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Abstract
Involvement of the Anesthesiologist in the early stages of care for acute ischemic stroke patient undergoing endovascular treatment is essential. Anesthetic management includes the anesthetic technique (general anesthesia vs sedation), a matter of much debate and an area in need of well-designed prospective studies. The large numbers of confounding factors make the design of such studies a difficult process. A universally agreed point in the endovascular management of acute ischemic stroke is the importance of decreasing the time to revascularization. Hemodynamic and ventilatory management and implementation of neuroprotective modalities and treatment of acute procedural complications are important components of the anesthetic plan.
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Affiliation(s)
- Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue E-31, Cleveland, OH 44195, USA.
| | - Sandra B Machado
- Department of General Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue E-31, Cleveland, OH 44195, USA
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202
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Kunz A, Ebinger M, Geisler F, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Zieschang K, Fiebach JB, Villringer K, Erdur H, Scheitz JF, Tütüncü S, Bollweg K, Grittner U, Kaczmarek S, Endres M, Nolte CH, Audebert HJ. Functional outcomes of pre-hospital thrombolysis in a mobile stroke treatment unit compared with conventional care: an observational registry study. Lancet Neurol 2016; 15:1035-43. [DOI: 10.1016/s1474-4422(16)30129-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/02/2016] [Accepted: 06/08/2016] [Indexed: 11/30/2022]
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203
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Rudd AG. Can emergency stroke care be delivered in an ambulance? Lancet Neurol 2016; 15:998-1000. [DOI: 10.1016/s1474-4422(16)30162-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 06/27/2016] [Indexed: 11/15/2022]
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204
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Williams DJP. The great ESCAPE - a clinical pharmacologist's journey in stroke research. Br J Clin Pharmacol 2016; 82:334-9. [PMID: 27062549 PMCID: PMC4972149 DOI: 10.1111/bcp.12966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/04/2016] [Accepted: 04/04/2016] [Indexed: 11/30/2022] Open
Affiliation(s)
- David J P Williams
- Royal College of Surgeons in Ireland (RCSI) and Beaumont Hospital Dublin, Dublin, Ireland
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205
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Cai C, Ning J, Huang X. A Bayesian multi-stage cost-effectiveness design for animal studies in stroke research. Stat Methods Med Res 2016; 27:1219-1229. [PMID: 27405325 DOI: 10.1177/0962280216657853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Much progress has been made in the area of adaptive designs for clinical trials. However, little has been done regarding adaptive designs to identify optimal treatment strategies in animal studies. Motivated by an animal study of a novel strategy for treating strokes, we propose a Bayesian multi-stage cost-effectiveness design to simultaneously identify the optimal dose and determine the therapeutic treatment window for administrating the experimental agent. We consider a non-monotonic pattern for the dose-schedule-efficacy relationship and develop an adaptive shrinkage algorithm to assign more cohorts to admissible strategies. We conduct simulation studies to evaluate the performance of the proposed design by comparing it with two standard designs. These simulation studies show that the proposed design yields a significantly higher probability of selecting the optimal strategy, while it is generally more efficient and practical in terms of resource usage.
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Affiliation(s)
- Chunyan Cai
- 1 Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, USA.,2 Biostatistics/Epidemiology/Research Design Core, Center for Clinical and Translational Sciences, The University of Texas Health Science Center at Houston, USA
| | - Jing Ning
- 3 Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, USA
| | - Xuelin Huang
- 3 Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, USA
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206
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Grunwald IQ, Ragoschke-Schumm A, Kettner M, Schwindling L, Roumia S, Helwig S, Manitz M, Walter S, Yilmaz U, Greveson E, Lesmeister M, Reith W, Fassbender K. First Automated Stroke Imaging Evaluation via Electronic Alberta Stroke Program Early CT Score in a Mobile Stroke Unit. Cerebrovasc Dis 2016; 42:332-338. [DOI: 10.1159/000446861] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/09/2016] [Indexed: 11/19/2022] Open
Abstract
Background: Recently, a mobile stroke unit (MSU) was shown to facilitate acute stroke treatment directly at the emergency site. The neuroradiological expertise of the MSU is improved by its ability to detect early ischemic damage via automatic electronic (e) evaluation of CT scans using a novel software program that calculates the electronic Alberta Stroke Program Early CT Score (e-ASPECTS). Methods: The feasibility of integrating e-ASPECTS into an ambulance was examined, and the clinical integration and utility of the software in 15 consecutive cases evaluated. Results: Implementation of e-ASPECTS onto the MSU and into the prehospital stroke management was feasible. The values of e-ASPECTS matched with the results of conventional neuroradiologic analysis by the MSU team. The potential benefits of e-ASPECTS were illustrated by three cases. In case 1, excluding early infarct signs supported the decision to directly perform prehospital thrombolysis. In case 2, in which stroke was caused by large-vessel occlusion, the high e-ASPECTS value supported the decision to initiate intra-arterial treatment and triage the patient to a comprehensive stroke center. In case 3, the e-ASPECTS value was 10, indicating the absence of early infarct signs despite pre-existing cerebral microangiopathy and macroangiopathy, a finding indicating the program's robustness against artefacts. Conclusions: This study on the integration of e-ASPECTS into the prehospital stroke management via a MSU showed for the first time that such integration is feasible, and aids both decision regarding the treatment option and the triage regarding the most appropriate target hospital.
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207
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Leira EC, Stilley JD, Schnell T, Audebert HJ, Adams HP. Helicopter transportation in the era of thrombectomy: The next frontier for acute stroke treatment and research. Eur Stroke J 2016; 1:171-179. [PMID: 31008278 DOI: 10.1177/2396987316658994] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/18/2016] [Indexed: 11/15/2022] Open
Abstract
Purpose Many patients suffer a stroke at a significant distance from a specialized center capable of delivering endovascular therapy. As a result, they require rapid transport by helicopter emergency medical services, sometimes while receiving a recombinant tissue plasminogen activator infusion (drip and ship). Despite its critical role in the new era of reperfusion, helicopter emergency medical services remains a poorly evaluated aspect of stroke care. Method Comprehensive narrative review of all published articles of helicopter emergency medical services related to acute stroke care in the inter-hospital and pre-hospital settings, including technical aspects and physical environment implications. Findings Helicopter emergency medical services transports are conducted during a critical early time period when specific interventions and ancillary care practices may have a significant influence on outcomes. We have limited knowledge of the potential impact of the unusual physical factors generated by the helicopter on the ischemic brain, which affects our ability to establish rational guidelines for ancillary care and the delivery of specific interventions. Discussion Unlike the pre-hospital and hospital settings where stroke interventions are delivered, the inter-hospital helicopter emergency medical services transfer setting remains a "black box" for acute stroke care and research. This gap is particularly relevant for many patients living in rural areas, or in congested urban areas, that depend on helicopter emergency medical services for rapid access to a tertiary stroke center. Conclusion Addressing the helicopter emergency medical services stroke gap in clinical trials and acute care delivery would homogenize capabilities through all care settings, thus minimizing potential disparities in research access and outcomes based on geographical location.
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Affiliation(s)
- Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Joshua D Stilley
- Department of Emergency Medicine-AirCare, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Thomas Schnell
- Department of Mechanical and Industrial Engineering, College of Engineering, University of Iowa, Iowa City, IA, USA
| | - Heinrich J Audebert
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Harold P Adams
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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208
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Turc G, Maïer B, Naggara O, Seners P, Isabel C, Tisserand M, Raynouard I, Edjlali M, Calvet D, Baron JC, Mas JL, Oppenheim C. Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion. Stroke 2016; 47:1466-72. [PMID: 27125526 DOI: 10.1161/strokeaha.116.013144] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/22/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Guillaume Turc
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Benjamin Maïer
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Olivier Naggara
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Pierre Seners
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Clothilde Isabel
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Marie Tisserand
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Igor Raynouard
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Myriam Edjlali
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - David Calvet
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Jean-Claude Baron
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Jean-Louis Mas
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
| | - Catherine Oppenheim
- From the Departments of Neurology (G.T., B.M., P.S., C.I., I.R., D.C., J.-C.B., J.-L.M.) and Radiology (O.N., M.T., M.E., C.O.), Hôpital Sainte-Anne, Paris, France; and Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France (G.T., B.M., O.N., P.S., C.I., M.T., I.R., M.E., D.C., J.-C.B., J.-L.M., C.O.)
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Shams T, Zaidat O, Yavagal D, Xavier A, Jovin T, Janardhan V. Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions. INTERVENTIONAL NEUROLOGY 2016; 5:1-28. [PMID: 27610118 PMCID: PMC4934489 DOI: 10.1159/000443617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.
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Affiliation(s)
- Tanzila Shams
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
| | - Osama Zaidat
- Mercy Neuroscience and Stroke Center, Toledo, Ohio, USA
| | - Dileep Yavagal
- Jackson Memorial Hospital, University of Miami Health System, Miami, Fla., USA
| | - Andrew Xavier
- Detroit Medical Center, Wayne State University, Detroit, Mich., USA
| | - Tudor Jovin
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburg, Pa., USA
| | - Vallabh Janardhan
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
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210
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Schwindling L, Ragoschke-Schumm A, Kettner M, Helwig S, Manitz M, Roumia S, Lesmeister M, Grunwald IQ, Fassbender K. Prehospital Imaging-Based Triage of Head Trauma with a Mobile Stroke Unit: First Evidence and Literature Review. J Neuroimaging 2016; 26:489-93. [PMID: 27159772 DOI: 10.1111/jon.12355] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/29/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND An ambulance equipped with a computed tomography (CT) scanner, point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit [MSU]) has been shown to enable delivery of thrombolysis to stroke patients at the emergency site, thereby significantly decreasing time to treatment. However, the MSU frequently assesses patients with cerebral disorders other than stroke. For some of these disorders, prehospital CT scanning may also be beneficial. METHODS Our institution manages a program investigating prehospital stroke treatment of patients with neurological emergencies. We assessed a patient with head trauma for whom prehospital CT scanning and laboratory tests allowed cause-based triage to the most appropriate hospital. We examined implications of this case for clinical practice in light of a literature review. RESULTS The MSU was dispatched to assess a 74-year-old woman with suspected head trauma or stroke, found lying on the floor with a left frontal laceration. Her Glasgow Coma Scale score was 13, apart from drowsiness she exhibited no neurologic deficit. A CT scan ruled out intracranial hemorrhage and skull fracture. On the basis of these prehospital diagnostic findings, the patient was taken to the nearest primary care hospital rather than to a trauma center with neurosurgery facilities. CONCLUSION Patients with neurologic disorders other than stroke, such as traumatic brain injury, may also benefit from prehospital CT studies. This case report and the results of our analysis of the literature support the potential benefit of prehospital imaging in correctly triaging patients with suspected traumatic brain injury to the appropriate target hospital.
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Affiliation(s)
- L Schwindling
- Department of Neurology, Saarland University, Homburg, Germany
| | | | - M Kettner
- Department of Neurology, Saarland University, Homburg, Germany
| | - S Helwig
- Department of Neurology, Saarland University, Homburg, Germany
| | - M Manitz
- Department of Neurology, Saarland University, Homburg, Germany
| | - S Roumia
- Institute of Neuroradiology, Saarland University, Homburg, Germany
| | - M Lesmeister
- Department of Neurology, Saarland University, Homburg, Germany
| | - I Q Grunwald
- Neuroscience Department, Anglia Ruskin University, Chelmsford, Essex, UK
| | - K Fassbender
- Department of Neurology, Saarland University, Homburg, Germany
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211
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Diogo LP, Bahlis LF, Wajner A, Waldemar FS. Decreased mortality in patients hospitalized due to respiratory diseases after installation of an intensive care unit in a secondary hospital in the interior of Brazil. Rev Bras Ter Intensiva 2016; 27:235-9. [PMID: 26465244 PMCID: PMC4592117 DOI: 10.5935/0103-507x.20150043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 07/18/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the association between the in-hospital mortality of patients hospitalized due to respiratory diseases and the availability of intensive care units. METHODS This retrospective cohort study evaluated a database from a hospital medicine service involving patients hospitalized due to respiratory non-terminal diseases. Data on clinical characteristics and risk factors associated with mortality, such as Charlson score and length of hospital stay, were collected. The following analyses were performed: univariate analysis with simple stratification using the Mantel Haenszel test, chi squared test, Student's t test, Mann-Whitney test, and logistic regression. RESULTS Three hundred thirteen patients were selected, including 98 (31.3%) before installation of the intensive care unit and 215 (68.7%) after installation of the intensive care unit. No significant differences in the clinical and anthropometric characteristics or risk factors were observed between the groups. The mortality rate was 18/95 (18.9%) before the installation of the intensive care unit and 21/206 (10.2%) after the installation of the intensive care unit. Logistic regression analysis indicated that the probability of death after the installation of the intensive care unit decreased by 58% (OR: 0.42; 95%CI 0.205 -0.879; p = 0.021). CONCLUSION Considering the limitations of the study, the results suggest a benefit, with a decrease of one death per every 11 patients treated for respiratory diseases after the installation of an intensive care unit in our hospital. The results corroborate the benefits of the implementation of intensive care units in secondary hospitals.
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Affiliation(s)
| | | | - André Wajner
- Serviço de Medicina Hospitalar, Hospital Montenegro, Montenegro, RS, BR
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212
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Gunter RL, Chouinard S, Fernandes-Taylor S, Wiseman JT, Clarkson S, Bennett K, Greenberg CC, Kent KC. Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review. J Am Coll Surg 2016; 222:915-27. [PMID: 27016900 PMCID: PMC5660861 DOI: 10.1016/j.jamcollsurg.2016.01.062] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Rebecca L Gunter
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | - Skyler Chouinard
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | | | - Jason T Wiseman
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | - Sam Clarkson
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | - Kyla Bennett
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | | | - K Craig Kent
- Department of Surgery, University of Wisconsin School of Medicine & Public Health, Madison, WI.
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213
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Luppa PB, Bietenbeck A, Beaudoin C, Giannetti A. Clinically relevant analytical techniques, organizational concepts for application and future perspectives of point-of-care testing. Biotechnol Adv 2016; 34:139-60. [DOI: 10.1016/j.biotechadv.2016.01.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/15/2016] [Accepted: 01/17/2016] [Indexed: 01/19/2023]
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214
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Feldman WB, Kim AS, Josephson SA, Lowenstein DH, Chiong W. Effect of waivers of consent on recruitment in acute stroke trials: A systematic review. Neurology 2016; 86:1543-51. [PMID: 27009262 PMCID: PMC4836887 DOI: 10.1212/wnl.0000000000002587] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 11/16/2015] [Indexed: 01/08/2023] Open
Abstract
There is urgent need for clinical trials of novel interventions to reduce the burden of acute ischemic stroke. A key impediment to such trials is slow recruitment. Since obtaining written informed consent in the setting of acute stroke is especially challenging, some experts have endorsed relaxing the requirement for informed consent by permitting verbal consent or waivers to facilitate recruitment. This systematic review of 36 randomized controlled trials of acute interventions for ischemic stroke assesses whether alternatives to written informed consent are associated with increased recruitment rates. After the exclusion of 2 outlier trials that differed from other trials in conduct and interventions studied, no association was observed on univariable analysis (8.9 participants/month in trials requiring written consent vs 6.1 participants/month in trials with alternatives, p = 0.43) or multivariable analysis (when adjusting for the number of centers, number of countries, and exclusions based on modified Rankin Scale scores). Alternatives to written informed consent in acute stroke trials may enable trial designs that would not be feasible otherwise. However, we did not find evidence that, within traditional trial designs, such alternatives are associated with faster recruitment.
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Affiliation(s)
- William B Feldman
- From the School of Medicine (W.B.F.), Department of Neurology (A.S.K., S.A.J., D.H.L., W.C.), and Memory and Aging Center (W.C.), University of California, San Francisco.
| | - Anthony S Kim
- From the School of Medicine (W.B.F.), Department of Neurology (A.S.K., S.A.J., D.H.L., W.C.), and Memory and Aging Center (W.C.), University of California, San Francisco
| | - S Andrew Josephson
- From the School of Medicine (W.B.F.), Department of Neurology (A.S.K., S.A.J., D.H.L., W.C.), and Memory and Aging Center (W.C.), University of California, San Francisco
| | - Daniel H Lowenstein
- From the School of Medicine (W.B.F.), Department of Neurology (A.S.K., S.A.J., D.H.L., W.C.), and Memory and Aging Center (W.C.), University of California, San Francisco
| | - Winston Chiong
- From the School of Medicine (W.B.F.), Department of Neurology (A.S.K., S.A.J., D.H.L., W.C.), and Memory and Aging Center (W.C.), University of California, San Francisco
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Navalkele DD, Cai C, Vahidy F, Rahbar MH, Pandurengan R, Wu TC, Sarraj A, Barreto A, Grotta JC, Gonzales N. Higher prehospital blood pressure prolongs door to needle thrombolysis times: a target for quality improvement? Am J Emerg Med 2016; 34:1268-72. [PMID: 27139258 DOI: 10.1016/j.ajem.2016.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 04/12/2016] [Accepted: 04/13/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Per the American Heart Association guidelines, blood pressure (BP) should be less than 185/110 to be eligible for stroke thrombolysis. No studies have focused on prehospital BP and its impact on door to needle (DTN) times. We hypothesized that DTN times would be longer for patients with higher prehospital BP. METHODS We conducted a retrospective review of acute ischemic stroke patients who presented between January 2010 and December 2010 to our emergency department (ED) through emergency medical services within 3 hours of symptom onset. Patients were categorized into 2 groups: prehospital BP greater than or equal to 185/110 (group 1) and less than 185/110 (group 2). Blood pressure records were abstracted from emergency medical services run sheets. Primary outcome measure was DTN time, and secondary outcome measures were modified Rankin Score at discharge, symptomatic intracranial hemorrhage, length of stay in stroke unit, and discharge disposition. RESULTS A total of 107 consecutive patients were identified. Of these, 75 patients (70%) were thrombolysed. Mean DTN times were significantly higher in group 1 (adjusted mean [95% confidence interval], 86minutes [76-97] vs 56minutes [45-68]; P<.0001). A greater number of patients required antihypertensive medications before thrombolysis in the ED in group 1 compared to group 2 (54% vs 27%; P=.02). CONCLUSION Higher prehospital BP is associated with prolonged DTN times and DTN time remains prolonged if prehospital BP greater than or equal to 185/110 is untreated before ED arrival. Prehospital BP control could be a potential area for improvement to reduce DTN times in patients with acute ischemic stroke.
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Affiliation(s)
| | - Chunyan Cai
- University of Texas Health Science Center at Houston, Houston, TX
| | - Farhaan Vahidy
- University of Texas Health Science Center at Houston, Houston, TX
| | | | | | - Tzu-Ching Wu
- University of Texas Health Science Center at Houston, Houston, TX
| | - Amrou Sarraj
- University of Texas Health Science Center at Houston, Houston, TX
| | - Andrew Barreto
- University of Texas Health Science Center at Houston, Houston, TX
| | | | - Nicole Gonzales
- University of Texas Health Science Center at Houston, Houston, TX
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216
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John S, Stock S, Masaryk T, Bauer A, Cerejo R, Uchino K, Winners S, Rasmussen P, Hussain MS. Performance of CT Angiography on a Mobile Stroke Treatment Unit: Implications for Triage. J Neuroimaging 2016; 26:391-4. [DOI: 10.1111/jon.12346] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 02/14/2016] [Accepted: 02/24/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Seby John
- Cerebrovascular Center; Cleveland Clinic; Cleveland OH
| | - Sarah Stock
- Department of Neuroradiology; Cleveland Clinic; Cleveland OH
| | - Thomas Masaryk
- Cerebrovascular Center; Cleveland Clinic; Cleveland OH
- Department of Neuroradiology; Cleveland Clinic; Cleveland OH
| | - Andrew Bauer
- Cerebrovascular Center; Cleveland Clinic; Cleveland OH
| | | | - Ken Uchino
- Cerebrovascular Center; Cleveland Clinic; Cleveland OH
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217
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Weber J, Ebinger M, Audebert HJ. Prehospital stroke care: telemedicine, thrombolysis and neuroprotection. Expert Rev Neurother 2016; 15:753-61. [PMID: 26109228 DOI: 10.1586/14737175.2015.1051967] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last 15 years, new approaches regarding neuroprotective and thrombolytic strategies in stroke management have been evaluated in the prehospital setting. These efforts have provided exciting new potentials of hyperacute stroke care. Trials have shown that the use of specialized stroke ambulances increases the proportion of patients receiving intravenous thrombolysis and shortens alarm-to-treatment time by approximately half an hour compared to standard care. Intravenous thrombolysis within the ultra-early time window of the 'golden hour' has become a realistic scenario. However, direct effects of prehospital stroke care on functional outcome have yet to be shown and other approaches such as neuroprotective treatments could not demonstrate clinical benefit so far. There is a clear need for systematic research in the prehospital field to test the clinical effectiveness and cost-effectiveness of new therapeutic strategies. It will be necessary to test various components of prehospital stroke care alone and in combination.
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Affiliation(s)
- Joachim Weber
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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218
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Glober NK, Sporer KA, Guluma KZ, Serra JP, Barger JA, Brown JF, Gilbert GH, Koenig KL, Rudnick EM, Salvucci AA. Acute Stroke: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2016; 17:104-28. [PMID: 26973735 PMCID: PMC4786229 DOI: 10.5811/westjem.2015.12.28995] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Nancy K Glober
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kama Z Guluma
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - John P Serra
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Joe A Barger
- EMS Medical Directors Association of California, California
| | - John F Brown
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California, California; Stanford University, Department of Emergency Medicine, Stanford, California
| | - Kristi L Koenig
- EMS Medical Directors Association of California, California; University of California Irvine, Center for Disaster Medical Sciences, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California, California
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219
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Theofanidis D, Savopoulos C, Hatzitolios A. Global specialized stroke care delivery models. JOURNAL OF VASCULAR NURSING 2016; 34:2-11. [PMID: 26897346 DOI: 10.1016/j.jvn.2015.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 07/15/2015] [Accepted: 07/15/2015] [Indexed: 10/22/2022]
Abstract
Stroke services still vary enormously from country to country, with many countries providing no special services at all. The aim of this article is to provide a concise overview of the various types of acute stroke delivery systems at present available and critically describe merits and shortcomings. A systematic literature review was undertaken from 1990 to July 2014. Several models for stroke services have been developed mostly in the past 3 decades, mainly in the Western world. These include state-of-the-art stroke services ranging from highly specialized stroke centers to mobile stroke units for the community. In this light, the recommendations of the structure and organization of stroke units and stroke centers by the European Stroke Organization were recently published. What differentiates the various models of stroke care delivery across the globe is the diversity of services ranging from low key conventional care to highly sophisticated facilities with life saving interventional features via integrated stroke care infrastructure. Effective in-hospital care for stroke should start in the emergency department where a swift and appropriate diagnosis should be made. The role of all brain neuroimaging procedures should have a defined a priori and proper demarcation between actions according to updated stroke care pathways and clinical protocols, which should be followed closely. These essential actions initiated by well-trained staff in the emergency department, should then be carried on in dedicated stroke facilities that is, a stroke unit.
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Affiliation(s)
- Dimitrios Theofanidis
- Nursing Department, Alexandreio Technological Educational Institute of Thesaloniki, Thessaloniki, Greece.
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, "AHEPA" University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, "AHEPA" University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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220
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Canadian Association of Emergency Physicians position statement on acute ischemic stroke. CAN J EMERG MED 2016; 17:217-26. [PMID: 26120643 DOI: 10.1017/cem.2015.26] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The CAEP Stroke Practice Committee was convened in the spring of 2013 to revisit the 2001 policy statement on the use of thrombolytic therapy in acute ischemic stroke. The terms of reference of the panel were developed to include national representation from urban academic centres as well as community and rural centres from all regions of the country. Membership was determined by attracting recognized stroke leaders from across the country who agreed to volunteer their time towards the development of revised guidance on the topic. The guideline panel elected to adopt the GRADE language to communicate guidance after review of existing systematic reviews and international clinical practice guidelines. Stroke neurologists from across Canada were engaged to work alongside panel members to develop guidance as a dyad-based consensus when possible. There was no unique systematic review performed to support this guidance, rather existing efficacy data was relied upon. After a series of teleconferences and face to face meetings, a draft guideline was developed and presented to the CAEP board in June of 2014. The panel noted the development of significant new evidence to inform a number of clinical questions related to acute stroke management. In general terms the recommendations issued by the CAEP Stroke Practice Committee are supportive of the use of thrombolytic therapy when treatment can be administered within 3 hours of symptom onset. The committee is also supportive of system-level changes including pre-hospital interventions, the transport of patients to dedicated stroke centers when possible and tele-health measures to support thrombolytic therapy in a timely window. Of note, after careful deliberation, the panel elected to issue a conditional recommendation against the use of thrombolytic therapy in the 3–4.5 hour window. The view of the committee was that as a result of a narrow risk benefit balance, one that is considerably narrower than the same considerations under 3 hours, a significant number of informed patients and families would opt against the risk of early intracranial hemorrhage and the possibility of increased 90-day mortality that is not seen for more timely treatment. Furthermore, the frequently impaired nature of patients suffering an acute stroke and the difficulties in asking families to make life and death decisions in a highly time-sensitive context led the panel to restrict a strong endorsement of thrombolytic to the 3 hour outermost limit. The committee noted as well that Health Canada has not approved a thrombolytic agent beyond a three hour window in acute ischemic stroke.
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221
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Khanna AB, Narula SA. Mobile health units: Mobilizing healthcare to reach unreachable. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2016. [DOI: 10.1080/20479700.2015.1101915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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222
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Sun J, Guo Y, Wang X, Zeng Q. mHealth For Aging China: Opportunities and Challenges. Aging Dis 2016; 7:53-67. [PMID: 26816664 DOI: 10.14336/ad.2015.1011] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 10/11/2015] [Indexed: 12/17/2022] Open
Abstract
The aging population with chronic and age-related diseases has become a global issue and exerted heavy burdens on the healthcare system and society. Neurological diseases are the leading chronic diseases in the geriatric population, and stroke is the leading cause of death in China. However, the uneven distribution of caregivers and critical healthcare workforce shortages are major obstacles to improving disease outcome. With the advancement of wearable health devices, cloud computing, mobile technologies and Internet of Things, mobile health (mHealth) is rapidly developing and shows a promising future in the management of chronic diseases. Its advantages include its ability to improve the quality of care, reduce the costs of care, and improve treatment outcomes by transferring in-hospital treatment to patient-centered medical treatment at home. mHealth could also enhance the international cooperation of medical providers in different time zones and the sharing of high-quality medical service resources between developed and developing countries. In this review, we focus on trends in mHealth and its clinical applications for the prevention and treatment of diseases, especially aging-related neurological diseases, and on the opportunities and challenges of mHealth in China. Operating models of mHealth in disease management are proposed; these models may benefit those who work within the mHealth system in developing countries and developed countries.
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Affiliation(s)
- Jing Sun
- 1Department of International Inpatient, Chinese PLA General Hospital, Beijing 100853, China
| | - Yutao Guo
- 2Department of Geriatric Cardiology, Institute of Health Management, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiaoning Wang
- 3The State Key Laboratory and Normal Aging, Chinese PLA General Hospital, Beijing 100853, China
| | - Qiang Zeng
- 1Department of International Inpatient, Chinese PLA General Hospital, Beijing 100853, China
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223
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Gonzales NR, Grotta JC. Pharmacologic Modification of Acute Cerebral Ischemia. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00055-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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224
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Ragoschke-Schumm A. Schlaganfall. Radiologe 2016; 56:4-8. [DOI: 10.1007/s00117-015-0051-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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225
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Peyron C, Wallut L. Tarification à l’activité et équilibre financier des prises en charge avec télémédecine : l’exemple du dispositif TéléAVC en Bourgogne. ACTA ACUST UNITED AC 2016. [DOI: 10.3917/jgem.168.0415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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226
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Hov MR, Lund CG. Den akutt syke hjernen må håndteres allerede prehospitalt. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:515. [DOI: 10.4045/tidsskr.16.0155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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228
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Goyal M, Hill MD, Saver JL, Fisher M. Challenges and Opportunities of Endovascular Stroke Therapy. Ann Neurol 2015; 79:11-7. [DOI: 10.1002/ana.24528] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/11/2015] [Accepted: 09/18/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Mayank Goyal
- Department of Radiology and Clinical Neurosciences; Foothills Hospital, Cuming School of Medicine, University of Calgary; Calgary Alberta Canada
| | - Michael D. Hill
- Department of Radiology and Clinical Neurosciences; Foothills Hospital, Cuming School of Medicine, University of Calgary; Calgary Alberta Canada
- Department of Community Health Sciences and Medicine; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Calgary Alberta Canada
| | - Jeffrey L. Saver
- Geffen School of Medicine at UCLA, UCLA Comprehensive Stroke Center; Los Angeles CA
| | - Marc Fisher
- Department of Neurology; Beth Israel Deaconess Medical Center, Harvard Medical School; Boston MA
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229
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Yang P, Niu K, Wu Y, Struffert T, Dorfler A, Schafer S, Royalty K, Strother C, Chen GH. Time-Resolved C-Arm Computed Tomographic Angiography Derived From Computed Tomographic Perfusion Acquisition. Stroke 2015; 46:3383-9. [DOI: 10.1161/strokeaha.115.011165] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/17/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Multimodal imaging using cone beam C-arm computed tomography (CT) may shorten the delay from ictus to revascularization for acute ischemic stroke patients with a large vessel occlusion. Largely because of limited temporal resolution, reconstruction of time-resolved CT angiography (CTA) from these systems has not yielded satisfactory results. We evaluated the image quality and diagnostic value of time-resolved C-arm CTA reconstructed using novel image processing algorithms.
Methods—
Studies were done under an Institutional Review Board approved protocol. Postprocessing of data from 21 C-arm CT dynamic perfusion acquisitions from 17 patients with acute ischemic stroke were done to derive time-resolved C-arm CTA images. Two observers independently evaluated image quality and diagnostic content for each case. ICC and receiver-operating characteristic analysis were performed to evaluate interobserver agreement and diagnostic value of this novel imaging modality.
Results—
Time-resolved C-arm CTA images were successfully generated from 20 data sets (95.2%, 20/21). Two observers agreed well that the image quality for large cerebral arteries was good but was more limited for small cerebral arteries (distal to M1, A1, and P1). receiver-operating characteristic curves demonstrated excellent diagnostic value for detecting large vessel occlusions (area under the curve=0.987–1).
Conclusions—
Time-resolved CTAs derived from C-arm CT perfusion acquisitions provide high quality images that allowed accurate diagnosis of large vessel occlusions. Although image quality of smaller arteries in this study was not optimal ongoing modifications of the postprocessing algorithm will likely remove this limitation. Adding time-resolved C-arm CTAs to the capabilities of the angiography suite further enhances its suitability as a one-stop shop for care for patients with acute ischemic stroke.
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Affiliation(s)
- Pengfei Yang
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
| | - Kai Niu
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
| | - Yijing Wu
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
| | - Tobias Struffert
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
| | - Arnd Dorfler
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
| | - Sebastian Schafer
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
| | - Kevin Royalty
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
| | - Charles Strother
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
| | - Guang-Hong Chen
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.); Departments of Radiology (P.Y., C.S., G.-H.C.) and Medical Physics (K.N., Y.W., G.-H.C.), University of Wisconsin-Madison; Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany (T.S., A.D.); and Department of Research Collaboration, Siemens Medical Solutions, USA, Inc, Hoffman Estates, IL (S.S., K.R.)
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John S, Stock S, Cerejo R, Uchino K, Winners S, Russman A, Masaryk T, Rasmussen P, Hussain MS. Brain Imaging Using Mobile CT: Current Status and Future Prospects. J Neuroimaging 2015; 26:5-15. [PMID: 26593629 DOI: 10.1111/jon.12319] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/22/2015] [Accepted: 09/27/2015] [Indexed: 11/28/2022] Open
Abstract
Computed tomography (CT) is an invaluable tool in the diagnosis of many clinical conditions. Several advancements in biomedical engineering have achieved increase in speed, improvements in low-contrast detectability and image quality, and lower radiation. Portable or mobile CT constituted one such important advancement. It is especially useful in evaluating critically ill, intensive care unit patients by scanning them at bedside. A paradigm shift in utilization of mobile CT was its installation in ambulances for the management of acute stroke. Given the time sensitive nature of acute ischemic stroke, Mobile stroke units (MSU) were developed in Germany consisting of an ambulance equipped with a CT scanner, point of care laboratory system, along with teleradiological support. In a radical reconfiguration of stroke care, the MSU would bring the CT scanner to the stroke patient, without waiting for the patient at the emergency room. Two separate MSU projects in Saarland and Berlin demonstrated the safety and feasibility of this concept for prehospital stroke care, showing increased rate of intravenous thrombolysis and significant reduction in time to treatment compared to conventional care. MSU also improved the triage of patients to appropriate and specialized hospitals. Although multiple issues remain yet unanswered with the MSU concept including clinical outcome and cost-effectiveness, the MSU venture is visionary and enables delivery of life-saving and enhancing treatment for ischemic and hemorrhagic stroke. In this review, we discuss the development of mobile CT and its applications, with specific focus on its use in MSUs along with our institution's MSU experience.
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Affiliation(s)
- Seby John
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH
| | - Sarah Stock
- Department of Neuroradiology, Cleveland Clinic, Cleveland, OH
| | | | - Ken Uchino
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH
| | | | | | - Thomas Masaryk
- Department of Neuroradiology, Cleveland Clinic, Cleveland, OH
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231
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Lorenz MW, Lauer A, Foerch C. Quantifying the Benefit of Prehospital Rapid Treatment in Acute Stroke. Stroke 2015; 46:3168-76. [DOI: 10.1161/strokeaha.115.010445] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/12/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In acute ischemic stroke, time from onset to tissue-type plasminogen activator treatment (OTT) is a major determinant of outcome. To reduce OTT, clinical trials have been undertaken evaluating prehospital cerebral imaging with mobile computed tomographic scanners. Furthermore, blood biomarkers may allow rapid differentiation between ischemic stroke and intracerebral hemorrhage before hospital admission. How such treatment strategies translate into clinical benefit has not been specifically evaluated.
Methods—
We constructed decision models to estimate the net clinical benefit yielded by shorter OTT. In different scenarios, we estimated the proportion of patients with favorable outcome and the average quality of life.
Results—
An OTT reduction of 60 minutes increases the probability of favorable outcome by 6.6% in a mixed stroke population. For comparison, the average effect of tissue-type plasminogen activator itself is 7.0%. Prehospital mobile computed tomography gaining 25 to 40 minutes increases the probability of favorable outcome by 3.0% to 4.6%. The additional benefit of prehospital computed tomography to deliver patients with large vessel occlusion directly to endovascular treatment centers increases the probability of favorable outcome by another 0.2% to 1.0%. A blood test discriminating ischemic stroke and intracerebral hemorrhage may beneficially substitute brain scan before tissue-type plasminogen activator if >32 to 40 minutes are gained and if sensitivity for intracerebral hemorrhage is >75% to 80%.
Conclusions—
Reducing the OTT has robust beneficial effects for acute stroke patients. Prehospital tissue-type plasminogen activator treatment without brain imaging may become conceivable under several preconditions, including a point-of-care test with >75% to 80% sensitivity to detect intracerebral hemorrhage and a time gain of >32 to 40 minutes. Ethical implications remain to be addressed.
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Affiliation(s)
- Matthias W. Lorenz
- From the Department of Neurology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Arne Lauer
- From the Department of Neurology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Christian Foerch
- From the Department of Neurology, University Hospital Frankfurt, Frankfurt/Main, Germany
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Bowry R, Parker S, Rajan SS, Yamal JM, Wu TC, Richardson L, Noser E, Persse D, Jackson K, Grotta JC. Benefits of Stroke Treatment Using a Mobile Stroke Unit Compared With Standard Management: The BEST-MSU Study Run-In Phase. Stroke 2015; 46:3370-4. [PMID: 26508753 DOI: 10.1161/strokeaha.115.011093] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/22/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Faster treatment with intravenous tissue-type plasminogen activator (tPA) is likely to improve outcomes. Optimizing prehospital triage by mobile stroke units (MSUs) may speed treatment times. The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study was launched in May 2014 using the first MSU in the United States to compare stroke management using an MSU versus standard management (SM). Herein, we describe the results of the prespecified, nonrandomized run-in phase designed to obtain preliminary data on study logistics. METHODS The run-in phase consisted of 8 MSU weeks when all-patient care occurred on the MSU and 2 SM weeks when the MSU nurse met personnel on scene or at the emergency department to ensure comparability with MSU patients. Telemedicine was independently performed in 9 MSU cases. RESULTS Of 130 alerts, 24 MSU and 2 SM patients were enrolled. Twelve of 24 MSU patients received tPA on board; 4 were treated within 60 minutes of last seen normal, and 4 went on to endovascular treatment. There were no hemorrhagic complications. Four had primary intracerebral hemorrhage. Agreement on tPA eligibility between the onsite and telemedicine physician was 90%. CONCLUSIONS The run-in phase provided a tPA treatment rate of 1.5 patients per week, assured us that treatment within 60 minutes of onset is possible, and enabled enrollment of patients on SM weeks. We also recognized the opportunity to assess the effect of the MSU on endovascular treatment and intracerebral hemorrhage. Challenges include the need to control biased patient selection on MSU versus SM weeks and establish inter-rater agreement for tPA treatment using telemedicine.
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Affiliation(s)
- Ritvij Bowry
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Stephanie Parker
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Suja S Rajan
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Jose-Miguel Yamal
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Tzu-Ching Wu
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Laura Richardson
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Elizabeth Noser
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - David Persse
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Kamilah Jackson
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - James C Grotta
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.).
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Hov MR, Nome T, Zakariassen E, Russell D, Røislien J, Lossius HM, Lund CG. Assessment of acute stroke cerebral CT examinations by anaesthesiologists. Acta Anaesthesiol Scand 2015; 59:1179-86. [PMID: 25976840 PMCID: PMC5029598 DOI: 10.1111/aas.12542] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/21/2015] [Accepted: 03/21/2015] [Indexed: 12/31/2022]
Abstract
Background and purpose It is essential to diagnose ischaemic stroke as soon as possible after symptom onset, so that thrombolytic treatment can be initiated as quickly as possible. This might be greatly facilitated if cerebral CT could be carried out in a pre‐hospital setting. The aim of this study was to evaluate if anaesthesiologists, who in Norway provide pre‐hospital medical care, could be trained to assess cerebral CT scans to exclude radiological contraindications for thrombolytic stroke treatment. Methods Thirteen anaesthesiologists attended an 8‐h course in acute stroke assessment, including a 2‐h introduction to the neuroradiology of acute stroke. Each participant then assessed 12 non‐contrast cerebral CT examinations of acute stroke patients with specific regard to radiological contraindications for thrombolytic therapy. Test results were compared with those of three experienced neuroradiologists. Inter‐rater agreement between anaesthesiologists and neuroradiologists was calculated using Cohen's Kappa statistics. Robustness of the results was assessed using the non‐parametric bootstrap. Results Among the neuroradiologists, Kappa was 1 for detecting radiological contraindications for thrombolytic therapy. Twelve of the 13 anaesthesiologists showed good or excellent agreement (Kappa > 0.60) with the neuroradiologists. The anaesthesiologists spent a median time of 2 min and 18 s on each CT scan. Conclusions This study suggests that anaesthesiologists who are experienced in pre‐hospital care may be quickly trained to assess cerebral CT examinations in acute stroke patients with regard to radiological contraindications for thrombolytic therapy.
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Affiliation(s)
- M. R. Hov
- Department of Research and Development The Norwegian Air Ambulance Foundation Drøbak Norway
| | - T. Nome
- Department of Neuroradiology Oslo Norway Oslo University Hospital Oslo Norway
| | - E. Zakariassen
- Department of Research and Development The Norwegian Air Ambulance Foundation Drøbak Norway
| | - D. Russell
- Department of Neurology Oslo University Hospital Oslo Norway
| | - J. Røislien
- Department of Health Sciences University of Stavanger Oslo Norway
- Department of Biostatistics University of Oslo Oslo Norway
| | - H. M. Lossius
- Department of Research and Development The Norwegian Air Ambulance Foundation Drøbak Norway
- Department of Biostatistics University of Oslo Oslo Norway
| | - C. G. Lund
- Department of Research and Development The Norwegian Air Ambulance Foundation Drøbak Norway
- Department of Neurology Oslo University Hospital Oslo Norway
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Abstract
In acute stroke, imaging provides different technologies to demonstrate stroke subtype, tissue perfusion and vessel patency. In this review, we highlight recent clinical studies that are likely to guide therapeutic decisions. Clot length in computed tomography (CT) and clot burden in MR, imaging of leptomeningeal collaterals and indicators for active bleeding are illustrated. Imaging-based concepts for treatment of stroke at awakening and pre-hospital treatment in specialized ambulances offer new potentials to improve patient outcome.
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Affiliation(s)
- Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany,
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235
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Abstract
Telestroke and teleneurologic intensive care units (teleneuro-ICUs) optimize the diagnosis and treatment of neurologic emergencies. Establishment of a telestroke or teleneuro-ICU program relies on investment in experienced stroke and neurocritical care personnel as well as advanced telecommunications technologies. Telemanagement of neurologic emergencies can be standardized to improve outcomes, but it is essential to have a relationship with a tertiary care facility that can use endovascular, neurosurgical, and neurocritical care advanced therapies after stabilization. The next stage in telestroke/teleneuro-ICU management involves the use of mobile stroke units to shorten the time to treatment in neurocritically ill patients.
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Wireklint Sundström B, Herlitz J, Hansson PO, Brink P. Comparison of the university hospital and county hospitals in western Sweden to identify potential weak links in the early chain of care for acute stroke: results of an observational study. BMJ Open 2015; 5:e008228. [PMID: 26351184 PMCID: PMC4563274 DOI: 10.1136/bmjopen-2015-008228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To identify weak links in the early chain of care for acute stroke. SETTING 9 emergency hospitals in western Sweden, each with a stroke unit, and the emergency medical services (EMS). PARTICIPANTS All patients hospitalised with a first and a final diagnosis of stroke-between 15 December 2010 and 15 April 2011. The university hospital in the city of Gothenburg was compared with 6 county hospitals. PRIMARY AND SECONDARY MEASURES: (1) The system delay, that is, median delay time from call to the EMS until diagnosis was designated as the primary end point. Secondary end points were: (2) the system delay time from call to the EMS until arrival in a hospital ward, (3) the use of the EMS, (4) priority at the dispatch centre and (5) suspicion of stroke by the EMS nurse. RESULTS In all, 1376 acute patients with stroke (median age 79 years; 49% women) were included. The median system delay from call to the EMS until (1) diagnosis (CT scan) and (2) arrival in a hospital ward was 3 h and 52 min and 4 h and 22 min, respectively. The system delay (1) was significantly shorter in county hospitals. (3) The study showed that 76% used the EMS (Gothenburg 71%; the county 79%; p<0.0001). (4) Priority 1 was given at the dispatch centre in 54% of cases. (5) Stroke was suspected in 65% of cases. A prenotification was sent in 32% (Gothenburg 52%; the county 20%; p<0.0001). CONCLUSIONS System delay is still long and only a small fraction of patients received thrombolysis. Three of four used the EMS (more frequent in the county). They were given the highest priority at the dispatch centre in half of the cases. Stroke was suspected in two-thirds of the cases, but a prenotification was seldom sent to the hospital.
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Affiliation(s)
- Birgitta Wireklint Sundström
- Faculty of Caring Science, Work Life and Social Welfare, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, Borås, Sweden
| | - Johan Herlitz
- Faculty of Caring Science, Work Life and Social Welfare, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, Borås, Sweden
| | - Per Olof Hansson
- Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Peter Brink
- Emergency Medical Service System, NU-Hospital Organisation,Trollhättan, Sweden
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Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [PMID: 26343551 DOI: 10.1002/14651858.cd002098.pub2.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care. OBJECTIVES To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation). SEARCH METHODS We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies. SELECTION CRITERIA We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions. DATA COLLECTION AND ANALYSIS For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes. MAIN RESULTS We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups. AUTHORS' CONCLUSIONS The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.
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Affiliation(s)
- Gerd Flodgren
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Roosevelt Drive, Headington, Oxford, Oxfordshire, UK, OX3 7LF
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Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2015; 2015:CD002098. [PMID: 26343551 PMCID: PMC6473731 DOI: 10.1002/14651858.cd002098.pub2] [Citation(s) in RCA: 343] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care. OBJECTIVES To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation). SEARCH METHODS We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies. SELECTION CRITERIA We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions. DATA COLLECTION AND ANALYSIS For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes. MAIN RESULTS We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups. AUTHORS' CONCLUSIONS The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.
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Affiliation(s)
- Gerd Flodgren
- Norwegian Institute of Public HealthThe Norwegian Knowledge Centre for the Health ServicesPilestredet Park 7OsloNorway0176
| | - Antoine Rachas
- European Hospital Georges Pompidou and Paris Descartes UniversityDepartment of IT and Public Health20‐40 Rue leBlancParisFrance75908
| | - Andrew J Farmer
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory Quarter, Walton StreetOxfordUKOX2 6GG
| | - Marco Inzitari
- Parc Sanitari Pere Virgili and Universitat Autònoma de BarcelonaDepartment of Healthcare/Medicinec Esteve Terrades 30BarcelonaSpain08023
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthRosemary Rue Building, Old Road CampusHeadingtonOxfordOxfordshireUKOX3 7LF
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Cerejo R, John S, Buletko AB, Taqui A, Itrat A, Organek N, Cho SM, Sheikhi L, Uchino K, Briggs F, Reimer AP, Winners S, Toth G, Rasmussen P, Hussain MS. A Mobile Stroke Treatment Unit for Field Triage of Patients for Intraarterial Revascularization Therapy. J Neuroimaging 2015; 25:940-5. [PMID: 26179631 DOI: 10.1111/jon.12276] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Favorable outcomes in intraarterial therapy (IAT) for acute ischemic stroke (AIS) are related to early vessel recanalization. The mobile stroke treatment unit (MSTU) is an on-site, prehospital, treatment team, laboratory, and CT scanner that reduces time to treatment for intravenous thrombolysis and may also shorten time to IAT. METHODS Using our MSTU database, we identified patients that underwent IAT for AIS. We compared the key time metrics to historical controls, which included patients that underwent IAT at our institution six months prior to implementation of the MSTU. We further divided the controls into two groups: (1) transferred to our institution for IAT and (2) directly presented to our emergency room and underwent IAT. RESULTS After 164 days of service, the MSTU transported 155 patients of which 5 underwent IAT. We identified 5 historical controls that were transferred to our center for IAT. Substantial reduction in times including median door to initial CT (12 minute vs. 32 minute), CT to IAT (82 minute vs. 165 minute), and door to MSTU/primary stroke center departure (37 minute vs. 106 minute) were noted among the two groups. Compared to the 6 patients who presented to our institution directly, the MSTU process times were also shorter. CONCLUSION Our initial experience shows that MSTU may help in early triage and shorten the time to IAT for AIS.
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Affiliation(s)
| | - Seby John
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH
| | | | - Ather Taqui
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH
| | - Ahmed Itrat
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH
| | | | - Sung-Min Cho
- Department of Neurology, Cleveland Clinic, Cleveland, OH
| | - Lila Sheikhi
- Department of Neurology, Cleveland Clinic, Cleveland, OH
| | - Ken Uchino
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH
| | - Farren Briggs
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Andrew P Reimer
- Critical Care Transport Team, Cleveland Clinic, Cleveland, OH.,Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH
| | | | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH
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240
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Fisher M, Saver JL. Future directions of acute ischaemic stroke therapy. Lancet Neurol 2015; 14:758-67. [DOI: 10.1016/s1474-4422(15)00054-x] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 03/28/2015] [Accepted: 04/21/2015] [Indexed: 12/22/2022]
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241
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Hill MD, Goyal M, Demchuk AM, Fisher M. Ischemic Stroke Tissue-Window in the New Era of Endovascular Treatment. Stroke 2015; 46:2332-4. [PMID: 26111893 DOI: 10.1161/strokeaha.115.009688] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/29/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Michael D Hill
- From the Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
| | - Mayank Goyal
- From the Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- From the Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Marc Fisher
- From the Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. CAN J EMERG MED 2015; 17:709-12. [PMID: 26012878 DOI: 10.1017/cem.2014.65] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED Article chosen Ebinger M, Winter B, Wendt M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014;311(16):1622-31. Clinical question Does prehospital thrombolysis in specialized ambulances reduce delay to thrombolysis in acute ischemic stroke? OBJECTIVE To determine the effect of prehospital thrombolysis for acute ischemic stroke administered in specialized ambulances on delay in thrombolytic administration, thrombolysis rate, post-thrombolysis intracerebral hemorrhage, and 7-day mortality.
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243
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Torres Zenteno AH, Fernández F, Palomino-García A, Moniche F, Escudero I, Jiménez-Hernández MD, Caballero A, Escobar-Rodriguez G, Parra C. Mobile platform for treatment of stroke: A case study of tele-assistance. Health Informatics J 2015; 22:676-90. [PMID: 25975806 PMCID: PMC4979250 DOI: 10.1177/1460458215572925] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article presents the technological solution of a tele-assistance process for stroke patients in acute phase in the Seville metropolitan area. The main objective of this process is to reduce time from symptom onset to treatment of acute phase stroke patients by means of telemedicine, regarding mobility between an intensive care unit ambulance and an expert center and activating the pre-hospital care phase. The technological platform covering the process has been defined following an interoperability model based on standards and with a focus on service-oriented architecture focus. Messaging definition has been designed according to the reference model of the CEN/ISO 13606, messages content follows the structure of archetypes. An XDS-b (Cross-Enterprise Document Sharing-b) transaction messaging has been designed according to Integrating the Healthcare Enterprise profile for archetype notifications and update enquiries.This research has been performed by a multidisciplinary group. The Virgen del Rocío University Hospital acts as Reference Hospital and the Public Company for Healthcare as mobility surroundings.
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Affiliation(s)
| | | | | | - Francisco Moniche
- Clinical Neuroscience Unit, Virgen del Rocío University Hospital, Spain
| | - Irene Escudero
- Clinical Neuroscience Unit, Virgen del Rocío University Hospital, Spain
| | | | | | | | - Carlos Parra
- Technological Innovation Group, Virgen del Rocío University Hospital, Spain
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244
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Parker SA, Bowry R, Wu TC, Noser EA, Jackson K, Richardson L, Persse D, Grotta JC. Establishing the First Mobile Stroke Unit in the United States. Stroke 2015; 46:1384-91. [DOI: 10.1161/strokeaha.114.007993] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/06/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Recently, the Mobile Stroke Unit (MSU) concept was introduced in Germany demonstrating prehospital treatment of more patients within the first hour of symptom onset. However, the details and complexities of establishing such a program in the United States are unknown. We describe the steps involved in setting up the first MSU in the United States.
Methods—
Implementation included establishing leadership, fund-raising, purchase and build-out, knitting a collaborative consortium of community stakeholders, writing protocols to ensure accountability, radiation safety, purchasing supplies, licensing, insurance, establishing a base station, developing a communication plan with city Emergency Medical Services, Emergency Medical Service training, staffing, and designing a research protocol.
Results—
The MSU was introduced after ≈1 year of preparation. Major obstacles to establishing the MSU were primarily obtaining funding, licensure, documenting radiation safety protocols, and establishing a smooth communication system with Emergency Medical Services. During an 8 week run-in phase, ≈2 patients were treated with recombinant tissue-type plasminogen activator per week, one-third within 60 minutes of symptom onset, with no complications. A randomized study to determine clinical outcomes, telemedicine reliability and accuracy, and cost effectiveness was formulated and has begun.
Conclusion—
The first MSU in the United States has been introduced in Houston, TX. The steps needed to accomplish this are described.
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Affiliation(s)
- Stephanie A. Parker
- From the Department of Neurology, University of Texas-Houston Medical School (S.A.P., R.B., T.-C.W., E.A.N., K.J., D.P.); Frazer Ltd, Houston, TX (L.R.); Department of Emergency Medicine, City of Houston Emergency Medical Services, Texas (D.P.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Ritvij Bowry
- From the Department of Neurology, University of Texas-Houston Medical School (S.A.P., R.B., T.-C.W., E.A.N., K.J., D.P.); Frazer Ltd, Houston, TX (L.R.); Department of Emergency Medicine, City of Houston Emergency Medical Services, Texas (D.P.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Tzu-Ching Wu
- From the Department of Neurology, University of Texas-Houston Medical School (S.A.P., R.B., T.-C.W., E.A.N., K.J., D.P.); Frazer Ltd, Houston, TX (L.R.); Department of Emergency Medicine, City of Houston Emergency Medical Services, Texas (D.P.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Elizabeth A. Noser
- From the Department of Neurology, University of Texas-Houston Medical School (S.A.P., R.B., T.-C.W., E.A.N., K.J., D.P.); Frazer Ltd, Houston, TX (L.R.); Department of Emergency Medicine, City of Houston Emergency Medical Services, Texas (D.P.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Kamilah Jackson
- From the Department of Neurology, University of Texas-Houston Medical School (S.A.P., R.B., T.-C.W., E.A.N., K.J., D.P.); Frazer Ltd, Houston, TX (L.R.); Department of Emergency Medicine, City of Houston Emergency Medical Services, Texas (D.P.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Laura Richardson
- From the Department of Neurology, University of Texas-Houston Medical School (S.A.P., R.B., T.-C.W., E.A.N., K.J., D.P.); Frazer Ltd, Houston, TX (L.R.); Department of Emergency Medicine, City of Houston Emergency Medical Services, Texas (D.P.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - David Persse
- From the Department of Neurology, University of Texas-Houston Medical School (S.A.P., R.B., T.-C.W., E.A.N., K.J., D.P.); Frazer Ltd, Houston, TX (L.R.); Department of Emergency Medicine, City of Houston Emergency Medical Services, Texas (D.P.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - James C. Grotta
- From the Department of Neurology, University of Texas-Houston Medical School (S.A.P., R.B., T.-C.W., E.A.N., K.J., D.P.); Frazer Ltd, Houston, TX (L.R.); Department of Emergency Medicine, City of Houston Emergency Medical Services, Texas (D.P.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
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245
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Gomes JA, Ahrens CL, Hussain MS, Winners S, Rasmussen PA, Uchino K. Prehospital Reversal of Warfarin-Related Coagulopathy in Intracerebral Hemorrhage in a Mobile Stroke Treatment Unit. Stroke 2015; 46:e118-20. [DOI: 10.1161/strokeaha.115.008483] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 02/25/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Joao A. Gomes
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Christine L. Ahrens
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Muhammad Shazam Hussain
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Stacey Winners
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Peter A. Rasmussen
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Ken Uchino
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
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Tsivgoulis G, Safouris A, Alexandrov AV. Safety of intravenous thrombolysis for acute ischemic stroke in specific conditions. Expert Opin Drug Saf 2015; 14:845-64. [DOI: 10.1517/14740338.2015.1032242] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Baird AE, Soper SA, Pullagurla SR, Adamski MG. Recent and near-future advances in nucleic acid-based diagnosis of stroke. Expert Rev Mol Diagn 2015; 15:665-79. [PMID: 25837776 DOI: 10.1586/14737159.2015.1024660] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Stroke is a leading cause of death and disability in adults, but at present, treatment for ischemic stroke reaches only a small percentage of patients. This is because of the very short time window for treatment and the time-consuming evaluation involved. Intense efforts are underway to find novel approaches to expedite stroke diagnosis and treatment. In this review, we provide the rationale for the use of blood-based nucleic acid biomarkers to advance stroke diagnosis. We describe mRNA markers identified in genomic profiling of circulating leukocytes and then outline technological issues involved in the application of these results. We then describe the novel point-of-care technology that is in development for the rapid detection of multiple mRNA molecules in circulating leukocytes.
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Affiliation(s)
- Alison E Baird
- Department of Neurology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203, USA
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Ramani L, Huang X, Cheripelli B, Muir KW. Intravenous thrombolysis for acute stroke: current standards and future directions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:373. [PMID: 25778425 DOI: 10.1007/s11936-015-0373-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OPINION STATEMENT Intravenous thrombolysis with the recombinant tissue plasminogen activator alteplase is the standard of care for patients with acute ischaemic stroke presenting within 4.5 h of symptom onset. The odds of independent survival decline steeply with longer time to treatment delivery, reflecting progressive ischaemic damage to the brain. Standards accordingly emphasise optimisation of patient pathways to minimise treatment delays. Observational data and international clinical guidelines support the safety and efficacy of alteplase in many patient groups currently excluded from treatment (e.g. seizure at onset, concomitant diabetes and previous stroke) on the basis of historical clinical trial criteria. Future evolution of thrombolysis will optimise dosing, apply advanced imaging to extend treatment to groups currently excluded and investigate novel drugs, and adjunctive drug and device therapies. To date, trials of novel therapeutic approaches that have been applied at later time points have failed to demonstrate benefit, suggesting that the future gains are likely to arise from applications within current time windows.
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Affiliation(s)
- Lucille Ramani
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, 1345 Govan Road, Glasgow, G51 3TF, Scotland, UK
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Wendt M, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Winter B, Koch PM, Freitag E, Reich J, Schremmer D, Audebert HJ. Improved prehospital triage of patients with stroke in a specialized stroke ambulance: results of the pre-hospital acute neurological therapy and optimization of medical care in stroke study. Stroke 2015; 46:740-5. [PMID: 25634000 DOI: 10.1161/strokeaha.114.008159] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Specialized management of patients with stroke is not available in all hospitals. We evaluated whether prehospital management in the Stroke Emergency Mobile (STEMO) improves the triage of patients with stroke. METHODS STEMO is an ambulance staffed with a specialized stroke team and equipped with a computed tomographic scanner and point-of-care laboratory. We compared the prehospital triage of patients with suspected stroke at dispatcher level who either received STEMO care or conventional care. We assessed transport destination in patients with different diagnoses. Status at hospital discharge was used as short-term outcome. RESULTS From May 2011 to January 2013, 1804 of 6182 (29%) patients received STEMO care and 4378 of 6182 (71%) patients conventional care. Two hundred forty-five of 2110 (11.6%) patients with cerebrovascular events were sent to hospitals without Stroke Unit in conventional care when compared with 48 of 866 (5.5%; P<0.01%) patients in STEMO care. In patients with ischemic stroke, STEMO care reduced transport to hospitals without Stroke Unit from 10.1% (151 of 1497) to 3.9% (24 of 610; P<0.01). The delivery rate of patients with intracranial hemorrhage to hospitals without neurosurgery department was 43.0% (65 of 151) in conventional care and 11.3% (7 of 62) in STEMO care (P<0.01). There was a slight trend toward higher rates of patients discharged home in neurological patients when cared by STEMO (63.5% versus 60.8%; P=0.096). CONCLUSIONS The triage of patients with cerebrovascular events to specialized hospitals can be improved by STEMO ambulances. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01382862.
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Affiliation(s)
- Matthias Wendt
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.).
| | - Martin Ebinger
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Alexander Kunz
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Michal Rozanski
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Carolin Waldschmidt
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Joachim E Weber
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Benjamin Winter
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Peter M Koch
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Erik Freitag
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Jenrik Reich
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Daniel Schremmer
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
| | - Heinrich J Audebert
- From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.)
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