The implementation of intravenous tissue plasminogen activator in acute ischaemic stroke – a scientific position statement from the National Stroke Foundation and the Stroke Society of Australasia

Intravenous tissue plasminogen activator (tPA) has been licensed in Australia for thrombolysis in selected patients with acute ischaemic stroke since 2003. The use of tPA is low but is increasing across Australia and national audits indicate efficacy and safety outcomes equivalent to international benchmarks. Implementing tPA therapy in clinical practice is, however, challenging and requires a coordinated multidisciplinary approach to acute stroke care across prehospital, emergency department and inpatient care sectors. Stroke care units are an essential ingredient underpinning safe implementation of stroke thrombolysis. Support systems such as care pathways, therapy delivery protocols, and thrombolysis-experienced multidisciplinary care teams are also important enablers. Where delivery of stroke thrombolysis is being planned, health systems need to be re-configured to provide these important elements. This consensus statement provides a review of the evidence for, and implementation of, tPA in acute ischaemic stroke with specific reference to the Australian health-care system.     

Stroke management in Europe

Stroke is a leading cause of death and disability in Europe. Standards of care vary widely, and the introduction of simple standards will improve mortality and morbidity. It has been shown, in the absence of any medical treatment for acute stroke, that improving the organization of care for people with stroke significantly improves outcome. Recommendations are made for simple changes to the organization of care. Preventative measures after first stroke reduce incidence of subsequent stroke; these could be made widely available. Rehabilitation for those with persisting disability should be patient centred and commence immediately after the patient is alert and medically stable. Urgent research is required to find out which components of rehabilitation are important, and measures should be in place to ensure that all who require rehabilitation receive it from appropriately trained professionals. Population-based monitoring systems covering incidence, case fatality, mortality and disability should be put in place in all European Member States by the year 2005.     

Acute stroke and transient ischaemic attack management – time to act fast

Stroke is Australia's second single greatest killer with 53 000 new events each year at a rate of 1 every 10 min. Stroke services should be organized to enable people to access proven therapies, such as stroke unit care and thrombolysis, to reduce the impact of stroke. Timely, efficient and coordinated care from ambulance services, emergency services and stroke services will maximize recovery and prevent costly complications and subsequent strokes. Efficient management of patients with transient ischaemic attack can produce significant reductions in subsequent stroke events and risk stratification using the ABCD2 tool can aid management decisions. Evidence for acute stroke care continues to evolve and it is crucial that health professionals are aware of, and implement, best practice clinical guidelines for stroke care.     

Acute gout management during hospitalization: a need for a protocol

Aim: To review systematically the management of acute gout during hospitalization. Methods: Case‐file review of all episodes of acute gout occurring in a large tertiary hospital over a 20‐month period. Results: Of 134 acute gout episodes identified, the large majority (118) occurred in patients not admitted under the rheumatology unit. Baseline anti‐gout medications were frequently ceased on admission and in 9% of episodes, no pharmacotherapy was prescribed. Delays in initiation of treatment occurred in up to 29% of patients. Acute management included anti‐inflammatory monotherapy, or combinations of colchicine, non‐steroidal anti‐inflammatory drugs (NSAIDs) and corticosteroids. Of patients prescribed colchicine, 26% received >1.5 mg/day and a strong correlation was found between colchicine dose and the occurrence of diarrhoea. NSAIDs were prescribed in 29% of patients with pre‐existing renal impairment. Overall, 25% of patients received inappropriate pharmacological management. In patients not under the direct care of the rheumatology unit, in‐hospital rheumatology consultation was sought by the treating unit in 34% of episodes. Consultation was sought more frequently in patients with multiple joint involvement, but there were no other obvious differences in baseline clinical characteristics between cases with or without rheumatology involvement. In cases with rheumatology involvement, patients were investigated more frequently, they received more pharmacotherapeutic intervention, in particular combination anti‐inflammatory therapy, and they achieved better symptomatic relief and long‐term follow up. Conclusion: Acute gout episodes in hospital are variably investigated and treated with frequent suboptimal management. We recommend establishment of a hospital‐wide protocol to support decision‐making regarding investigations, treatment and follow up.     

Stroke therapy — time for a clinical breakthrough

Abstract. Attempts to limit brain infarct size and improve clinical outcome in patients with acute ischaemic stroke have focused on the restoration of blood flow and neuroprotection. Haemodilution to improve blood flow in the low-flow zone (penumbra) surrounding the core of the infarct has not been successful in clinical trials. No consistent effect of prostacyclin has been documented. In contrast, beneficial effects of thrombolytic agents (streptokinase, urokinase or t-PA) have been reported in animal models of stroke and in small series of patients with ischaemic stroke. There is a substantial risk of intracerebral bleeding that increases with delay from onset of symptoms to start of treatment. Large-scale, placebo-controlled trials of intravenous rt-PA and streptokinase are ongoing. Interventional neurovascular techniques have been successfully applied in patients with acute embolic occlusion of extracranial or intracranial arteries, and these procedures are now ready for randomized trials. Amongst neuroprotective agents, calcium-channel blockers have been most extensively studied in clinical trials, but no convincing benefits have been shown. Scavengers of free radicals and inhibitors of presynaptic glutamate release and glutamate-receptor blockers reduce brain infarct size in laboratory animals and are now being investigated in clinical trials. To fully exploit, in routine clinical practice, a breakthrough in reperfusion and/or neuroprotection therapy, a drastic reorganization of the management of stroke patients before and immediately after arrival to hospital will be needed.     

Stroke beyond the First Hours: The Role of Monitoring

It is now recognized that a specialized multidisciplinary team, focusing on the care of stroke patients, leads to lower mortality and better outcomes. The positive effect of stroke units in regard to the outcome of stroke patients seems to be related to the careful monitoring of clinical parameters and clinical emergencies. The monitoring of physiological parameters in the acute phase of stroke can be considered an important management tool that can improve significantly the quality of care provided. It allows timely detection and correction of complications and consequently has a beneficial effect on outcome.     

Worldwide guidelines for chronic obstructive pulmonary disease: a comparison of diagnosis and treatment recommendations

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is a leading cause of worldwide burden of disease, but is underdiagnosed and undertreated. We performed a systematic review of worldwide COPD clinical practice guidelines (CPG) to determine the degree of international consensus on major guideline recommendations. METHODS: The COPD CPG were identified from the medical literature and through contact with respiratory experts and organizations. An abstraction form was developed to collect information related to COPD diagnosis and management. RESULTS: Locally developed COPD CPG are based upon expert consensus, but do not explicitly rate the strength of the evidence for recommendations. The detail and clarity of the 41 CPG varied regarding the diagnosis and management of COPD. Key differences included the lung function parameters that define a diagnosis and severity assignment of COPD. The use of anticholinergics, alone or in combination, was listed as a consideration for first-line therapy for persistent COPD in all 41 CPG. There was consensus regarding reserving corticosteroids for selected patients. CONCLUSIONS: There is variation and ambiguity within COPD CPG regarding specific recommendations that can be applied by clinicians at a patient-specific level. The variation in CPG for COPD may contribute to the underdiagnosis and suboptimal treatment of COPD. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop report may help resolve some of the variation surrounding COPD diagnosis and treatment. However, local guideline implementation efforts must assist physicians in applying guideline recommendations to support patient-specific management.     

慢性肾脏病并发症治疗现状及思考

慢性肾脏病(CKD)已经成为影响公众健康的重要疾病。无论接受替代治疗与否,各种并发症如控制不当都将导致CKD患者预后不良和过早死亡,其中心脑血管并发症是最重要原因。CKD并发症的发生时间可能较预想的要早。应重视对其早期发现、积极干预、定期监测并及时调整治疗方案。基于循证医学研究制定的临床指南对于指导CKD并发症的治疗具有重要意义,同时也应注意个体化治疗,以提高患者存活率、改善生活质量,使之更好地回归社会。     

《亚太肝病学会乙型肝炎管理的临床实践指南(2015年更新)》推荐意见

2015年亚太肝病学会发布了最新的关于乙型肝炎管理的临床实践指南(2015年更新),在此翻译全文推荐意见以供临床医生参考.推荐强度及证据质量分级参考表1.1 慢性HBV感染的筛查(1)筛查是发现新发慢性HBV感染的重要方法(A1).(2)尚无充足的证据来推荐对慢性乙型肝炎(CHB)的任何特异性筛查,且这方面还需进一步研究(C1).(3)现有的出生前及血液供应的HBV筛查手段应当加强(A1).(4)应当优先考虑对高危人群进行筛查(A1).(5)应当研究提高筛查手段接受度和采纳的方法(C1).     

关于2014年美国脑卒中和短暂性脑缺血发作二级预防指南更新的解读与思考

2014年,美国心脏协会(AHA)/美国卒中协会(ASA)发布了最新的脑卒中和短暂性脑缺血发作(TIA)的二级预防指南,是继2011年之后的再次更新和总结。本文就2014年指南中的一些主要更新内容进行解读与思考。     

急性重症脑血管病亚低温治疗的分析

目的:分析急性重症脑血管病(SCD)亚低温治疗的临床疗效。方法:选取60例SCD患者,随机分为2组,各30例,研究组应用SDLV型双控局部颅脑降温仪实施亚低温治疗;对照组采取常规治疗;比较2组患者临床疗效。结果:研究组恢复良好率明显高于对照组(46.67%vs 23.33%,P0.05);病死率明显低于对照组(20.00%vs43.33%,P0.05)。治疗后研究组内皮素(ET)、精氨酸加压素(AVP)、丙二醛(MDA)、血清一氧化氮(NO)等指标改善均明显优于对照组(均P0.05)。研究组血清L-选择素(L-selectin)、细胞间粘附分子-1(ICAM-1)水平明显优于对照组(均P0.05)。治疗后研究组神经功能缺损评分(ESS)、日常生活能力Bathel指数评分(BI)、运动功能评分(FMA)、生活质量评分(QOL评分)改善均明显优于对照组(均P0.05)。结论:亚低温治疗SCD患者,可促进神经功能恢复,改善患者预后,降低病死率,提高患者生活质量。     

Management guideline for Werner syndrome 2020. 7. Skin ulcer associated with Werner syndrome: Dermatological treatment

Skin ulcers in Werner's syndrome often arise from hyperkeratotic lesions and trauma to pressure points such as the plantar region, and are more difficult to treat than wound healing in healthy individuals. Multiple factors contribute to the intractable skin ulcers in Werner's syndrome, including skin thinning, sclerosis, fatty tissue loss, impaired blood flow, calcification, and excessive pressure due to osteoarticular deformity. Treatment includes topical application of a keratolytic agent for keratosis around the ulcer. Treatment of ulcers is the same as for normal ulcers, and if the ulcer is associated with infection and necrotic tissue, surgical debridement with a scalpel or scissors should be performed as much as possible after washing with saline or mildly warm water or with an antibacterial agent. Topical medications that promote softening and debridement of the necrotic tissue are used with careful control of moisture in the wound. Topical agents that promote granulation should be used in wounds where necrotic tissue has been removed without infection. Dressings to maintain a moist environment in the wound may also be useful. If the wound does not improve with conservative treatment, surgical treatment should be considered. Geriatr Gerontol Int 2021; 21: 160–162 .