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Stephen J Louw

Publications and source records attributed to Stephen J Louw.

8 recordsLinked to original sources
PubMed2005

The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument.

BACKGROUND: In patients with acute stroke, rapid intervention is crucial to maximise early treatment benefits. Stroke patients commonly have their first contact with medical staff in the emergency room (ER). We designed and validated a stroke recognition tool-the Recognition of Stroke in the Emergency Room (ROSIER) scale-for use by ER physicians. METHODS: We prospectively collected data for 1 year (development phase) on the clinical characteristics of patients with suspected acute stroke who were admitted to hospital from the ER. We used logistic regression analysis and clinical reasoning to develop a stroke recognition instrument for application in this setting. Patients with suspected transient ischaemic attack (TIA) with no symptoms or signs when assessed in the ER were excluded from the analysis. The instrument was assessed using the baseline 1-year dataset and then prospectively validated in a new cohort of ER patients admitted over a 9-month period. FINDINGS: In the development phase, 343 suspected stroke patients were assessed (159 stroke, 167 non-stroke, 32 with TIA [17 with symptoms when seen in ER]). Common stroke mimics were seizures (23%), syncope (23%), and sepsis (10%). A seven-item (total score from -2 to +5) stroke recognition instrument was constructed on the basis of clinical history (loss of consciousness, convulsive fits) and neurological signs (face, arm, or leg weakness, speech disturbance, visual field defect). When internally validated at a cut-off score greater than zero, the instrument showed a diagnostic sensitivity of 92%, specificity of 86%, positive predictive value (PPV) of 88%, and negative predictive value (NPV) of 91%. Prospective validation in 173 consecutive suspected stroke referrals (88 stroke, 59 non-stroke, 26 with TIA [13 with symptoms]) showed sensitivity of 93% (95% CI 89-97), specificity 83% (77-89), PPV 90% (85-95), and NPV 88% (83-93). The ROSIER scale had greater sensitivity than existing stroke recognition instruments in this population. INTERPRETATION: The ROSIER scale was effective in the initial differentiation of acute stroke from stroke mimics in the ER. Introduction of the instrument improved the appropriateness of referrals to the stroke team.

Aged↗
PubMed2003

Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test.

BACKGROUND AND PURPOSE: Timely referral of appropriate patients to acute stroke units is necessary for effective provision of skilled care. We compared the characteristics of referrals with suspected stroke to an academic acute stroke unit via 3 primary referral routes: ambulance paramedics using a rapid ambulance protocol and stroke recognition instrument, the Face Arm Speech Test; primary care doctors (PCDs); and emergency room (ER) referrals. METHODS: Patient characteristics, final diagnosis, and admission delay were recorded in all suspected acute stroke referrals in a 6-month period. RESULTS: Four hundred eighty-seven patients (356 strokes/transient ischemic attacks) were admitted by the 3 routes: 178 by ambulance, 216 by PCDs, and 93 through the ER. The proportion of nonstrokes admitted by each route was similar (23%, 29%, and 29%, respectively). Ambulance paramedics' stroke diagnosis was correct in 144 of 183 (79%) stroke patients who initially presented to them. Thirty-nine of 66 strokes/transient ischemic attacks referred via ER were taken there following initial ambulance assessment. Compared with PCDs, paramedics referred more total anterior circulation (39% versus 14%, P<0.0001) and fewer lacunar strokes (14% versus 31%, P<0.001) and admitted more patients (46% versus 12%, P<0.01) within 3 hours of symptom onset. The most common nonstroke conditions were seizures, infections and confusion, cardiovascular collapse, and cerebral tumors. Paramedics admitted more patients with seizures. CONCLUSIONS: Misdiagnosis of stroke is common in the ER and by PCDs. Paramedics using the Face Arm Speech Test achieved high levels of detection and diagnostic accuracy of stroke.

Adult↗
PubMed2002

Confidentiality and cognitive impairment: professional and philosophical ethics.

In the UK, the General Medical Council's new guidance on confidentiality restates the professional duty for doctors to regard personal information revealed to them as confidential. Such information can be shared only with the patient's explicit consent--the exceptions to this are narrowly defined. We believe the guidance does not adequately address the reality of confidentiality in modern practice, particularly in relation to patients with dementia. It seems to be naïve or lacking in the subtlety required in complex clinical situations, perhaps because its legalistic, professional ethics have a philosophically limited view of confidentiality. A more sophisticated philosophical picture regards people as embedded in a shared, worldly context, in which relationships and mutual engagement become crucial. Attending to the reality of cognitively impaired people emphasizes this context and suggests that confidentiality cannot be an overriding principle--it is best regarded as a token of trust.

Aged↗
PubMed2002

Stroke medicine-ethical and legal considerations.

In this short paper we set out to demonstrate common ground between Medical Ethics and Jurisprudence. We delineate the scope of the debate entailing juristic and medical ethical issues in stroke medicine. The article refers to joint legal and ethical issues pertaining to withholding and withdrawing life-sustaining treatment and advance directives. A key concern is that certain essential clinical prognostic questions require to be evaluated before any justifiable discussion about their ethical implications can ensue. The pre-eminence of the principle of autonomy in medical ethics and jurisprudence is emphasised throughout the paper.

Advance Directives↗