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Intravenous fibrinolysis eligibility: a survey of stroke clinicians' practice patterns and review of the literature.

ABSTRACT: The indications and contraindications for intravenous (IV) recombinant tissue plasminogen activator (rtPA) use in ischemic stroke can be confusing to the practicing neurologist. Here we seek to describe practice patterns regarding decision-making among US stroke clinicians.Stroke clinicians (attending and fellow) from the 8 National Institutes of Health SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) centers were asked to complete a survey ahead of the 2012 SPOTRIAS Investigators' meeting.A total of 51 surveys were collected (71% response rate). Most of the responders were attending physicians (68%). Only 18% of clinicians reported strictly adhering to current American Heart Association guidelines for treatment within 3 hours from symptom onset; this increased to 51% for the European Cooperative Acute Stroke Study (ECASS) III criteria in the 3 to 4.5 hours time frame. All clinicians treat eligible patients in the 3 to 4.5 hours time frame. The great majority will recommend rtPA in the following scenarios: (1) elderly individuals irrespective of age (97%); (2) severe stroke irrespective of National Institutes of Health Stroke Scale (NIHSS) (95%); or (3) suspected stroke with seizures at symptom onset (91%). None recommended rtPA in the setting of an international normalized ratio >1.7. Most clinicians defined mild strokes as an exclusion based on the perceived disability of the deficit (80%) rather than on a specific NIHSS threshold.Most surveyed stroke clinicians seem to find that the current IV rtPA eligibility criteria for the 3-hour time frame too restrictive. All would recommend rtPA to eligible patients in the 3 to 4.5 hours time frame despite the absence of an U.S. Food and Drug Administration (FDA)-approved indication.

SUBMITTER: De Los Rios F

PROVIDER: S-EPMC4157964 | biostudies-other | 2014 Sep

REPOSITORIES: biostudies-other

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Project description:Importance: Early mobilization, out-of-bed activity, is a component of acute stroke unit care; however, stroke patient heterogeneity requires complex decision-making. Clinically credible and applicable CPGs are needed to support and optimize the delivery of care. In this study, we are specifically exploring the role of clinical practice guidelines to support individual patient-level decision-making by stroke clinicians about early mobilization post-stroke. Methods: Our study uses a novel, two-pronged approach. (1) A review of CPGs containing recommendations for early mobilization practices published after 2015 was appraised using purposely selected items from the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) tool relevant to decision-making for clinicians. (2) A cross-sectional study involving semi-structured interviews with Australian expert stroke clinicians representing content experts and CPG target users. Every CPG was independently assessed against the AGREE-REX standard by two reviewers. Expert stroke clinicians, invited via email, were recruited between June 2019 to March 2020.The main outcomes from the review was the proportion of criteria addressed for each AGREE-REX item by individual and all CPG(s). The main cross-sectional outcomes were the distributions of stroke clinicians' responses about the utility of CPGs, specific areas of uncertainty in early mobilization decision-making, and suggested parameters for inclusion in future early mobilization CPGs. Results: In 18 identified CPGs, many did not adequately address the "Evidence" and "Applicability to Patients" AGREE-REX items. Out of 30 expert stroke clinicians (11 physicians [37%], 11 physiotherapists [37%], 8 nurses [26%]; median [IQR] years of experience, 14 [10-25]), 47% found current CPGs "too broad or vague," while 40% rely on individual clinical judgement and interpretation of the evidence to select an evidence-based choice of action. The areas of uncertainty in decision-making revealed four key suggestions: (1) more granular descriptions of patient and stroke characteristics for appropriate tailoring of decisions, (2) clear statements about when clinical flexibility is appropriate, (3) detailed description of the intervention dose, and (4) physical assessment criteria including safety parameters. Conclusions: The lack of specificity, clinical applicability, and adaptability of current CPGs to effectively respond to the heterogeneous clinical stroke context has provided a clear direction for improvement.

Project description:Historically, people with hemophilia have been warned to avoid physical activities as a possible cause of bleeding; however, currently, sport is considered necessary, especially in the developmental age, for providing a good quality of life. A survey was proposed to a group of hematologists and sports physicians working in Puglia, Italy, to explore their approach to physical activities for their patients with hemophilia and to obtain suggestions about possible interventions to promote the access of patients to sports. The survey was answered by 6 hematologists and 15 sports physicians. In total, 71% (about six patients/year/physician) of patients with hemophilia seen by sports physicians asked for counseling about sports, and 67% (about five patients/year/physician) actually practiced sports. On the other hand, only 31% (about 16 patients/year/hematologist) of patients asked hematologists questions on sports, and only 16% (about seven patients/year/hematologist) of patients with hemophilia and that were followed-up by hematologists practiced sports. The sports most often recommended to patients with hemophilia by physicians included swimming, athletics, tennis, running and gymnastics. According to hematologists, physical activity was very efficient in improving the quality of life of patients; stability of joints; their psychological, social and musculoskeletal wellbeing; and in reducing the risk of bleedings. On the other hand, physical activity was considered less important in all these areas by sport physicians. In conclusion, answers to this survey suggested that sports could be promoted among hemophilic patients by increasing the sports physicians' knowledge about hemophilia and their special role in this area. In addition, interviewed clinicians were of the opinion that increased awareness of specific guidelines and clinical practice protocols among both hematologists and sports physicians could be beneficial. Finally, answers suggested that access to fitness certification should be facilitated.

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Intravenous fibrinolysis eligibility: a survey of stroke clinicians' practice patterns and review of the literature.

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