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Lin N, Mandel D, Chuck CC, Kalagara R, Doelfel SR, Zhou H, Dandapani H, Mahmoud LN, Stretz C, Mac Grory BC, Wendell LC, Thompson BB, Furie KL, Mahta A, Reznik ME. Risk Factors for Opioid Utilization in Patients with Intracerebral Hemorrhage. Neurocrit Care 2021; 36:964-973. [PMID: 34931281 DOI: 10.1007/s12028-021-01404-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Headache is a common presenting symptom of intracerebral hemorrhage (ICH) and often necessitates treatment with opioid medications. However, opioid prescribing patterns in patients with ICH are not well described. We aimed to characterize the prevalence and risk factors for short and longer-term opioid use in patients with ICH. METHODS We conducted a retrospective cohort study using data from a single-center registry of patients with nontraumatic ICH. This registry included data on demographics, ICH-related characteristics, and premorbid, inpatient, and postdischarge medications. After excluding patients who died or received end-of-life care, we used multivariable regression models adjusted for premorbid opioid use to determine demographic and ICH-related risk factors for inpatient and postdischarge opioid use. RESULTS Of 468 patients with ICH in our cohort, 15% (n = 70) had premorbid opioid use, 53% (n = 248) received opioids during hospitalization, and 12% (n = 53) were prescribed opioids at discharge. The most commonly used opioids during hospitalization were fentanyl (38%), oxycodone (30%), morphine (26%), and hydromorphone (7%). Patients who received opioids during hospitalization were younger (univariate: median [interquartile range] 64 [53.5-74] vs. 76 [67-83] years, p < 0.001; multivariable: odds ratio [OR] 0.96 per year, 95% confidence interval [CI] 0.94-0.98) and had larger ICH volumes (univariate: median [interquartile range] 10.1 [2.1-28.6] vs. 2.7 [0.8-9.9] cm3, p < 0.001; multivariable: OR 1.05 per cm3, 95% CI 1.03-1.08) than those who did not receive opioids. All patients who had external ventricular drain placement and craniotomy/craniectomy received inpatient opioids. Additional risk factors for increased inpatient opioid use included infratentorial ICH location (OR 4.8, 95% CI 2.3-10.0), presence of intraventricular hemorrhage (OR 3.9, 95% CI 2.2-7.0), underlying vascular lesions (OR 3.0, 95% CI 1.1-8.1), and other secondary ICH etiologies (OR 7.5, 95% CI 1.7-32.8). Vascular lesions (OR 4.0, 95% CI 1.3-12.5), malignancy (OR 5.0, 95% CI 1.5-16.4), vasculopathy (OR 10.0, 95% CI 1.8-54.2), and other secondary etiologies (OR 7.2, 95% CI 1.8-29.9) were also risk factors for increased opioid prescriptions at discharge. Among patients who received opioid prescriptions at discharge, 43% (23 of 53) continued to refill their prescriptions at 3 months post discharge. CONCLUSIONS Inpatient opioid use in patients with ICH is common, with some risk factors that may be mechanistically connected to primary headache pathophysiology. However, the lower frequency of opioid prescriptions at discharge suggests that inpatient opioid use does not necessarily lead to a high rate of long-term opioid dependence in patients with ICH.
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Affiliation(s)
- Nelson Lin
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Daniel Mandel
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Carlin C Chuck
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | | | - Savannah R Doelfel
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Helen Zhou
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Hari Dandapani
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Leana N Mahmoud
- Department of Pharmacy, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Brown University, 593 Eddy St, APC 712, Providence, RI, USA
| | - Christoph Stretz
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Brian C Mac Grory
- Department of Neurology, Duke University School of Medicine, Duke University, Durham, NC, USA
| | - Linda C Wendell
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA.,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Bradford B Thompson
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA.,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Karen L Furie
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Ali Mahta
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA.,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA. .,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA.
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Chuck CC, Kim D, Kalagara R, Rex N, Madsen TE, Mahmoud L, Thompson BB, Jones RN, Furie KL, Reznik ME. Modeling the Clinical Implications of Andexanet Alfa in Factor Xa Inhibitor-Associated Intracerebral Hemorrhage. Neurology 2021; 97:e2054-e2064. [PMID: 34556569 DOI: 10.1212/wnl.0000000000012856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/11/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Andexanet alfa was recently approved as a reversal agent for the factor Xa inhibitors (FXais) apixaban and rivaroxaban, but its impact on long-term outcomes in FXai-associated intracerebral hemorrhage (ICH) is unknown. We aimed to explore potential clinical implications of andexanet alfa in FXai-associated ICH in this simulation study. METHODS We simulated potential downstream implications of andexanet alfa across a range of possible hemostatic effects using data from a single center that treats FXai-associated ICH with prothrombin complex concentrate (PCC). We determined baseline probabilities of inadequate hemostasis across patients taking FXai and those not taking FXai via multivariable regression models and then determined the probabilities of unfavorable 3-month outcome (modified Rankin Scale score 4-6) using models comprising established predictors and each patient's calculated probability of inadequate hemostasis. We applied bootstrapping with model parameters from this derivation cohort to simulate a range of hemostatic improvements and corresponding outcomes and then calculated absolute risk reduction (relative to PCC) and projected number needed to treat (NNT) to prevent 1 unfavorable outcome. RESULTS Training models using real-world patients (n = 603 total, 55 on FXai) had good accuracy in predicting inadequate hemostasis (area under the curve [AUC] 0.78) and unfavorable outcome (AUC 0.78). Inadequate hemostasis was strongly associated with unfavorable outcome (odds ratio 4.5, 95% confidence interval [CI] 2.0-9.9) and occurred in 11.4% of patients taking FXai. Across simulated patients taking FXai comparable to those in A Study in Participants With Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors (ANNEXA-4) study, predicted absolute risk reduction of unfavorable outcome was 4.9% (95% CI 1.3%-7.8%) when the probability of inadequate hemostasis was reduced by 33% and 7.4% (95% CI 2.0%-11.9%) at 50% reduction, translating to projected NNT of 21 (cumulative cost $519,750) and 14 ($346,500), respectively. DISCUSSION Even optimistic simulated hemostatic effects suggest that the costs and potential benefits of andexanet alfa should be carefully considered. Placebo-controlled randomized trials are needed before its use can definitively be recommended.
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Affiliation(s)
- Carlin C Chuck
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Daniel Kim
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Roshini Kalagara
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Nathaniel Rex
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Tracy E Madsen
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Leana Mahmoud
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Bradford B Thompson
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Richard N Jones
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Karen L Furie
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Michael E Reznik
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence.
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Chuck CC, Martin TJ, Kalagara R, Madsen TE, Furie KL, Yaghi S, Reznik ME. Statewide Emergency Medical Services Protocols for Suspected Stroke and Large Vessel Occlusion. JAMA Neurol 2021; 78:1404-1406. [PMID: 34542567 DOI: 10.1001/jamaneurol.2021.3227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Carlin C Chuck
- Alpert Medical School, Brown University, Providence, Rhode Island
| | - Thomas J Martin
- Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Karen L Furie
- Department of Neurology, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Shadi Yaghi
- Department of Neurology, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Michael E Reznik
- Department of Neurology, Alpert Medical School, Brown University, Providence, Rhode Island
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Doelfel SR, Kalagara R, Han EJ, Chuck CC, Dandapani H, Stretz C, Mahta A, Wendell LC, Thompson BB, Yaghi S, Furie KL, Madsen TE, Reznik ME. Gender Disparities in Stroke Code Activation in Patients with Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106119. [PMID: 34560379 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/24/2021] [Accepted: 09/10/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Routine implementation of protocol-driven stroke "codes" results in timelier and more effective acute stroke management. However, it is unclear if patient demographics contribute to disparities in stroke code activation. We aimed to explore these demographic factors in a retrospective cohort study of patients with intracerebral hemorrhage (ICH). MATERIALS AND METHODS We identified consecutive patients with non-traumatic ICH who presented directly to our Comprehensive Stroke Center over 2 years and collected data on demographics, clinical features, and stroke code activation. We used multivariable logistic regression to examine differences in stroke code activation based on patient demographics while adjusting for initial clinical features (NIH Stroke Scale, FAST [facial drooping, arm weakness, speech difficulties] vs. non-FAST symptoms, time from last-known-well [LKW], and systolic blood pressure [SBP]). RESULTS Among 265 patients, 68% (n=179) had a stroke code activation. Stroke codes occurred less frequently in women (62%) than men (72%) and in non-white (57%) vs. white patients (70%). Non-stroke code patients were less likely to have FAST symptoms (37% vs. 87%) and had lower initial SBP (mean±SD 159.3±34.2 vs. 176.0±31.9 mmHg) than stroke code patients. In our primary multivariable models, neither age nor race were associated with stroke code activation. However, women were significantly less likely to have stroke codes than men (OR 0.49 [95% CI 0.24-0.98]), as were non-FAST symptoms (OR 0.11 [95% CI 0.05-0.22]). CONCLUSIONS Our data suggest gender disparities in emergency stroke care that should prompt further investigations into potential systemic biases. Increased awareness of atypical stroke symptoms is also warranted.
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Affiliation(s)
- Savannah R Doelfel
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States
| | - Roshini Kalagara
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ethan J Han
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States
| | - Carlin C Chuck
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States
| | - Hari Dandapani
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States
| | - Christoph Stretz
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States
| | - Ali Mahta
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, United States
| | - Linda C Wendell
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, United States
| | - Bradford B Thompson
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, United States
| | - Shadi Yaghi
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States
| | - Karen L Furie
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States
| | - Tracy E Madsen
- Department of Emergency Medicine, Brown University, Alpert Medical School, Providence, RI, United States
| | - Michael E Reznik
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, United States; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, United States.
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Chuck CC, Martin TJ, Kalagara R, Shaaya E, Kheirbek T, Cielo D. Emergency medical services protocols for traumatic brain injury in the United States: A call for standardization. Injury 2021; 52:1145-1150. [PMID: 33487407 DOI: 10.1016/j.injury.2021.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/01/2021] [Accepted: 01/06/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) with acute elevation in intracranial pressure (ICP) is a neurologic emergency associated with significant morbidity and mortality. In addition to indicated trauma resuscitation, emergency department (ED) management includes empiric administration of hyperosmolar agents, rapid diagnostic imaging, anticoagulation reversal, and early neurosurgical consultation. Despite optimization of in-hospital care, patient outcomes may be worsened by variation in prehospital management. In this study, we evaluate geographic variation between emergency medical services (EMS) protocols for patients with suspected TBI. METHODS We performed a cross-sectional analysis of statewide EMS protocols in the United States in December 2020 and included all complete protocols published on government websites. Outcome measures were defined to include protocols or orders for the following interventions, given TBI: (1) hyperventilation and end-tidal capnography (EtCO2) goals, (2) administration of hyperosmolar agents, (3) tranexamic acid (TXA) administration for isolated head injury, (4) non-invasive management including head-of-bed elevation, and (5) hemodynamic goals. RESULTS We identified 32 statewide protocols including Washington, D.C., 4 of which did not include specific guidance for TBI. Of 28 states providing ventilatory guidance, 22/28 (78.6%) recommend hyperventilation, with 17/22 (77.3%) restricting hyperventilation to signs of acute herniation. The remaining 6 states prohibited hyperventilation. Regarding EtCO2 goals among states permitting hyperventilation, 17/22 (77.3%) targeted an EtCO2 of < 35 mmHg, while 5/22 (22.7%) provided no guide EtCO2 for hyperventilation. Rhode Island was the only state identified that included hypertonic saline (3%), and Delaware was the only state that allowed TXA in the setting of isolated TBI with GCS ≤ 12. Only 15/32 (46.9%) identified states recommend head-of-bed elevation. For blood pressure goals, 12/28 (42.9%) of states set minimum systolic blood pressure at 90 mmHg, while 10/28 (35.7%) set other SBP goals. The remaining 6/28 (21.4%) did not provide TBI-specific SBP goals. CONCLUSIONS There is wide variation among civilian prehospital protocols for traumatic brain injury. Prehospital care within the first "golden hour" may dramatically affect patient outcomes. Neurocritical care providers should be mindful of geographic variation in local protocols when designing and evaluating quality improvement interventions and should aim to standardize prehospital care protocols.
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Affiliation(s)
- Carlin C Chuck
- The Warren Alpert Medical School of Brown University, Providence, RI, United States..
| | - Thomas J Martin
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Roshini Kalagara
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Elias Shaaya
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Tareq Kheirbek
- Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Deus Cielo
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States
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Han EJ, Chuck CC, Martin TJ, Madsen TE, Claassen J, Reznik ME. Statewide Emergency Medical Services Protocols for Status Epilepticus Management. Ann Neurol 2021; 89:604-609. [PMID: 33305853 DOI: 10.1002/ana.2598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 05/27/2023]
Abstract
Although seizures are common in prehospital settings, standardized emergency medical services (EMS) treatment algorithms do not exist nationally. We examined nationwide variability in status epilepticus treatment by analyzing 33 publicly available statewide EMS protocols. All adult protocols recommend intravenous benzodiazepines (midazolam, n = 33; lorazepam, n = 23; diazepam, n = 24), 30 recommend intramuscular benzodiazepines (midazolam, n = 30; lorazepam, n = 8; diazepam, n = 3), and 27 recommend intranasal benzodiazepines (midazolam, n = 27; lorazepam, n = 3); pediatric protocols also frequently recommend rectal diazepam (n = 14). Recommended dosages vary widely, and first- and second-line agents are designated in only 18 and 2 states, respectively. Given this degree of variability, standardized national EMS guidelines are needed. ANN NEUROL 2021;89:604-609.
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Affiliation(s)
- Ethan J Han
- Department of Neuroscience, Brown University, Providence, RI
| | - Carlin C Chuck
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI
| | - Thomas J Martin
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, RI
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Michael E Reznik
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI
- Department of Neurosurgery, Alpert Medical School, Brown University, Providence, RI
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Lin NF, Mahta A, Chuck CC, Kalagara R, Doelfel SR, Zhou H, Mahmoud LN, Stretz C, Wendell LC, Thompson BB, Furie KL, Reznik ME. Abstract P393: Risk Factors for Opioid Use in Patients With Intracerebral Hemorrhage. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p393] [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:
Opioids are often used as analgesics in patients with subarachnoid hemorrhage, but their use in the setting of intracerebral hemorrhage (ICH) is not well described. We aimed to determine risk factors for opioid use in both the acute and post-discharge settings in patients with ICH.
Methods:
We analyzed data from a single-center cohort of consecutive ICH patients admitted over two years. Demographics and ICH-related characteristics were prospectively collected as part of an institutional ICH registry, while pre-morbid, in-hospital, and post-discharge medications were retrospectively abstracted from medication administration records and physician documentation. After excluding patients who received end-of-life care, we used multivariable regression models adjusted for pre-morbid opioid use to determine demographic and ICH-related risk factors for in-hospital and post-discharge opioid use.
Results:
Of 468 patients in our cohort, 15% (n=70) had pre-morbid opioid use, 53% (n=248) had in-hospital opioid use, and 12% (n=53) of survivors had opioids prescribed at discharge. The most commonly used in-hospital opioids were fentanyl (38% of patients), oxycodone (30%), morphine (26%), and hydromorphone (7%). Patients who received in-hospital opioids were significantly younger (mean 62.7 vs. 74.0 years, p<0.001) and had larger ICH volumes (mean 18.7 vs. 8.1 cc, p<0.001), with additional risk factors including infratentorial location (OR 4.0, 95% CI 2.0-8.0), presence of intraventricular hemorrhage (OR 4.3, 95% CI 2.5-7.5), and vascular, neoplastic, or other secondary ICH etiologies (OR 2.6, 95% CI 1.4-4.7) in multivariable models. However, only secondary ICH etiologies (OR 4.1, 95% CI 1.8-9.1) remained significant risk factors for opioid prescriptions at discharge in ICH survivors.
Conclusion:
Inpatient opioid use in ICH patients is common, with risk factors that may be mechanistically connected to headache pathophysiology. However, the lower frequency of post-discharge opioid prescriptions may be reassuring given the prevalence of opioid dependence nationwide.
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Doelfel SR, Moody S, Chuck CC, Kalagara R, Zhou H, Stretz C, Madsen TE, Mahta A, Wendell LC, Thompson BB, Furie KL, Reznik ME. Abstract P175: Dizziness-Related Symptoms are Associated With Delayed Diagnostic Imaging in Patients With Intracerebral Hemorrhage. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p175] [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:
Acute dizziness can present diagnostic challenges for emergency department (ED) clinicians because of the potential for an underlying cerebrovascular cause. Although various strategies may aid in diagnosing cases caused by stroke, it is unclear whether dizziness due to intracerebral hemorrhage (ICH) is associated with delays in diagnostic imaging.
Methods:
We performed a single center cohort study on consecutive ICH patients admitted over 2 years. We retrospectively abstracted initial reported symptoms and aggregated patients with dizziness, vertigo, lightheadedness, or nausea under the category of dizziness-related symptoms. After excluding patients with ED intubation due to potential procedural delays, we calculated time from initial ED arrival to first computed tomography (CT) scan. Using linear regression, we determined associations between dizziness-related symptoms and ED-to-CT time after adjusting for demographics and time from symptom onset, with additional analyses considering the presence of typical stroke symptoms and cerebellar ICH.
Results:
Of 427 patients, 110 (26%) presented with dizziness-related symptoms and 36 (8%) had cerebellar ICH. In univariate analyses, patients with dizziness-related symptoms had longer ED-to-CT times than other patients (median [IQR] 51 [21-144] vs. 32 [14-92] min, p=0.007), as did those with cerebellar ICH (71 [27-182] min). In our primary adjusted model, dizziness-related symptoms were associated with longer ED-to-CT times (+26 min [95% CI 6-46]). This imaging delay was further compounded in a subgroup analysis of patients without typical stroke symptoms (+45 min [95% CI 7-84], and in a separate model considering patients with cerebellar ICH (+48 min [95% CI 17-80]).
Conclusions:
Dizziness-related symptoms are associated with delayed diagnostic imaging in patients with ICH, which suggests the need for increased early awareness and urgency in these cases.
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Kalagara R, Lin NF, Chuck CC, Doelfel SR, Zhou H, Moody S, Stretz C, Mahta A, Wendell LC, Thompson BB, Furie KL, Reznik ME. Abstract P452: Impact of Socioeconomic Status in Intracerebral Hemorrhage. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p452] [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:
Socioeconomic status (SES) has been associated with intracerebral hemorrhage (ICH) incidence, but its impact on ICH-related features and outcomes is unclear.
Methods:
We performed a single-center cohort study on consecutive ICH patients admitted over 2 years. Demographics, ICH characteristics, and outcomes were prospectively collected, while SES-related data were retrospectively abstracted. We classified SES quartiles using census estimates of median household incomes corresponding to patients’ home ZIP codes, then categorized patients as “lower SES” if their ZIP code was in the lowest SES quartile, if they were uninsured, or had Medicaid as their source of insurance. We compared ICH characteristics between patients with lower vs. higher SES, then determined associations between lower SES and unfavorable 3-month outcome (modified Rankin Scale 4-6) using multivariable logistic regression.
Results:
Of 665 patients, 31% (n=207) were categorized as lower SES. Patients with lower SES were significantly younger (mean [SD] 64.7 [16.1] vs. 73.1 [14.2] years, p<0.001), more often non-white (38% vs. 8%, p<0.001), and had a higher prevalence of multiple vascular risk factors. There were no significant differences in ICH volume or prevalence of infratentorial or intraventricular hemorrhage. However, patients with lower SES had a shorter time-to-presentation (median [IQR] 4.5 [1.3-15.2] vs. 7.4 [1.4-21.7]), hours from last known well, p=0.01), and had fewer ICH due to cerebral amyloid angiopathy (13% vs. 30%, p<0.001). Despite these differences, patients with lower SES did not have a significantly higher likelihood of unfavorable 3-month outcomes (OR 1.2 [95% CI 0.7-1.8]).
Conclusions:
Differences in ICH features may be driven by pre-morbid healthcare disparities in lower SES patients. Although their younger age and shorter time to presentation may have mitigated the deleterious effects of comorbidities on long-term outcomes, these factors may also belie a greater loss of quality-adjusted life years from ICH-related disability.
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Han EJ, Chuck CC, Martin TJ, Madsen TE, Claassen J, Reznik ME. Statewide Emergency Medical Services Protocols for Status Epilepticus Management. Ann Neurol 2020; 89:604-609. [PMID: 33305853 DOI: 10.1002/ana.25989] [Citation(s) in RCA: 4] [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: 08/19/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 11/09/2022]
Abstract
Although seizures are common in prehospital settings, standardized emergency medical services (EMS) treatment algorithms do not exist nationally. We examined nationwide variability in status epilepticus treatment by analyzing 33 publicly available statewide EMS protocols. All adult protocols recommend intravenous benzodiazepines (midazolam, n = 33; lorazepam, n = 23; diazepam, n = 24), 30 recommend intramuscular benzodiazepines (midazolam, n = 30; lorazepam, n = 8; diazepam, n = 3), and 27 recommend intranasal benzodiazepines (midazolam, n = 27; lorazepam, n = 3); pediatric protocols also frequently recommend rectal diazepam (n = 14). Recommended dosages vary widely, and first- and second-line agents are designated in only 18 and 2 states, respectively. Given this degree of variability, standardized national EMS guidelines are needed. ANN NEUROL 2021;89:604-609.
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Affiliation(s)
- Ethan J Han
- Department of Neuroscience, Brown University, Providence, RI
| | - Carlin C Chuck
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI
| | - Thomas J Martin
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, RI
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Michael E Reznik
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI.,Department of Neurosurgery, Alpert Medical School, Brown University, Providence, RI
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