Barriers to the utilization of thrombolysis for acute ischaemic stroke

What is known and Objective: Thrombolysis is currently the only evidence‐based pharmacological treatment available for acute ischaemic stroke (AIS); however, its current utilization is suboptimal (administered to <3% of AIS patients). The aim of this article was to identify the potential barriers to the use of thrombolysis via a review of the available literature. Methods: Medline, Embase, International Pharmaceutical Abstracts and Google Scholar were searched to identify relevant original articles, review papers and other literature published in the period 1995–2011. Results and Discussion: Several barriers to the utilization of thrombolysis in stroke have been identified in the literature and can be broadly classified as ‘preadmission’ barriers and ‘post‐admission’ barriers. Preadmission barriers include patient and paramedic‐related factors leading to late patient presentation for treatment (i.e. outside the therapeutic time window for the administration of thrombolysis). Post‐admission barriers include in‐hospital factors, such as suboptimal triage of stroke patients and inefficient in‐hospital acute stroke care systems, a lack of appropriate infrastructure and expertise to administer thrombolysis, physician uncertainty in prescribing thrombolysis and difficulty in obtaining informed consent for thrombolysis. Suggested strategies to overcome these barriers include public awareness campaigns, prehospital triage by paramedics, hospital bypass protocols and prenotification systems, urgent stroke‐unit admission, on‐call multidisciplinary acute stroke teams, urgent neuroimaging protocols, telestroke interventions and risk‐assessment tools to aid physicians when considering thrombolysis. Additionally, greater pharmacists’ engagement is warranted to help identify the people at risk of stroke and support preventative strategies, and provide the public with information regarding the recognition of stroke, as well as facilitate the access and use of thrombolysis. What is new and Conclusion: The most effective interventions appear to be those comprising several strategies and those that target more than one barrier simultaneously. Therefore, optimal utilization of thrombolysis requires a systematic, integrated multidisciplinary approach across the continuum of acute care.     

Warfarin management after discharge from hospital: a qualitative analysis

What is Known and Objective: Warfarin is recognized as a high‐risk medication for adverse events, and the risks are particularly heightened in the period immediately following a patient’s discharge from hospital. This qualitative study aimed to explore the experiences of Australian patients and healthcare professionals of warfarin management in the post‐discharge period and identify the benefits and deficiencies of existing systems, to inform the development of a model for a new collaborative post‐discharge warfarin management service. Methods: Healthcare professionals, professional organization representatives and patients recently discharged from hospital taking warfarin (consumers) were recruited via purposive, criterion‐based sampling within two Australian states. Semi‐structured telephone interviews were conducted between August and October 2008 using standard discussion guides. Data were manually analyzed to identify emergent themes using a phenomenological approach. Results: Forty‐seven participants were involved in the telephone interviews. Three major themes emerged: (i) appropriate warfarin education is integral to effective warfarin management, (ii) problems occur in communication along the continuum of care and (iii) home‐delivered services are valuable to both patients and healthcare professionals. Discussion: Although high‐quality warfarin education and effective communication at the hospital–community interface were identified as important in post‐discharge warfarin management, deficiencies were perceived within current systems. The role of home‐delivered services in ensuring timely follow‐up and promoting continuity of care was recognized. Previous studies exploring anticoagulation management in other settings have identified similar themes. Post‐discharge management should therefore focus on providing patients with a solid foundation to minimize future problems. What is New and Conclusion: Addressing the three identified facets of care within a new, collaborative post‐discharge warfarin management service may address the perceived deficiencies in existing systems. Improvements may result in the short‐ and longer‐term health outcomes of patients discharged from hospital taking warfarin, including a reduction in their risk of adverse events.     

BIOLOGY OF NEUROCYSTICERCOSIS – PARASITE RELATED FACTORS MODULATING HOST RESPONSE

Neurocysticercosis, caused by infestation of the nervous system by the larval form of Taenia solium, continues to baffle the neurologist, because of varied clinical manifestations. A large body of the literature related to this disease is clinically oriented, enough attention has not been given to parasite related factors modulating the host response. Using immunohistochemical techniques, three features related to the biology of the Cysticercus cellulosa e were studied. Firstly, to the question as to which part of the worm is recognised by the host immune system, the surface glycoprotein is found to be immunolabelled by the CSF from patients of neurocysticercosis. This surface protein is depleted following specific antihelmenthic therapy, thus accounting for a fall in anticysticercal antibosy level in the CSF. Secondly, the cysticercal cyst, by immunochemical and histochemical methods, is found to have “ACTH like” molecule in the body wall and has neurotransmitter and mitochondrial metabolic pathways similar to the host, facilitating the immune evasion and successful parasitisation. Finally, Cysticercus cellulosae is found to contain a “peptide” opening the blood brain barrier at the arteriolar level when injected into mice intravenously. Similar phenomenon may be functional in the patients as well, resulting in cerebral oedema, especially following praziquintel therapy.KEY WORDS: Cystericercus cellulosae, I mmunohistochemistry, Blood Brain Barrier, Immune evasion, Parasite metabolism     

Monitoring the pathophysiological correlates of postmenopausal hot flushes

Clinical assessment of the severity and frequency of post-menopausal hot flushes can be made objectively by measuring the associated changes in skin conductance and skin and core temperature. Such measurements provide a more reliable index of the response to therapy than does subjective reporting which has been employed in the past. The design and use of a working analyzer is presented that is sufficiently simple, rugged, safe and portable to be used under normal clinical conditions to provide a permanent record of the attacks.     

Are interventions recommended by pharmacists during Home Medicines Review evidence‐based?

Introduction Over the past decade medication review services have been implemented in many countries, including Australia, UK and USA. Although, the attitudes and barriers to the implementation of evidence‐based medicine have been investigated, the extent to which medication review recommendations are evidence‐based is not known. Objective To determine (1) the extent to which pharmacist's recommendations during medication review services were consistent with the evidence‐based guides at the time of the review; and (2) the nature and extent of drug‐related problems (DRPs) and the actions recommended by pharmacists to resolve DRPs. Method A retrospective review of Home Medicines Review cases performed on 224 community‐dwelling older people (65 years or older). The chi‐squared test for categorical variables was used to compare the proportion of recommendations that were evidence‐based and recommendations for which no evidence could be identified in the most common Australian information sources. DRPs and the actions recommended to resolve the DRPs were classified according to previously employed criteria. Results Pharmacists made a total of 1114 therapeutic recommendations to general practitioners, of which 964 required supporting pharmacotherapeutic evidence. The majority (94%) of the pharmacists' recommendations were in accordance with the evidence‐based guides, as compared with the recommendations for which no evidence could be identified (P < 0.001). Pharmacists reported that 98% of the patients had at least one problem with use of their medication detected. Conclusion The majority of the actions recommended by pharmacists during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging, as highlighted by the DRPs identified in 98% of our patients. A suitably trained pharmacist, with full access to the patient, medical record and supporting resources, can help to improve the quality use of medicines in this at‐risk population.     

Associations Among Hip and Shoulder Range of Motion and Shoulder Injury in Professional Baseball Players

Context:

The overhead throwing motion is complex, and restrictions in range of motion (ROM) at the hip may place additional demands on the shoulder that lead to injury. However, the relationship between hip and shoulder ROM in athletes with and without a history of shoulder injury is unknown.

Objective:

To (1) determine if differences exist in hip and shoulder ROM between professional baseball players with a history of shoulder injury and those with no history of shoulder injury and (2) assess relationships between hip and shoulder ROM in these players.

Design:

Cross-sectional study.

Patients or Other Participants:

Fifty-seven professional baseball players.

Main Outcome Measure(s):

Outcome measures consisted of hip extension and internal rotation, shoulder internal and external rotation, glenohumeral internal-rotation deficit, and history of shoulder injury. Differences in shoulder and hip ROM were assessed with a 1-way analysis of variance. Associations between hip and shoulder ROM were assessed with linear regression.

Results:

Nonpitchers with a history of shoulder injury had more external rotation and less internal rotation of the shoulder than nonpitchers with no history of shoulder injury. Glenohumeral internal-rotation deficit was greater in both pitchers and nonpitchers with a history of shoulder injury. The relationship between dominant hip extension and shoulder external rotation was significant for pitchers with a history of shoulder injury and nonpitchers with a history of shoulder injury.

Conclusions:

Shoulder injury may be associated with specific measures of hip and shoulder ROM, and hip extension and shoulder external rotation may be related in baseball players with a history of shoulder injury. Additional research is necessary to understand the specific mechanisms of shoulder injury in the throwing athlete.     

Contemporary approaches to managing atrial fibrillation: A survey of Australian general practitioners

Background

Recent attention to the management of atrial fibrillation (AF) and stroke prevention has emphasised the need to support the use of existing pharmacotherapy through available services and resources, in preference to using the new, more expensive, novel oral anticoagulants. In this regard, general practitioners (GPs) are at the core of care.

Aims

To survey Australian GPs regarding their approach to managing AF, particularly in relation to stroke prevention therapy, and to identify the range of services to support patient care.

Methods

A structured questionnaire, comprising quantitative and qualitative responses, was administered to participating GPs within four geographical regions of NSW (metropolitan, regional, rural areas).

Results

Fifty GPs (mean age 53.74±9.94 years) participated. Most (98 per cent) GPs regarded themselves as primarily responsible for the management of AF, only referring patients to specialists when needed. However, only 10 per cent of GPs specialised in “heart/vascular health”. Most (76 per cent) GPs offered point-of-care international normalised ratio (INR) testing, with 90 per cent also offering patient support via practice nurses and home visits. Overall, key determinants influencing GPs’ initiation of antithrombotic therapy were: “stroke risk”/”CHADS₂ score”, followed by “patients’ adherence/compliance”. GPs focused more on medication safety considerations and the day-to-day management of therapy than on the risk of bleeding.

Conclusion

Australian GPs are actively engaged in managing AF, and appear to be well resourced. Importantly, there is a greater focus on the benefits of therapy during decision-making, rather than on the risks. However, medication safety considerations affecting routine management of therapy remain key concerns, with patients’ adherence to therapy a major determinant in decision-making.