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Perry C, Alsbrooks K, Mares A, Hoerauf K. Comparison of Clinical, Economic, and Humanistic Outcomes Between Blood Collection Approaches: A Systematic Literature Review. J Healthc Qual 2023; 45:359-370. [PMID: 37788441 PMCID: PMC10624413 DOI: 10.1097/jhq.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND A systematic literature review was performed to understand the prevalence, advantages, and disadvantages of blood collection using different approaches (direct venipuncture or vascular access devices), and interventions used to mitigate the disadvantages. METHODS The review included a broad range of study designs and outcomes. Database searches (Embase, MEDLINE, Cochrane library, and Centre for Reviews and Dissemination) were conducted in March 2021 and supplemented by hand searching. RESULTS One hundred forty-one publications were included. The data indicate that blood sampling from vascular access devices is common in emergency departments, trauma centers, and intensive care units. Studies showed that hemolysis and sample contamination place a considerable economic burden on hospitals. Significant cost savings could be made through enforcing strict aseptic technique, or using the initial specimen diversion technique. CONCLUSIONS Hemolysis and sample contamination are far from inevitable in vascular access device-collected or venipuncture samples; both can be reduced through adherence to strict blood sampling protocols and utilization of the initial specimen diversion technique. Needle-free blood collection devices offer further hope for reducing hemolysis. No publication focused on the difficult venous access population; insertion success rates are likely to be lower (and the benefits of vascular access devices higher) in these patients.
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2
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Ebinger M, Audebert HJ. Shifting acute stroke management to the prehospital setting. Curr Opin Neurol 2022; 35:4-9. [PMID: 34799513 DOI: 10.1097/wco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The earlier the treatment, the better the outcomes after acute ischemic stroke. Optimizing prehospital care bears potential to shorten treatment times. We here review the recent literature on mothership vs. drip-and-ship as well as mobile stroke unit concepts. RECENT FINDINGS Mobile stroke units result in the shortest onset-to-treatment times in mostly urban settings. SUMMARY Future research should focus on further streamlining processes around mobile stroke units, especially improving dispatch algorithms and improve referral for endovascular therapy.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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3
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Stopyra JP, Snavely AC, Ashburn NP, Nelson R, McMurray EL, Hunt MR, Miller CD, Mahler SA. EMS blood collection from patients with acute chest pain reduces emergency department length of stay. Am J Emerg Med 2021; 47:248-252. [PMID: 33964547 PMCID: PMC9052866 DOI: 10.1016/j.ajem.2021.04.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/16/2021] [Accepted: 04/23/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Expediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States. METHODS A prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016-4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin. RESULTS The use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6-100). NPV improved to 100% (95% CI: 92.9-100) when using the EMS and 3-h ED troponin measures. CONCLUSIONS EMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.
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Affiliation(s)
- Jason P. Stopyra
- Corresponding author at: Department of Emergency Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA., (J.P. Stopyra)
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Mattila OS, Ashton NJ, Blennow K, Zetterberg H, Harve-Rytsälä H, Pihlasviita S, Ritvonen J, Sibolt G, Nukarinen T, Curtze S, Strbian D, Pystynen M, Tatlisumak T, Kuisma M, Lindsberg PJ. Ultra-Early Differential Diagnosis of Acute Cerebral Ischemia and Hemorrhagic Stroke by Measuring the Prehospital Release Rate of GFAP. Clin Chem 2021; 67:1361-1372. [PMID: 34383905 DOI: 10.1093/clinchem/hvab128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/11/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Plasma glial fibrillary acidic protein (GFAP) and tau are promising markers for differentiating acute cerebral ischemia (ACI) and hemorrhagic stroke (HS), but their prehospital dynamics and usefulness are unknown. METHODS We performed ultra-sensitivite single-molecule array (Simoa®) measurements of plasma GFAP and total tau in a stroke code patient cohort with cardinal stroke symptoms [National Institutes of Health Stroke Scale (NIHSS) ≥3]. Sequential sampling included 2 ultra-early samples, and a follow-up sample on the next morning. RESULTS We included 272 cases (203 ACI, 60 HS, and 9 stroke mimics). Median (IQR) last-known-well to sampling time was 53 (35-90) minutes for initial prehospital samples, 90 (67-130) minutes for secondary acute samples, and 21 (16-24) hours for next morning samples. Plasma GFAP was significantly higher in patients with HS than ACI (P < 0.001 for <1 hour and <3 hour prehospital samples, and <3 hour secondary samples), while total tau showed no intergroup difference. The prehospital GFAP release rate (pg/mL/minute) occurring between the 2 very early samples was significantly higher in patients with HS than ACI [2.4 (0.6-14.1)] versus 0.3 (-0.3-0.9) pg/mL/minute, P < 0.001. For cases with <3 hour prehospital sampling (ACI n = 178, HS n = 59), a combined rule (prehospital GFAP >410 pg/mL, or prehospital GFAP 90-410 pg/mL together with GFAP release >0.6 pg/mL/minute) enabled ruling out HS with high certainty (NPV 98.4%) in 68% of patients with ACI (sensitivity for HS 96.6%, specificity 68%, PPV 50%). CONCLUSIONS In comparison to single-point measurement, monitoring the prehospital GFAP release rate improves ultra-early differentiation of stroke subtypes. With serial measurement GFAP has potential to improve future prehospital stroke diagnostics .
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Affiliation(s)
- Olli S Mattila
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nicholas J Ashton
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,NIHR Biomedical Research Centre for Mental Health and Biomedical Research Unit for Dementia at South London and Maudsley NHS Foundation, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Heini Harve-Rytsälä
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Saana Pihlasviita
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juhani Ritvonen
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Gerli Sibolt
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Nukarinen
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sami Curtze
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Pystynen
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience/Neurology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Markku Kuisma
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Perttu J Lindsberg
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Gyldenholm T, Stengaard C, Sørensen JT, Bøtker MT, Ladefoged SA. Haemolysis in prehospital blood samples. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:508-510. [PMID: 34182857 DOI: 10.1080/00365513.2021.1941234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The increasing use of Point Of Care Testing (POCT) in the prehospital setting demands a high and consistent quality of blood samples. We have investigated the degree of haemolysis in 779 prehospital blood samples and found a significant increase in haemolysis compared to intrahospital samples. The degree of haemolysis was within acceptable limits for current analyses. However, haemolysis should be taken into account when implementing future analyses in the prehospital field.
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Affiliation(s)
- Tua Gyldenholm
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Carsten Stengaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Morten T Bøtker
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Søren A Ladefoged
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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6
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Dagonnier M, Donnan GA, Davis SM, Dewey HM, Howells DW. Acute Stroke Biomarkers: Are We There Yet? Front Neurol 2021; 12:619721. [PMID: 33633673 PMCID: PMC7902038 DOI: 10.3389/fneur.2021.619721] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Distinguishing between stroke subtypes and knowing the time of stroke onset are critical in clinical practice. Thrombolysis and thrombectomy are very effective treatments in selected patients with acute ischemic stroke. Neuroimaging helps decide who should be treated and how they should be treated but is expensive, not always available and can have contraindications. These limitations contribute to the under use of these reperfusion therapies. Aim: An alternative approach in acute stroke diagnosis is to identify blood biomarkers which reflect the body's response to the damage caused by the different types of stroke. Specific blood biomarkers capable of differentiating ischemic from hemorrhagic stroke and mimics, identifying large vessel occlusion and capable of predicting stroke onset time would expedite diagnosis and increase eligibility for reperfusion therapies. Summary of Review: To date, measurements of candidate biomarkers have usually occurred beyond the time window for thrombolysis. Nevertheless, some candidate markers of brain tissue damage, particularly the highly abundant glial structural proteins like GFAP and S100β and the matrix protein MMP-9 offer promising results. Grouping of biomarkers in panels can offer additional specificity and sensitivity for ischemic stroke diagnosis. Unbiased “omics” approaches have great potential for biomarker identification because of greater gene, protein, and metabolite coverage but seem unlikely to be the detection methodology of choice because of their inherent cost. Conclusion: To date, despite the evolution of the techniques used in their evaluation, no individual candidate or multimarker panel has proven to have adequate performance for use in an acute clinical setting where decisions about an individual patient are being made. Timing of biomarker measurement, particularly early when decision making is most important, requires urgent and systematic study.
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Affiliation(s)
- Marie Dagonnier
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Department of Neurology, Ambroise Paré Hospital, Mons, Belgium
| | - Geoffrey A Donnan
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Melbourne Brain Centre at the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Helen M Dewey
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - David W Howells
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Faculty of Health, School of Medicine, University of Tasmania, Hobart, TAS, Australia
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7
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Lumley HA, Flynn D, Shaw L, McClelland G, Ford GA, White PM, Price CI. A scoping review of pre-hospital technology to assist ambulance personnel with patient diagnosis or stratification during the emergency assessment of suspected stroke. BMC Emerg Med 2020; 20:30. [PMID: 32336270 PMCID: PMC7183583 DOI: 10.1186/s12873-020-00323-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pre-hospital identification of key subgroups within the suspected stroke population could reduce delays to emergency treatment. We aimed to identify and describe technology with existing proof of concept for diagnosis or stratification of patients in the pre-hospital setting. METHODS A systematic electronic search of published literature (from 01/01/2000 to 06/06/2019) was conducted in five bibliographic databases. Two reviewers independently assessed eligibility of studies or study protocols describing diagnostic/stratification tests (portable imaging/biomarkers) or technology facilitating diagnosis/stratification (telemedicine) used by ambulance personnel during the assessment of suspected stroke. Eligible descriptions required use of tests or technology during the actual assessment of suspected stroke to provide information directly to ambulance personnel in the pre-hospital setting. Due to study, intervention and setting heterogeneity there was no attempt at meta-analysis. RESULTS 2887 articles were screened for eligibility, 19 of which were retained. Blood biomarker studies (n = 2) were protocols of prospective diagnostic accuracy studies, one examining purines and the other a panel of known and novel biomarkers for identifying stroke sub-types (versus mimic). No data were yet available on diagnostic accuracy or patient health outcomes. Portable imaging studies (n = 2) reported that an infrared screening device for detecting haemorrhages yielded moderate sensitivity and poor specificity in a small study, whilst a dry-EEG study to detect large vessel occlusion in ischaemic stroke has not yet reported results. Fifteen evaluations of pre-hospital telemedicine were identified (12 observational and 3 controlled comparisons) which all involved transmission of stroke assessment data from the pre-hospital setting to the hospital. Diagnosis was generally comparable with hospital diagnosis and most telemedicine systems reduced time-to-treatment; however, it is unknown whether this time saving translated into more favourable clinical outcomes. Telemedicine systems were deemed acceptable by clinicians. CONCLUSIONS Pre-hospital technologies to identify clinically important subgroups amongst the suspected stroke population are in development but insufficient evidence precludes recommendations about routine use in the pre-hospital setting. Multi-centre diagnostic accuracy studies and clinical utility trials combining promising technologies are warranted.
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Affiliation(s)
- Hannah A Lumley
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health and Social Care, Teesside University, Tees Valley, UK
| | - Lisa Shaw
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Graham McClelland
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, England
| | - Gary A Ford
- Medical Sciences Division, Oxford Academic Health Science Network, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil M White
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, England
| | - Christopher I Price
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, England
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8
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Biomarker Application for Precision Medicine in Stroke. Transl Stroke Res 2019; 11:615-627. [PMID: 31848851 PMCID: PMC7299765 DOI: 10.1007/s12975-019-00762-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022]
Abstract
Stroke remains one of the leading causes of long-term disability and mortality despite recent advances in acute thrombolytic therapies. In fact, the global lifetime risk of stroke in adults over the age of 25 is approximately 25%, with 24.9 million cases of ischemic stroke and 18.7 million cases of hemorrhagic stroke reported in 2015. One of the main challenges in developing effective new acute therapeutics and enhanced long-term interventions for stroke recovery is the heterogeneity of stroke, including etiology, comorbidities, and lifestyle factors that uniquely affect each individual stroke survivor. In this comprehensive review, we propose that future biomarker studies can be designed to support precision medicine therapeutic interventions after stroke. The current challenges in defining ideal biomarkers for stroke are highlighted, including consideration of disease course, age, lifestyle factors, and subtypes of stroke. This overview of current clinical trials includes biomarker collection, and concludes with an example of biomarker design for aneurysmal subarachnoid hemorrhage. With the advent of “-omics” studies, neuroimaging, big data, and precision medicine, well-designed stroke biomarker trials will greatly advance the treatment of a disease that affects millions globally every year.
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Mattila OS, Puolakka T, Ritvonen J, Pihlasviita S, Harve H, Alanen A, Sibolt G, Curtze S, Strbian D, Pystynen M, Tatlisumak T, Kuisma M, Lindsberg PJ. Targets for improving dispatcher identification of acute stroke. Int J Stroke 2019; 14:409-416. [DOI: 10.1177/1747493019830315] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Accurate identification of acute stroke by Emergency Medical Dispatchers (EMD) is essential for timely and purposeful deployment of Emergency Medical Services (EMS), and a prerequisite for operating mobile stroke units. However, precision of EMD stroke recognition is currently modest. Aims We sought to identify targets for improving dispatcher stroke identification. Methods Dispatch codes and EMS patient records were cross-linked to investigate factors associated with an incorrect dispatch code in a prospective observational cohort of 625 patients with a final diagnosis of acute stroke or transient ischemic attack (TIA), transported to our stroke center as candidates for recanalization therapies. Call recordings were analyzed in a subgroup that received an incorrect low-priority dispatch code indicating a fall or unknown acute illness ( n = 46). Results Out of 625 acute stroke/TIA patients, 450 received a high-priority stroke dispatch code (sensitivity 72.0%; 95% CI, 68.5–75.5). Independent predictors of dispatcher missed acute stroke included a bystander caller (aOR, 3.72; 1.48–9.34), confusion (aOR, 2.62; 1.59–4.31), fall at onset (aOR, 1.86; 1.24–2.78), and older age (aOR [per year], 1.02; 1.01–1.04). Of the analyzed call recordings, 71.7% revealed targets for improvement, including failure to recognize a Face Arm Speech Time (FAST) test symptom (21/46 cases, 18 with speech disturbance), or failure to thoroughly evaluate symptoms (12/46 cases). Conclusions Based on our findings, efforts to improve dispatcher stroke identification should primarily focus on improving recognition of acute speech disturbance, and implementing screening of FAST-symptoms in emergency phone calls revealing a fall or confusion. Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT02145663.
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Affiliation(s)
- Olli S Mattila
- Neurology, Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Molecular Neurology, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Tuukka Puolakka
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juhani Ritvonen
- Molecular Neurology, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Saana Pihlasviita
- Molecular Neurology, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Heini Harve
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ari Alanen
- Emergency Response Center Administration, Kerava, Finland
| | - Gerli Sibolt
- Neurology, Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sami Curtze
- Neurology, Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Neurology, Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Pystynen
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Neurology, Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Neuroscience/Neurology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Markku Kuisma
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Perttu J Lindsberg
- Neurology, Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Molecular Neurology, Research Programs Unit, University of Helsinki, Helsinki, Finland
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10
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Pihlasviita S, Mattila OS, Ritvonen J, Sibolt G, Curtze S, Strbian D, Harve H, Pystynen M, Kuisma M, Tatlisumak T, Lindsberg PJ. Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes. Neurology 2018; 91:e498-e508. [DOI: 10.1212/wnl.0000000000005954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/24/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectivesTo clarify diagnostic accuracy and consequences of misdiagnosis in the admission evaluation of stroke-code patients in a neurologic emergency department with less than 20-minute door-to-thrombolysis times.MethodsAccuracy of admission diagnostics was studied in an observational cohort of 1,015 stroke-code patients arriving by ambulance as candidates for recanalization therapy between May 2013 and November 2015. Immediate admission evaluation was performed by a stroke neurologist or a neurology resident with dedicated stroke training, primarily utilizing CT-based imaging.ResultsThe rate of correct admission diagnosis was 91.1% (604/663) for acute cerebral ischemia (ischemic stroke/TIA), 99.2% (117/118) for hemorrhagic stroke, and 61.5% (144/234) for stroke mimics. Of the 150 (14.8%) misdiagnosed patients, 135 (90.0%) had no acute findings on initial imaging and 100 (67.6%) presented with NIH Stroke Scale score 0 to 2. Misdiagnosis altered medical management in 70 cases, including administration of unnecessary treatments (thrombolysis n = 13, other n = 24), omission of thrombolysis (n = 5), delays to specific treatments of stroke mimics (n = 13, median 56 [31–93] hours), and delays to antiplatelet medication (n = 14, median 1 [1–2] day). Misdiagnosis extended emergency department stay (median 6.6 [4.7–10.4] vs 5.8 [3.7–9.2] hours; p = 0.001) and led to unnecessary stroke unit stay (n = 10). Detailed review revealed 8 cases (0.8%) in which misdiagnosis was possible or likely to have worsened outcomes, but no death occurred as a result of misdiagnosis.ConclusionsOur findings support the safety of highly optimized door-to-needle times, built on thorough training in a large-volume, centralized stroke service with long-standing experience. Augmented imaging and front-loaded specialist engagement are warranted to further improve rapid stroke diagnostics.
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Lindsberg PJ, Kuisma M, Mattila OS. How development of blood biomarkers could benefit prehospital management of acute stroke. Biomark Med 2017; 11:1043-1046. [PMID: 29182027 DOI: 10.2217/bmm-2017-0238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Perttu J Lindsberg
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,Molecular Neurology, Research Programs Unit & Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Markku Kuisma
- Section of Emergency Medical Services, Department of Emergency Medicine, Helsinki University Hospital & University of Helsinki, Finland
| | - Olli S Mattila
- Molecular Neurology, Research Programs Unit & Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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12
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Gandolfi M, Smania N, Vella A, Picelli A, Chirumbolo S. Assessed and Emerging Biomarkers in Stroke and Training-Mediated Stroke Recovery: State of the Art. Neural Plast 2017; 2017:1389475. [PMID: 28373915 PMCID: PMC5360976 DOI: 10.1155/2017/1389475] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/11/2017] [Indexed: 12/13/2022] Open
Abstract
Since the increasing update of the biomolecular scientific literature, biomarkers in stroke have reached an outstanding and remarkable revision in the very recent years. Besides the diagnostic and prognostic role of some inflammatory markers, many further molecules and biological factors have been added to the list, including tissue derived cytokines, growth factor-like molecules, hormones, and microRNAs. The literatures on brain derived growth factor and other neuroimmune mediators, bone-skeletal muscle biomarkers, cellular and immunity biomarkers, and the role of microRNAs in stroke recovery were reviewed. To date, biomarkers represent a possible challenge in the diagnostic and prognostic evaluation of stroke onset, pathogenesis, and recovery. Many molecules are still under investigation and may become promising and encouraging biomarkers. Experimental and clinical research should increase this list and promote new discoveries in this field, to improve stroke diagnosis and treatment.
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Affiliation(s)
- Marialuisa Gandolfi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- UOC Neurorehabilitation, AOUI Verona, Verona, Italy
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- UOC Neurorehabilitation, AOUI Verona, Verona, Italy
| | - Antonio Vella
- Immunology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- UOC Neurorehabilitation, AOUI Verona, Verona, Italy
| | - Salvatore Chirumbolo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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