ABSTRACT
Post-traumatic stress disorder (PTSD) affects about 20% of US military veterans and is a major cause of mortality in these men and women. The incidence of PTSD has persisted over the last decade with the Iraq and Afghanistan wars, yet treatment and adherence remain inadequate in part due to clinician lack of knowledge about cognitive processing therapy and prolonged exposure, the proven gold standards in treatment. This article reviews the most current and successful PTSD treatment options and identifies risk factors for patient nonadherence in hopes of reducing the rate of veteran suicide related to PTSD.
Subject(s)
Patient Compliance , Stress Disorders, Post-Traumatic , Veterans , Cognitive Behavioral Therapy , Delivery of Health Care , Evidence-Based Medicine , Female , Humans , Male , Physician Assistants , Risk Factors , Stress Disorders, Post-Traumatic/diagnosis , Stress Disorders, Post-Traumatic/epidemiology , Stress Disorders, Post-Traumatic/psychology , Stress Disorders, Post-Traumatic/therapy , Suicide/statistics & numerical data , Suicide PreventionABSTRACT
We carried out a quality improvement project utilizing the electronic medical record (EMR) to determine (1) the quality of vascular neurologists' recommendations for recurrent stroke prevention and (2) primary care provider (PCP) acknowledgement of the vascular neurologists' recurrent stroke prevention recommendations and their frequency of meeting the recommended metrics for risk factor control and lifestyle modification. We conducted a retrospective EMR chart review on a convenience sample of ischemic stroke patients during two epochs. Data collected included risk factors, stroke subtype, and process and outcome guidance metrics for recurrent ischemic stroke prevention according to American Heart Association/American Stroke Association (AHA/ASA) recommendations. Overall, vascular neurologists commonly recommended appropriate AHA/ASA risk factor management standards, but were less likely to do so for lifestyle management. Improvements in the EMR system over time, including the establishment of guideline-driven importable recurrent stroke prevention templates, led to a high frequency of proper risk factor and lifestyle recommendations made by vascular neurologists. Statistical analysis provided further evidence that the EMR positively influenced the delivery of proper recurrent stroke prevention guidance. Although PCPs infrequently acknowledged receipt of vascular neurology consultations, there was a relatively high frequency of achieved risk factor control. The latter may be attributed at least in part to pre-existent quality improvement programs implemented at primary care offices. Our exploratory findings suggest that proper use of the EMR may heighten efforts to provide appropriate and consistent recurrent stroke prevention recommendations in a primary care setting.
Subject(s)
Ambulatory Care , Brain Ischemia/prevention & control , Electronic Health Records , Neurologists , Referral and Consultation , Stroke/prevention & control , Aged , Ambulatory Care/methods , Female , Humans , Male , Middle Aged , Physicians, Primary Care , Quality Improvement , Retrospective Studies , Risk Reduction Behavior , Secondary PreventionABSTRACT
Patent foramen ovale (PFO) has been proposed as a mechanism for cardioembolic stroke, especially in younger patient populations. Complex PFOs, with tunnel lengths exceeding 8 mm, lead to a higher risk of neurological sequelae than simple PFOs and may also be harder to detect with transthoracic echocardiography (TTE). In this article, we present a 29-year-old woman who, after polypharmacy overdose, developed deep venous thrombosis and multiple pulmonary emboli (PE) and subsequent cardioembolic stroke. Initial TTE showed intact interatrial septum with late appearance of agitated saline in the left atrium after the seventh cardiac cycle. Subsequent transesophageal echocardiography, after treatment of PE with an intravenous thrombolytic (alteplase) and anticoagulation with heparin, showed a complex PFO with a 19-mm overlap of the septum primum and secundum without active flow. It is suggested that this PFO allowed for flow only in the situation of elevated right heart strain with PE, causing cardioembolic stroke and detection of agitated saline in the left atrium on TTE. However, under normal physiological situations, which resumed after treatment of PE with alteplase and heparin, the PFO did not allow for flow. This case demonstrates the potential importance of recognition of complex PFOs in diagnosis and management of cardioembolic stroke.
ABSTRACT
Older adults account for an increasingly large proportion of the population. These patients have more comorbidities as well as indications for surgical interventions. Current preoperative risk assessment tools have limited utility. This article describes methods of assessing patient frailty, which offers superior predictive power about postoperative complications, discharge disposition, and mortality.
