Estimated versus actual weight when dosing rt-PA in acute ischemic stroke: is there a difference?

INTRODUCTION: Intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is the standard of care for patients exhibiting signs of acute ischemic stroke. IV rt-PA uses weight-based dosing, and often an estimated weight is used. The clinical effects of using estimated weight in dosing IV rt-PA remain unclear. The goal of this descriptive study was to determine if there was a significant difference in estimated versus actual weight dosing of rt-PA. METHODS: A retrospective chart review was performed to compare estimated versus actual patient weight. The sample consisted of patients from the hospital database who received IV rt-PA during June 2009-June 2010. Patients were included if they presented to the emergency department with stroke symptoms, received IV rt-PA, and had documented estimated and actual weights. Recorded (prescribed) dosing of IV rt-PA was compared with the suggested dosing using the admission weight. The differences between the weights and doses were calculated, analyzed, and categorized as being underdosed or overdosed. RESULTS: Twenty-six charts met the inclusion criteria. Using descriptive statistics and tests of difference, the mean estimated weight was 79.9 kg (±3.92 kg) and the mean actual weight was 78.5 kg (±3.86 kg); four patients had an estimated weight discrepancy of ≥5 kg. Six had correct estimated dosing; however, all of these patients were greater than 100 kg and received the maximum dose of 90 mg. Eleven patients' estimated weights were underestimated, resulting in underdosing of IV rt-PA. Nine estimated weights were overestimated, leading to overdosing of the medication, but none of the dosing overages exceeded 10%. No statistical significance was found between the two groups' estimated weights or dosing errors, t(26) = 0.69, p = .79. DISCUSSION: Results from this study found documented estimated weights were not significantly different from actual weights and the precision of estimated weight were similar to weights obtained using a scale. Despite these results, methods for obtaining actual weights in the emergency department for high-risk patients should be explored.

Improving stroke alert response time: applying quality improvement methodology to the inpatient neurologic emergency.

BACKGROUND: Stroke often leaves its victims with devastating disabilities if not treated promptly. Guidelines recommend that brain imaging be obtained within 25 minutes, yet this benchmark is rarely achieved for the in-hospital stroke. PURPOSE: To reduce time to evaluation for strokes occurring in patients already hospitalized, through systematic analysis of current processes and application of standardized quality improvement methodology. METHODS: Improving the quality of care for in-hospital stroke patients involved 4 key steps: (1) creation of a detailed process map to identify inefficiencies in the current process for identifying and treating hospitalized stroke patients, (2) development of an optimized care pathway, (3) implementation of a checklist of optimal practices for the acute stroke response team and nursing staff, and (4) real-time feedback. Time from stroke alert to initiation of computed tomography (CT) scan was prospectively tracked for the 6-month period prior to intervention. After a 3-month interval for intervention roll-out, the response times for the pre-intervention period were compared to a 6-month post-intervention evaluation period. RESULTS: Pre-intervention median inpatient stroke alert-to-CT time was 69.0 minutes, with 19% meeting the goal of 25 minutes from alert to CT time. Post-intervention median inpatient stroke alert-to-CT time was reduced to 29.5 minutes, with 32% at goal (P < 0.0001). CONCLUSIONS: This inpatient stroke alert quality improvement initiative decreased median inpatient alert-to-CT time by 57%, and demonstrated that speed of in-hospital stroke evaluation can be improved through systematic application of quality improvement principles.

Strategic cognition in paranoia: the use of thought control strategies in a non-clinical population.

BACKGROUND: Recent work in the area of cognition and emotion has focused on the process as well as the content of thought. Metacognitive approaches have included studies of people's relationship with internal experience (cf. Teasdale and Barnard, 1993), and the overarching beliefs that guide allocation of internal resources to manage distress (cf. Wells, 2000). At the same time, cognitive models of psychosis have emphasized the clinical value of a multidimensional understanding of paranoia (Chadwick, 2006; Freeman and Garety, 2004b). METHOD: This study examined paranoia in a non-clinical group, specifically (i) the relationship between a single measure of trait paranoia and dimensions of paranoid thought frequency, belief conviction and distress, and (ii) the metacognitive strategies that people use. It was predicted that trait paranoia would be associated with (i) dimensions of thought frequency, belief conviction and distress, and (ii) the internal strategies of "punishment" and "worry." RESULTS: Regression analyses showed that trait paranoia uniquely predicted frequency, conviction and distress associated with paranoid thoughts. Trait paranoia accounted for the use of "reappraisal", whereas "punishment" and "worry" were accounted for by anxiety. CONCLUSIONS: The implications for clinical work and further research are discussed.

An investigation into the psychometric properties of the Stirling Eating Disorder Scales.

The Stirling Eating Disorder Scales (SEDS) are widely used in clinical practice, however evidence regarding the internal consistency and validity of the measure is limited. The aim of this study was to investigate the psychometric properties of the SEDS in a mixed eating disorder population. The SEDS and the Eating Disorder Examination (EDE) were administered to 241 consecutive patients attending an adult out-patient eating disorder service in the UK. The internal consistency of the overall SEDS was good, but there was variation in the internal consistency of the individual subscales. There were differences across diagnosis for all SEDS subscales, and some significant correlations were found between the EDE and SEDS subscales. It was not possible to replicate the derivation of the original SEDS subscales using a principal components analysis (PCA); further analysis was conducted on the new subscales that were identified. It is suggested that information obtained from the administration of the SEDS should be interpreted with caution, and also that further exploration of the psychometric properties of the SEDS is warranted.

Relationship between parental psychopathology, parenting strategies and child mental health--findings from the GB national study.

BACKGROUND: Parental and child psychiatric disorders have been found to be associated, and this association can be mediated by other psychosocial variables, including parenting attitudes and strategies. As most previous studies included clinical samples, the purpose of this study was to establish the relationship between parental psychopathology and parenting strategies with child psychiatric disorders in a national survey population. METHODS: The sample included 10,438 children of 5-15 years and their parents, from representative UK households. Families were assessed on child psychiatric diagnosis, parental psychopathology, family functioning, and socioeconomic status. Parenting strategies included using rewards, physical and non-physical punishments towards their child. FINDINGS: Parental psychopathology scores (OR 3.99, 95% CI 3.13-5.09) and non-physical punishment (OR 1.50, 95% CI 1.27-1.76) were associated with child psychiatric disorders. This association was particularly prominent among children with conduct disorders: parental psychopathology scores (OR 3.13, 95% CI 2.28-4.30) and non-physical punishment (OR 3.19, 95% CI 2.55-3.97). Absence of child psychopathology was associated with a combination of rewarding and non-punitive parenting strategies. CONCLUSIONS: Although parents in the general population may be using less physical strategies than in the past, non-physical punishment is strongly related to mental health problems in children. Enhancement of positive parenting through universal and targeted interventions is an important preventive strategy.