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An Update on Secondary Stroke Prevention

An Update on Secondary Stroke Prevention

In 2014, the American Heart Association/American Stroke Association (AHA/ASA) updated guidelines for secondary prevention in patients with ischemic stroke or transient ischemic attack (TIA). “These guidelines are updated every few years so that clinicians can stay up to date on the most current research on strategies to maintain a low risk of recurrent events,” explains Walter N. Kernan, MD, who chaired the AHA/ASA writing group that updated the recommendations. The document, which was published online in Stroke: Journal of the American Heart Association, was last updated in 2011. After an initial ischemic stroke or TIA, 3% to 4% of affected patients will have a new ischemic stroke each year. “This figure is historically low because careful attention has been paid to using science-based interventions for secondary prevention,” says Dr. Kernan. “However, the scientific developments in the area of secondary prevention for stroke and TIA are accumulating rapidly. As a result, guideline updates are needed at least every few years.” New Features The updated guidelines include new sections on nutrition and sleep apnea (Table 1) and revisions of several other sections, including those dealing with hypertension, dyslipidemia, diabetes, carotid stenosis, and atrial fibrillation (AF). Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances. These include aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. The AHA/ASA document also has made it easier for clinicians to recognize new changes to the guidelines by including a table that details the major additions and revisions. Using the Guidelines “For clinicians who use...

New Missouri Law: Practicing Without Residency Training

Everyone knows there’s a shortage of primary care physicians, especially in rural areas. The state of Missouri has decided to alleviate this problem with a bill, signed into law by the governor this month, authorizing medical school graduates who have not done any residency training to act as “assistant physicians.” The assistant physicians will come from the pool of 7000 to 8000 graduates, mostly of offshore medical schools, who were unable to match to any residency. After spending 30 days with a “physician collaborator,” assistant physicians would be allowed to practice independently as long as they were within 50 miles of their collaborator. The physician collaborator is also required to review 10% of the assistant physician’s charts. Assistant physicians would be expected to treat simple problems and could prescribe Schedule III [including hydroxycodone or codeine when compounded with an NSAID as well as synthetic tetrahydrocannabinol], IV, and V drugs. Opponents of the bill included the American Medical Association, the Accreditation Council for Graduate Medical Education, and the American Academy of Physician Assistants. According to healthleadersmedia.com, the Missouri State Medical Association supported the bill. Its government relations director and general counsel, Jeffrey Howell, said the new rules would be no different than those for older doctors. “A lot of those guys didn’t have to go through a residency program. They just graduated from medical school and went back to the farming communities they grew up in, hung out their shingles, and treated people.” Perhaps Mr. Howell hasn’t heard that medicine is a bit more complex than it was 50 or 60 years ago. Proponents of the bill felt that rural...
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