warfarin and Deglutition-Disorders

The aim of this project was to determine whether a tailored multifaceted intervention aimed at site-specific barriers is more effective than audit feedback alone for improving adherence to inhospital stroke performance measures (PMs): door to needle time of less than 1 hour for tissue plasminogen activator, dysphagia screening, deep venous thrombosis prophylaxis, and warfarin treatment for atrial fibrillation.. Hospitals were paired on baseline adherence to dysphagia screening and quality improvement infrastructure and randomized to receive audit feedback alone (n=7) versus audit feedback plus site-specific interventions (n=6). Data were collected on all admitted patients with stroke seen in the neurology department before and after a 6-month implementation period. The primary end point was the difference in postintervention adherence rates for each PM, except tissue plasminogen activator because of low sample size.. Data were collected on 2071 preintervention patients and 1240 postintervention patients. Targeted site-specific interventions, such as standing orders and standardized dysphagia screens, were imperfectly implemented during the 6-month intervention period. For atrial fibrillation, the intervention group had an 11% higher postintervention adherence rate beyond that of the control group (98% v 87%, P < .005). No other statistically significant changes in PM adherence were observed.. Implementation of site-specific interventions for quality improvement of specific measures in stroke was difficult to achieve in a 6-month time frame and led to improved adherence for only one of 3 PMs. Studies with a longer intervention period and more sites are required to determine whether tailored interventions can enhance stroke improvement.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Combined Modality Therapy; Commission on Professional and Hospital Activities; Deglutition Disorders; Emergency Medical Services; Emergency Service, Hospital; Feedback; Female; Guideline Adherence; Humans; Intensive Care Units; Male; Mass Screening; Quality Assurance, Health Care; Quality of Health Care; Stroke; Tissue Plasminogen Activator; Venous Thrombosis; Warfarin

Early or delayed onset of oral anticoagulant therapy in patients with acute ischemic stroke with atrial fibrillation is an unsolved issue. Retrospectively, 294 patient records at two hospitals were scrutinized according to a protocol consisting of 20 items regarding choice of therapy (warfarin or NOAC), time for onset of therapy, CT findings of bleeding, capacity to swallow, and occurrence of clinical deterioration during the acute phase. Out of 249 patients who survived the acute phase, 116 (47%) patients were given a new prescription of warfarin or NOAC at discharge, while 43 (17 %) continued with anticoagulant therapy already prescribed before the onset of stroke. The median value for new prescriptions in relation to stroke admission was 5 days. The pattern was similar for warfarin and NOAC. Patients in whom anticoagulant therapy was started early were characterized by good capacity to swallow and no signs of bleeding on initial CT. The question »early or delayed onset of oral anticoagulant therapy after acute ischemic stroke with atrial fibrillation« needs to be tested in a randomized clinical trial.

Topics: Anticoagulants; Atrial Fibrillation; Cerebral Hemorrhage; Dabigatran; Deglutition Disorders; Humans; Medical Records; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Retrospective Studies; Risk Assessment; Rivaroxaban; Stroke; Time Factors; Time-to-Treatment; Treatment Outcome; Warfarin

Intramural esophageal hematoma is part of a spectrum of esophageal injuries. Vomiting and straining, endoscopic procedures and bleeding disorders are the most common predisposing factors. However, it can also be an unusual complication of anticoagulation and/or thrombolysis therapy. The most common symptoms are retrosternal chest pain, dysphagia and hematemesis. Computed tomography is the modality of choice and treatment is medically conservative with the cessation of Warfarin and thrombolysis use. When anticoagulation and/or thrombolysis therapy is necessary, periodic reassessment for symptoms of intramural esophageal hematoma may be helpful for early identification and management. We described one case of intramural esophageal hematoma possibly resulting from anticoagulation and/or thrombolysis therapy in the setting of pulmonary embolism.

Topics: Aged; Anticoagulants; Chest Pain; Deglutition Disorders; Diagnosis, Differential; Esophageal Diseases; Fatal Outcome; Hematemesis; Hematoma; Humans; Male; Pulmonary Embolism; Thrombolytic Therapy; Tomography, X-Ray Computed; Warfarin

Limited information is available on the effect of age on stroke management and care delivery. Our aim was to determine whether access to stroke care, delivery of health services, and clinical outcomes after stroke are affected by age.. This was a prospective cohort study of patients with acute ischemic stroke in the province of Ontario, Canada, admitted to stroke centers participating in the Registry of the Canadian Stroke Network between July 1, 2003 and March 31, 2005. Primary outcomes were the following selected indicators of quality stroke care: (1) use of thrombolysis; (2) dysphagia screening; (3) admission to a stroke unit; (4) carotid imaging; (5) antithrombotic therapy; and (6) warfarin for atrial fibrillation at discharge. Secondary outcomes were risk-adjusted stroke fatality, discharge disposition, pneumonia, and length of hospital stay.. Among 3631 patients with ischemic stroke, 1219 (33.6%) were older than 80 years. There were no significant differences in stroke care delivery by age group. Stroke fatality increased with age, with a 30-day risk adjusted fatality of 7.1%, 6.5%, 8.8%, and 14.8% for those aged 59 or younger, 60 to 69, 70 to 79, and 80 years or older, respectively. Those aged older than 80 years had a longer length of hospitalization, increased risk of pneumonia, and higher disability at discharge compared to those younger than 80. This group was also less likely to be discharged home.. In the context of a province-wide coordinated stroke care system, stroke care delivery was similar across all age groups with the exception of slightly lower rates of investigations in the very elderly. Increasing age was associated with stroke severity and stroke case-fatality.

Topics: Activities of Daily Living; Aged; Aged, 80 and over; Aging; Atrial Fibrillation; Cohort Studies; Cost of Illness; Deglutition Disorders; Emergency Medical Services; Female; Health Policy; Health Services; Hospital Units; Hospitalization; Humans; Longevity; Male; Middle Aged; Mortality; Ontario; Outcome Assessment, Health Care; Patient Discharge; Pneumonia; Prospective Studies; Quality of Health Care; Quality of Life; Severity of Illness Index; Stroke; Thrombolytic Therapy; Warfarin

A 57-year-old man treated with Coumadin for an episode of paroxysmal atrial fibrillation presented to the Emergency Department with progressive dysphagia and odynophagia. Physical examination revealed a large right-sided lateral and posterior pharyngeal wall mass. Laboratory studies were significant for an international normalized ratio (INR) of 5.4 with a white blood cell count of 11,600/muL and a hematocrit of 33.2%. A lateral soft tissue radiograph and computed tomography (CT) scan of the neck demonstrated a retropharyngeal hematoma compromising the airway. Rapid reversal of the coagulopathy was achieved with fresh frozen plasma and vitamin K. Patients with space-occupying retropharyngeal masses present a significant management dilemma. The choice between observation, intubation, or a surgical airway intervention must rely upon knowledge of the natural course and high rate of airway occlusion when faced with a patient who presents with a retropharyngeal hematoma. Once symptoms of airway compromise manifest, the airway must be expeditiously secured before complete obstruction occurs. This diagnosis should be sought when an anticoagulated patient presents with upper airway symptoms.

Topics: Airway Obstruction; Anticoagulants; Atrial Fibrillation; Blood Transfusion; Deglutition Disorders; Disease Progression; Emergency Treatment; Hematocrit; Hematoma; Humans; Laryngoscopy; Leukocyte Count; Male; Middle Aged; Pharyngeal Diseases; Plasma; Risk Factors; Tomography, X-Ray Computed; Vitamin K; Warfarin

We report facial palsy as the sole cranial neuropathy complicating an ipsilateral internal carotid artery dissection. A previously healthy 44-year-old man developed retro-orbital and temporal headache with associated nausea while engaged in modest physical exercise. On the following morning he noticed a left ptosis and miotic pupil. One week later he woke with a left facial weakness. On the same day he had a 90-minute episode of expressive dysphasia. Magnetic resonance imaging and angiography demonstrated left internal carotid artery dissection. The temporal association between our patient's facial nerve palsy and typical features of spontaneous internal carotid artery dissection suggests a common aetiology. We suggest that involvement of the VII cranial nerve in isolation followed disruption of an anomalous nutrient artery. The delay in clinical manifestation may imply extension of the dissection.

Topics: Adult; Aneurysm; Anticoagulants; Blepharoptosis; Brain; Carotid Artery, Internal, Dissection; Deglutition Disorders; Exercise; Facial Paralysis; Heparin, Low-Molecular-Weight; Humans; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Male; Tinzaparin; Warfarin

Topics: Aged; Aged, 80 and over; Deglutition Disorders; Diverticulum; Heparin; Humans; Male; Pharyngeal Diseases; Pulmonary Embolism; Tablets; Thrombolytic Therapy; Warfarin