Attitudes and Practices on the Consent Process and Decision-making for Intravenous Stroke Thrombolysis: Physicians' Perspective

<p><b>INTRODUCTION</b>Earlier treatment with intravenous stroke thrombolysis improves outcomes and lowers risk of bleeding complications. The decision-making and consent process is one of the rate-limiting steps in the duration between hospital arrival and treatment initiation. We aim to describe the attitudes and practices of neurologists in Singapore on the consent and decision-making processes for stroke thrombolysis.</p><p><b>MATERIALS AND METHODS</b>A survey of neurologists and neurologists-in-training in 2 large tertiary public hospitals in Singapore was conducted.</p><p><b>RESULTS</b>Among 46 respondents, 94% of them considered stroke thrombolysis an emergency treatment and 67% of them indicated there is a need for written informed consent. The majority (87%) knew that from a legal perspective, the doctor should be the decision-maker in an emergency treatment for a mentally incapacitated patient. However, 63% of respondents reported that it is the next-of-kin who usually makes the decision in actual practice. If confronted with a mentally incapacitated stroke patient, 57% of them were willing to be the proxy decision-maker and 13% of them were not. In 3 commonly encountered vignettes when a mentally incapacitated patient was being considered for stroke thrombolysis, there was no clear consensus on the respondents' practices.</p><p><b>CONCLUSION</b>The next-of-kin is usually the decision-maker for stroke thrombolysis in practice for a mentally incapacitated patient despite most doctors considering thrombolysis an emergency treatment. This, together with the lack of consensus and variance in decision-making and consent practice amongst neurologists for stroke thrombolysis, demonstrates the need to develop best practice guidelines to standardise healthcare practices for greater consistency in health service delivery.</p>

Presumed dapsone-induced drug hypersensitivity syndrome causing reversible hypersensitivity myocarditis and thyrotoxicosis

<p><b>INTRODUCTION</b>A 22-year-old Malay soldier developed dapsone hypersensitivity syndrome 12 weeks after taking maloprim (dapsone 100 mg/pyrimethamine 12.5 mg) for anti-malarial prophylaxis.</p><p><b>CLINICAL PICTURE</b>He presented with fever, rash, lymphadenopathy and multiple-organ involvement including serositis, hepatitis and thyroiditis. Subsequently, he developed congestive heart failure with a reduction in ejection fraction on echocardiogram, and serum cardiac enzyme elevation consistent with a hypersensitivity myocarditis.</p><p><b>TREATMENT</b>Maloprim was discontinued and he was treated with steroids, diuretics and an angiotensin-converting-enzyme inhibitor.</p><p><b>OUTCOME</b>He has made a complete recovery with resolution of thyroiditis and a return to normal ejection fraction 10 months after admission.</p><p><b>CONCLUSION</b>In summary, we report a case of dapsone hypersensitivity syndrome with classical symptoms of fever, rash and multi-organ involvement including a rare manifestation of myocarditis. To our knowledge, this is the first case of dapsone-related hypersensitivity myocarditis not diagnosed in a post-mortem setting. As maloprim is widely used for malaria prophylaxis, clinicians need to be aware of this unusual but potentially serious association.</p>