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Schwabauer E, Piccininni M, Freitag E, Ebinger M, Geisler F, Harmel P, Hille A, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Kurth T, Rohmann JL, Endres M, Schlunk F, Weber J, Wendt M, Audebert HJ. Effects of Mobile Stroke Unit dispatch on blood pressure management and outcomes in patients with intracerebral haematoma: Results from the Berlin_Prehospital Or Usual Care Delivery in acute Stroke (B_PROUD) controlled intervention study. Eur Stroke J 2024; 9:366-375. [PMID: 38014623 DOI: 10.1177/23969873231213156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION In patients with acute intracerebral haemorrhage (ICH) and elevated systolic blood pressure (BP), guidelines suggest that systolic BP reduction to <140 mmHg should be rapidly initiated. Compared with conventional care, Mobile Stroke Units (MSUs) allow for earlier ICH diagnosis through prehospital imaging and earlier BP lowering. PATIENTS AND METHODS ICH patients were prospectively evaluated as a cohort of the controlled B_PROUD-study in which MSU availability alone determined MSU dispatch in addition to conventional ambulance. We used inverse probability of treatment weighting to adjust for confounding to estimate the effect of additional MSU dispatch in ICH patients. Outcomes of interest were 7-day mortality (primary), systolic BP (sBP) at hospital arrival, dispatch-to-imaging time, largest haematoma volume, anticoagulation reversal, length of in-hospital stay, 3-month functional outcome. RESULTS Between February 2017 and May 2019, MSUs were dispatched to 95 (mean age: 72 ± 13 years, 45% female) and only conventional ambulances to 78 ICH patients (mean age: 71 ± 12 years, 44% female). After adjusting for confounding, we found shorter dispatch-to-imaging time (mean difference: -17.75 min, 95% CI: -27.16 to -8.21 min) and lower sBP at hospital arrival (mean difference = -16.31 mmHg, 95% CI: -30.64 to -6.19 mmHg) in the MSU group. We found no statistically significant difference for the other outcomes, including 7-day mortality (adjusted odds ratio: 1.43, 95% CI: 0.68 to 3.31) or favourable outcome (adjusted odds ratio = 0.67, 95% CI: 0.27 to 1.67). CONCLUSIONS Although MSU dispatch led to sBP reduction and lower dispatch-to-imaging time compared to conventional ambulance care, we found no evidence of better outcomes in the MSU dispatch group.
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Nechaeva T, Verra L, Pucek J, Ranc L, Bergamaschi M, Zevi Della Porta G, Muggli P, Agnello R, Ahdida CC, Amoedo C, Andrebe Y, Apsimon O, Apsimon R, Arnesano JM, Bencini V, Blanchard P, Burrows PN, Buttenschön B, Caldwell A, Chung M, Cooke DA, Davut C, Demeter G, Dexter AC, Doebert S, Farmer J, Fasoli A, Fonseca R, Furno I, Granados E, Granetzny M, Graubner T, Grulke O, Gschwendtner E, Guran E, Henderson J, Kedves MÁ, Kim SY, Kraus F, Krupa M, Lefevre T, Liang L, Liu S, Lopes N, Lotov K, Martinez Calderon M, Mazzoni S, Moon K, Morales Guzmán PI, Moreira M, Okhotnikov N, Pakuza C, Pannell F, Pardons A, Pepitone K, Poimenidou E, Pukhov A, Rey S, Rossel R, Saberi H, Schmitz O, Senes E, Silva F, Silva L, Spear B, Stollberg C, Sublet A, Swain C, Topaloudis A, Torrado N, Turner M, Velotti F, Verzilov V, Vieira J, Welsch C, Wendt M, Wing M, Wolfenden J, Woolley B, Xia G, Yarygova V, Zepp M. Hosing of a Long Relativistic Particle Bunch in Plasma. PHYSICAL REVIEW LETTERS 2024; 132:075001. [PMID: 38427892 DOI: 10.1103/physrevlett.132.075001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/16/2024] [Indexed: 03/03/2024]
Abstract
Experimental results show that hosing of a long particle bunch in plasma can be induced by wakefields driven by a short, misaligned preceding bunch. Hosing develops in the plane of misalignment, self-modulation in the perpendicular plane, at frequencies close to the plasma electron frequency, and are reproducible. Development of hosing depends on misalignment direction, its growth on misalignment extent and on proton bunch charge. Results have the main characteristics of a theoretical model, are relevant to other plasma-based accelerators and represent the first characterization of hosing.
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Kaffes M, Bondi F, Geisler F, Grittner U, Haacke L, Ihl T, Lorenz M, Schehadat MS, Schwabauer E, Wendt M, Zuber M, Kübler-Weller D, Lorenz-Meyer I, Sanchez JC, Montaner J, Audebert HJ, Weber JE. Optimization of sensitivity and specificity of a biomarker-based blood test (LVOCheck-Opti): A protocol for a multicenter prospective observational study of patients suspected of having a stroke. Front Neurol 2024; 14:1327348. [PMID: 38371304 PMCID: PMC10870936 DOI: 10.3389/fneur.2023.1327348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Introduction Acute ischemic stroke (AIS) is a time-critical medical emergency. For patients with large-vessel occlusions (LVO), mechanical thrombectomy (MT) is the gold-standard treatment. Mobile Stroke Units (MSUs) provide on-site diagnostic capabilities via computed tomography (CT) and have been shown to improve functional outcomes in stroke patients, but are cost-efficient only in urban areas. Blood biomarkers have recently emerged as possible alternative to cerebral imaging for LVO diagnosis. Prehospital LVO diagnosis offers the potential to transport patients directly to centers that have MT treatment available. In this study, we assess the accuracy of combining two biomarkers, HFABP and NT-proBNP, with clinical indicators to detect LVO using ultra-early prehospital blood samples. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00030399). Methods and analysis We plan a multicenter prospective observational study with 800 patients with suspected stroke enrolled within 24 h of symptom onset. Study participants will be recruited at three sites (MSUs) in Berlin, Germany. Blood-samples will be taken pre-hospitally at the scene and tested for HFABP and NT-proBNP levels. Additional clinical data and information on final diagnosis will be collected and documented in an electronic case report form (eCRF). Sensitivity and specificity of the combination will be calculated through iterative permutation-response calculations. Discussion This study aims to evaluate the diagnostic capabilities of a combination of the biomarkers HFABP and NT-proBNP in LVO prediction. In contrast to most other biomarker studies to date, by employing MSUs as study centers, ultra-early levels of biomarkers can be analyzed. Point-of-care LVO detection in suspected stroke could lead to faster treatment in both urban and rural settings and thus improve functional outcomes on a broader scale. Clinical trial registration Deutsches Register klinischer Studien https://drks.de/search/de/trial/DRKS00030399, DRKS00030399.
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Geisler F, Haacke L, Lorenz M, Schwabauer E, Wendt M, Bernhardt L, Dashti E, Freitag E, Kunz A, Hofmann-Shen C, Zuber M, Waldschmidt C, Kandil FI, Kappert K, Dang-Heine C, Lorenz-Meyer I, Audebert HJ, Weber JE. Prospective collection of blood plasma samples to identify potential biomarkers for the prehospital stroke diagnosis (ProGrEss-Bio): study protocol for a multicenter prospective observational study. Front Neurol 2023; 14:1201130. [PMID: 37483444 PMCID: PMC10359480 DOI: 10.3389/fneur.2023.1201130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/09/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are well-established, evidence-based, time-critical therapies that reduce morbidity and mortality in acute ischemic stroke (AIS) patients. The exclusion of intracerebral hemorrhage (ICH) is mandatory and has been performed by cerebral imaging to date. Mobile stroke units (MSUs) have been shown to improve functional outcomes by bringing cerebral imaging and IVT directly to the patient, but they have limited coverage. Blood biomarkers clearly distinguishing between AIS, ICH, and stroke mimics (SM) could provide an alternative to cerebral imaging if concentration changes are detectable in the hyperacute phase after stroke with high diagnostic accuracy. In this study, we will take blood samples in a prehospital setting to evaluate potential biomarkers. The study was registered in the German Clinical Trials Register (https://drks.de/search/de) with the identifier DRKS00023063. Methods and analysis We plan a prospective, observational study involving 300 patients with suspected stroke and symptom onset of ≤4.5 h before the collection of biomarkers. Study participants will be recruited from three sites in Berlin, Germany during MSU deployments. The focus of the study is the collection of blood samples from participants at the prehospital scene and from participants with AIS or ICH at a second-time point. All samples will be analyzed using targeted and untargeted analytical approaches. Study-related information about participants, including medical information and discharge diagnoses from the subsequent treating hospital, will be collected and documented in an electronic case report form (eCRF). Discussion This study will evaluate whether a single blood biomarker or a combination of biomarkers can distinguish patients with AIS and ICH from patients with stroke and SM in the early phase after symptom onset in the prehospital setting. In addition, the kinetics of blood biomarkers in AIS and ICH patients will be investigated. Our goal is to evaluate new ways to reliably diagnose stroke in the prehospital setting and thus accelerate the application of evidence-based therapies to stroke patients.
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Czycholl I, Büttner K, Becker D, Schwennen C, Baumgärtner W, Otten W, Wendt M, Puff C, Krieter J. Are biters sick? Health status of tail biters in comparison to control pigs. Porcine Health Manag 2023; 9:19. [PMID: 37161469 PMCID: PMC10170755 DOI: 10.1186/s40813-023-00314-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/27/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Tail biting is a multifactorial problem. As the health status is one of the factors commonly linked to tail biting, this study focuses on the health of identified biters. 30 (obsessive) biters are compared to 30 control animals by clinical and pathological examination as well as blood and cerebrospinal fluid samples. In that way, altogether 174 variables are compared between the groups. Moreover, connections between the variables are analysed. RESULTS In the clinical examination, 6 biters, but only 2 controls (P = 0.019) were noticeably agitated in the evaluation of general behaviour, while 8 controls were noticeably calmer (2 biters, P = 0.02). Biters had a lower body weight (P = 0.0007) and 13 biters had overlong bristles (4 controls, P = 0.008). In the pathological examination, 5 biters, but none of the controls had a hyperceratosis or inflammation of the pars proventricularis of the stomach (P = 0.018). However, 7 controls and only 3 biters were affected by gut inflammation (P = 0.03). In the blood sample, protein and albumin levels were below normal range for biters (protein: 51.6 g/l, albumin: 25.4 g/l), but not for controls (protein: 53.7 g/l, albumin: 27.4 g/l), (protein: P = 0.05, albumin: P = 0.02). Moreover, 14 biters, but only 8 controls had poikilocytosis (P = 0.05). Although not statistically different between groups, many animals (36/60) were affected by hypoproteinemia and hyponatremia as well as by hypokalemia (53/60) and almost all animals (58/60) had hypomagnesemia. For hypomagnesemia, significant connections with variables linked to tail damage and ear necrosis were detected (rs/V/ρ ≥ 0.4, P ≤ 0.05). CONCLUSION The results suggest that behavioural tests might be helpful in identifying biters. Moreover, cornification and inflammation of the pars proventricularis is linked to becoming a biter. Furthermore, the results highlight the need for appropriate and adjusted nutrient and mineral supply, especially with regard to magnesium.
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Rohmann JL, Piccininni M, Ebinger M, Wendt M, Weber JE, Schwabauer E, Geisler F, Freitag E, Harmel P, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Nolte CH, Nabavi DG, Schmehl I, Ekkernkamp A, Endres M, Audebert HJ. Effect of Mobile Stroke Unit Dispatch in all Patients with Acute Stroke or TIA. Ann Neurol 2023; 93:50-63. [PMID: 36309933 DOI: 10.1002/ana.26541] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/28/2022] [Accepted: 10/28/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the effect of additional mobile stroke unit (MSU) dispatch on functional outcomes among the full spectrum of stroke patients, regardless of subtype or potential contraindications to reperfusion therapies. METHODS We used data from the nonrandomized Berlin-based B_PROUD study (02/2017 to 05/2019), in which MSUs were dispatched based solely on availability, and the linked B-SPATIAL stroke registry. All patients with final stroke or transient ischemic attack (TIA) diagnoses were eligible. The intervention under study was the additional dispatch of an MSU, an emergency physician-staffed ambulance equipped to provide prehospital imaging and thrombolytic treatment, compared to conventional ambulance alone. The primary outcome was the 3-month modified Rankin Scale (mRS) score, and the co-primary outcome was a 3-tiered disability scale. We identified confounders using directed acyclic graphs and obtained adjusted effect estimates using inverse probability of treatment weighting. RESULTS MSUs were dispatched to 1,125 patients (mean age: 74 years, 46.5% female), while for 1,141 patients only conventional ambulances were dispatched (75 years, 49.9% female). After confounding adjustment, MSU dispatch was associated with more favorable 3-month mRS scores (common odds ratio [cOR] = 0.82; 95% confidence interval [CI]: 0.71-0.94). No statistically significant association was found with the co-primary outcome (cOR = 0.86; 9% CI: 0.72-1.01) or 7-day mortality (OR = 0.94; 95% CI: 0.59-1.48). INTERPRETATION When considering the entire population of stroke/TIA patients, MSU dispatch improved 3-month functional outcomes without evidence of compromised safety. Our results are relevant for decision-makers since stroke subtype and treatment eligibility are unknown at time of dispatch. ANN NEUROL 2023;93:50-63.
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Schoekel A, Etter M, Glaser L, Rothkirch A, Wendt M. Strain mapping of metallic cultural heritage objects with synchrotron microbeams. ACTA CRYSTALLOGRAPHICA SECTION A FOUNDATIONS AND ADVANCES 2022. [DOI: 10.1107/s2053273322090076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Verra L, Zevi Della Porta G, Pucek J, Nechaeva T, Wyler S, Bergamaschi M, Senes E, Guran E, Moody JT, Kedves MÁ, Gschwendtner E, Muggli P, Agnello R, Ahdida CC, Goncalves MCA, Andrebe Y, Apsimon O, Apsimon R, Arnesano JM, Bachmann AM, Barrientos D, Batsch F, Bencini V, Blanchard P, Burrows PN, Buttenschön B, Caldwell A, Chappell J, Chevallay E, Chung M, Cooke DA, Davut C, Demeter G, Dexter AC, Doebert S, Elverson FA, Farmer J, Fasoli A, Fedosseev V, Fonseca R, Furno I, Gorn A, Granados E, Granetzny M, Graubner T, Grulke O, Hafych V, Henderson J, Hüther M, Khudiakov V, Kim SY, Kraus F, Krupa M, Lefevre T, Liang L, Liu S, Lopes N, Lotov K, Martinez Calderon M, Mazzoni S, Medina Godoy D, Moon K, Morales Guzmán PI, Moreira M, Nowak E, Pakuza C, Panuganti H, Pardons A, Pepitone K, Perera A, Pukhov A, Ramjiawan RL, Rey S, Schmitz O, Silva F, Silva L, Stollberg C, Sublet A, Swain C, Topaloudis A, Torrado N, Tuev P, Velotti F, Verzilov V, Vieira J, Weidl M, Welsch C, Wendt M, Wing M, Wolfenden J, Woolley B, Xia G, Yarygova V, Zepp M. Controlled Growth of the Self-Modulation of a Relativistic Proton Bunch in Plasma. PHYSICAL REVIEW LETTERS 2022; 129:024802. [PMID: 35867433 DOI: 10.1103/physrevlett.129.024802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/12/2022] [Indexed: 06/15/2023]
Abstract
A long, narrow, relativistic charged particle bunch propagating in plasma is subject to the self-modulation (SM) instability. We show that SM of a proton bunch can be seeded by the wakefields driven by a preceding electron bunch. SM timing reproducibility and control are at the level of a small fraction of the modulation period. With this seeding method, we independently control the amplitude of the seed wakefields with the charge of the electron bunch and the growth rate of SM with the charge of the proton bunch. Seeding leads to larger growth of the wakefields than in the instability case.
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Glazyrin K, Khandarkhaeva S, Fedotenko T, Dong W, Laniel D, Seiboth F, Schropp A, Garrevoet J, Brückner D, Falkenberg G, Kubec A, David C, Wendt M, Wenz S, Dubrovinsky L, Dubrovinskaia N, Liermann HP. Sub-micrometer focusing setup for high-pressure crystallography at the Extreme Conditions beamline at PETRA III. JOURNAL OF SYNCHROTRON RADIATION 2022; 29:654-663. [PMID: 35510998 PMCID: PMC9070721 DOI: 10.1107/s1600577522002582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/07/2022] [Indexed: 06/14/2023]
Abstract
Scientific tasks aimed at decoding and characterizing complex systems and processes at high pressures set new challenges for modern X-ray diffraction instrumentation in terms of X-ray flux, focal spot size and sample positioning. Presented here are new developments at the Extreme Conditions beamline (P02.2, PETRA III, DESY, Germany) that enable considerable improvements in data collection at very high pressures and small scattering volumes. In particular, the focusing of the X-ray beam to the sub-micrometer level is described, and control of the aberrations of the focusing compound refractive lenses is made possible with the implementation of a correcting phase plate. This device provides a significant enhancement of the signal-to-noise ratio by conditioning the beam shape profile at the focal spot. A new sample alignment system with a small sphere of confusion enables single-crystal data collection from grains of micrometer to sub-micrometer dimensions subjected to pressures as high as 200 GPa. The combination of the technical development of the optical path and the sample alignment system contributes to research and gives benefits on various levels, including rapid and accurate diffraction mapping of samples with sub-micrometer resolution at multimegabar pressures.
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Greif G, Mrowietz C, Wendt M, Jung F, Hiebl B, Meyer-Sievers H. Differences in human and minipig platelet number, volume and activation induced by borosilicate glass beads in a modified chandler loop-system. Clin Hemorheol Microcirc 2021; 79:149-155. [PMID: 34487038 DOI: 10.3233/ch-219201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The pig is the most widely used large animal model in Europe, with cardiovascular research being one of the main areas of application. Adequate refinement of interventional studies in this field, meeting the requirements of Russel and Burchs' 3 R concept, can only be performed if blood-contacting medical devices are hemocompatible. Because most medical devices for cardiovascular interventional procedures are developed for humans they are tested mostly for compatibility with human blood. The aim of this study was therefore to determine whether there are differences in behavior of porcine and human platelets when they come into contact with glass, which was used as an exemplary thrombogenic material. For this purpose changes of platelet count, platelet volume and platelet expression of the activation markers CD61, CD62P and CD63 were measured using a modified chandler loop-system simulating the fluidic effects of the blood flow. Minipig and human platelets showed significant differences in number and volume, but not in activation after 4-8 min exposure to glass.
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Batsch F, Muggli P, Agnello R, Ahdida CC, Amoedo Goncalves MC, Andrebe Y, Apsimon O, Apsimon R, Bachmann AM, Baistrukov MA, Blanchard P, Braunmüller F, Burrows PN, Buttenschön B, Caldwell A, Chappell J, Chevallay E, Chung M, Cooke DA, Damerau H, Davut C, Demeter G, Deubner HL, Doebert S, Farmer J, Fasoli A, Fedosseev VN, Fiorito R, Fonseca RA, Friebel F, Furno I, Garolfi L, Gessner S, Gorgisyan I, Gorn AA, Granados E, Granetzny M, Graubner T, Grulke O, Gschwendtner E, Hafych V, Helm A, Henderson JR, Hüther M, Kargapolov IY, Kim SY, Kraus F, Krupa M, Lefevre T, Liang L, Liu S, Lopes N, Lotov KV, Martyanov M, Mazzoni S, Medina Godoy D, Minakov VA, Moody JT, Moon K, Morales Guzmán PI, Moreira M, Nechaeva T, Nowak E, Pakuza C, Panuganti H, Pardons A, Perera A, Pucek J, Pukhov A, Ramjiawan RL, Rey S, Rieger K, Schmitz O, Senes E, Silva LO, Speroni R, Spitsyn RI, Stollberg C, Sublet A, Topaloudis A, Torrado N, Tuev PV, Turner M, Velotti F, Verra L, Verzilov VA, Vieira J, Vincke H, Welsch CP, Wendt M, Wing M, Wiwattananon P, Wolfenden J, Woolley B, Xia G, Zepp M, Zevi Della Porta G. Transition between Instability and Seeded Self-Modulation of a Relativistic Particle Bunch in Plasma. PHYSICAL REVIEW LETTERS 2021; 126:164802. [PMID: 33961468 DOI: 10.1103/physrevlett.126.164802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/18/2021] [Accepted: 03/09/2021] [Indexed: 06/12/2023]
Abstract
We use a relativistic ionization front to provide various initial transverse wakefield amplitudes for the self-modulation of a long proton bunch in plasma. We show experimentally that, with sufficient initial amplitude [≥(4.1±0.4) MV/m], the phase of the modulation along the bunch is reproducible from event to event, with 3%-7% (of 2π) rms variations all along the bunch. The phase is not reproducible for lower initial amplitudes. We observe the transition between these two regimes. Phase reproducibility is essential for deterministic external injection of particles to be accelerated.
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Wendt M, Kocur P, Lewandowski J, Waszak M. Effect of the Combined Therapy of the Muscle Energy Technique and Trigger Point Therapy on the Biophysical Parameters of the Trapezius Muscle: a Randomized Clinical Trial. Muscles Ligaments Tendons J 2021. [DOI: 10.32098/mltj.01.2021.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ebinger M, Siegerink B, Kunz A, Wendt M, Weber JE, Schwabauer E, Geisler F, Freitag E, Lange J, Behrens J, Erdur H, Ganeshan R, Liman T, Scheitz JF, Schlemm L, Harmel P, Zieschang K, Lorenz-Meyer I, Napierkowski I, Waldschmidt C, Nolte CH, Grittner U, Wiener E, Bohner G, Nabavi DG, Schmehl I, Ekkernkamp A, Jungehulsing GJ, Mackert BM, Hartmann A, Rohmann JL, Endres M, Audebert HJ. Association Between Dispatch of Mobile Stroke Units and Functional Outcomes Among Patients With Acute Ischemic Stroke in Berlin. JAMA 2021; 325:454-466. [PMID: 33528537 PMCID: PMC7856548 DOI: 10.1001/jama.2020.26345] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE Effects of thrombolysis in acute ischemic stroke are time-dependent. Ambulances that can administer thrombolysis (mobile stroke units [MSUs]) before arriving at the hospital have been shown to reduce time to treatment. OBJECTIVE To determine whether dispatch of MSUs is associated with better clinical outcomes for patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This prospective, nonrandomized, controlled intervention study was conducted in Berlin, Germany, from February 1, 2017, to October 30, 2019. If an emergency call prompted suspicion of stroke, both a conventional ambulance and an MSU, when available, were dispatched. Functional outcomes of patients with final diagnosis of acute cerebral ischemia who were eligible for thrombolysis or thrombectomy were compared based on the initial dispatch (both MSU and conventional ambulance or conventional ambulance only). EXPOSURE Simultaneous dispatch of an MSU (computed tomographic scanning with or without angiography, point-of-care laboratory testing, and thrombolysis capabilities on board) and a conventional ambulance (n = 749) vs conventional ambulance alone (n = 794). MAIN OUTCOMES AND MEASURES The primary outcome was the distribution of modified Rankin Scale (mRS) scores (a disability score ranging from 0, no neurological deficits, to 6, death) at 3 months. The coprimary outcome was a 3-tier disability scale at 3 months (none to moderate disability; severe disability; death) with tier assignment based on mRS scores if available or place of residence if mRS scores were not available. Common odds ratios (ORs) were used to quantify the association between exposure and outcome; values less than 1.00 indicated a favorable shift in the mRS distribution and lower odds of higher levels of disability. RESULTS Of the 1543 patients (mean age, 74 years; 723 women [47%]) included in the adjusted primary analysis, 1337 (87%) had available mRS scores (primary outcome) and 1506 patients (98%) had available the 3-tier disability scale assessment (coprimary outcome). Patients with an MSU dispatched had lower median mRS scores at month 3 (1; interquartile range [IQR], 0-3) than did patients without an MSU dispatched (2; IQR, 0-3; common OR for worse mRS, 0.71; 95% CI, 0.58-0.86; P < .001). Similarly, patients with an MSU dispatched had lower 3-month coprimary disability scores: 586 patients (80.3%) had none to moderate disability; 92 (12.6%) had severe disability; and 52 (7.1%) had died vs patients without an MSU dispatched: 605 (78.0%) had none to moderate disability; 103 (13.3%) had severe disability; and 68 (8.8%) had died (common OR for worse functional outcome, 0.73, 95% CI, 0.54-0.99; P = .04). CONCLUSIONS AND RELEVANCE In this prospective, nonrandomized, controlled intervention study of patients with acute ischemic stroke in Berlin, Germany, the dispatch of mobile stroke units, compared with conventional ambulances alone, was significantly associated with lower global disability at 3 months. Clinical trials in other regions are warranted.
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Geisler F, Wesirow M, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Audebert HJ. Probability assessment of intracerebral hemorrhage in prehospital emergency patients. Neurol Res Pract 2021; 3:1. [PMID: 33499926 PMCID: PMC7786495 DOI: 10.1186/s42466-020-00100-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Routing of patients with intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) to the most appropriate hospital is challenging for emergency medical services particularly when specific treatment options are only provided by specialized hospitals and determination of the exact diagnosis is difficult. We aimed to develop a prehospital score - called prehospital-intracerebral hemorrhage score (ph-ICH score) - to assist in discriminating between both conditions. METHODS The ph-ICH score was developed with data from patients treated aboard a mobile stroke unit in Berlin, Germany, between 2011 and 2013 (derivation cohort) and in 2018 (validation cohort). Diagnosis of ICH or AIS was established using clinical data and neuroradiological cerebral imaging. Diagnostic accuracy was measured with significance testing, Cohen's d and receiver-operating-characteristics. RESULTS We analyzed 416 patients (32 ICH, 224 AIS, 41 transient ischemic attack, 119 stroke mimic) in the derivation cohort and 285 patients (33 ICH and 252 AIS) in the validation cohort. Systolic blood pressure, level of consciousness and severity of neurological deficits (i. e. certain items of the National Institutes of Health Stroke Scale) were used to calculate the ph-ICH score that showed higher values in the ICH compared to the AIS group (derivation cohort: 1.8 ± 1.2 vs. 1.0 ± 0.9 points; validation cohort: 1.8 ± 0.9 vs. 0.8 ± 0.7 points; d = 0.9 and 1.4, both p < 0.01). Receiver-operating-characteristics showed fair and good accuracy with an area under the curve of 0.71 for the derivation and 0.81 for the validation cohort. CONCLUSIONS The ph-ICH score can assist medical personnel in the field to assess the likelihood of ICH and AIS in emergency patients.
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Geisler F, Kunz A, Winter B, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Zieschang K, Ebinger M, Audebert HJ. Telemedicine in Prehospital Acute Stroke Care. J Am Heart Assoc 2020; 8:e011729. [PMID: 30879372 PMCID: PMC6475065 DOI: 10.1161/jaha.118.011729] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Mobile stroke units (MSUs), equipped with an integrated computed tomography scanner, can shorten time to thrombolytic treatment and may improve outcome in patients with acute ischemic stroke. Original (German) MSUs are staffed by neurologists trained as emergency physicians, but patient assessment and treatment decisions by a remote neurologist may offer an alternative to neurologists aboard MSU. Methods and Results Remote neurologists examined and assessed emergency patients treated aboard the MSU in Berlin, Germany. Audiovisual quality was rated by the remote neurologist from 1 (excellent) to 6 (insufficient), and duration of video examinations was assessed. We analyzed interrater reliability of diagnoses, scores on the National Institutes of Health Stroke Scale and treatment decisions (intravenous thrombolysis) between the MSU neurologist and the remote neurologist. We included 90 of 103 emergency assessments (13 patients were excluded because of either failed connection, technical problems, clinical worsening during teleconsultation, or missing data in documentation) in this study. The remote neurologist rated audiovisual quality with a median grade for audio quality of 3 (satisfactory) and for video quality of 2 (good). Mean time for completion of teleconsultations was about 19±5 minutes. The interrater reliabilities between the onboard and remote neurologist were high for diagnoses (Cohen's κ=0.86), National Institutes of Health Stroke Scale sum scores (intraclass correlation coefficient, 0.87) and treatment decisions (16 treatment decisions agreed versus 2 disagreed; Cohen's κ=0.93). Conclusions Remote assessment and treatment decisions of emergency patients are technically feasible with satisfactory audiovisual quality. Agreement on diagnoses, neurological examinations, and treatment decisions between onboard and remote neurologists was high. See Editorial by Derry et al
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Gschwendtner E, Turner M, Adli E, Ahuja A, Apsimon O, Apsimon R, Bachmann AM, Batsch F, Bracco C, Braunmüller F, Burger S, Burt G, Buttenschön B, Caldwell A, Chappell J, Chevallay E, Chung M, Cooke D, Damerau H, Deubner LH, Dexter A, Doebert S, Farmer J, Fedosseev VN, Fiorito R, Fonseca RA, Friebel F, Garolfi L, Gessner S, Goddard B, Gorgisyan I, Gorn AA, Granados E, Grulke O, Hartin A, Helm A, Henderson JR, Hüther M, Ibison M, Jolly S, Keeble F, Kelisani MD, Kim SY, Kraus F, Krupa M, Lefevre T, Li Y, Liu S, Lopes N, Lotov KV, Martyanov M, Mazzoni S, Minakov VA, Molendijk JC, Moody JT, Moreira M, Muggli P, Panuganti H, Pardons A, Peña Asmus F, Perera A, Petrenko A, Pukhov A, Rey S, Sherwood P, Silva LO, Sosedkin AP, Tuev PV, Velotti F, Verra L, Verzilov VA, Vieira J, Welsch CP, Wendt M, Williamson B, Wing M, Woolley B, Xia G. Correction to 'Proton-driven plasma wakefield acceleration in AWAKE'. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2020; 378:20190539. [PMID: 31865874 PMCID: PMC6939239 DOI: 10.1098/rsta.2019.0539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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17
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Gschwendtner E, Turner M, Adli E, Ahuja A, Apsimon O, Apsimon R, Bachmann AM, Batsch F, Bracco C, Braunmüller F, Burger S, Burt G, Buttenschön B, Caldwell A, Chappell J, Chevallay E, Chung M, Cooke D, Damerau H, Deubner LH, Dexter A, Doebert S, Farmer J, Fedosseev VN, Fiorito R, Fonseca RA, Friebel F, Garolfi L, Gessner S, Goddard B, Gorgisyan I, Gorn AA, Granados E, Grulke O, Hartin A, Helm A, Henderson JR, Hüther M, Ibison M, Jolly S, Keeble F, Kelisani MD, Kim SY, Kraus F, Krupa M, Lefevre T, Li Y, Liu S, Lopes N, Lotov KV, Martyanov M, Mazzoni S, Minakov VA, Molendijk JC, Moody JT, Moreira M, Muggli P, Panuganti H, Pardons A, Peña Asmus F, Perera A, Petrenko A, Pukhov A, Rey S, Sherwood P, Silva LO, Sosedkin AP, Tuev PV, Velotti F, Verra L, Verzilov VA, Vieira J, Welsch CP, Wendt M, Williamson B, Wing M, Woolley B, Xia G. Proton-driven plasma wakefield acceleration in AWAKE. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2019; 377:20180418. [PMID: 31230571 PMCID: PMC6602911 DOI: 10.1098/rsta.2018.0418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/25/2019] [Indexed: 06/09/2023]
Abstract
In this article, we briefly summarize the experiments performed during the first run of the Advanced Wakefield Experiment, AWAKE, at CERN (European Organization for Nuclear Research). The final goal of AWAKE Run 1 (2013-2018) was to demonstrate that 10-20 MeV electrons can be accelerated to GeV energies in a plasma wakefield driven by a highly relativistic self-modulated proton bunch. We describe the experiment, outline the measurement concept and present first results. Last, we outline our plans for the future. This article is part of the Theo Murphy meeting issue 'Directions in particle beam-driven plasma wakefield acceleration'.
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Jenei Z, Liermann HP, Husband R, Méndez ASJ, Pennicard D, Marquardt H, O'Bannon EF, Pakhomova A, Konopkova Z, Glazyrin K, Wendt M, Wenz S, McBride EE, Morgenroth W, Winkler B, Rothkirch A, Hanfland M, Evans WJ. New dynamic diamond anvil cells for tera-pascal per second fast compression x-ray diffraction experiments. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2019; 90:065114. [PMID: 31255042 DOI: 10.1063/1.5098993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/27/2019] [Indexed: 06/09/2023]
Abstract
Fast compression experiments performed using dynamic diamond anvil cells (dDACs) employing piezoactuators offer the opportunity to study compression-rate dependent phenomena. In this paper, we describe an experimental setup which allows us to perform time-resolved x-ray diffraction during the fast compression of materials using improved dDACs. The combination of the high flux available using a 25.6 keV x-ray beam focused with a linear array of compound refractive lenses and the two fast GaAs LAMBDA detectors available at the Extreme Conditions Beamline (P02.2) at PETRA III enables the collection of x-ray diffraction patterns at an effective repetition rate of up to 4 kHz. Compression rates of up to 160 TPa/s have been achieved during the compression of gold in a 2.5 ms fast compression using improved dDAC configurations with more powerful piezoactuators. The application of this setup to low-Z compounds at lower compression rates is described, and the high temporal resolution of the setup is demonstrated. The possibility of applying finely tuned pressure profiles opens opportunities for future research, such as using oscillations of the piezoactuator to mimic propagation of seismic waves in the Earth.
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Winter B, Wendt M, Waldschmidt C, Rozanski M, Kunz A, Geisler F, Grittner U, Kaczmarek S, Ebinger M, Audebert HJ. 4G versus 3G-enabled telemedicine in prehospital acute stroke care. Int J Stroke 2019; 14:620-629. [DOI: 10.1177/1747493019830303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Time to reperfusion treatment is closely related to outcome in ischemic stroke. Prehospital stroke work-up in CT-equipped mobile stroke units is effective in reducing time to thrombolytic treatment. Current evidence predominantly comes from mobile stroke units staffed with neurologists but telemedicine-guided management may be acceptable for providing neurological expertise in ambulances. With unsatisfactory experiences in third-generation (3G)-based approaches, fourth-generation (4G) networks may provide adequate audio-visual quality but systematic comparisons of technological parameters and decision-making are lacking. Methods Trained actors presented stroke symptoms and paramedics assisted the remotely guided extended National Institutes of Health Stroke Scale (eNIHSS) assessment on the mobile stroke unit in Berlin, Germany. We compared technical parameters of 4G and 3G connections, assessed audio-visual quality of examination, and analyzed reliability of neurological assessment and treatment decisions made by the remote neurologist versus the mobile stroke unit neurologist. Results 4G and 3G connections were evaluated in 40 scenarios each. Connectivity was not available in 17% of 4G- and 15% of 3G-attempts with 6% simultaneous unavailability of both networks. The remote examiners graded audio and video quality in 4G better than in 3G with slightly shorter assessment duration in 4G (mean: 9 (SD:5) vs. mean 11 (SD:3) min, p = 0.10). Reliability of the eNIHSS sum scores was high with intraclass correlation coefficients of 0.99 (95% CI: 0.987–1.00) for 4G and 0.98 (95% CI: 0.96–0.99) for 3G. None of the remote treatment decisions differed from onsite decisions. Conclusions 4G mobile communications provided higher quality of video-examination and allowed reliable remote assessment of stroke symptoms but coverage was still incomplete in both networks.
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Kunz A, Nolte CH, Erdur H, Fiebach JB, Geisler F, Rozanski M, Scheitz JF, Villringer K, Waldschmidt C, Weber JE, Wendt M, Winter B, Zieschang K, Grittner U, Kaczmarek S, Endres M, Ebinger M, Audebert HJ. Effects of Ultraearly Intravenous Thrombolysis on Outcomes in Ischemic Stroke: The STEMO (Stroke Emergency Mobile) Group. Circulation 2019; 135:1765-1767. [PMID: 28461420 DOI: 10.1161/circulationaha.117.027693] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wisotzki L, Bacon R, Brinchmann J, Cantalupo S, Richter P, Schaye J, Schmidt KB, Urrutia T, Weilbacher PM, Akhlaghi M, Bouché N, Contini T, Guiderdoni B, Herenz EC, Inami H, Kerutt J, Leclercq F, Marino RA, Maseda M, Monreal-Ibero A, Nanayakkara T, Richard J, Saust R, Steinmetz M, Wendt M. Author Correction: Nearly all the sky is covered by Lyman-α emission around high-redshift galaxies. Nature 2018; 563:E31. [PMID: 30377312 DOI: 10.1038/s41586-018-0664-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Change history: In this Letter, author M. Akhlaghi should be associated with affiliation (2) rather than (3). This error has been corrected online.
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Geisler F, Ali SF, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Schwamm LH, Audebert HJ. Evaluation of a score for the prehospital distinction between cerebrovascular disease and stroke mimic patients. Int J Stroke 2018; 14:400-408. [DOI: 10.1177/1747493018806194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Patients with a sudden onset of focal neurological deficits consistent with stroke, who turn out to have alternative conditions, have been labeled stroke mimics. Aims We assessed a recently validated telemedicine-based stroke mimic score (TeleStroke mimic score; TM-score) and individual patient characteristics with regard to its discriminative value between cerebrovascular disease and stroke mimic patients in the in-person, pre-hospital setting. Methods We evaluated patients cared for in a mobile stroke unit in Berlin, Germany. We investigated whether the TM-score (comprising six parameters), Face Arm Speech Time test, and individual patient characteristics were able to differentiate cerebrovascular disease from stroke mimic patients. Results We included 423 patients (299 (70.7%) cerebrovascular disease and 124 (29.3%) stroke mimic) in the final analysis. A TM-score > 30 indicated a high probability of a cerebrovascular disease and a score ≤15 of a stroke mimic. The TM-score performed well to identify stroke mimics (area under the curve of 0.74 under receiver-operating characteristic curve analysis). The cerebrovascular disease patients were older (74.8 vs. 69.8 years, p = 0.001), had more often severe strokes (NIHSS > 14 25.8% vs. 11.3%, p = 0.001), presented more often with weakness of the face (70.9% vs. 42.7%, p = 0.001) or arm (60.9% vs. 33.9%, p = 0.001), dysarthria (59.5% vs. 40.3%, p < 0.001), history of atrial fibrillation (38.1% vs. 21.0%, p = 0.001), arterial hypertension (78.9% vs. 53.2%, p < 0.001), and less often with seizure (0.7% vs. 21.0%, p < 0.001). Conclusions The TM-score and certain patient characteristics can help paramedics and emergency physicians in the field to identify stroke mimic patients and select the most appropriate hospital destination.
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Tsivgoulis G, Geisler F, Katsanos AH, Kõrv J, Kunz A, Mikulik R, Rozanski M, Wendt M, Audebert HJ. Ultraearly Intravenous Thrombolysis for Acute Ischemic Stroke in Mobile Stroke Unit and Hospital Settings. Stroke 2018; 49:1996-1999. [DOI: 10.1161/strokeaha.118.021536] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Winterberg B, Ramme K, Tenschert W, Winterberg G, Rolf N, Wendt M, Teerling K, Lison A, Zumkley H. Hemofiltration in Myoglobinuric Acute Renal Failure. Int J Artif Organs 2018. [DOI: 10.1177/039139889001300211] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The frequency of myoglobinuric renal failure is estimated between 8 and 20%. Despite early onset of therapy often the use of renal substitution by hemodialysis or hemofiltration is required. This study of the clinical course of nine patients with myoglobinuric acute renal failure reveals continuous arterio-venous hemofiltration (CAVH) to have an effective clearance for myoglobin. Thus, the time until recovery of renal function as well as the frequency of secondary complications in rhabdomyolysis induced acute renal failure can be distinctly reduced.
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Nolte CH, Ebinger M, Scheitz JF, Kunz A, Erdur H, Geisler F, Braemswig TB, Rozanski M, Weber JE, Wendt M, Zieschang K, Fiebach JB, Villringer K, Grittner U, Kaczmarek S, Endres M, Audebert HJ. Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Stroke 2018; 49:646-651. [DOI: 10.1161/strokeaha.117.019060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/13/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Data on effects of intravenous thrombolysis on outcome of patients with ischemic stroke who are dependent on assistance in activities of daily living prestroke are scarce. Recent registry based analyses in activities of daily –independent patients suggest that earlier start of intravenous thrombolysis in the prehospital setting leads to better outcomes when compared with the treatment start in hospital. We evaluated whether these observations can be corroborated in patients with prestroke dependency.
Methods—
This observational, retrospective analysis included all patients with acute ischemic stroke depending on assistance before stroke who received intravenous thrombolysis either on the Stroke Emergency Mobile (STEMO) or through conventional in-hospital care (CC) in a tertiary stroke center (Charité, Campus Benjamin Franklin, Berlin) during routine care. Prespecified outcomes were modified Rankin Scale scores of 0 to 3 and survival at 3 months, as well as symptomatic intracranial hemorrhage. Outcomes were adjusted in multivariable logistic regression.
Results—
Between February 2011 and March 2015, 122 of 427 patients (28%) treated on STEMO and 142 of 505 patients (28%) treated via CC needed assistance before stroke. Median onset-to-treatment times were 97 (interquartile range, 69–159; STEMO) and 135 (interquartile range, 98–184; CC;
P
<0.001) minutes. After 3 months, modified Rankin Scale scores of 0 to 3 was observed in 48 STEMO patients (39%) versus 35 CC patients (25%;
P
=0.01) and 86 (70%, STEMO) versus 85 (60%, CC) patients were alive (
P
=0.07). After adjustment, STEMO care was favorable with respect to modified Rankin Scale scores of 0 to 3 (odds ratio, 1.99; 95% confidence interval, 1.02–3.87;
P
=0.042) with a nonsignificant result for survival (odds ratio, 1.73; 95% confidence interval, 0.95–3.16;
P
=0.07). Symptomatic intracranial hemorrhage occurred in 5 STEMO versus 12 CC patients (4.2% versus 8.5%;
P
=0.167).
Conclusions—
The results of this study suggest that earlier, prehospital (as compared with in-hospital) start of intravenous thrombolysis in acute ischemic stroke may translate into better clinical outcome in patients with prestroke dependency.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT02358772.
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