health care

Burton J. Tabaac, MD
@burtontabaac

Diegoli H, Magalhães PSC, Martins SCO, Moro CHC, França PHC, Safanelli J, Nagel, V, Venancio VG, Liberato RB, Longo AL. Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era. Stroke. 2020.

On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic. As of this writing, the global number of cases exceeds 8.1 million. However, despite the rapidly increasing prevalence of COVID-19, many questions remain regarding this unusual and highly lethal disease. The pathogenesis of COVID-19–associated neurologic injury remains to be established. SARS-CoV-2 has been shown to induce a hypercoagulable state, thus increasing the risk of arterial thrombosis with acute ischemic stroke.(1)

From late 2019 to early 2020, COVID-19 started to disrupt the healthcare systems of many nations. From the beginning of the pandemic, it has been a major concern for doctors and public authorities that resources needed to treat other conditions such as stroke are diverted for COVID-19.(2) The authors are keen to note that “patients may be unwilling to go to a hospital for stroke treatment due to fear of becoming contaminated with the disease.” Using a population-based stroke registry, the authors of this original contribution investigated the impact of the onset of the COVID-19 pandemic on stroke admissions in Joinville, Brazil. The authors’ hypotheses were as follows: First, hospital admissions for stroke were reduced after the onset of the COVID-19 pandemic. Next, the reduction occurred only in transient ischemic attacks (TIA) and mild cases. Also, there was a change in the time between stroke onset and hospital admissions. Finally, the number of patients receiving reperfusion therapies (IVT and MT) has decreased.

Rachel Forman, MD

Haslett JJ, Genadry L, Zhang X, LaBelle LA, Bederson J, Mocco J, et al. Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke. Stroke. 2019

When I read the title of this article, the first thing that came to mind was the bleeding risk associated with tPA. After all, we carefully read through the tPA contraindications checklist making sure we will not cause harm to our patients. It turns out that there is a lot more to worry about! 

In the article “Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke,” Haslett et al. discuss characteristics of malpractice cases related to acute stroke management. 

It was helpful that the authors first defined some legal terms, specifically that “to prove medical malpractice occurred, a plaintiff must show that during the course of treatment, the physician deviated from the standard of care as defined by the medical community, and that caused injury to the patient.”

Lina Palaiodimou, MD

Lip GYH, Keshishian A, Li X, Hamilton M, Masseria C, Gupta K, et al. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients: The ARISTOPHANES Study. Stroke. 2018

The ARISTOPHANES study is a large retrospective observational study with real-world data pooled from 5 data sources in the United States, in order to compare stroke/systemic embolism (SE) and major bleeding (MB) among nonvalvular atrial fibrillation patients treated with either non-vitamin K antagonist oral anticoagulants (NOACs) or warfarin.

The researchers of this study collected data about a total of 321182 patients with a diagnosis of AF, who had an active medical and pharmacy health plan enrollment and were prescribed treatment with either NOAC or warfarin according to pharmacy claims. Exclusion criteria were the following: evidence of valvular heart disease, venous thromboembolism, previous oral anticoagulant treatment, transient AF due to treatable causes (pericarditis, hyperthyroidism, thyrotoxicity), heart valve replacement or transplant, pregnancy and recent surgical operations. Demographic data, Charlson Comorbidity Index score, baseline bleeding and stroke/SE history, comorbidities, baseline comedication and dose of NOAC were recorded about all patients. In contrast, reason for lose-dose NOAC prescription, creatinine clearance, international normalized ratio (INR) measurements in warfarin-treatment group and patient adherence data were not available. The outcome measures were time to stroke (either ischemic or hemorrhagic) or systemic embolism and time to major bleeding, either gastrointestinal or intracranial or at other key sites (eyes, pericardium, urinary tract, joints). Identification of these events were based just on hospitalization incidence with stroke/SE or MB as the principal diagnosis according to International Classification of Diseases, Ninth Revision (ICD-9). Mortality due to all-causes was also evaluated, but just for the patients enlisted in only one out of five data sources. Patients were followed up each for a different period, according to drug discontinuation date, switch to another drug date, death, end of medical and pharmacy health plan enrollment, or end of study period, whichever occurred first. In the conducted sensitivity analysis, the follow-up period was restricted to 1 year, to better achieve balance between the cohorts.

Kevin S. Attenhofer, MD

Dijkland SA, Voormolen DC, Venema E, Roozenbeek B, Polinder S, Haagsma JA, et al. Utility-Weighted Modified Rankin Scale as Primary Outcome in Stroke Trials: A Simulation Study. Stroke. 2018

As stroke neurologists, we are all intimately familiar with the modified Rankin Scale (mRS) as a measure of degree of disability. It is a common outcome measure in stroke research and can be statistically analyzed as a simple dichotomization or ordinal shift (among other options). The dichotomized outcome takes varied and complex neurological outcomes and simplifies them down to nominal variables of “good” or “bad.” This is statistically more straightforward, but does result in some outcome information being discarded. The ordinal shift retains more of this information, but typically requires larger sample size to maintain adequate power. Even when well powered, however, the mRS still has a disproportionate focus on motor function when compared to other neurological domains, such as cognition or patient metrics such as quality of life.