The changing patient profile: A retrospective study of trends in perioperative bleeding management and challenges in surgical care.

Objective. To determine relations between quality of life, morbidity of chronic non-infectious diseases and use of pharmaceuticals by stroke patients. Material and methods. The case group consisted of 508 Kaunas citizens, aged 25-84 years, who survived the stroke. The control group consisted of randomly chosen 508 sex- and age-matched Kaunas citizens without stroke. SF-12 questionnaire on the quality of life was used. Quality of life was analysed in physical and mental health domains taking into consideration morbidity of chronic non-infectious diseases and use of pharmaceuticals. The percentage of those who had more than one chronic non-infectious disease was 38.6 in the case group and 17.2 in the control group (p<0.001). With respect to the use of antihypertensive (66.5% in the case group and 67.3% in the control group), antithrombotic (21.5% and 24.6%) and antidepressant (100% and 100%) medication, case and control groups were similar. Results and conclusion. Compared to people without arterial hypertension, scores in physical health domain were lower in people with arterial hypertension (p=0.018) and the control group (p=0,0005). In the main group, people without atrial fibrillation scored lower (p=0.0005) in physical health domain compared to those with atrial fibrillation. Scores in mental health domain were lower in the control group (p=0.048). Compared to people with diabetes mellitus (DM), those with DM scored lower in the case group (p=0.0005). The use of antihypertensive or antithrombotic medication before stroke did not predict quality of life in patients with chronic non-infectious diseases. Meanwhile, in the control group the use of antithrombotic medication improved (p<0.05) the quality of life in physical health domain.

Introduction: Withdrawal of antithrombotic medication for medical procedures is a potentially important cause of ischemic stroke (Broderick, Stroke, 2011). However, population estimates of how commonly persons in the general population withdraw from antithrombotic medication during a given year are not available. Methods: Telephone survey respondents were drawn from our biracial population of 1.3 million using random-digit dialing in 2011 to reflect the age, race, and gender distribution of stroke patients, based on an ongoing stroke incidence study in the same region. In addition to demographic and medical history questions, we also asked if they had stopped the medication on request of their physician for scheduled surgery or other procedure during the past 60 days. Results: There were a total of 2036 surveyed, 1959 self-identified as either black (544) or white (1415) race. 62% were on antithrombotic medication overall of which 7% were on an anticoagulant and 58% were on an antiplatelet medication and 4% on both (Table 1). Use of antithrombotic medication increased with advancing age (p&lt;0.0001) and was more common in men (64%) than women (60%), p=0.09 and whites (64%) than blacks (55%), p=0.0003. Of those persons 75 years or older, 72% were taking an antithrombotic medication: an antiplatelet agent alone in 60%, anticoagulant alone in 6% and both in 6%. Of those using an antithrombotic medication, 10% indicated that they had stopped the medication in the past 60 days prior to interview. Of those that stopped the meds, 27/134 (20%) were on anticoagulants, and 101/1144 (9%) were on antiplatelet agents. Conclusions: Use of antithrombotic medication is widely prevalent in the population as is discontinuance of such medication for medical procedures, particularly warfarin. Withdrawal of anti-thrombotic medications for surgical procedures and diagnostic testing is a potential risk factor for ischemic stroke and is an important area for ongoing study.

Atrial fibrillation (AF) is the leading cause of ischemic stroke. Preventive antithrombotic use, especially for anticoagulation, reduces the incidence of ischemic stroke in patients with AF. Using data from the nationwide multicenter stroke registry, we investigated the trends of preceding antithrombotic medication use in patients with acute ischemic stroke (AIS) with AF and its association with initial stroke severity and in-hospital outcomes. This study included 6786 patients with AIS with known AF before stroke admission across 39 hospitals between June 2008 and December 2018. We collected the data on antithrombotic medication use (no antithrombotic/antiplatelet/anticoagulant) preceding AIS. Initial stroke severity was measured using the National Institutes of Health Stroke Scale, and in-hospital outcome was determined by modified Rankin Scale score at discharge. During the study period, anticoagulant use continued to increase. However, nearly one-third of patients with AIS with known AF did not receive antithrombotics before stroke. Initial National Institutes of Health Stroke Scale scores varied according to preceding antithrombotic therapy (P<0.001). It was higher in patients who did not receive antithrombotics than in those who received antiplatelets or anticoagulants (median National Institutes of Health Stroke Scale score: 8 versus 7 and 8 versus 6, respectively). Favorable outcome at discharge (modified Rankin Scale score, 0-2) was more prevalent in patients who received antiplatelets or anticoagulants (P<0.001). Use of antiplatelets (odds ratio, 1.23 [95% CI, 1.09-1.38]) and anticoagulants (odds ratio, 1.31 [95% CI, 1.15-1.50]) was associated with a mild initial neurological deficit (National Institutes of Health Stroke Scale score ≤5) in patients with AIS with AF. Throughout the study period, the proportion of patients taking anticoagulants increased among patients with AIS with known AF. However, a large portion of AF patients still did not receive antithrombotics before AIS. Furthermore, prehospitalization use of anticoagulants was associated with a significantly higher likelihood of a mild initial neurological deficit and favorable outcome at discharge.

Various studies have shown a beneficial effect of statins in patients with chronic subdural hematoma (cSDH) who do not require surgery. In surgical cohorts, however, the results of statin treatment in cSDH have been inconsistent, and meta-analyses showed no significant effect. It has been hypothesized that this lack of effect may be due to a higher proportion of patients in the statin group taking antithrombotic medication. Therefore, we designed a study to analyze the impact of statins on surgical cSDH patients who did not receive antithrombotic drugs. We conducted a retrospective chart review of patients who received cSDH evacuation via burr-hole trepanation with the implantation of a subdural drain at our institution from 2012 through 2021. The data were pooled with a previously analyzed cohort to result in a two-center analysis. Patients who received antithrombotic medication were excluded. We separated the patients into a statin group and a control group based on whether they received a statin as part of their home medication and evaluated the rate of reoperations for any reason as the primary outcome parameter, and reoperations for residual hematoma and hematoma recurrence, respectively, as secondary outcome parameters. We identified 614 patients in the total cohort, of whom 297 did not take antithrombotic medication. The mean age of these patients was 71.75 ± 13.27 years, and 195 were male (65.66%). A total of 42 patients took statins (14.14%). A reoperation was necessary in 5 patients in the statin group (11.90%) and 35 patients in the control group (13.73%), p = 0.749. Residual hematoma after the initial surgery was ascertained in 2 patients in the statin group (4.76%) and 17 in the control group (6.67%), p = 0.640, whereas 3 patients in the statin group (7.14%) and 18 patients in the control group (7.06%) experienced hematoma recurrence, p = 0.984. Logistic regression analysis revealed no significant associations with reoperation. We found no evidence of a beneficial effect of statins in patients undergoing surgery for cSDH, regardless of the use of antithrombotic medication.

The first wave of COVID led to an alarmingly high mortality rate among nursing home residents (NHRs). In hospitalised patients, the use of anticoagulants may be associated with a favourable prognosis. However, it is unknown whether the use of antithrombotic medication also protected NHRs from COVID-19-related mortality. To investigate the effect of current antithrombotic therapy in NHRs with COVID-19 on 30-day all-cause mortality during the first COVID-19 wave. We performed a retrospective cohort study linking electronic health records and pharmacy data in NHRs with COVID-19. A propensity score was used to match NHRs with current use of therapeutic dose anticoagulants to NHRs not using anticoagulant medication. The primary outcome was 30-day all-cause mortality, which was evaluated using a logistic regression model. In a secondary analysis, multivariable logistic regression was performed in the complete study group to compare NHRs with current use of therapeutic dose anticoagulants and those with current use of antiplatelet therapy to those without such medication. We included 3521 NHRs with COVID-19 based on a positive RT-PCR for SARS-CoV-2 or with a well-defined clinical suspicion of COVID-19. In the matched propensity score analysis, NHRs with current use of therapeutic dose anticoagulants had a significantly lower all-cause mortality (OR = 0.73; 95% CI: 0.58-0.92) compared to NHRs who did not use therapeutic anticoagulants. In the secondary analysis, current use of therapeutic dose anticoagulants (OR: 0.62; 95% CI: 0.48-0.82) and current use of antiplatelet therapy (OR 0.80; 95% CI: 0.64-0.99) were both associated with decreased mortality. During the first COVID-19 wave, therapeutic anticoagulation and antiplatelet use were associated with a reduced risk of all-cause mortality in NHRs. Whether these potentially protective effects are maintained in vaccinated patients or patients with other COVID-19 variants, remains unknown.

Background: Stroke is the fourth leading killer in the US, the first in Brazil and a leading cause of adult long-term disability in both countries. In spite of widespread recommendation, clinical practice guidelines have had limited effect on changing physician behavior. Recognizing that both knowledge and acceptance of guidelines do not necessarily imply guideline adherence, the American Heart Association/American Stroke Association (AHA/ASA) developed a national stroke quality improvement program, the ‘Get With The Guidelines (GWTG) stroke’. Even though GWTG has produced remarkable results in the US, other countries have not adopted the program. Methods: We compared the stroke treatment quality indicators from a private Brazilian tertiary hospital to those published by the GWTG stroke program. Seven predefined performance measures selected by the GWTG stroke program as targets for stroke quality improvement were evaluated: (1) tissue plasminogen activator use in patients who arrived <2 h from symptom onset; (2) antithrombotic medication use within 48 h of admission; (3) deep vein thrombosis prophylaxis within 48 h of admission for nonambulatory patients; (4) discharge use of antithrombotics; (5) discharge use of anticoagulation for atrial fibrillation; (6) dosing of LDL and treatment for LDL >100 mg/dl in patients meeting the National Cholesterol Education Program Adult Treatment Panel (NCEP) III guidelines, and (7) counseling for smoking cessation. Results: A total of 343 consecutive patients with acute ischemic stroke (70.8%) or transient ischemic attack (29.2%) were evaluated from August 2008 to December 2010. Antithrombotic medication within 48 h was used in 98.5% of the eligible patients and deep vein thrombosis prophylaxis in 100%. A total of 123 patients arrived within 2 h from symptoms onset, 23 were eligible for intravenous thrombolysis and 16 were treated (69.5%). All eligible patients were discharged using antithrombotic medication, and 86.9% of the eligible patients who had atrial fibrillation received anticoagulation. Only 56.1% of the eligible patients were treated according to the NCEP III guidelines. Counseling for smoking cessation was done in 63.6% of the eligible patients. Conclusions: Our study is the first in Brazil and the second outside the US to analyze compliance with the GWTG recommendations. Close attention to a better implementation of these measures may produce an improvement in such results similar to what happened after the full implementation of the program in the US. Whether or not a US disease-based registry such as GWTG can be adopted with success beyond the US is still a matter of debate.

Background:A broad variety of topical hemostatic agents are used in the surgical disciplines. We analysed the most widely used topical hemostatic agents and compared them to a recently developed, synthetic topical hemostatic agent based on polyurethane (PU). The materials were compared using a novel testing method based on a rat tail-tip model. Tests were also performed with PU that was enriched with the procoagulant substance chitosan to evaluate if this could increase its hemostatic efficacy.Methods: The following topical hemostatic agents were compared using a rat tail tip model: Collagen, gelatin, oxidized regenerated cellulose, chitosan dressing, PU and PU with chitosan. The tail tip was fixated on a developed test device to ensure a constant and equal pressure of the test material on the wound. The mean bleeding time was determined and compared between the groups.Results:PU showed a mean bleeding time of 23.9 min. This was not significantly shorter or longer than gelatin (23.6 min), collagen (28.2 min) or oxidized regenerated cellulose (26.9 min). The addition of chitosan to PU did lead to the shortest mean bleeding time (21.5 min) but this was not significantly faster than PU without chitosan.Conclusions:These results show that PU is a promising alternative for the most widely used topical hemostatic agents. Future studies will have to show if the addition of procoagulant substances like chitosan can significantly improve the hemostatic efficacy of PU.

Antithrombotic Therapy and Direct Medical Costs in Patients with Acute Coronary Syndrome in Shanghai, China

The recommendations about antithrombotic medication use after bioprosthetic aortic valve replacement (bAVR) vary. To describe the post-bAVR antithrombotic medication practice across the Veterans Health Administration (VHA) and to assess the association between antithrombotic strategies and post-bAVR outcomes. Retrospective cohort study. Multivariable modeling with propensity scores was conducted to adjust for differences in patient characteristics across the 3 most common antithrombotic medication strategies (aspirin plus warfarin sodium, aspirin only, and dual antiplatelets). Text mining of notes was used to identify the patients with bAVR (fiscal years 2005-2015). This study used VHA and non-VHA outpatient pharmacy data and text notes to classify the following antithrombotic medications prescribed within 1 week after discharge from the bAVR hospitalization: aspirin plus warfarin, aspirin only, dual antiplatelets, no antithrombotics, other only, and warfarin only. The 90-day outcomes included all-cause mortality, thromboembolism risk, and bleeding events. Outcomes were identified using primary diagnosis codes from emergency department visits or hospital admissions. The cohort included 9060 veterans with bAVR at 47 facilities (mean [SD] age, 69.3 [8.8] years; 98.6% male). The number of bAVR procedures per year increased from 610 in fiscal year 2005 to 1072 in fiscal year 2015. The most commonly prescribed antithrombotic strategy was aspirin only (4240 [46.8%]), followed by aspirin plus warfarin (1638 [18.1%]), no antithrombotics (1451 [16.0%]), dual antiplatelets (1010 [11.1%]), warfarin only (439 [4.8%]), and other only (282 [3.1%]). Facility variation in antithrombotic prescription patterns was observed. During the 90-day post-bAVR period, adverse events were uncommon, including all-cause mortality in 127 (1.4%), thromboembolism risk in 142 (1.6%), and bleeding events in 149 (1.6%). No differences in 90-day mortality or thromboembolism were identified across the 3 antithrombotic medication groups in either the unadjusted or adjusted models. Patients receiving the combination of aspirin plus warfarin had higher odds of bleeding than patients receiving aspirin only in the unadjusted analysis (odds ratio, 2.58; 95% CI, 1.71-3.89) and after full risk adjustment (adjusted odds ratio, 1.92; 95% CI, 1.17-3.14). These data demonstrate that bAVR procedures are increasingly being performed in VHA facilities and that aspirin only was the most commonly used antithrombotic medication strategy after bAVR. The risk-adjusted results suggest that the combination of aspirin plus warfarin does not improve either all-cause mortality or thromboembolism risk but increases the risk of bleeding events compared with aspirin only.

IntroductionEpistaxis represents a massive burden upon NHS resources. Despite being an extremely common reason for emergency ENT admissions, there remains significant variation in its management. Although the evidence base is continually growing, there appears to be a lack of guidance towards managing anti-coagulants and anti-platelet medications and identifying patient-specific outcomes in this setting. Epistaxis has long been associated with a multitude of risk factors but none have shown consistent, direct correlation.Materials and methodsWe aimed to identify if the use of anti-thrombotic medication was associated with a longer length of hospital admission or conferred a higher requirement for nasal packing, re-packing, surgery or re-admission. We conducted a retrospective analysis of 100 consecutive adult patients admitted over a 6-month period. Statistical analysis was conducted using SPSS software.ResultsSixty-five percent of patients were taking anti-thrombotic medication. The variability of admission INR values in those taking warfarin did not relate with any outcome measure. There was no statistical difference between patients taking anti-thrombotic medication and those who do not, with regards to our primary outcome measures. Re-admission rates within 28 days were found to be 13%, with anti-thrombotic medication use and pre-existing cardiovascular disease recognised as commonly encountered risk factors. Three percent of patients required surgical intervention. Eight percent of patients required re-packing, with a Rapid Rhino chosen in all instances.ConclusionThe use of anti-thrombotic medication is not associated with increased morbidity or increased rate of complications. Anti-thrombotic usage and more than one medical co-morbidity increase the risk of re-admission within 28 days.

Atrial fibrillation is the most common cardiac arrhythmia associated with significant medical complications. We examined trends in the medical therapy of atrial fibrillation in the United States from 1991 through 2000. Data from 1355 visits among patients with atrial fibrillation were obtained from the National Ambulatory Medical Care Survey, a nationally representative assessment of office-based practice. We assessed trends in medication use for ventricular rate control (digoxin, beta-blockers, and calcium channel blockers), sinus rhythm maintenance (class IA, IC, and III antiarrhythmics), and thromboembolism prevention (oral anticoagulants and aspirin). Overall rate control medication use decreased from 72% of visits in 1991-1992 to 56% in 1999-2000 (P =.01 for trend) due to declining digoxin use (64% to 37%, P<.001 for trend). beta-Blocker and calcium channel blocker use remained unchanged. Although there was no change in overall sinus rhythm medication use over time, amiodarone hydrochloride use increased from 0.2% to 6.4% (P<.001 for trend), while quinidine use decreased from 5.0% to 0.0% (P =.01 for trend). Oral anticoagulant use increased (28% to 41%, P =.01 for trend), with the greatest increase in patients aged 80 years and older (14% to 48%, P<.001 for trend). Despite this, only 46.5% of patients at high risk for stroke were taking anticoagulants in 1999-2000. Digoxin use in atrial fibrillation decreased over time, without concomitant increases in beta-blocker or calcium channel blocker use. Amiodarone replaced quinidine as the dominant sinus rhythm medication. Although oral anticoagulant use increased over time, particularly in the oldest patients, fewer than half of the patients at high risk for stroke were anticoagulated.

Get With The Guidelines®-Stroke is an in-hospital program for improving stroke care by promoting adherence to scientific guidelines. Of the patients with transient ischemic attack (TIA), 10-15% have a stroke within three months, and many patients do not receive the recommended interventions to prevent this outcome. The goal of this study was to assess the adherence to stroke quality indicators in patients with TIA. This retrospective observational study evaluated consecutive patients admitted to a primary stroke center with TIA or acute ischemic stroke (AIS) from August 2008 to December 2013. Six quality indicators applicable to both TIA and AIS were analyzed and compared between groups. A total of 357 patients with TIA and 787 patients with AIS were evaluated. Antithrombotic medication use within 48 hours of admission, discharge use of anticoagulation for atrial fibrillation and counseling for smoking cessation were similar between groups. In the TIA group, discharge use of antithrombotic medication (95% versus 98%; p = 0.01), lipid-lowering treatment (57.7% versus 64.1%; p < 0.01) and stroke education (56.5% versus 74.5%; p < 0.01) were all less frequently observed compared with patients with AIS. The adherence to some of the Get With The Guidelines®-Stroke quality indicators was lower in patients with TIA than in patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.

Secondary stroke prevention strategies include pharmacologic approaches to control hypertension and reduce thromboembolic risk. To describe antithrombotic and antihypertensive medication use, and rates of blood pressure control in the Kansas City Stroke Study, a prospective stroke cohort receiving community-based care after primarily mild and moderate stroke. Participants from 12 area hospitals provided information about medication use prior to stroke. Study personnel measured blood pressures at enrollment and at one, three, and six months, and collected medication data at six months during in-home assessment. Complete data at six months were available for 355 subjects with ischemic stroke, among whom 13% had atrial fibrillation and 67% had prior hypertension. Prior to stroke, only 45% of the patients were receiving any antithrombotic (anticoagulant and/or antiplatelet) therapy; this figure rose to 77% at six months. Antithrombotic treatment rates among those with atrial fibrillation were 59% before stroke and 83% at six months, including warfarin in 64%. Approximately 70% of subjects had controlled blood pressures one, three, and six months after stroke, defined as systolic blood pressure < or = 140 mm Hg and diastolic blood pressure < or = 90 mm Hg. Use of multiple antihypertensive agents was common; calcium-channel blockers and angiotensin-converting enzyme inhibitors were used most frequently. However, 19% of subjects with uncontrolled blood pressure were untreated at six months. Although room for improvement remains, these data suggest improved rates of antithrombotic and antihypertensive medication use after stroke in community-based care in a midwestern metropolitan community, compared with previous reports.

Previous studies have identified decreased esophageal blood flow during anterior cervical surgery as a contributing factor to postoperative dysphagia. However, the effects of antithrombotic agents on esophageal blood flow during recovery from surgery have yet to be explored. This study examines the relationship between antithrombotic medication use and postoperative dysphagia in patients undergoing anterior cervical spine procedures. A prospectively collected multi-institutional quality registry was retrospectively reviewed. Patients undergoing cervical spine surgery were categorized based on preoperative antithrombotic drug usage and propensity score matched by age, race, sex, and other baseline characteristics. Dysphagia rates were compared between groups using Eating Assessment Tool-10 questionnaires. Univariate analyses were used to examine the effects of antithrombotic medications on the rates of postoperative dysphagia. Of 1661 patients meeting inclusion criteria, 629 (37.9%) reported taking antithrombotic agents preoperatively. Propensity score matching yielded 784 patients, with 392 (50%) who took prescription antithrombotic medications. Patients taking antithrombotic agents experienced significantly lower rates of postoperative dysphagia at 1 (48% vs 58%, p = 0.049), 3 (21% vs 28%, p = 0.033), and 12 (19% vs 26%, p = 0.048) months after surgery compared with those who did not. After separating the cohorts by surgical approach, patients taking antithrombotic medications who underwent anterior cervical surgery experienced significantly lower rates of dysphagia at 3 months (21% vs 30%, p = 0.019) but not at 1 month (51% vs 59%, p = 0.2) or 12 months (19% vs 26%, p = 0.058) postoperatively, while rates for patients undergoing a posterior approach were similar regardless of antithrombotic drug use. Patients taking antithrombotic medications experience significantly lower rates of dysphagia after anterior cervical surgery. Antithrombotic drugs may enhance microcirculation within the esophagus postoperatively, protecting against the detrimental effects of prolonged esophageal retraction during anterior cervical surgery that have been found to contribute to postoperative dysphagia. This novel finding warrants further investigation.

Introduction: Atrial fibrillation (AFib) patients who have recently experienced intracerebral hemorrhage (ICH) may otherwise have an indication for preventive anticoagulation. The use of anticoagulation in these patients, despite strong evidence of reduction of embolic risk, is controversial and lacks high quality supportive evidence. Methods: Using data from the National Inpatient Sample from 2010-2012, we estimated the proportion of ICH patients that survive their hospitalization, have AFib, and also an indication for anticoagulation. ICD-9 codes were used to identify ICH patients and relevant co-morbidities. Descriptive statistics and multivariate logistic regression were used. Results: 39,395 patients had a primary ICD-9 diagnosis of ICH. The mean age was 69 years (SD 15), 49% were women, 18.5% had AFib and 25% died in hospital. Of AFib ICH patients that survived hospitalization (13% of all ICHs), 73% had a CHADS2 score &gt;= 2. In multivariate analysis AFib ICH patients were significantly older, more likely male, Caucasian, had worse outcomes and higher prevalence of all CHADS2 risk factors compared to non-AFib ICHs (all p &lt;= 0.001). AFib ICH patients discharged home with CHADS2 &gt;= 2 comprised 2.2% of all ICH patients, and an additional 7.3% were discharged to rehabilitation or skilled nursing facilities. Conclusions: AFib ICH patients with appropriate indications for long term preventive anticoagulation represent up to 9.5% of all ICH patients. More research is needed to accurately estimate the rates of subsequent ischemic and hemorrhagic events, stratified by antithrombotic medication use. Such rates can then be used to estimate sample size for a randomized trial comparing the effectiveness of antiplatelet and anticoagulant medications.