ACP HospitalistWeekly 6-10-09
- Guidelines expand window for tPA (alteplase) after stroke in some patients
- Recurrent stroke common within 24 hours of a first TIA
- Mobilization during “sedation stops” improves outcomes in ICU
- Propylthiouracil associated with liver failure, death
From ACP Hospitalist
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Physician editor: A. Scott Keller, MD
Guidelines expand window for tPA (alteplase) after stroke in some patients
New guidelines released last week call for expanding the poststroke treatment window for recombinant tissue plasminogen activator (alteplase) in selected patients.
Previous recommendations called for administration of alteplase no more than 3 hours after stroke onset. In light of new research, the American Heart Association and American Stroke Association have issued a scientific advisory expanding this time window to 3 to 4.5 hours in patients who are eligible for alteplase. However, in the following groups, the 3-hour window still applies.
- Patients older than age 80;
- Patients receiving oral anticoagulation who have an international normalized ratio of 1.7 or less;
- Patients with a National Institutes of Health Stroke Scale score over 25; and
- Patients with a history of stroke and diabetes.
The statement stressed that treatment within 3 hours is still preferable in all cases, because patients treated earlier are more likely to improve (“time is brain”). The full recommendations were published by Stroke on May 28 and are available online.
Recurrent stroke common within 24 hours of a first TIA
Recurrent stroke often occurs within the first 24 hours of a first transient ischemic attack (TIA), a new study has reported.
Researchers from the United Kingdom performed a prospective, population-based study to determine the incidence of recurrent strokes soon after TIA and to assess the reliability of the ABCD2 risk score in identifying such recurrences. Risks at 6, 12, and 24 hours were determined. The study results appear in the June 2 Neurology.
Among 1,247 patients with first TIA or stroke, 35 (2.8%) experienced recurrent stroke within 24 hours. Among 488 patients with first TIAs, 6-, 12-, and 24-hour stroke risks were 1.2% (95% CI, 0.2% to 2.2%), 2.1% (0.8% to 3.2%), and 5.1% (3.1% to 7.1%), respectively. Of strokes occurring within 30 days after a first TIA, 42% took place in the first 24 hours. ABCD2 score was strongly correlated with risk for recurrent stroke within 24 hours (P= 0.00025): Patients with scores of 4 or less had a 2.0% risk, those with a score of 5 had a 6.5% risk, those with a score of 6 had an 11.8% risk, and those with a score of 7 had a 33% risk.
The study had several potential limitations, the authors noted, including possible underestimation of early stroke risk. However, they concluded that the common occurrence of stroke soon after a TIA "highlights the need for emergency assessment" and that the reliability of the ABCD2 score "shows that appropriately triaged emergency assessment and treatment are feasible."
More information on TIAs and the ABCD2 score is available online from the National Stroke Association.
Mobilization during “sedation stops” improves outcomes in ICU
Interrupting sedation and initiating physical and occupational therapy in the early days of a critical illness resulted in better outcomes at hospital discharge and fewer days on ventilation, a recent study found.
The randomized controlled trial included 104 sedated adults in the ICU at two university hospitals who had been on mechanical ventilation for less than 72 hours, were expected to continue for at least 24 hours, and met criteria for baseline functional independence. Patients in the intervention group underwent exercise and mobilization during daily interruptions of sedation while patients in the control group had daily sedation stops only. The study appears in the current issue of The Lancet.
Researchers found that 59% of patients in the intervention group returned to premorbid independent functional status at discharge (defined as the ability to perform six activities of daily living and to walk independently) versus 35% in the control group. In addition, patients in the intervention group had a shorter duration of delirium (2 vs. 4 days, P=0.02) and more ventilator-free days (23.5 vs. 21 days, P=0.05) than control group patients during the 28-day follow-up period.
An accompanying editorial noted that the study's findings on delirium deserve further study because of the difficulty of assessing confusion in critically ill patients, almost all of whom would test positive for one or more of the criteria for delirium. Future studies should examine whether delirium is actually reduced or whether physical therapy enhances patients' ability to reach an awakened state, the editorial said.
Propylthiouracil associated with liver failure, death
Propylthiouracil carries the risk of serious liver injury, including liver failure and death, in adult and pediatric patients, the FDA said last week in a safety alert.
Thirty-two patient reports of serious liver injury with propylthiouracil have been made to the FDA's Adverse Event Reporting System (AERS), compared to five reports with methimazole. Thirteen of the propylthiouracil cases resulted in death, compared to three with methimazole. Both drugs are indicated to treat hyperthyroidism due to Graves’ disease, but propylthiouracil is generally considered second-line therapy except in patients who are allergic to or intolerant of methimazole.
Patients who are put on propylthiouracil therapy should be closely monitored for symptoms and signs of liver injury, especially during the first six months after the start of therapy. Propylthiouracil shouldn't be used in pediatric patients unless the patient is allergic to or intolerant of methimazole, and there are no other treatment options available, the FDA said.
From ACP Hospitalist.
Suggest a colleague as a Top Hospitalist
ACP Hospitalist is seeking candidates for our second annual Top Hospitalists issue. We're looking for the hospitalists who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.
Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 13, 2009, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2009 issue..
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Do you have a case where a medical diagnosis required you to dig beyond the obvious? Submit the diagnosis and a two-sentence summary of the case for consideration in future columns of Mindful Medicine, ACP Hospitalist's column by Jerome Groopman, FACP, author of New York Times best-seller "How Doctors Think," and endocrinologist Pamela Hartzband, FACP, both Harvard faculty and staff physicians at Beth Israel Deaconess Medical Center in Boston. Based on reader submissions, Drs. Groopman and Hartzband will analyze how doctors arrive at a correct diagnosis, and the missteps that can lead to errors.
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