David Spriggs

Cannabis, Ischemic Stroke, and Transient Ischemic Attack A Case-Control Study

Background and Purpose— There is a temporal relationship between cannabis use and stroke in case series and population-based studies. Methods— Consecutive stroke patients, aged 18 to 55 years, who had urine screens for cannabis were compared with a cohort of control patients admitted to hospital without cardiovascular or neurological diagnoses. Results— One hundred sixty of 218 (73%) ischemic stroke/transient ischemic attack patients had urine drug screens (100 men; mean [SD] age, 44.8 [8.7] years). Twenty-five (15.6%) patients had positive cannabis drug screens. These patients were more likely to be men (84% versus 59%; &khgr;2: P=0.016) and tobacco smokers (88% versus 28%; &khgr;2: P<0.001). Control urine samples were obtained from 160 patients matched for age, sex, and ethnicity. Thirteen (8.1%) control participants tested positive for cannabis. In a logistic regression analysis adjusted for age, sex, and ethnicity, cannabis use was associated with increased risk of ischemic stroke/transient ischemic attack (odds ratio, 2.30; 95% confidence interval, 1.08–5.08). However after adjusting for tobacco use, an association independent of tobacco could not be confirmed (odds ratio, 1.59; 95% confidence interval, 0.71–3.70). Conclusions— This study provides evidence of an association between a cannabis lifestyle that includes tobacco and ischemic stroke. Further research is required to clarify whether there is an association between cannabis and stroke independent of tobacco. Clinical Trial Registration— URL: http://www.anzctr.org.au. Unique identifier: ACTRN12610000198022

Not All Patients With Atrial Fibrillation–Associated Ischemic Stroke Can Be Started on Anticoagulant Therapy

Background and Purpose— Ischemic stroke patients in atrial fibrillation (AF) have a 10% to 20% risk of recurrent stroke. Warfarin reduces this risk by two thirds. However, warfarin is underutilized in this patient group. We performed a prospective study to determine the reasons why warfarin is not started in these patients. Methods— All patients with AF-associated ischemic stroke over a 12-month period were identified. Demographic and other data, including whether warfarin was commenced or recommended at discharge, and if not why not, were recorded. Results— Ninety-three of 412 (23%) ischemic stroke patients had paroxysmal or permanent AF. Of these patients, 17 (18%) died, 48 (52%) were discharged home, and 28 (30%) were discharged to institutional care. Only 13 of 64 (20%) patients with known AF were taking warfarin at stroke onset. Warfarin was started (or recommended) in 35 of 76 (46%) survivors. Of those not commenced on warfarin, 32 (78%) were dependent (P<0.001) and 23 (56%) were discharged to institutional care (P<0.001). Warfarin was not started because of severe disability and frailty in 13 (32%), risk of falls in 12 (30%), and limited life expectancy in 4 (10%). Conclusions— In this cohort of patients with AF, warfarin was primarily underutilized before stroke onset, and it was too late to use anticoagulation, in approximately half, once a stroke had occurred. The decision to start or continue anticoagulation requires clinical judgment and should be made on a case by case basis after a complete risk benefit assessment.

Medical service redesign shares the load saving 6000 bed days and improving morale

In 2010, demand on the Auckland City Hospital general medical service exceeded capacity. A review by the Royal Australasian College of Physicians was critical of training offered to registered medical officers, and low morale was a problem across the service. Management offered support for an improved model that would solve these problems.

Changing attitudes to the management of ischaemic stroke between 1997 and 2004: a survey of New Zealand physicians

Aim: In 1997, a survey of New Zealand physicians’ opinions on the management of stroke was carried out. Since then, there have been a number of advances in stroke therapy. We have repeated the 1997 survey to assess changes in physicians’ opinions on stroke management.

New antithrombotic drugs for atrial fibrillation: caution is needed

www.thelancet.com Vol 379 January 28, 2012 e24 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ in other trials, a reduced dose of antithrombotic drugs was considered when the creatinine clearance was between 30 and 49 mL/min, as well as for patients who met two of the following criteria: age 80 years or older, bodyweight 60 kg or less, or a serum creatinine concen tration of 133 μmol/L or higher. Taken together, there are also substantial data to support the need for special caution or even contraindication for their use in elderly patients, those with a low bodyweight, and, more importantly, in those with renal failure, even it is mild. The eff ect of each of these factors has been shown. We totally agree that observational studies, based on the “real life” use of dabigatran, can add substantial complementary information about its adverse eff ects, and should therefore be started early. However, such registries would only be possible if the prescription of dabigatran is possible. Finally, we have to admit that any antithrombotic drugs have been and will be responsible for haemorrhagic complications, irrespective of adherence to the prescription guidelines. To the best of our knowledge, the delay since the publication of the fi rst results of the RE-LY trial was not related to the need for a further assessment of the drug, particularly safety and benefi t/ risk concerns. The cause of the delay was rather negotiation of the price of the drug, and it seems likely that this delay resulted in a loss of chance for a substantial number of patients.

Followership: a critical shortfall in health leadership.

believed working 61 10 h per week was ‘about right’ to meet their technical training needs, approximately 10 h more than the average hours worked by registrars in Australia. Ongoing review of supervision and rostering is necessary to ensure the hours worked by specialty trainees are optimised to build technical competency and clinical judgement. Serious discussion needs to occur at a college and governmental level regarding fair remuneration for trainees in specialties that may require longer work hours. Finally, this study found that there was pressure on junior doctors to under claim or not claim their overtime. This has been reported in another small study in Australia. Further investigation is necessary to ascertain the reasons why doctors are being discouraged, directly or indirectly, from claiming overtime.

407: Not all patients with atrial fibrillation associated ischemic stroke can be started on anticoagulant therapy

BACKGROUND AND PURPOSE Ischemic stroke patients in atrial fibrillation (AF) have a 10% to 20% risk of recurrent stroke. Warfarin reduces this risk by two thirds. However, warfarin is underutilized in this patient group. We performed a prospective study to determine the reasons why warfarin is not started in these patients. METHODS All patients with AF-associated ischemic stroke over a 12-month period were identified. Demographic and other data, including whether warfarin was commenced or recommended at discharge, and if not why not, were recorded. RESULTS Ninety-three of 412 (23%) ischemic stroke patients had paroxysmal or permanent AF. Of these patients, 17 (18%) died, 48 (52%) were discharged home, and 28 (30%) were discharged to institutional care. Only 13 of 64 (20%) patients with known AF were taking warfarin at stroke onset. Warfarin was started (or recommended) in 35 of 76 (46%) survivors. Of those not commenced on warfarin, 32 (78%) were dependent (P<0.001) and 23 (56%) were discharged to institutional care (P<0.001). Warfarin was not started because of severe disability and frailty in 13 (32%), risk of falls in 12 (30%), and limited life expectancy in 4 (10%). CONCLUSIONS In this cohort of patients with AF, warfarin was primarily underutilized before stroke onset, and it was too late to use anticoagulation, in approximately half, once a stroke had occurred. The decision to start or continue anticoagulation requires clinical judgment and should be made on a case by case basis after a complete risk benefit assessment.