1
|
Srinivasan M, Scott A, Soo J, Sreedhara M, Popat S, Beasley KL, Jackson TN, Abbas A, Keaton WA, Holmstedt C, Harvey J, Kruis R, McLeod S, Ahn R. The role of stroke care infrastructure on the effectiveness of a hub-and-spoke telestroke model in South Carolina. J Stroke Cerebrovasc Dis 2024; 33:107702. [PMID: 38556068 PMCID: PMC11088489 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE To examine the relationship between stroke care infrastructure and stroke quality-of-care outcomes at 29 spoke hospitals participating in the Medical University of South Carolina (MUSC) hub-and-spoke telestroke network. MATERIALS AND METHODS Encounter-level data from MUSC's telestroke patient registry were filtered to include encounters during 2015-2022 for patients aged 18 and above with a clinical diagnosis of acute ischemic stroke, and who received intravenous tissue plasminogen activator. Unadjusted and adjusted generalized estimating equations assessed associations between time-related stroke quality-of-care metrics captured during the encounter and the existence of the two components of stroke care infrastructure-stroke coordinators and stroke center certifications-across all hospitals and within hospital subgroups defined by size and rurality. RESULTS Telestroke encounters at spoke hospitals with stroke coordinators and stroke center certifications were associated with shorter door-to-needle (DTN) times (60.9 min for hospitals with both components and 57.3 min for hospitals with one, vs. 81.2 min for hospitals with neither component, p <.001). Similar patterns were observed for the percentage of encounters with DTN time of ≤60 min (63.8% and 68.9% vs. 32.0%, p <.001) and ≤45 min (34.0% and 38.4% vs. 8.42%, p <.001). Associations were similar for other metrics (e.g., door-to-registration time), and were stronger for smaller (vs. larger) hospitals and rural (vs. urban) hospitals. CONCLUSIONS Stroke coordinators or stroke center certifications may be important for stroke quality of care, especially at spoke hospitals with limited resources or in rural areas.
Collapse
Affiliation(s)
- Mithuna Srinivasan
- NORC at the University of Chicago, 4350 East-West Hwy 8th Floor, Bethesda, MD 20814, United States.
| | - Amber Scott
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States; Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | - Jackie Soo
- NORC at the University of Chicago, Chicago, IL, United States
| | - Meera Sreedhara
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States; Cherokee Nation Operational Solutions, Tulsa, OK, United States
| | - Shena Popat
- NORC at the University of Chicago, 4350 East-West Hwy 8th Floor, Bethesda, MD 20814, United States
| | - Kincaid Lowe Beasley
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States
| | - Tiara N Jackson
- Decision Information Resources, Inc., Houston, TX, United States
| | - Amena Abbas
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States; ASRT, Inc., Atlanta, GA, United States
| | - W Alexander Keaton
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States; Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | | | - Jillian Harvey
- Medical University of South Carolina, Charleston, SC, United States
| | - Ryan Kruis
- Medical University of South Carolina, Charleston, SC, United States
| | - Shay McLeod
- Medical University of South Carolina, Charleston, SC, United States
| | - Roy Ahn
- NORC at the University of Chicago, Chicago, IL, United States
| |
Collapse
|
2
|
Chen Y, Lei Q, Li J, Li J, He Y, Li J, Xing S, Fan Y, Zeng J. Certification of stroke centers at primary hospitals and the improvement of thrombolysis n South China during 2020-2022. Eur Stroke J 2024; 9:477-485. [PMID: 38189301 DOI: 10.1177/23969873231223062] [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: 01/09/2024] Open
Abstract
INTRODUCTION IVT use declined globally in 2020 due to the Corona Virus Disease 2019 (COVID-19) pandemic, but it increased in South China. This study was conducted to evaluate the association of establishing Stroke Prevention Centers (SPCs) at primary hospitals with IVT increase in South China. MATERIALS AND METHODS We conducted a longitudinal observational study across 336 hospitals in 114 areas in South China during 2020-2022. Data regarding certified stroke centers, IVT volumes, and IVT rates were collected. Correlations between IVT rates and the number or density of stroke centers were accessed. IVT use was compared among areas with different levels of stroke centers or on different certification process. RESULTS During 2020-2022, there were 83, 125, and 152 stroke centers, with 26, 65, and 92 SPCs, respectively. IVT therapies were 12,795, 17,266, and 20,411, representing a 29.8% increase/year (all p < 0.001). IVT rates increased from 7.2% in 2020 to 8.8% and 10.4% in 2021 and 2022, demonstrating a 22.2% increase/year (all p < 0.001). IVT rates correlated with the number and density of SPCs (all p < 0.05). IVT rates were higher in areas equipped with SPCs than in those without stroke centers (all p < 0.05). IVT rates consistently increased during the SPC certification process from 1 year before through the certification and subsequent maintenance (both p < 0.05). DISCUSSION AND CONCLUSION Well-organised SPCs and IVT therapy demonstrated substantial increase during the 3-year period. Certification of SPCs at primary hospitals is associated with improved IVT therapy in South China even with city lockdown during COVID-19 pandemic.
Collapse
Affiliation(s)
- Yicong Chen
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Qingfeng Lei
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
- Department of Neurology, The Sixth Affiliated Hospital, Sun Yat-sen University, Yuancun, Guangzhou, China
| | - Jiaoxing Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jianle Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Yinxin He
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jingjing Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Shihui Xing
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Yuhua Fan
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jinsheng Zeng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| |
Collapse
|
3
|
Aljuwaiser S, Abdel-Fattah AR, Brown C, Kane L, Cooper J, Mostafa A. Evaluating the effects of simulation training on stroke thrombolysis: a systematic review and meta-analysis. Adv Simul (Lond) 2024; 9:11. [PMID: 38424568 PMCID: PMC10905914 DOI: 10.1186/s41077-024-00283-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/17/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Ischaemic strokes are medical emergencies, and reperfusion treatment, most commonly intravenous thrombolysis, is time-critical. Thrombolysis administration relies on well-organised pathways of care with highly skilled and efficient clinicians. Simulation training is a widespread teaching modality, but results from studies on the impact of this intervention have yet to be synthesised. This systematic review and meta-analysis aimed to synthesise the evidence and provide a recommendation regarding the effects of simulation training for healthcare professionals on door-to-needle time in the emergency thrombolysis of patients with ischaemic stroke. METHODS Seven electronic databases were systematically searched (last updated 12th July 2023) for eligible full-text articles and conference abstracts. Results were screened for relevance by two independent reviewers. The primary outcome was door-to-needle time for recombinant tissue plasminogen activator administration in emergency patients with ischaemic stroke. The secondary outcomes were learner-centred, improvements in knowledge and communication, self-perceived usefulness of training, and feeling 'safe' in thrombolysis-related decision-making. Data were extracted, risk of study bias assessed, and analysis was performed using RevMan™ software (Web version 5.6.0, The Cochrane Collaboration). The quality of the evidence was assessed using the Medical Education Research Study Quality Instrument. RESULTS Eleven studies were included in the meta-analysis and nineteen in the qualitative synthesis (n = 20,189 total patients). There were statistically significant effects of simulation training in reducing door-to-needle time; mean difference of 15 min [95% confidence intervals (CI) 8 to 21 min]; in improving healthcare professionals' acute stroke care knowledge; risk ratio (RR) 0.42 (95% CI 0.30 to 0.60); and in feeling 'safe' in thrombolysis-related decision-making; RR 0.46 (95% CI 0.36 to 0.59). Furthermore, simulation training improved healthcare professionals' communication and was self-perceived as useful training. CONCLUSION This meta-analysis showed that simulation training improves door-to-needle times for the delivery of thrombolysis in ischaemic stroke. However, results should be interpreted with caution due to the heterogeneity of the included studies.
Collapse
Affiliation(s)
- Sameera Aljuwaiser
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | | | - Craig Brown
- Emergency Medicine, NHS Grampian, Aberdeen, Scotland
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Leia Kane
- Emergency Medicine, NHS Grampian, Aberdeen, Scotland
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Jamie Cooper
- Emergency Medicine, NHS Grampian, Aberdeen, Scotland
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Alyaa Mostafa
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
| |
Collapse
|
4
|
Popa D, Iancu A, Petrica A, Buleu F, Williams CG, Sutoi D, Trebuian C, Tudor A, Mederle OA. Emergency Department Time Targets for Interhospital Transfer of Patients with Acute Ischemic Stroke. J Pers Med 2023; 14:13. [PMID: 38276228 PMCID: PMC10820891 DOI: 10.3390/jpm14010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/13/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024] Open
Abstract
Background and objectives: Although the intravenous tissue plasminogen activator (rt-PA) has been shown to be effective in the treatment of acute ischemic stroke (AIS), only a small proportion of stroke patients receive this drug. The low administration rate is mainly due to the delayed presentation of patients to the emergency department (ED) or the lack of a stroke team/unit in most of the hospitals. Thus, the aim of this study is to analyze ED time targets and the rate of rt-PA intravenous administration after the initial admission of patients with AIS in an ED from a traditional healthcare center (without a neurologist or stroke team/unit). Methods: To analyze which factors influence the administration of rt-PA, we split the general sample (n = 202) into two groups: group No rt-PA (n = 137) and group rt-PA (n = 65). This is based on the performing or no intravenous thrombolysis. Results: Analyzing ED time targets for all samples, we found that the median onset-to-ED door time was 180 min (IQR, 120-217.5 min), door-to-physician time was 4 min (IQR, 3-7 min), door-to-CT time was 52 min (IQR, 48-55 min), and door-in-door-out time was 61 min (IQR, 59-65 min). ED time targets such as door-to-physician time (p = 0.245), door-to-CT time (p = 0.219), door-in-door-out time (p = 0.24), NIHSS at admission to the Neurology department (p = 0.405), or NIHSS after 24 h (p = 0.9) did not have a statistically significant effect on the administration or no rt-PA treatment in patients included in our study. Only the highest door-to-CT time was statistically significantly correlated with the death outcome. Conclusion: In our study, the iv rt-PA administration rate was 32.18%. A statistically significant correlation between the highest door-to-CT time and death outcome was found.
Collapse
Affiliation(s)
- Daian Popa
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
| | - Aida Iancu
- Department of Radiology, “Victor Babes” University of Medicine and Pharmacy, E. Murgu Square no. 2, 300041 Timisoara, Romania
| | - Alina Petrica
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
| | - Florina Buleu
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, E. Murgu Square no. 2, 300041 Timisoara, Romania;
| | | | - Dumitru Sutoi
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
| | - Cosmin Trebuian
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
| | - Anca Tudor
- Department of Functional Sciences, “Victor Babes” University of Medicine and Pharmacy, E. Murgu Square no. 2, 300041 Timisoara, Romania;
| | - Ovidiu Alexandru Mederle
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
- Department of Surgery, Multidisciplinary Center for Research, Evaluation, Diagnosis and Therapies in Oral Medicine, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| |
Collapse
|
5
|
Li SJ, Li F, Kong N, Liu JR, Zhu X. Near Infrared Emissive Lanthanide Luminescence Nanoparticle Used in Early Diagnosis and Brain Temperature Detection for Ischemic Stroke. Adv Healthc Mater 2023; 12:e2302276. [PMID: 37717206 DOI: 10.1002/adhm.202302276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/14/2023] [Indexed: 09/18/2023]
Abstract
Ischemic stroke (IS) is one of the most dangerous medical conditions resulting in high mortality and morbidity. The increased brain temperature after IS is closely related to prognosis, making it highly significant for the early diagnosis and the progression evaluation of IS. Herein, a temperature-responsive near infrared (NIR) emissive lanthanide luminescence nanoparticle is developed for the early diagnosis and brain temperature detection of IS. After intravenous injection, the nanoparticles can pass through the damaged blood-brain barrier of the ischemic region, allowing the extravasation and enrichment of nanoparticles into the ischemic brain tissue. The NIR luminescence signals of the nanoparticles are used not only to judge the location and severity of the cerebral ischemic injury but also to report the brain temperature variation in the ischemic area through a visualized way. The results show that the designed nanoparticles can be used for the early diagnosis of ischemic stroke and minimally invasive temperature detection of cerebral ischemic tissues in transient middle cerebral artery occlusion mice model, which is expected to make the clinical diagnosis of ischemic stroke more rapid and convenient, more accurately evaluate the state of brain injury in stroke patients and also guide stroke hypothermia treatment.
Collapse
Affiliation(s)
- Shen-Jie Li
- Department of Neurology, Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 ZhiZaoJu Road, Huangpu District, Shanghai, 200011, China
| | - Fang Li
- School of Physical Science and Technology, ShanghaiTech University, 393 Middle Huaxia Road, Shanghai, 201210, China
| | - Na Kong
- School of Physical Science and Technology, ShanghaiTech University, 393 Middle Huaxia Road, Shanghai, 201210, China
| | - Jian-Ren Liu
- Department of Neurology, Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 ZhiZaoJu Road, Huangpu District, Shanghai, 200011, China
| | - Xingjun Zhu
- School of Physical Science and Technology, ShanghaiTech University, 393 Middle Huaxia Road, Shanghai, 201210, China
| |
Collapse
|
6
|
Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
Collapse
Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
| |
Collapse
|
7
|
Phuyal S, Paudel R, Lamsal R, Thapa L, Maharjan AMS, Gajurel BP. Initial Results of a Direct Aspiration First-Pass Technique to Treat Acute Ischemic Stroke Patients in Nepal. Asian J Neurosurg 2023; 18:75-79. [PMID: 37056878 PMCID: PMC10089751 DOI: 10.1055/s-0043-1761233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Objective Endovascular therapy has become the mainstay of treatment of acute ischemic stroke (AIS) due to large vessel occlusion. A direct aspiration first-pass technique (ADAPT) using large bore aspiration catheters has been introduced as a rapid, simple method for achieving good revascularization and good clinical outcomes. The aim of this study was to assess the safety and efficacy of ADAPT in the treatment of AIS due to large-vessel occlusion in the Nepali patient population.
Materials and Methods Retrospective data were collected for all consecutive patients treated for AIS with ADAPT from March 2019 through January 2021 at two hospitals. Outcomes were successful revascularization (modified thrombolysis in cerebral infarction score of 2b-3), time to revascularization, procedural complications, and good clinical outcome (modified Rankin Scale score of 0 to 2) and mortality at 90 days.
Statistical Analysis Retrospective data were collected and descriptive statistics were calculated.
Results Sixty-eight patients treated for AIS with ADAPT were included. The median National Institutes of Health Stroke Scale score at presentation was 13 (IQR 10–13.25). The median time from arterial puncture to revascularization was 40 minutes (IQR 30–45). Successful revascularization was achieved in 54 patients (79.4%). No cases of symptomatic intracranial hemorrhage occurred. At 90-day follow-up, good clinical outcome was achieved in 57 patients (83.8%), and 4 patients died (5.9%).
Conclusion A direct aspiration first pass technique appears to be a fast, simple, safe, and effective method for the management of AIS in the Nepali patient population.
Collapse
|
8
|
Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke 2023; 18:499-531. [PMID: 36725717 DOI: 10.1177/17474930231156753] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. AIMS To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). SUMMARY OF REVIEW Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. CONCLUSION The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
Collapse
Affiliation(s)
- Gillian E Mead
- Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.,Heart & Brain Lab, Western University, London, ON, Canada.,Robarts Research Institute, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laetitia Yperzeele
- Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.,Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - P N Sylaja
- Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kelvin Hill
- Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA
| | | |
Collapse
|
9
|
Olson DM, Provencher M, Stutzman SE, Hynan LS, Novakovic S, Guttikonda S, Figueroa S, Novakovic-White R, Yang JP, Goldberg MP. Outcomes From a Nursing-Driven Acute Stroke Care Protocol for Telehealth Encounters. J Emerg Nurs 2022; 48:406-416. [PMID: 35487769 DOI: 10.1016/j.jen.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/06/2022] [Accepted: 01/31/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Nursing care is widely recognized to be a vital element in stroke care delivery. However, no publications examining clinical education and optimal workflow practices as predictors of acute ischemic stroke care metrics exist. This study aimed to explore the impact of a nurse-led workflow to improve patient care that included telestroke encounters in the emergency department. METHODS A nonrandomized prospective pre- and postintervention unit-level feasibility study design was used to explore how implementing nurse-driven acute stroke care affects the efficiency and quality of telestroke encounters in the emergency department. Nurses and providers in the emergency department received education/training, and then the Nursing-Driven Acute Ischemic Stroke Care protocol was implemented. RESULTS There were 180 acute ischemic stroke encounters (40.3%) in the control phase and 267 (59.7%) in the postintervention phase with similar demographic characteristics. Comparing the control with intervention times directly affected by the nurse-driven protocol, there was a significant reduction in median door-to-provider times (5 [interquartile range 12] vs 2 [interquartile range 9] minutes, P < .001) and in median door-to-computed tomography scan times (9 [interquartile range 18] vs 5 [interquartile range 11] minutes, P < .001); however, the metrics potentially affected by extraneous variables outside of the nurse-driven protocol demonstrated longer median door-to-ready times (21 [interquartile range 24] vs 25 [interquartile range 25] minutes, P < .001). Door-to-specialist and door-to-needle times were not significantly different. DISCUSSION In this sample, implementation of the nurse-driven acute stroke care protocol is associated with improved nurse-sensitive stroke time metrics but did not translate to faster delivery of thrombolytic agents for acute ischemic stroke, emphasizing the importance of well-outlined workflows and standardized stroke code protocols at every point in acute ischemic stroke care.
Collapse
|
10
|
Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
11
|
Czap AL, Harmel P, Audebert H, Grotta JC. Stroke Systems of Care and Impact on Acute Stroke Treatment. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
12
|
Xian Y, Xu H, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Hernandez AF, Peterson ED, Schwamm LH, Fonarow GC. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke 2021; 53:1328-1338. [PMID: 34802250 DOI: 10.1161/strokeaha.121.035853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. METHODS We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. RESULTS Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. CONCLUSIONS A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.
Collapse
Affiliation(s)
- Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX. (Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (E.E.S.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric D Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX. (E.D.P.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California at Los Angeles (G.C.F.)
| |
Collapse
|
13
|
Ifejika NL, Wiegand J, Harbold H, Botello AA, Babalola BA, Venkatachalam AM, Novakovic R, Cannell MB. The "Network Effect" on Interfacility Transfers Among Regional Stroke Certified Hospitals. J Stroke Cerebrovasc Dis 2021; 30:106056. [PMID: 34450478 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND PURPOSE Timely inter-facility transfer of thrombectomy-eligible patients is a mainstay of Stroke Systems of Care. We investigated transfer patterns among stroke certified hospitals in the Dallas-Fort Worth (DFW) Metroplex (19 counties, 9,286 sq mi, > 7.7 million people), by hospital network and stroke center status. METHODS We conducted a North Central Texas Trauma Regional Advisory Council (NCTTRAC) Stroke Regional Care Survey at all 44 centers involved in the treatment of MT-eligible ischemic stroke patients between June-September 2019, with a response rate of 100%. All hospitals identified network status, stroke designation - Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), Comprehensive Stroke Center (CSC) - and geographic location. Stroke Assessment and Large Vessel Occlusion (LVO) screening tool use was evaluated. The distance between the sending and receiving facility was calculated using GPS coordinates. If the closest CSC was not used, the average distance between the selected and the closest CSC was geospatially mapped via R statistical analysis software (Vienna, Austria) gmapsdistance package. RESULTS Of the 44 facilities, 6 were ASRHs, 27 were PSCs, 11 were CSCs. Seventy-seven percent (n=34) belonged to one of four hospital networks. All facilities used stroke assessment tools; 57% completed LVO screening. There was significant heterogeneity in inter-facility transfer patterns with no regional standardization. Seventeen percent of ASRHs (n=1) and 56% of PSCs (n=15) conducted inter-facility transfers using ground transportation via EMS. Sixty percent of non-network facilities transferred to the closest CSC. Of the remaining 40%, the average distance between the closest and the selected CSC was 1.5 miles (min max 0.2-2.9 miles). Seventeen percent of network facilities transferred to the closest CSC. Among the remaining 83%, the average distance between the closest and the selected CSC was 4.1 miles (min-max 1-8 miles). CONCLUSIONS Non-network facility status increased the likelihood of transfer to the closest Comprehensive Stroke Center. Transfer distance variability among network facilities may contribute to delays in reperfusion therapy.
Collapse
Affiliation(s)
- Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9055, United States; Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States.
| | - Jared Wiegand
- University of Texas Health Science Center at Houston School of Public Health, Dallas, TX, United States.
| | - Hunter Harbold
- Parker County Hospital District, Weatherford, TX, United States.
| | - Adrian A Botello
- North Central Texas Trauma Regional Advisory Council, Arlington, TX, United States.
| | - Babatunde A Babalola
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9055, United States.
| | | | - Roberta Novakovic
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States; Department of Radiology, UT Southwestern Medical Center, Dallas, TX, United States.
| | - Michael B Cannell
- University of Texas Health Science Center at Houston School of Public Health, Dallas, TX, United States; Department of Internal Medicine, Division of Geriatric Medicine, UT Southwestern Medical Center, Dallas, TX, United States.
| |
Collapse
|
14
|
Stromberga Z, Phelps C, Smith J, Moro C. Teaching with Disruptive Technology: The Use of Augmented, Virtual, and Mixed Reality (HoloLens) for Disease Education. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1317:147-162. [PMID: 33945136 DOI: 10.1007/978-3-030-61125-5_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Modern technologies are often utilised in schools or universities with a variety of educational goals in mind. Of particular interest is the enhanced interactivity and engagement offered by mixed reality devices such as the HoloLens, as well as the ability to explore anatomical models of disease using augmented and virtual realities. As the students are required to learn an ever-increasing number of diseases within a university health science or medical degree, it is crucial to consider which technologies provide value to educators and students. This chapter explores the opportunities for using modern disruptive technologies to teach a curriculum surrounding disease. For relevant examples, a focus will be placed on asthma as a respiratory disease which is increasing in prevalence, and stroke as a neurological and cardiovascular disease. The complexities of creating effective educational curricula around these diseases will be explored, along with the benefits of using augmented reality and mixed reality as viable teaching technologies in a range of use cases.
Collapse
Affiliation(s)
- Zane Stromberga
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Charlotte Phelps
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Jessica Smith
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Christian Moro
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia.
| |
Collapse
|
15
|
Establishing a Baseline: Evidence-Supported State Laws to Advance Stroke Care. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 26 Suppl 2, Advancing Legal Epidemiology:S19-S28. [PMID: 32004219 DOI: 10.1097/phh.0000000000001126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Approximately 800 000 strokes occur annually in the United States. Stroke systems of care policies addressing prehospital and in-hospital care have been proposed to improve access to time-sensitive, lifesaving treatments for stroke. Policy surveillance of stroke systems of care laws supported by best available evidence could reveal potential strengths and weaknesses in how stroke care delivery is regulated across the nation. DESIGN This study linked the results of an early evidence assessment of 15 stroke systems of care policy interventions supported by best available evidence to a legal data set of the body of law in effect on January 1, 2018, for the 50 states and Washington, District of Columbia. RESULTS As of January 1, 2018, 39 states addressed 1 or more aspects of prehospital or in-hospital stroke care in law; 36 recognized at least 1 type of stroke center. Thirty states recognizing stroke centers also had evidence-supported prehospital policy interventions authorized in law. Four states authorized 10 or more of 15 evidence-supported policy interventions. Some combinations of prehospital and in-hospital policy interventions were more prevalent than other combinations. CONCLUSION The analysis revealed that many states had a stroke regulatory infrastructure for in-hospital care that is supported by best available evidence. However, there are gaps in how state law integrates evidence-supported prehospital and in-hospital care that warrant further study. This study provides a baseline for ongoing policy surveillance and serves as a basis for subsequent stroke systems of care policy implementation and policy impact studies.
Collapse
|
16
|
Reifegerste D, Harst L, Otto L. Sauerbruch, STARPAHC, and SARS: Historical Perspectives on Readiness and Barriers in Telemedicine. JOURNAL OF PUBLIC HEALTH-HEIDELBERG 2021; 30:11-20. [PMID: 33777654 PMCID: PMC7987372 DOI: 10.1007/s10389-021-01513-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/09/2021] [Indexed: 08/30/2023]
Abstract
Aim Telemedicine is a promising solution to extend traditional health care services. Even though mainly discussed during the past two decades, its roots go back into the past century and even further, considering the use of bonfires to warn other villages of diseases. Insights from historical cases can therefore be useful for the ongoing discussion regarding the successful implementation of telemedicine. Subject and Methods We analyzed three historical telemedicine cases (varying regarding time and place) and extracted their success factors and barriers as well as assessed their maturity by using the Telemedicine Community Readiness Model (TCRM). Evidence-based categories of success factors and barriers as well as the TCRM’s dimensions were used as deductive categories to analyze the study material’s content. Results The analysis showed that the readiness for telemedicine is higher when the technology is the only option to access health care services. In all three cases, core readiness played a central role. However, the health sector, existing technology, and finance were barriers present at all times, while during pandemics, some barriers are only temporarily removed, for example, by putting legal issues on hold. The analyzed cases were all on lower levels of maturity as they mainly represent pilot tests or exceptional circumstances. Conclusion Results indicate the important core functions in telemedicine initiatives as well as the diversity of their circumstances. Insights from such historical meta-perspectives can, for example, help to strengthen the sustainability of the increased use of telemedicine during the COVID-19 pandemic and scale up current telemedicine projects.
Collapse
Affiliation(s)
- Doreen Reifegerste
- School of Public Health, Bielefeld University, Universitätsstrasse 25, 33615 Bielefeld, Germany
| | - Lorenz Harst
- Technische Universität Dresden, Dresden, Germany
| | - Lena Otto
- Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
17
|
Yang X, Wang Z, Huang H, Ling S, Zhang R, Zhang Y, Chen G, Li C, Wang Q. A Targeted Activatable NIR-IIb Nanoprobe for Highly Sensitive Detection of Ischemic Stroke in a Photothrombotic Stroke Model. Adv Healthc Mater 2021; 10:e2001544. [PMID: 33002345 DOI: 10.1002/adhm.202001544] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/21/2020] [Indexed: 11/11/2022]
Abstract
Ischemic stroke is a devastating disease resulting in high morbidity and mortality. To date, its early diagnosis still faces challenges. Herein, an efficient detection strategy is proposed, in which a targeted activatable NIR-IIb nanoprobe (V&C/PbS@Ag2 Se) is constructed for in vivo highly sensitive detection of early ischemic stroke in a photothrombotic stroke model. At first, the fluorescence of V&C/PbS@Ag2 Se displays an "off" state due to the competitive absorption of excitation irradiation between Cy7.5 fluorophores and PbS@Ag2 Se quantum dots (QDs). Upon intravenous injection, the V&C/PbS@Ag2 Se quickly accumulates in the lesion regions based on VCAM1 binding peptide target to the inflamed vascular endothelium of ischemic stroke. Later, the nanoprobes can be rapidly activated via Cy7.5 oxidation by peroxynitrite (ONOO- ), the prodromal biomarker of ischemic stroke, instantly illuminating the lesion regions. Such a targeted activatable strategy offers a favorable approach for in vivo early real-time assessment of ischemic stroke, which can be expanded to other diseases as a general mothed for in vivo precise diagnosis.
Collapse
Affiliation(s)
- Xiaohu Yang
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
| | - Zan Wang
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
| | - Haoying Huang
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
- Department of Nuclear Medicine and PET Center The Second Hospital of Zhejiang University School of Medicine Hangzhou 31009 China
| | - Sisi Ling
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
| | - Rong Zhang
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
| | - Yejun Zhang
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
| | - Guangcun Chen
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
| | - Chunyan Li
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
| | - Qiangbin Wang
- CAS Key Laboratory of Nano‐Bio Interface Suzhou Key Laboratory of Functional Molecular Imaging Technology Division of Nanobiomedicine and i‐Lab Suzhou Institute of Nano‐Tech and Nano‐Bionics Chinese Academy of Sciences Suzhou 215123 China
- School of Nano‐Tech and Nano‐Bionics University of Science and Technology of China Hefei 230036 China
- College of Materials Sciences and Opto‐Electronic Technology University of Chinese Academy of Sciences Beijing 100049 China
| |
Collapse
|
18
|
Zhang X, Cao D, Liu J, Zhang Q, Liu M. Effectiveness and safety of brain-computer interface technology in the treatment of poststroke motor disorders: a protocol for systematic review and meta-analysis. BMJ Open 2021; 11:e042383. [PMID: 33509848 PMCID: PMC7845677 DOI: 10.1136/bmjopen-2020-042383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION About 85% of stroke survivors have upper extremity dysfunction, and more than 60% have continuing hand dysfunction and cannot live independently after treatment. Numerous recent publications have explored brain-computer interfaces technology as rehabilitation tools to help subacute and chronic stroke patients recover upper extremity movement. Our study aims to synthesise results from randomised controlled trials to assess the effectiveness and safety of brain-computer interface technology in the treatment of poststroke motor disorders(PSMD). METHODS AND ANALYSIS English and Chinese search strategies will be conducted in eight databases: the China National Knowledge Infrastructure, Chinese Scientific Journal Database, Wanfang Database, China Doctoral Dissertations Full-Text Database, China Master's Theses Full-Text Database, Cochrane Central Register of Controlled Trials, PubMed and Embase. In addition, manual retrieval of research papers, conference papers, ongoing experiments and internal reports, among others, will supplement electronic retrieval. The searches will select all eligible studies published on or before 8 June 2020. To enhance the effectiveness of the study, only randomised controlled trials related to brain-computer interface technology for poststroke motor disorders will be included. The Fugl-Meyer Motor Function score will be the primary outcome measure; the Modified Barthel Index, Modified Ashworth Score and the upper extremity freehand muscle strength assessment will be secondary outcomes. Side effects and adverse events will be included as safety evaluations. To ensure the quality of the systematic evaluation, study selection, data extraction and quality assessment will be independently performed by two authors, and a third author will handle any disagreement. Review Manager V.5.3.3 and STATA V.15.1 will be used to perform the data synthesis and subgroup analysis. ETHICS AND DISSEMINATION This systemic review will evaluate the efficacy and safety of brain-computer interface technology combined with routine rehabilitation treatment for treatment of poststroke motor disorders. Since all included data will be obtained from published articles,the review does not require ethical approval. The review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020190868.
Collapse
Affiliation(s)
- Xiaolin Zhang
- College of acupuncture and massage, Changchun University of Chinese Medicine, Changchun, China
| | - Di Cao
- Department of rehabilitation, the Second Affiliated Hospital of Changchun University of Chinese Medicine(Changchun Hospital of Chinese Medicine), Changchun, China
| | - Junnan Liu
- Department of lung diseases, the Third Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, China
| | - Qi Zhang
- Changchun University of Chinese Medicine, Changchun, China
| | - Mingjun Liu
- Changchun University of Chinese Medicine, Changchun, China
| |
Collapse
|
19
|
Triage and systems of care in stroke. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:401-407. [PMID: 33272408 DOI: 10.1016/b978-0-444-64034-5.00018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There has been increasing adoption of endovascular stroke treatment in the United States following multiple clinical trials demonstrating superior efficacy. Next steps in enhancing this treatment include an analysis and development of stroke systems of care geared toward efficient delivery of endovascular and comprehensive stroke care. The chapter presents epidemiological data and an overview of the current state of stroke delivery and potential improvements for the future in the light of clinical data.
Collapse
|
20
|
Harsanyi S, Balogh N, Kolozsvari LR, Mezes L, Papp C, Zsuga J. Acute stroke awareness of family physicians: translation of policy to practice. Health Res Policy Syst 2020; 18:128. [PMID: 33129338 PMCID: PMC7603710 DOI: 10.1186/s12961-020-00642-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 10/06/2020] [Indexed: 01/01/2023] Open
Abstract
Background Translating clinical guidelines into routine clinical practice is mandatory to achieve population level improvement of health. Emergence of specific therapy for acute stroke yielded the ‘time is brain’ concept introducing the need for emergency treatment, pointing to the need for increasing stroke awareness of the general population. General practitioners (GPs) manage chronic diseases and could hence catalyse stroke awareness. In our study, the knowledge of general practitioners toward accurate identification of acute stroke candidacy was investigated. Methods GPs and residents in training for family medicine participated in a survey on a voluntary basis using supervised self-administration between the 1st of February 2018 and 31st July 2018. Two clinical cases of acute stroke that differed only regarding the patient’s eligibility for intravenous thrombolysis were presented. Participants answered two open-ended questions. Text analysis was performed using NVIVO software. Results Of the 127 respondents, 69 (54.3%) were female. The median age was 49 (34–62) years. The median time spent working after graduation was 14.5 (2–22.5) years. Board-certified GPs made up 77.2% of the sample. Qualitative analysis revealed stroke as the most frequent diagnosis for both cases. Territorial localization and possible aetiology were also established. Respondents properly identified eligibility for thrombolysis. Quantitative assessment showed that having the practice closer to the stroke centre increases the likelihood of adequate diagnosis for acute stroke. Conclusions Our results show that GPs properly diagnose acute stroke and identify intravenous thrombolysis candidates. Moreover, we found that a vigorous acute stroke triage system facilitates the translation of theory into practice.
Collapse
Affiliation(s)
- Szilvia Harsanyi
- Department of Health Systems Management and Quality Management for Health Care, Faculty of Public Health, University of Debrecen, Nagyerdei krt. 98, Debrecen, 4032, Hungary.,University of Debrecen, Doctoral School of Health Sciences, Debrecen, Hungary
| | - Nandor Balogh
- Department of Health Systems Management and Quality Management for Health Care, Faculty of Public Health, University of Debrecen, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Laszlo Robert Kolozsvari
- Department of Family and Occupational Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Laszlo Mezes
- Department of Health Systems Management and Quality Management for Health Care, Faculty of Public Health, University of Debrecen, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Csaba Papp
- Institute for Primary Health Care and Health Development of Debrecen, Clinical Centre, University of Debrecen, Debrecen, Hungary
| | - Judit Zsuga
- Department of Health Systems Management and Quality Management for Health Care, Faculty of Public Health, University of Debrecen, Nagyerdei krt. 98, Debrecen, 4032, Hungary.
| |
Collapse
|
21
|
Kang J, Kim SE, Park HK, Cho YJ, Kim JY, Lee KJ, Park JM, Park KY, Lee KB, Lee SJ, Lee JS, Lee J, Yang KH, Choi AR, Kang MY, Choi NC, Gorelick PB, Bae HJ. Routing to Endovascular Treatment of Ischemic Stroke in Korea: Recognition of Need for Process Improvement. J Korean Med Sci 2020; 35:e347. [PMID: 33107228 PMCID: PMC7590651 DOI: 10.3346/jkms.2020.35.e347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/19/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To track triage, routing, and treatment status regarding access to endovascular treatment (EVT) after acute ischemic stroke (AIS) at a national level. METHODS From national stroke audit data, potential candidates for EVT arriving within 6 hours with National Institute of Health Stroke Scale score of ≥ 7 were identified. Acute care hospitals were classified as thrombectomy-capable hospitals (TCHs, ≥ 15 EVT cases/year) or primary stroke hospital (PSH, < 15 cases/year), and patients' initial routes and subsequent inter-hospital transfer were described. Impact of initial routing to TCHs vs. PSHs on EVT and clinical outcomes were analyzed using multilevel generalized mixed effect models. RESULTS Out of 14,902 AIS patients, 2,180 (14.6%) were EVT candidates. Eighty-one percent of EVT candidates were transported by ambulance, but only one-third were taken initially to TCHs. Initial routing to TCHs was associated with greater chances of receiving EVT compared to initial routing to PSHs (33.3% vs 12.1%, P < 0.001; adjusted odds ratio [aOR], 2.21; 95% confidence interval [CI], 1.59-2.92) and favorable outcome (38.5% vs. 28.2%, P < 0.001; aOR, 1.52; 95% CI, 1.16-2.00). Inter-hospital transfers to TCHs occurred in 17.4% of those initially routed to a PSH and was associated with the greater chance of EVT compared to remaining at PSHs (34.8% vs. 7.5%, P < 0.001), but not with better outcomes. CONCLUSION Two-thirds of EVT candidates were initially routed to PSHs despite greater chance of receiving EVT and having favorable outcomes if routed to a TCH in Korea. Process improvement is needed to direct appropriate patients to TCHs.
Collapse
Affiliation(s)
- Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Seong Eun Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hong Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Yong Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Jun Yup Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Keon Joo Lee
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Kwang Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea
| | - Soo Joo Lee
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ah Rum Choi
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Mi Yeon Kang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Nack Cheon Choi
- Department of Neurology, Gyeongsang National University College of Medicine, Jinju, Korea.
| | - Philip B Gorelick
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hee Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
| |
Collapse
|
22
|
Chen H, Ren M, Li H, Xie Q, Ma R, Li Y, Guo X, Wang J, Gong D, Gao T. Neuroprotection of benzoinum in cerebral ischemia model rats via the ACE-AngI-VEGF pathway. Life Sci 2020; 260:118418. [PMID: 32931799 DOI: 10.1016/j.lfs.2020.118418] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/03/2020] [Accepted: 09/07/2020] [Indexed: 11/26/2022]
Abstract
AIMS Stroke is a devastating event with a limited choice of intervention. Benzoinum is frequently used to treat stroke in traditional Chinese medicine. Our team has found that the neuroprotection of benzoinum may related to angiogenesis, but the exact biological mechanism is unclear. The objective of this study was to explore its biological mechanism of angiogenesis in cerebral ischemia model rats. MAIN METHODS First, network pharmacology and molecular docking were performed to predict the possible targets and mechanisms of benzoinum in treating ischemic stroke. The best dose was then selected according to pharmacodynamic indexes such as those for neurological deficit, cerebral infarction rate, and brain histopathology in middle cerebral artery occlusion (MCAO) model rats. Finally, RT-PCR, Western Blot and immunohistochemical analysis were applied to verify the prediction results from molecular docking. KEY FINDINGS Network pharmacology and molecular docking demonstrated that the targets of treating cerebral ischemia were PDE4D, ACE and TTR, and the mechanism may be related to the ACE-AngI-VEGF signaling pathway. Experimental verification results suggested that 0.50 g/kg and 1.00 g/kg benzoinum could significantly protect against neurological deficit and reduce cerebral infarction rate in the cerebral cortex and hippocampus in MCAO model rats. At an optimal dose, benzoinum could significantly up-regulate VEGF, SHH and ANG-1, yet down-regulate ACE expression in MCAO model rats. SIGNIFICANCE Balsamic acid is the active ingredient of benzoinum that protects against ischemic stroke and the possible mechanism is related to the promotion of angiogenesis via regulating ACE-AngI-VEGF pathway.
Collapse
Affiliation(s)
- Hai Chen
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China; State Key Laboratory of Southwest Characteristic Traditional Chinese Medicine Resources, Chengdu, Sichuan 611137, China; Key Laboratory of Standardization of Chinese Medicinal Materials, Ministry of Education, Chengdu, Sichuan 611137, China
| | - Mihong Ren
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China; State Key Laboratory of Southwest Characteristic Traditional Chinese Medicine Resources, Chengdu, Sichuan 611137, China; Key Laboratory of Standardization of Chinese Medicinal Materials, Ministry of Education, Chengdu, Sichuan 611137, China
| | - Hongyan Li
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China; State Key Laboratory of Southwest Characteristic Traditional Chinese Medicine Resources, Chengdu, Sichuan 611137, China; Key Laboratory of Standardization of Chinese Medicinal Materials, Ministry of Education, Chengdu, Sichuan 611137, China
| | - Qian Xie
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China; State Key Laboratory of Southwest Characteristic Traditional Chinese Medicine Resources, Chengdu, Sichuan 611137, China; Key Laboratory of Standardization of Chinese Medicinal Materials, Ministry of Education, Chengdu, Sichuan 611137, China
| | - Rong Ma
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China; State Key Laboratory of Southwest Characteristic Traditional Chinese Medicine Resources, Chengdu, Sichuan 611137, China; Key Laboratory of Standardization of Chinese Medicinal Materials, Ministry of Education, Chengdu, Sichuan 611137, China
| | - Yong Li
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China; State Key Laboratory of Southwest Characteristic Traditional Chinese Medicine Resources, Chengdu, Sichuan 611137, China; Key Laboratory of Standardization of Chinese Medicinal Materials, Ministry of Education, Chengdu, Sichuan 611137, China
| | - Xiaoqing Guo
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China; State Key Laboratory of Southwest Characteristic Traditional Chinese Medicine Resources, Chengdu, Sichuan 611137, China; Key Laboratory of Standardization of Chinese Medicinal Materials, Ministry of Education, Chengdu, Sichuan 611137, China
| | - Jian Wang
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China; State Key Laboratory of Southwest Characteristic Traditional Chinese Medicine Resources, Chengdu, Sichuan 611137, China; Key Laboratory of Standardization of Chinese Medicinal Materials, Ministry of Education, Chengdu, Sichuan 611137, China.
| | - Daoyin Gong
- The First Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 610072, China.
| | - Tian Gao
- The First Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 610072, China
| |
Collapse
|
23
|
Jin H, Qu Y, Guo ZN, Yan XL, Sun X, Yang Y. Impact of Jilin Province Stroke Emergency Maps on Acute Stroke Care Improvement in Northeast China. Front Neurol 2020; 11:734. [PMID: 32774322 PMCID: PMC7387724 DOI: 10.3389/fneur.2020.00734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/15/2020] [Indexed: 01/01/2023] Open
Abstract
Objectives: Stroke burden is especially heavy in northeast China. Facilities with the capacity to perform acute reperfusion therapies for stroke are unevenly dispersed and are especially inadequate in rural areas. The aim of this study was to establish an effective measure to improve stroke emergency care, eventually increasing the capacity for reperfusion therapy in Jilin province, a less developed province in northeast China. Methods: We created the Jilin province Stroke Emergency Maps (JSEM), a regional stroke emergency network. Qualified hospitals in Jilin province were integrated into JSEM according to strict inclusion criteria. With constant evaluation and screening, more qualified hospitals may be enrolled into the JSEM, which is updated and published once per year. Locations of hospitals with the capacity to perform intravenous thrombolysis and emergency mechanical thrombectomy were labeled on the map. Results: After strict evaluation and screening, 19 designated hospitals were integrated into the JSEM in August 2017 (baseline). Following the implementation of the JSEM, 21 more designated hospitals (40 in all) were included in 2018, and 48 more designated hospitals were included in 2019. With the guidance of the JSEM, the rate of intravenous thrombolysis in Jilin province increased remarkably from 3.3% (2017, baseline) and 4.6% (2018) to 5.5% (2019). Mean door-to-needle time decreased from 62 min at baseline (2017) to 45 min 2 years later. The number of mechanical thrombectomy was increased from 457 at baseline (2017) to 749 (2018) and 1,137 (2019) per year, respectively, and mean door-to-puncture time was shortened from 136 to 120 min. Conclusion: The JSEM, a regional stroke emergency network, serves to improve patient care for stroke. The map's publication increased rates of intravenous thrombolysis and mechanical thrombectomy. JSEM effectively connected more qualified designated hospitals, stroke patients and emergency medical service systems in Jilin province.
Collapse
Affiliation(s)
- Hang Jin
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China
| | - Yang Qu
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China
| | - Zhen-Ni Guo
- Department of Neurology, Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
| | - Xiu-Li Yan
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China
| | - Xin Sun
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China.,Department of Neurology, Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
24
|
Kamal N, Jeerakathil T, Stang J, Liu M, Rogers E, Smith EE, Demchuk AM, Siddiqui M, Mann B, Bestard J, Lang E, Shand E, Benard M, Collins L, Martin K, Hartley C, Reiber M, Valaire S, Mrklas KJ, Hill MD, Allen D, Anderson B, Angelstand J, Anokye E, Antymniuk C, Arsenault N, Ashman B, Baker K, Bakker J, Balenga D, Berg M, Berry LA, Betzner M, Black L, Blain D, Boutilier T, Brady J, Lynn Brewster S, Brown P, Buchynski K, Bugbee E, Bullard M, Burke D, Burnett C, Butcher K, Cackett P, Canham H, Chiovetti A, Chivers L, Cobb C, Cote M, Coutts S, Currie D, Eric Daniels J, Desouza N, Diebert M, Dixon T, Dotchin J, Duckett S, Dustow V, Dwyer R, Dymond M, Edmond C, Eesa M, Elias N, Elliott T, Empson S, Falls L, Forder M, Foreman R, Forsythe D, Fortier T, Fowler L, Franklin S, Garland J, Garon C, Gerl D, Ghauri I, Gough S, Mark KG, Mary-Lou Halabi G, Halldorson S, Harsch J, Hatcher C, Hebner K, Hemsley R, Holloway D, Holman D, Holsworth S, Holton S, Hull G, Hyciek B, Ibach R, Imoukhuede O, Jeal B, Jill D, Johnson M, Jones O, Kabaroff A, Kalashyan H, Kay F, Kaytor P, Keppy T, King P, Kiszszak S, Klick R, Koshurba E, Kruhlak R, Lacasse J, Lane M, Laughs T, Laut-Barss L, Lavalee P, Leclair T, Linden P, Linderman T, Livingstone J, Lodder M, Lundgard K, Lyle E, Mackenzie K, Malarczuk A, Malfair D, Malone J, Manosalva Alzate H, McCann K, McCarthy S, McKenzie M, McRobert L, Meroniuk D, Millar R, Miller R, Mir B, Montpetit J, Morissette J, Morrison L, Murray-Galbraith F, Mydeen F, Namagiri L, Neidig N, Neil G, Newcommon N, Newell C, Nichol C, Norris C, Norton D, Noseworthy S, O’Hara L, O’Neail S, Orr W, Panes E, Panes T, Paradis J, Parry T, Peacock D, Peebles T, Petersen S, Phelps I, Pooley R, Potvin N, Pryor R, Ramsahoye M, Rashead M, Reedyk K, Reynolds D, Rideout S, Rimmer K, Salih E, San Agustin P, Sandbeck D, Sattar S, Sauter N, Schmidt K, Seib E, Selzler J, Sevcik B, Sharman D, Shuaib A, Smith D, Snider B, Snider J, Stander J, Stephenson C, Stewart C, Stoyberg C, Suranyi Y, Tablin M, Taralson C, Throndson J, Traverse K, van der Nest D, Van Mulligan T, Van Vuuren C, Vanderlinde E, Vilneff R, Volk G, Wall K, Wang DJ(T, Warharft D, Watson J, Weir L, Weiss D, Welch D, Winder T, Winsor W, Woudstra D, Youn D, Young L, Zerna C. Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population. Stroke 2020; 51:2339-2346. [DOI: 10.1161/strokeaha.120.029734] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes.
Methods:
A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback.
Results:
Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51–93) to 39.0 minutes (interquartile range, 27–58) for patients treated per guideline (
P
<0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% (
P
<0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3–55.8) to 53.6 days (interquartile range, 36.8–64.6) (
P
=0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% (
P
=0.0990).
Conclusions:
The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.
Collapse
Affiliation(s)
- Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (T.J., M.S.)
| | - Jillian Stang
- Data Analytics, Alberta Health Services, Canada (J.S., M.L.)
| | - Mingfu Liu
- Data Analytics, Alberta Health Services, Canada (J.S., M.L.)
| | - Edwin Rogers
- Strategic Management Branch, Government of Saskatchewan, Regina, Canada (E.R.)
| | - Eric E. Smith
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Radiology (A.M.D., M.D.H.), University of Calgary, Alberta, Canada
| | - Muzaffar Siddiqui
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (T.J., M.S.)
- Grey Nuns Community Hospital, Edmonton, Alberta, Canada (M.S.)
| | - Balraj Mann
- Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta Health Services, Edmonton, Canada (B.M., S.V.)
| | | | - Eddy Lang
- Department of Emergency Medicine (E.L.), University of Calgary, Alberta, Canada
| | - Elaine Shand
- Red Deer Regional Hospital Centre, Alberta, Canada (J.B., E.S.)
| | | | - Lisa Collins
- North Zone, Alberta Health Services, Cold Lake, Canada (L.C.)
| | - Kevin Martin
- Chinook Regional Hospital, Lethbridge, Alberta, Canada (K.M., C.H.)
| | - Corinna Hartley
- Chinook Regional Hospital, Lethbridge, Alberta, Canada (K.M., C.H.)
| | - Marnie Reiber
- Lloydminster Hospital, Lloydminster, Alberta/Saskatchewan, Canada (M.R.)
| | - Shelley Valaire
- Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta Health Services, Edmonton, Canada (B.M., S.V.)
| | - Kelly J. Mrklas
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
- System Innovation and Programs, Strategic Clinical Networks, Alberta Health Services, Calgary, Canada (K.J.M.)
| | - Michael D. Hill
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
- Department of Radiology (A.M.D., M.D.H.), University of Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Shkirkova K, Connor M, Hodis DM, Lamorie-Foote K, Patel A, Liu Q, Ding L, Amar A, Sanossian N, Attenello F, Mack W. Comparison of Rates and Outcomes of Readmission to Index vs Non-index Hospitals After Intravenous Thrombolysis in Acute Stroke Patients. Cureus 2020; 12:e8952. [PMID: 32765996 PMCID: PMC7398710 DOI: 10.7759/cureus.8952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
National and regional systems of stroke care are designed to provide patients with widespread access to hospitals with thrombolytic capabilities. However, such triaging systems may contribute to fragmentation of care. This study aims to compare rates of readmission and outcomes between index and non-index hospitals for stroke patients following intravenous thrombolytic therapy (IVT). This study utilized a nationally representative sample of stroke patients with IVT from the Nationwide Readmissions Database from 2010 to 2014. Descriptive and regression analyses were performed for patient and hospital level factors that influenced 90-day readmissions and regression models were used to identify differences in mortality, complications, and repeat readmissions between patients readmitted to index (facility where IVT was administered) and non-index hospitals. In the study, 49415 stroke patients were treated with IVT, of whom 21.7% were readmitted within 90 days. Among readmissions, 79.4% of patients were readmitted to index hospitals and 20.6% to non-index hospitals. On multivariate logistic regression analysis, index hospital readmission was independently associated with lower frequency of second readmissions (non-index OR 1.09, 95%CI 1.07-1.11, p<0.0001) but not with increased mortality or major complications (p=ns). Approximately one-fifth of stroke patients treated with thrombolysis were readmitted within 90 days, one-fifth of whom were readmitted to non-index hospitals. Although readmission to index hospital was associated with lower frequency of subsequent readmissions, readmission to non-index hospital was not associated with increased mortality or major complications. This difference may be due to standardized algorithms, mature systems of care, and demanding metrics required of stroke centers.
Collapse
Affiliation(s)
- Kristina Shkirkova
- Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - Michelle Connor
- Neurological Surgery, University of Southern California, Los Angeles, USA
| | - Drew M Hodis
- Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, USA
| | | | - Arati Patel
- Neurological Surgery, University of California, San Francisco, San Francisco, USA
| | - Qinghai Liu
- Neurological Surgery, University of Southern California, Los Angeles, USA
| | - Li Ding
- Preventive Medicine, University of Southern California, Los Angeles, USA
| | - Arun Amar
- Neurological Surgery, University of Southern California, Los Angeles, USA
| | | | - Frank Attenello
- Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - William Mack
- Neurological Surgery, University of Southern California, Los Angeles, USA
| |
Collapse
|
26
|
Shkirkova K, Wang TT, Vartanyan L, Liebeskind DS, Eckstein M, Starkman S, Stratton S, Pratt FD, Hamilton S, Kim-Tenser M, Conwit R, Saver JL, Sanossian N. Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals. Front Neurol 2020; 10:1396. [PMID: 32038463 PMCID: PMC6987385 DOI: 10.3389/fneur.2019.01396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose: Primary stroke center (PSC) certification is associated with improvements in stroke care and outcome. However, these improvements may reflect a higher baseline level of care delivery in hospitals eventually achieving certification. This study examines whether advancements in acute stroke care at PSCs are due to certification or factors intrinsic to the hospital. Methods: Data was obtained from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) trial with participation of 40 Emergency Medical System agencies, 315 ambulances, and 60 acute receiving hospitals in Los Angeles and Orange Counties. Subjects were transported to one of three types of destinations: PSC certified hospitals (PSCs), hospitals that were not PSCs at time of enrollment but would later become certified (pre-PSCs), and hospitals that would never be certified (non-PSCs). Metrics of acute stroke care quality included time arrival to imaging, use of intravenous tPA, and arrival to treatment. Results: Of 1,700 cases, 856(50%) were at certified PSCs, 529(31%) were at pre-PSCs, and 315 (19%) were at non-PSCs. Mean (SD) was 33min (±76.1) at PSCs, 47(±86.6) at pre-PSCs, and 49(±71.7) at non-PSCs. Of 1,223 cerebral ischemia cases, rate of tPA utilization was 43% at PSCs, 27% at pre-PSCs, and 28% at non-PSCs. Mean ED arrival to thrombolysis was 71(±32.7) at PSC, 98(±37.6) at pre-PSC, and 95(±45.0) at non-PSCs. PSCs had improved time to imaging (p = 0.014), percent tPA use (p < 0.001), and time to treatment (p = 0.003). Conclusions: Stroke care at hospitals prior to PSC certification is equivalent to care at non-PSCs. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.
Collapse
Affiliation(s)
- Kristina Shkirkova
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Theodore T Wang
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Lily Vartanyan
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - David S Liebeskind
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Marc Eckstein
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA, United States
| | - Sidney Starkman
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Samuel Stratton
- Department of Community Health Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Franklin D Pratt
- Los Angeles County Department of Public Health, Los Angeles, CA, United States
| | - Scott Hamilton
- Department of Neurology, Stanford Stroke Center, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - May Kim-Tenser
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Robin Conwit
- National Institutes of Health, Bethesda, MD, United States
| | - Jeffrey L Saver
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Nerses Sanossian
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
27
|
Shkirkova K, Schuberg S, Balouzian E, Starkman S, Eckstein M, Stratton S, Pratt FD, Hamilton S, Sharma L, Liebeskind DS, Conwit R, Saver JL, Sanossian N. Paramedic Global Impression of Change During Prehospital Evaluation and Transport for Acute Stroke. Stroke 2020; 51:784-791. [PMID: 31955642 DOI: 10.1161/strokeaha.119.026392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background and Purpose- The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods- In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results- Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27-39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions- The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00059332.
Collapse
Affiliation(s)
- Kristina Shkirkova
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles
| | - Samuel Schuberg
- Department of Emergency Medicine (S. Schuberg, M.E.), University of Southern California, Los Angeles
| | - Emma Balouzian
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles
| | - Sidney Starkman
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Emergency Medicine (S. Starkman, S. Stratton), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - Marc Eckstein
- Department of Emergency Medicine (S. Schuberg, M.E.), University of Southern California, Los Angeles
| | - Samuel Stratton
- Department of Emergency Medicine (S. Starkman, S. Stratton), University of California Los Angeles
| | | | - Scott Hamilton
- School of Public Health (S.H.), University of California Los Angeles.,Stanford University, CA (S.H.)
| | - Latisha Sharma
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - David S Liebeskind
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Neurovascular Imaging Core (D.S.L.), University of California Los Angeles
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke (R.C.)
| | - Jeffrey L Saver
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - Nerses Sanossian
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles.,Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S.), University of Southern California, Los Angeles
| | | |
Collapse
|
28
|
Quig K, Wheatley EG, O'Hara M. Perspectives On Blood-Based Point-Of-Care Diagnostics. Open Access Emerg Med 2019; 11:291-296. [PMID: 31814781 PMCID: PMC6861530 DOI: 10.2147/oaem.s223667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/02/2019] [Indexed: 12/14/2022] Open
Abstract
Background Point of Care (POC) diagnostics are an essential component of modern medicine and are employed in a variety of clinical disciplines to improve patient outcomes and provider efficiency. Despite these benefits, there are aspects of POC testing which may still hold room for improvement. In the present study, a group of healthcare professionals familiar with different facets of blood-based POC testing provided their perspectives on the benefits and challenges of POC testing within their respective fields. Materials and methods The study was conducted from April to June 2019, in Colorado, United States of America. Five healthcare professionals, each working in a distinct field (anesthesiology, nursing, emergency medicine, trauma surgery, and POC management) were interviewed. Results from each of the interviews were transcribed as qualitative perspectives on POC diagnostics. Discussion The general consensus among participants in this study is that POC testing is tremendously beneficial, providing rapid test results, increased access to diagnostics, and improvements in hospital efficiency. However, significant challenges remain in blood-based POC diagnostics, particularly in maintaining sample quality, due to the fact that devices used for sample acquisition and handling are not designed for POC. This raises the possibility for interferents like hemolysis to occur, which may alter diagnostic results. Errors in POC diagnostics, whether due to sample, operator, or instrument error, may cause providers to lose confidence in the test. This lack of confidence can lead to duplicate testing and delayed patient diagnoses. Conclusion The perspectives presented in this study suggest there is a significant need for improvement in the pre-analytical phase of POC testing, and that current practice employs specimen collection technology not designed for POC. Therefore, one hypothesis is that the introduction of a collection device designed specifically for POC could reduce pre-analytical errors, standardize sample quality, improve efficiency, and further benefit patient care.
Collapse
|
29
|
Govindarajan P, Shiboski S, Grimes B, Cook LJ, Ghilarducci D, Meng T, Trickey AW. Effect of Acute Stroke Care Regionalization on Intravenous Alteplase Use in Two Urban Counties. PREHOSP EMERG CARE 2019; 24:505-514. [PMID: 31599705 DOI: 10.1080/10903127.2019.1679303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Importance: Intravenous alteplase is an effective treatment for acute ischemic stroke and is significantly underutilized. It is known that stroke centers with accreditation are more likely to provide intravenous alteplase treatment, and therefore, policies that increase the number of certified stroke centers and the number of acute ischemic stroke patients routed to these centers may be beneficial. Objective: To determine whether increasing access to primary stroke centers (regionalization) led to an increase in intravenous alteplase use in acute ischemic stroke patients. Design: An observational, longitudinal study to examine treatment trends with log-link binomial regression modeling to compare pre-post policy implementation changes in the proportions of patients treated with intravenous alteplase in two counties. Setting: Two urban counties, Santa Clara and San Mateo, in the western region of US that regionalized acute stroke care between 2005 and 2010. Participants: Patients with primary or secondary diagnosis of stroke were identified from the statewide patient discharge database by International Classification of Diseases (ICD-9) codes. We linked ambulance and hospital data to create complete patient care records. Main outcomes and measures: Stroke treatment, defined as a documented primary procedure code for intravenous alteplase administration (ICD-9: 99.10). Results: In Santa Clara County, intravenous alteplase was administered to 35 patients (1.7%) in the pre-regionalization period and 240 patients (2.1%) in the post-regionalization period. In San Mateo County, intravenous alteplase was administered to 29 patients (1.3%) in the pre-policy period and 135 patients (3.2%) in the post-policy period. After regionalization of stroke care, intravenous alteplase increased two-fold in San Mateo County [adjusted RR 2.20, p = 0.003, 95% CI (1.31, 3.69)] but did not show any statistically significant change in Santa Clara County [adjusted RR 1.10, p = 0.55, 95% CI (0.80, 1.51)]. In the post-regionalization phase, when compared with Santa Clara County, we found that San Mateo County had greater change in paramedic stroke detection, higher number of transports to primary stroke centers and more frequent use of intravenous alteplase at stroke centers. Conclusions: Our findings suggest that greater post-regionalization improvements in San Mateo County contributed to significantly better county-level thrombolysis use than Santa Clara County.
Collapse
|
30
|
Stroke Center Care and Outcome: Results from the CSPPC Stroke Program. Transl Stroke Res 2019; 11:377-386. [PMID: 31494833 DOI: 10.1007/s12975-019-00727-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
Abstract
The aim of this study was to assess the association between admission to stroke centers for acute ischemic stroke and complications and mortality during hospitalization in a Chinese population by means of an observational study using data from the China Stroke Center Data-Sharing Platform. We compared in-hospital complications and mortality for patients admitted with acute ischemic stroke (N = 13,236) between November 1, 2018 and December 31, 2018 at stroke center (SH) and non-stroke center (CH) hospitals using distance to hospitals as an instrumental variable to adjust for potential prehospital selection bias. The results showed that complication rates during hospitalization among ischemic stroke patients who received thrombolytic therapy (n = 11,203) were lower in the SH group than in the CH group: 11.1% vs 15.7% (absolute difference, - 5.11% [95% CI, - 6.05 to - 3.99%], odds ratio [OR] 0.85 [95% CI, 0.74 to 0.92]). The incidence of intracranial hemorrhage was reduced from 4.2 to 3.2%: SH group vs CH group, 3.2% vs 4.2% (absolute difference, - 1.24% [95% CI, - 1.65 to - 0.82%], OR 0.83 [95% CI, 0.69 to 0.0.98]). Furthermore, the total mortality rate in the SH group was also lower than in the CH group: SH group vs CH group, 2.2% vs 3.0% (absolute difference, - 0.92% [95% CI, - 1.48 to - 0.53%], OR 0.85 [95% CI, 0.73 to 0.96]). The data showed that admission to SH hospitals was associated with a lower risk of treatment complications and death for patients with an acute ischemic stroke receiving thrombolytic therapy.
Collapse
|
31
|
Ali SF, Fonarow G, Liang L, Xian Y, Smith EE, Bhatt DL, Schwamm L. Rates, Characteristics, and Outcomes of Patients Transferred to Specialized Stroke Centers for Advanced Care. Circ Cardiovasc Qual Outcomes 2019; 11:e003359. [PMID: 30354551 DOI: 10.1161/circoutcomes.116.003359] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background While many patients are transferred to specialized stroke centers for advanced acute ischemic stroke (AIS) care, few studies have characterized these patients. We sought to determine variation in the rates and differences in the baseline characteristics and clinical outcomes between AIS cases presenting directly to stroke centers' front door versus Transfer-Ins from another hospital. Methods and Results We analyzed 970 390 AIS cases in the Get With The Guidelines-Stroke registry from January 2010 to March 2014 to compare hospitals with high Transfer-In rates (≥15%) versus those with low Transfer-In rates (<5%) and to compare the front-door versus Transfer-In patients admitted to those hospitals with high Transfer-In rates (high Transfer-In hospitals). Of 970 390 patients discharged from 1646 hospitals, 87% initially presented via the emergency department versus 13% were a Transfer-In from another hospital. High Transfer-In hospitals had a median 31% Transfer-In rate among all stroke discharges, were larger, had higher annual AIS volume and intravenous tPA (tissue-type plasminogen activator) rates, and were more often Midwest teaching hospitals and stroke centers. Compared with front-door, Transfer-In patients were younger, more often white, had higher median National Institutes of Health Stroke Scale scores, less often hypertension and previous stroke/transient ischemic attack, and higher in-hospital mortality (7.9% versus 4.9%; standardized difference, 12.4%). After multivariable adjustment, Transfer-In patients had higher in-hospital mortality and discharge modified Rankin scale. Conclusions There is significant regional variability in the transfer of patients with AIS. Because Transfer-In patients seem to have worse short-term outcomes, these patients have the potential to negatively influence institutional mortality rates and should be accounted for explicitly in hospital risk-profiling measures.
Collapse
Affiliation(s)
- Syed F Ali
- University of Arkansas for Medical Sciences, Little Rock (S.F.A.)
| | | | - Li Liang
- Duke Clinical Research Institute, Durham, NC (L.L., Y.X.)
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC (L.L., Y.X.)
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, AB (E.E.S.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center (D.L.B.)
| | - Lee Schwamm
- Massachusetts General Hospital (L.S.), Harvard Medical School, Boston, MA
| |
Collapse
|
32
|
Feng Z, Yu X, Jiang M, Zhu L, Zhang Y, Yang W, Xi W, Li G, Qian J. Excretable IR-820 for in vivo NIR-II fluorescence cerebrovascular imaging and photothermal therapy of subcutaneous tumor. Theranostics 2019; 9:5706-5719. [PMID: 31534513 PMCID: PMC6735390 DOI: 10.7150/thno.31332] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 06/16/2019] [Indexed: 02/07/2023] Open
Abstract
Rationale: Cerebrovascular diseases, together with malignancies, still pose a huge threat to human health nowadays. With the advantages of its high spatial resolution and large penetration depth, fluorescence bioimaging in the second near-infrared spectral region (NIR-II, 900-1700 nm) and its related imaging-guided therapy based on biocompatible fluorescence dyes have become a promising theranostics method. Methods: The biocompatibility of IR-820 we used in NIR-II fluorescence bioimaging was verified by long-term observation. The model of the mouse with a cranial window, the mouse model of middle cerebral artery occlusion (MCAO) and a subcutaneous xenograft mouse model of bladder tumor were established. NIR-II fluorescence cerebrovascular functional imaging was carried out by IR-820 assisted NIR-II fluorescence microscopy. Bladder tumor was treated by NIR-II fluorescence imaging-guided photothermal therapy. Results: We have found that IR-820 has considerable NIR-II fluorescence intensity, and shows increased brightness in serum than in water. Herein, we achieved real time and in vivo cerebrovascular functional imaging of mice with high spatial resolution and large penetration depth, based on IR-820 assisted NIR-II fluorescence microscopy. In addition, IR-820 was successfully employed for NIR-II fluorescence imaging and photothermal therapy of tumor in vivo, and the subcutaneous tumors were inhibited obviously or eradicated completely. Conclusion: Due to the considerable fluorescence intensity in NIR-II spectral region and the good photothermal effect, biocompatible and excretable IR-820 holds great potentials for functional angiography and cancer theranostics in clinical practice.
Collapse
Affiliation(s)
- Zhe Feng
- State Key Laboratory of Modern Optical Instrumentations, Centre for Optical and Electromagnetic Research; JORCEP (Sino-Swedish Joint Research Center of Photonics), Zhejiang University, Hangzhou, 310058, China
| | - Xiaoming Yu
- Department of Urology, Sir Run-Run Shaw Hospital College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Minxiao Jiang
- Department of Urology, Sir Run-Run Shaw Hospital College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Liang Zhu
- Interdisciplinary Institute of Neuroscience and Technology (ZIINT), Zhejiang University, Hangzhou, 310058, China
| | - Yi Zhang
- School of Basic Medical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Wei Yang
- School of Basic Medical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Wang Xi
- Interdisciplinary Institute of Neuroscience and Technology (ZIINT), Zhejiang University, Hangzhou, 310058, China
| | - Gonghui Li
- Department of Urology, Sir Run-Run Shaw Hospital College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Jun Qian
- State Key Laboratory of Modern Optical Instrumentations, Centre for Optical and Electromagnetic Research; JORCEP (Sino-Swedish Joint Research Center of Photonics), Zhejiang University, Hangzhou, 310058, China
- Department of Urology, Sir Run-Run Shaw Hospital College of Medicine, Zhejiang University, Hangzhou 310016, China
| |
Collapse
|
33
|
Abstract
PURPOSE OF REVIEW This article provides updated information regarding the diagnosis and treatment (specifically critical care management) of acute ischemic stroke. This article also discusses the increased use of thrombolysis and thrombectomy in clinical practice. RECENT FINDINGS Stroke is the leading cause of disability in the United States. A significant proportion of patients with acute ischemic stroke require critical care management. Much has changed in the early evaluation and treatment of patients presenting with acute ischemic stroke. The introduction of embolectomy in large vessel occlusions for up to 24 hours post-symptom onset has resulted in one in every three eligible patients with acute ischemic stroke with the potential to lead an independent lifestyle. These patients increasingly require recognition of complications and initiation of appropriate interventions as well as earlier admission to dedicated neurocritical care units to ensure better outcomes. SUMMARY This article emphasizes issues related to the management of patients with acute ischemic stroke undergoing mechanical thrombectomy and thrombolysis and addresses the complex physiologic changes affecting neurologic and other organ systems.
Collapse
|
34
|
Phan TG, Beare R, Srikanth V, Ma H. Googling Service Boundaries for Endovascular Clot Retrieval (ECR) Hub Hospitals in Metropolitan Sydney. Front Neurol 2019; 10:708. [PMID: 31333564 PMCID: PMC6614527 DOI: 10.3389/fneur.2019.00708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 06/17/2019] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Endovascular clot retrieval (ECR) has revolutionized acute stroke therapy but is expensive to run and staff with accredited interventional neuroradiologists 24/7; consequently, it is only feasible for each metropolitan city to have a minimum number of hubs that is adequate to service the population. This method is applied to search the minimum number of hospitals to be designated as ECR hubs in Sydney as well as the population at risk of stroke reachable within 30 min. Methods: Traveling time from the centroids of each suburbs to five ECR capable hubs [Royal Prince Alfred/RPA, Prince of Wales/POW, Royal North Shore/RNS, Liverpool/LH and Westmead/WH]. This step was performed using ggmap package in R to interface with Google Map application program interface (API). Next, we calculate the percentage of suburbs within each catchment in which traveling time to the ECR hub is <30 min. This step was performed for all possible combination of ECR hubs. The maps are available at https://gntem3.shinyapps.io/ambsydney/. The population at risk of stroke was estimated using stroke incident studies in Melbourne and Adelaide. Results: The best 3-hospital combinations are LPH/WH/RNS (82.3, 45.7, and 79.7% of suburbs reachable within 30 min or 187 of 226 suburbs) follow by RPA/LPH/RNS (100.0, 80.9, and 73.1% of suburbs) and LPH/POW/RNS (83.3, 90.7, and 76.6% of suburbs). The best 4-hospital model is LPH/WH/POW/RNS (84.2%, 91.1%, 90.7%, 77.8%). In the 5-hospital model, ECR is available for 191 suburbs within 30 min: LPH (83%), RPA (100%), WH (90.2%), RNS (72.7%), POW (88.9%). Based on 3-hospital model and 15% of patient eligible for ECR, the expected number of cases to be handled by each hospital is 465. This number drops down to 374 if a 4-hospital model is preferred. Conclusions: The simulation studies supported a minimum of 4 ECR hubs servicing Sydney. This model provides data on number of suburbs and population at risk of stroke that can reach these hubs within 30 min.
Collapse
Affiliation(s)
- Thanh G Phan
- Department of Neurology, Monash Health, Melbourne, VIC, Australia.,Clinical Trials, Imaging and Infomatics (CTI), Division of Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Richard Beare
- Clinical Trials, Imaging and Infomatics (CTI), Division of Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children Research Institute, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Department of Neurology, Monash Health, Melbourne, VIC, Australia.,Clinical Trials, Imaging and Infomatics (CTI), Division of Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Henry Ma
- Department of Neurology, Monash Health, Melbourne, VIC, Australia.,Clinical Trials, Imaging and Infomatics (CTI), Division of Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
35
|
Tajaddini A, Phan TG, Beare R, Ma H, Srikanth V, Currie G, Vu HL. Application of Strategic Transport Model and Google Maps to Develop Better Clot Retrieval Stroke Service. Front Neurol 2019; 10:692. [PMID: 31316457 PMCID: PMC6611389 DOI: 10.3389/fneur.2019.00692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022] Open
Abstract
Background and purpose: Two hubs are designated to provide endovascular clot retrieval (ECR) for the State of Victoria, Australia. In an earlier study, Google Maps application programming interface (API) was used to perform modeling on the combination of hospitals optimizing for catchment in terms of current traveling time and road conditions. It is not known if these findings would remain the same if the modeling was performed with a large-scale transport demand model such as Victorian Integrated Transport Model (VITM). This model is developed by the Victorian State Government Transport has the capability to forecast travel demand into the future including future road conditions which is not possible with a Google Maps based applications. The aim of this study is to compare the travel time to potential ECR hubs using both VITM and the Google Maps API and model stability in the next 5 and 10 years. Methods: The VITM was used to generate travel time from randomly generated addresses to four existing ECR capable hubs in Melbourne city, Australia (i.e., Royal Melbourne Hospital/RMH, Monash Medical Center/MMC, Alfred Hospital/ALF, and Austin Hospital/AUS) and the optimal service boundaries given a delivering time threshold are then determined. Results: The strategic transport model and Google map methods were similar with the R2 of 0.86 (peak and off peak) and the Nash-Sutcliffe model of efficiency being 0.83 (peak) and 0.76 (off-peak travel). Futures modeling using VITM found that this proportion decreases to 82% after 5 years and 80% after 10 years. The combination of RMH and ALF provides coverage for 74% of cases, 68% by 5 years, and 66% by 10 years. The combination of RMH and AUS provides coverage for 70% of cases in the base case, 65% at 5 years, and 63% by 10 years. Discussion: The results from strategic transport model are similar to those from Google Maps. In this paper we illustrate how this method can be applied in designing and forecast stroke service model in different cities in Australia and around the world.
Collapse
Affiliation(s)
- Atousa Tajaddini
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
| | - Thanh G Phan
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Richard Beare
- Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Henry Ma
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Graham Currie
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
| | - Hai L Vu
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
36
|
Pahigiannis K, Thompson-Paul AM, Barfield W, Ochiai E, Loustalot F, Shero S, Hong Y. Progress Toward Improved Cardiovascular Health in the United States. Circulation 2019; 139:1957-1973. [PMID: 30986104 PMCID: PMC8428048 DOI: 10.1161/circulationaha.118.035408] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The Healthy People Initiative has served as the leading disease prevention and health promotion roadmap for the nation since its inception in 1979. Healthy People 2020 (HP2020), the initiative's current iteration, sets a national prevention agenda with health goals and objectives by identifying nationwide health improvement priorities and providing measurable objectives and targets from 2010 to 2020. Central to the overall mission and vision of Healthy People is an emphasis on achieving health equity, eliminating health disparities, and improving health for all population groups. The Heart Disease and Stroke (HDS) Work Group of the HP2020 Initiative aims to leverage advances in biomedical science and prevention research to improve cardiovascular health across the nation. The initiative provides a platform to foster partnerships and empower professional societies and nongovernmental organizations, governments at the local, state, and national levels, and healthcare professionals to strengthen policies and improve practices related to cardiovascular health. Disparities in cardiovascular disease burden are well recognized across, for example, race/ethnicity, sex, age, and geographic region, and improvements in cardiovascular health for the entire population are only possible if such disparities are addressed through efforts that target individuals, communities, and clinical and public health systems. This article summarizes criteria for creating and tracking the 50 HDS HP2020 objectives in 3 areas (prevention, morbidity/mortality, and systems of care), reports on progress toward the 2020 targets for these objectives based on the most recent data available, and showcases examples of relevant programs led by participating agencies. Although most of the measurable objectives have reached the 2020 targets ahead of time (n=14) or are on track to meet the targets (n=7), others may not achieve the decade's targets if the current trends continue, with 3 objectives moving away from the targets. This summary illustrates the utility of HP2020 in tracking measures of cardiovascular health that are of interest to federal agencies and policymakers, professional societies, and other nongovernmental organizations. With planning for Healthy People 2030 well underway, stakeholders such as healthcare professionals can embrace collaborative opportunities to leverage existing progress and emphasize areas for improvement to maximize the Healthy People initiative's positive impact on population-level health.
Collapse
Affiliation(s)
- Katherine Pahigiannis
- National Institute of Neurological Disorders and Stroke (K.P.), National Institutes of Health, Bethesda, MD
| | - Angela M Thompson-Paul
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (A.M.T.-P., F.L., Y.H)
| | - Whitney Barfield
- National Heart, Lung, and Blood Institute (W.B., S.S.), National Institutes of Health, Bethesda, MD
| | - Emmeline Ochiai
- Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, US Department of Health and Human Services, Rockville, MD (E.O.)
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (A.M.T.-P., F.L., Y.H)
| | - Susan Shero
- National Heart, Lung, and Blood Institute (W.B., S.S.), National Institutes of Health, Bethesda, MD
| | - Yuling Hong
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (A.M.T.-P., F.L., Y.H)
| |
Collapse
|
37
|
Tiedeman C, Suthers B, Julien B, Hackett A, Oakley P. Management of stroke in the Australian Indigenous population: from hospitals to communities. Intern Med J 2019; 49:962-968. [PMID: 30907045 DOI: 10.1111/imj.14303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/07/2019] [Accepted: 03/18/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ischaemic strokes lead to significant morbidity and mortality within the Australian Indigenous population, with known variances in the management of strokes between indigenous and non-indigenous populations. AIMS To compare investigations and management of indigenous and non-indigenous patients presenting to a New South Wales rural referral hospital with an ischaemic stroke to the national stroke standards across inpatient and outpatient settings. METHODS Historical cohort study of 43 indigenous and 167 non-indigenous patients admitted to Tamworth Rural Referral Hospital with an ischaemic cerebrovascular accident. RESULTS Indigenous patients were significantly less likely to have investigations completed, including carotid imaging (93.8% vs 100%, P = 0.012) and echocardiography (73.3% vs 97.7%, P = 0.004). Discharge follow up was significantly lower for the indigenous population (74.4% vs 87.4%, P = 0.034). Indigenous stroke patients were 15.8 years younger than non-indigenous subjects (56.8 vs 72.6 years old; P < 0.001). Indigenous patients were more likely to have stroke risk factors, including smoking (51.2% vs 15.0%; P < 0.001), diabetes mellitus (37.2% vs 16.8%, P = 0.003) and past history of cerebrovascular accident or transient ischaemic attack (50.2% vs 31.1%, P = 0.032). CONCLUSIONS The investigation and post-discharge care of indigenous ischaemic stroke patients is inferior to non-indigenous patients. Indigenous patients within rural NSW have a higher prevalence of preventable disease, including those that confer a higher stroke risk. Further research is needed to investigate the cause of these discrepancies and to improving indigenous stroke care between hospitals and primary care providers.
Collapse
Affiliation(s)
- Clare Tiedeman
- General Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Belinda Suthers
- General Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia.,Department of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Respiratory and Sleep Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Benjamin Julien
- General Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Anna Hackett
- Department of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Clinical Governance Hunter New England Health, Newcastle, New South Wales, Australia
| | - Patrick Oakley
- General Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia.,Department of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Research Medical Institute, Newcastle, New South Wales, Australia
| |
Collapse
|
38
|
Horlick E, Kavinsky CJ, Amin Z, Boudoulas KD, Carroll JD, Hijazi ZM, Leifer D, Lutsep HL, Rhodes JF, Tobis JM. SCAI expert consensus statement on operator and institutional requirements for PFO closure for secondary prevention of paradoxical embolic stroke. Catheter Cardiovasc Interv 2019; 93:859-874. [DOI: 10.1002/ccd.28111] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Eric Horlick
- Institute of Medical ScienceUniversity Health Network Toronto Ontario
| | - Clifford J. Kavinsky
- Section of Structural and Interventional CardiologyRush University Medical Center Chicago Illinois
| | - Zahid Amin
- Division of Pediatric CardiologyAugusta University Augusta Georgia
| | | | - John D. Carroll
- Department of Medicine‐CardiologyUniversity of Colorado Denver Colorado
| | - Ziyad M. Hijazi
- Department of PediatricsSidra Medicine Doha Qatar
- Department of PediatricsWeill Cornell Medicine New York New York
| | - Dana Leifer
- Department of NeurologyWeill Cornell Medicine New York New York
| | - Helmi L. Lutsep
- Department of NeurologyOregon Health and Science University Portland Oregon
| | - John F. Rhodes
- Congenital Heart CenterMedical University of South Carolina Charleston South Carolina
| | - Jonathan M. Tobis
- Department of MedicineUniversity of California Los Angeles California
| |
Collapse
|
39
|
Nakao M, Izumi S, Yokoshima Y, Matsuba Y, Maeno Y. Prediction of life-space mobility in patients with stroke 2 months after discharge from rehabilitation: a retrospective cohort study. Disabil Rehabil 2019; 42:2035-2042. [PMID: 30676134 DOI: 10.1080/09638288.2018.1550533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To determine the predictors of life-space mobility among patients with stroke 2 months after discharge from a post-acute rehabilitation unit.Materials and methods: The study population was 1023 patients discharged from a post-acute rehabilitation unit in Japan. We assessed the relationships between life-space mobility 2 months after discharge and age, sex, length of hospital stay, cognition and motor function (Functional Independence Measure), severity of hemiparesis, falls efficacy, physical function (Timed Up and Go (TUG) test), walking distance ability and social support from family and friends.Results: Bivariate and multiple regression analyses showed that life-space mobility was predicted by sex, age, cognitive score at discharge, TUG score <15 s, length of hospital stay and falls efficacy at discharge. Taken together, these factors accounted for 54% of the variability in life-space mobility. A predictive formula was determined for clinical use.Conclusions: The predictive formula provides an objective measure of life-space mobility for stroke patients after discharge. The clinical application of this formula could help health care professionals working in stroke rehabilitation to prepare patients for discharge and to set concrete goals for in-hospital rehabilitation to improve life-space mobility after discharge.Implications for rehabilitationAccurate prediction of the prognosis for life-space mobility 2 months after discharge is useful in establishing clear goals for community-based rehabilitation.Long-term life-space mobility in the community is not only affected by physical function, but also by sex, age, cognitive ability and falls efficacy at discharge.Life-space mobility in female patients is affected by factors reflecting physical function, whereas life-space mobility in male patients is affected by both physical and cognitive function.Prediction of life-space mobility after stroke is important to determine unique mobility goals in rehabilitation and the required use of adaptive equipment after discharge (e.g., returning to work, engaging in a hobby or travelling beyond the immediate neighbourhood).
Collapse
Affiliation(s)
- Mari Nakao
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai, Japan.,Rehabilitation Department, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Shinichi Izumi
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuki Yokoshima
- Rehabilitation Department, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Yoshiko Matsuba
- Rehabilitation Department, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Yutaka Maeno
- Rehabilitation Department, Yokohama Brain and Spine Center, Yokohama, Japan
| |
Collapse
|
40
|
Promoting Evidence-Based Practice at a Primary Stroke Center: A Nurse Education Strategy. Dimens Crit Care Nurs 2018; 36:244-252. [PMID: 28570379 DOI: 10.1097/dcc.0000000000000251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Promoting a culture of evidence-based practice within a health care facility is a priority for health care leaders and nursing professionals; however, tangible methods to promote translation of evidence to bedside practice are lacking. OBJECTIVES The purpose of this quality improvement project was to design and implement a nursing education intervention demonstrating to the bedside nurse how current evidence-based guidelines are used when creating standardized stroke order sets at a primary stroke center, thereby increasing confidence in the use of standardized order sets at the point of care and supporting evidence-based culture within the health care facility. METHODS This educational intervention took place at a 286-bed community hospital certified by the Joint Commission as a primary stroke center. Bedside registered nurse (RN) staff from 4 units received a poster presentation linking the American Heart Association's and American Stroke Association's current evidence-based clinical practice guidelines to standardized stroke order sets and bedside nursing care. The 90-second oral poster presentation was delivered by a graduate nursing student during preshift huddle. The poster and supplemental materials remained in the unit break room for 1 week for RN viewing. After the pilot unit, a pdf of the poster was also delivered via an e-mail attachment to all RNs on the participating unit. A preintervention online survey measured nurses' self-perceived likelihood of performing an ordered intervention based on whether they were confident the order was evidence based. The preintervention survey also measured nurses' self-reported confidence in their ability to explain how the standardized order sets are derived from current evidence. The postintervention online survey again measured nurses' self-reported confidence level. However, the postintervention survey was modified midway through data collection, allowing for the final 20 survey respondents to retrospectively rate their confidence before and after the educational intervention. This modification ensured that the responses for each individual participant in this group were matched. RESULTS Registered nurses reported a significant increase in perceived confidence in ability to explain how standardized stroke order sets reflect current evidence after the intervention (n = 20, P < .001). This sample was matched for each individual respondent. No significant change was shown in unmatched group mean self-reported confidence ratings overall after the intervention or separately by unit for the progressive care unit, critical care unit, or intensive care unit (n = 89 preintervention, n = 43 postintervention). However, the emergency department demonstrated a significant increase in group mean perceived confidence scores (n = 20 preintervention, n = 11 postintervention, P = .020). Registered nurses reported a significantly higher self-perceived likelihood of performing an ordered nursing intervention when they were confident that the order was evidence based compared with if they were unsure the order was evidence based (n = 88, P < .001). DISCUSSION This nurse education strategy increased RNs' confidence in ability to explain the path from evidence to bedside nursing care by demonstrating how evidence-based clinical practice guidelines provide current evidence used to create standardized order sets. Although further evaluation of the intervention's effectiveness is needed, this educational intervention has the potential for generalization to different types of standardized order sets to increase nurse confidence in utilization of evidence-based practice.
Collapse
|
41
|
Thrombolysis Therapy in Specialized and Non-specialized Stroke Units. Arch Med Res 2018; 49:588-597. [DOI: 10.1016/j.arcmed.2019.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/02/2019] [Indexed: 12/11/2022]
|
42
|
Abstract
Pediatric stroke is relatively rare, with approximately 1000 childhood strokes in the United States per year. However, the occurrence of stroke in children leads to significant morbidity and mortality, warranting the development proven screening tools, protocols, and treatment options. Because significant delays in seeking medical attention can occur, time to recognition of pediatric stroke in the emergency department is uniquely challenging and critical. Once recognized, a trained multidisciplinary team with a multifaceted approach is needed to provide the best possible outcome for the patient. Key elements of the pediatric stroke protocol should include recognition tools, stroke alert mechanism, stroke order sets, timely imaging, laboratory evaluation, and treatment options. Substantial advancements have been made in the field of pediatric stroke protocols mainly due to formation of international consortiums and clinical trial. Despite significant progress, treatment options remain controversial.
Collapse
|
43
|
Hacein-Bey L, Heit JJ, Konstas AA. Neuro-Interventional Management of Acute Ischemic Stroke. Neuroimaging Clin N Am 2018; 28:625-638. [PMID: 30322598 DOI: 10.1016/j.nic.2018.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Restoration of cerebral blood flow is the most important step in preventing irreversible damage to hypoperfused brain cells after ischemic stroke from large-vessel occlusion. For those patients who do not respond to (or are not eligible for) intravenous thrombolysis, endovascular therapy has become standard of care. A shift is currently taking place from rigid time windows for intervention (time is brain) to physiology-driven paradigms that rely heavily on neuroimaging. At this time, one can reasonably anticipate that more patients will be treated, and that outcomes will keep improving. This article discusses in detail recent advances in endovascular stroke therapy.
Collapse
Affiliation(s)
- Lotfi Hacein-Bey
- Interventional Neuroradiology and Neuroradiology, Department of Medical Imaging, Sutter Health, Sacramento, CA 95815, USA; Radiology Department, University of California Davis Medical School of Medicine, 4860 Y Street, Sacramento, CA 95817, USA.
| | - Jeremy J Heit
- Division of Neuroimaging and Neurointervention, Stanford Healthcare, 300 Pasteur Drive, Grant S047, Stanford, CA 94305, USA
| | - Angelos A Konstas
- Interventional Neuroradiology and Neuroradiology, Department of Radiology, Huntington Memorial Hospital, 100 West California Boulevard, Pasadena, CA 91105, USA
| |
Collapse
|
44
|
Zhang X, Li Z, Zhao X, Xian Y, Liu L, Wang C, Wang C, Li H, Prvu Bettger J, Yang Q, Wang D, Jiang Y, Bao X, Yang X, Wang Y, Wang Y. Relationship between hospital performance measures and outcomes in patients with acute ischaemic stroke: a prospective cohort study. BMJ Open 2018; 8:e020467. [PMID: 30068610 PMCID: PMC6074631 DOI: 10.1136/bmjopen-2017-020467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Evidence-based performance measures have been increasingly used to evaluate hospital quality of stroke care, but their impact on stroke outcomes has not been verified. We aimed to evaluate the correlations between hospital performance measures and outcomes among patients with acute ischaemic stroke in a Chinese population. METHODS Data were derived from a prospective cohort, which included 120 hospitals participating in the China National Stroke Registry between September 2007 and August 2008. Adherence to nine evidence-based performance measures was examined, and the composite score of hospital performance measures was calculated. The primary stroke outcomes were hospital-level, 30-day and 1-year risk-standardised mortality (RSM). Associations of individual performance measures and composite score with stroke outcomes were assessed using Spearman correlation coefficients. RESULTS One hundred and twenty hospitals that recruited 12 027 patients with ischaemic stroke were included in our analysis. Among 12 027 patients, 61.59% were men, and the median age was 67 years. The overall composite score of performance measures was 63.3%. The correlation coefficients between individual performance measures ranged widely from 0.01 to 0.66. No association was observed between the composite score and 30-day RSM. The composite score was modestly associated with 1-year RSM (Spearman correlation coefficient, 0.34; p<0.05). The composite score explained only 2.53% and 10.18% of hospital-level variation in 30-day and 1-year RSM for patients with acute stroke. CONCLUSIONS Adherence to evidence-based performance measures for acute ischaemic stroke was suboptimal in China. There were various correlations among hospital individual performance measures. The hospital performance measures had no correlations with 30-day RSM rate and modest correlations with 1-year RSM rate.
Collapse
Affiliation(s)
- Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Ying Xian
- Department of Neurology, Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chunxue Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Janet Prvu Bettger
- Department of Neurology, Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
- Duke University School of Nursing, Duke University, Durham, North Carolina, USA
| | - Qing Yang
- Duke University School of Nursing, Duke University, Durham, North Carolina, USA
| | - David Wang
- INI Stroke Network, OSF Healthcare System, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolei Bao
- Statistical Analysis Office, Department of Information, General Hospital of Lanzhou Military Area Command, Lanzhou, Gansu, China
| | - Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| |
Collapse
|
45
|
Niemantsverdriet E, Ottoy J, Somers C, De Roeck E, Struyfs H, Soetewey F, Verhaeghe J, Van den Bossche T, Van Mossevelde S, Goeman J, De Deyn PP, Mariën P, Versijpt J, Sleegers K, Van Broeckhoven C, Wyffels L, Albert A, Ceyssens S, Stroobants S, Staelens S, Bjerke M, Engelborghs S. The Cerebrospinal Fluid Aβ1-42/Aβ1-40 Ratio Improves Concordance with Amyloid-PET for Diagnosing Alzheimer's Disease in a Clinical Setting. J Alzheimers Dis 2018; 60:561-576. [PMID: 28869470 PMCID: PMC5611891 DOI: 10.3233/jad-170327] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Evidence suggests that the concordance between amyloid-PET and cerebrospinal fluid (CSF) amyloid-β (Aβ) increases when the CSF Aβ1–42/Aβ1–40 ratio is used as compared to CSF Aβ1–42 levels alone. Objective: In order to test this hypothesis, we set up a prospective longitudinal study comparing the concordance between different amyloid biomarkers for Alzheimer’s disease (AD) in a clinical setting. Methods: Seventy-eight subjects (AD dementia (n = 17), mild cognitive impairment (MCI, n = 48), and cognitively healthy controls (n = 13)) underwent a [18F]Florbetapir ([18F]AV45) PET scan, [18F]FDG PET scan, MRI scan, and an extensive neuropsychological examination. In a large subset (n = 67), a lumbar puncture was performed and AD biomarkers were analyzed (Aβ1–42, Aβ1–40, T-tau, P-tau181). Results: We detected an increased concordance in the visual and quantitative (standardized uptake value ratio (SUVR) and total volume of distribution (VT)) [18F]AV45 PET measures when the CSF Aβ1–42/Aβ1–40 was applied compared to Aβ1–42 alone. CSF biomarkers were stronger associated to [18F]AV45 PET for SUVR values when considering the total brain white matter as reference region instead of cerebellar grey matter Conclusions: The concordance between CSF Aβ and [18F]AV45 PET increases when the CSF Aβ1–42/Aβ1–40 ratio is applied. This finding is of most importance for the biomarker-based diagnosis of AD as well as for selection of subjects for clinical trials with potential disease-modifying therapies for AD.
Collapse
Affiliation(s)
- Ellis Niemantsverdriet
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, UAntwerp, Antwerp, Belgium
| | - Julie Ottoy
- Molecular Imaging Center Antwerp (MICA), UAntwerp, Antwerp, Belgium
| | - Charisse Somers
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, UAntwerp, Antwerp, Belgium
| | - Ellen De Roeck
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, UAntwerp, Antwerp, Belgium.,Faculty of Psychology and Educational Sciences, Vrije Universiteit Brussels, Brussels, Belgium
| | - Hanne Struyfs
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, UAntwerp, Antwerp, Belgium
| | - Femke Soetewey
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, UAntwerp, Antwerp, Belgium
| | - Jeroen Verhaeghe
- Molecular Imaging Center Antwerp (MICA), UAntwerp, Antwerp, Belgium
| | - Tobi Van den Bossche
- VIB-UAntwerp Center for Molecular Neurology, Antwerp, Belgium.,Laboratory of Neurogenetics, Institute Born-Bunge, UAntwerp, Antwerp, Belgium.,Department of Neurology and Memory Clinic, Hospital Network Antwerp (ZNA) Middelheim and Hoge Beuken, Antwerp, Belgium
| | - Sara Van Mossevelde
- VIB-UAntwerp Center for Molecular Neurology, Antwerp, Belgium.,Laboratory of Neurogenetics, Institute Born-Bunge, UAntwerp, Antwerp, Belgium.,Department of Neurology and Memory Clinic, Hospital Network Antwerp (ZNA) Middelheim and Hoge Beuken, Antwerp, Belgium
| | - Johan Goeman
- Department of Neurology and Memory Clinic, Hospital Network Antwerp (ZNA) Middelheim and Hoge Beuken, Antwerp, Belgium
| | - Peter Paul De Deyn
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, UAntwerp, Antwerp, Belgium.,Department of Neurology and Memory Clinic, Hospital Network Antwerp (ZNA) Middelheim and Hoge Beuken, Antwerp, Belgium
| | - Peter Mariën
- Department of Neurology and Memory Clinic, Hospital Network Antwerp (ZNA) Middelheim and Hoge Beuken, Antwerp, Belgium.,Clinical and Experimental Neurolinguistics, CLIN, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jan Versijpt
- Vrije Universiteit Brussel(VUB), University Hospital Brussels (UZ Brussel), Department of Neurology, Brussels, Belgium
| | - Kristel Sleegers
- VIB-UAntwerp Center for Molecular Neurology, Antwerp, Belgium.,Laboratory of Neurogenetics, Institute Born-Bunge, UAntwerp, Antwerp, Belgium
| | - Christine Van Broeckhoven
- VIB-UAntwerp Center for Molecular Neurology, Antwerp, Belgium.,Laboratory of Neurogenetics, Institute Born-Bunge, UAntwerp, Antwerp, Belgium
| | - Leonie Wyffels
- Molecular Imaging Center Antwerp (MICA), UAntwerp, Antwerp, Belgium.,Departmentof Nuclear Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Adrien Albert
- Departmentof Nuclear Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Sarah Ceyssens
- Departmentof Nuclear Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Sigrid Stroobants
- Molecular Imaging Center Antwerp (MICA), UAntwerp, Antwerp, Belgium.,Departmentof Nuclear Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Steven Staelens
- Molecular Imaging Center Antwerp (MICA), UAntwerp, Antwerp, Belgium
| | - Maria Bjerke
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, UAntwerp, Antwerp, Belgium
| | - Sebastiaan Engelborghs
- Reference Center for Biological Markers of Dementia (BIODEM), Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, UAntwerp, Antwerp, Belgium.,Department of Neurology and Memory Clinic, Hospital Network Antwerp (ZNA) Middelheim and Hoge Beuken, Antwerp, Belgium
| |
Collapse
|
46
|
Mullen MT, Pajerowski W, Messé SR, Mechem CC, Jia J, Abboud M, David G, Carr BG, Band R. Geographic Modeling to Quantify the Impact of Primary and Comprehensive Stroke Center Destination Policies. Stroke 2018; 49:1021-1023. [PMID: 29491140 DOI: 10.1161/strokeaha.118.020691] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/08/2018] [Accepted: 01/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated the impact of a primary stroke center (PSC) destination policy in a major metropolitan city and used geographic modeling to evaluate expected changes for a comprehensive stroke center policy. METHODS We identified suspected stroke emergency medical services encounters from 1/1/2004 to 12/31/2013 in Philadelphia, PA. Transport times were compared before and after initiation of a PSC destination policy on 10/3/2011. Geographic modeling estimated the impact of bypassing the closest hospital for the closest PSC and for the closest comprehensive stroke center. RESULTS There were 2 326 943 emergency medical services runs during the study period, of which 15 099 had a provider diagnosis of stroke. Bypassing the closest hospital for a PSC was common before the official policy and increased steadily over time. Geographic modeling suggested that bypassing the closest hospital in favor of the closest PSC adds a median of 3.1 minutes to transport time. Bypassing to the closest comprehensive stroke center would add a median of 8.3 minutes. CONCLUSIONS Within a large metropolitan area, the time cost of routing patients preferentially to PSCs and comprehensive stroke centers is low.
Collapse
Affiliation(s)
- Michael T Mullen
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.).
| | - William Pajerowski
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Steven R Messé
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - C Crawford Mechem
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Judy Jia
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Michael Abboud
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Guy David
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Brendan G Carr
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Roger Band
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| |
Collapse
|
47
|
Miller EC. Response by Miller to Letter Regarding Article, "Incorporating Nonphysician Stroke Specialists into the Stroke Team". Stroke 2018; 49:e33. [PMID: 29284728 PMCID: PMC5780251 DOI: 10.1161/strokeaha.117.020000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eliza C. Miller
- Department of Neurology, Columbia University Medical Center, Address: 710 West 168 Street, 6 floor, New York, NY 10032, 212-305-8389
| |
Collapse
|
48
|
Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: dawn of a new era? BMC Neurol 2018; 18:8. [PMID: 29338750 PMCID: PMC5771207 DOI: 10.1186/s12883-017-1007-y] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
Collapse
Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
| |
Collapse
|
49
|
Kamal N, Smith EE, Jeerakathil T, Hill MD. Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review. Int J Stroke 2017; 13:268-276. [PMID: 29140185 DOI: 10.1177/1747493017743060] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.
Collapse
Affiliation(s)
- Noreen Kamal
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Michael D Hill
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada.,4 Department of Medicine, University of Calgary, Calgary, Canada.,5 Department of Radiology, University of Calgary, Calgary, Canada
| |
Collapse
|
50
|
Alves MB, Silva GS, Miranda RCA, Massaud RM, Vaccari AMH, Cendoroglo-Neto M, Diccini S. Patterns of Care and Temporal Trends in Ischemic Stroke Management: A Brazilian Perspective. J Stroke Cerebrovasc Dis 2017. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|