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By: F. Umbrak, M.B.A., M.B.B.S., M.H.S.
Program Director, University of Minnesota Medical School
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To maximise the potential benefit from revascularization treatments and the acute management of intracerebral haemorrhage, the Working Party has further reduced the recommended maximum time between admission and brain imaging for suspected stroke from 12 hours to ‘urgently and at most within 1 hour of arrival at hospital’. Multi modal imaging is becoming more widely available and quicker to undertake and interpret. Underlying causes of stroke such as heart disease, diabetes and hypertension need diagnosis and management in their own right, but these are outside the scope of this guideline. Interpretation of acute stroke imaging by trained non-radiologists is safe and effective (Spokoyny et al, 2014). B Patients with suspected acute stroke should receive brain imaging urgently and at most within 1 hour of arrival at hospital. C Interpretation of acute stroke imaging for thrombolysis decisions should only be made by healthcare professionals who have received appropriate training. Hyperacute stroke services will need to review their provision of specialist assessment and imaging policies for suspected acute stroke, which in many centres will involve a step-change in provision. Treatment with alteplase should only be given in units where staff are trained and experienced in the provision of stroke thrombolysis, with a thorough knowledge of the contraindications to treatment and the management of complications such as neurological deterioration (in 13% of patients) and anaphylaxis (in 0. Endovascular therapy for acute ischaemic stroke is a major development since the 2012 edition and new guidance is included in this section. Urgent neurosurgical intervention for acute ischaemic stroke is also considered in this section. Evidence to recommendations Research has established that the current licensed indications for alteplase treatment should be widened. These analyses emphasise how critical it is that treatment is given as quickly as possible after the onset of stroke. The Cochrane review and meta-analysis shows that older patients benefit at least as much as those below the age of 80 years, so there is no upper age limit for treatment, particularly within the first 3 hours. Patients with mild and severe stroke and those with early signs of infarction on initial brain imaging also benefit from treatment, as long as early radiological changes are consistent with the stated time of onset. These findings suggest that there may be circumstances in which the treating physician and/or the patient wish to forgo some of the potential disability benefit from standard dose alteplase in order to reduce the early risk of intracerebral haemorrhage through the use of the lower dose. A meta-analysis of risk factors for intracerebral haemorrhage with alteplase (Whiteley et al, 2012) suggested a greater risk with atrial fibrillation, congestive cardiac failure, renal impairment, prior antiplatelet treatment, leukoaraiosis and visible cerebral infarction on pre-treatment brain imaging, but the extent to which any of these factors should influence dose selection for alteplase remains unknown. In an individual patient meta-analysis of these 5 trials involving 1287 patients (Goyal et al, 2016) endovascular therapy showed significant improvements in functional outcomes at 90 days. The trials varied in onset to endovascular treatment from a maximum of 6 up to 12 hours, and it is pertinent that all the trials with an extended time window required a favourable profile of salvageable brain tissue imaging prior to randomisation. The proven time window for endovascular therapy without such imaging is to perform thrombectomy. Decisions to undertake major life-saving surgery need to be carefully considered on an individual basis, but patients should not be excluded from treatment by age alone.
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Effects of a perindopril dictive factors of early seizures after acute cerebrovascular disease. Effect of treating isolated rhage and the role of long-term antiepileptic therapy. J Crit Care systolic hypertension on the risk of developing various types and 2009; 24:335–9. Treatment of warfarin-associated outcome following intracerebral hemorrhage: a systematic review. Thromb Haemost age closure for stroke prophylaxis in patients with atrial fibrillation: 2012; 107:241–7. Appendage System for Embolic Protection in Patients with Atrial Prescribing antiplatelet medicine and subsequent events after intrac Fibrillation) Trial. Aspirin and recurrent intracere occlusion in atrial fibrillation after intracranial hemorrhage. When are ran anticoagulation in patients who suffer an intracranial bleed who also domised trials unnecessary? Restarting anticoagulation therapy after warfarin-associated intrac Supporting information erebral hemorrhage. Pharmacological prophylaxis of venous thromboembo version of this article at the publisher’s web-site: lism during acute phase of spontaneous intracerebral hemorrhage: what do we know about risks and benefits? Endorsed by the American Association of Neurological Surgeons and Congress of Neurological Surgeons 0 Copyright © 2013 American Heart Association Edward C. Copyright © 2013 American Heart Association– the time between the receipt of the call and the dispatch of the response team is less than 90 seconds. Forming a clinical process improvement team and establishing a stroke care data bank is helpful for such quality of care assurances. The data repository can be used to identify the gaps or disparities of quality stroke care. The evaluation and initial treatment of patients with stroke should be performed expeditiously. Because time is critical, a limited number of essential diagnostic tests are recommended Copyright © 2013 American Heart Association. Stroke protocols and pathways should clearly define which tests must be performed prior to acute treatment decisions and which may be performed subsequent to acute stroke therapies Copyright © 2013 American Heart Association 12 V. Copyright © 2013 American Heart Association Designation of an acute stroke team that includes physicians, nurses, and laboratory/radiology personnel is encouraged. These techniques provide additional information that may improve diagnosis, mechanism, and Copyright © 2013 American Heart Association severity of ischemic stroke and allow more informed clinical decision-making.
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In addition, on-the-job training, vocational counseling, supported employment, and case-management services have been identifed as predictors of positive employment outcomes (Chesnut et al. This also has a bearing on research because fnding Some have called for increased eforts to manualize a sizeable study population with similar attributes for treatment. In addition, pre-injury instructions) to enhance the comparability of treatment factors such as age, pre-injury functioning, socioeconomic across treatment sites and research studies (Gordon, status, caregiver and family functioning, social support, 2010). However, it may be premature to focus too many and access to care, can infuence the recovery of a patient. Also, with regard to the intensity better ensure that sufcient levels of treatment are covered. Also, the need to develop timing of rehabilitation, evidence suggests that intensive and evaluate service models must be addressed so that intervention in the very acute stage of motor recovery parents will have the assistance to better navigate the (less than 2 months post-injury) is not advantageous post-acute rehabilitation setting, ensuring that needed and can actually exacerbate defcits (Dromerick et al. T erefore, it is important several facets of the rehabilitation research community to to establish integrated healthcare models that support develop usable and meaningful models for classifying and ongoing treatment, community integration, and cognitive measuring rehabilitation interventions. Robust research methods are needed to resolve these gaps Comparative efectiveness studies are needed to examine within each discipline or specialty of rehabilitation. Despite the ongoing needs documenting the overall economic beneft of rehabilitation. Attempts should be made rehabilitation services would likely be helpful in expanding within all rehabilitation outcomes studies to measure the coverage for these services. Evidence suggests research studies should be continued and expanded to that rehabilitation services can improve a person’s quality of better document the real-world utility of rehabilitation. Research is lacking relative to the efectiveness of Researchers and practitioners must collaborate to identify rehabilitation services following acute rehabilitation, and pursue opportunities to strengthen the rehabilitation such as community-based rehabilitation and vocational system and coordination of care, so that appropriate rehabilitation interventions. Conduct research studies to better examine the optimal timing, intensity, and dose of rehabilitation interventions. Examining effectiveness among particular sub-populations can help to identify ways in which rehabilitation might be tailored to the particular needs of sub-groups to optimize effectiveness. Conduct research studies to examine the effectiveness of rehabilitation services following acute inpatient rehabilitation, such as community-based rehabilitation and vocational rehabilitation. Evaluate the effectiveness and cost effectiveness of alternative delivery models—especially those that might overcome barriers to rehabilitation access caused by factors such as rural residence and lack of transportation. Increase widespread dissemination of emerging practices such as the use of global positioning system devices, paging systems, and smartphones to aid with cognitive rehabilitation. Maintaining a comprehensive and coordinated system of rehabilitation interventions is critical to achieve this end. The development of guidelines is a systematic process in which a panel of experts assesses the scientifc literature to produce practice recommendations. Ideally, any guidelines developed will help clinicians to make evidence-based decisions supported by research. These challenges must be addressed in order to improve the evidence base before proceeding to guideline development. In addition, studies examining the relationship between the cost-beneft ratio and the length, duration, and intensity of rehabilitation services are needed.
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Patient Ultimately, as with all clinical guidelines, decisions regarding screening and clinical management for any specifc patient should be individually Preferences tailored, taking into consideration the patient’s treatment history, risk factors, co-morbidities, and lifestyle. These guidelines are therefore not intended to replace clinical judgment or to exclude other reasonable alternative follow-up procedures. Implementation Implementation of these guidelines is intended to standardize and enhance follow-up care provided to survivors of pediatric malignancies throughout Considerations: the lifespan. Considerations in this regard include the practicality and effciency of applying these broad guidelines in individual clinical situations. Issues being addressed include description of anticipated barriers to application of the recommendations in the guidelines and development of review criteria for measuring changes in care when the guidelines are implemented. Additional concerns surround the lack of current evidence establishing the effcacy of screening for late complications in pediatric cancer survivors. While most clinicians believe that ongoing surveillance for these late complications is important in order to allow for early detection and intervention for complications that may arise, development of studies addressing the effcacy of this approach is imperative in order to determine which screening modalities are optimal for asymptomatic survivors. While recognizing that the length and depth of these guidelines is important in order to provide clinically-relevant, evidence-based recommendations and supporting health education materials, clinician time limitations and the effort required to identify the specifc recommendations relevant to individual patients have been identifed as barriers to their clinical application. The Pasport for Care application is available to Children’s Oncology member institutions at no cost. The guidelines outline minimum recommendations for specifc health screening evaluations in order to detect potential late effects arising as a result of therapeutic exposures received during treatment of childhood, adolescent, and young adult cancers. Each score relates to the strength of the association of the identifed late effect with the specifc therapeutic exposure based on current literature, and is coupled with a recommendation for periodic health screening based on the collective clinical experience of the panel of experts. This is due to the fact that there are no randomized clinical trials (and none forthcoming in the foreseeable future) on which to base recommendations for periodic screening evaluations in this population; therefore, the guidelines should not be misconstrued as representing conventional “evidence-based clinical practice guidelines” or “standards of care”. Each item was scored based on the level of evidence currently available to support it. Scores were assigned according to a modifed version of the National Comprehensive Cancer Network “Categories of Consensus,” as follows: Category Statement of Consensus 1 There is uniform consensus of the panel that: (1) there is high-level evidence linking the late effect with the therapeutic exposure and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members. Non-uniform consensus: the majority of panel members agree with the recommendation; however, there is recognition among panel members that, given the quality of evidence, clinicians may choose to adopt different approaches. High-level evidence: Evidence derived from high quality case control or cohort studies. Lower-level evidence: Evidence derived from non-analytic studies, case reports, case series, and clinical experience. Therapeutic Agent Therapeutic intervention for malignancy, including chemotherapy, radiation, surgery, blood/serum products, hematopoietic cell transplant, and other therapeutic modalities. Potential Late Effects Most common late treatment complications associated with specifed therapeutic intervention.