Naeem Dean

Royal Alexandra Hospital, Edmonton, Alberta, Canada

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Publications (17)106.74 Total impact

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    ABSTRACT: Survivors of ischemic stroke/transient ischemic attack (TIA) are at high risk for other vascular events. We evaluated the impact of 2 types of case management (hard touch with pharmacist or soft touch with nurse) added to usual care on global vascular risk. This is a prespecified secondary analysis of a 6-month trial conducted in outpatients with recent stroke/TIA who received usual care and were randomized to additional monthly visits with either nurse case managers (who counseled patients, monitored risk factors, and communicated results to primary care physicians) or pharmacist case managers (who were also able to independently prescribe according to treatment algorithms). The Framingham Risk Score [FRS]) and the Cardiovascular Disease Life Expectancy Model (CDLEM) were used to estimate 10-year risk of any vascular event at baseline, 6 months (trial conclusion), and 12 months (6 months after last trial visit). Mean age of the 275 evaluable patients was 67.6 years. Both study arms were well balanced at baseline and exhibited reductions in absolute global vascular risk estimates at 6 months: median 4.8% (Interquartile range (IQR) 0.3%-11.3%) for the pharmacist arm versus 5.1% (IQR 1.9%-12.5%) for the nurse arm on the FRS (P = .44 between arms) and median 10.0% (0.1%-31.6%) versus 12.5% (2.1%-30.5%) on the CDLEM (P = .37). These reductions persisted at 12 months: median 6.4% (1.2%-11.6%) versus 5.5% (2.0%-12.0%) for the FRS (P = .83) and median 8.4% (0.1%-28.3%) versus 13.1% (1.6%-31.6%) on the CDLEM (P = .20). Case management by nonphysician providers is associated with improved global vascular risk in patients with recent stroke/TIA. Reductions achieved during the active phase of the trial persisted after trial conclusion. Copyright © 2014 Mosby, Inc. All rights reserved.
    American heart journal. 12/2014; 168(6):924-30.
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    ABSTRACT: BACKGROUND:Optimization of systolic blood pressure and lipid levels are essential for secondary prevention after ischemic stroke, but there are substantial gaps in care, which could be addressed by nurse- or pharmacist-led care. We compared 2 types of case management (active prescribing by pharmacists or nurse-led screening and feedback to primary care physicians) in addition to usual care. METHODS:We performed a prospective randomized controlled trial involving adults with recent minor ischemic stroke or transient ischemic attack whose systolic blood pressure or lipid levels were above guideline targets. Participants in both groups had a monthly visit for 6 months with either a nurse or pharmacist. Nurses measured cardiovascular risk factors, counselled patients and faxed results to primary care physicians (active control). Pharmacists did all of the above as well as prescribed according to treatment algorithms (intervention). RESULTS:Most of the 279 study participants (mean age 67.6 yr, mean systolic blood pressure 134 mm Hg, mean low-density lipoprotein [LDL] cholesterol 3.23 mmol/L) were already receiving treatment at baseline (antihypertensives: 78.1%; statins: 84.6%), but none met guideline targets (systolic blood pressure ≤ 140 mm Hg, fasting LDL cholesterol ≤ 2.0 mmol/L). Substantial improvements were observed in both groups after 6 months: 43.4% of participants in the pharmacist case manager group met both systolic blood pressure and LDL guideline targets compared with 30.9% in the nurse-led group (12.5% absolute difference; number needed to treat = 8, p = 0.03). INTERPRETATION:Compared with nurse-led case management (risk factor evaluation, counselling and feedback to primary care providers), active case management by pharmacists substantially improved risk factor control at 6 months among patients who had experienced a stroke. Trial registration: ClinicalTrials.gov, no. NCT00931788.
    Canadian Medical Association Journal 04/2014; · 6.47 Impact Factor
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    ABSTRACT: Background Survivors of ischemic stroke/TIA are at high risk for other vascular events. We evaluated the impact of two types of case-management (hard touch with pharmacist or soft touch with nurse) added to usual care on global vascular risk. Methods Pre-specified secondary analysis of a 6 month trial conducted in outpatients with recent stroke/TIA who received usual care and were randomized to additional monthly visits with either nurse case-managers (who counseled patients, monitored risk factors, and communicated results to primary care physicians) or pharmacist case-managers (who were also able to independently prescribe according to treatment algorithms). The Framingham Risk Score [FRS]) and the Cardiovascular Disease Life Expectancy Model (CDLEM) were used to estimate 10-year risk of any vascular event at baseline, 6-months (trial conclusion), and 12-months (6 months after last trial visit). Results Mean age of the 275 evaluable patients was 67.6 years. Both study arms were well balanced at baseline and exhibited reductions in absolute global vascular risk estimates at 6 months: median 4.8% [IQR 0.3%-11.3%] for the pharmacist arm versus 5.1% [IQR 1.9%-12.5%] for the nurse arm on the FRS (p = 0.44 between arms) and median 10.0% [0.1%-31.6%] versus 12.5% [2.1%-30.5%] on the CDLEM (p = 0.37). These reductions persisted at 12 months: median 6.4% [1.2%-11.6%] versus 5.5% [2.0%-12.0%] for the FRS (p = 0.83) and median 8.4% [0.1%-28.3%] versus 13.1% [1.6%-31.6%] on the CDLEM (p = 0.20). Conclusions Case-management by non-physician providers is associated with improved global vascular risk in patients with recent stroke/TIA. Reductions achieved during the active phase of the trial persisted after trial conclusion.
    American Heart Journal. 01/2014;
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    ABSTRACT: RATIONALE: Stroke risk after transient ischaemic attack is high and, it is a challenge worldwide to provide urgent assessment and preventive services to entire populations. AIMS: To determine whether a province-wide transient ischaemic attack Triaging algorithm and transient ischaemic attack hotline (the Alberta Stroke Prevention in transient ischaemic attacks and mild strokes intervention) can reduce the rate of stroke recurrence following transient ischaemic attack across the population of Alberta, Canada (population 3·7 million, 90-day rate of post-stroke transient ischaemic attack currently 9·5%). It also seeks to improve upon current transient ischaemic attack triaging rules by incorporating time from symptom onset as a predictive variable. DESIGN: The transient ischaemic attack algorithm and hotline were developed with a broad consensus of clinicians, patients, policy-makers, and researchers and based on local adaptation of the work of others and research and insights developed within the province. Because neither patient-level nor region-level randomization was possible, we conducted a quasi-experimental design examining changes in the post-transient ischaemic attack rate of stroke recurrence before and after the 15-month implementation period using an interrupted time-series regression analysis. The design controls for changes in case-mix, co-interventions, and secular trends. A prospective transient ischaemic attack cohort will also be concurrently created with telephone follow-up at seven-days and 90 days as well as passive follow-up over the longer term using linkages to provincial healthcare administrative databases. STUDY OUTCOMES: The primary outcome measure is the change in recurrence rate of stroke following transient ischaemic attack at seven-days and 90 days, comparing a period of two-years before vs. two-years after the intervention is implemented. All cases of recurrent stroke will be validated. Secondary outcomes include functional status, hospitalizations, morbidity, and mortality. CONCLUSIONS: We are undertaking a rigorous evaluation of a population-based approach to improving quality of transient ischaemic attack care. Whether positive or negative, our work should provide important insights for all potential stakeholders.
    International Journal of Stroke 10/2012; · 4.03 Impact Factor
  • The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 09/2011; 38(5):777-82. · 1.33 Impact Factor
  • Naeem Dean, Ashfaq Shuaib
    Lancet Neurology - LANCET NEUROL. 01/2011; 10(7):606-607.
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    ABSTRACT: Survivors of transient ischemic attack (TIA) or stroke are at high risk for recurrent vascular events and aggressive treatment of vascular risk factors can reduce this risk. However, vascular risk factors, especially hypertension and high cholesterol, are not managed optimally even in those patients seen in specialized clinics. This gap between the evidence for secondary prevention of stroke and the clinical reality leads to suboptimal patient outcomes. In this study, we will be testing a pharmacist case manager for delivery of stroke prevention services. We hypothesize this new structure will improve processes of care which in turn should lead to improved outcomes. We will conduct a prospective, randomized, controlled open-label with blinded ascertainment of outcomes (PROBE) trial. Treatment allocation will be concealed from the study personnel, and all outcomes will be collected in an independent and blinded manner by observers who have not been involved in the patient's clinical care or trial participation and who are masked to baseline measurements. Patients will be randomized to control or a pharmacist case manager treating vascular risk factors to guideline-recommended target levels. Eligible patients will include all adult patients seen at stroke prevention clinics in Edmonton, Alberta after an ischemic stroke or TIA who have uncontrolled hypertension (defined as systolic blood pressure (BP) > 140 mm Hg) or dyslipidemia (fasting LDL-cholesterol > 2.00 mmol/L) and who are not cognitively impaired or institutionalized. The primary outcome will be the proportion of subjects who attain 'optimal BP and lipid control'(defined as systolic BP < 140 mm Hg and fasting LDL cholesterol < 2.0 mmol/L) at six months compared to baseline; 12-month data will also be collected for analyses of sustainability of any effects. A variety of secondary outcomes related to vascular risk and health-related quality of life will also be collected. Nearly one-quarter of those who survive a TIA or minor stroke suffer another vascular event within a year. If our intervention improves the provision of secondary prevention therapies in these patients, the clinical (and financial) implications will be enormous.
    Implementation Science 04/2010; 5:27. · 2.37 Impact Factor
  • Naeem Dean, Ashfaq Shuaib
    The Lancet Neurology 03/2009; 8(3):218-9. · 23.92 Impact Factor
  • Naeem Dean, Ashfaq Shuaib
    The Lancet 11/2007; 370(9596):1398-400. · 39.21 Impact Factor
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    ABSTRACT: To evaluate the referral patterns of patients to a stroke prevention clinic (SPC) and to test the adequacy of prereferral diagnosis and management of modifiable risk factors for stroke. We collected prospective data on consecutive patients referred to the SPC at University of Alberta Hospital in Edmonton, Alberta, Canada. Outcome measures included: alternate diagnoses to stroke or transient ischemic attack (TIA), uncontrolled or undiagnosed hypertension, hyperlipidemia and diabetes, therapies, and investigations leading to carotid endarterectomy. Two thousand and eleven patients were referred to SPC. Nearly 25% of the referrals originated from the emergency room and the rest from general physicians. Of the referrals, 68.7% were confirmed as TIA or stroke at the SPC. Among 1381 patients with TIA or stroke, 736 had history of hypertension. Uncontrolled hypertension was found in 265 patients (36.0% of those with hypertension: 95% CI: 32.5-39.5) while undiagnosed hypertension was found in 103 (15.9% of those without hypertension: 95%CI: 13.14-18.79). History of hyperlipidemia was present in 451 patients (32.6%) and 356 (78.9%: 95% CI: 75.2-82.69) of these patients were not at target for secondary prevention. Among 930 patients without history of hyperlipidemia, 739 (79.5%: 95% CI: 76.8-82.1) were diagnosed with hyperlipidemia through the SPC. Fasting blood glucose levels above 7.1 mmol/L in patients with and without history of diabetes were 221 (79.2%: 95% CI: 74.5-83.9) and 66 (6%: 95%CI: 4.6-7.4) respectively. Management of risk factors for stroke needs improvement. SPCs should consider actively managing the classical modifiable risk factors of stroke.
    The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 12/2005; 32(4):496-500. · 1.33 Impact Factor
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    ABSTRACT: To study the short and long term differences in outcome between patients > or =80 years of age and those < or =79 years of age who received intravenous recombinant tissue plasminogen activator (iv rt-PA) for acute stroke within the first 3 hours of symptom onset. We studied consecutive patients treated with iv rt-PA for acute stroke, with prospective follow up of up to 3 years. Outcome measures included National Institutes of Health Stroke Scale (NIHSS) score, Barthel Index (BI), modified Rankin score (MRS), and stroke mortality. Patients were split into two groups: younger (< or =79 years) and older (> or =80 years). There were 65 patients in the younger cohort and 31 patients in the older. Older patients were more likely to present with more severe baseline stroke (p = 0.04; odds ratio (OR) 3.04; 95% confidence interval (CI) 1.03 to 8.98). Stroke mortality at 90 days was 10.8% in the younger and 32.3% in the older cohort (p = 0.01). At 90 days' follow up, patients in the older cohort with more severe stroke (NIHSS score > or =11) were nearly 10 times more likely to have poor outcome compared with their younger counterparts presenting with severe stroke (p = 0.001; OR = 10.36; 95% CI 2.16 to 49.20). Baseline stroke severity and age were the only independent and equal predictors for stroke outcome. No threshold was found for age or baseline stroke severity predicting outcome. Older patients presenting with more severe baseline stroke are much less likely to benefit from iv rt-PA as compared with their younger counterparts.
    Journal of Neurology Neurosurgery & Psychiatry 09/2005; 76(9):1234-7. · 4.92 Impact Factor
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    ABSTRACT: Doppler ultrasound (DUS) is used as a screening tool to assess internal carotid artery (ICA) disease. Recent reports suggest that the DUS may be inaccurate in over 28% of patients. We sought to evaluate the accuracy of DUS, when performed in a dedicated stroke prevention clinic (SPC). We retrospectively reviewed the charts of patients who had a DUS performed in our SPC, followed by conventional cerebral angiography. Three groups of patients were defined. Group 1 had DUS measured ICA stenosis of >50%; Group II had a DUS measured ICA stenosis of <50%; Group III had complete ICA occlusion on DUS. Sixty-seven patients (69 arteries) were included in the study. There were 45 patients in Group I and based on the findings of cerebral angiography, carotid endarterectomy was considered inappropriate in only one patient--a misclassification rate of 2.2% (95% CI: 0 - 6.5%). Group II consisted of 19 patients and on cerebral angiography, none of these patients had a stenosis of >50%--a misclassification rate of 0%. Group III consisted of five patients in whom DUS showed complete ICA occlusion. The angiogram confirmed the occlusion in all five patients--a misclassification rate of 0%. Overall, misclassification rate was 1.45% (95% CI: 0 - 4.3%). Doppler ultrasound when performed in a stroke prevention clinic (SPC), has a high accuracy in measuring ICA stenosis of >50%. Doppler ultrasound is reliable in detecting complete ICA occlusion and finally DUS is a reliable screening tool to rule out clinically significant ICA stenosis.
    The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 09/2005; 32(3):327-31. · 1.33 Impact Factor
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    ABSTRACT: Identifying internal carotid artery (ICA) stenosis in the acute stroke setting can provide clinically useful information. Transcranial Doppler (TCD) through the orbital window is an easy test to perform and to track and identify different vessels. Previous TCD studies have suggested that a reversed ophthalmic artery (OA) flow is a useful collateral pattern to predict ICA disease. The authors sought to evaluate the TCD orbital window for predicting cervical ICA (cICA) stenosis in the setting of acute stroke and TIA. Power M-mode/TCD was performed in acute stroke and transient ischemic attack patients at 2 institutions. Each orbital window depth was detected on M-mode and evaluated for the direction of flow and resistance pattern. Gold standard for comparison was carotid evaluation using carotid duplex, computed tomography angiogram, or conventional angiography. The assessment of cICA disease was categorized by degree of stenosis or occlusion. A total of 216 transorbital exams were performed in 117 patients. Twenty-five cICA occlusions and 8 critical cICA stenoses (>or=95%) were identified by gold standard imaging. Reversed OA flow at 50 to 60 mm depth revealed high specificity (100%; confidence interval [CI], 97.6%-100.0%) and good sensitivity (75%; CI, 53.3%-90.2%) for identifying cICA occlusion or critical stenosis (>or=95%). Low pulsatility index (<1.2) and mean flow velocity (<15 cm/s) discriminated critical severe ICA stenosis or occlusion when OA flow was anterograde with good sensitivity (87.2%) and specificity (95.2%). The reversed OA sign at 50 to 60 mm depth is very specific for identifying cICA occlusion or critical stenosis. When OA flow is anterograde, a low mean flow velocity or pulsatility index is also useful to identify cICA critical stenosis or occlusion.
    Journal of Neuroimaging 05/2005; 15(2):138-43. · 1.41 Impact Factor
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    ABSTRACT: Stroke is a major cause of morbidity and mortality in an aging population. The current understanding of the pathophysiology of atherosclerotic diseases, the most common cause of stroke, and the evidence for existing therapeutic interventions for the prevention of stroke are presented. Specifically, we review the evidence for antiplatelet agents, anticoagulants, antihypertensive medications, lipid-lowering agents and carotid endarterectomy for stroke prevention.
    Canadian Medical Association Journal 04/2004; 170(7):1123-33. · 6.47 Impact Factor
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    ABSTRACT: Background- Power motion-mode transcranial Doppler (TCD) (PMD) is a new, multigated technique that may simplify and enhance detection of embolus. We developed criteria for emboli detection using PMD. Then, we performed a blinded comparison of transcranial PMD with single-gate spectral TCD in TCD bubble study patients. Patients with right-to-left shunt as detected with standard TCD were selected for this study. The international emboli criteria for spectral TCD were used. We defined novel PMD criteria for detecting emboli signature on PMD as follows: (1) signature at least 3 dB higher than the highest spontaneous PMD display of background blood flow; (2) embolic signature reflects motion in one direction at a minimum spatial extent of 7.5 mm and temporal extent of 30 ms; (3) embolus must traverse a prespecified depth. Each study was blindly assessed for microbubble signals (MBS) count on either modality. Thirty-six patients were included in the study. Mean age was 44.4 (SD 14.4), 50% were male, and median time from stroke onset to TCD bubble test was 12 days. Median MBS count in middle cerebral arteries (MCA) was 4 on both modalities. Spectral TCD MBS counts were highly correlated (rho=0.97) with PMD MBS counts in MCA and similarly in anterior cerebral arteries (ACA) (rho=0.79). When PMD microbubble counts in the ACA and MCA were summed, a clear 2-fold difference emerged between 2 modalities (P<0.001). When compared with spectral TCD, PMD detects more MBS with higher counts by identifying ACA as well as MCA emboli. Pitfalls of overcounting emboli with PMD can be avoided by following such criteria.
    Stroke 01/2004; 35(1):e14-7. · 6.16 Impact Factor
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    ABSTRACT: Cardiac myxoma is a source of emboli to the central nervous system and elsewhere in the vascular tree. However, nonspecific systemic symptoms and minor embolic phenomena may be overlooked in the absence of any history of cardiac problems. In this situation, cardiac investigations may not be performed, and diagnosis of this rare condition may be delayed until the onset of more significant embolic disease, such as stroke with functional impairment, as in the case reported here. The clinical presentation of cardiac myxoma is discussed, along with appropriate investigations and treatment, which may prevent such sequelae.
    Canadian Medical Association Journal 12/2003; 169(10):1049-51. · 6.47 Impact Factor
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    ABSTRACT: Carotid artery dissection resulting in occlusion or severe narrowing and massive intracranial embolism can result in life-threatening hemispheric ischemia. Aggressive endovascular and microsurgical measures may be necessary to salvage life and minimize stroke morbidity in this extreme situation. We have treated two middle-aged women who presented within an hour of spontaneous cervical internal carotid artery (ICA) dissection causing hemiplegia, forced head and eye deviation, and declining consciousness. The first patient had a carotid occlusion through which a catheter could not be passed, so intracranial thrombolysis was achieved through a microcatheter navigated through the posterior circulation. Surgical intimectomy and thrombectomy of the dissected ICA was then carried out using an intraoperative Fogarty arterial embolectomy catheter passed up the dissected ICA, followed by endovascular stenting of the reopened cervical ICA. The second patient underwent intracranial microsurgical embolectomy and, after an unsuccessful attempt of stenting the dissected and severely narrowed cervical ICA, surgical reopening again with a Fogarty catheter. Both patients suffered basal ganglionic infarcts but most of the middle cerebral artery territories were preserved and the patients made satisfactory recoveries. "Malignant" carotid artery dissection causing occlusion or near occlusion with intracranial embolism is an important cause of severe and life-threatening hemispheric ischemia. Treatment should include aggressive endovascular and microsurgical interventions when the hemisphere is at risk.
    The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 12/2002; 29(4):378-85. · 1.33 Impact Factor

Publication Stats

103 Citations
106.74 Total Impact Points

Institutions

  • 2007–2014
    • Royal Alexandra Hospital
      Edmonton, Alberta, Canada
  • 2011
    • Sunnybrook Health Sciences Centre
      Toronto, Ontario, Canada
  • 2002–2010
    • University of Alberta
      • • Division of General Internal Medicine
      • • Division of Neurology
      • • Division of Neurosurgery
      Edmonton, Alberta, Canada