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Wechsler PM, Pandya A, Parikh NS, Razzak JA, White H, Navi BB, Kamel H, Liberman AL. Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke. J Am Heart Assoc 2024; 13:e032808. [PMID: 38533952 DOI: 10.1161/jaha.123.032808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. METHODS AND RESULTS We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case. CONCLUSIONS Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.
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Affiliation(s)
- Paul M Wechsler
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Ankur Pandya
- Department of Health Policy and Management Harvard T.H. Chan School of Public Health Boston MA
| | - Neal S Parikh
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Junaid A Razzak
- Department of Emergency Medicine Weill Cornell Medicine New York NY
| | - Halina White
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Babak B Navi
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Ava L Liberman
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
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Chen PL, Wu YH, Huang JA, Liao NC, Chao YT, Wang CS. Dual antiplatelet therapy is associated with favorable outcome in acute minor stroke with an onset-to-door time beyond 24 h. J Formos Med Assoc 2024; 123:501-509. [PMID: 37838539 DOI: 10.1016/j.jfma.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/05/2023] [Accepted: 09/26/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND/PURPOSE In patients with noncardioembolic acute minor ischemic stroke (AMIS), dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel within 24 h after stroke onset was more effective than aspirin alone. This study investigated the efficacy and safety of DAPT in AMIS patients with an onset-to-door time (OTDT) of more than 24 h. METHODS This was a retrospective analysis of a prospective stroke registry from 2015 to 2021. Patients with AMIS and an OTDT within seven days were classified into the Early (≤24 h) and Late groups (>24 h) according to the time of antiplatelet administration after stroke onset. RESULTS In total, 691 patients were identified. Of these, 446 (64.5%) and 245 (35.5%) patients were classified into the Early and Late groups, respectively. The rates of recurrent infarction and symptomatic intracranial hemorrhage at 90 days were similar between the single antiplatelet therapy (SAPT) and DAPT subgroups in both the Early and Late groups. More patients in the DAPT subgroup had a favorable outcome (modified Rankin scale of 0-1) at 90 days in both Early (84.2% versus 75.0%, p = 0.016) and Late (88.2% versus 76.9%, p = 0.040) groups. DAPT was independently associated with a favorable outcome in both the Early (odds ratio, 1.95; 95% CI, 1.15-3.32; p = 0.013) and Late (odds ratio, 2.72; 95% CI, 1.14-6.48; p = 0.024) groups. CONCLUSION In patients with AMIS and an OTDT of more than 24 h, DAPT was associated with a favorable outcome at 90 days.
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Affiliation(s)
- Po-Lin Chen
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yu-Hsuan Wu
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan
| | - Jin-An Huang
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Department of Health Business Administration, Hungkuang University, Taichung, Taiwan
| | - Nien-Chen Liao
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Ting Chao
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan; Center of Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chi-Sheng Wang
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan.
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Bala F, Almekhlafi M, Singh N, Alhabli I, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Appireddy R, Moreau F, Phillips S, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar J, Williams H, Field TS, Manosalva A, Siddiqui M, Zafar A, Imoukhoude O, Hunter G, Benali F, Horn M, Hill MD, Shamy M, Sajobi TT, Buck BH, Swartz RH, Menon BK, Poppe AY. Safety and efficacy of tenecteplase versus alteplase in stroke patients with carotid tandem lesions: Results from the AcT trial. Int J Stroke 2024; 19:322-330. [PMID: 37731173 PMCID: PMC10903116 DOI: 10.1177/17474930231205208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Carotid tandem lesions ((TL) ⩾70% stenosis or occlusion) account for 15-20% of acute stroke with large vessel occlusion. AIMS We investigated the safety and efficacy of intravenous tenecteplase (0.25 mg/kg) versus intravenous alteplase (0.9 mg/kg) in patients with carotid TL. METHODS This is a substudy of the alteplase compared with the tenecteplase trial. Patients with ⩾70% stenosis of the extracranial internal carotid artery (ICA) and concomitant occlusion of the intracranial ICA, M1 or M2 segments of the middle cerebral artery on baseline computed tomography angiography (CTA) were included. Primary outcome was 90-day-modified Rankin Scale (mRS) 0-1. Secondary outcomes were mRS 0-2, mortality, and symptomatic ICH (sICH). Angiographic outcomes were successful recanalization (revised Arterial Occlusive Lesion (rAOL) 2b-3) on first and successful reperfusion (eTICI 2b-3) on final angiographic acquisitions. Multivariable mixed-effects logistic regression was performed. RESULTS Among 1577 alteplase versus tenecteplase randomized controlled trial (AcT) patients, 128 (18.8%) had carotid TL. Of these, 93 (72.7%) underwent intravenous thrombolysis plus endovascular thrombectomy (IVT + EVT), while 35 (27.3%) were treated with IVT alone. In the IVT + EVT group, tenecteplase was associated with higher odds of 90-day-mRS 0-1 (46.0% vs. 32.6%, adjusted OR (aOR) 3.21; 95% CI = 1.06-9.71) compared with alteplase. No statistically significant differences in rates of mRS 0-2 (aOR 1.53; 95% CI = 0.51-4.55), initial rAOL 2b-3 (16.3% vs. 28.6%), final eTICI 2b-3 (83.7% vs. 85.7%), and mortality (18.0% vs. 16.3%) were found. SICH only occurred in one patient. There were no differences in outcomes between thrombolytic agents in the IVT-only group. CONCLUSION In patients with carotid TL treated with EVT, intravenous tenecteplase may be associated with similar or better clinical outcomes, similar angiographic reperfusion rates, and safety outcomes as compared with alteplase.
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Affiliation(s)
- Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Yan Deschaintre
- Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | | | | | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - George Medvedev
- The University of British Columbia, Vancouver, BC, Canada
- Fraser Health Authority, New Westminster, BC, Canada
| | - Jennifer Mandzia
- London Health Sciences Centre, Western University, London, ON, Canada
| | - Aleksandra Pikula
- Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Jay Shankar
- University of Manitoba, Winnipeg, MB, Canada
| | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, The University of British Columbia, Vancouver, BC, Canada
| | | | | | - Atif Zafar
- St. Michael’s Hospital, Toronto, ON, Canada
| | | | - Gary Hunter
- University of Saskatchewan, Saskatoon, SK, Canada
| | - Faysal Benali
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Michel Shamy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tolulope T Sajobi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Richard H Swartz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Alexandre Y Poppe
- Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
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4
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Sajobi TT, Arimoro OI, Ademola A, Singh N, Bala F, Almekhlafi MA, Deschaintre Y, Coutts SB, Thirunavukkarasu S, Khosravani H, Appireddy R, Moreau F, Gubitz GJ, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JS, Williams H, Field TS, Manosalva A, Siddiqui M, Zafar A, Imoukhuede O, Hunter G, Demchuk AM, Mishra SM, Gioia LC, Jalini S, Cayer C, Phillips SJ, Elamin E, Shoamanesh A, Subramaniam S, Kate MP, Jacquin G, Camden MC, Benali F, Alhabli I, Horn M, Stotts G, Hill MD, Gladstone DJ, Poppe AY, Sehgal A, Zhang Q, Lethebe B, Doram C, Shamy M, Kenney C, Buck BH, Swartz RH, Menon BK. Quality of Life After Intravenous Thrombolysis for Acute Ischemic Stroke: Results From the AcT Randomized Controlled Trial. Stroke 2024; 55:524-531. [PMID: 38275116 DOI: 10.1161/strokeaha.123.044690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/30/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Recent evidence from thrombolysis trials indicates the noninferiority of intravenous tenecteplase to intravenous alteplase with respect to good functional outcomes in patients with acute stroke. We examined whether the health-related quality of life (HRQOL) of patients with acute stroke differs by the type of thrombolysis treatment received. In addition, we examined the association between the modified Rankin Scale score 0 to 1 and HRQOL and patient-reported return to prebaseline stroke functioning at 90 days. METHODS Data were from all patients included in the AcT trial (Alteplase Compared to Tenecteplase), a pragmatic, registry-linked randomized trial comparing tenecteplase with alteplase. HRQOL at 90-day post-randomization was assessed using the 5-item EuroQOL questionnaire (EQ5D), which consists of 5 items and a visual analog scale (VAS). EQ5D index values were estimated from the EQ5D items using the time tradeoff approach based on Canadian norms. Tobit regression and quantile regression models were used to evaluate the adjusted effect of tenecteplase versus alteplase treatment on the EQ5D index values and VAS score, respectively. The association between return to prebaseline stroke functioning and the modified Rankin Scale score 0 to 1 and HRQOL was quantified using correlation coefficient (r) with 95% CI. RESULTS Of 1577 included in the intention-to-treat analysis patients, 1503 (95.3%) had complete data on the EQ5D. Of this, 769 (51.2%) were administered tenecteplase and 717 (47.7%) were female. The mean EQ5D VAS score and EQ5D index values were not significantly higher for those who received intravenous tenecteplase compared with those who received intravenous alteplase (P=0.10). Older age (P<0.01), more severe stroke assessed using the National Institutes of Health Stroke Scale (P<0.01), and longer stroke onset-to-needle time (P=0.004) were associated with lower EQ5D index and VAS scores. There was a strong association (r, 0.85 [95% CI, 0.81-0.89]) between patient-reported return to prebaseline functioning and modified Rankin Scale score 0 to 1 Similarly, there was a moderate association between return to prebaseline functioning and EQ5D index (r, 0.45 [95% CI, 0.40-0.49]) and EQ5D VAS scores (r, 0.42 [95% CI, 0.37-0.46]). CONCLUSIONS Although there is no differential effect of thrombolysis type on patient-reported global HRQOL and EQ 5D-5L index values in patients with acute stroke, sex- and age-related differences in HRQOL were noted in this study. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249.
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Affiliation(s)
- Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Olayinka I Arimoro
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
| | - Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Nishita Singh
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
- University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
| | - Fouzi Bala
- Department of Diagnostic and Interventional Neuroradiology, Tours University Hospital, France (F. Bala)
| | - Mohammed A Almekhlafi
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - Yan Deschaintre
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Shelagh B Coutts
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - Sibi Thirunavukkarasu
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Houman Khosravani
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada (R.A., S.J.)
| | | | - Gordon J Gubitz
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre, McMaster University, Hamilton, ON, Canada (L.C.)
| | - Dar Dowlatshahi
- Department of Medicine, Ottawa Heart Research Institute, University of Ottawa, ON, Canada (D.D., M. Shamy)
| | - George Medvedev
- Department of Medicine, University of British Columbia & Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
- University of British Columbia, Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | | | - Jai Shiva Shankar
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
- University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
| | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, The University of British Columbia, Vancouver, Canada (T.S.F.)
| | | | | | - Atif Zafar
- St. Michael's Hospital, Toronto, ON, Canada (A.Z.)
| | | | - Gary Hunter
- University of Saskatchewan, Saskatoon, Canada (G.H.)
| | - Andrew M Demchuk
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Sachin M Mishra
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Laura C Gioia
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Shirin Jalini
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada (R.A., S.J.)
| | - Caroline Cayer
- Centre de recherche du CHUS, Centre intégré Universitaire de Santé et des Services Sociaux de l'Estrie, Sherbrooke, QC, Canada (C.C.)
| | - Stephen J Phillips
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | | | - Ashkan Shoamanesh
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | - Suresh Subramaniam
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Mahesh P Kate
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Gregory Jacquin
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Marie-Christine Camden
- Enfant-Jésus Hospital, Centre Hospitalier Universitaire de Québec, Laval University, Canada (M.-C.C.)
| | - Faysal Benali
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Grant Stotts
- Department of Medicine, University of British Columbia & Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
- University of British Columbia, Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - David J Gladstone
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Alexandre Y Poppe
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Arshia Sehgal
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Qiao Zhang
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brendan Lethebe
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
| | - Craig Doram
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Michel Shamy
- Department of Medicine, Ottawa Heart Research Institute, University of Ottawa, ON, Canada (D.D., M. Shamy)
| | - Carol Kenney
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Bijoy K Menon
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
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5
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Luo W, Xu Y, Liu C, Zhang H. The Influence of the Novel Computer-Aided Triage System Based on Artificial Intelligence on Endovascular Therapy in Patients with Large Vascular Occlusions: A Meta-Analysis. World Neurosurg 2024; 182:200-207.e2. [PMID: 38048961 DOI: 10.1016/j.wneu.2023.11.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 11/28/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE The integration of artificial intelligence (AI) with modern healthcare has become increasingly prominent. The purpose of this study is to explore the impact of the novel computer-aided triage system based on artificial intelligence (AI-CTS) on endovascular therapy (EVT) in patients with large vascular occlusions (LVO). This study marks the first comprehensive systematic review and meta-analysis on the subject. METHODS A comprehensive study was performed on PubMed, Medline, Embase, Cochrane Library, and Chinese databases from their establishment to September 2023, in accordance with PRISMA recommendations. RevMan 5.4 software was used for summative analysis. The outcomes included door-to-groin (DTG) time, time from CT scan initiation to EVT, time from CT scan to reperfusion, and 90-day modified Rankin Scale (mRS). RESULTS A total of 7 studies involving 752 participants were included in the meta-analysis. The pooled results demonstrated that patients in the post-AI group had less time of DTG [SMD, 0.54; 95% CI, 0.40-0.69; P < 0.00001] and CT scan to EVT [SMD, 0.57; 95% CI, 0.42-0.73; P < 0.00001], as well as less time of CTA to recanalization [SMD, 0.63; 95% CI, 0.36-0.90; P < 0.00001]. There was no significant difference between the 2 groups in terms of the mRS at 90 days [OR, 0.66; 95% CI, 0.43-1.01; P = 0.06]. CONCLUSIONS The combination of AI-CTS and EVT has improved the therapy process for LVO patients. However, the improvement in mRS at 90 days was not significant; further research is warranted.
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Affiliation(s)
- Wenmiao Luo
- Department of Neurosurgery, Susong Hospital, Xiamen, China; Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yonggang Xu
- Department of Neurosurgery, Susong Hospital, Xiamen, China
| | - Chao Liu
- Department of Neurosurgery, Susong Hospital, Xiamen, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Lee P, Dhillon G, Pourafkari M, DaBreo D, Jaff Z, Appireddy R, Jin A, Boissé Lomax L, Durafourt BA, Boyd JG, Nasirzadeh AR, Tampieri D, Jalini S. Non-ECG-gated cardiac CT angiography in acute stroke is feasible and detects sources of embolism. Int J Stroke 2024; 19:189-198. [PMID: 37515467 PMCID: PMC10811964 DOI: 10.1177/17474930231193335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/15/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND A significant portion of cryptogenic stroke is hypothesized to be secondary to cardiac embolism. However, transthoracic echocardiogram is usually delayed after stroke, and more detailed cardiac imaging is not routinely done. AIMS This study aimed to determine whether non-ECG-gated cardiac CT angiography (cCTA) during hyperacute stroke would provide diagnostic quality images and act as an adjunct modality of cardiac imaging to detect sources of emboli. METHODS In this single-center prospective cohort study, modified Code Stroke imaging was implemented with a 64-slice CT scanner, where the longitudinal axis of CT angiography was extended from the carina to the diaphragm. The primary outcomes of image quality, recruitment feasibility, impact on hyperacute time metrics, and additional radiation dose were assessed. Secondary outcomes consisted of detection of high-risk cardiac sources of embolism, mediastinal or lung pathology, and impact on etiologic classification. RESULTS One hundred and twenty eligible patients were enrolled, of which 105 (87.5%) had good/moderate quality images for motion artifact and 119 (99.2%) for contrast opacification. Total CT time, door-to-needle time, and door-to-groin puncture time were unchanged with the addition of cCTA. Eighty-nine patients received a final diagnosis of ischemic stroke, of which 12/89 (13.5%) had high-risk cardioembolic findings on cCTA. Incidental findings, such as pulmonary embolism (PE) (7/89, 7.9%) and malignancy (6/89, 6.7%), were observed. cCTA led to changes in management for 19/120 (15.8%) of all patients, and reclassification of stroke etiology for 8/89 (9%) of patients. CONCLUSIONS Non-ECG-gated cCTA can be feasibly incorporated into Code Stroke and provide diagnostic quality images without delays in hyperacute time metrics. It can detect high-risk cardiac sources, and other findings impacting patient care. This may help reclassify a subset of cryptogenic stroke cases and improve secondary prevention.
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Affiliation(s)
- Peter Lee
- School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Gurmohan Dhillon
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Marina Pourafkari
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Dominique DaBreo
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Zardasht Jaff
- Division of Cardiology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Albert Jin
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Lysa Boissé Lomax
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Bryce A Durafourt
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - John Gordon Boyd
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Amir Reza Nasirzadeh
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Donatella Tampieri
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Shirin Jalini
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
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7
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Nakajima M, Oki K, Omori T, Koyama T, Oyama N, Koga M, Hayase M, Ohta T, Matsumoto K, Iguchi Y, Fujimoto S, Kakuda W, Ogasawara K. A nationwide survey for the provision of acute stroke rehabilitation in Japan: initial dose and weekend/holiday rehabilitation. J Stroke Cerebrovasc Dis 2024; 33:107550. [PMID: 38142566 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 12/26/2023] Open
Abstract
OBJECTIVES The early initiation of acute stroke rehabilitation with a sufficient dose, including at weekends/holidays, is important to improve functional outcome. We investigated the status of acute stroke rehabilitation in Japan by using a nationwide survey. MATERIALS AND METHODS Facility features, rehabilitation dose provided in the first week in each stroke subtype, and weekend/holiday rehabilitation were investigated by using the results of a web-based survey among primary stroke centers. The relationships between facility features and weekend/holiday rehabilitation were also analyzed. RESULTS A total of 639 stroke centers (66.6%) completed the questionnaire. The overall median dose was 2.0 (interquartile range, 1.7-3.0) U/day (1U = 20 min). After 7 days, the overall median dose increased to 4.0 (2.0-5.4) U/day. Almost 50% of facilities replied that they could not provide a sufficient dose of rehabilitation; the main reason was a lack of therapists (31%). For rehabilitation on long weekends, no rehabilitation was provided on 3-day weekends in 19% of facilities, and in 5% of facilities on ≥4-day weekends. The mean number of therapists was almost 50% less in the facilities that provided no rehabilitation on 3-day weekends compared to those that provided daily rehabilitation (19.4 vs. 36.2 therapists, respectively, p < 0.001). CONCLUSIONS In this survey, the provision of acute stroke rehabilitation, including non-working days, was clarified. According to the results, prospective interventional or observational studies are needed to design more effective rehabilitation programs to improve outcome. In particular, it is important to determine the optimal dose and intensity of acute stroke rehabilitation.
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Affiliation(s)
- Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Koichi Oki
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
| | - Tomohiro Omori
- Division of Rehabilitation Medicine, International University of Health and Welfare Narita Hospital, Japan.
| | - Tetsuo Koyama
- Department of Rehabilitation Medicine, Nishinomiya Kyoritsu Neurosurgical Hospital, Hyogo, Japan.
| | - Naoki Oyama
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan.
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Makoto Hayase
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Hyogo, Japan.
| | - Koichi Matsumoto
- Division of Rehabilitation Medicine, General Tokyo Hospital, Japan.
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan.
| | - Wataru Kakuda
- Rehabilitation Medicine, International University of Health and Welfare Narita Hospital, Chiba, Japan.
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan.
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8
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McGlinchey MP, Faulkner-Gurstein R, Sackley CM, McKevitt C. Factors guiding therapist decision making in the rehabilitation of physical function after severely disabling stroke - an ethnographic study. Disabil Rehabil 2024; 46:672-684. [PMID: 36734838 DOI: 10.1080/09638288.2023.2172463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Whilst strong evidence supports rehabilitation to improve outcomes post-stroke, there is limited evidence to guide rehabilitation in the most severely disabled group. In an era of evidence-based practice, the aim of the study was to understand what factors guide physiotherapists (PTs) and occupational therapists (OTs) to select particular interventions in the rehabilitation of physical function after severely disabling stroke. MATERIAL AND METHODS An ethnographic study was undertaken over an 18-month period involving five London, UK stroke services. Seventy-nine primary participants (30 PTs, 22 OTs, and 27 stroke survivors) were recruited to the study. Over 400 h of observation, 52 semi-structured interviews were conducted. Study data were analysed through thematic analysis. RESULTS Key factors guiding therapist decision making were clinical expertise, professional role, stroke survivors' clinical presentation, therapist perspectives about stroke recovery, and clinical guidelines. Research evidence, stroke survivors' treatment preferences, organisational type, and pathway design were less influential factors. Therapy practice did not always address the physical needs of severely disabled stroke survivors. CONCLUSIONS Multiple factors guided therapist decision making after severely disabling stroke. Alternative ways of therapist working should be considered to address the physical needs of severely disabled stroke survivors more fully.Implications for rehabilitationMultiple factors guide therapist decision making after severely disabling stroke, some of which result in the use of interventions that do not fully address stroke survivors' clinical needs.Therapists should critically reflect upon their personal beliefs and attitudes about severely disabling stroke to reduce potential sources of bias on decision making.Therapists should consider the timing and intensity of therapy delivery as well as their treatment approach to optimise outcomes after severely disabling stroke.
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Affiliation(s)
- Mark P McGlinchey
- Neurorehabilitation Service, Integrated Local Services, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rachel Faulkner-Gurstein
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Catherine M Sackley
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Christopher McKevitt
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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9
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Du Y, Xue N, Liang J, Deng Y. Knowledge, Attitude, Skill, and Practice of Emergency Nurses Regarding the Early Management of Patients With Acute Ischemic Stroke in Beijing. J Emerg Nurs 2024; 50:95-105. [PMID: 37831051 DOI: 10.1016/j.jen.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/20/2023] [Accepted: 08/24/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Emergency nurses play an important role in the early management of acute ischemic stroke. The purpose of this study was to evaluate the knowledge, attitudes, skills, and practice of emergency nurses in Beijing regarding the early management of acute ischemic stroke. METHODS This cross-sectional study enrolled emergency nurses in 26 hospitals in Beijing between August and November 2022. Correlations among knowledge, attitude, and skill/practice were evaluated by Pearson correlation analysis. RESULTS This study included 564 nurses (82.98% were female). The average knowledge, attitude, and skill/practice scores were 15.48 ± 2.39 (possible range, 0-22), 39.84 ± 4.89 (possible range, 9-45), and 40.59 ± 5.21 (possible range, 13-52). The knowledge was significantly positively correlated with attitude and skill/practice (all P< .001). There was also a positive correlation between attitude and skill/practice (P< .001). DISCUSSION These findings may facilitate the implementation of education/training programs to improve the early management of acute ischemic stroke by nurses in emergency departments.
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10
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Heran M, Lindsay P, Gubitz G, Yu A, Ganesh A, Lund R, Arsenault S, Bickford D, Derbyshire D, Doucette S, Ghrooda E, Harris D, Kanya-Forstner N, Kaplovitch E, Liederman Z, Martiniuk S, McClelland M, Milot G, Minuk J, Otto E, Perry J, Schlamp R, Tampieri D, van Adel B, Volders D, Whelan R, Yip S, Foley N, Smith EE, Dowlatshahi D, Mountain A, Hill MD, Martin C, Shamy M. Canadian Stroke Best Practice Recommendations: Acute Stroke Management, 7 th Edition Practice Guidelines Update, 2022. Can J Neurol Sci 2024; 51:1-31. [PMID: 36529857 DOI: 10.1017/cjn.2022.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention, the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7th edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.
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Affiliation(s)
- Manraj Heran
- Division of Neuroradiology, University of British Columbia, Vancouver, Canada
| | | | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Stroke Program, Halifax, Canada
- Division of Neurology, Dalhousie University, Halifax, Canada
| | - Amy Yu
- Division of Neurology, Department of Medicine, and Regional Stroke Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Aravind Ganesh
- University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences and Community Health Sciences, Calgary, Canada
| | - Rebecca Lund
- Heart and Stroke Foundation of Canada, Toronto, Canada
| | - Sacha Arsenault
- Stroke Services BC, Provincial Health Systems Authority, Vancouver, Canada
| | - Doug Bickford
- London Health Sciences Centre, London, Canada (Previous Appointment at Time of Participation)
| | - Donnita Derbyshire
- Saskatchewan College of Paramedics, Paramedic Practice Committee, Saskatoon, Canada
| | - Shannon Doucette
- Enhanced District Stroke Program, Royal Victoria Regional Health Centre, Barrie, Canada (Previous Appointment at Time of Participation)
| | - Esseddeeg Ghrooda
- Section of Neurology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Devin Harris
- Quality and Patient Safety Division, Interior Health, Kelowna, Canada
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Nick Kanya-Forstner
- Northern Ontario School of Medicine, Sudbury, Canada
- Timmins & District Hospital, Timmins, Canada
| | - Eric Kaplovitch
- Faculty of Medicine, University of Toronto, Toronto, Canada
- University Health Network, Department of Medicine (Hematology), Toronto, Canada
| | - Zachary Liederman
- Faculty of Medicine, University of Toronto, Toronto, Canada
- University Health Network, Department of Medicine (Hematology), Toronto, Canada
| | - Shauna Martiniuk
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Schwartz-Reisman Emergency Centre, Mount Sinai Hospital, Toronto, Canada
| | | | - Genevieve Milot
- Department of Surgery, Laval University, Quebec City, Canada
| | - Jeffrey Minuk
- Division of Neurology, The Integrated Health and Social Services, University Network for West Central Montreal, Montreal, Canada
| | - Erica Otto
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Rob Schlamp
- British Columbia Emergency Health Services, Vancouver, Canada
| | | | - Brian van Adel
- Department of Neurointerventional Surgery, McMaster University, Hamilton, Canada
| | - David Volders
- Department of Radiology, Dalhousie University, Halifax, Canada
| | - Ruth Whelan
- Royal University Hospital Stroke Program, Saskatoon, Canada
| | - Samuel Yip
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Norine Foley
- WorkHORSE Consulting Group, Epidemiology, London, Canada
| | - Eric E Smith
- University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences and Community Health Sciences, Calgary, Canada
| | - Dar Dowlatshahi
- Department of Neurology, University of Ottawa, Ottawa, Canada
| | - Anita Mountain
- Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Michael D Hill
- University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences and Community Health Sciences, Calgary, Canada
| | - Chelsy Martin
- Heart and Stroke Foundation of Canada, Toronto, Canada
| | - Michel Shamy
- Department of Neurology, University of Ottawa, Ottawa, Canada
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Abstract
CTP is an important diagnostic tool in managing patients with acute ischemic stroke, but challenges persist in the agreement of stroke lesion volumes and ischemic core-penumbra mismatch profiles determined with different CTP post-processing software. We investigated a systematic method of calibrating CTP stroke lesion thresholds between deconvolution algorithms using a digital perfusion phantom to improve inter-software agreement of mismatch profiles. Deconvolution-estimated cerebral blood flow (CBF) and Tmax was compared to the phantom ground truth via linear regression for one model-independent and two model-based deconvolution algorithms. Using the clinical standard of model-independent CBF < 30% and Tmax > 6 s as reference thresholds for ischemic core and penumbra, respectively, we determined that model-based CBF < 15% and Tmax > 6 s were the corresponding calibrated thresholds after accounting for quantitative differences revealed at linear regression. Calibrated thresholds were then validated in 63 patients with large vessel stroke by evaluating agreement (concordance and Cohen's kappa, κ) between the two model-based and model-independent deconvolution methods in determining mismatch profiles used for clinical decision-making. Both model-based deconvolution methods achieved 95% concordance with model-independent assessment and Cohen's kappa was excellent (κ = 0.87; 95% confidence interval [CI] 0.72-1.00 and κ = 0.86; 95% CI 0.70-1.00). Our systematic method of calibrating CTP stroke lesion thresholds may help harmonize mismatch profiles determined by different software.
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Affiliation(s)
- Kevin J Chung
- Department of Medical Biophysics, University of Western Ontario, London, ON, Canada
- Robarts Research Institute, University of Western Ontario, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Danny De Sarno
- Robarts Research Institute, University of Western Ontario, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, University of Western Ontario, London, ON, Canada.
- Robarts Research Institute, University of Western Ontario, London, ON, Canada.
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.
- Department of Medical Imaging, University of Western Ontario, London, ON, Canada.
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Campbell A, Gustafsson L, Grimley R, Gullo H, Rosbergen I, Summers M. Mapping the trajectory of acute mild-stroke cognitive recovery using serial computerised cognitive assessment. BRAIN IMPAIR 2023; 24:629-648. [PMID: 38167363 DOI: 10.1017/brimp.2022.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Cognitive impairment is common post-stroke. There is a need to understand patterns of early cognitive recovery post-stroke to guide both clinical and research practice. The aim of the study was to map the trajectory of cognitive recovery during the first week to 90-days post-stroke using serial computerised assessment. METHOD An observational cohort study recruited consecutive stroke patients admitted to a stroke unit within 48 hours of onset. Cognitive function was assessed using the computerised Cambridge Neuropsychological Test Automated Battery (CANTAB) daily for seven days, then 14, 30 and 90 days post-stroke. The CANTAB measured visual episodic memory and learning, information processing speed, visuo-spatial working memory, complex sustained attention and mental flexibility. Repeated measures MANOVA/ANOVA with Least Squares Difference post-hoc analyses were performed to ascertain significant change over time. RESULT Forty-eight participants, mean age 73, primarily mild, ischaemic stroke, completed all assessment timepoints. There was a trajectory of early, global cognitive improvement, indicative of a post-stroke delirium, that largely stabilised between 6 and 14-days post-stroke. Change over time was examined within each cognitive test, with one measure stabilising by day 6 (Reaction Time) and others detecting improving performances up to 14 days post-stroke. CONCLUSIONS Serial, computerised cognitive assessment can effectively map post-stroke cognitive recovery and revealed an early phase of global improvement over 14 days that is evidence for an acute post-stroke delirium. Resolution of post-stroke delirium in the second week following mild stroke indicates more extensive neuropsychological testing may be undertaken earlier than previously thought.
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Affiliation(s)
- Alana Campbell
- The University of Queensland (School of Health and Rehabilitation Sciences), Brisbane, Queensland, Australia
- Queensland Health (Sunshine Coast Hospital and Health Service), Sunshine Coast, Queensland, Australia
| | - Louise Gustafsson
- Griffith University (School of Health Sciences and Social Work), Brisbane, Queensland, Australia
| | - Rohan Grimley
- Queensland Health (Sunshine Coast Hospital and Health Service), Sunshine Coast, Queensland, Australia
- Griffith University (School of Medicine), Sunshine Coast, Queensland, Australia
| | - Hannah Gullo
- The University of Queensland (School of Health and Rehabilitation Sciences), Brisbane, Queensland, Australia
| | - Ingrid Rosbergen
- Queensland Health (Sunshine Coast Hospital and Health Service), Sunshine Coast, Queensland, Australia
- University of Applied Sciences, UAS, Leiden, The Netherlands
| | - Mathew Summers
- University of the Sunshine Coast (School of Health and Behavioural Sciences), Sunshine Coast, Queensland, Australia
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Liu X, Jiang J, Li D, Horrow J, Tamada H, Kahl A, Hariharan V, Avinav A, Li X. Antiplatelet Treatment Patterns and Outcomes for Secondary Stroke Prevention in the United Kingdom. Cardiol Ther 2023; 12:675-687. [PMID: 37789237 DOI: 10.1007/s40119-023-00332-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/08/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Stroke is a leading cause of death and disability worldwide. Antiplatelet therapies are recommended to reduce the risk of recurrent stroke in patients with ischemic stroke/transient ischemic attack (IS/TIA). This study evaluated outpatient antiplatelet treatment patterns and outcomes for secondary stroke prevention (SSP) among UK adults without atrial fibrillation who were hospitalized for IS/TIA. METHODS This retrospective observational study utilized data from the UK Clinical Practice Research Datalink linked with Hospital Episode Statistics data (01/01/2011-30/06/2019). Treatment patterns included type and duration of treatments. Treatment outcomes included IS, myocardial infarction, major bleeding, and cardiovascular-related and all-cause mortality. Descriptive statistics were reported. RESULTS Of 9270 patients, 13.9% (1292) might not receive antithrombotic therapy within 90 days of hospital discharge. Of 7978 patients who received antiplatelet therapies, most used clopidogrel (74.8%) or aspirin (16.7%) single antiplatelet therapy and clopidogrel + aspirin dual antiplatelet therapy (DAPT, 5.9%). At 1-year post-hospitalization, 36.9, 43.3, and 35.1% of those receiving these treatments discontinued them, respectively, and of the patients initiating DAPT, 62.3% switched to single antiplatelet therapy. At 1-year post-discharge, the incidence rate (per 100 person-years) of IS, myocardial infarction, major bleeding, cardiovascular-related mortality, and all-cause mortality among the treated were 6.5, 0.7, 4.1, 5.0, and 7.3, respectively, and among the untreated were 14.9, 0.7, 8.6, 28.1, and 39.8, respectively. CONCLUSIONS In the United Kingdom, 13.9% of patients hospitalized for stroke might not have any antiplatelet treatment to prevent secondary stroke; among the treated, clopidogrel, aspirin, and DAPT were commonly used. These study findings suggest that improved anti-thrombotic therapies for long-term SSP treatment are needed, which may lead to higher treatment and persistence rates and, therefore, improved outcomes in this population.
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Affiliation(s)
- Xuejun Liu
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Jenny Jiang
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Danshi Li
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Jay Horrow
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Hiroshi Tamada
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Anja Kahl
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | | | | | - Xiaoyan Li
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA.
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Feigin VL, Owolabi MO. Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission. Lancet Neurol 2023; 22:1160-1206. [PMID: 37827183 PMCID: PMC10715732 DOI: 10.1016/s1474-4422(23)00277-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/14/2023] [Indexed: 10/14/2023]
Abstract
Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met. In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases. Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders. The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.
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Affiliation(s)
- Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.
| | - Mayowa O Owolabi
- Centre for Genomics and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria; Blossom Specialist Medical Centre, Ibadan, Nigeria.
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Samaniego EA, Boltze J, Lyden PD, Hill MD, Campbell BCV, Silva GS, Sheth KN, Fisher M, Hillis AE, Nguyen TN, Carone D, Favilla CG, Deljkich E, Albers GW, Heit JJ, Lansberg MG. Priorities for Advancements in Neuroimaging in the Diagnostic Workup of Acute Stroke. Stroke 2023; 54:3190-3201. [PMID: 37942645 PMCID: PMC10841844 DOI: 10.1161/strokeaha.123.044985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/03/2023] [Indexed: 11/10/2023]
Abstract
STAIR XII (12th Stroke Treatment Academy Industry Roundtable) included a workshop to discuss the priorities for advancements in neuroimaging in the diagnostic workup of acute ischemic stroke. The workshop brought together representatives from academia, industry, and government. The participants identified 10 critical areas of priority for the advancement of acute stroke imaging. These include enhancing imaging capabilities at primary and comprehensive stroke centers, refining the analysis and characterization of clots, establishing imaging criteria that can predict the response to reperfusion, optimizing the Thrombolysis in Cerebral Infarction scale, predicting first-pass reperfusion outcomes, improving imaging techniques post-reperfusion therapy, detecting early ischemia on noncontrast computed tomography, enhancing cone beam computed tomography, advancing mobile stroke units, and leveraging high-resolution vessel wall imaging to gain deeper insights into pathology. Imaging in acute ischemic stroke treatment has advanced significantly, but important challenges remain that need to be addressed. A combined effort from academic investigators, industry, and regulators is needed to improve imaging technologies and, ultimately, patient outcomes.
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Affiliation(s)
- Edgar A. Samaniego
- Department of Neurology, Radiology and Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Johannes Boltze
- School of Life Sciences, The University of Warwick, Coventry, United Kingdom
| | - Patrick D. Lyden
- Zilkha Neurogenetic Institute of the Keck School of Medicine at USC, Los Angeles, California, United States
| | - Michael D. Hill
- Department of Clinical Neuroscience & Hotchkiss Brain Institute, University of Calgary & Foothills Medical Centre, Calgary, Canada
| | - Bruce CV Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, United States
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Argye E. Hillis
- Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United Stated
| | - Thanh N. Nguyen
- Department of Neurology, Boston Medical Center, Massachusetts, United States
| | - Davide Carone
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Christopher G. Favilla
- Department of Neurology, University of Pennsylvania Philadelphia, Pennsylvania, Unites States
| | | | - Gregory W. Albers
- Department of Neurology, Stanford University, Stanford, California, United States
| | - Jeremy J. Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, California, United States
| | - Maarten G Lansberg
- Department of Neurology, Stanford University, Stanford, California, United States
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Murray J, Gunasekaran S, Doeltgen S, George S, Harvey G. Implementing a Screen-Clean-Hydrate bundle of care for improving swallow screening, oral health, and hydration in acute stroke: Protocol for a Type 2 hybrid-effectiveness pre-post study. Res Nurs Health 2023; 46:566-575. [PMID: 37837417 DOI: 10.1002/nur.22346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/13/2023] [Accepted: 09/29/2023] [Indexed: 10/16/2023]
Abstract
Stroke clinical guidelines recommend care processes that optimize patient outcomes and minimize hospital-acquired complications. However, audits and surveys illustrate that recommended care is not always consistently or thoroughly implemented. This paper outlines the methods for implementing and evaluating a new bundle of care. Screen-Clean-Hydrate bundles together recommendations from the Australian Clinical Guidelines for Stroke Management and supplements these with evidence-informed best practice from the literature for: swallow screening within 4 h of presentation to hospital (Screen); oral health assessment and delivery of oral care (Clean); and hydration assessment and management (Hydrate). The study is a pre-post Type 2 hybrid effectiveness/implementation design with an embedded process evaluation, which will be conducted in two acute stroke units in a capital city of Australia. The integrated-Promoting Action on Research Implementation in Health Services (iPARIHS) framework will be used to guide study design, conduct, and evaluation. Clinical effectiveness will be measured by rates of hospital-acquired complications and proxy measures of cost (length of stay, procedure costs) for 60 patient participants pre- and postimplementation. Implementation outcomes will focus on acceptability, feasibility, uptake and fidelity, and identification of barriers and enablers to implementation through staff interviews, medical record audits, and researcher field notes. Due to its design as a hybrid effectiveness/implementation study, once completed, the study will provide information on both intervention and implementation effectiveness, including details of successful and unsuccessful multidisciplinary implementation strategies. This will inform a larger multisite effectiveness/implementation trial for future upscale, leading to improved compliance with stroke guidelines and therefore stroke outcomes.
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Affiliation(s)
- Joanne Murray
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Caring Futures Institute, Flinders University, Adelaide, Australia
- Swallowing Neurorehabilitation Research Laboratory, Flinders University, Adelaide, Australia
| | - Sulekha Gunasekaran
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Sebastian Doeltgen
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Caring Futures Institute, Flinders University, Adelaide, Australia
- Swallowing Neurorehabilitation Research Laboratory, Flinders University, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Gillian Harvey
- Caring Futures Institute, Flinders University, Adelaide, Australia
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17
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Taghdiri F, Vyas MV, Kapral MK, Lapointe-Shaw L, Austin PC, Tse P, Porter J, Chen Y, Fang J, Yu AYX. Association of Neighborhood Deprivation With Thrombolysis and Thrombectomy for Acute Stroke in a Health System With Universal Access. Neurology 2023; 101:e2215-e2222. [PMID: 37914415 PMCID: PMC10727218 DOI: 10.1212/wnl.0000000000207924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/22/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The association between socioeconomic status and acute ischemic stroke treatments remain uncertain, particularly in countries with universal health care systems. This study aimed to investigate the association between neighborhood-level material deprivation and the odds of receiving IV thrombolysis or thrombectomy for acute ischemic stroke within a single-payer, government-funded health care system. METHODS We conducted a population-based cohort study using linked administrative data from Ontario, Canada. This study involved all community-dwelling adult Ontario residents hospitalized with acute ischemic stroke between 2017 and 2022. Neighborhood-level material deprivation, measured in quintiles from least to most deprived, was our main exposure. We considered the receipt of thrombolysis or thrombectomy as the primary outcome. We used multivariable logistic regression models adjusted for baseline differences to estimate the association between material deprivation and outcomes. We performed a sensitivity analysis by additionally adjusting for hospital type at initial assessment. Furthermore, we tested whether hospital type modified the associations between deprivation and outcomes. RESULTS Among 57,704 patients, those in the most materially deprived group (quintile 5) were less likely to be treated with thrombolysis or thrombectomy compared with those in the least deprived group (quintile 1) (16.6% vs 19.6%, adjusted odds ratio [aOR] 0.76, 95% CI 0.63-0.93). The association was consistent when evaluating thrombolysis (13.0% vs 15.3%, aOR 0.78, 95% CI 0.64-0.96) and thrombectomy (6.4 vs 7.8%, aOR 0.73, 95% CI 0.59-0.90) separately. There were no statistically significant differences between the middle 3 quintiles and the least deprived group. These associations persisted after additional adjustment for hospital type, and there was no interaction between material deprivation and hospital type (p interaction >0.1). DISCUSSION We observed disparities in the use of thrombolysis or thrombectomy for acute ischemic stroke by socioeconomic status despite access to universal health care. Targeted health care policies, public health messaging, and resource allocation are needed to ensure equitable access to acute stroke treatments for all patients.
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Affiliation(s)
- Foad Taghdiri
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Manav V Vyas
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Moira K Kapral
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Lauren Lapointe-Shaw
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Peter C Austin
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Preston Tse
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Joan Porter
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Yue Chen
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Jiming Fang
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada
| | - Amy Ying Xin Yu
- From the Division of Neurology (F.T., M.V.V., A.Y.X.Y.), Department of Medicine, University of Toronto; St. Michael's Research Institute (M.V.V.), St. Michael's Hospital-Unity Health Toronto; Institute of Health Policy, Management and Evaluation (M.V.V., M.K.K., P.C.A., A.Y.X.Y.) and Division of General Internal Medicine (M.K.K., L.L.-S.), Department of Medicine, University of Toronto; Toronto General Research Institute (M.K.K., L.L.-S.), University Health Network; ICES (M.K.K., L.L.-S., P.C.A., J.P., Y.C., J.F., A.Y.X.Y.); Sunnybrook Research Institute (M.K.K., P.C.A., A.Y.X.Y.), Toronto; and McMaster University (P.T.), Hamilton, Ontario, Canada.
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Fan K, Cao W, Chang H, Tian F. Predicting prognosis in patients with stroke treated with intravenous alteplase through blood pressure changes: A machine learning-based approach. J Clin Hypertens (Greenwich) 2023; 25:1009-1018. [PMID: 37843065 PMCID: PMC10631101 DOI: 10.1111/jch.14732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/21/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023]
Abstract
The use of machine learning (ML) in predicting disease prognosis has increased, and researchers have adopted different methods for variable selection to optimize early screening for AIS to determine its prognosis as soon as possible. We aimed to improve the understanding of the predictors of poor functional outcome at three months after discharge in AIS patients treated with intravenous thrombolysis and to construct a highly effective prognostic model to improve prediction accuracy. And four ML methods (random forest, support vector machine, naive Bayesian, and logistic regression) were used to screen and recombine the features for construction of an ML prognostic model. A total of 352 patients that had experienced AIS and had been treated with intravenous thrombolysis were recruited. The variables included in the model were NIHSS on admission, age, white blood cell count, percentage of neutrophils and triglyceride after thrombolysis, tirofiban, early neurological deterioration, early neurological improvement, and BP at each time point or period. The model's area under the curve for predicting 30-day modified Rankin scale was 0.790 with random forest, 0.542 with support vector machine, 0.411 with naive Bayesian, and 0.661 with logistic regression. The random forest model was shown to accurately evaluate the prognosis of AIS patients treated with intravenous thrombolysis, and therefore they may be helpful for accurate and personalized secondary prevention. The model offers improved prediction accuracy that may reduce rates of misdiagnosis and missed diagnosis in patients with AIS.
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Affiliation(s)
- Kaiting Fan
- Department of NeurologyXuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric DiseaseBeijingChina
| | - Wenya Cao
- Department of NeurologyXuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric DiseaseBeijingChina
| | - Hong Chang
- Department of NeurologyXuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric DiseaseBeijingChina
| | - Fei Tian
- Department of NeurologyXuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric DiseaseBeijingChina
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19
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Singh N, Almekhlafi MA, Bala F, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Buck B, Appireddy R, Moreau F, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JJ, Ghrooda E, Poppe AY, Williams H, Field TS, Manosalva A, Siddiqui MM, Zafar A, Imoukhoude O, Hunter G, Shamy M, Demchuk AM, Claggett BL, Hill MD, Sajobi TT, Swartz RH, Menon BK. Effect of Time to Thrombolysis on Clinical Outcomes in Patients With Acute Ischemic Stroke Treated With Tenecteplase Compared to Alteplase: Analysis From the AcT Randomized Controlled Trial. Stroke 2023; 54:2766-2775. [PMID: 37800372 DOI: 10.1161/strokeaha.123.044267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/23/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND The AcT (Alteplase Compared to Tenecteplase) randomized controlled trial showed that tenecteplase is noninferior to alteplase in treating patients with acute ischemic stroke within 4.5 hours of symptom onset. The effect of time to treatment on clinical outcomes with alteplase is well known; however, the nature of this relationship is yet to be described with tenecteplase. We assessed whether the association of time to thrombolysis treatment with clinical outcomes in patients with acute ischemic stroke differs by whether they receive intravenous tenecteplase versus alteplase. METHODS Patients included were from AcT, a pragmatic, registry-linked, phase 3 randomized controlled trial comparing intravenous tenecteplase to alteplase in patients with acute ischemic stroke. Eligible patients were >18 years old, with disabling neurological deficits, presenting within 4.5 hours of symptom onset, and eligible for thrombolysis. Primary outcome was modified Rankin Scale score 0 to 1 at 90 days. Safety outcomes included 24-hour symptomatic intracerebral hemorrhage and 90-day mortality rates. Mixed-effects logistic regression was used to assess the following: (a) the association of stroke symptom onset to needle time; (b) door (hospital arrival) to needle time with outcomes; and (c) if these associations were modified by type of thrombolytic administered (tenecteplase versus alteplase), after adjusting for age, sex, baseline stroke severity, and site of intracranial occlusion. RESULTS Of the 1538 patients included in this analysis, 1146 (74.5%; 591 tenecteplase and 555 alteplase) presented within 3 hours versus 392 (25.5%; 196: TNK and 196 alteplase) who presented within 3 to 4.5 hours of symptom onset. Baseline patient characteristics in the 0 to 3 hours versus 3- to 4.5-hour time window were similar, except patients in the 3- to 4.5-hour window had lower median baseline National Institutes of Health Stroke Severity Scale (10 versus 7, respectively) and lower proportion of patients with large vessel occlusion on baseline CT angiography (26.9% versus 18.7%, respectively). Type of thrombolytic agent (tenecteplase versus alteplase) did not modify the association between continuous onset to needle time (Pinteraction=0.161) or door-to-needle time (Pinteraction=0.972) and primary clinical outcome. Irrespective of the thrombolytic agent used, each 30-minute reduction in onset to needle time was associated with a 1.8% increase while every 10 minutes reduction in door-to-needle time was associated with a 0.2% increase in the probability of achieving 90-day modified Rankin Scale score 0 to 1, respectively. CONCLUSIONS The effect of time to tenecteplase administration on clinical outcomes is like that of alteplase, with faster administration resulting in better clinical outcomes. REGISTRATION URL: https://classic. CLINICALTRIALS gov; Unique identifier: NCT03889249.
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Affiliation(s)
- Nishita Singh
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada (N.S., E.G.)
| | - Mohammed A Almekhlafi
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Fouzi Bala
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
- Diagnostic and Interventional Neuroradiology, Tours University Hospital, France (F.B.)
| | - Ayoola Ademola
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
| | - Shelagh B Coutts
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Yan Deschaintre
- Department of Clinical Neurosciences, Université de Montréal, Canada (Y.D., A.Y.P.)
| | - Houman Khosravani
- Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada (H.K., R.H.S.)
| | - Brian Buck
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada (B.B.)
| | - Ramana Appireddy
- Department of Medicine, Division of Neurology, Queen's University, Kingston, ON, Canada (R.A.)
| | - Francois Moreau
- Department of Internal Medicine, Université de Sherbrooke, QC, Canada (F.M.)
| | - Gord Gubitz
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.G.)
| | - Aleksander Tkach
- Department of Neurosciences, Kelowna General Hospital, Canada (A.T.)
| | - Luciana Catanese
- Department of Medicine, McMaster University, Hamilton, Canada (L.C.)
| | - Dar Dowlatshahi
- Department of Medicine, and Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., M.S.)
| | - George Medvedev
- Department of Neurosciences, University of British Columbia, Vancouver, Canada (G.M., T.S.F.)
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | - Aleksandra Pikula
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | - Jai Jai Shankar
- Department of Radiology, Health Sciences Center, University of Manitoba, Winnipeg, Canada (J.J.S.)
| | - Esseeddeegg Ghrooda
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada (N.S., E.G.)
| | - Alexandre Y Poppe
- Department of Clinical Neurosciences, Université de Montréal, Canada (Y.D., A.Y.P.)
| | - Heather Williams
- Department of Medicine, Queen Elizabeth Health Sciences Centre, Charlottetown, Canada (H.W.)
| | - Thalia S Field
- Department of Neurosciences, University of British Columbia, Vancouver, Canada (G.M., T.S.F.)
| | - Alejandro Manosalva
- Department of Medicine, Medicine Hat Regional Hospital, Calgary, Canada (A.M.)
| | | | - Atif Zafar
- St Michael's Hospital, Toronto, ON, Canada (A.Z.)
| | - Oje Imoukhoude
- Department of Medicine, Red Deer Regional Hospital, Calgary, Canada (O.I.)
| | - Gary Hunter
- Department of Medicine, University of Saskatoon, Canada (G.H.)
| | - Michel Shamy
- Department of Medicine, and Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., M.S.)
| | - Andrew M Demchuk
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
| | - Brian L Claggett
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA (B.L.C.)
| | - Michael D Hill
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Tolulope T Sajobi
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
| | - Richard H Swartz
- Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada (H.K., R.H.S.)
| | - Bijoy K Menon
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
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Kaźmierski R. Brain injury mobile diagnostic system: Applications in civilian medical service and on the battlefield-General concept and medical aspects. J Clin Ultrasound 2023; 51:1598-1606. [PMID: 37702254 DOI: 10.1002/jcu.23545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 09/14/2023]
Abstract
To present the concept of a portable ultrasound tomography device for diagnosing traumatic and vascular brain lesions. The device consisting of multiple transcranial ultrasound probes placed on the surface of the head, specifically but not exclusively in natural acoustic windows. An integral part of the mobile diagnostic system (MDS) is a decision support system based on artificial intelligence algorithms utilizing information from: head images, laboratory data, and assessment of the patient's clinical condition. The MDS can significantly reduce the time from stroke onset to rtPA therapy in civilian medical services and support therapeutic and evacuation strategies in instances of brain and skull trauma on the battlefield.
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Affiliation(s)
- Radosław Kaźmierski
- Department of Neurology, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland
- Department for Neurology, Poznan University of Medical Sciences, Poznan, Poland
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21
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Eagles ME, Beall RF, Ben-Israel D, Wong JH, Hill MD, Spackman E. Neighbourhood deprivation, distance to nearest comprehensive stroke centre and access to endovascular thrombectomy for ischemic stroke: a population-based study. CMAJ Open 2023; 11:E1181-E1187. [PMID: 38114260 PMCID: PMC10743637 DOI: 10.9778/cmajo.20230046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has revolutionized ischemic stroke care. We aimed to assess whether neighbourhood socioeconomic status is predictive of access to EVT after receipt of alteplase for ischemic stroke among patients living in Alberta, Canada, and whether this relation is mediated by the distance a person lives to the nearest comprehensive stroke centre (CSC). METHODS We performed a retrospective study including all people older than 18 years living in Alberta who were admitted to hospital with an ischemic stroke and who received intravenous alteplase treatment between Jan. 1, 2017, and Dec. 31, 2019. Data were obtained through administrative data sets. The primary outcome was treatment with EVT. We assigned neighbourhood deprivation quintile based on the Material and Social Deprivation Index. We used logistic regression modelling to assess for a relation between deprivation and treatment with EVT. We adjusted for age, sex, stroke severity and distance to the nearest CSC. We calculated the average causal mediation effect of distance to the nearest CSC on the relation between neighbourhood deprivation level and treatment with EVT. RESULTS The study cohort consisted of 1335 patients, of whom 181 (13.6%) had missing data and were excluded from the main regression analysis. Endovascular thrombectomy was performed or attempted in 314 patients (23.5%). In the primary model, patients from the most deprived neighbourhoods were less likely than those from less deprived neighbourhoods to have received EVT (adjusted odds ratio 0.43, 95% confidence interval 0.24 to 0.77). Neighbourhood deprivation level was not significantly associated with EVT when distance to the nearest CSC was included as a covariate. Mediation analysis suggested that 48% of the total effect that neighbourhood deprivation level had on the odds of receiving EVT was attributable to the distance a person lived from the nearest CSC. INTERPRETATION The results suggest that people from more deprived neighbourhoods in Alberta were less likely to be treated with EVT than those from less deprived neighbourhoods. Improving access to EVT for people living in remote locations may improve the equitable distribution of this treatment.
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Affiliation(s)
- Matthew E Eagles
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta.
| | - Reed F Beall
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
| | - David Ben-Israel
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
| | - John H Wong
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
| | - Michael D Hill
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
| | - Eldon Spackman
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
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22
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Riera-López N, Aranda-Aguilar F, Gorchs-Molist M, Iglesias-Vázquez JA. Effect of the COVID-19 pandemic on advanced life support units' prehospital management of the stroke code in four Spanish regions: an observational study. BMC Emerg Med 2023; 23:116. [PMID: 37794327 PMCID: PMC10552388 DOI: 10.1186/s12873-023-00886-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 09/13/2023] [Indexed: 10/06/2023] Open
Abstract
INTRODUCTION Stroke is the most common time-dependent pathology that pre-hospital emergency medical services (EMS) are confronted with. Prioritisation of ambulance dispatch, initial actions and early pre-notification have a major impact on mortality and disability. The COVID-19 pandemic has led to disruptions in the operation of EMS due to the implementation of self-protection measures and increased demand for care. It is crucial to evaluate what has happened to draw the necessary conclusions and propose changes to improve the system's strength for the future. The study aims to compare prehospital time and neuroprotective care metrics for acute stroke patients during the first wave of COVID-19 and the same periods in the years before and after. METHODS Analytical, observational, multicentre study conducted in the autonomous communities of Andalusia, Catalonia, Galicia, and Madrid in the pre-COVID-19 (2019), "first wave" of COVID-19 (2020) and post-COVID-19 (2021) periods. Consecutive non-randomized sampling. Descriptive statistical analysis and hypothesis testing to compare the three time periods, with two by two post-hoc comparisons, and multivariate analysis. RESULTS A total of 1,709 patients were analysed. During 2020 there was a significant increase in attendance time of 1.8 min compared to 2019, which was not recovered in 2021. The time of symptom onset was recorded in 82.8% of cases, and 83.3% of patients were referred to specialized stroke centres. Neuroprotective measures (airway, blood glucose, temperature, and blood pressure) were performed in 43.6% of patients. CONCLUSION During the first wave of COVID-19, the on-scene times of pre-hospital emergency teams increased while keeping the same levels of neuroprotection measures as in the previous and subsequent years. It shows the resilience of EMS under challenging circumstances such as those experienced during the pandemic.
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23
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Kida H, Sakai K, Sato T, Nakada R, Kitagawa T, Takatsu H, Komatsu T, Sakuta K, Mitsumura H, Iguchi Y. Follow-Up Diffusion-Weighted Image Reveals Delayed Appearance of Ischemic Lesions in Suspected Transient Ischemic Attack. Cureus 2023; 15:e47405. [PMID: 38022071 PMCID: PMC10657785 DOI: 10.7759/cureus.47405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION In patients suspected of transient ischemic attack (TIA), it is not uncommon to find no lesion on the diffusion-weighted image (DWI) on admission but a delayed appearance on the follow-up DWI. METHODS Enrolled patients met the following criteria: (1) MRI performed within 24 hours of onset and seven days after admission; (2) National Institutes of Health Stroke Scale (NIHSS) score ≦4 on admission; (3) pre-stroke modified Rankin scale (mRS) score of 0-1. Patients were divided as follows: no lesion on the first DWI and a new lesion on the second DWI (delayed-specified ischemic stroke; DSIS); and no lesion on either the first or second DWI (well-screened TIA; WSTIA). We compared both groups regarding the clinical background and the outcome at three months. RESULTS We identified 144 cases (male 70%; median age 64 years; DSIS, n=34) between October 2012 and March 2019. DSIS was older (71 vs. 60 years, p=0.006) and had a higher NIHSS score on admission (1 vs. 0, p=0.041), a higher rate of large vessel occlusion (LVO) (17% vs. 2%, p=0.008), and symptom duration over one hour (82% vs. 64%, p=0.041). A favorable outcome mRS score of 0-1 at three months was less frequent in DSIS (85% vs. 96%, p=0.004). Age/10 (OR 1.62, 95%CI 1.17-2.24; p=0.004) and LVO (OR 10.84, 95%CI 1.87-63.06; p=0.008) were independent factors for DSIS. CONCLUSIONS In suspected TIA with age or LVO but no lesion in the initial DWI, the second DWI should be considered to identify the delayed appearance of an ischemic stroke.
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Affiliation(s)
- Hiroyuki Kida
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Kenichiro Sakai
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Takeo Sato
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Ryoji Nakada
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Tomomichi Kitagawa
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Hiroki Takatsu
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Teppei Komatsu
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Kenichi Sakuta
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Hidetaka Mitsumura
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Yasuyuki Iguchi
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
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24
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Burton B, Isaacs M, Brogan E, Shrubsole K, Kilkenny MF, Power E, Godecke E, Cadilhac DA, Copland D, Wallace SJ. An updated systematic review of stroke clinical practice guidelines to inform aphasia management. Int J Stroke 2023; 18:1029-1039. [PMID: 36803248 PMCID: PMC10614176 DOI: 10.1177/17474930231161454] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/12/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Aphasia is a common consequence of stroke, and people who live with this condition experience poor outcomes. Adherence to clinical practice guidelines can promote high-quality service delivery and optimize patient outcomes. However, there are currently no high-quality guidelines specific to post-stroke aphasia management. AIMS To identify and evaluate recommendations from high-quality stroke guidelines that can inform aphasia management. SUMMARY OF REVIEW We conducted an updated systematic review in accordance with PRISMA guidelines to identify high-quality clinical guidelines published between January 2015 and October 2022. Primary searches were performed using electronic databases: PubMed, EMBASE, CINAHL, and Web of Science. Gray literature searches were conducted using Google Scholar, guideline databases, and stroke websites. Clinical practice guidelines were evaluated using the Appraisal of Guidelines and Research and Evaluation (AGREE II) tool. Recommendations were extracted from high-quality guidelines (scored > 66.7% on Domain 3: "Rigor of Development"), classified as aphasia-specific or aphasia-related, and categorized into clinical practice areas. Evidence ratings and source citations were assessed, and similar recommendations were grouped. Twenty-three stroke clinical practice guidelines were identified and 9 (39%) met our criteria for rigor of development. From these guidelines, 82 recommendations for aphasia management were extracted: 31 were aphasia-specific, 51 aphasia-related, 67 evidence-based, and 15 consensus-based. CONCLUSION More than half of stroke clinical practice guidelines identified did not meet our criteria for rigorous development. We identified 9 high-quality guidelines and 82 recommendations to inform aphasia management. Most recommendations were aphasia-related; aphasia-specific recommendation gaps were identified in three clinical practice areas: "accessing community supports," "return to work, leisure, driving," and "interprofessional practice."
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Affiliation(s)
- Bridget Burton
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Queensland Aphasia Research Centre, Brisbane, QLD, Australia
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Health,
Queensland, Australia
| | - Megan Isaacs
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Queensland Aphasia Research Centre, Brisbane, QLD, Australia
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Health,
Queensland, Australia
| | - Emily Brogan
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Kirstine Shrubsole
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Queensland Aphasia Research Centre, Brisbane, QLD, Australia
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Health,
Queensland, Australia
| | - Monique F Kilkenny
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Emma Power
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- University of Technology Sydney, Graduate School of Health, Speech Pathology, Sydney, NSW, Australia
| | - Erin Godecke
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Dominique A Cadilhac
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - David Copland
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Queensland Aphasia Research Centre, Brisbane, QLD, Australia
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Health,
Queensland, Australia
| | - Sarah J Wallace
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Queensland Aphasia Research Centre, Brisbane, QLD, Australia
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Health,
Queensland, Australia
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Ozaki K, Tohara H, Baba M, Teranaka S, Kawai Y, Komatsumoto S. A Dentist-Led Oral Care System Can Prevent Stroke-Associated Pneumonia: The Effects of Early Intervention by Dental Team. J Multidiscip Healthc 2023; 16:2937-2945. [PMID: 37795380 PMCID: PMC10546933 DOI: 10.2147/jmdh.s415572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/07/2023] [Indexed: 10/06/2023] Open
Abstract
Background Our facility's dental team consists of a full-time dentists and dental hygienists who work exclusively in the wards to implement best practices in oral healthcare. We executed the dental care system (DCS) that includes lectures and practical training for nurses conducted by dentists and dental hygienists, the introduction to oral assessment, standardization of oral care procedures, a process for nurses to request the dental team, and early bedside oral screening conducted by the dental team. This study investigated the DCS's effects on the incidence of stroke-associated pneumonia (SAP). Methods This single-center retrospective cohort study included 2,771 acute stroke patients who were newly hospitalized between April 1, 2012, and March 31, 2020. The 8-year period was divided into four phases at two-year intervals as follows: Pre (N=632), Post-1 (N=642), Post-2 (N=716), and Post-3 (N=781). Pre was prior to DCS practice. Post-1 was an early introduction to DCS. Post-2 simplified dental team requests from nurses, and Post-3 added bedside oral screening within 72 hours of admission by the dental team. Statistical analysis was performed using the Cochran-Armitage trend test, followed by multivariate logistic regression. Results A decrease in SAP rates was observed across the four groups (P<0.0001). Logistic regression analysis revealed a significant difference for respiratory disease (odds ratio 7.74, 95% confidence interval 5.49-10.90), hypertension (2.28, 1.39-3.73), cardiac failure (1.72, 1.04-2.85), and diabetes (1.59, 1.11-2.26), 3-digit code on the Japan coma scale (3.57, 2.53-5.05 [reference ≤2-digit code]), age ≥90 years (2.34, 1.15-4.77 [reference 18-59 years]), male (1.86, 1.31-2.67), and the Post-1 (0.49, 0.31-0.76 [reference Pre]), Post-2 (0.38, 0.25-0.61 [reference Pre]), and Post-3 (0.24, 0.15-0.40 [reference Pre]) periods. Conclusion The suppression of SAP is effectively achieved through early intervention and education of nurses by dental professionals.
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Affiliation(s)
- Kenichiro Ozaki
- Department of Physical Medicine and Rehabilitation, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
- Dysphagia Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
| | - Haruka Tohara
- Dysphagia Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
| | - Mikoto Baba
- Department of Physical Medicine and Rehabilitation, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
| | - Satoshi Teranaka
- Department of Physical Medicine and Rehabilitation, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
- Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
| | - Yosuke Kawai
- Department of Physical Medicine and Rehabilitation, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
- Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
| | - Satoru Komatsumoto
- Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
- Fujita Health University, Toyoake, Aichi, Japan
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Fahmi A, Garon M, Ribon-Demars A, Dubois L, Caouette M, Lamontagne MÈ, Beaulieu-Bonneau S. Learning to drive with neurological conditions: profile of users of an adapted driver training program and cognitive factors associated with success. Disabil Rehabil 2023:1-9. [PMID: 37728095 DOI: 10.1080/09638288.2023.2258332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE To describe the sociodemographic and cognitive profile of participants enrolled in an adapted driving program for individuals with neurological conditions, to explore the association between cognitive functioning and driving program outcome, and to describe driving habits after program completion. METHODS This study combined retrospective chart review and cross-sectional data collection. RESULTS The sample included 71 participants with neurological disorders (aged 15-56 years, M = 22.2 ± 8.6; 39% women). Driving program was either successful (47%), failed (7%), discontinued (34%), or ongoing (13%). Among 35 participants with complete neuropsychological and driving program outcome data, those who successfully completed the program showed better attention functioning, and better performance relative to global functioning for attention, executive functions, and working memory, compared to those who discontinued/failed the program. Among 21 participants who completed a telephone questionnaire on average 3.7 years after program enrollment, 67% obtained their driver's license and drove regularly. Participants reported high levels of satisfaction with the program. CONCLUSION These results suggest that approximately half of the persons enrolled in a driver training program designed for learners with neurological conditions, obtain a driver's license; and that attention, and to a lesser extent executive functioning and working memory, are related to driving program success.IMPLICATIONS FOR REHABILITATIONIn individual with neurological conditions, learning how to drive can be challenging.An adapted driver training program, involving collaboration between driving instructors and healthcare professionals, simplification of theoretical learning, and increasing driving practice opportunities, can be effective, both in terms of licensing success and client satisfaction.Conducting a pre-driving program neuropsychological assessment, with identification of cognitive strengths and weaknesses, can provide valuable information for clinicians and driving instructors for optimizing training and predicting outcome.Better performance in attention, and better relative to global cognitive functioning in attention, executive functions, and working memory, are related to higher success rate of an adapted driving program.
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Affiliation(s)
- Adam Fahmi
- École de psychologie, Faculté des sciences sociales, Université Laval, Québec, QC, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
| | - Mathieu Garon
- Centre intégré universitaire de santé et de services sociaux de l'Estrie, Centre hospitalier universitaire de Sherbrooke; Sherbrooke, QC, Canada
| | - Alexandra Ribon-Demars
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
| | - Laurie Dubois
- École de psychologie, Faculté des sciences sociales, Université Laval, Québec, QC, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
| | - Martin Caouette
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
- Département de psychoéducation, Université du Québec à Trois-Rivières; Trois-Rivières, QC, Canada
| | - Marie-Ève Lamontagne
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
- École des sciences de la réadaptation, Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Simon Beaulieu-Bonneau
- École de psychologie, Faculté des sciences sociales, Université Laval, Québec, QC, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
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Mirmozaffari M, Kamal N. The Application of Data Envelopment Analysis to Emergency Departments and Management of Emergency Conditions: A Narrative Review. Healthcare (Basel) 2023; 11:2541. [PMID: 37761738 PMCID: PMC10530342 DOI: 10.3390/healthcare11182541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
The healthcare industry is one application for data envelopment analysis (DEA) that can have significant benefits for standardizing health service delivery. This narrative review focuses on the application of DEA in emergency departments (EDs) and the management of emergency conditions such as acute ischemic stroke and acute myocardial infarction (AMI). This includes benchmarking the proportion of patients that receive treatment for these emergency conditions. The most frequent primary areas of study motivating work in DEA, EDs and management of emergency conditions including acute management of stroke are sorted into five distinct clusters in this study: (1) using basic DEA models for efficiency analysis in EDs, i.e., applying variable return to scale (VRS), or constant return to scale (CRS) to ED operations; (2) combining advanced and basic DEA approaches in EDs, i.e., applying super-efficiency with basic DEA or advanced DEA approaches such as additive model (ADD) and slack-based measurement (SBM) to clarify the dynamic aspects of ED efficiency throughout the duration of a first-aid program for AMI or heart attack; (3) applying DEA time series models in EDs like the early use of thrombolysis and percutaneous coronary intervention (PCI) in AMI treatment, and endovascular thrombectomy (EVT) in acute ischemic stroke treatment, i.e., using window analysis and Malmquist productivity index (MPI) to benchmark the performance of EDs over time; (4) integrating other approaches with DEA in EDs, i.e., combining simulations, machine learning (ML), multi-criteria decision analysis (MCDM) by DEA to reduce patient waiting times, and futile transfers; and (5) applying various DEA models for the management of acute ischemic stroke, i.e., using DEA to increase the number of eligible acute ischemic stroke patients receiving EVT and other medical ischemic stroke treatment in the form of thrombolysis (alteplase and now Tenecteplase). We thoroughly assess the methodological basis of the papers, offering detailed explanations regarding the applied models, selected inputs and outputs, and all relevant methodologies. In conclusion, we explore several ways to enhance DEA's status, transforming it from a mere technical application into a strong methodology that can be utilized by healthcare managers and decision-makers.
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Affiliation(s)
- Mirpouya Mirmozaffari
- Department of Industrial Engineering, Dalhousie University, 5269 Morris Street, Halifax, NS B3H 4R2, Canada;
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Kim BJ, Singh N, Kim H, Menon BK, Almekhlafi M, Ryu WS, Kim JT, Kang J, Baik SH, Kim JY, Lee KJ, Jung C, Han MK, Bae HJ. Association between blood pressure and endovascular treatment outcomes differs by baseline perfusion and reperfusion status. Sci Rep 2023; 13:13776. [PMID: 37612355 PMCID: PMC10447432 DOI: 10.1038/s41598-023-40572-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 08/13/2023] [Indexed: 08/25/2023] Open
Abstract
We hypothesized that the association between BP and endovascular treatment (EVT) outcomes would differ by baseline perfusion and recanalization status. We identified 388 ICA or M1 occlusion patients who underwent EVT ≤ 24 h from onset with successful recanalization (TICI ≥ 2b). BP was measured at 5-min intervals from arrival and during the procedure. Systolic BPs (SBP) were summarized as dropmax (the maximal decrease over two consecutive measurements), incmax (the maximal increase), mean, coefficient of variation (cv), and standard deviation. Adequate baseline perfusion was defined as hypoperfusion intensity ratio (HIR) ≤ 0.5; infarct proportion as the volume ratio of final infarcts within the Tmax > 6 s region. In the adequate perfusion group, infarct proportion was closely associated with SBPdropmax (β ± SE (P-value); 1.22 ± 0.48, (< 0.01)), SBPincmax (1.12 ± 0.33, (< 0.01)), SBPcv (0.61 ± 0.15 (< 0.01)), SBPsd (0.66 ± 0.08 (< 0.01)), and SBPmean (0.71 ± 0.37 (0.053) before recanalization. The associations remained significant only in SBPdropmax, SBPincmax, and SBPmean after recanalization. SBPincmax, SBPcv and SBPsd showed significant associations with modified Rankin Scale score at 3 months in the pre-recanalization period. In the poor perfusion group, none of the SBP indices was associated with any stroke outcomes regardless of recanalization status. BP may show differential associations with stroke outcomes by the recanalization and baseline perfusion status.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea.
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.
| | - Nishita Singh
- Neurology division, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Hyeran Kim
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Mohammed Almekhlafi
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jun Yup Kim
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
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Bala F, Singh N, Buck B, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Appireddy R, Moreau F, Phillips S, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JJ, Williams H, Field TS, Manosalva Alzate A, Siddiqui M, Zafar A, Imoukhoude O, Hunter G, Alhabli I, Benali F, Horn M, Hill MD, Shamy M, Sajobi TT, Swartz RH, Menon BK, Almekhlafi M. Safety and Efficacy of Tenecteplase Compared With Alteplase in Patients With Large Vessel Occlusion Stroke: A Prespecified Secondary Analysis of the ACT Randomized Clinical Trial. JAMA Neurol 2023; 80:824-832. [PMID: 37428494 PMCID: PMC10334294 DOI: 10.1001/jamaneurol.2023.2094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/28/2023] [Indexed: 07/11/2023]
Abstract
Importance It is unknown whether intravenous thrombolysis using tenecteplase is noninferior or preferable compared with alteplase for patients with acute ischemic stroke. Objective To examine the safety and efficacy of tenecteplase compared to alteplase among patients with large vessel occlusion (LVO) stroke. Design, Setting, and Participants This was a prespecified analysis of the Intravenous Tenecteplase Compared With Alteplase for Acute Ischaemic Stroke in Canada (ACT) randomized clinical trial that enrolled patients from 22 primary and comprehensive stroke centers across Canada between December 10, 2019, and January 25, 2022. Patients 18 years and older with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly assigned (1:1) to either intravenous tenecteplase or alteplase and were monitored for up to 120 days. Patients with baseline intracranial internal carotid artery (ICA), M1-middle cerebral artery (MCA), M2-MCA, and basilar occlusions were included in this analysis. A total of 1600 patients were enrolled, and 23 withdrew consent. Exposures Intravenous tenecteplase (0.25 mg/kg) vs intravenous alteplase (0.9 mg/kg). Main Outcomes and Measures The primary outcome was the proportion of modified Rankin scale (mRS) score 0-1 at 90 days. Secondary outcomes were an mRS score from 0 to 2, mortality, and symptomatic intracerebral hemorrhage. Angiographic outcomes were successful reperfusion (extended Thrombolysis in Cerebral Infarction scale score 2b-3) on first and final angiographic acquisitions. Multivariable analyses (adjusting for age, sex, National Institute of Health Stroke Scale score, onset-to-needle time, and occlusion location) were carried out. Results Among 1577 patients, 520 (33.0%) had LVO (median [IQR] age, 74 [64-83] years; 283 [54.4%] women): 135 (26.0%) with ICA occlusion, 237 (45.6%) with M1-MCA, 117 (22.5%) with M2-MCA, and 31 (6.0%) with basilar occlusions. The primary outcome (mRS score 0-1) was achieved in 86 participants (32.7%) in the tenecteplase group vs 76 (29.6%) in the alteplase group. Rates of mRS 0-2 (129 [49.0%] vs 131 [51.0%]), symptomatic intracerebral hemorrhage (16 [6.1%] vs 11 [4.3%]), and mortality (19.9% vs 18.1%) were similar in the tenecteplase and alteplase groups, respectively. No difference was noted in successful reperfusion rates in the first (19 [9.2%] vs 21 [10.5%]) and final angiogram (174 [84.5%] vs 177 [88.9%]) among 405 patients who underwent thrombectomy. Conclusions and Relevance The findings in this study indicate that intravenous tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO.
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Affiliation(s)
- Fouzi Bala
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Internal Medicine, Neurology Division, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelagh B. Coutts
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Yan Deschaintre
- Department of Neurosciences, Université de Montréal, Montréal, Québec, Canada
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | | | - Stephen Phillips
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre and McMaster University, Hamilton, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Ontario, Canada
| | - George Medvedev
- University of British Columbia and the Fraser Health Authority, New Westminster, British Columbia, Canada
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, London, Ontario, Canada
| | - Aleksandra Pikula
- Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Jai Jai Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Heather Williams
- Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada
| | - Thalia S. Field
- Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Atif Zafar
- St Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Faysal Benali
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - MacKenzie Horn
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D. Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Michel Shamy
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Ontario, Canada
| | - Tolulope T. Sajobi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Richard H. Swartz
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
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Adenova G, Kausova G, Tazhiyeva A. Improving multidisciplinary hospital care for acute cerebral circulation disorders in Kazakhstan. Heliyon 2023; 9:e18435. [PMID: 37593645 PMCID: PMC10427984 DOI: 10.1016/j.heliyon.2023.e18435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Background According to the World Stroke Organization, there was a significant increase in stroke cases, stroke deaths, and the DALY rate in low- and middle-income countries in 2022. The number of stroke cases rose by 70.0%, stroke deaths reached 86.0%, and the DALY rate reached 89.0%. Among cerebrovascular diseases, ischemic stroke accounts for 62.0% of all strokes, with more than 7.6 million cases reported annually.Kazakhstan, with a population of 19,832,737, is the largest country in Central Asia in terms of territory. In Kazakhstan, the incidence of cerebrovascular disease has risen from 258.4 cases per 100,000 population in 2015 to 433.7 cases per 100,000 population in 2020. Official statistics indicate that the average inpatient mortality rate from stroke in the country is 16.2%, and the average time for patients to be delivered to the hospital after an ambulance call is 40 min (83.2%).Our study findings reveal that in the regions of Kazakhstan, the main contributors to the high morbidity and mortality rates in stroke are a shortage of doctors, inadequate primary healthcare, insufficient follow-up and treatment, and delayed hospitalization. Consequently, this study has helped fill knowledge gaps regarding the epidemiological situation in these regions and underscores the need for training doctors in managing high-risk patients, establishing multidisciplinary home visit teams, and establishing "Stroke Schools" to enhance public awareness of early stroke signs and the fundamentals of a healthy lifestyle. Future research endeavors should consider these study results as valuable contributions towards addressing the existing problems. Aim To study the prevalence and mortality of acute cerebral circulation impairment in the population within multidisciplinary hospitals in the cities of Nur-Sultan and Almaty, Republic of Kazakhstan, for the period of 2018-2020.This retrospective study was conducted in two stages. In the first stage, an analysis of morbidity, prevalence, and mortality was conducted for the population of Nur-Sultan and Almaty cities, as well as for the overall population of Kazakhstan. This analysis was based on data from the "Electronic Register of Discharged Patients" (IS ERDB) and the annual collection "Health of the Population of the Republic of Kazakhstan and the Activities of Health Organizations in 2015-2020". In the second stage, we examined the care provided to patients with acute impaired cerebral circulation in a multidisciplinary hospital in these two cities. The analysis was based on data regarding the sex and age composition of treated patients in hospitals across the Republic of Kazakhstan, categorized according to the ICD-10 code "Acute Impaired Cerebral Circulation" (I60-I64). We investigated the methods of patients' delivery to medical organizations, types of hospitalization, and outcomes of treated patients. The sample of patients was selected using data from the "Electronic Register of Dispensary Patients" of the Ministry of Health of the Republic of Kazakhstan, along with the statistical collection "Health of the Population of the Republic of Kazakhstan and the Activities of Healthcare Organizations". Between January 1, 2018, and December 31, 2020, a total of 5965 patients were diagnosed with a cerebrovascular event and admitted to a general hospital in Nur-Sultan city, while 13,498 patients were diagnosed and admitted in Almaty city.
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Affiliation(s)
| | - Galina Kausova
- Kazakhstan Medical University “KSPH”, Almaty, Kazakhstan
| | - Aigul Tazhiyeva
- Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
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Levy TJ, Hoare B. Therapy Choices for Children With Difficulties Using 1 Hand After a Brain Injury. Arch Phys Med Rehabil 2023; 104:1363-1366. [PMID: 37037294 DOI: 10.1016/j.apmr.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 04/12/2023]
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Leentjens J, Chornenki NLJ, Spiegelenberg J, Ly V, Dowlatshahi D, Siegal DM. A scoping review protocol on diagnostic strategies to detect occult malignancies in individuals with ischemic stroke. PLoS One 2023; 18:e0289048. [PMID: 37478139 PMCID: PMC10361530 DOI: 10.1371/journal.pone.0289048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 07/05/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Emerging data show an increased risk of ischemic stroke in patients with a new diagnosis of cancer. As the risk of stroke begins to increase 150 days before cancer is diagnosed, stroke may be the first clinical manifestation of undiagnosed cancer. About 6% of patients with cryptogenic ischemic stroke (unknown etiology after diagnostic evaluations) are diagnosed with cancer within one year. However, the optimal cancer screening strategy in this population is not known. We aim to conduct a scoping review of screening strategies for occult cancer in individuals with ischemic stroke. METHODS Electronic databases including MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCOhost) and Scopus will be systematically searched to identify articles that report on screening strategies for occult cancer in individuals with ischemic stroke. At least two investigators will independently perform two-stage study selection consisting of title/abstract screening and full-text review, followed by data extraction. Thereafter, a thematic analysis will be conducted to provide an overview of what diagnostic tests/strategies have been used, and their clinical utility in terms of positive and negative predictive value (when available). CONCLUSION We anticipate that the findings of this scoping review will identify strategies used to detect occult cancer in individuals with ischemic stroke and summarize their clinical utility (if reported). Addressing this knowledge gap will help guide the development of future clinical trials on occult cancer screening patients with ischemic stroke.
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Affiliation(s)
- Jenneke Leentjens
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Janneke Spiegelenberg
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Synapse Research Institute, Maastricht, The Netherlands
| | - Valentina Ly
- Health Sciences Library, University of Ottawa, Ottawa, Canada
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Affiliation(s)
- Melinda Davis
- Department of Anesthesiology, Perioperative, and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Sanjuan E, Pancorbo O, Santana K, Miñarro O, Sala V, Muchada M, Boned S, Juega JM, Pagola J, García-Tornel Á, Requena M, Rodríguez-Villatoro N, Rodríguez-Luna D, Deck M, Ribo M, Molina CA, Meler P, Romero V, Dalmases G, Rodríguez-Samaniego MT, Calleja L, Gutierrez T, Peña L, Gallego JC, Lorenzo E, Gonzalez Y, Moreno R, Rubiera M. Management of acute stroke. Specific nursing care and treatments in the stroke unit. Neurologia 2023:S2173-5808(23)00022-6. [PMID: 37120108 DOI: 10.1016/j.nrleng.2020.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/29/2020] [Indexed: 05/01/2023] Open
Abstract
OBJECTIVE This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.
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Affiliation(s)
- E Sanjuan
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| | - O Pancorbo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - K Santana
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - O Miñarro
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - V Sala
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Muchada
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - S Boned
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J M Juega
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J Pagola
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Á García-Tornel
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Requena
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - N Rodríguez-Villatoro
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - D Rodríguez-Luna
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Deck
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Ribo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - C A Molina
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - P Meler
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - V Romero
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - G Dalmases
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M T Rodríguez-Samaniego
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - L Calleja
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - T Gutierrez
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - L Peña
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J C Gallego
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - E Lorenzo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Y Gonzalez
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - R Moreno
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Rubiera
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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Bond VE, Doeltgen S, Kleinig T, Murray J. Dysphagia-related acute stroke complications: A retrospective observational cohort study. J Stroke Cerebrovasc Dis 2023; 32:107123. [PMID: 37058873 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107123] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/16/2023] Open
Abstract
OBJECTIVES Post-stroke dysphagia is associated with aspiration pneumonia, but strategies intended to mitigate this complication, such as oral intake modifications, may unintentionally lead to dehydration-related complications such as urinary tract infections (UTIs) and constipation. This study aimed to determine the rates of aspiration pneumonia, dehydration, UTI and constipation in a large cohort of acute stroke patients and the independent predictors of each complication. MATERIALS AND METHODS Data were extracted retrospectively for 31,953 acute stroke patients admitted to six hospitals in Adelaide, South Australia over a 20-year period. Tests of difference compared rates of complications between patients with and without dysphagia. Multiple logistic regression modelling explored variables that significantly predicted each complication. RESULTS In this consecutive cohort of acute stroke patients, with a mean (SD) age of 73.8 (13.8) years and 70.2% presenting with ischaemic stroke, rates of complications were: aspiration pneumonia (6.5%); dehydration (6.7%); UTI (10.1%); and constipation (4.4%). Each complication was significantly more prevalent for patients with dysphagia compared to those without. Controlling for demographic and other clinical variables, the presence of dysphagia independently predicted aspiration pneumonia (OR=2.61, 95% CI 2.21-3.07; p<.001), dehydration (OR=2.05, 95% CI 1.76-2.38; p<.001), UTI (OR=1.34, 95% CI 1.16-1.56; p<.001), and constipation (OR=1.30, 95% CI 1.07-1.59; p=.009). Additional predictive factors were increased age and prolonged hospitalisation. CONCLUSIONS Aspiration pneumonia, dehydration, UTI, and constipation are common acute sequelae of stroke and independently associated with dysphagia. Future dysphagia intervention initiatives may utilise these reported complication rates to evaluate their impact on all four adverse health complications.
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Affiliation(s)
- Verity E Bond
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Sebastian Doeltgen
- Speech Pathology, College of Nursing and Health Sciences, Swallowing Neurorehabilitation Research Laboratory, Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Timothy Kleinig
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Australia
| | - Joanne Murray
- Speech Pathology, College of Nursing and Health Sciences, Swallowing Neurorehabilitation Research Laboratory, Caring Futures Institute, Flinders University, Adelaide, Australia.
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Yuan J, Lu ZK, Xiong X, Li M, Liu Y, Wang LD, Liu R, Zhao J. Age and geographic disparities in acute ischaemic stroke prehospital delays in China: a cross-sectional study using national stroke registry data. Lancet Reg Health West Pac 2023; 33:100693. [PMID: 37181525 PMCID: PMC10166992 DOI: 10.1016/j.lanwpc.2023.100693] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/26/2022] [Accepted: 01/03/2023] [Indexed: 05/16/2023]
Abstract
Background Stroke has been the leading cause of death in China for decades. The extremely low intravenous thrombolysis rate is largely due to the prehospital delays that make patients ineligible for the time-sensitive therapy. Limited studies evaluated prehospital delays across China. We investigated prehospital delays in the stroke population across China and the associated age, rurality, and geographic disparities. Methods A cross-sectional study design was employed using the Bigdata Observatory platform for Stroke of China in 2020, the nationwide, prospective, multicentre registry of patients with acute ischaemic stroke (AIS). Mixed-effect regression models were used to account for the clustered data. Findings The sample contained 78,389 AIS patients. The median onset-to-door (OTD) time was 24 h, with only 11.79% (95% confidence interval [CI]: 11.56-12.02%) patients arriving at hospitals within 3 h. About 12.43% (95% CI: 12.11-12.74%) of patients 65 years or older arrived at hospitals within 3 h, which was significantly higher than the young and middle-aged patients (11.03%; 95% CI: 10.71-11.36%). After controlling for potential confounders, young and middle-aged patients were less likely to present to hospitals within 3 h (adjusted odds ratio: 0.95; 95% CI: 0.90-0.99) compared to patients 65 years or older. The 3-h hospital arrival rate was the highest in Beijing (18.40%, 95% CI: 16.01-20.79%), which was almost 5 times higher than that in Gansu (3.45%, 95% CI: 2.69-4.20%). The arrival rate in urban areas was almost 2 times higher than that in rural areas (13.35% versus. 7.66%). Interpretation We found that the low rates of timely arrival at hospitals after a stroke is more salient in the younger population, rural settings, or those residing in less developed geographic regions. This study calls for more tailored interventions focusing on younger people, rural areas, and less developed geographic regions. Funding The National Natural Science Foundation of China; CIHR, Grant/Award Number: 81973157, PI: JZ. Natural Science Foundation of Shanghai; CIHR, Grant/Award Number: 17dz2308400, PI: JZ. Funding from the University of Pennsylvania; Grant/Award Number: CREF-030, PI: RL.
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Affiliation(s)
- Jing Yuan
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, 826 Zhangheng Road, Pudong District, Shanghai, 201203, PR China
| | - Z. Kevin Lu
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, 715 Sumter Street, CLS Building 311, Columbia, SC, 29208, USA
| | - Xiaomo Xiong
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, 715 Sumter Street, CLS Building 311, Columbia, SC, 29208, USA
| | - Minghui Li
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis TN, USA
| | - Yang Liu
- Department of Neurology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201100, PR China
| | - Long-De Wang
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, 100053, PR China
| | - Renyu Liu
- Departments of Anesthesiology and Critical Care, and Neurology, Perelman School of Medicine at the University of Pennsylvania, 336 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201100, PR China
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Ye S, Pan H, Li W, Wang J, Zhang H. Development and validation of a clinical nomogram for differentiating hemorrhagic and ischemic stroke prehospital. BMC Neurol 2023; 23:95. [PMID: 36864378 PMCID: PMC9983153 DOI: 10.1186/s12883-023-03138-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/27/2023] [Indexed: 03/04/2023] Open
Abstract
OBJECTIVES The early detection and identification of stroke are essential to the prognosis of patients with suspected stroke symptoms out-of-hospital. We aimed to develop a risk prediction model based on the FAST score to identify the different types of strokes early for emergency medical services (EMS). METHODS This retrospective observational study enrolled 394 stroke patients at a single center from January 2020 to December 2021. Demographic data, clinical characteristics, and stroke risk factors with patients were collected from the EMS record database. Univariate and multivariate logistic regression analysis was used to identify the independent risk predictors. The nomogram was developed based on the independent predictors, in which the discriminative value and calibration of the nomogram were verified by the receiver operator characteristic (ROC) curve and calibration plots. RESULTS A total of 31.90% (88/276) of patients were diagnosed with hemorrhagic stroke in the training set, while 36.40% (43/118) in the validation set. The nomogram was developed based on the multivariate analysis, including age, systolic blood pressure, hypertension, vomiting, arm weakness, and slurred speech. The area under the curve (AUC) of the ROC with nomogram was 0.796 (95% CI: 0.740-0.852, P < 0.001) and 0.808 (95% CI:0.728-0.887, P < 0.001) in the training set and validation set, respectively. In addition, the AUC with the nomogram was superior to the FAST score in both two sets. The calibration curve showed a good agreement with the nomogram and the decision curves analysis also demonstrated that the nomogram had a wider range of threshold probabilities than the FAST score in the prediction risk of hemorrhagic stroke. CONCLUSIONS This novel noninvasive clinical nomogram shows a good performance in differentiating hemorrhagic and ischemic stroke for EMS staff prehospital. Moreover, all of the variables of nomogram are acquired in clinical practice easily and inexpensively out-of-hospital.
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Affiliation(s)
- Sheng Ye
- grid.443626.10000 0004 1798 4069Department of Emergency Medicine, The Second Affiliated Hospital of Wannan Medical College, Wuhu, Anhui China ,grid.443626.10000 0004 1798 4069Emergency Sub-Station, The Second Affiliated Hospital of Wannan Medical College, Wuhu, Anhui China
| | - Huiqing Pan
- grid.443626.10000 0004 1798 4069Department of Emergency Medicine, The Second Affiliated Hospital of Wannan Medical College, Wuhu, Anhui China ,grid.443626.10000 0004 1798 4069Emergency Sub-Station, The Second Affiliated Hospital of Wannan Medical College, Wuhu, Anhui China
| | - Weijia Li
- grid.443626.10000 0004 1798 4069School of Clinical Medicine, Wannan Medical College, Wuhu, Anhui China
| | - Jinqiang Wang
- grid.443626.10000 0004 1798 4069Emergency Sub-Station, The Second Affiliated Hospital of Wannan Medical College, Wuhu, Anhui China ,Department of Emergency Medicine, Wuhu Emergency Medical Center, Wuhu, Anhui China
| | - Hailong Zhang
- Emergency Sub-Station, The Second Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China. .,Department of Emergency Medicine, Wuhu Emergency Medical Center, Wuhu, Anhui, China.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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O'Brien E, Milentijevic D, Roychowdhury R, Mitra S, Chen CY. Antiplatelet treatment patterns and outcomes of secondary stroke prevention in the United States. Heliyon 2023; 9:e13579. [PMID: 36852046 DOI: 10.1016/j.heliyon.2023.e13579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 01/20/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
Objective Patients who have an ischemic stroke (IS) or transient ischemic attack (TIA) are at risk of having a secondary stroke. Single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) may be recommended for secondary stroke prevention (SSP), depending on severity and etiology. This study evaluated outpatient antiplatelet treatment patterns for SSP and outcomes after first hospitalization for IS/TIA among adults without atrial fibrillation in the United States. Materials and methods This retrospective observational study utilized data from an adjudicated administrative health claims database. Eligible patients had an imputed National Institutes of Health Stroke Scale index event score ≤7. Over-the-counter medication use (eg, aspirin) was not captured. Results Of 154,273 patients, 41,622 (27%) were prescribed antiplatelet therapy within 90 days of the event; 93.8% received SAPT, 6.1% received DAPT. The first line of antiplatelet therapy after discharge was started a mean of 17.0 days after the event; mean treatment duration was 61.9 days. The incidence rate for secondary IS was 5.53, 2.03, and 1.17 per person-year 90-days, 1-year, and 3-years following treatment initiation, respectively. Among patients matched for demographic and clinical characteristics, the risk of secondary IS was increased with DAPT versus SAPT (hazard ratio [95% CI]: 1.27 [1.20-1.34]; p < 0.0001). Conclusions Many patients were not prescribed or discontinued antiplatelet therapy within 90 days of hospitalization for IS/TIA and, in most cases, prescriptions were not compliant with SSP consensus guidelines. Patients remained at risk for IS, which was highest within 90 days. More effective strategies for SSP are needed to improve outcomes in this patient population.
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Ducroux C, Derex L, Nourredine M, Haesebaert J, Buisson M, Alesefir W, Boisseau W, Daneault N, Deschaintre Y, Diestro JDB, Eker O, Eneling J, Gioia LC, Iancu D, Jacquin G, Odier C, Stapf C, Raymond J, Roy D, Weill A, Lapergue B, Poppe AY; ETIS (Endovascular Treatment in Ischemic Stroke) Investigators. Successful thrombectomy is beneficial in patients with pre-stroke disability: Results from an international multicenter cohort study. J Neuroradiol 2023; 50:59-64. [PMID: 35341899 DOI: 10.1016/j.neurad.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion. METHODS Consecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes. RESULTS Among 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11-11.5]; p 0.048). CONCLUSION In patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.
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Field TS, Sposato LA, Hill MD, Healey JS, Andrade JG, Zhou LW. Embolic Stroke of Undetermined Source: Current Perspectives on Diagnosis, Investigations, and Management. Can J Cardiol 2023; 39:172-186. [PMID: 36272633 DOI: 10.1016/j.cjca.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 02/07/2023] Open
Abstract
In 2014, Hart et al. introduced the concept of "embolic stroke of undetermined source" (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, 2 large clinical trials have shown that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform poststroke workup, and secondary prevention strategies. Herein, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing, and anticipated clinical trials that will guide earlier and later secondary prevention strategies and poststroke cardiac investigations.
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Affiliation(s)
- Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Luciano A Sposato
- Schulich School of Medicine and Dentistry, Robarts Research Institute, Heart and Brain Laboratory, London, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jason G Andrade
- Division of Cardiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lily W Zhou
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada
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Abuelazm M, Seri AR, Awad AK, Ahmad U, Mahmoud A, Albazee E, Kambalapalli S, Abdelazeem B. The efficacy and safety of tenecteplase versus alteplase for acute ischemic stroke: an updated systematic review, pairwise, and network meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2023; 55:322-38. [PMID: 36449231 DOI: 10.1007/s11239-022-02730-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 12/05/2022]
Abstract
Tenecteplase (TNK) is a promising candidate to replace alteplase as the standard of care for acute ischemic stroke (AIS); however, the optimal dosage is still to be investigated. Therefore, we aim to evaluate the safety and efficacy of TNK versus alteplase and to investigate the optimal TNK dosage. A systematic review, pairwise, and network meta-analysis synthesizing randomized controlled trials (RCTs) from WOS, SCOPUS, EMBASE, and PubMed until July 26th, 2022. We used the risk ratio (RR) for dichotomous outcomes presented with the corresponding 95% confidence interval (CI). We registered our protocol in PROSPERO with ID: CRD42022352038. Nine RCTs with a total of 3,707 patients were included. TNK significantly led to complete recanalization (RR: 1.27 with 95% CI [1.02, 1.57], P = 0.03); however, we found no difference regarding early neurological improvement (RR: 1.07 with 95% CI [0.94, 1.21], P = 0.33) and excellent neurological recovery (RR: 1.03 with 95% CI [0.96, 1.10], P = 0.42). Also, TNK was similar to alteplase regarding mortality (RR: 0.99 with 95% CI [0.82, 1.18], P = 0.88), intracranial haemorrhage (RR: 1.00 with 95% CI [0.85, 1.18], P = 0.99), and parenchymal hematoma (RR: 1.13 with 95% CI [0.83, 1.54], P = 0.44). TNK in the dose of 0.25 mg is a viable candidate to displace alteplase as the standard of care in patients with an AIS within 4.5 h of presentation due to its better rate of early neurological recovery and non-inferiority in terms of safety outcomes. However, the evidence regarding TNK's role in AIS presenting after 4.5 h from symptoms onset, wake-up stroke, and minor stroke/TIA is still lacking, necessitating further double-blinded pragmatic RCTs in this regard.
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Cardoso AF, Ribeiro LE, Santos T, Pinto M, Rocha C, Magalhães J, Augusto B, Santos D, Duque FM, Fernandes BL, Sousa RC, Silva R, Ventura F, Fernandes AM, Cardoso D, Rodrigues R. Oral Hygiene in Patients with Stroke: A Best Practice Implementation Project Protocol. Nurs Rep 2023; 13:148-156. [PMID: 36810267 PMCID: PMC9944467 DOI: 10.3390/nursrep13010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
Oral hygiene has been shown to reduce adverse events and promote the quality of life of patients with stroke. However, a stroke can result in the impairment of physical, sensory, and cognitive abilities, and comprise self-care. Although nurses recognize its benefits, there are areas for improvement in the implementation of the best evidence-based recommendations. The aim is to promote compliance with the best evidence-based recommendations on oral hygiene in patients with stroke. This project will follow the JBI Evidence Implementation approach. The JBI Practical Application of Clinical Evidence System (JBI PACES) and the Getting Research into Practice (GRiP) audit and feedback tool will be used. The implementation process will be divided into three phases: (i) establishing a project team and undertaking the baseline audit; (ii) providing feedback to the healthcare team, identifying barriers to the implementation of best practices, and co-designing and implementing strategies using GRIP, and (iii) undertaking a follow-up audit to assess the outcomes and plan for sustainability. So, the successful adoption of the best evidence-based recommendations on oral hygiene in patients with stroke will reduce the adverse events related to poor oral care and may improve patients' quality of care. This implementation project has great transferability potential to other contexts.
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Affiliation(s)
- Ana Filipa Cardoso
- Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
- Health Sciences Research Unit: Nursing, Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence, Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- Correspondence:
| | - Liliana Escada Ribeiro
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
- Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-076 Coimbra, Portugal
| | - Teresa Santos
- Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-076 Coimbra, Portugal
| | - Maribel Pinto
- Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-076 Coimbra, Portugal
| | - Cláudia Rocha
- Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-076 Coimbra, Portugal
| | - Joana Magalhães
- Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-076 Coimbra, Portugal
| | - Berta Augusto
- Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-076 Coimbra, Portugal
| | - Diana Santos
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
- Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-076 Coimbra, Portugal
| | - Filipa Margarida Duque
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
| | - Beatriz Lavos Fernandes
- Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- Hospital de Cascais Dr. José de Almeida, Av. Brigadeiro Victor Novais Gonçalves, 2755-009 Alcabideche, Portugal
| | - Rosário Caixeiro Sousa
- Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- Hospital da Luz, Praceta Robalo Cordeiro, 1, 3020-479 Coimbra, Portugal
| | - Rosa Silva
- Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
- Health Sciences Research Unit: Nursing, Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence, Nursing School of Coimbra, 3004-011 Coimbra, Portugal
| | - Filipa Ventura
- Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
| | - António Manuel Fernandes
- Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
- Health Sciences Research Unit: Nursing, Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence, Nursing School of Coimbra, 3004-011 Coimbra, Portugal
| | - Daniela Cardoso
- Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
- Health Sciences Research Unit: Nursing, Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence, Nursing School of Coimbra, 3004-011 Coimbra, Portugal
| | - Rogério Rodrigues
- Nursing School of Coimbra, 3004-011 Coimbra, Portugal
- The Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Avenida Bissaya Barreto, 3004-011 Coimbra, Portugal
- Health Sciences Research Unit: Nursing, Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence, Nursing School of Coimbra, 3004-011 Coimbra, Portugal
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Brisebois A, Brambati SM, Rochon E, Leonard C, Marcotte K. The longitudinal trajectory of discourse from the hyperacute to the chronic phase in mild to moderate poststroke aphasia recovery: A case series study. Int J Lang Commun Disord 2023. [PMID: 36705070 DOI: 10.1111/1460-6984.12844] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/23/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Discourse analysis has recently received much attention in the aphasia literature. Even if post-stroke language recovery occurs throughout the longitudinal continuum of recovery, very few studies have documented discourse changes from the hyperacute to the chronic phases of recovery. AIMS To document a multilevel analysis of discourse changes from the hyperacute phase to the chronic phase of post-stroke recovery using a series of single cases study designs. METHODS & PROCEDURES Four people with mild to moderate post-stroke aphasia underwent four assessments (hyperacute: 0-24 h; acute: 24-72 h; subacute: 7-14 days; and chronic: 6-12 months post-onset). Three discourse tasks were performed at each time point: a picture description, a personal narrative and a story retelling. Multilevel changes in terms of macro- and microstructural aspects were analysed. The results of each discourse task were combined for each time point. Individual effect sizes were computed to evaluate the relative strength of changes in an early and a late recovery time frame. OUTCOMES & RESULTS Macrostructural results revealed improvements throughout the recovery continuum in terms of coherence and thematic efficiency. Also, the microstructural results demonstrated linguistic output improvement for three out of four participants. Namely, lexical diversity and the number of correct information units/min showed a greater gain in the early compared with the late recovery phase. CONCLUSIONS & IMPLICATIONS This study highlights the importance of investigating all discourse processing levels as the longitudinal changes in discourse operate differently at each phase of recovery. Overall results support future longitudinal discourse investigation in people with post-stroke aphasia. WHAT THIS PAPER ADDS What is already known on the subject Multi-level discourse analysis allows for in-depth analysis of underlying discourse processes. To date, very little is known on the longitudinal discourse changes from aphasia onset through to the chronic stage of recovery. This study documents multi-level discourse features in four people with mild to moderate aphasia in the hyperacute, acute, subacute and chronic stage of post-stroke aphasia recovery. What this paper adds to existing knowledge The study found that most discourse variables demonstrated improvement throughout time. Macrostructural variables of coherence and thematic units improved throughout the continuum whereas microstructural variables demonstrated greater gains in the early compared to the late period of recovery. What are the potential or actual clinical implications of this work? This study suggests that multilevel discourse analysis will allow a better understanding of post-stroke aphasia recovery, although more research is needed to determine the clinical utility of these findings. Future research may wish to investigate longitudinal discourse recovery in a larger sample of people with aphasia with heterogenous aphasia profiles and severities.
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Affiliation(s)
- Amélie Brisebois
- École d'orthophonie et d'audiologie, Faculté de médecine, Université de Montréal, Montreal, QC, Canada
- Centre de recherche du Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (Hôpital du Sacré-Cœur de Montréal), Montreal, QC, Canada
| | - Simona Maria Brambati
- Département de psychologie, Faculté des arts et des sciences, Université de Montréal, Montreal, QC, Canada
- Centre de recherche de l'Institut Universitaire de Gériatrie de Montréal, Montreal, QC, Canada
| | - Elizabeth Rochon
- Department of Speech-Language Pathology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Heart and Stroke Foundation, Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Carol Leonard
- Department of Speech-Language Pathology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Heart and Stroke Foundation, Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
- School of Rehabilitation Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Karine Marcotte
- École d'orthophonie et d'audiologie, Faculté de médecine, Université de Montréal, Montreal, QC, Canada
- Centre de recherche du Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (Hôpital du Sacré-Cœur de Montréal), Montreal, QC, Canada
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Zhang X, Liu J, Han H, Zhang P, Chen X, Yuan H, Chen M, Zhu Q, Liebeskind DS, Miao Z. Effectiveness and safety of the Trevo® Retriever for mechanical thrombectomy in Chinese patients with acute ischemic stroke: Trevo Retriever China Registry. Interv Neuroradiol 2023:15910199231151275. [PMID: 36703568 DOI: 10.1177/15910199231151275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND To quantify the effectiveness and safety of the Trevo® Retriever for endovascular treatment of acute ischemic stroke (AIS) patients in China. METHODS Trevo Retriever Registry (China) was a prospective, multicenter, non-comparative, open-label study of patients with AIS treated with the Trevo Retriever. The primary outcome was the proportion of patients achieving an expanded Thrombolysis in Cerebral Infarction (eTICI) score ≥2b at the end of endovascular treatment. Secondary outcomes included first-pass eTICI score ≥2b and 90-day modified Rankin Scale (mRS) score ≤2. RESULTS The Trevo Retriever Registry (China) enrolled and followed 201 patients (62.1 ± 12.5 years-old; 70.6% male) at 11 centers. The pre-procedure NIHSS score and ASPECTS were 16 (interquartile range (IQR), 13-21) and 7 (IQR, 6-9), respectively, and 188 (93.5%) patients had an mRS score of 0 prior to the stroke. The main stroke etiology was large artery atherosclerosis, accounting for 71.6% (144/201) of patients. Post-procedure eTICI ≥2b was 98.4% (187/190). First-pass eTICI ≥2b was 74.7% (136/182). The 90-day good outcome (mRS ≤2) rate was 73.6% (148/201). The 90-day all-cause mortality was 5.5% (11/201). Neurological deterioration at 24 h post-procedure was observed in 7.7% (15/195) patients. Embolism in a new territory was seen in one patient (0.5%). Two (1.0%) procedure-related adverse events (AEs) occurred, which were intra-procedure cerebral artery embolism. No Trevo related AEs occurred. CONCLUSIONS This real-world study of the Trevo Retriever in China demonstrated a high rate of revascularization and first-pass success that resulted in an overall high good function outcome rate and low mortality.
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Affiliation(s)
- Xuelei Zhang
- Department of Neurointerventional, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Jinchao Liu
- 117938Puyang Oilfield General Hospital, Puyang, China
| | - Hongxing Han
- Department of Neurology, 529858Linyi People's Hospital, Linyi, China
| | - Pinyuan Zhang
- Department of Neurosurgery (Cerebrovascular Disease), The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xianglin Chen
- Department of Cerebrovascular Disease, 534795Qingyuan People's Hospital, Qingyuan, China
| | - Haicheng Yuan
- Department of Neurology, Qingdao Central Hospital, Qingdao, China
| | - Maohua Chen
- Department of Neurosurgery, Wenzhou Central Hospital, Wenzhou, China
| | - Qiyi Zhu
- Department of Neurology, 529858Linyi People's Hospital, Linyi, China
| | - David S Liebeskind
- Department of Neurology and UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - Zhongrong Miao
- Department of Neurointerventional, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
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Rizos T, Jenetzky E, Nabavi DG, Haeusler KG, Wachter R, Ossenbrink M, Ringleb PA, Busse O. Echocardiography in acute stroke patients: a nationwide analysis in departments with certified stroke units in Germany. Neurol Res Pract 2023; 5:3. [PMID: 36653887 PMCID: PMC9850591 DOI: 10.1186/s42466-022-00229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/19/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Echocardiography is highly relevant in patients with ischemic stroke or TIA. Utilization of routine echocardiographic examinations [transthoracic (TTE) or transesophageal (TEE)] on stroke units remains however unknown. To representatively examine echocardiographic rates on stroke units in Germany and to evaluate structural factors that may influence the decision to conduct echocardiography. METHODS A nationwide analysis was performed by using certification audit data of all primary and comprehensive stroke centers (pSC and cSC) in Germany. RESULTS Structural and organizational requirements of 310 departments (cSCs: 42.6%) were extracted. Median TTE rate was 63.3% (IQR 39.3-80.8), median TEE rate 21.3% (IQR 16.4-29.5). A cardiological department on site was present in 74.2%, and they were associated with higher TEE rates. TTE rates decreased with increasing numbers of patients (p = 0.026). Likewise, TEE rates decreased with increasing numbers of patients (p = 0.006), mediated by departments with cSCs (p = 0.008 for cSCs vs p = 0.230 for pSCs). TTE rates were far more inhomogeneously distributed than TEE rates and higher in pSCs (p = 0.011). Overall, 12.9% of centers did not perform any echocardiographic examination in at least 50% of all stroke patients. CONCLUSION More detailed recommendations regarding echocardiography should be included in future guidelines. Moreover, evaluating the impact of echocardiographic examinations on long-term prognosis in stroke patients should be focus of further evaluations.
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Affiliation(s)
- Timolaos Rizos
- grid.7700.00000 0001 2190 4373Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Ekkehart Jenetzky
- grid.412581.b0000 0000 9024 6397Faculty of Health/School of Medicine, Witten/Herdecke University, Witten, Germany ,grid.5802.f0000 0001 1941 7111Department for Child and Adolescent Psychiatry, Johannes Gutenberg-University, Mainz, Germany
| | - Darius Günther Nabavi
- grid.433867.d0000 0004 0476 8412Department of Neurology, Vivantes Klinikum Neukölln, Rudower Str 48, 12351 Berlin, Germany
| | - Karl Georg Haeusler
- grid.8379.50000 0001 1958 8658Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Rolf Wachter
- grid.411339.d0000 0000 8517 9062Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Martin Ossenbrink
- grid.469884.f0000 0001 2034 2604LGA InterCert GmbH, Nuremberg, Germany
| | - Peter Arthur Ringleb
- grid.7700.00000 0001 2190 4373Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Otto Busse
- Deutsche Schlaganfall Gesellschaft, Berlin, Germany
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Lee SY, Ro YS, Shin SD, Ko E, Kim SJ. Epidemiology of patients who died in the emergency departments and need of end-of-life care in Korea from 2016 to 2019. Sci Rep 2023; 13:686. [PMID: 36639721 PMCID: PMC9839758 DOI: 10.1038/s41598-023-27947-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
The need of palliative care at the end-of-life in the emergency departments (ED) is growing. The study aims to investigate the epidemiology of patients who died during care in ED using nationwide database, and to estimate the need for palliative care in the ED. A retrospective observational study was conducted using the National Emergency Department Information System (NEDIS) database. Patients who died during ED care between 2016 and 2019 were included. Palliative care-eligible disease was defined as cancer (C00-C99 of ICD-10), chronic respiratory disease (CRD, J44-J46), chronic liver disease (CLD, K70-K77), and heart failure (HF, I50). Among the 36,538,486 ED visits during 4 years, 34,086 ED deaths were included. The crude incidence rate of ED deaths per 100,000 person-year was steady between 16.6 in 2016 and 16.3 in 2019 (p-for-trend = 0.067). Only 3370 (9.9%) ED deaths were injury, while 30,716 (90.1%) deaths were related to diseases. The most common ED diagnosis was cardiac arrest (22.1%), followed by pneumonia (8.6%) and myocardial infarction (4.7%). In cases of disease-related ED deaths, about 34.0% stayed longer than 8 h in the ED (median (interquartile range): 4.5 (1.9-11.7) h) and 44.2% received cardiopulmonary resuscitation (CPR) at end-of-life time. A quarter of the disease-related ED deaths were diagnosed with palliative care eligible disease: cancer (16.9%), CLD (3.8%), HF (3.5%), and CRD (1.4%). Cancer patients received less CPR (23.4%) and stayed longer in the ED (median (interquartile range): 7.3 (3.2-15.9) h). Over the past 4 years, more than 30,000 patients, including 5200 cancer patients, died during care in the ED. A quarter of disease-related ED death were patients with palliative care-eligible condition and more than 30% of them stayed longer than 8 h in the ED before death. It is time to discuss about need of palliative care in the ED.
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Affiliation(s)
- Sun Young Lee
- grid.412484.f0000 0001 0302 820XPublic Healthcare Center, Seoul National University Hospital, Seoul, Korea ,grid.412484.f0000 0001 0302 820XLaboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea ,grid.31501.360000 0004 0470 5905Department of Medicine, Seoul National University college of Medicine, Seoul, Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea. .,Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Korea. .,Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea. .,National Emergency Medical Center, National Medical Center, Seoul, Korea.
| | - Sang Do Shin
- grid.412484.f0000 0001 0302 820XLaboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea ,grid.412484.f0000 0001 0302 820XDepartment of Emergency Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Korea ,grid.31501.360000 0004 0470 5905Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eunsil Ko
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, Seoul, Korea
| | - Seong Jung Kim
- National Emergency Medical Center, National Medical Center, Seoul, Korea. .,Department of Emergency Medicine, Chosun University Hospital, 365 Pilmun-Daero, Dong-Gu, Gwangju, 61453, Korea.
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 158] [Impact Index Per Article: 158.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Chen BY, Gupta H, Yacas C, Snyder HE, Lee C, Bharwani A, Jung J, Suk Y, Surendran V, Chen S, Zawawi I, Ma YF, MacGregor S, Sharma M. Effects of delay to stroke unit admission in patients with ischemic and hemorrhagic stroke. Can J Neurol Sci 2023; 50:10-6. [PMID: 35094743 DOI: 10.1017/cjn.2021.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the association between delay in transfer to a central stroke unit from peripheral institutions and outcomes. METHODS We conducted a retrospective cohort study of all patients with acute stroke, admitted to a comprehensive stroke center (CSC) from three emergency departments (EDs), between 2016 and 2018. The primary outcomes were length of stay, functional status at 3 months, discharge destination, and time to stroke investigations. RESULTS One thousand four hundred thirty-five patients were included, with a mean age of 72.9 years, and 92.4% ischemic stroke; 663 (46.2%) patients were female. Each additional day of delay was associated with 2.0 days of increase in length of stay (95% confidence interval [CI] 0.8-3.2, p = 0.001), 11.5 h of delay to vascular imaging (95% CI 9.6-13.4, p < 0.0001), 24.2 h of delay to Holter monitoring (95% CI 7.9-40.6, p = 0.004), and reduced odds of nondisabled functional status at 3 months (odds ratio 0.98, 95% CI 0.96-1.00, p = 0.01). Factors affecting delay included stroke onset within 6 h of ED arrival (605.9 min decrease in delay, 95% CI 407.9-803.9, p < 0.0001), delay to brain imaging (59.4 min increase in delay for each additional hour, 95% CI 48.0-71.4, p < 0.0001), admission from an alternative service (3918.7 min increase in delay, 95% CI 3621.2-4079.9, p < 0.0001), and transfer from a primary stroke center (PSC; 740.2 min increase in delay, 95% CI 456.2-1019.9, p < 0.0001). CONCLUSION Delay to stroke unit admission in a system involving transfer from PSCs to a CSC was associated with longer hospital stay and poorer functional outcomes.
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