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Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

10.5005/jp-journals-10071-24685
Letter to the Editor
Author Response
Panda Bijoy K 1https://orcid.org/0000-0001-8807-196X

Suryawanshi Vaibhav R 2https://orcid.org/0000-0001-8334-4025

Attarde Gargi 3https://orcid.org/0009-0003-4795-1145

Borkar Nilima 4https://orcid.org/0009-0008-9402-9504

Iyer Shivakumar 5https://orcid.org/0000-0001-5814-2691

Shah Jignesh 6https://orcid.org/0000-0002-8812-8791

1 Department of Pharmacy Practice, Krishna Institute of Pharmacy, Krishna Vishwa Vidyapeeth (Deemed to be University), Karad, Maharashtra, India
2–4 Department of Pharmacy Practice, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
5,6 Department of Critical Care Medicine, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
Vaibhav R Suryawanshi, Department of Pharmacy Practice, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India, Phone: +91 9552956860, e-mail: phdrvaibhav@gmail.com
4 2024
30 3 2024
28 4 408409
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Author Response. Indian J Crit Care Med 2024;28(4):408–409.

Keywords

Clinical outcomes
Intracerebral hemorrhage
Ischemic stroke
Quality metrics
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pmc Dear Editor,

Thank you for the opportunity to respond to the letter regarding our article.1,2 We read it with great interest and would like to discuss our viewpoint about the queries raised by Mehri and Finsterer1 We would like to draw their attention to our study's main objective, which was to determine the compliance rates with stroke quality metrics adopted from AHA/ASA's GWTG approach and to study the clinical outcomes associated with them in ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients.3,4 They have raised a few questions regarding the patient outcomes associated with the quality of interventions provided. They have also mentioned the concern regarding stroke-associated outcomes, which may have a considerable impact due to potential disease-related factors.

We believe that the clinical outcomes of patients with strokes of either type may be contingent not only on satisfying performance quality metrics but also on the specifics of the intervention unit's equipments, facilities, and their quality standards. We understand that the patients who were eligible for medical interventions including [thromboendarterectomy (TEA) and/or mechanical thrombectomy (MTE)] but could not undergo these procedures due to resource limitations, their clinical outcomes would have worsened compared to those who underwent these interventions. Their concern about the lack of availability of the desired neuroimaging in some patients [computed tomography (CT) performed instead of magnetic resonance imaging (MRI)] and the same could result in an inappropriate intervention is relevant. However, we would like to mention here that the study hospital facility is equipped with both CT and MRI; having said this, we were unable to perform MTE or TEA due to the fact that these facilities are being made available now but were not available at the time of the study. Considering door-to-imaging time (DIT) and door-to-needle time (DTN), we have used the same metrics in IS as well as ICH (except DTN, since it doesn't imply hemorrhagic stroke). We have found time delays in DIT in 45% and 40% of IS and ICH patients, respectively.2 Quality improvement strategies with regards to MTE/TEA and DIT have since been implemented.

In response to Mehri and Finsterer's following queries, AHA/ASA's GWTG approach clearly defines the need for the appropriate use of antihypertensives and antidiabetics in ICH, in addition to other medical and/or pharmacotherapy interventions.3,4 We are unanimous that the degree of bleeding, the degree of perifocal edema, the presence or absence of intraventricular incursion, and the decision between conservative and surgical treatment plays an important role in the course of an ICH. Studying the impact of these factors in addition to the impact of compliance with stroke quality metrics will require a prospectively designed study with a larger sample size or probably registry-based data systems wherein the risks of data bias are minimized, which was not feasible for us; hence, we have not considered studying this factors. In response to the ICH classification, of 56 patients with ICH; 40 had primary ICH (mainly caused due to malignant hypertension), and the remaining had secondary ICH. Of 16 patients with secondary ICH, 10 had ICH caused by vascular malformations, mainly aneurysm and cavernous angioma; 3 patients had cerebral venous sinus thrombosis; and 3 patients had ICH with underlying vasculitis. We believe that the ICH classification exerts a considerable impact on patient outcomes. However, due to the relatively small number, we did not study the impact of these factors on ICH outcomes.

During our study period, on admission, 35 patients with IS and 6 patients with ICH were diagnosed with having carotid artery stenosis (CAS) or occlusion (CAO), which was assessed using carotid artery ultrasound at a median (IQR) of 14 (8–21) h of admission. Due to the scattered data about the patients with IS caused by CAS or CAO and the relatively small sample size, we were unable to study the impact of these factors on patient outcomes. It has been demonstrated that individuals who receive carotid artery stenting, or TEA, within two weeks following IS achieve better long-term outcomes than those who do not receive it. Therefore, as a practice, we usually transfer such patients to healthcare institutes where similar facilities are available, especially those patients who have a larger amount of CAS or CAO and those who are willing to undergo stenting/TEA. With regards to the next query, a total of 30 patients with IS who were included in our study were on prehospital anticoagulation with rivaroxaban (26 patients) and warfarin (4 patients). We couldn't measure the anti-factor-Xa activity due to patients’ unaffordability and other laboratory/resource limitations. The patients who were on rivaroxaban did not receive thrombolysis. Three of the four patients on warfarin had an INR of less than 1.5 and hence received thrombolysis. None of the ICH patients in our study were on therapeutic anticoagulation. To answer the next query by Mehri and Finsterer, we would like to cite data from our study's discussion section regarding the clinical outcomes of IS patients who did not undergo thrombolysis. In our study, 144/200 (72%) did not receive thrombolysis, mainly due to presentation outside the time window.2 The middle cerebral artery (MCA) stroke accounted for 45% of the patients in our study, followed by internal carotid artery (ICA) (18%), posterior cerebral artery (PCA) (15%), anterior cerebral artery (ACA) (11%), brainstem (7%), and MCA plus ICA (4%). While we believe that the stroke subtype has an important impact on clinical outcomes; acute stroke care, and discharge care, including adequate rehabilitation, enable IS patients to attain functional independence between 30 and 90 days, especially when it's their first-ever stroke.4–6 Assessment of clinical outcomes of individual stroke subtypes and outcomes associated with ICH location and stroke volume is out of the scope of our study.2 Looking at associations of these factors with individual patients, disease, and/or intervention-based factors will require a larger sample size (probably registry-based). We could not analyze this further as suggested by Mehri and Finsterer1 due to sample size limitations.

At last, we express our gratitude to Mehri and Finsterer, for posing important clinical questions and highlighting several points for the discussion regarding our study. Their letter will definitely help us improve the design of future studies.

Availability of Data and Material

All the data regarding study is included in the article.

Author Contribution

VRS, BP, and SI: Design and conception and discussed available data with coauthors; VRS: Literature search, wrote the first draft, and gave final approval; SI and JS: Discussion, correction, and final approval.

Orcid

Bijoy K Panda https://orcid.org/0000-0001-8807-196X

Vaibhav R Suryawanshi https://orcid.org/0000-0001-8334-4025

Gargi Attarde https://orcid.org/0009-0003-4795-1145

Nilima Borkar https://orcid.org/0009-0008-9402-9504

Shivakumar Iyer https://orcid.org/0000-0001-5814-2691

Jignesh Shah https://orcid.org/0000-0002-8812-8791

Source of support: Nil

Conflict of interest: None
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References

1. Mehri S Finsterer J Impact of quality standards on stroke management and outcome requires appropriately designed studies Indian J Crit Care Med 2024 28 4 xx-xx
2. Panda BK Suryawanshi VR Attarde G Borkar N Iyer S Shah J Correlation of quality metrics of acute stroke care with clinical outcomes in an Indian tertiary-care university hospital: A prospective evidence-based study Indian J Crit Care Med 2023 27 11 806 815 10.5005/jp-journals-10071-24566 37936803
3. Reeves MJ Parker C Fonarow GC Smith EE Schwamm LH Development of stroke performance measures: Definitions, methods, and current measures Stroke 2010 41 7 1573 1578 10.1161/STROKEAHA.109.577171 20489174
4. Fonarow GC Reeves MJ Smith EE Saver JL Zhao X Olson DW et al. Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke Circ Cardiovasc Qual Outcomes 2010 3 3 291 302 10.1161/CIRCOUTCOMES.109.921858 20177051
5. Ng YS Stein J Ning M Black-Schaffer RM Comparison of clinical characteristics and functional outcomes of ischemic stroke in different vascular territories Stroke 2007 38 8 2309 2314 10.1161/STROKEAHA.106.475483 17615368
6. Wang Y Li Z Zhao X Liu L Wang C Wang C et al. Evidence-based performance measures and outcomes in patients with acute ischemic stroke Circ Cardiovasc Qual Outcomes 2018 11 12 e001968 10.1161/CIRCOUTCOMES.115.001968 30557048
