reactivity in the setting of normothermia, a negative drug screen, and the absence of sedation. The delayed recovery of EEG reactivity without previously established confounding factors is novel. Serial EEGs may be beneficial as the available literature on reactivity and prognostication is based on an average of 24 to 48 hours of EEG tracing. Prognostication after cardiac arrest continues to require a multimodal approach.
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13
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Affiliation(s)
- Joseph Zachariah
- Department of Neurology, St Marys Hospital, Mayo Clinic, Rochester, MN, USA
| | - Sunil Manjila
- Department of Neurological Surgery, The Neurological Institute, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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14
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Zachariah J, Nijhawan P, Manjila S. Ominous Etiology of Blurry Vision. Neurohospitalist 2017; 7:53-54. [PMID: 28042373 DOI: 10.1177/1941874416648196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Joseph Zachariah
- Department of Neurology, St Marys Hospital, Mayo Clinic, Rochester, MN, USA
| | - Parul Nijhawan
- Department of Neurosurgery, Case Medical Center, Cleveland, OH, USA
| | - Sunil Manjila
- Department of Neurosurgery, Case Medical Center, Cleveland, OH, USA
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15
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Zachariah J, Britton J, Hocker S. Super Refractory Status Epilepticus. Continuous EEG Monitoring 2017. [PMCID: PMC7123027 DOI: 10.1007/978-3-319-31230-9_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Earlier definitions of status epilepticus (SE) were based on the duration of seizures, but newer definitions rely more on a pragmatic staging based on treatment failures (Table 23.1). Refractory status epilepticus (RSE) is defined as SE that continues despite administration of both benzodiazepines and an appropriately dosed second-line antiseizure drug. Depending on the semiology of the seizures and comorbidities of the patient, this stage may be treated with further antiseizure drugs or anesthesia. When seizures recur upon weaning the anesthetic agent, typically after 24 h of seizure suppression, or in the rare cases where seizure control cannot be achieved with anesthesia, status epilepticus is considered to be super refractory (SRSE). The incidence of status epilepticus has been increasing, from 3.5 to 12.5/100,000 population between 1979 and 2010. During this time hospital mortality has not changed [1].
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16
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Zachariah J, Aliku T, Scheel A, Hasan B, Lwabi P, Sable C, Beaton A. PS287 Aminoterminal Pro-Brain Natriuretic Peptide in Children with Latent Rheumatic Heart Disease. Glob Heart 2016. [DOI: 10.1016/j.gheart.2016.03.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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17
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Zachariah J, Stanich JA, Braksick SA, Wijdicks EF, Campbell RL, Bell MR, White R. Indicators of Subarachnoid Hemorrhage as a Cause of Sudden Cardiac Arrest. Clin Pract Cases Emerg Med 2016; 1:132-135. [PMID: 29849421 PMCID: PMC5973610 DOI: 10.5811/cpcem.2017.1.33061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/27/2016] [Accepted: 01/11/2017] [Indexed: 11/14/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) may present with cardiac arrest (SAH-CA). We report a case of SAH-CA to assist providers in distinguishing SAH as an etiology of cardiac arrest despite electrocardiogram findings that may be suggestive of a cardiac etiology. SAH-CA is associated with high rates of return of spontaneous circulation, but overall poor outcome. An initially non-shockable cardiac rhythm and the absence of brain stem reflexes are important clues in indentifying SAH-CA.
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Affiliation(s)
| | | | | | | | - Ronna L Campbell
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - Malcolm R Bell
- Mayo Clinic, Department of Internal Medicine, Division of Cardiovascular Diseases, Rochester, Minnesota
| | - Roger White
- Mayo Clinic, Departments of Anesthesiology and Internal Medicine, Division of Cardiovascular Diseases, Rochester, Minnesota
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18
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Zachariah J, Snyder KA, Graffeo CS, Khanal DR, Lanzino G, Wijdicks EFM, Rabinstein AA. Risk of Ventriculostomy-Associated Hemorrhage in Patients with Aneurysmal Subarachnoid Hemorrhage Treated with Anticoagulant Thromboprophylaxis. Neurocrit Care 2016; 25:224-9. [DOI: 10.1007/s12028-016-0262-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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19
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Norby E, Zachariah J, Wijdicks EFM. Laying on the cause of stroke? Pract Neurol 2016; 16:157-9. [PMID: 26786008 DOI: 10.1136/practneurol-2015-001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Erin Norby
- Division of Critical Care Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph Zachariah
- Division of Critical Care Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eelco F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic, Rochester, Minnesota, USA
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20
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Langvad E, Zachariah J, Pindborg JJ. Lactate dehydrogenase isoenzyme patterns in leukoplakia, submucous fibrosis and carcinoma of the oral mucosa in south Indians. Acta Pathol Microbiol Scand A 2009; 78:509-15. [PMID: 5476642 DOI: 10.1111/j.1699-0463.1970.tb02533.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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21
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Kyle C, Zachariah J, Kinch H, Ellis G, Andrews C, Adekunle F. A randomised, double-blind study comparing lumiracoxib with naproxen for acute musculoskeletal pain. Int J Clin Pract 2008; 62:1684-92. [PMID: 19143855 DOI: 10.1111/j.1742-1241.2008.01906.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Some selective cyclooxygenase-2 (COX-2) inhibitors have been shown to provide analgesic efficacy in patients with acute pain. AIM To compare the efficacy and safety of the COX-2 inhibitor lumiracoxib 400 mg once daily (qd) and naproxen 500 mg twice daily (bid) in patients with acute musculoskeletal pain caused by uncomplicated soft tissue injury. METHODS This was a randomised, double-blind, parallel-group, non-inferiority study set in 39 primary care centres in the UK. Patients were randomised to lumiracoxib 400 mg qd or naproxen 500 mg bid and took the study medication for as long as they felt that it was needed, up to day 7. The primary efficacy analysis was the sum of the pain intensity difference (0-100 mm visual analogue scale) determined morning and evening over the first 5 days of treatment (SPID-5). RESULTS The intention-to-treat population comprised 406 patients [lumiracoxib 400 mg qd (n = 207); naproxen 500 mg bid (n = 199)]. Both treatments were effective in reducing pain intensity over 5 days. The mean SPID-5 scores were 117.0 mm.day for lumiracoxib and 118.2 mm.day for naproxen [the treatment difference based on adjusted means from the ANCOVA was -2.78 mm.day, 95% confidence interval (CI) -17.4, 11.9]. The lower margin of the 95% CI was above the predetermined non-inferiority margin (-50 mm.day) for SPID-5, indicating non-inferiority of lumiracoxib compared with naproxen. Both treatments were well tolerated. CONCLUSION Lumiracoxib 400 mg qd is as effective as naproxen 500 mg bid for the management of moderate-to-severe acute musculoskeletal pain.
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Affiliation(s)
- C Kyle
- Glengormley Practice, Belfast, Northern Ireland, UK
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22
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Allin D, James I, Zachariah J, Carr W, Cullen S, Middleton A, Newson P, Lytle T, Coles S. Comparison of once- and twice-daily clarithromycin in the treatment of adults with severe acute lower respiratory tract infections. Clin Ther 2001; 23:1958-68. [PMID: 11813931 DOI: 10.1016/s0149-2918(01)80149-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although the modified-release (MR) formulation of clarithromycin has demonstrated bioequivalence to the immediate-release (IR) formulation and thus can be prescribed for lower respiratory tract infections (LRTIs), a MEDLINE search from 1995 through 1998 and information on file with the manufacturer indicate that no data are available on the effectiveness of this new formulation in the treatment of severe LRTIs such as community-acquired pneumonia. OBJECTIVE This study was designed to compare clinical success rates (percentage of patients with clinical cure or improvement) with once- and twice-daily regimens of clarithromycin in the treatment of patients with severe, acute LRTIs requiring oral antibiotic therapy. METHODS In this multicenter, investigator-blinded, randomized, parallel-group study, adult patients with clinical evidence suggesting severe, acute LRTI were recruited from 22 general practices in the United Kingdom. Patients were randomly allocated to receive either clarithromycin 500 mg BID (IR tablets) or clarithromycin 1 g OD (two 500-mg MR tablets) for 7 to 14 days. The outcome measures were resolution of or improvement in clinical signs and symptoms (including resolution of cough), unscheduled visits for the same symptom, days to resumption of normal activities, and improvements in quality of life (assessed using the EQ-5D version of the EuroQoL questionnaire). Clinical, microbiologic, and serologic assessments were performed before, during, and after treatment. Efficacy and safety data were analyzed on an intent-to-treat basis. RESULTS One hundred sixty men (n = 83) and women (n = 77) between the ages of 19 and 88 years took part in the study, 78 receiving clarithromycin 500 mg BID and 82 receiving clarithromycin 1 g OD. At 4 weeks after the start of treatment, the high clinical success rates were comparable between groups: 84.6% with clarithromycin 500 mg BID and 90.2% with clarithromycin 1 g OD. No significant differences in outcome measures were noted between the 2 regimens. Both treatments were well tolerated, with taste disturbance being the most commonly reported adverse event (10.6% vs 6.1% with clarithromycin 500 mg BID and 1 g OD, respectively). CONCLUSIONS The 2 clarithromycin regimens were equally efficacious and well tolerated in the treatment of severe, acute LRTIs. However, caution should be exercised in applying these results to the general population, because the study excluded certain categories of patients who would normally be treated. In addition, the small sample size may have obscured clinically significant differences between the 2 regimens.
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Affiliation(s)
- D Allin
- Gresford Medical Centre, Liverpool, United Kingdom
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23
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Sarin YK, Jacob S, Zachariah J. Congenital lobar emphysema. Indian Pediatr 1998; 35:917. [PMID: 10216606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- Y K Sarin
- Department of Surgery, Christian Medical College, Ludhiana, India
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24
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Zachariah J. A randomized, comparative study to evaluate the efficacy and tolerability of a 3-day course of azithromycin versus a 10-day course of co-amoxiclav as treatment of adult patients with lower respiratory tract infections. J Antimicrob Chemother 1996; 37 Suppl C:103-13. [PMID: 8818851 DOI: 10.1093/jac/37.suppl_c.103] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Clinical and bacteriological efficacy and tolerability of azithromycin (500 mg once daily for 3 days) and those of a 10-day regimen of co-amoxiclav (37 mg three times daily) were evaluated in a large-scale, double-blind comparative study of 369 patients (> or = 18 years old) with acute lower respiratory tract infections. After treatment, 165/173 (95%) azithromycin- and 166/173 (96%) co-amoxiclav-treated patients had responded satisfactorily (cure or improvement). Baseline pathogens (mainly Streptococcus pneumoniae and Haemophilus influenzae) were eradicated in 82/82 (100%) azithromycin- and 73/74 (99%) co-amoxiclav-treated patients who were bacteriologically assessable. Adverse events, which were predominantly of mild to moderate severity and mostly affected the gastrointestinal system, were recorded in 13/186 (7%) azithromycin- and 19/183 (10%) co-amoxiclav-treated patients. Only two (1%) azithromycin-treated patients discontinued treatment due to adverse events compared with eight (4%) who received co-amoxiclav. The results show that azithromycin at a dose of 500 mg once daily for 3 days is an effective and safe alternative to a 10-day, three-times-daily course of co-amoxiclav in the treatment of lower respiratory tract infections in adults.
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Affiliation(s)
- J Zachariah
- ICON Clinical Research Ltd., Dublin, Ireland
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25
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Cook RC, Zachariah J, Cree F, Harrison HE. Efficacy of twice-daily amoxycillin/clavulanate ('Augmentin-Duo' 400/57) in mild to moderate lower respiratory tract infection in children. Br J Clin Pract 1996; 50:125-8. [PMID: 8733329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A new amoxycillin/clavulanate regimen ('Augmentin-Duo' 400/57), to be given orally in two divided doses, has been proposed to overcome the inconvenience of tid dosing. This observer-blind, multicentre study randomised children aged two to 12 years with lower respiratory tract infection to seven days' treatment with either amoxycillin/clavulanate bid at a dose of 25/3.6mg/kg/day (221 patients) or the currently prescribed amoxycillin/clavulanate regimen of 20/5mg/kg/day tid (216 patients). Clinical success (cure) rates at follow up were 81.0% for the bid group and 77.8% for the tid group [difference 3.2%; 95% CI (-4.36, 10.80)], indicating that the regimens were of equivalent efficacy. Both regimens were well tolerated, and there was no statistically significant difference in the incidence of adverse experiences between the two groups. Compliance with study medication was high and similar for both groups (80% compliance: bid 90.0%; tid 87.0%).
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Affiliation(s)
- R C Cook
- Saltash Health Centre, Saltash, Cornwall
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26
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Abstract
One hundred thirteen patients with fixed drug eruption (FDE) were studied for any drug-specific clinical pattern. The causative drugs were identified and confirmed by provocation tests. A trimethoprim-sulfamethoxazole combination caused maximum incidence (36.3%), followed by tetracycline (15.9%), pyrazolones (14.2%), sulfadiazine (12.4%), dipyrine (9.3%), acetaminophen (7.9%), aspirin (1.7%), thiacetazone (0.88%), and levamizole (0.88%). Sulfas, including trimethoprim-sulfamethoxazole, induced lesions on the lips (91%) and trunk and limbs (89%), with only minimal involvement of mucosae. Tetracycline caused lesions only on the glans penis, sparing other sites. Pyrazolones affected mainly the lips and mucosae, with a few lesions of the trunk and limbs. Dipyrine, aspirin, and acetaminophen caused lesions of the trunk and limbs, sparing the lips, genitalia, and mucosae. Levamizole caused associated constitutional disturbances with extensive skin lesions, as did thiacetazone. The current study indicates that the clinical pattern and distribution of lesions in FDE are influenced by the drug in question, and the study of the pattern may provide useful information in selecting the most likely causative drug, especially when the details of the drugs are unknown.
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Affiliation(s)
- T P Thankappan
- Department of Dermatology and Venereology, Medical College Hospital, Alleppey, South India
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27
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Hazarika P, Murty PS, Nooruddin SM, Zachariah J, Rao NR. Lingual thyroid. Ear Nose Throat J 1988; 67:161-5. [PMID: 3366090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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28
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Suja V, Zachariah J. Milker's Dermatitis. Indian J Dermatol Venereol Leprol 1987; 53:267-268. [PMID: 28145367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Twenty five cases suspected to have milker's dertiatitiswere clinically studied including tests with various self-made antigens. Eight cases showed positive patch tests results. Two cases showed cay saliva and one case showed under shaves as the allergen.
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Zachariah J. Oral cancer prevention. J Indian Dent Assoc 1974; Spec Issue:33-42. [PMID: 4535071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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30
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Mathew B, Warrier PK, Zachariah J, Ramchandran P. Oesophageal changes in oral submucous firbosis. (Preliminary report). Indian J Pathol Bacteriol 1967; 10:349-53. [PMID: 5595630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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32
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Zachariah J, Mathew B, Varma NA, Iqbal AM, Pindborg JJ. Frequency of oral mucosal lesions among 5000 individuals in Trivandrum, South India. Preliminary report. J Indian Dent Assoc 1966; 38:290-4. [PMID: 5236641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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33
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Pindborg JJ, Zachariah J. Frequency of oral submucous fibrosis among 100 South Indians with oral cancer. Bull World Health Organ 1965; 32:750-3. [PMID: 5294188 PMCID: PMC2555246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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