ORCID Profile
0000-0002-8976-5696
Current Organisations
National University Singapore Yong Loo Lin School of Medicine
,
National University Hospital
,
National University of Singapore
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Publisher: SAGE Publications
Date: 21-06-2019
Abstract: To investigate the comparative efficacy and safety of the low-dose versus standard-dose alteplase using real-world acute stroke registry data from Asian countries. In idual participant data were obtained from nine acute stroke registries from China, Japan, Philippines, Singapore, South Korea, and Taiwan between 2005 and 2018. Inverse probability of treatment weight was used to remove baseline imbalances between those receiving low-dose versus standard-dose alteplase. The primary outcome was death or disability defined by modified Rankin Scale scores of 2 to 6 at 90 days. Secondary outcomes were symptomatic intracerebral hemorrhage and death. Generalized linear mixed models with the in idual registry as a random intercept were performed to determine associations of treatment with low-dose alteplase and outcomes. Of the 6250 patients (mean age 66 years, 36% women) included in these analyses, 1610 (24%) were treated with low-dose intravenous alteplase. Clinical outcomes for low-dose alteplase were not significantly different to those for standard-dose alteplase, adjusted odds ratios for death or disability: 1.00 (0.85–1.19) and symptomatic intracerebral hemorrhage 0.87 (0.63–1.19), except for lower death with borderline significance, 0.77 (0.59–1.01). The present analyses of real-world Asian acute stroke registry data suggest that low-dose intravenous alteplase has overall comparable efficacy for functional recovery and greater potential safety in terms of reduced mortality, to standard-dose alteplase for the treatment of acute ischemic stroke.
Publisher: Elsevier BV
Date: 03-2019
Publisher: Wiley
Date: 05-03-2015
DOI: 10.1111/JON.12100
Abstract: Transcranial Doppler (TCD) ultrasonography is a noninvasive bedside tool that can evaluate cerebral blood flow hemodynamics in major intracranial arteries. TCD-derived pulsatility index (PI) is believed to be influenced by intracranial pressure (ICP). To correlate TCD-PI with cerebrospinal fluid (CSF) pressure (representing ICP), measured by standard lumbar puncture (LP) manometry. CSF pressures (CSF-P) were measured in 78 patients by LP manometry. Stable TCD spectra were obtained 5 minutes before LP from either middle cerebral arteries using Spencer's head frame and 2-MHz transducer. PI values were calculated from the TCD spectra by an independent neurosonologist. Factors displaying a significant relationship with CSF-P included age (R = -.426, P < .0005) EDV (R = -.328, P = .002 ) and PI (R = .650, P < .0005). On analyzing dichotomized data (CSF-P < 20 vs. ≥ 20 cm H2 0) TCD-PI was an independent determinant (OR per .1 increase in PI = 2.437 95% CI, 1.573-3.777 P < .0005). PI ≥ 1.26 could reliably predict CSF-P ≥ 20 cm H2 0 (sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were 81.1%, 96.3%, 93.8%, 88.1%, and 90.1% respectively). TCD-derived PI could be used to identify patients with CSF-P ≥ 20 cm H2 0 and may play an important role as a monitoring tool.
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1016/J.IJHEH.2021.113908
Abstract: Haemorrhagic stroke (HS) is a major cause of mortality and disability. Previous studies reported inconsistent associations between ambient air pollutants and HS risk. We evaluated the association between air pollutant exposure and the risk of HS in a cosmopolitan city in the tropics. We performed a nationwide, population-based, time-stratified case-crossover analysis on all HS cases reported to the Singapore Stroke Registry from 2009 to 2018 (n = 12,636). We estimated the risk of HS across tertiles of air pollutant concentrations in conditional Poisson models, adjusting for meteorological confounders. We stratified our analysis by age, atrial fibrillation and smoking status, and investigated the lagged effects of each pollutant on the risk of HS up to 5 days. All 12,636 episodes of HS were included. The median (1st-to 3rd-quartile) daily pollutant levels from 22 remote stations deployed across the island were as follows: (PM Short-term exposure to ambient CO levels was associated with an increased risk of HS. A reduction in CO emissions may reduce the burden of HS in the population.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2020
DOI: 10.1161/STROKEAHA.119.027268
Abstract: In randomized trials of symptomatic carotid endarterectomy, only modest benefit occurred in patients with moderate stenosis and important subgroups experienced no benefit. Carotid plaque 18 F-fluorodeoxyglucose uptake on positron emission tomography, reflecting inflammation, independently predicts recurrent stroke. We investigated if a risk score combining stenosis and plaque 18 F-fluorodeoxyglucose would improve the identification of early recurrent stroke. We derived the score in a prospective cohort study of recent ( days) non-severe (modified Rankin Scale score ≤3) stroke/transient ischemic attack. We derived the SCAIL (symptomatic carotid atheroma inflammation lumen-stenosis) score (range, 0–5) including 18 F-fluorodeoxyglucose standardized uptake values (SUV max g/mL, 0 points SUV max 2–2.99 g/mL, 1 point SUV max 3–3.99 g/mL, 2 points SUV max ≥4 g/mL, 3 points) and stenosis ( %, 0 points 50%–69%, 1 point ≥70%, 2 points). We validated the score in an independent pooled cohort of 2 studies. In the pooled cohorts, we investigated the SCAIL score to discriminate recurrent stroke after the index stroke/transient ischemic attack, after positron emission tomography-imaging, and in mild or moderate stenosis. In the derivation cohort (109 patients), recurrent stroke risk increased with increasing SCAIL score ( P =0.002, C statistic 0.71 [95% CI, 0.56–0.86]). The adjusted (age, sex, smoking, hypertension, diabetes mellitus, antiplatelets, and statins) hazard ratio per 1-point SCAIL increase was 2.4 (95% CI, 1.2–4.5, P =0.01). Findings were confirmed in the validation cohort (87 patients, adjusted hazard ratio, 2.9 [95% CI, 1.9–5], P .001 C statistic 0.77 [95% CI, 0.67–0.87]). The SCAIL score independently predicted recurrent stroke after positron emission tomography-imaging (adjusted hazard ratio, 4.52 [95% CI, 1.58–12.93], P =0.005). Compared with stenosis severity (C statistic, 0.63 [95% CI, 0.46–0.80]), prediction of post-positron emission tomography stroke recurrence was improved with the SCAIL score (C statistic, 0.82 [95% CI, 0.66–0.97], P =0.04). Findings were confirmed in mild or moderate stenosis (adjusted hazard ratio, 2.74 [95% CI, 1.39–5.39], P =0.004). The SCAIL score improved the identification of early recurrent stroke. Randomized trials are needed to test if a combined stenosis-inflammation strategy improves selection for carotid revascularization where benefit is currently uncertain.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 18-09-2020
Publisher: American Medical Association (AMA)
Date: 11-2017
Publisher: MDPI AG
Date: 15-09-2022
DOI: 10.3390/JCM11185429
Abstract: Acute ischemic strokes (AIS) are closely linked with air pollution, and there is some evidence that traditional cardiovascular risk factors may alter the relationship between air pollution and strokes. We investigated the effect of atrial fibrillation (AF) on the association of AIS with air pollutants. This was a nationwide, population-based, case-only study that included all AIS treated in public healthcare institutions in Singapore from 2009 to 2018. Using multivariable logistic regression, adjusted for time-varying meteorological effects, we examined how AF modified the association between AIS and air pollutant exposure. A total of 51,673 episodes of AIS were included, with 10,722 (20.7%) having AF. The odds of AIS in patients with AF is higher than those without AF for every 1 µg/m3 increase in O3 concentration (adjusted OR [aOR]: 1.005, 95% CI 1.003–1.007) and every 1 mg/m3 increase in CO concentration (aOR: 1.193, 95% CI 1.050–1.356). However, the odds of AIS in patients with AF is lower than those without AF for every 1 µg/m3 increase in SO2 concentration (aOR: 0.993, 95% CI 0.990–0.997). Higher odds of AIS among AF patients as O3− and CO concentrations increase are also observed in patients aged ≥65 years and non-smokers. The results suggest that AF plays an important role in exacerbating the risk of AIS as the levels of O3 and CO increase.
Publisher: SAGE Publications
Date: 2019
Abstract: Results of our recently published phase III randomized clinical trial of ultrasound-enhanced thrombolysis (sonothrombolysis) using an operator-independent, high frequency ultrasound device revealed heterogeneity of patient recruitment among centers. We performed a post hoc analysis after excluding subjects that were recruited at centers reporting a decline in the balance of randomization between sonothrombolysis and concurrent endovascular trials. From a total of 676 participants randomized in the CLOTBUST-ER trial we identified 52 patients from 7 centers with perceived equipoise shift in favor of endovascular treatment. Post hoc sensitivity analysis in the intention-to-treat population adjusted for age, National Institutes of Health Scale score at baseline, time from stroke onset to tPA bolus and baseline serum glucose showed a significant (p 0.01) interaction of perceived endovascular equipoise shift on the association between sonothrombolysis and 3 month functional outcome [adjusted common odds ratio (cOR) in centers with perceived endovascular equipoise shift: 0.22, 95% CI 0.06–0.75 p = 0.02 adjusted cOR for centers without endovascular equipoise shift: 1.20, 95% CI 0.89–1.62 p = 0.24)]. After excluding centers with perceived endovascular equipoise shift, patients randomized to sonothrombolysis had higher odds of 3 month functional independence (mRS scores 0–2) compared with patients treated with tPA only (adjusted OR: 1.53 95% CI 1.01–2.31 p = 0.04). Our experience in CLOTBUST-ER indicates that increasing implementation of endovascular therapies across major academic stroke centers raises significant challenges for clinical trials aiming to test noninterventional or adjuvant reperfusion strategies.
Publisher: Cambridge University Press (CUP)
Date: 15-01-2014
DOI: 10.1017/S1041610213002457
Abstract: The Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) were compared with and without the addition of a brief processing speed test, the symbol digit modalities test (SDMT), for vascular cognitive impairment (VCI) screening at three to six months after stroke. Patients with ischemic stroke and transient ischemic attack were assessed with MoCA and MMSE, as well as a formal neuropsychological battery three to six months after stroke. VCI was defined by impairment in any cognitive domain on neuropsychological testing. The area under the receiver operating characteristic curve (AUC) was used to compare test discriminatory ability. One hundred and eighty-nine patients out of 327 (58%) had VCI, of whom 180 (95%) had vascular mild cognitive impairment (VaMCI), and nine (5%) had dementia. The overall AUCs of the MoCA and MMSE scores and performance at their respective cut-off points were equivalent in detecting VCI (AUCs: 0.87 (95% CI 0.83–0.91) vs. 0.84 (95% CI 0.80–0.88), p = 0.13 cut-offs: MoCA (≤23) vs. MMSE (≤26), sensitivity: 0.78 vs. 0.71 specificity: 0.80 vs. 0.82 positive predictive value: 0.84 vs. 0.84 negative predictive value: 0.72 vs. 0.67 and correctly classified 78.6% vs. 75.5% p = 0.42). The AUCs of MMSE and MoCA were improved significantly by the SDMT (AUCs: MMSE+SDMT 0.90 (95% CI 0.87–0.93), p .001 MoCA+SDMT 0.91 (95% CI 0.88–0.94), p 0.02). The MoCA and MMSE are equivalent and moderately sensitive, and can be supplemented with the SDMT to improve their accuracy in VCI screening.
Publisher: BMJ
Date: 11-04-2012
Abstract: To determine the prognostic value of brief cognitive screening tests administered in the subacute stroke phase (initial 2 weeks) for the detection of significant cognitive impairment 3-6 months after stroke, the authors compared the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE). Patients with ischaemic stroke and transient ischaemic attack were assessed with both MoCA and MMSE within 14 days after index stroke, followed by a formal neuropsychological evaluation of seven cognitive domains 3-6 months later. Cognitive outcomes were dichotomised as either no-mild (impairment in ≤2 cognitive domains) or moderate-severe (impairment in ≥ 3 cognitive domains) vascular cognitive impairment. Area under the receiver operating characteristic (ROC) curve analysis was used to compare discriminatory ability. 300 patients were recruited, of whom 239 received formal neuropsychological assessment 3-6 months after the stroke. 60 (25%) patients had moderate-severe VCI. The overall discriminant validity for detection of moderate-severe cognitive impairment was similar for MoCA (ROC 0.85 (95% CI 0.79 to 0.90) and MMSE (ROC 0.83 (95% CI 0.77 to 0.89)), p=0.96). Both MoCA (21/22) and MMSE (25/26) had similar discriminant indices at their optimal cutoff points sensitivity 0.88 versus 0.88 specificity 0.64 versus 0.67 70% versus 72% correctly classified. Moreover, both tests had similar discriminant indices in detecting impaired cognitive domains. Brief screening tests during acute admission in patients with mild stroke are predictive of significant vascular cognitive impairment 3-6 months after stroke.
Publisher: SAGE Publications
Date: 08-07-2021
Abstract: To examine sex differences in disease profiles and short-term outcomes after acute ischemic stroke treated with recombinant tissue plasminogen activator. Eight national and regional stroke registries contributed in idual participant data from mainland China, Japan, Philippines, Singapore, South Korea and Taiwan in 2005–2018. The primary outcome was ordinal-modified Rankin scale at 90 days. Key safety outcome was symptomatic intracerebral hemorrhage (sICH). Of 4453 patients included in the analyses, 1692 (36.3%) were women who were older, more likely to have a more severe neurological deficit, history of hypertension and atrial fibrillation, and a cardioembolic stroke compared to men. Women were more likely than men to have unfavorable shift of modified Rankin scale (fully adjusted odds ratio) (women vs. men) 1.14, 95% confidence interval 1.02–1.28). There was no significant sex difference for death 1.05 (0.84–1.31) or sICH (1.17, 0.89–1.54). Women were more likely to have unfavorable functional outcome with increasing age (P = 0.022 for interaction). In the age groups 70–80 and ≥80 years, women had a worse functional outcome compared to men (1.22, 1.02–1.47 and 1.43, and 1.06–1.92, respectively). In this pooled data from Asian acute stroke registries, women had poorer prognosis than men after receiving recombinant tissue plasminogen activator for acute ischemic stroke, which worsened with age. Women older than 70 appear to have a worse outcome than men which could be explained by greater stroke severity, more AF, and cardioembolic stroke.
Publisher: S. Karger AG
Date: 2019
DOI: 10.1159/000504745
Abstract: b i Objective: /i /b To determine the extent to which the effects of intensive blood pressure (BP) lowering are modified by doses of alteplase in thrombolysis-eligible acute ischemic stroke (AIS) patients. b i Methods: /i /b Prespecified analyses of the Enhanced Control of Hypertension and Thrombolysis Stroke Study for patients enrolled in both arms: (i) low-dose (0.6 mg/kg body weight) or standard-dose (0.9 mg/kg) alteplase and (ii) intensive (target systolic BP [SBP] 130–140 mm Hg) or guideline-recommended (target SBP & #x3c mm Hg) BP management. The primary outcome was functional recovery, measured by a shift in scores on modified Rankin scale at 90 days. The safety outcome was any intracranial hemorrhage (ICH). b i Results: /i /b There were 925 participants (mean age 67 years, 39% female, 77% Asian) randomized to both arms: 242 randomly assigned to guideline/standard-dose (GS) 234 to guideline/low-dose (GL) 227 to intensive/standard-dose (IS) and 222 to intensive/low-dose (IL). Overall, average SBP levels within 24 h were lower in the low-dose compared to standard-dose alteplase group (146 and 144 vs. 151 and 150 mm Hg, for GS and GL vs. IS and IL, respectively, i /i & #x3c 0.0001). There was no heterogeneity of the effects of BP lowering (intensive vs. guideline) on functional recovery between standard-dose (OR 0.81, 95% CI 0.59–1.12) and low-dose alteplase (1.06, 0.77–1.47 i /i = 0.25 for interaction). Similar results were observed for ICH ( i /i = 0.50 for interaction). b i Conclusions: /i /b In thrombolysis-treated patients with predominantly mild-to-moderate severity AIS, intensive BP lowering neither improve functional recovery, either with low- or standard-dose intravenous alteplase, nor beneficially interact with low-dose alteplase in reducing ICH. b i Trial Registration: /i /b The trial is registered with ClinicalTrials.gov (NCT01422616).
Publisher: Wiley
Date: 25-10-2018
DOI: 10.1002/ANA.25342
Abstract: Whether intracerebral hemorrhage (ICH) associated with non-vitamin K antagonist oral anticoagulants (NOAC-ICH) has a better outcome compared to ICH associated with vitamin K antagonists (VKA-ICH) is uncertain. We performed a systematic review and in idual patient data meta-analysis of cohort studies comparing clinical and radiological outcomes between NOAC-ICH and VKA-ICH patients. The primary outcome measure was 30-day all-cause mortality. All outcomes were assessed in multivariate regression analyses adjusted for age, sex, ICH location, and intraventricular hemorrhage extension. We included 7 eligible studies comprising 219 NOAC-ICH and 831 VKA-ICH patients (mean age = 77 years, 52.5% females). The 30-day mortality was similar between NOAC-ICH and VKA-ICH (24.3% vs 26.5% hazard ratio = 0.94, 95% confidence interval [CI] = 0.67-1.31). However, in multivariate analyses adjusting for potential confounders, NOAC-ICH was associated with lower admission National Institutes of Health Stroke Scale (NIHSS) score (linear regression coefficient = -2.83, 95% CI = -5.28 to -0.38), lower likelihood of severe stroke (NIHSS > 10 points) on admission (odds ratio [OR] = 0.50, 95% CI = 0.30-0.84), and smaller baseline hematoma volume (linear regression coefficient = -0.24, 95% CI = -0.47 to -0.16). The two groups did not differ in the likelihood of baseline hematoma volume < 30cm Although functional outcome at discharge, 1 month, or 3 months was comparable after NOAC-ICH and VKA-ICH, patients with NOAC-ICH had smaller baseline hematoma volumes and less severe acute stroke syndromes. Ann Neurol 2018 :702-712.
Publisher: Wiley
Date: 17-08-2020
DOI: 10.1111/ENE.14447
Abstract: Blood pressure (BP) variability has been associated with worse neurological outcomes in acute ischaemic stroke (AIS) patients receiving treatment with intravenous thrombolysis (IVT). However, no study to date has investigated whether pulse pressure (PP) variability may be a superior indicator of the total cardiovascular risk, as measured by clinical outcomes. Pulse pressure variability was calculated from 24‐h PP measurements following tissue plasminogen activator bolus in AIS patients enrolled in the Combined Lysis of Thrombus using Ultrasound and Systemic Tissue Plasminogen Activator for Emergent Revascularization (CLOTBUST‐ER) trial. The outcomes of interest were the pre‐specified efficacy and safety end‐points of CLOTBUST‐ER. All associations were adjusted for potential confounders in multivariable regression models. Data from 674 participants was analyzed. PP variability was identified as the BP parameter with the most parsimonious fit in multivariable models of all outcomes, and was independently associated ( P 0.001) with lower likelihood of both 24‐h neurological improvement and 90‐day independent functional outcome. PP variability was also independently related to increased odds of any intracranial bleeding ( P = 0.011) and 90‐day mortality ( P 0.001). Every 5‐mmHg increase in the 24‐h PP variability was independently associated with a 36% decrease in the likelihood of 90‐day independent functional outcome (adjusted odds ratio 0.64, 95% confidence interval 0.52–0.80) and a 60% increase in the odds of 90‐day mortality (adjusted odds ratio 1.60, 95% confidence interval 1.23–2.07). PP variability was not associated with symptomatic intracranial bleeding at either 24 or 36 h after IVT administration. Increased PP variability appears to be independently associated with adverse short‐term and long‐term functional outcomes of AIS patients treated with IVT.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-10-2021
Publisher: S. Karger AG
Date: 2018
DOI: 10.1159/000488911
Abstract: b i Background: /i /b Debate exists as to whether statin pretreatment confers an increased risk of 90-day mortality and symptomatic intracranial haemorrhage (sICH) in acute ischaemic stroke (AIS) patients treated with intravenous thrombolysis. We assessed the effects of undifferentiated lipid-lowering pretreatment on outcomes and interaction with low-dose versus standard-dose alteplase in a post hoc subgroup analysis of the Enhanced Control of Hypertension and Thrombolysis Stroke Study. b i Methods: /i /b In all, 3,284 thrombolysis-eligible AIS patients (mean age 66.6 years 38% women), with information on lipid-lowering pretreatment, were randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 h of symptom onset. Of the total number of patients, 615 (19%) received statin or other lipid-lowering pretreatment. The primary clinical outcome was combined endpoint of death or disability (modified Rankin Scale scores 2–6) at 90 days. b i Results: /i /b Compared with patients with no lipid-lowering pretreatment, those with lipid-lowering pretreatment were significantly older, more likely to be non-Asian and more likely to have a medical history including vascular co-morbidity. After propensity analysis assessment and adjustment for important baseline variables at the time of randomisation, as well as imbalances in management during the first 7 days of hospital admission, there were no significant differences in mortality (OR 0.85 95% CI 0.58–1.25, i /i = 0.42), or in overall 90-day death and disability (OR 0.85, 95% CI 0.67–1.09, i /i = 0.19), despite a significant decrease in sICH among those with lipid-lowering pretreatment according to the European Co-operative Acute Stroke Study 2 definition (OR 0.49, 95% CI 0.28–0.83, i /i = 0.009). No differences in key efficacy or safety outcomes were seen in patients with and without lipid-lowering pretreatment between low- and standard-dose alteplase arms. b i Conclusions: /i /b Lipid-lowering pretreatment is not associated with adverse outcome in AIS patients treated with intravenous alteplase, whether assessed by 90-day death and disability or death alone.
Publisher: SAGE Publications
Date: 04-01-2022
DOI: 10.1177/17474930211066745
Abstract: Air quality is an important determinant of cardiovascular health such as ischemic heart disease and acute ischemic stroke (AIS) with substantial mortality and morbidity reported across the globe. However, associations between air quality and AIS in the current literature remain inconsistent, with few studies undertaken in cosmopolitan cities located in the tropics. We evaluated the associations between in idual ambient air pollutants and AIS. We performed a nationwide, population-based, time-stratified case-crossover analysis on all AIS cases reported to the Singapore Stroke Registry from 2009 to 2018. We estimated the incidence rate ratio (IRR) of AIS across different concentrations of each pollutant by quartiles (referencing the 25th percentile), in single-pollutant conditional Poisson models adjusted for time-varying meteorological effects. We stratified our analysis by predetermined subgroups deemed at higher risk. A total of 51,675 episodes of AIS were included. Ozone (O 3 ) (IRR 4th quartile : 1.05, 95% confidence interval (CI): 1.01–1.08) and carbon monoxide (CO) (IRR 2nd quartile : 1.05, 95% CI: 1.02–1.08, IRR 3rd quartile : 1.07, 95% CI: 1.04–1.10, IRR 4th quartile : 1.07, 95% CI: 1.04–1.11) were positively associated with AIS incidence. The increased incidence of AIS due to O 3 and CO persisted for 5 days after exposure. Those under 65 years of age were more likely to experience AIS when exposed to CO. In iduals with atrial fibrillation (AF) were more susceptible to exposure from O 3 , CO, and PM 10 . Current/ex-smokers were more vulnerable to the effect of O 3 . Air pollution increases the incidence of AIS, especially in those with AF and in those who are current or ex-smokers.
Publisher: Medknow
Date: 10-02-2022
Abstract: Introduction: The COVID-19 pandemic has had an unprecedented impact in Asia and has placed significant burden on already stretched healthcare systems. We examined the impact of COVID-19 on safety attitudes among healthcare workers (HCWs) as well as their associated demographic and occupational factors, and measures of burnout, depression and anxiety. Methods: A cross-sectional survey study utilising snowball s ling was performed involving doctors, nurses and allied health professions from 23 hospitals in Singapore, Malaysia, India and Indonesia between 29 May 2020 and 13 July 2020. This survey collated demographic data and workplace conditions and included three validated questionnaires: Safety Attitudes Questionnaire (SAQ) Oldenburg Burnout Inventory and Hospital and Anxiety Depression Scale. We performed multivariate mixed model regression to assess for independent associations with the SAQ Total Percentage Agree Rates (PAR). Results: We obtained 3,163 responses. A SAQ Total PAR of 35.7%, 15.0%, 51.0% and 3.3% was calculated among respondents from Singapore, Malaysia, India and Indonesia, respectively. Burnout scores were highest among respondents from Indonesia and lowest in respondents from India at 70.9%–85.4% versus 56.3%–63.6%, respectively. Multivariate analyses revealed that meeting burnout and depression thresholds, and shifts lasting ≥ 12 hours were significantly associated with lower SAQ Total PAR. Conclusion: Addressing factors contributing to high burnout and depression, and placing strict limits on work hours per shift may contribute significantly towards improving safety culture among HCWs and should remain priorities as this pandemic continues.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2022
DOI: 10.1161/STROKEAHA.121.034580
Abstract: In thrombolysis-eligible patients with acute ischemic stroke, there is uncertainty over the most appropriate systolic blood pressure (SBP) lowering profile that provides an optimal balance of potential benefit (functional recovery) and harm (intracranial hemorrhage). We aimed to determine relationships of SBP parameters and outcomes in thrombolyzed acute ischemic stroke patients. Post hoc analyzes of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study), a partial-factorial trial of thrombolysis-eligible and treated acute ischemic stroke patients with high SBP (150–180 mm Hg) assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) alteplase and intensive (target SBP, 130–140 mm Hg) or guideline-recommended (target SBP mm Hg) treatment. All patients were followed up for functional status and serious adverse events to 90 days. Logistic regression models were used to analyze 3 SBP summary measures postrandomization: attained (mean), variability (SD) in 1–24 hours, and magnitude of reduction in 1 hour. The primary outcome was a favorable shift on the modified Rankin Scale. The key safety outcome was any intracranial hemorrhage. Among 4511 included participants (mean age 67 years, 38% female, 65% Asian) lower attained SBP and smaller SBP variability were associated with favorable shift on the modified Rankin Scale (per 10 mm Hg increase: odds ratio, 0.76 [95% CI, 0.71–0.82] P .001 and 0.86 [95% CI, 0.76–0.98] P =0.025) respectively, but not for magnitude of SBP reduction (0.98, [0.93–1.04] P =0.564). Odds of intracranial hemorrhage was associated with higher attained SBP and greater SBP variability (1.18 [1.06–1.31] P =0.002 and 1.34 [1.11–1.62] P =0.002) but not with magnitude of SBP reduction (1.05 [0.98–1.14] P =0.184). Attaining early and consistent low levels in SBP mm Hg, even as low as 110 to 120 mm Hg, over 24 hours is associated with better outcomes in thrombolyzed acute ischemic stroke patients. URL: www.clinicaltrials.gov Unique identifier: NCT01422616.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2017
DOI: 10.1161/STROKEAHA.117.017808
Abstract: Renal dysfunction (RD) is associated with poor prognosis after stroke. We assessed the effects of RD on outcomes and interaction with low- versus standard-dose alteplase in a post hoc subgroup analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study). A total of 3220 thrombolysis-eligible patients with acute ischemic stroke (mean age, 66.5 years 37.8% women) were randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset. Six hundred and fifty-nine (19.8%) patients had moderate-to-severe RD (estimated glomerular filtration rate, mL/min per 1.73 m 2 ) at baseline. The impact of RD on death or disability (modified Rankin Scale scores, 2–6) at 90 days, and symptomatic intracerebral hemorrhage, was assessed in logistic regression models. Compared with patients with normal renal function ( mL/min per 1.73 m 2 ), those with severe RD ( mL/min per 1.73 m 2 ) had increased mortality (adjusted odds ratio, 2.07 95% confidence interval, 0.89–4.82 P =0.04 for trend) every 10 mL/min per 1.73 m 2 lower estimated glomerular filtration rate was associated with an adjusted 9% increased odds of death from thrombolysis-treated acute ischemic stroke. There was no significant association with modified Rankin Scale scores 2 to 6 (adjusted odds ratio, 1.03 95% confidence interval, 0.62–1.70 P =0.81 for trend), modified Rankin Scale 3 to 6 (adjusted odds ratio, 1.20 95% confidence interval, 0.72–2.01 P =0.44 for trend), or symptomatic intracerebral hemorrhage, or any heterogeneity in comparative treatment effects between low-dose and standard-dose alteplase by RD grades. RD is associated with increased mortality but not disability or symptomatic intracerebral hemorrhage in thrombolysis-eligible and treated acute ischemic stroke patients. Uncertainty persists as to whether low-dose alteplase confers benefits over standard-dose alteplase in acute ischemic stroke patients with RD. URL: www.clinicaltrials.gov . Unique identifier: NCT01422616.
Publisher: SAGE Publications
Date: 02-04-2015
DOI: 10.1111/IJS.12486
Abstract: Controversy exists over the optimal dose of intravenous (iv) recombinant tissue plasminogen activator (rt-PA) and degree of blood pressure (BP) control in acute ischaemic stroke (AIS). Asian studies suggest low-dose (0·6 mg/kg) is more efficacious than standard-dose (0·9 mg/kg) iv rt-PA, and guidelines recommend reducing systolic BP to mmHg before and mmHg after use of iv rt-PA, despite observational studies indicating better outcomes at much lower ( mmHg) systolic BP levels in this patient group. The study aims to assess in thrombolysis-eligible AIS patients whether: (i) low-dose (0·6 mg/kg body weight maximum 60 mg) iv rt-PA has non-inferior efficacy and lower risk of symptomatic intracerebral haemorrhage (sICH) compared to standard-dose (0·9 mg/kg body weight maximum 90 mg) iv rt-PA and (ii) early intensive BP lowering (systolic target 130–140 mmHg) has superior efficacy and lower risk of any ICH compared to guideline-recommended BP control (systolic target 180 mmHg). The ENhanced Control of Hypertension And Thrombolysis strokE stuDy (ENCHANTED) trial is an independent, 2 × 2 quasi-factorial, active-comparison, prospective, randomized, open blinded endpoint (PROBE), clinical trial that is evaluating Arm [A] ‘rt-PA dose’ and/or Arm [B] ‘BP control’, using central Internet randomization and data collection in patients fulfilling local criteria for thrombolysis and clinician uncertainty over the study treatments. The treatment arms will be analyzed separately. The primary study outcome in both trial Arms is death or disability according to the modified Rankin scale (mRS, scores 2–6) assessed at 90 days. Secondary outcomes include sICH, any ICH, a shift (‘improvement’) in function across mRS scores, separately on death and disability, early neurological deterioration, recurrent major vascular events, health-related quality of life, length of hospital stay, need for permanent residential care, and health care costs. Following launch of the trial in February 2012, the study has recruited more than 2500 patients across a global network of approximately 100 sites in 15 countries. The required s le sizes are 3300 for Arm [A] and 2300 for Arm [B], which will provide % power to detect non-inferiority of low-dose iv rt-PA and superiority of intensive BP lowering on the primary clinical outcome, respectively. Low-dose iv rt-PA and early intensive BP lowering could provide more affordable and safer use of thrombolysis treatment for patients with AIS worldwide.
Publisher: BMJ
Date: 08-2013
Publisher: JCDR Research and Publications
Date: 2014
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2017
DOI: 10.1161/STROKEAHA.116.016274
Abstract: Many patients receiving thrombolysis for acute ischemic stroke are on prior antiplatelet therapy (APT), which may increase symptomatic intracerebral hemorrhage risk. In a prespecified subgroup analysis, we report comparative effects of different doses of intravenous alteplase according to prior APT use among participants of the international multicenter ENCHANTED study (Enhanced Control of Hypertension and Thrombolysis Stroke Study). Among 3285 alteplase-treated patients (mean age, 66.6 years 38% women) randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset, 752 (22.9%) reported prior APT use. Primary outcome at 90 days was the combined end point of death or disability (modified Rankin Scale [mRS] scores, 2–6). Other outcomes included mRS scores 3 to 6, ordinal mRS shift, and symptomatic intracerebral hemorrhage by various standard criteria. There were no significant differences in outcome between patients with and without prior APT after adjustment for baseline characteristics and management factors during the first week defined by mRS scores 2 to 6 (adjusted odds ratio [OR], 1.01 95% confidence interval [CI], 0.81–1.26 P =0.953), 3 to 6 (OR, 0.95 95% CI, 0.75–1.20 P =0.662), or ordinal mRS shift (OR, 1.03 95% CI, 0.87–1.21 P =0.770). Alteplase-treated patients on prior APT had higher symptomatic intracerebral hemorrhage (OR, 1.82 95% CI, 1.00–3.30 P =0.051) according to the safe implementation of thrombolysis in stroke-monitoring study definition. Although not significant ( P -trend, 0.053), low-dose alteplase tended to have better outcomes than standard-dose alteplase in those on prior APT compared with those not using APT (mRS scores of 2–6 OR, 0.84 95% CI, 0.62–1.12 versus OR, 1.16 95% CI, 0.99–1.36). Low-dose alteplase may improve outcomes in thrombolysis-treated acute ischemic stroke patients on prior APT, but this requires further evaluation in a randomized controlled trial. URL: www.clinicaltrials.gov . Unique identifier: NCT01422616.
Publisher: SAGE Publications
Date: 08-04-2019
Abstract: Randomized controlled trials provide high-level evidence, but the necessity to include selected patients may limit the generalisability of their results. Comparisons were made of baseline and outcome data between patients with acute ischemic stroke (AIS) recruited into the alteplase-dose arm of the international, multi-center, Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED) in the United Kingdom (UK), and alteplase-treated AIS patients registered in the UK Sentinel Stroke National Audit Programme (SSNAP) registry, over the study period June 2012 to October 2015. There were 770 AIS patients (41.2% female mean age 72 years) included in ENCHANTED at sites in England and Wales, which was 19.5% of alteplase-treated AIS patients registered in the SSNAP registry. Trial participants were significantly older, had lower baseline neurological severity, less likely Asian, and had more premorbid symptoms, hypertension and atrial fibrillation. Although ENCHANTED participants had higher rates of symptomatic intracerebral hemorrhage than those in SSNAP, there were no differences in onset-to-treatment time, levels of disability (assessed by the modified Rankin scale) at hospital discharge, and mortality over 90 days between groups. Despite the high level of participation, equipoise over the dose of alteplase among UK clinician investigators favored the inclusion of older, frailer, milder AIS patients in the ENCHANTED trial. Clinical Trial Registration-URL: www.clinicaltrials.gov . Unique identifier: NCT01422616
Publisher: Massachusetts Medical Society
Date: 16-06-2016
Publisher: BMJ
Date: 13-01-2018
Abstract: The optimal dose of recombinant tissue plasminogen activator (rtPA) for acute ischaemic stroke (AIS) remains controversial, especially in Asian countries. We aimed to update the evidence regarding the use of low-dose versus standard-dose rtPA. We performed a systematic literature search across MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO and Cumulative Index to Nursing and Allied Health Literature ( CINAHL) from inception to 22 August 2016 to identify all related studies. The outcomes were death or disability (defined by modified Rankin Scale 2–6), death, and symptomatic intracerebral haemorrhage (sICH). Where possible, data were pooled for meta-analysis with ORs and corresponding 95% CIs by means of random-effects or fixed-effects meta-analysis. We included 26 observational studies and 1 randomised controlled trial with a total of 23 210 patients. Variable doses of rtPA were used for thrombolysis of AIS in Asia. Meta-analysis shows that low-dose rtPA was not associated with increased risk of death or disability (OR 1.13, 95% CI 0.95 to 1.33), or death (OR 0.86, 95% CI 0.74 to 1.01), or decreased risk of sICH (OR 1.06, 95% CI 0.65 to 1.72). The results remained consistent when sensitivity analyses were performed including only low-dose and standard-dose rtPA or only Asian studies. Our review shows small difference between the outcomes or the risk profile in the studies using low-dose and/or standard-dose rtPA for AIS. Low-dose rtPA was not associated with lower risk of death or disability, death alone, or sICH.
Publisher: Elsevier BV
Date: 11-2012
DOI: 10.1016/J.JNS.2012.07.034
Abstract: The direct impact of external carotid-internal carotid (EC-IC) bypass surgery on cognition of patients with severe steno-occlusive disease of internal carotid (ICA) or middle cerebral artery (MCA) is unknown. In this pilot study, we evaluated changes in cerebral hemodynamic and cognition in these patients. Patients with severe steno-occlusive disease and impaired cerebral vasodilatory reserve (CVR) with transcranial Doppler (TCD) breath holding index (BHI) and acetazolamide-challenged HMPAO-Single Photon Emission Tomographic (SPECT) imaging were offered EC-IC bypass surgery. CVR and cognitive performance using a formal neuropsychological battery were evaluated before and 3-6 months after surgery. Nine patients and 9 matched controls were recruited. Significant CVR improvement from TCD-BHI [median 0 (Inter-quartile range IQR 0.45) to 1.10 (IQR 0.73), p<0.001] and SPECT (p<0.001) was observed in surgery patients. EC-IC bypass patients had significant improvement in verbal memory (p=0.037) and executive function (p=0.043) and a trend of improvement in visual memory (p=0.052) compared to controls. EC-IC bypass surgery in carefully selected patients could improve cerebral hemodynamics and verbal memory and executive function.
Publisher: Elsevier BV
Date: 04-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2015
Location: Singapore
No related grants have been discovered for Vijay sharma.