Recommendations for Improving the Quality of Care Through Stroke Centers and Systems: An Examination of Stroke Center Identification Options

Mechanical thrombectomy in children and adolescents: report of five cases and literature review

Background

Paediatric arterial ischaemic stroke is an important cause of morbidity and mortality among children. Currently, there are no recommendations regarding mechanical thrombectomy in children despite overwhelming evidence of improved outcomes in adults. Therefore, the need for individual case reports and case series is important to highlight potential advantages and disadvantages in this approach.

Case descriptions

We retrospectively searched our prospectively maintained database of patients undergoing mechanical thrombectomy for ischaemic stroke. We describe five children, aged between 7 and 17, who underwent mechanical thrombectomy for acute ischaemic stroke. We provide an account of their clinical presentations, operative treatment and postoperative outcome.

Discussion

Mechanical thrombectomy in children, especially older children, can be performed safely and with existing devices. Although a randomised controlled trial would provide compelling evidence of the potential advantages to this technique, the lack of this should not prevent the use of this procedure by trained neurointerventionists.

Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography

Objective

To describe and explain stroke survivors and informal caregivers’ experiences of primary care and community healthcare services. To offer potential solutions for how negative experiences could be addressed by healthcare services.

Design

Systematic review and meta-ethnography.

Data sources

Medline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015).

Eligibility criteria

Primary qualitative studies focused on adult community-dwelling stroke survivors’ and/or informal caregivers’ experiences of primary care and/or community healthcare services.

Data synthesis

A set of common second order constructs (original authors’ interpretations of participants’ experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods’ criteria.

Results

51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke.

Limitations

Potential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems.

Conclusions

Stroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services.

Systematic review registration number

PROSPERO 2015:CRD42015026602

Correlation between CH2DS2-VASc Score and Serum Leptin Levels in Cardioembolic Stroke Patients: The Impact of Metabolic Syndrome

OBJECTIVE

To determine adipokines levels in patients with different etiologic subtypes of acute ischemic stroke (AIS) and metabolic syndrome (MetS) status.

METHODS

Serum adiponectin, leptin, and resistin levels were determined by ELISA in 99 AIS patients and 59 stroke-free control group subjects. Stroke patients were grouped based on MetS, modified TOAST classification, and CHA2DS2-VASc scale in case of cardioembolic stroke following atrial fibrillation.

RESULTS

No differences were found in all adipokine serum levels between AIS patients and appropriately matched control group. MetS-AIS patients had significantly higher leptin levels (22.71 ± 19.01 ng/ml versus 8.95 ± 9.22 ng/ml, p < 0.001) and lower adiponectin levels (10.71 ± 8.59 ng/ml versus 14.93 ± 10.95 ng/ml, p < 0.05) than non-MetS-AIS patients. In patients with cardioembolic stroke, leptin levels were significantly higher than in remaining stroke cases (19.57 ± 20.53 ng/ml versus 13.17 ± 12.36 ng/ml, p < 0.05) and CHA2DS2-VASc score positively correlated with leptin levels only (p < 0.001). Analysis of individual components of CHA2DS2-VASc score showed that hypertension, female gender, and diabetes had greatest impact on elevated serum leptin level.

CONCLUSION

This pilot study revealed that leptin could be a potential biomarker for risk stratification of cardioembolic stroke in MetS patients and that heterogeneity of stroke subtypes should be considered for more refined and precise clinical stroke studies.

A pediatric institutional acute stroke protocol improves timely access to stroke treatment

AIM

We aimed to evaluate whether an institutional acute stroke protocol (ASP) could accelerate the diagnosis and secondary treatment of pediatric stroke.

METHOD

We initiated an ASP in 2005. We compared 209 children (125 males, 84 females; median age 4.8y, interquartile range [IQR] 1.2-9.3y, range 0.09-17.7y) diagnosed with arterial ischemic stroke 'pre-protocol' (1992-2004) to 112 children (60 males, 52 females; median age 5.8y, IQR 1.0-11.4y, range 0.08-17.7y) diagnosed 'post-protocol' (2005-2012) for time-to-diagnosis, mode of diagnostic imaging, and time-to-treatment with antithrombotic medication (aspirin or anticoagulants).

RESULTS

Overall, the interval from symptom onset to diagnosis was similar post-protocol compared to pre-protocol (20.3 vs 22.7h; p=0.109), although mild strokes (Pediatric National Institute of Health Stroke Scale [PedNIHSS] 0-4), were diagnosed faster post-protocol (12.1 vs 36.3h; p=0.003). Magnetic resonance imaging (MRI) was the initial diagnostic modality more often post-protocol (25% vs 1.4%; p<0.001). Initial MRI was more accurate for diagnosing stroke than initial CT (100% vs 47%; p<0.001) with similar time-to-diagnosis. The proportion of children receiving antithrombotic medication within 24 hours doubled in the post-protocol period (83% vs 36%; p<0.001).

INTERPRETATION

A pediatric ASP accelerated time-to-treatment, time-to-diagnosis in children with subtle strokes, and increased MRI as initial imaging, reducing the need for computed tomography. Implementing optimized ASPs can facilitate more timely access to diagnosis and management of children with acute stroke.

Development of regional stroke programs

The organization of stroke care has undergone a dramatic evolution in the USA over the last two decades. Beginning with the recommendation for Primary Stroke Centers (PSCs) in 1994, there has been a concerted effort by physicians, the American Heart Association/American Stroke Association (AHA/ASA), National Institutes of Health (NIH), and state legislatures to advance an evidence-based system of care with several tiers of stroke centers. At the apex of this structure are Regional Stroke Centers (RSCs), which do not have official recognition like PSCs and Comprehensive Stroke Centers (CSCs), but their existence as a hub for the many disparate spokes of stroke care in their region is increasingly necessary. Observational evidence suggests that this approach is improving the delivery of stroke care and reducing costs in the USA. Similar efforts are being made in Europe and Asia with encouraging results. The RSC model has the potential to lead to more uniform evidence-based stroke medicine, but many challenges exist.

Association Between TRAF6 Gene Polymorphisms and Susceptibility of Ischemic Stroke in Southern Chinese Han Population

The tumor necrosis factor receptor-associated factor 6 (TRAF6) gene encodes a protein that acts downstream of the Toll-like receptor (TLR) pathway. TLRs activate inflammatory cascades and mediate inflammatory injury after cerebral ischemia. However, the role of TFAR6 gene polymorphisms in ischemic stroke (IS) remains unknown. This study aims to investigate the associations of TRAF6 gene polymorphisms with susceptibility to IS and IS-related quantitative traits in Southern Chinese Han population. A total of 816 IS cases and 816 age- and gender-matched controls were included. Two variants of the TRAF6 gene (rs5030411 and rs5030416) were genotyped using the Sequenom MassARRAY iPLEX platform. Our study showed that rs5030416 was significantly associated with increased susceptibility to IS in the additive model [ORadj 1.25(1.04-1.51), P adj = 0.019, P Bc = 0.038] and dominant model [ORadj 1.23(1.04-1.60), P adj = 0.021, P Bc = 0.042] after adjusting by age and sex and applying a Bonferroni correction. No significant association was found between rs5030411 and IS susceptibility (all P > 0.05). The haplotype rs5030416 (allele C)-rs5030411 (allele C) was significantly associated with IS susceptibility (P adj = 0.015). Moreover, a significant association of rs5030411 with TC levels in IS patients under the additive model [β 0.16(0.01-0.30), P adj = 0.034] and recessive model [β 0.45(0.12-0.78), P adj = 0.007] was observed after adjustment by age and sex. This association remained statistically significant under the recessive model (P Bc = 0.042) after Bonferroni correction. Our results suggest that TRAF6 gene polymorphisms may be involved in the pathogenesis of IS.

The US emergency care system: meeting everyday acute care needs while being ready for disasters

The emergency care system is an essential part of the US health care system. In addition to providing acute resuscitation and life- and limb-saving care, the emergency care system provides considerable support to physicians outside the emergency department and serves as an important safety-net provider. In times of disaster, the emergency care system must be able to surge rapidly to accommodate a massive influx of patients, sometimes with little or no notice. Extreme daily demands on the system can promote innovations and adaptations that are invaluable in responding to disasters. However, excessive and inappropriate utilization is wasteful and can diminish "surge capacity" when it is most needed. Certain features of the US health care system have imposed strains on the emergency care system. We explore policy issues related to moving toward an emergency care system that can more effectively meet both individuals' needs for acute care and the broader needs of the community in times of disaster. Strategies for the redesign of the emergency care system must include the active engagement of both patients and the community and a close look at how to align incentives to reward quality and efficiency throughout the health care system.

Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions

PURPOSE

To identify and evaluate the effectiveness of conservative treatment approaches used in children and adolescents to manage and prevent low back pain (LBP).

METHODS

Five electronic databases and the reference lists of systematic reviews were searched for relevant studies. Randomised controlled trials (RCTs) were considered eligible for inclusion if they enrolled a sample of children or adolescents (<18 years old) and evaluated the effectiveness of any conservative intervention to treat or prevent LBP. Two authors independently screened search results, extracted data, assessed risk of bias using the PEDro scale, and rated the quality of evidence using the GRADE criteria.

RESULTS

Four RCTs on intervention and eleven RCTs on prevention of LBP were included. All included studies had a high risk of bias scoring ≤7 on the PEDro scale. For the treatment of LBP, a supervised exercise program compared to no treatment improved the average pain intensity over the past month by 2.9 points (95 % CI 1.6-4.1) measured by a 0-10 scale (2 studies; n = 125). For the prevention of LBP, there was moderate quality evidence to suggest back education and promotion programs are not effective in reducing LBP prevalence in children and adolescents.

CONCLUSIONS

While exercise interventions appear to be promising to treat LBP in children and adolescents, there is a dearth of research data relevant to paediatric populations. Future studies conducted in children and adolescents with LBP should incorporate what has been learnt from adult LBP research and be of rigorous methodological quality.

A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013

BACKGROUND

The aging of America poses a challenge to emergency departments (EDs). Studies show that elderly patients have poor outcomes despite increased testing, prolonged periods of observation, and higher admission rates. In response, emergency medicine (EM) leaders have implemented strategies for improved ED elder care, enhancing expertise, equipment, policies, and protocols. One example is the development of geriatric EDs gaining in popularity nationwide. To the authors' knowledge, this is the first research to systematically identify and qualitatively characterize the existence, locations, and features of geriatric EDs across the United States.

OBJECTIVES

The primary objective was to determine the number, distribution, and characteristics of geriatric EDs in the United States in 2013.

METHODS

This was a survey with potential respondents identified via a snowball sampling of known geriatric EDs, EM professional organizations' geriatric interest groups, and a structured search of the Internet using multiple search engines. Sites were contacted by telephone, and those confirming geriatric EDs presence received the survey via e-mail. Category questions included date of opening, location, volumes, staffing, physical plant changes, screening tools, policies, and protocols. Categories were reported based on general interest to those seeking to understand components of a geriatric ED.

RESULTS

Thirty-six hospitals confirmed geriatric ED existence and received surveys. Thirty (83%) responded to the survey and confirmed presence or plans for geriatric EDs: 24 (80%) had existing geriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDs are located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent serve from 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the main ED, and 66% have from one to 10 geriatric beds. Physical plant changes include modifications to beds (96%), lighting (90%), flooring (83%), visual aids (73%), and sound level (70%). Seventy-seven percent have staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staff didactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and 90% of geriatric EDs had direct follow-up through patient callbacks.

CONCLUSIONS

The snowball sample identification of U.S. geriatric EDs resulted in 30 confirmed respondents. There is significant variation in the components constituting a geriatric ED. The United States should consider external validation of self-identified geriatric EDs to standardize the quality and type of care patients can expect from an institution with an identified geriatric ED.

The cost of first-ever stroke in Valle d'Aosta, Italy: linking clinical registries and administrative data

BACKGROUND

Stroke is one of the most relevant reasons of death and disability worldwide. Many cost of illness studies have been performed to evaluate direct and indirect costs of ischaemic stroke, especially within the first year after the acute episode, using different methodologies.

METHODS

We conducted a longitudinal, retrospective, bottom-up cost of illness study, to evaluate clinical and economic outcomes of a cohort of patients affected by a first cerebrovascular event, including subjects with ischaemic, haemorrhagic or transient episodes. The analysis intended to detect direct costs, within 1, 2 and 3 years from the index event. Clinical patient data collected in regional disease registry were integrated and linked to regional administrative databases to perform the analysis.

RESULTS

The analysis of costs within the first year from the index event included 800 patients. The majority of patients (71.5%) were affected by ischaemic stroke. Overall, per patient costs were €7,079. Overall costs significantly differ according to the type of stroke, with costs for haemorrhagic stroke and ischaemic stroke amounting to €9,044 and €7,289. Hospital costs, including inpatient rehabilitation, were driver of expenditure, accounting for 89.5% of total costs. The multiple regression model showed that sex, level of physical disability and level of neurological deficit predict direct healthcare costs within 1 year. The analysis at 2 and 3 years (per patient costs: €7,901 and €8,874, respectively) showed that majority of costs are concentrated in the first months after the acute event.

CONCLUSIONS

This cost analysis highlights the importance to set up significant prevention programs to reduce the economic burden of stroke, which is mostly attributable to hospital and inpatient rehabilitation costs immediately after the acute episode. Although some limitation typical of retrospective analyses the approach of linking clinical and administrative database is a power tool to obtain useful information for healthcare planning.

The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact

BACKGROUND

Healthcare accreditation standards are advocated as an important means of improving clinical practice and organisational performance. Standard development agencies have documented methodologies to promote open, transparent, inclusive development processes where standards are developed by members. They assert that their methodologies are effective and efficient at producing standards appropriate for the health industry. However, the evidence to support these claims requires scrutiny. The study's purpose was to examine the empirical research that grounds the development methods and application of healthcare accreditation standards.

METHODS

A multi-method strategy was employed over the period March 2010 to August 2011. Five academic health research databases (Medline, Psych INFO, Embase, Social work abstracts, and CINAHL) were interrogated, the websites of 36 agencies associated with the study topic were investigated, and a snowball search was undertaken. Search criteria included accreditation research studies, in English, addressing standards and their impact. Searching in stage 1 initially selected 9386 abstracts. In stage 2, this selection was refined against the inclusion criteria; empirical studies (n = 2111) were identified and refined to a selection of 140 papers with the exclusion of clinical or biomedical and commentary pieces. These were independently reviewed by two researchers and reduced to 13 articles that met the study criteria.

RESULTS

The 13 articles were analysed according to four categories: overall findings; standards development; implementation issues; and impact of standards. Studies have only occurred in the acute care setting, predominately in 2003 (n = 5) and 2009 (n = 4), and in the United States (n = 8). A multidisciplinary focus (n = 9) and mixed method approach (n = 11) are common characteristics. Three interventional studies were identified, with the remaining 10 studies having research designs to investigate clinical or organisational impacts. No study directly examined standards development or other issues associated with their progression. Only one study noted implementation issues, identifying several enablers and barriers. Standards were reported to improve organisational efficiency and staff circumstances. However, the impact on clinical quality was mixed, with both improvements and a lack of measurable effects recorded.

CONCLUSION

Standards are ubiquitous within healthcare and are generally considered to be an important means by which to improve clinical practice and organisational performance. However, there is a lack of robust empirical evidence examining the development, writing, implementation and impacts of healthcare accreditation standards.

Outcomes before and after initiation of an acute aortic treatment center

BACKGROUND

Acute aortic syndromes remain life-threatening. Time is of the essence, as mortality rises with increasing time after the acute episode. The aim of this report is to show changes in practice and outcomes after the establishment of an acute aortic treatment center (AATC) to expedite the care of acute aortic syndromes in a major metropolitan area with the belief that "door to intervention time under 90 minutes" reduces mortality and morbidity from acute aortic disease.

METHODS

A database of patients admitted with acute aortic disease (Type A and B aortic dissections, acute thoraco-abdominal aortic aneurysms, acute and ruptured abdominal aortic aneurysms) for 1 year prior to initiation (2007) and 1 year after initiation of the pathway (AATC) in 2008 was developed. Comorbidities were scored according to Society of Vascular Surgery criteria. Anatomic and functional outcomes were determined and categorized by Society of Vascular Surgery reporting criteria. Multivariate analysis was performed for categorical outcomes and Cox proportional hazard analyses for time-dependent outcomes.

RESULTS

Six hundred twenty-one patients reported with aortic disease to the cardiovascular services; 306 patients were considered to have acute disease. When compared with the year before the AATC was instituted, there was a 30% increase in the total number of admissions and a 25% increase in acute pathology after setting up the AATC (P = .02). There was a two-fold increase in thoracic aortic dissections admitted to the service. Initiation of the treatment pathway resulted in a highly significant 64% reduction in time to definitive therapy (526 ± 557 vs 187 ± 258 minutes, mean ± SD pre-AATC vs AATC; P = .0001). Comorbidity scores were equivalent between the two cohorts. Despite the increase in acuity, mortality (4% vs 6%) and morbidity (41% vs 45%) rates were unchanged, and there was a significant decrease in intensive care unit length of stay (5 vs 4 days, pre-AATC cohort vs the AATC cohort), but total hospital length of stay (11 vs 10 days) was unchanged. There was no correlation between deaths within 30 days and length of stay in the intensive care unit.

CONCLUSION

Establishment of a multidisciplinary AATC pathway was associated with a 30% increase in volume, 64% reduction in time to definitive treatment, improved throughput with reduced intensive care unit time, and maintained clinical efficacy despite an increase in acute admissions. These results suggest the concept be further evaluated.

Barriers and facilitators to implementing primary stroke center policy in the United States: results from 4 case study states

OBJECTIVES

We identified barriers and facilitators to the state-level implementation of primary stroke center (PSC) policies, which encourage the certification or designation of specialized stroke treatment facilities and may address concerns such as transportation bypass, telemedicine, and treatment protocols.

METHODS

We studied the experiences of 4 states (Florida, Massachusetts, New Mexico, and New York) selected from the 18 states that had enacted PSC policies or were actively considering doing so. We conducted semistructured interviews during fieldwork in each case study state.

RESULTS

Our results showed that system fragmentation, gaps in human and financial resources, and complexity at the interorganizational and operational levels are common barriers and that policy champions, stakeholder support and communication, and operational adaptation are essential facilitators in the adoption and implementation of PSC policies.

CONCLUSIONS

The identification of barriers and facilitators reveals the contextual elements that can help or hinder policy implementation and may be useful in informing policy formulation and implementation in other jurisdictions. Proactively identifying jurisdictional challenges and opportunities may help facilitate the policy process for PSC designation and allow jurisdictions to develop more effective stroke systems of care.

Get With The Guidelines-Stroke Performance Indicators: Surveillance of Stroke Care in the Taiwan Stroke Registry

Background— Stroke is a leading cause of death around the world. Improving the quality of stroke care is a global priority, despite the diverse healthcare economies across nations. The American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke) has improved the quality of stroke care in 790 US academic and community hospitals, with broad implications for the rest of the country. The generalizability of GWTG-Stroke across national and economic boundaries remains to be tested. The Taiwan Stroke Registry, with 30 599 stroke admissions between 2006 and 2008, was used to assess the applicability of GWTG-Stroke in Taiwan, which spends ≈1/10 of what the United States does in medical costs per new or recurrent stroke.

Methods and Results— Taiwan Stroke Registry, sponsored by the Taiwan Department of Health, engages 39 academic and community hospitals and covers the entire country with 4 steps of quality control to ensure the reliability of entered data. Five GWTG-Stroke performance measures and 1 safety indicator are applicable to assess Taiwan Stroke Registry quality of stroke care. Demographic and outcome figures are comparable between GWTG-Stroke and Taiwan Stroke Registry. Two indicators (early and discharge antithrombotics) are close to GWTG-Stroke standards, while 3 other indicators (intravenous tissue plasminogen activator, anticoagulation for atrial fibrillation, lipid-lowering medication) and 1 safety indicator fall behind. Preliminary analysis shows that compliance with selected GWTG-Stroke guidelines is associated with better outcomes.

Conclusions— Results suggest that GWTG-Stroke performance measures, with modification for ethnic factors, can become global standards across national and economic boundaries for assessing and improving quality of stroke care and outcomes. GWTG-Stroke can be incorporated into ongoing stroke registries across nations.

Performance and training standards for endovascular ischemic stroke treatment

Stroke is the third leading cause of death in the USA, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, there are now 750,000 new strokes that occur each year, resulting in 200,000 deaths, or 1 of every 16 deaths, per year in the USA alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intraarterial thrombolysis in selected patients. Intraarterial thrombolysis has been studied in two randomized trials and numerous case series. Although two devices have been granted FDA approval with an indication for mechanical stroke thrombectomy, none of these thrombectomy devices has demonstrated efficacy for the improvement of patient outcomes. The purpose of the present document is to define what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and what performance standards should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies which historically have been directly involved in the medical, surgical and endovascular care of patients with acute stroke. The participating member organizations of the Neurovascular Coalition involved in the writing and endorsement of this document are the Society of NeuroInterventional Surgery, the American Academy of Neurology, the American Association of Neurological Surgeons/Congress of Neurological Surgeons Cerebrovascular Section, and the Society of Vascular & Interventional Neurology.

Excess body weight and incidence of stroke: meta-analysis of prospective studies with 2 million participants

BACKGROUND AND PURPOSE

A systematic review of the prospective studies addressing the relationship of overweight and obesity to major stroke subtypes is lacking. We evaluated the occurrence of a graded association between overweight, obesity, and incidence of ischemic and hemorrhagic stroke by a meta-analysis of cohort studies.

METHODS

A search of online databases and relevant reviews was performed. Inclusion criteria were original article in English, prospective study design, follow-up > or = 4 years, indication of number of subjects exposed, and number of events across body mass index categories. Crude unadjusted relative risk (RR) and 95% CI were calculated for each study for overweight or obese compared with normal-weight categories. Log-transformed values and SE were used to calculate the pooled RR with random effects models; publication bias was checked. Additional analyses were performed using the multivariate estimates of risk reported in the individual studies.

RESULTS

Twenty-five studies were included, with 2 274 961 participants and 30 757 events. RR for ischemic stroke was 1.22 (95% CI, 1.05-1.41) for overweight and 1.64 (95% CI, 1.36-1.99) for obesity, whereas RR for hemorrhagic stroke was 1.01 (95% CI, 0.88-1.17) and 1.24 (95% CI, 0.99-1.54), respectively. Subgroup and meta-regression analyses ruled out gender, population average age, body mass index and blood pressure, year of recruitment, year of study publication, and length of follow-up as significant sources of heterogeneity. The additional analyses relying on the published multivariate estimates of risk provided qualitatively similar results.

CONCLUSIONS

Overweight and obesity are associated with progressively increasing risk of ischemic stroke, at least in part, independently from age, lifestyle, and other cardiovascular risk factors.

Performance and training standards for endovascular ischemic stroke treatment

Stroke is the third-leading cause of death in the United States, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, 750,000 new strokes occur each year, resulting in 200,000 deaths (or 1 of every 16 deaths) per year in the United States alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intra-arterial (IA) thrombolysis in selected patients. IA thrombolysis has been studied in 2 randomized trials and numerous case series. Although 2 devices have been granted FDA 3 approval with an indication for mechanical stroke thrombectomy, none of these devices has demonstrated efficacy in improving patient outcomes. This report defines what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and identifies the performance standards that should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies that historically have been directly involved in the medical, surgical, and endovascular care of patients with acute stroke, including the Neurovascular Coalition and its participating societies: the Society of NeuroInterventional Surgery; American Academy of Neurology; American Association of Neurological Surgeons, Cerebrovascular Section; and Society of Vascular & Interventional Neurology.

Stroke patient outcomes in US hospitals before the start of the Joint Commission Primary Stroke Center certification program

BACKGROUND AND PURPOSE

The Joint Commission (JC) began certifying Primary Stroke Centers in November 2003. Cross-sectional studies assessing the impact of certification could be biased if these centers had better outcomes before the start of the program. We determined whether hospitals certified within the first years of the JC program had better outcomes than noncertified hospitals before the start of the certification program.

METHODS

The study sample included Medicare fee-for-service beneficiaries >or=65 years of age discharged with ischemic stroke in 2002 from 5070 hospitals, 317 of which were JC-certified by June 2007. Hierarchical logistic regression and Cox proportional hazards models were used to compare in-hospital mortality, 30-day mortality, and 30-day readmission for patients treated at future JC-certified versus noncertified hospitals.

RESULTS

Among 366 551 patients, 18% (66 300) were treated at hospitals with centers that were JC-certified within the first few years of the program. These patients were younger, more likely to be white and male, and had fewer comorbidities and hospitalizations within the prior year. Unadjusted in-hospital mortality (4.7% versus 5.5%), 30-day mortality (9.8% versus 11.3%), and readmissions (13.8% versus 14.6%) were lower in the future JC-certified hospitals (all P<0.001). These differences remained after risk adjustment (in-hospital mortality: OR, 0.93; 95% CI, 0.90 to 0.96; 30-day mortality: OR, 0.92; 95% CI, 0.87 to 0.96; 30-day readmission: hazard ratio, 0.97; 95% CI, 0.95 to 0.99).

CONCLUSIONS

JC Primary Stroke Center-certified hospitals had better outcomes than noncertified hospitals even before the program began. Cross-sectional studies assessing the effects of stroke center certification need to account for these pre-existing differences.

Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack

BACKGROUND

Adherence to evidence-based guidelines for treatment of stroke or transient ischemic attack is suboptimal. We sought to establish whether participation in Get With the Guidelines-Stroke was associated with improvements in adherence.

METHODS AND RESULTS

This prospective, nonrandomized, national quality improvement program measured adherence to guideline recommendations in 322 847 hospitalized patients discharged with a diagnosis of ischemic stroke or transient ischemic attack. A volunteer sample of 790 US academic and community hospitals participated from 2003 through 2007. The main outcome measures were change in adherence over time to 7 prespecified performance measures and a composite measure (total number of interventions provided in eligible patients divided by total number of care opportunities among eligible patients). Generalized estimating equations were used to identify factors associated with improvement. Participation in Get With the Guidelines-Stroke was associated with improvements in the 7 individual and 1 composite measures from baseline to the fifth year: intravenous thrombolytics (42.09% versus 72.84%), early antithrombotics (91.46% versus 97.04%), deep vein thrombosis prophylaxis (73.79% versus 89.54%), discharge antithrombotics (95.68% versus 98.88%), anticoagulation for atrial fibrillation (95.03% versus 98.39%), lipid treatment for low-density lipoprotein >100 mg/dL (73.63% versus 88.29%), smoking cessation (65.21% versus 93.61%), and composite (83.52% versus 93.97%) (P<0.0001 for all comparisons). Multivariate analysis showed that time in Get With the Guidelines-Stroke was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends.

CONCLUSIONS

Get With the Guidelines-Stroke participation was associated with increased adherence to all stroke performance measures. Markedly improved stroke care was seen in all hospitals regardless of size, geography, and teaching status.

Development of a metropolitan matrix of primary stroke centers: the Phoenix experience

BACKGROUND AND PURPOSE

In 1998, 2947 patients in metropolitan Phoenix were hospitalized for acute cerebral infarction. Only 2 of the 26 regional hospitals satisfied criteria for primary stroke center (PSC) designation. Fewer than 1% of patients with ischemic stroke received tissue plasminogen activator for thrombolysis. We sought to develop and evaluate the effectiveness of a metropolitan prehospital emergency medical system for effectively identifying and transporting patients with acute stroke to a matrix of predesignated PSCs and increasing to 20% the proportion of all such patients receiving tissue plasminogen activator.

METHODS

The American Stroke Association Phoenix Operation Stroke partnered with the Arizona Emergency Medical Systems in 1998 to 1999 to list goals and objectives, identify key stakeholders, and develop committees to address community education, emergency medical system training, and PSC designation.

RESULTS

Over 8 years, emergency medical system personnel were trained to identify and transport patients with acute stroke to PSCs, 8 hospitals met PSC criteria, the metropolitan matrix of PSCs became operational (in 2003), and 18% of patients with acute ischemic stroke received thrombolysis.

CONCLUSIONS

It is feasible to develop and operationalize a successful metropolitan-wide matrix of PSCs to accommodate emergency medical system-identified and transported patients with acute stroke in a 9000-square-mile region with a population of 3.5 million people.

National estimates of severe sepsis in United States emergency departments

OBJECTIVE

The emergency department (ED) often serves as the first site for the recognition and treatment of patients with suspected severe sepsis. However, few evaluations of the national epidemiology and distribution of severe sepsis in the ED exist. We sought to determine national estimates of the number, timing, ED length of stay, and case distribution of patients presenting to the ED with suspected severe sepsis.

DESIGN

Analysis of 2001-2004 ED data from the National Hospital Ambulatory Medical Care Survey.

SETTING

National multistage probability sample of United States ED data.

PATIENTS

Adult (age, >or=18 yrs) patients with suspected severe sepsis, defined as the concurrent presence of an infec-tion (ED International Classification of Diseases, 9th Revision; ICD-9) diagnosis of infection, or a triage temperature <96.8 degrees F or >or=100.4 degrees F) and organ dysfunction (ED ICD-9) diagnosis of organ dysfunction, intubation, or a triage systolic blood pressure <or=90 mm Hg).

INTERVENTIONS

None.

MEASUREMENTS

Estimated number of ED patients presenting with suspected severe sepsis, and their times of arrival, ED lengths of stay, and clinical characteristics.

MAIN RESULTS

Of 331.5 million adult ED visits, approximately 2.3 million (571,000 annually, 0.69%; 95% confidence interval [CI], 0.61-0.77%) were for suspected severe sepsis. Mean ED length of stay for suspected severe sepsis was 4.7 hrs (95% CI, 4.3-5.1 hrs), with 20.4% spending >6 hrs in the ED. Of suspected severe sepsis patients, 20.6% presented to a low-volume ED (<or=20,000 annual visits), 15.6% presented to ED in non-Metropolitan Statistical Areas, and 53.5% presented to EDs without medical school affiliations. More than half arrived by ambulance.

CONCLUSIONS

Suspected severe sepsis patients account for more than 500,000 ED visits annually, with individual patients spending an average of almost 5 hrs in the ED. These national data offer key systemwide information for designing and implementing strategies for severe sepsis treatment.

How Would Minimum Experience Standards Affect the Distribution of Out-of-Hospital Endotracheal Intubations?

STUDY OBJECTIVE

Out-of-hospital endotracheal intubation is a complex intervention. One strategy for improving the quality of a complex intervention is to limit the procedure to practitioners or agencies that meet minimum procedure experience standards. The system-level influence of such limits is unknown. We seek to determine how minimum endotracheal intubation experience standards influence the number and distribution of out-of-hospital endotracheal intubations.

METHODS

We used 2003 Pennsylvania statewide emergency medical services (EMS) data. We included endotracheal intubations that could be attributed to a valid rescuer, EMS agency, and minor civil division. We calculated the total number of endotracheal intubations performed across the state. We calculated the absolute and relative changes in total, cardiac arrest, nonarrest, pediatric, and trauma endotracheal intubation when the procedure was limited to on-scene rescuers meeting minimum endotracheal intubation experience standards, ranging from zero to 20 annual endotracheal intubations. We evaluated the same relationships when the procedure was limited to EMS agencies meeting minimum endotracheal intubation experience standards, ranging from zero to 200 annual endotracheal intubations. We evaluated these relationships with line plots and geographic information system maps.

RESULTS

During the study period there were 11,771 endotracheal intubations (7,854 cardiac arrest, 3,917 non-arrest, 1,325 trauma and 561 pediatric endotracheal intubations). Limiting endotracheal intubations to rescuers with at least 3, 5, 10, and 15 endotracheal intubations per year would result in relative endotracheal intubation reductions of 12%, 32%, 79%, and 93%, respectively. Limiting endotracheal intubations to EMS agencies with at least 20, 30, 50, 100, and 150 endotracheal intubations per year would result in relative endotracheal intubation reductions of 15%, 27%, 41%, 65%, and 73%, respectively. Cardiac arrest endotracheal intubations would exhibit the largest absolute reduction.

CONCLUSION

Minimum endotracheal intubation experience standards would result in absolute and relative reductions in total and subgroup endotracheal intubations. These findings provide vital perspectives about the system-wide organization of out-of-hospital airway management.

P2 receptor antagonist trinitrophenyl-adenosine-triphosphate protects hippocampus from oxygen and glucose deprivation cell death

In this work, we mainly used the organotypic model of rat hippocampus to demonstrate the protective role of the P2 receptor antagonist trinitrophenyl-adenosine-triphosphate (TNP-ATP) during oxygen/glucose deprivation. Among the P2X receptors that TNP-ATP specifically blocks, mainly P2X1 seems to be involved in the processes of cell damage after oxygen/glucose deprivation. P2X1 receptor is strongly and transiently up-regulated in 24 h after an ischemic insult on structures likely corresponding to mossy fibers and Schaffer collaterals of CA1-3 and dentate gyrus. Furthermore, P2X1 receptor is down-regulated by pharmacological treatment with TNP-ATP, which is also found neuroprotective against ischemic cell death. Morphological studies conducted through immunofluorescence and confocal analysis in primary organotypic, in dissociated cultures, and in adult rat in vivo demonstrated the neuronal colocalization of P2X1 protein with neurofilament light chain and neuronal nuclei immunoreactivity in myelinated and unmyelinated fibers of both granular and pyramidal neurons. In conclusion, with this work, we proved the neuronal distribution of P2X1 receptor in hippocampus, and we presented evidence for a potential disadvantageous role of its expression during the path of in vitro ischemia.

Guidelines for the Early Management of Adults With Ischemic Stroke

Purpose— Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

Methods— Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

Results— Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

PURPOSE

Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

METHODS

Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

RESULTS

Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

A case of conversion disorder presenting as a severe acute stroke

Conversion disorders often present with dramatic physical presentations suggestive of severe organic disease. We present the case of a young woman who presented to the Emergency Department with a dense left hemiparesis suggestive of a severe acute stroke. Emergent referral to a regional stroke center facilitated rapid medical evaluation, exclusion of organic disease, and confirmation of conversion disorder as the etiology for the symptoms. This report highlights the dramatic clinical presentations that may result from conversion disorders as well as the benefits of rapid medical evaluation by specialty stroke centers.

Recommendations for Comprehensive Stroke Centers

Background and Purpose— To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease.

Summary of Review— A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors.

Conclusions— There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

A Genetic Approach to Ischemic Stroke Therapy

Stroke therapy will undergo a great revolution in the present decade. The knowledge of the human genome, gene interactions and proteomics will permit a new concept of drug development for stroke. Gene therapy by modification of gene expression will be useful to treat atherosclerosis and hypertensive microangiopathy, or in the acute phase, we will manipulate the acute gene expression induced by ischemia or the apoptotic gene program. However, a single abnormal gene, as in monogenic diseases, is easier to replace than several genes in complex multigenic disorders. Gene therapy, stem cell therapy and neurological grafts for stroke are still in the experimental phase, and many hurdles will have to be jumped before the introduction of these therapies into human clinical stroke trials. A more immediate clinical application of genetics to stroke therapy is the development of pharmacogenetics that analyzes the influence of genetic variability of individuals on drug response. A new era of personalized therapy is dawning where specific DNA biochips will help stroke clinicians to decide on the better use of thrombolytics, neuroprotectants, antithrombotics, statins or antihypertensives.

Is Dementia a Disease?

BACKGROUND

It is customary for many neurologists to think that dementia is a disease. This view is based on the following reasons: (1) a brain disease is the cause of cognitive impairment; (2) therefore, such cognitive impairment is substituted for the disease, becoming dementia, which is then also regarded as a mental disease.

OBJECTIVE

In this brief article, I take exception to such a view, contrary to the common belief in the medical field, on the ground that senile plaques and/or neurofibrillary tangles or any other factors cause neuronal apoptosis but they do not cause dementia directly.

METHODS

Literature on dementia and aphasia are critically and briefly reviewed to get the historical perspective that it is the progressive neuronal losses, losing brain functions as a result, that cause dementia; that is, brain diseases cause neuronal losses which then result in the decrease of brain functions, thereby leading to dementia.

RESULTS

There is no direct cause-effect relationship between brain disease, be it caused by vascular factors or not, and dementia which is the consequence or sequela of neuronal losses.

CONCLUSIONS

It is concluded that dementia is not a disease and yet it occurs not only in Parkinson's disease, Alzheimer's disease (AD), Huntington's disease and Pick's disease, but also in any other neurodegenerative disease, e.g., spinocerebellar ataxia, or vascular disease, e.g., Binswanger's disease, as part of the process of aging; in fact, AD is now regarded by some as a vascular disorder with neurodegenerative consequence, rather than a neurodegenerative disorder with vascular consequence. But vascular disorder is misleading if AD includes both neurofibrillary tangles and senile plaques; on the other hand, AD cannot be a vascular disorder if it includes only neurofibrillary tangles, as it should. Dementia, in this context, is re-defined as the differential manifestation of deteriorating brain functions over time as a part of aging due to cell deaths in the brain caused by any neurodegenerative disease. Its prominent symptoms are language disorders which must be distinguished from aphasias. It is also suggested that in fairness to Fischer, senile plaques be designated as Fischer's disease separate from neurofibrillary tangles for which AD was originally named as an eponym.

Thrombolytic treatment of acute ischemic stroke

Intravenous recombinant tissue-type plasminogen activator is approved by the US Food and Drug Administration for treating acute ischemic stroke within 3 hours of onset of symptoms. Initiation of thrombolysis within 90 minutes of onset of symptoms is a treatment goal supported by current studies. Postmarketing data suggest that the risk of intracranial hemorrhage may be unacceptably high when recombinant tissue-type plasminogen activator is given to patients who would not have been eligible for enrollment in the pivotal phase 3 clinical trials. Further studies of local intra-arterial thrombolysis and improved selection of patients with advanced brain imaging are expected in the future, but the emphasis at present should be on rapid identification, evaluation, and treatment of appropriate patients with intravenous therapy.