Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.)

Exploring threats to generalisability in a large international rehabilitation trial (AVERT)

OBJECTIVE

The purpose of this paper is to examine potential threats to generalisability of the results of a multicentre randomised controlled trial using data from A Very Early Rehabilitation Trial (AVERT).

DESIGN

AVERT is a prospective, parallel group, assessor-blinded randomised clinical trial. This paper presents data assessing the generalisability of AVERT.

SETTING

Acute stroke units at 44 hospitals in 8 countries.

PARTICIPANTS

The first 20,000 patients screened for AVERT, of whom 1158 were recruited and randomised.

MODEL

We use the Proximal Similarity Model, which considers the person, place, and setting and practice, as a framework for considering generalisability. As well as comparing the recruited patients with the target population, we also performed an exploratory analysis of the demographic, clinical, site and process factors associated with recruitment.

RESULTS

The demographics and stroke characteristics of the included patients in the trial were broadly similar to population-based norms, with the exception that AVERT had a greater proportion of men. The most common reason for non-recruitment was late arrival to hospital (ie, >24 h). Overall, being older and female reduced the odds of recruitment to the trial. More women than men were excluded for most of the reasons, including refusal. The odds of exclusion due to early deterioration were particularly high for those with severe stroke (OR=10.4, p<0.001, 95% CI 9.27 to 11.65).

CONCLUSIONS

A model which explores person, place, and setting and practice factors can provide important information about the external validity of a trial, and could be applied to other clinical trials.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12606000185561) and Clinicaltrials.gov (NCT01846247).

The effects of telemedicine on racial and ethnic disparities in access to acute stroke care

Racial and ethnic disparities have been previously reported in acute stroke care. We sought to determine the effect of telemedicine (TM) on access to acute stroke care for racial and ethnic minorities in the state of Texas. Data were collected from the US Census Bureau, The Joint Commission and the American Hospital Association. Access for racial and ethnic minorities was determined by summing the population that could reach a primary stroke centre (PSC) or telemedicine spoke within specified time intervals using validated models. TM extended access to stroke expertise by 1.5 million residents. The odds of providing 60-minute access via TM were similar in Blacks and Whites (prevalence odds ratios (POR) 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.001). The odds of providing access via TM were also similar for Hispanics and non-Hispanics (POR 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.000). We found that telemedicine increased access to acute stroke care for 1.5 million Texans. While racial and ethnic disparities exist in other components of stroke care, we did not find evidence of disparities in access to the acute stroke expertise afforded by telemedicine.

Factors delaying hospital arrival of patients with acute stroke

Background:

Low rates of thrombolysis for ischemic stroke in India and other developing countries have been attributed to delays in presentation to the hospital.

Materials and Methods:

A prospective study was carried out during a 12-month period ending December 2012 in the department of Neurology, Malabar Institute of Medical Sciences, Kerala, India, to look for the factors contributing to delay in hospital arrival of patients with acute stroke. Patients and or their relatives were interviewed within 48 hours of admission using a structured questionnaire.

Results:

A total of 264 patients attending the emergency department were included. There were 170 men and 94 women. The mean age was 61.5 ± 12.4 years. A total of 67 (25%) patients presented within 4 hours of stroke onset. Factors associated with early arrival (multivariate logistic regression analysis) were distance 15 km or less from hospital (P 0.03, odds ratio (OR) 2.7), directly reaching the stroke department (P < 0.001, OR 9.7), history of coronary artery disease (P 0.001, OR 3.84), higher educational status (P 0.001, OR 3.7), and presence of hemiplegia (P 0.001, OR 5.5).

Conclusions:

We found a considerable delay in the early arrival of patients to our stroke department. Health promotion strategies to improve community awareness of early symptoms of stroke, education of local physicians about the importance of early referrals to the stroke centers, and wider availability and use of ambulance services are promising methods to help expedite presentation to hospital post stroke and thereby improve the management of stroke in India.

Strategies for streamlining emergency stroke care

There has been a tremendous evolution in the stroke systems of care in the USA. Public awareness, prehospital care, and in-hospital protocols have never been so effectively connected. However, given the critical role of time to effective reperfusion in the setting of acute ischemic stroke, it is vital and timely to implement strategies to further streamline emergency stroke care. This article reviews the most current standards and guidelines related to the flow of stroke care in the prehospital and emergency settings.

Tailored approaches to stroke health education (TASHE): study protocol for a randomized controlled trial

Background

Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 − 4½ h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City.

Design and Methods

In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films – one in English and one in Spanish – on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up.

Discussion

This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities.

Trial registration

NCT01909271; July 22, 2013

From mice to mind: Strategies and progress in translating neuroregeneration

Decisions about what experimental therapies are advanced to clinical trials are based almost exclusively on findings in preclinical animal studies. Over the past 30 years, animal models have forecast the success of hundreds of neuroprotective pharmacological therapies for stroke, Alzheimer׳s disease, spinal cord injury, traumatic brain injury and amyotrophic lateral sclerosis. Yet almost without exception, all have failed. Rapid advances in stem cell technologies have raised new hopes that these neurological diseases may one day be treatable. Still, how can neuroregenerative therapies be translated into clinical realities if available animal models are such poor surrogates of human disease? To address this question we discuss human and rodent neurogenesis, evaluate mechanisms of action for cellular therapies and describe progress in translating neuroregeneration to date. We conclude that not only are appropriate animal models critical to the development of safe and effective therapies, but that the multiple mechanisms of stem cell-mediated therapies may be particularly well suited to the mechanistically diverse nature of central nervous system diseases in mice and man.

Race and sex disparities in prehospital recognition of acute stroke

OBJECTIVES

The objective of this study was to examine prehospital provider recognition of stroke by race and sex.

METHODS

Diagnoses at emergency department (ED) and hospital discharge from a statewide database in California were linked to prehospital diagnoses from an electronic database from two counties in Northern California from January 2005 to December 2007 using probabilistic linkage. All patients 18 years and older, transported by ambulances (n = 309,866) within the two counties, and patients with hospital-based discharge diagnoses of stroke (n = 10,719) were included in the study. Logistic regression was used to analyze the independent association of race and sex with the correct prehospital diagnosis of stroke.

RESULTS

There were 10,719 patients discharged with primary diagnoses of stroke. Of those, 3,787 (35%) were transported by emergency medical services providers. Overall, 32% of patients ultimately diagnosed with stroke were identified in the prehospital setting. Correct prehospital recognition of stroke was lower among Hispanic patients (odds ratio [OR] = 0.77, 95% confidence interval [CI] 0.61 to 0.96), Asians (OR = 0.66, 95% CI 0.55 to 0.80), and others (OR = 0.71, 95% CI = 0.53 to 0.94), when compared with non-Hispanic whites, and in women compared with men (OR = 0.82, 95% CI = 0.71 to 0.94). Specificity for recognizing stroke was lower in females than males (OR = 0.84, 95% CI = 0.78 to 0.90).

CONCLUSIONS

Significant disparities exist in prehospital stroke recognition.

Evaluation of pre-hospital transport time of stroke patients to thrombolytic treatment

BACKGROUND

Effective treatment of stroke is time dependent. Pre-hospital management is an important link in reducing the time from occurrence of stroke symptoms to effective treatment. The aim of this study was to evaluate time used by emergency medical services (EMS) for stroke patients during a five-year period in order to identify potential delays and evaluate the reorganization of EMS in Copenhagen in 2009.

METHODS

We performed a retrospective analysis of ambulance records from stroke patients suitable for thrombolysis from 1 January 2006 to 7 July 2011. We noted response time from dispatch of the ambulance to arrival at the scene, on-scene time and transport time to the hospital-in total, alarm-to-door time. In addition, we noted baseline characteristics.

RESULTS

We reviewed 481 records (58% male, median age 66 years). The median (IQR) alarm-to-door time in minutes was 41 (33-52), of which 18 (12-24) minutes were spent on scene. Response time was reduced from the period before to the period after reorganization (7 vs. 5 minutes, p <0.001). In a linear multiple regression model, higher patient age and longer distance to the hospital correlated with significantly longer transportation time (p <0.001).

CONCLUSIONS

This study shows an unchanged alarm-to-door time of 41 minutes over a five-year period. Response time, but not total alarm-to-door time, was reduced during the five years. On-scene time constituted nearly half of the total alarm-to-door time and is thus a point of focus for improvement.

Evaluation of the Recognition of Stroke in the Emergency Room (ROSIER) scale in Chinese patients in Hong Kong

BACKGROUND AND PURPOSE

The objective of this study was to determine the performance of the Recognition Of Stroke In the Emergency Room (ROSIER) scale in risk-stratifying Chinese patients with suspected stroke in Hong Kong.

METHODS

This was a prospective cohort study in an urban academic emergency department (ED) over a 7-month period. Patients over 18 years of age with suspected stroke were recruited between June 2011 and December 2011. ROSIER scale assessment was performed in the ED triage area. Logistic regression analysis was used to estimate the impacts of diagnostic variables, including ROSIER scale, past history and ED characteristics.

FINDINGS

715 suspected stroke patients were recruited for assessment, of whom 371 (52%) had acute cerebrovascular disease (302 ischaemic strokes, 24 transient ischaemic attacks (TIA), 45 intracerebral haemorrhages), and 344 (48%) had other illnesses i.e. stroke mimics. Common stroke mimics were spinal neuropathy, dementia, labyrinthitis and sepsis. The suggested cut-off score of>0 for the ROSIER scale for stroke diagnosis gave a sensitivity of 87% (95%CI 83-90), a specificity of 41% (95%CI 36-47), a positive predictive value of 62% (95%CI 57-66), and a negative predictive value of 75% (95%CI 68-81), and the AUC was 0.723. The overall accuracy at cut off>0 was 65% i.e. (323+141)/715.

INTERPRETATION

The ROSIER scale was not as effective at differentiating acute stroke from stroke mimics in Chinese patients in Hong Kong as it was in the original studies, primarily due to a much lower specificity. If the ROSIER scale is to be clinically useful in Chinese suspected stroke patients, it requires further refinement.

The quality of prehospital ischemic stroke care: compliance with guidelines and impact on in-hospital stroke response

BACKGROUND

A number of emergency medical services (EMSs) performance measures for stroke have been proposed to promote early stroke recognition and rapid transportation to definitive care. This study examined performance measure compliance among EMS-transported stroke patients and the relationship between compliance and in-hospital stroke response.

METHODS

Eight quality indicators were derived from American Stroke Association guidelines. A prospective cohort of consecutive, EMS-transported patients discharged from 2 large Midwestern stroke centers with a diagnosis of acute ischemic stroke was identified. Data were abstracted from hospital and EMS records. Compliance with 8 prehospital quality indicators was calculated. Univariate and multivariable logistic regression analysis were performed to measure the association between prehospital compliance and a binary outcome of door-to-computed tomography (CT) time less than or equal to 25 minutes.

RESULTS

Over the 12 month study period, 186 EMS-transported ischemic stroke patients were identified. Compliance was highest for prehospital documentation of a glucose level (86.0%) and stroke screen (78.5%) and lowest for on-scene time less than or equal to 15 minutes (46.8%), hospital prenotification (56.5%), and transportation at highest priority (55.4%). After adjustment for age, time from symptom onset, and stroke severity, transportation at highest priority (odds ratio [OR], 13.45) and hospital prenotification (OR, 3.75) were both associated with significantly faster door-to-CT time. No prehospital quality metric was associated with tissue-plasminogen activator delivery.

CONCLUSIONS

EMS transportation at highest priority and hospital prenotification were associated with faster in-hospital stroke response and represent logical targets for EMS quality improvement efforts.

Patient awareness and perception of stroke symptoms and the use of 911

BACKGROUND

Response to stroke symptoms and the use of 911 can vary by race/ethnicity. The quickness with which a patient responds to such symptoms has implications for the outcome and treatment. We sought to examine a sample of patients receiving a Remote Evaluation of Acute isCHemic stroke (REACH) telestroke consult in South Carolina regarding their awareness and perception of stroke symptoms related to the use of 911 and to assess possible racial/ethnic disparities.

METHODS

As of September 2013, 2325 REACH telestroke consults were conducted in 13 centers throughout South Carolina. Telephone surveys assessing use of 911 were administered from March 2012-January 2013 among 197 patients receiving REACH consults. Univariate and multivariate logistic regression was performed to assess factors associated with use of 911.

RESULTS

Most participants (73%) were Caucasian (27% were African-American) and male (54%). The mean age was 66 ± 14.3 years. Factors associated with use of 911 included National Institutes of Health Stroke Scale scores >4 (odds ratio [OR], 5.4; 95% confidence interval [CI], 2.63-11.25), unknown insurance which includes self-pay or not charged (OR, 2.90; 95% CI, 1.15-7.28), and perception of stroke-like symptoms as an emergency (OR, 4.58; 95% CI, 1.65-12.67). African-Americans were significantly more likely than Caucasians to call 911 (62% vs. 43%, P = .02).

CONCLUSIONS

African-Americans used 911 at a significantly higher rate. Use of 911 may be related to access to transportation, lack of insurance, or proximity to the hospital although this information was not available. Interventions are needed to improve patient arrival times to telemedicine equipped emergency departments after stroke.

Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association

BACKGROUND AND PURPOSE

This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA's 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.

METHODS

Writing group members were nominated by the AHA's Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.

CONCLUSIONS

Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.

Factors associated with early hospital arrival in acute ischemic stroke patients

Early diagnosis and treatment in acute ischemic stroke are crucial in terms of survival and disability. Many stroke patients remain disabled because of the treatment delay. The purpose of this study was to investigate the factors associated with the early hospital arrival in acute ischemic stroke patients. 113 patients diagnosed with acute ischemic stroke were included in this prospective study performed at the Karadeniz Technical University Medical Faculty Hospital. Patients' characteristics and patients' and relatives' emotional and behavioral reactions were compared between early (within 3 h) and late (after 3 h) arrival groups. 72.6 % of patients arrived at hospital within 3 h from symptoms onset. Univariate analysis revealed that history of atrial fibrillation (p = 0.04) and coronary heart disease (p = 0.02), sudden onset of symptoms (p = 0.001), loss of consciousness (p = 0.03), recognizing symptoms as stroke (p = 0.01), seeking immediate medical attention (p < 0.001), feelings of fear and panic (p = 0.001), arriving at hospital by ambulance having called the emergency medical services (p = 0.04) and National Institute of Health Stroke Scale (NIHSS) score (p = 0.001) were associated with hospital arrival within 3 h. A multivariate regression model demonstrated that recognizing symptoms as stroke (OR, 3.4; 95 % CI, 1.2-9.3) and atrial fibrillation (OR, 4.3; 95 % CI, 1.1-15.7) were independent factors associated with early arrival. The role in early arrival at hospital of recognizing symptoms as stroke and seeking immediate medical attention with transportation by ambulance emphasize the importance of public awareness concerning recognizing the symptoms of stroke and accessing emergency medical assistance.

Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) – a programme of research to facilitate recognition of stroke by emergency medical dispatchers

Background

Rapid access to emergency stroke care can reduce death and disability by enabling immediate provision of interventions such as thrombolysis, physiological monitoring and stabilisation. One of the ways that access to services can be facilitated is through emergency medical service (EMS) dispatchers. The sensitivity of EMS dispatchers for identifying stroke is < 50%. Studies have shown that activation of the EMSs is the single most important factor in the rapid triage and treatment of acute stroke patients.

Objectives

To facilitate recognition of stroke by emergency medical dispatchers (EMDs).

Design

An eight-phase mixed-methods study. Phase 1: a retrospective cohort study exploring stroke diagnosis. Phase 2: semi-structured interviews exploring public and EMS interactions. Phases 3 and 4: a content analysis of 999 calls exploring the interaction between the public and EMDs. Phases 5–7: development and implementation of stroke-specific online training (based on phases 1–4). Phase 8: an interrupted time series exploring the impact of the online training.

Setting

One ambulance service and four hospitals.

Participants

Patients arriving at hospital by ambulance with stroke suspected somewhere on the stroke pathway (phases 1 and 8). Patients arriving at hospital by ambulance with a final diagnosis of stroke (phase 2). Calls to the EMSs relating to phase 1 patients (phases 3 and 4). EMDs (phase 7).

Interventions

Stroke-specific online training package, designed to improve recognition of stroke for EMDs.

Main outcome measures

Phase 1: symptoms indicative of a final and dispatch diagnosis of stroke. Phase 2: factors involved in the decision to call the EMSs when stroke is suspected. Phases 3 and 4: keywords used by the public when describing stroke and non-stroke symptoms to EMDs. Phase 8: proportion of patients with a final diagnosis of stroke correctly dispatched as stroke by EMDs.

Results

Phase 1: for patients with a final diagnosis of stroke, facial weakness and speech problems were significantly associated with an EMD code of stroke. Phase 2: four factors were identified – perceived seriousness; seeking and receiving lay or professional advice; caller’s description of symptoms and emotional response to symptoms. Phases 3 and 4: mention of ‘stroke’ or one or more Face Arm Speech Test (FAST) items is much more common in stroke compared with non-stroke calls. Consciousness level was often difficult for callers to determine and/or communicate. Phase 8: there was a significant difference (p = 0.003) in proportions correctly dispatched as stroke – before the training was implemented 58 out of 92 (63%); during implementation of training 42 out of 48 (88%); and after training implemented 47 out of 59 (80%).

Conclusions

EMDs should be aware that callers are likely to describe loss of function (e.g. unable to grip) rather than symptoms (e.g. weakness) and that callers using the word ‘stroke’ or describing facial weakness, limb weakness or speech problems are likely to be calling about a stroke. Ambiguities and contradictions in dialogue about consciousness level arise during ambulance calls for suspected and confirmed stroke. The online training package improved recognition of stroke by EMDs. Recommendations for future research include testing the effectiveness of the Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) training package on the recognition of stroke across other EMSs in England; and exploring the impact of the early identification of stroke by call handlers on patient and process outcomes.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Análise das barreiras à utilização de trombolíticos em casos de acidente vascular cerebral isquêmico em um hospital privado do Rio de Janeiro, Brasil

O acidente vascular cerebral isquêmico (AVCi) é uma importante causa de sequela e morte. A correta utilização do trombolítico enfrenta várias barreiras. O objetivo foi discutir as barreiras à terapia trombolítica em pacientes que chegam, com sintomas de AVCi agudo, à emergência de um hospital privado do Rio de Janeiro, Brasil. Coorte retrospectiva de pacientes entre 2009 e 2011. Foram admitidos 257 pacientes com suspeita de AVCi. Dos pacientes com diagnóstico confirmado (156), 11,5% (18) foram trombolisados. Dos 30 pacientes com diagnóstico de AVCi, dentro da janela terapêutica e com NIHSS na faixa para trombólise, 20 não foram trombolisados, 9 por barreiras administrativas (45%). Neste trabalho o percentual de trombólise foi superior ao observado nos Estados Unidos, mas barreiras impediram o tratamento de 45% dos pacientes com indicação à trombólise. Imagina-se que na rede pública brasileira a situação seja ainda mais desfavorável.

Time to hospital admission and start of treatment in patients with ischemic stroke in northern Italy and predictors of delay

BACKGROUND AND PURPOSE

Early treatment (i.e. thrombolysis) is crucial for a successful care of ischemic stroke. In the management of stroke, two phases are crucial: the pre-hospital and the in-hospital interval. This work investigated factors influencing pre- and in-hospital delay in a large geographic area of Northern Italy.

METHODS

Enrolled were patients presenting with ischemic stroke in four administrative districts of Northern Italy (Como, Lecco, Sondrio and Varese) over a 4-month period. Pre-hospital time and in-hospital time with single management steps were recorded prospectively. Age, gender, recruiting hospital, EMS transport and triage codes, clinical severity and thrombolytic treatment were also recorded. Univariate and multivariate analysis of factors predicting pre- and in-hospital delay were performed.

RESULTS

Median pre-hospital time and in-hospital time were, respectively, 120 min (interquartile range, IQR 62-271) and 150 min (IQR 80-214). Pre-hospital time was halved in patients hospitalized via EMS (p<0.001) and clinically more severe (p<0.001). At multivariate analysis, transport code was associated with delay at any time (p<0.05).

CONCLUSIONS

EMS use and transport code predicted treatment delay in patients with ischemic stroke. A more intensive use of EMS and high urgency codes could help increase the number of stroke patients treated appropriately.

An evaluation of emergency medical services stroke protocols and scene times

BACKGROUND

Acute stroke patients require immediate medical attention. Therefore, American Stroke Association guidelines recommend that for suspected stroke cases, emergency medical services (EMS) personnel spend less than 15 minutes on-scene at least 90% of the time. However, not all EMS providers include specific scene time limits in their stroke patient care protocols.

OBJECTIVE

We sought to determine whether having a protocol with a specific scene time limit was associated with less time EMS spent on scene. Methods. Stroke protocols from the 100 EMS systems in North Carolina were collected and abstracted for scene time instructions. Suspected stroke events occurring in 2009 were analyzed using data from the North Carolina Prehospital Medical Information System. Scene time was defined as the time from EMS arrival at the scene to departure with the patient. Quantile regression was used to estimate how the 90th percentile of the scene time distribution varied by systems with protocol instructions limiting scene time, adjusting for system patient volume and metropolitan status.

RESULTS

In 2009, 23 EMS systems in North Carolina had no instructions regarding scene time; 73 had general instructions to minimize scene time; and 4 had a specific limit for scene time (i.e., 10 or 15 min). Among 9,723 eligible suspected stroke events, mean scene time was 15.9 minutes (standard deviation 6.9 min) and median scene time was 15.0 minutes (90th percentile 24.3 min). In adjusted quantile regression models, the estimated reduction in the 90th percentile scene time, comparing protocols with a specific time limit to no instructions, was 2.2 minutes (95% confidence interval 1.3, 3.1 min). The difference in 90th percentile scene time between general and absent instructions was not statistically different (0.7 min [95% confidence interval -0.1, 1.4 min]).

CONCLUSION

Protocols with specific scene time limits were associated with EMS crews spending less time at the scene while general instructions were not. These findings suggest EMS systems can modestly improve scene times for stroke by specifying a time limit in their protocols.

Delay in presentation after acute ischemic stroke: the Careggi Hospital Stroke Registry

Intravenous thrombolysis with recombinant tissue-type plasminogen activator is the approved treatment for acute ischemic stroke within 4.5 h from symptoms onset. Evidence suggests the earlier treatment was given, the greater the chance of a favorable outcome. We investigated if the delay in hospital presentation has been modified in the past 8 years. Acute ischemic strokes admitted to the Emergency Department of the Careggi Hospital, Florence from March 2004 to December 2012 were prospectively collected in the Careggi Hospital Stroke Registry. Proportion of patients presenting ≤ 2 h, 2-3.5, 3.5-6, and >6 h from symptom onset or with awakening stroke were compared. From March 2004 to December 2012, 3,856 patients with acute ischemic stroke arrived to the Careggi Emergency Department. During the period, 28.3 % of patients arrived ≤ 2 h from symptoms onset and 9.8 % between 2 and 3.5 h. The proportion of time-eligible patients is steady in the first years with a slight increase in 2011 and 2012. Early presentation is significantly associated with younger age, intracerebral hemorrhage, and stroke severity. In this study, about one-third of acute ischemic strokes arrived at the Emergency Department within the therapeutic time-window for intravenous thrombolysis. There is only a slight increase in early presentation through the period, mainly in the last 2 years. Additional efforts are required to impact deeply on the rates of time-eligible patients.

Patterns of Emergency Medical Services Use and Its Association With Timely Stroke Treatment

Background—

Prior studies found that only about half of stroke patients arrived at hospitals via emergency medical services (EMSs), yet since then, there have been efforts to increase public awareness that time is brain. Using contemporary Get With the Guidelines-Stroke data, we assessed nationwide EMS use by stroke patients.

Methods and Results—

We analyzed data from 204 591 patients with ischemic and hemorrhagic stroke admitted to 1563 Get With the Guidelines-Stroke participating hospitals with data on National Institute of Health Stroke Score and insurance status. Hospital arrival by EMSs was observed in 63.7% of patients. Older patients, those with Medicaid and Medicare insurance, and those with severe stroke were more likely to activate EMSs. In contrast, minority race and ethnicity and living in rural communities were associated with decreased odds of EMS use. EMS transport was independently associated with earlier arrival (onset-to-door time, ≤3 hours; adjusted odds ratio, 2.00; 95% confidence interval, 1.93–2.08), prompter evaluation (more patients with door-to-imaging time, ≤25 minutes; odds ratio, 1.89; 95% confidence interval, 1.78–2.00), more rapid treatment (more patients with door-to-needle time, ≤60 minutes; odds ratio, 1.44; 95% confidence interval, 1.28–1.63), and more eligible patients to be treated with tissue-type plasminogen activator if onset is ≤2 hours (67% versus 44%; odds ratio, 1.47; 95% confidence interval, 1.33–1.64).

Conclusions—

Although EMS use is independently associated with more rapid evaluation and treatment of stroke, more than one third of stroke patients fail to use EMSs. Interventions aimed at increasing EMS activation should target populations at risk, particularly younger patients and those of minority race and ethnicity.

Effects of comprehensive education protocol in decreasing pre-hospital stroke delay among Chinese urban community population

BACKGROUND AND PURPOSE

Studies have shown that awareness of early stroke symptoms and the use of ambulances are two important factors in decreasing pre-hospital stroke delay. The purpose of this study is to evaluate a comprehensive educational stroke protocol in improving stroke response times.

METHOD

Two urban communities in Beijing (population ≍50 000), matched in economic status and geography, were enrolled in this study. A comprehensive educational protocol, which included public lectures and distribution of instructive material for the community and its medical staff, was implemented from August 2008 to December 2010. Surveillance of new onset stroke in both communities was carried out during the same period. Pre-hospital delay time and percentage of patients using emergency medical services (EMS) were compared between the two communities.

RESULTS

After comprehensive educational protocol, we found that: (i) pre-hospital delay (time from stroke symptom onset to hospital arrival) decreased from 180 to 79 minutes, (ii) the proportion of patients arriving within three hours of stroke onset increased from 55·8% to 80·4%, (iii) pre-hospital delay of stroke patients with symptoms of paralysis, numbness, and speech impediments was decreased, and (iv) the proportion of stroke patients calling for EMS increased from 50·4% to 60·7%.

CONCLUSION

The comprehensive educational stroke protocol was significantly effective in decreasing pre-hospital stroke delay.

Epidemiological study and risk factors of stroke in Assiut Governorate, Egypt: community-based study

BACKGROUND

Because there have been no epidemiological studies of stroke in Egypt, a community-based survey was conducted in the Assiut Governorate to estimate the prevalence and risk factors of stroke in our community.

METHODS

A three-phase door-to-door study was performed in which 6,498 participants were chosen by random sampling from 7 districts in Assiut (first phase). Out of this sample, 578 dropped out leaving 3,066 males (51.8%) and 2,854 females (48.2%). There were 3,660 (61.8%) urban residents and 2,260 (38.2%) from the rural community. In the second phase participants were screened using the questionnaire for stroke, while the third phase involved medical evaluation of all suspected cases, with diagnosis of stroke confirmed by evaluation of CT scans. The Mini Mental State Examination and Hamilton Depression Scale were evaluated for each patient.

RESULTS

65 participants were identified as positive on the survey questionnaire, but only 57 patients were found to have stroke, giving a crude prevalence rate of 963/100,000 inhabitants with an age-adjusted local prevalence rate of 699.2/100,000 and an age-adjusted prevalence relative to the standard world population of 980.9/100,000. The prevalence among males was higher than females (1174/100,000 vs. 736/100,000) with a ratio 1.7:1. There was a significantly higher prevalence of ischemic (895/100,000) than hemorrhagic (68/100,000) stroke. Stroke prevalence was the same in rural and urban areas and in males and females. There was, however, a significantly higher prevalence in illiterate (2413/100,000) than literate participants (357/100,000). Forty-two patients (73.7%) had one or more risk factors for stroke, hypertension being the commonest (66%) and diabetes mellitus second (38.6%). Nine cases had poststroke dementia (15.8%) and 14 cases (24.6%) had mild depression.

CONCLUSIONS

The overall prevalence rate of stroke is high, especially in older adults, men and illiterate individuals. A higher prevalence of ischemic than hemorrhagic stroke was recorded, with hypertension and diabetes mellitus being the commonest risk factors in our community.

The science of cerebral ischemia and the quest for neuroprotection: navigating past failure to future success

Ischemic stroke remains a leading cause of morbidity and death for which few therapeutic options are available. The development of neuroprotective agents, a once promising field of investigation, has failed to translate from bench to bedside successfully. This work reviews the ischemic cascade, agents targeting steps within the cascade, and potential reasons for lack of translation. Additional therapeutic targets are highlighted and areas requiring further investigation are discussed. It is clear that alternative targets need to be pursued, such as the role glia play in neurological injury and recovery, particularly the interactions between neurons, astrocytes, microglia, and the vasculature. Similarly, the biphasic nature of many signaling molecules such as matrix metalloproteinases and high-mobility group box 1 protein must be further investigated to elucidate periods of detrimental versus beneficial activity.

Improving public education about stroke

Stroke is a common and serious disease. Most studies have shown that basic public knowledge about what a stroke is, symptoms of a stroke, and the proper reaction to a stroke is quite deficient. The fact that a stroke affects cognitive, communicative, and motor functions may partially explain the poor reaction to acute stroke symptoms. Several educational studies, using diverse formats and messaging paradigms, have been shown to positively affect public knowledge of stroke symptoms. Such efforts have often used mass media public education campaigns with an emphasis on recognizing symptoms of an acute stroke. Some have been able to demonstrate an increase in the chance of patients (or by-standers) calling 911 and seeking emergency care. However, many programs were of brief duration, and their long-term benefits are uncertain. Continual educational efforts will be needed to improve stroke knowledge and increase the percentage of patients who seek emergency care.

Impact of regional pre-hospital emergency medical services in treatment of patients with acute ischemic stroke

Stroke is a major public health concern afflicting an estimated 795,000 Americans annually. The associated morbidity and mortality is staggering. Early treatment with thrombolytics is beneficial. The window for treatment is narrow and minimization of the time from symptom onset to treatment is vital. The general population is not well informed as to the warning signs or symptoms of stroke, leading to substantial delays in emergency medical services (EMS) activation. Ambulance transport of stroke patients to the hospital has demonstrated improvements in key benchmarks such as door to physician evaluation, door to CT initiation, and increased thrombolytic treatment. Pre-hospital notification of the impending arrival of a stroke patient allows for vital preparation in the treating emergency department, and improving timely evaluation and treatment upon arrival of the stroke patient. EMS systems are a vital component of the management of stroke patients, and resources used to improve these systems are beneficial.

Relationship between time from ambulance call to arrival at emergency center and level of consciousness at admission in severe stroke patients

INTRODUCTION

Timely access to acute medical treatment can be critical for patients suffering from severe stroke. Little information is available about the impact of prehospital delays on the clinical conditions of stroke patients, but it is possible that prehospital delays lead to neurological deterioration. The aim of this study was to examine the impact of prehospital delays related to emergency medical services on the level of consciousness at admission in patients with severe stroke.

METHODS

This retrospective study assessed 712 consecutive patients diagnosed with cerebrovascular diseases who were admitted to an intensive care unit in Tokyo, Japan, from April 1998 through March 2008. Data, including the time from the call to the ambulance service to the arrival of the ambulance at the patient location (on-scene), and the time from the arrival of the ambulance on-scene to its arrival at the emergency center were obtained. The following demographic and clinical information also were obtained from medical records: sex, age, and Glasgow Coma Scale (GCS) score at admission.

RESULTS

The mean time from ambulance call to arrival on-scene was 7 (SD=3) minutes, and the mean time from ambulance call to arrival at the center was 37 (SD=8) minutes. A logistic regression model for predicting GCS scores of 3 and 4 at admission was produced. After adjusting for sex, age, and time from arrival on-scene to arrival at the center, a longer call-to-on-scene time was significantly associated with poor GCS scores (OR = 1.056/min; 95% confidence interval, [CI] = 1.008-1.107). After adjusting for sex and age, a longer call-to-arrival at the center time also was significantly associated with poor GCS scores (OR = 1.020; 95% CI = 1.002-1.038).

CONCLUSIONS

Prehospital delays were significantly associated with decreased levels of consciousness at admission in patients suffering from a stroke. As level of consciousness is the strongest predictor of outcome, reducing prehospital delays may be necessary to improve the outcomes in patients with severe stroke.

Prehospital delay in acute stroke and TIA

BACKGROUND

Early management improves outcome in acute stroke. This study was designed to assess the prehospital path from symptom onset to arrival in hospital and to identify factors associated with prehospital delay.

METHODS

A prospective study was conducted including patients with acute ischaemic stroke, intracerebral haemorrhage and transient ischaemic attack admitted to hospital. Time intervals for prehospital delay, background data, severity, type of first medical contact and mode of transport were recorded. Univariate and multivariate analyses were performed to identify factors influencing prehospital delay.

RESULTS

A total of 440 patients were included, with a mean age of 71.4±13.0 years (44.3% female subjects), consisting of 65.9% patients with ischaemic stroke, 11.4% with intracerebral haemorrhage and 22.7% with transient ischaemic attack. The median time from symptom onset to admission was 3.0 h (179 min; IQR 77-542). The median decision delay was 1.5 h (92 min, IQR 25-405) and accounted for 55.1% (median value) of the prehospital delay. 310 (70.5%) patients arrived by ambulance. In the multivariate linear regression analysis, high National Institute of Health Stroke Scale score (p<0.001), transport by ambulance (p<0.001) and lower age (p=0.048) were significantly associated with early admission.

CONCLUSIONS

Severe strokes, use of ambulance and lower age are associated with reduced prehospital delay. The present study shows that more than half of the delay is caused by the hesitation to contact medical services. Public information campaigns should focus on fast symptom recognition and the importance of immediately contacting the Emergency Medical Services upon symptom onset.

Short-term effects of ambient air pollution on stroke: who is most vulnerable?

Several studies have demonstrated positive associations between day-to-day increases in air pollution and stroke. These findings have been inconsistent, and the influence of patient characteristics has been largely ignored. In this study, we investigated the short-term effects of air pollution on stroke using a time-stratified case-crossover design. Data for hospital visits for stroke were extracted from 5927 medical charts of patients who presented to emergency departments between 2003 and 2009 in Edmonton, Canada. Daily concentrations of five air pollutants (NO(2), PM (2.5), CO, O(3), and SO(2)) were obtained from fixed-site monitors. Relative humidity and temperature were obtained from a metrological station operating at the city's airport. Chart data included: disease history, medication use, and smoking status. Conditional logistic regression was used to estimate the odds ratio (OR) of stroke in relation to an increase in the interquartile range for each pollutant. Positive associations were observed between ischemic stroke and air pollution during the 'warm' season (April through September). Specifically, the OR for an increase in 9.4 ppb in the 3-day average of NO(2) was 1.50 (95% CI: 1.12, 2.01). There were no statistically significant associations with any of the other pollutants after adjusting for NO(2) concentrations. Associations with ischemic stroke were stronger for those with a history of stroke (OR=2.31; 95% CI: 1.39, 3.83), heart disease (OR=1.99; 95% CI: 1.20, 3.28), and taking medication for diabetes (OR=2.03; 95% CI: 1.14, 3.59). Temperature was inversely associated with ischemic stroke during the 'warm' season, but no associations were evident with the other stroke subtypes. Air pollution was not associated with hemorrhagic stroke or transient ischemic attacks. The findings suggest that specific patient characteristics modify associations between air pollution and ischemic stroke.

Delay in presentation after an acute stroke in a multiethnic population in South london: the South london stroke register

BACKGROUND

Delayed presentation to hospital after an acute stroke is a major explanation given for low thrombolysis rates. This study aimed to investigate the factors associated with delays in presentation after an acute stroke and changes after a mass media campaign.

METHODS AND RESULTS

Data were from a population-based study involving 1392 patients with first-ever strokes between 2002 and 2010 in a multiethnic South London population. Associations were determined between prehospital delay (≥3 hours) and variables of interest, including ethnicity, by using multivariate logistic regression analyses. Differences in prehospital delay and thrombolysis rates were determined for the period immediately before and after the FAST mass media campaign (2007/2008 versus 2009/2010). The median (Q(1) to Q(3)) time to presentation was 4.73 (1.55 to 12.70) hours, and 550 (39.5%) presented within 3 hours of symptom onset. In multivariate analysis, patients of black ethnicity had increased odds of delay (odds ratio: 1.63; 95% confidence interval, 1.11 to 2.38), whereas those with more severe strokes characterized by a higher National Institutes of Health Stroke Scale score (odds ratio: 0.35; 95% confidence interval, 0.20 to 0.61) had reduced odds of delay. There was no difference in the proportion of patients who arrived within 3 hours (P=0.30) in the period immediately before and after the FAST campaign (40.7% in 2007/2008 versus 44.9% in 2009/2010). Among patients with ischemic stroke, 119 (11.0%) received thrombolysis between 2002 and 2010, with no difference observed between the pre- and postcampaign periods (16.9% versus 16.4%).

CONCLUSION

Significant delays in seeking care after stroke still occur in this population despite efforts to increase public awareness. Future educational programs must identify and specifically address factors that influence behavior and should target those at higher risk of delay. (J Am Heart Assoc. 2012;1:e001685 doi: 10.1161/JAHA.112.001685.).

Telestroke ambulances in prehospital stroke management: concept and pilot feasibility study

BACKGROUND AND PURPOSE

Pre- and intrahospital time delays are major concerns in acute stroke care. Telemedicine-equipped ambulances may improve time management and identify patients with stroke eligible for thrombolysis by an early prehospital stroke diagnosis. The aims of this study were (1) to develop a telestroke ambulance prototype; (2) to test the reliability of stroke severity assessment; and (3) to evaluate its feasibility in the prehospital emergency setting.

METHODS

Mobil, real-time audio-video streaming telemedicine devices were implemented into advanced life support ambulances. Feasibility of telestroke ambulances and reliability of the National Institutes of Health Stroke Scale assessment were tested using current wireless cellular communication technology (third generation) in a prehospital stroke scenario. Two stroke actors were trained in simulation of differing right and left middle cerebral artery stroke syndromes. National Institutes of Health Stroke Scale assessment was performed by a hospital-based stroke physician by telemedicine, by an emergency physician guided by telemedicine, and "a posteriori" on the basis of video documentation.

RESULTS

In 18 of 30 scenarios, National Institutes of Health Stroke Scale assessment could not be performed due to absence or loss of audio-video signal. In the remaining 12 completed scenarios, interrater agreement of National Institutes of Health Stroke Scale examination between ambulance and hospital and ambulance and "a posteriori" video evaluation was moderate to good with weighted κ values of 0.69 (95% CI, 0.51-0.87) and 0.79 (95% CI, 0.59-0.98), respectively.

CONCLUSION

Prehospital telestroke examination was not at an acceptable level for clinical use, at least on the basis of the used technology. Further technical development is needed before telestroke is applicable for prehospital stroke management during patient transport.

Evolving role of biomarkers in acute cerebrovascular disease

The development of a clinically validated biomarker of acute cerebral ischemia would have the potential to facilitate the use of time-sensitive reperfusion strategies, allow for individualization of patient care by predicting relative risk of hemorrhage and volume of penumbral tissue, and add valuable prognostic information for patients presenting with acute stroke. Additionally, a stroke biomarker might benefit early stage clinical research by serving as a surrogate measure of ischemic injury. Although at present there are no clinically validated biomarkers of acute stroke, previous studies have focused on markers associated with different components of the ischemic cascade, including microglial activation, inflammation, oxidative stress, neuronal injury, hemostasis, and endothelial dysfunction. Evolving technologies have provided high throughput approaches to investigate potential gene and protein signatures, and methods to measure newly discovered markers of cell death and immune responses. Prior to defining the clinical utility of stroke biomarkers, it is critical to understand the inherent limitations of a biomarker-based approach and define its potential value for providing adjunctive diagnostic and prognostic information. The identification and validation of a clinically relevant biomarker, or panel of markers, of stroke will ultimately require incorporation of both stringent research design and assessment in the clinical context in which the marker will be used.

[What are the crucial factors affecting the time to admission of patients with suspected stroke to the emergency department?]

OBJECTIVE

To analyse the factors influencing the time of admission of patients presenting an acute ischaemic stroke (AIS) to the emergency department.

PATIENTS AND METHODS

Between May 2006 and July 2007, all patients with suspected stroke admitted to the emergency department were included. Patients' characteristics and the nature and timing of the events following symptom detection were recorded in the emergency department. The symptoms observed, the person telephoning for help, the person or establishment contacted, the measures implemented (attendance of a physician, medical or paramedical intervention) and the means of transport to the hospital were noted. The overall population was analysed descriptively and patients admitted within 3 hours of symptom onset (group I) were compared with those admitted after a longer interval (group II). The final diagnosis of AIS was confirmed on patient discharge. The results were expressed as the mean (± SD) or median (interquartile range), Mann-Whitney and Chi(2) tests being used to analyse differences between the two groups (threshold of statistical significance: P<0.05).

RESULTS

Among the 678 patients admitted with suspected stroke, 536 were diagnosed as having experienced an AIS, 65 a haemorrhagic stroke, 3 a cerebral venous thrombosis and 74 an event other than an acute neurovascular event. The results therefore concern 536 patients (median age: 75 years), of whom 166 (31%, group I) were admitted within 3 hours of symptom onset and 370 after a longer interval (group II). The median time between symptom onset and the call for help was 15 min (1-26) in group I and 300 min (60-960) in group II (P<0.0001). The median times to intervention of a physician (the patient's regular general practitioner, the physician on duty, or the SMUR [Mobile Emergency and Resuscitation Service] physician) ranged from 10 to 60 min. Median transport times ranged from 30 to 120 min depending on the type of transport employed. The two groups differed significantly with regard to intervention of a physician before admission to the emergency department (40% of patients in group I vs. 72% in group II, P<0.0001), initial call to the emergency medical call centre ("15" in France) (42% vs. 17%, P<0.001), presence of a relative or other person at the time of functional symptom onset (58% vs. 39%, P<0.01), and immediate transport to hospital without medical intervention (49 vs. 11%). Finally, irrespective of the time to hospital admission, 12% of the patients studied were eligible for intravenous thrombolysis.

CONCLUSION

In the event of a suspected stroke, these results favour contacting the emergency medical call centre and immediate transfer of the patient to an appropriate hospital establishment without waiting for prior medical intervention.

Stroke-Unit and emergency medical service: a 48-month experience in northern Italy

Since the therapeutic window for acute ischaemic stroke is very short, early arrival at emergency care rooms is mandatory. Emergency medical service (EMS), assuring fast patients transportations, plays a fundamental role in the management of stroke. We have prospectively analysed the utilisation of EMS in the management of stroke patients in a countryside area of northern Italy. Among patients presenting with an acute stroke during the period January 2007-December 2010, those with an ascertained time of onset and documented ongoing brain ischaemia at neuroimaging were included in the study. For all of those patients, the personal data, means of arrival, nature of stroke, whether first stroke or recurrence, severity of stroke and the in-hospital outcome were recorded. Of 1,188 patients hospitalised with a definite diagnosis of stroke, 757 patients were included in the study. Of those, 285 patients (37.6 %) were transported by EMS. EMS allowed earlier admissions (75 % within 3 h of stroke onset), but also transportation of patients of an older age (75 vs. 71 years, p < 0.001), and with more severe strokes (62 % of total anterior circulation infarctions). Our study confirms that EMS is essential in delivering the earliest therapy to patients with acute cerebral infarction living in an extra-urban area of northern Italy. However, work is needed in optimising EMS, since transported patients are often not prone to therapy.

Regional differences in emergency medical services use for patients with acute stroke (findings from the National Hospital Ambulatory Medical Care Survey Emergency Department Data File)

BACKGROUND

Our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide and to examine regional differences and factors associated with the mode of transport to the emergency department (ED).

METHODS

Patients with a primary discharge diagnosis of stroke based on previously validated International Classification of Disease, 9th revision codes were abstracted from the National Hospital Ambulatory Medical Care Survey for the years 2007 to 2009. We excluded subjects<18 years of age and those with missing data. Using logistic regression, we identified independent predictors of arrival by ambulance to the ED.

RESULTS

Overall, 566 patients met the entry criteria, representing 2,153,234 patient records nationally, based on 2010 US census data. Of these, 50.4% arrived by ambulance. After adjustment for potential confounders, age was associated with use of an ambulance. In addition, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (South: odds ratio [OR] 0.45 and 95% confidence interval [CI] 0.26-0.76; West: OR 0.45 and 95% CI 0.25-0.84; Midwest: OR 0.56 and 95% CI 0.31-1.01). Compared to the Medicare population, privately insured and self-insured patients had lower odds of arriving by ambulance (OR for private insurance 0.48 and 95% CI 0.28-0.84; OR for self-payers 0.36 and 95% CI 0.14-0.93). Gender, race, urban or rural location of ED, and safety net status was not independently associated with ambulance use.

CONCLUSIONS

Patients with stroke arrive by ambulance more frequently in the Northeast than in other regions of the United States. Identifying reasons for this difference may be useful in improving stroke care.

Stroke in South Asia: a systematic review of epidemiologic literature from 1980 to 2010

BACKGROUND

Globally 15 million people have an acute stroke every year and one third of them die secondary to stroke events. Most research on stroke prevention and treatment is done in developed countries, yet more than 85% of strokes occur in developing countries. In particular, stroke remains an underrecognized cause of death and disability in South Asia.

METHODS

We conducted a systematic review to identify reliable and comparable epidemiological evidence on stroke in South Asia from 1980 to 2010. Publications were screened for eligibility to identify only population-based stroke studies.

RESULTS

Of the 71 studies retrieved, only 6 studies from South Asia gave us acceptable estimates of the burden of stroke. Population-based studies from South Asia have stroke prevalence in the range of 45-471 per 100,000. The age-adjusted incidence rate varied from approximately 145 per 100,000 to 262 per 100,000. Rural parts of South Asia have a lower stroke prevalence compared with urban areas.

CONCLUSIONS

Our review highlights the paucity of research data in South Asia. This must be addressed in order to accurately determine the burden of stroke in South Asia, so that specific policy recommendations can be formulated to combat the stroke epidemic in this region.