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  • 1
    Keywords: GROWTH ; Germany ; PATIENT ; COMPLEX ; COMPLEXES ; REDUCTION ; EFFICACY ; MANAGEMENT ; GUIDELINES ; STROKE ; ADULTS ; monitoring ; methods ; PHASE ; ANTAGONISTS ; INR ; ORAL ANTICOAGULANT-THERAPY ; PROTHROMBIN COMPLEX CONCENTRATE ; VITAMIN-K ; WARFARIN REVERSAL
    Abstract: Objective: Rapid reversal of the anticoagulatory effect of vitamin K antagonists represents the primary emergency treatment for oral anticoagulant-related intracerebral hemorrhage (OAC-ICH). Predicting the amount of prothrombin complex concentrate (PCC) needed to reverse OAC in individual patients is difficult, and repeated international normalized ratio (INR) measurements in central laboratories (CLs) are time-consuming. Accuracy and effectiveness of point-of-care INR coagulometers (POCs) for INR reversal in OAC-ICH have not been evaluated. Methods: In phase 1, the agreement of emergency POC and CL INR measurements was determined. In phase 2, stepwise OAC reversal was performed with PCC using a predetermined dosing schedule. Concordance of POC and CL INR measurements during reversal and time gain due to POC were determined. Results: In phase 1 (n = 165), Bland-Altman analysis showed close agreement between POCs and CLs (mean INR deviation 0.04). In phase 2 (n = 26), POCs caused a median initial net time gain of 24 minutes for the start of treatment with PCC. Median time for POC-documented complete OAC reversal was 28 minutes, compared with 120 minutes for CLs. Bland-Altman analysis between POCs and CLs revealed a mean INR deviation of 0.13 during stepwise PCC administration. POCs tended to slightly overestimate the INR, especially at higher INR levels. Remarkably, POC-guided reversal led to a median reduction of 30.5% of PCC dose compared with the a priori dose calculation. Hematomas enlarged in 20% of patients. Interpretation: POC INR monitoring is a fast, effective, and economic means of PCC dose-titration in OAC-ICH. Larger studies examining the clinical efficacy of this procedure are warranted. ANN NEUROL 2010;67:788-793
    Type of Publication: Journal article published
    PubMed ID: 20517940
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  • 2
    Keywords: THERAPY ; GUIDELINES ; STROKE ; ATRIAL-FIBRILLATION ; intracranial hemorrhage ; intracerebral hemorrhage ; INR ; PROTHROMBIN COMPLEX CONCENTRATE ; WARFARIN REVERSAL ; COAGULOPATHY ; Oral anticoagulation ; Reversal treatment ; Subdural hemorrhage
    Abstract: Emergency reversal of the international normalized ratio (INR) in patients who develop nontraumatic subdural hemorrhage (SDH) due to oral anticoagulants (OAC) represents a primary treatment strategy but it is difficult to predict the amount of prothrombin complex concentrate (PCC) needed for reversal treatment. Moreover, repeated INR testings in central laboratories (CL) are time consuming. The usefulness of point-of-care INR coagulometers (POC) to test the success of INR reversal in OAC-SDH has not yet been investigated. Prospectively, INR reversal was performed by administering PCC to patients suffering from acute SDH-OAC using a predefined dosing schedule. Accuracy and time gained by using POC were assessed and compared with CL measurements. A total of 10 patients were treated according to the protocol (male: 5). Bland-Altman analysis between POC and CL revealed a mean INR deviation of 0.013 for initial INR values and of 0.081 during reversal treatment. Using POC, the median initial net time gain (accounting for clinical examination and CT) for the start of PCC was 21 min. Median total time for POC-documented reversal was 27 min, as compared to 70 min for CL. The shortest interval between head CT and start of emergency SDH evacuation surgery was 37 min. By employing stepwise POC-guided reversal of the anticoagulatory effect of OAC, the calculated PCC dose could be reduced by 25% in the median. Using POC to measure INR values and patient-adapted PCC administration is a fast and economic method to reverse anticoagulation in patients with acute OAC-SDH
    Type of Publication: Journal article published
    PubMed ID: 20878267
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  • 3
    Keywords: IN-VIVO ; SYSTEM ; magnetic resonance ; virus ; monitoring
    Type of Publication: Journal article published
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  • 4
  • 5
    Abstract: BACKGROUND: Atrial fibrillation (AF) is a frequent cause of stroke, but detecting paroxysmal AF (pAF) poses a challenge. We investigated whether continuous bedside ECG monitoring in a stroke unit detects pAF more sensitively than 24-hour Holter ECG, and tested whether examining RR interval dynamics on short-term ECG recordings using an automated screening algorithm (ASA) for pAF detection is a useful tool to predict the risk of pAF outside periods of manifest AF. METHODS: Patients 〉60 years with acute ischemic stroke or transient ischemic attacks (TIA) were prospectively enrolled unless initial ECG revealed AF or they had a history of paroxysmal or persistent AF. ASA was performed on 1- to 2-hour ECG recordings in the emergency room and patients were classified into 5 risk categories for pAF. All patients underwent continuous bedside ECG monitoring for 〉48 h. Additionally, 24-hour Holter ECG was performed. RESULTS: 136 patients were enrolled (median age: 72 years, male: 58.8%). In 29 (21.3%), pAF was newly diagnosed by continuous bedside ECG monitoring. pAF increased with age (p = 0.031). Median time to first pAF detection on continuous bedside ECG monitoring was 36 h. In 16 patients, pAF was detected by continuous bedside ECG monitoring prior to the performance of 24-hour Holter ECG. Thirteen of the remaining patients were pAF positive on continuous bedside ECG monitoring, but 24-hour Holter detected only 3 patients. Accordingly, the sensitivity of 24-hour Holter was 0.23. Sensitivity of higher-risk categories of ASA compared to continuous bedside ECG monitoring was 0.72, and specificity 0.63. CONCLUSION: Continuous bedside ECG monitoring is more sensitive than 24-hour Holter ECG for pAF detection in acute stroke/TIA patients. Screening patients for pAF outside AF episodes using ASA requires further development.
    Type of Publication: Journal article published
    PubMed ID: 20720410
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  • 6
    Keywords: THERAPY ; TIME ; ASSOCIATION ; PREVALENCE ; GUIDELINES ; ATRIAL-FIBRILLATION ; INR ; SELF-MANAGEMENT
    Abstract: Abstract: Background and Purpose-Thrombolysis in patients using oral anticoagulants (OAC) and in patients for whom information on OAC status is not available is frequently delayed because the standard coagulation analysis procedure in central laboratories (CL) is time-consuming. By using point-of-care (POC) coagumeters, international normalized ratio (INR) values can be measured immediately at the bedside. The accuracy and effectiveness of POC devices for emergency management in acute ischemic stroke has not been tested. Methods-In phase 1, the reliability of emergency INR POC measurements in comparison to CL was determined. In phase 2, patients with ischemic stroke admitted within the time frame for systemic thrombolysis and who were either using OAC or for whom information on OAC status was not available were enrolled. Patients received thrombolysis if POC INR was 〈= 1.5. Precision and time gain was recorded for INR as measured by POC vs CL. Results-In phase 1 (n = 113), Bland-Altman analysis showed close agreement between POC and CL, and Pearson correlation was highly significant (r = 0.98; P〈0.01). In phase 2, 48 patients were included, of whom 70.8% were using OAC; 23 patients received thrombolysis. After subtracting the time needed for the diagnostic work-up, the net time gain was 28 +/- 12 minutes (mean +/- SD). Conclusions-Measuring INR by POC in an emergency setting is sufficiently precise in OAC acute stroke patients and substantially reduces the time interval until INR values are available and therefore may hasten the initiation of thrombolysis. (Stroke. 2009; 40: 3547-3551.)
    Type of Publication: Journal article published
    PubMed ID: 19696414
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  • 7
    Keywords: RISK-FACTORS ; INTERVENTION ; prevention ; MANAGEMENT ; GUIDELINES ; acute ischemic stroke ; transient ischemic attack ; Oral anticoagulation ; ANTITHROMBOTIC THERAPY ; Atrial fibrillation cardiogenic embolism ; CARDIOVASCULAR RADIOLOGY ; EARLY DEATH ; PREVENT STROKE ; SYMPTOMATIC PATIENTS
    Abstract: BACKGROUND: Atrial fibrillation (AF) is a common cause of ischemic stroke and transient ischemic attack (TIA). More extensive diagnostic effort is required to detect paroxysmal AF (pxAF) than persistent AF (pAF); the prevalence of pxAF in stroke patients is unknown. We evaluated the prevalence of pAF and pxAF in ischemic stroke and TIA patients. METHODS: Consecutive patients with acute ischemic stroke/TIA were enrolled prospectively. We aimed to detect patients with a history of AF, with AF newly diagnosed in the emergency room (ER), or with newly diagnosed AF during a 3-month period following the event. Differences in the frequency of AF diagnosis with respect to the disposition of patients after ER work-up were assessed. RESULTS: A total of 692 patients were enrolled (male: 52.2%; ischemic stroke: 69.1%; TIA: 30.9%). A previously documented history of AF was present in 19.7% (pAF: 47.1%, pxAF: 52.9%). In 3.8% of patients, AF was newly diagnosed in the ER (pxAF: 61.5%) and in 5.2% during the 3-month follow-up period. The overall prevalence of AF was 28.6% (pxAF: 62.6%). Previously documented pxAF evaded diagnosis at ER presentation in 48.6%. The prevalence of AF increased with age (p 〈 0.001). Patients with pxAF were younger than those with pAF (p = 0.004) and more often female (p = 0.05). The presence of any AF was associated with higher initial NIHSS scores (p 〈 0.001) and higher modified Rankin scores after 3 months (p 〈 0.001). CONCLUSION: pxAF occurs more often than pAF in stroke/TIA patients. As effective stroke prevention is available for AF, it is important to develop and evaluate sensitive methods for detecting pxAF.
    Type of Publication: Journal article published
    PubMed ID: 21893980
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  • 8
    Keywords: THERAPY ; DISEASE ; MANAGEMENT ; GUIDELINES ; FLUTTER ; ACUTE ISCHEMIC-STROKE ; Oral anticoagulation ; EVENT RECORDERS ; IMPROVE ; ATTACK
    Abstract: BACKGROUND AND PURPOSE: Cardioembolism in paroxysmal atrial fibrillation (pxAF) is a frequent cause of ischemic stroke. Sensitive detection of pxAF after stroke is crucial for adequate secondary stroke prevention; the optimal diagnostic modality to detect pxAF on stroke units is unknown. We compared 24-hour Holter electrocardiography (ECG) with continuous stroke unit ECG monitoring (CEM) for pxAF detection. METHODS: Patients with acute ischemic stroke or transient ischemic attack were prospectively enrolled. After a 12-channel ECG on admission, all patients received 24-hour Holter ECG and CEM. Additionally, ECG monitoring data underwent automated analysis using dedicated software to identify pxAF. Patients with a history of atrial fibrillation or with atrial fibrillation on the admission ECG were excluded. RESULTS: Four hundred ninety-six patients (median age, 69 years; 61.5% male) fulfilled all inclusion criteria (ischemic stroke: 80.4%; transient ischemic attack: 19.6%). Median stroke unit stay lasted 88.8 hours (interquartile range, 65.0-122.0). ECG data for automated CEM analysis were available for a median time of 64.0 hours (43.0-89.8). Paroxysmal AF was documented in 41 of 496 patients (8.3%). Of these, Holter detected pxAF in 34.1%; CEM in 65.9%; and automated CEM in 92.7%. CEM and automated CEM detected significantly more patients with pxAF than Holter (P〈0.001), and automated CEM detected more patients than CEM (P〈0.001). CONCLUSIONS: Automated analysis of CEM improves pxAF detection in patients with stroke on stroke units compared with 24-hour Holter ECG. The comparative usefulness of prolonged or repetitive Holter ECG recordings requires further evaluation.
    Type of Publication: Journal article published
    PubMed ID: 22871678
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  • 9
    ISSN: 1432-1238
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Type of Medium: Electronic Resource
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  • 10
    ISSN: 1432-1246
    Keywords: Key words Painters ; Organic solvents ; Neurotoxicity ; Symptoms
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objectives: The main aim of the study was to examine possible solvent-associated effects on the nervous system in currently employed painters. Special attention was paid to evaluate subtle health effects. Materials and methods: A total of 401 painters and 209 construction workers without solvent exposure with at least 10 years of professional experience were subjected to a clinical, neurological, psychiatric, neuropsychological and neurophysiological examination. For personal medical and occupational history, standardized questionnaires were used. A quantitative rating of exposure was obtained by expert rating of the respective occupational history without knowledge of the individual test results. Results: There was no excess of somatic disorders or solvent-associated adverse effects on the nervous system. No distinct effects of solvent exposure on nerve conduction velocities (NCV) or cognition were found. Discrete NCV deficits in painters were not considered a sign of subclinical polyneuropathy. Painters, however, reported an excess of specific symptoms that could be assigned to “mood and behaviour”. The differences between specific and non-specific questionnaire outcomes on the one hand and the positive correlation between chronic exposure index and symptom scores on the other hand support the hypothesis of solvent-induced effects. Because data is lacking on past solvent exposure, it is not possible to relate these effects to current exposure limits. Conclusions: Currently employed painters differ from controls not exposed to solvents with respect to the frequency of certain symptoms in mood and behaviour. These symptoms are related to life-long solvent exposure rather than to current exposure. At present, the issue of time course and reversibility or irreversibility of these symptoms cannot be answered. The predictive value for subsequent neuropsychiatric morbidity remains to be elucidated in follow-up studies.
    Type of Medium: Electronic Resource
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