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#61
28.11.2006, 08:09
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И это еще не сеIn the second scenario, a young woman age 51 presented to the emergency department with a severe ischemic stroke, NIHSS score of 29. Her systolic blood pressure was 165 mm Hg, serum glucose was 13.1 mmol/L, and after all her examinations, diagnostic tests, and brain imaging were performed, 2 hours had already elapsed since symptom onset. Once again, a critical treatment decision had to be made. The prevailing thought that ran through the mind of the treating physician was that the woman’s prognosis was invariably extremely poor, based on the clinical stroke severity at presentation.10,11 Additionally, the physician was reminded that a very high NIHSS score was at least a relative contraindication to administration of rt-PA. The physician recalled that the stroke severity was an independent predictor of symptomatic intracranial hemorrhage. Most patients with a symptomatic intracranial hemorrhage had experienced a severe stroke (NIHSS score >20). The physician estimated the risk of such a hemorrhage in this woman to exceed 17%.12 After presenting the pros and cons to the family, the collective decision was that rt-PA treatment was probably futile and even potentially harmful. The family grieved but felt that they understood the logic behind withholding rt-PA therapy.
In these fictional examples, the evidence-based and experience-based clinical decision-making is vulnerable to potential errors in judgment. Only some of the available evidence was used by the decision-making parties. Most of the physicians’ predictive estimates of prognosis were nonquantitative, imprecise, and even vague. Even the quoted quantitative estimates of various potential outcomes of effect and harm with or without rt-PA were hard to interpret for patients, family members, and clinicians. Now imagine the same 2 clinical scenarios with the Stroke-TPI available for use by the treating physician. In the first case, the following patient characteristics were entered into the Stroke-TPI on a handheld computer system: age 77 years, female gender, diabetes, no prior stroke, 140 mm Hg systolic blood pressure, glucose of 15.2 mmol/L, NIHSS score of 5, and a symptom onset to treatment time of 179 minutes. The patient-specific predictions of outcome probabilities were instantly calculated and presented. As the physician had suspected, the probability of a normal or near-normal outcome without rt-PA was already quite good, at 48%, and the probability of having a catastrophic outcome was truly low, at only 13%. What was incredibly valuable was the estimate of a normal or near-normal outcome after administration of rt-PA in this woman, 72%. This quantity could easily be compared with the 48% chance of a good outcome without treatment, yielding an impressive 24% absolute risk difference. It is this risk difference that was formerly falsely perceived, by the decision-making parties, to be low or even negligible. Given this valuable, tailored, applicable, quantitative information, a different conclusion might have been reached—to treat—despite the mild stroke and late symptom onset to treatment time. In the second case, these patient characteristics were entered: age 51 years, female gender, no diabetes or prior stroke, 165 mm Hg systolic blood pressure, serum glucose of 13.1 mmol/L, NIHSS score of 29, and 122 minutes from symptom onset to treatment time. The patient-specific predictions of outcome probabilities were calculated and presented. It was confirmed that the 
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#62
28.11.2006, 08:14
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В заключении; probability of a catastrophic outcome was very high, 51%, whether rt-PA was used or not. It was also confirmed that the probability of a good outcome, without rt-PA, was extremely low, 4%. What was better presented using the Stroke-TPI tool was the 9% probability of a good outcome with administration of rt-PA. If the husband of this woman was presented quantitative estimates of various outcomes, in this fashion, the ultimate treatment decision may have been a different one. Although he already appreciated that there was a fifty-fifty chance of catastrophic outcome regardless of treatment choice, he could now see that his wife had a 1 in 11 (9%) chance of making a good recovery with rt-PA versus a 1 in 25 (4%) chance without rt-PA. Armed with this quantitative information, a treatment attempt with rt-PA might not seem quite so futile. These case examples illustrate how this predictive instrument could potentially support point-of-care physician decision-making and counseling of patients and families.
A few limitations exist. The authors point out that the predictive equations are based on outcomes achieved in major randomized clinical trials. Thus, the outcome predictions may not be reliable for patients who are not well represented in the database (eg, the very elderly and those with pre-existing disability) and for instances when there is less than strict adherence to treatment protocols. The Stroke-TPI appears to be a well-conceived, valid, and potentially useful predictive instrument. The next natural step would be to study the effect it has on physician clinical decision-making and on patient outcomes. The Stroke-Thrombolytic Predictive Instrument Provides Valid Quantitative Estimates of Outcome Probabilities and Aids Clinical Decision-Making Key Words: acute care • acute stroke • emergency medicine • thrombolysis • thrombolytic RX Computerized clinical decision support systems are increasingly popular in health sciences and have been demonstrated to improve practitioner performance.1 For an emergency closely related to ischemic stroke, acute myocardial infarction, a thrombolytic predictive instrument was developed for real-time use in emergency medical-service settings to identify patients likely to benefit from thrombolysis and to facilitate the earliest possible use of this therapy.2,3 A similar instrument, designed for ischemic stroke, could also prove to be useful. Thrombolysis for ischemic stroke remains underused even under ideal circumstances. Approximately 40% of emergency physicians in a national survey report that they would not use recombinant tissue plasminogen activator (rt-PA) for stroke, citing the risk of symptomatic intracranial hemorrhage and relative lack of benefit.4 Similar results were reported by Bobrow et al in a survey of the Arizona chapter of the American College of Emergency Physicians. Only 52% of the emergency physicians who responded to the survey indicated that they would endorse rt-PA use for stroke under ideal conditions.5 Physicians’ perceptions of risks and benefits of rt-PA for stroke are not uniformly accurate.6 Merino et al reported that only 11% (95% CI, 0 to 22) of surveyed emergency medicine physicians and neurologists could correctly convey the expected magnitude of beneficial effect of rt-PA, and that only 39% (95% CI, 21 to 57) could accurately report the expected rate of symptomatic and fatal intracranial hemorrhage of rt-PA.6 This misperception may interfere with their willingness to endorse this treatment. It would be helpful to draw a distinction between true and perceived efficacy and between true and perceived
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#63
29.11.2006, 15:50
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ESTAT trial
Hennerici MG, Kay R, Bogousslavsky J, Lenzi GL, Verstraete M, Orgogozo JM; ESTAT investigators. Intravenous ancrod for acute ischaemic stroke in the European Stroke Treatment with Ancrod Trial: a randomised controlled trial. Lancet. 2006 Nov 25;368(9550):1871-8.
Department of Neurology, University of Heidelberg, Universitatsklinikum Mannheim, D-68135 Mannheim, Germany. [Ссылки доступны только зарегистрированным пользователям ] BACKGROUND: Intravenous tissue plasminogen activator is the only approved specific treatment for acute ischaemic stroke. Ancrod, a natural defibrinogenating agent from snake venom, has proved to have a favourable effect when given within 3 h after an acute ischaemic stroke. The European Stroke Treatment with Ancrod Trial was undertaken to assess the effects of ancrod when given within 6 h. METHODS: 1222 patients with an acute ischaemic stroke were included in this randomised double-blind placebo-controlled trial. Brain CT scans were done to exclude intracranial haemorrhages and large evolving ischaemic infarctions. Patients were randomly assigned ancrod (n=604) or placebo (n=618). The primary outcome was functional success at 3 months (survival, Barthel Index of 95 or 100, or return to prestroke level). The analysis was by intention-to-treat. This trial is registered with ClinicalTrials.gov, trial number NCT00343174. FINDINGS: Functional success at 3 months did not differ between patients given ancrod (42%) and those given placebo (42%) (p=0.94, OR=0.99, 95% CI, 0.76-1.29). INTERPRETATION: On the basis of our findings, ancrod should not be recommended for use in acute ischaemic stroke beyond 3 h.
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#65
16.09.2009, 22:19
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Немножно оффтопик. "Гайдлайн" по лечению инсульта от завед.н/отд. Цитирую дословно:
Цитата:
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#67
20.10.2009, 13:36
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Тромболизис при инсульте и при инфаркте - это таки "две большие разницы" (с). Насколько мне известно, никто эффективность и безопасность тромболизиса стрептокиназой при инсульте должным образом не проверял. Есть предположение, что риск геморрагических осложнений существенно выше возможной пользы.
Пару нескромных вопросов, если позволите ? 1. Где в Екатеринбурге есть стрептокиназа (для тромболизиса при инсульте), но нет альтеплазы ? Я лично стрептокиназу видел всего пару раз в жизни. 2. Если у Вас возник такой вопрос, то где именно в Екб Вы хотите проводить тромболизис при инсульте ?
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#69
28.02.2010, 10:46
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Интересная тема. Пока шла дискуссия, в стране стартовала сосудистая программа. Больных с инфарктами, инсультами везут в межрайонные центры. Министр сказала, что смертность от сосудистых заболевания снизилась в этих регионах на 14%. Поделитесь опытом(если кто участвует) в данной программе
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#70
28.02.2010, 12:07
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Если раньше были ограничения по возрасту для транспортировки в стационар, престарелых лиц и лиц в терминальном состоянии оставляли лечиться на дому под наблюдением участкового врача, где они умирали от голода и гиповолемии, то сейчас ограничения сняты- всех везут в стационар, где активно лечат, кормят, ухаживают, и многие выживают. Но количество инсультов медленно идет в рост.
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#71
28.02.2010, 13:50
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Цитата:
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#72
28.02.2010, 16:56
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Уважаемые коллеги!
Тема инсультов интересная сама по себе, но, я не думаю что решить вопрос с ишемическими инсультами удастся при помощи тромболизиса. И дело даже не в том, что ещё очень долго больные не будут поступать к вам в положенное время (от 0 до 3-х часов), да ещё полностью обследованными; дело также не в том, что вы не сможете мониторировать, что происходит в ГМ при проведении процедуры, и не сможете управлять процессом. Дело в том, что сами эти препараты (альтеплаза не исключение) могут вести к геморрагиям именно в головной мозг. А вы прекрасно знаете, что при ишемическом инсульте очень быстро формируется и продолжает нарастать зона некроза с исходом в инфаркт. И что получим, затратив ого-го какие деньги даже на одного больного. Я не скупой, но в ваших больницах таких денег никогда не будет. Платные клиники? А вы сможете гарантировать успех такого лечения, получив у родственников деньги? Нет, это не тот путь, как и не та золотая жила, которую следует разрабатывать. Это авантюра. Моё глубокое убеждение - искать другие пути. А тромболизис в данной ситуации пострашнее хирургического вмешательства. С уважением, Я.
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#73
28.02.2010, 17:28
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Цитата:
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#74
28.02.2010, 18:28
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Цитата:
Тромболизис при инсульте вполне осуществим и в муниципальных больницах. Основное условие - организационно, наличие круглосуточно работающего томографа и минимальная задержка пациента на этапе приемного отделения. В наших условиях - от поступления до собственно введения альтеплазы проходит обычно не более 15 минут. В этом году провели уже 8 - 10 случаев, во всех случаях отмечался позитивный эффект, в некоторых - даже очень очевидный.
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Линейный вид
