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Broderick JP, Mistry E. Evolution and Future of Stroke Trials. Stroke 2024; 55:1932-1939. [PMID: 38328974 PMCID: PMC11196204 DOI: 10.1161/strokeaha.123.044265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Affiliation(s)
- Joseph P. Broderick
- University of Cincinnati Gardner Neuroscience Institute, Department of Neurology and Rehabilitation Medicine, Cincinnati, Ohio, USA
| | - Eva Mistry
- University of Cincinnati Gardner Neuroscience Institute, Department of Neurology and Rehabilitation Medicine, Cincinnati, Ohio, USA
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2
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Hassan AE, Ringheanu VM, Tekle WG. The implementation of artificial intelligence significantly reduces door-in-door-out times in a primary care center prior to transfer. Interv Neuroradiol 2023; 29:631-636. [PMID: 36017543 PMCID: PMC10680953 DOI: 10.1177/15910199221122848] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Viz LVO artificial intelligence (AI) software utilizes AI-powered large vessel occlusion (LVO) detection technology which automatically identifies suspected LVO through CT angiogram (CTA) imaging and alerts on-call stroke teams. This analysis was performed to determine whether AI software can reduce the door-in-door-out (DIDO) time interval within the primary care center (PSC) prior to transfer to the comprehensive care center (CSC). METHODS We compared the DIDO time interval for all LVO transfer patients from a single-spoke PSC to our CSC prior to (February 2017 to November 2018) and after (November 2018 to June 2020) incorporating AI. Using a stroke database at a CSC, demographics, DIDO time at PSC, modified Rankin Scale (mRS) at 90-days, mortality rate at discharge, length of stay (LOS), and intracranial hemorrhage rates were examined. RESULTS There were a total of 63 patients during the study period (average age 69.99 ± 13.72, 55.56% female). We analyzed 28 patients pre-AI (average age 71.64 ± 12.28, 46.4% female), and 35 patients post-AI (average age 68.67 ± 14.88, 62.9% female). After implementing the AI software, the mean DIDO time interval within the PSC significantly improved by 102.3 min (226.7 versus 124.4 min; p = 0.0374). CONCLUSION The incorporation of the AI software was associated with a significant improvement in DIDO times within the PSC as well as CTA to door-out time in the PSC. More extensive studies are warranted to expand on the ability of AI technology to improve transfer times and outcomes for LVO patients.
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Affiliation(s)
- Ameer E. Hassan
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, USA
- Department of Neurology, UTRGV School of Medicine, Edinburg, TX, USA
| | - Victor M. Ringheanu
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, USA
| | - Wondwossen G. Tekle
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, USA
- Department of Neurology, UTRGV School of Medicine, Edinburg, TX, USA
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Turner AC, Etherton MR. Utilization of Telestroke Prior to and Following the COVID-19 Pandemic. Semin Neurol 2022; 42:3-11. [PMID: 35576926 DOI: 10.1055/s-0041-1742181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For over two decades, telestroke has been utilized as a means for improving acute access to a stroke specialist when this expertise is otherwise unavailable. During this time, telestroke use has increased and improvements in care metrics have been widely reported. Several telestroke model variations are utilized; each has different workflow implications. A successful telestroke system should include adequate protocols and training, equipment, documentation system, and tracking of quality metrics. Upfront costs of needed technology and devices, credentialing hurdles, and limited reimbursement are all reported barriers to the utilization of telestroke. Emphasis on safety measures during the COVID-19 pandemic resulted in the dramatic upscaling of telehealth utilization, although overall stroke volumes declined in many areas in the early phases of the pandemic. Going forward, continued reduction in cost of required devices and broadband connections, increased use of automated and advanced analytical software, and a universal licensing and credentialing system are needed to continue the expansion of telestroke use.
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Affiliation(s)
- Ashby C Turner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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4
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Design of Stroke-Related Clinical Trials. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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5
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Xian Y, Xu H, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Hernandez AF, Peterson ED, Schwamm LH, Fonarow GC. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke 2021; 53:1328-1338. [PMID: 34802250 DOI: 10.1161/strokeaha.121.035853] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. METHODS We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. RESULTS Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. CONCLUSIONS A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.
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Affiliation(s)
- Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX. (Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (E.E.S.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric D Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX. (E.D.P.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California at Los Angeles (G.C.F.)
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Tilley BC, Mainous AG, Amorrortu RP, McKee MD, Smith DW, Li R, DeSantis SM, Vernon SW, Koch G, Ford ME, Diaz V, Alvidrez J. Using increased trust in medical researchers to increase minority recruitment: The RECRUIT cluster randomized clinical trial. Contemp Clin Trials 2021; 109:106519. [PMID: 34333138 PMCID: PMC8665835 DOI: 10.1016/j.cct.2021.106519] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/07/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
While extensive literature exists on barriers and strategies to increase minority participation in clinical trials, progress is limited. Few strategies were evaluated in randomized trials. We studied the impact of RECRUIT, a trust-based, cluster randomized minority recruitment trial layered on top of four traditional NIH-funded parent trials (BMT CTN, CABANA, PACES, STEADY-PD III; fifty specialty sites). RECRUIT was conducted from July 2013 through April 2017. Intervention sites implemented trust-based approaches customized to individual sites, promoting relationships between physician-investigators and minority-serving physicians and their minority patients. Control sites implemented only parent trials' recruitment procedures. Adjusting for within-site clustering, we detected no overall intervention effect, odds ratio 1.3 (95% confidence limits 0.7,2.4). Heterogeneity among parent trials may have obscured the effect. Of the four parent trials, three enrolled more minorities in intervention versus control sites. CABANA odds ratio = 4.2 (adjusted 95%CL 1.5,11.3). PACES intervention sites enrolled 63% (10/16) minorities; control sites enrolled one participant in total, a minority, yielding an incalculable odds ratio. STEADY-PD III odds ratio = 2.2 (adjusted 95%CL 0.6,8.5). BMT CTN odds ratio < 1, 0.8 (adjusted 95%CL 0.4,1.8). In conclusion, RECRUIT findings suggest the unique trust-based intervention increased minority recruitment to intervention trials in ¾ of studied trials. Physician-investigators' participation was critical to recruitment success. Lack of commitment to minority recruitment remained a barrier for some physician-investigators, especially in control sites. We recommend prospective physician investigators commit to minority recruitment activities prior to selection as site investigators and trial funding include some compensation for minority recruitment efforts. TRIAL REGISTRATION ClinicalTrials.govNCT01911208.
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Affiliation(s)
- Barbara C Tilley
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health (SPH), Houston, TX, United States of America.
| | - Arch G Mainous
- Department of Health Services Research Management and Policy, University of Florida College of Public Health and Health Professions, Gainesville, FL, United States of America
| | - Rossybelle P Amorrortu
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health (SPH), Houston, TX, United States of America; Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, United States of America
| | - M Diane McKee
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, United States of America; Department of Family Medicine, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Daniel W Smith
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States of America
| | - Ruosha Li
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health (SPH), Houston, TX, United States of America
| | - Stacia M DeSantis
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health (SPH), Houston, TX, United States of America
| | - Sally W Vernon
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States of America
| | - Gary Koch
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Marvella E Ford
- Hollings Cancer Center, Population Science and Health Disparities, Medical University of South Carolina, Charleston, SC, United States of America
| | - Vanessa Diaz
- Department of Family Medicine, Medical University of South Carolina, Charleston, SC, United States of America
| | - Jennifer Alvidrez
- National Institute on Minority Health and Health Disparities, Bethesda, MD, United States of America
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A Comparison of Time to Treatment between an Emergency Department Focused Stroke Protocol and Mobile Stroke Units. Prehosp Disaster Med 2021; 36:426-430. [PMID: 33973501 DOI: 10.1017/s1049023x2100042x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND San Francisco (California USA) is a relatively compact city with a population of 884,000 and nine stroke centers within a 47 square mile area. Emergency Medical Services (EMS) transport distances and times are short and there are currently no Mobile Stroke Units (MSUs). METHODS This study evaluated EMS activation to computed tomography (CT [EMS-CT]) and EMS activation to thrombolysis (EMS-TPA) times for acute stroke in the first two years after implementation of an emergency department (ED) focused, direct EMS-to-CT protocol entitled "Mission Protocol" (MP) at a safety net hospital in San Francisco and compared performance to published reports from MSUs. The EMS times were abstracted from ambulance records. Geometric means were calculated for MP data and pooled means were similarly calculated from published MSU data. RESULTS From July 2017 through June 2019, a total of 423 patients with suspected stroke were evaluated under the MP, and 166 of these patients were either ultimately diagnosed with ischemic stroke or were treated as a stroke but later diagnosed as a stroke mimic. The EMS and treatment time data were available for 134 of these patients with 61 patients (45.5%) receiving thrombolysis, with mean EMS-CT and EMS-TPA times of 41 minutes (95% CI, 39-43) and 63 minutes (95% CI, 57-70), respectively. The pooled estimates for MSUs suggested a mean EMS-CT time of 35 minutes (95% CI, 27-45) and a mean EMS-TPA time of 48 minutes (95% CI, 39-60). The MSUs achieved faster EMS-CT and EMS-TPA times (P <.0001 for each). CONCLUSIONS In a moderate-sized, urban setting with high population density, MP was able to achieve EMS activation to treatment times for stroke thrombolysis that were approximately 15 minutes slower than the published performance of MSUs.
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Chen G, Bai C, Zhu Z, Li J, Shao S. Effectiveness and safety of different doses of tenecteplase in the treatment of acute ischemic stroke: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e23805. [PMID: 33545944 PMCID: PMC7837936 DOI: 10.1097/md.0000000000023805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Tenecteplase is a modified recombinant tissue-plasminogen activator, which is effective and safe in the treatment of acute ischemic stroke. However, the therapeutic dose of tenecteplase has been controversial. The purpose of this study is to systematically investigate the efficacy and safety of different doses of tenecteplase thrombolytic therapy for acute ischemic stroke. METHODS Computer retrieval of English databases (PubMed, EMBASE, Web of Science, the Cochrane Library) and Chinese databases (CNKI, Wanfang, Viper, and Chinese Biomedical Database) is conducted for a randomized controlled clinical study on thrombolytic treatment of acute ischemic stroke with different doses of tenecteplase from the establishment of the database to October 2020. Two researchers independently conduct data extraction and literature quality evaluation on the quality of the included studies, and meta-analysis is conducted on the included literatures using RevMan5.3 software. OUTCOME In this study, National Institute of Health Stroke Scale (NIHSS) score, Modified Rankin Scale (mRS) score scale, symptomatic intracranial hemorrhage (SICH) incidence, All-cause mortality, and so on are used to evaluate the efficacy and safety of tenecteplase thrombolytic therapy in acute ischemic stroke with different doses. CONCLUSION This study will provide reliable evidence-based evidence for the clinical application of different doses of tenecteplase in thrombolytic therapy for acute ischemic stroke. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/2MPCW.
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Turner AC, Schwamm LH, Etherton MR. Acute ischemic stroke: improving access to intravenous tissue plasminogen activator. Expert Rev Cardiovasc Ther 2020; 18:277-287. [PMID: 32323590 DOI: 10.1080/14779072.2020.1759422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Since approval by the United States Food and Drug Administration in 1996, alteplase utilization rates for acute ischemic stroke have increased. Despite its efficacy for improving stroke outcomes, however, the majority of ischemic stroke patients still do not receive alteplase. To address this issue, different methods for improving access to alteplase have been tested with varying degrees of success. AREAS COVERED This article gives an overview of the recent approaches pursued to improve access to alteplase for acute ischemic stroke patients. Utilization of stroke systems of care, quality metrics, and quality-improvement initiatives to improve alteplase treatment rates are discussed. The implementation of Telestroke networks to improve access and timely evaluation by a stroke specialist are also reviewed. Lastly, this review discusses the use of neuroimaging techniques to identify alteplase candidates in stroke of unknown symptom onset or beyond the 4.5-h treatment window. EXPERT COMMENTARY Expanding access to alteplase therapy for acute ischemic stroke is a multi-faceted approach. Specific considerations based on region, population, and health-care resources should be considered for each strategy. Neuroimaging approaches to identify alteplase-eligible patients beyond the 4.5-h treatment window are a recent development in acute stroke care that holds promise for increasing alteplase treatment rates.
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Affiliation(s)
- Ashby C Turner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
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Wang LH, Zhang GL, Liu XY, Peng A, Ren HY, Huang SH, Liu T, Wang XJ. CELSR1 Promotes Neuroprotection in Cerebral Ischemic Injury Mainly Through the Wnt/PKC Signaling Pathway. Int J Mol Sci 2020; 21:E1267. [PMID: 32070035 PMCID: PMC7072880 DOI: 10.3390/ijms21041267] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/08/2020] [Accepted: 02/10/2020] [Indexed: 01/26/2023] Open
Abstract
Cadherin epidermal growth factor (EGF) laminin G (LAG) seven-pass G-type receptor 1 (CELSR1) is a member of a special subgroup of adhesion G protein-coupled receptors. Although Celsr1 has been reported to be a sensitive gene for stroke, the effect of CELSR1 in ischemic stroke is still not known. Here, we investigated the effect of CELSR1 on neuroprotection, neurogenesis and angiogenesis in middle cerebral artery occlusion (MCAO) rats. The mRNA expression of Celsr1 was upregulated in the subventricular zone (SVZ), hippocampus and ischemic penumbra after cerebral ischemic injury. Knocking down the expression of Celsr1 in the SVZ with a lentivirus significantly reduced the proliferation of neuroblasts, the number of CD31-positive cells, motor function and rat survival and increased cell apoptosis and the infarct volume in MCAO rats. In addition, the expression of p-PKC in the SVZ and peri-infarct tissue was downregulated after ischemia/ reperfusion. Meanwhile, in the dentate gyrus of the hippocampus, knocking down the expression of Celsr1 significantly reduced the proliferation of neuroblasts; however, it had no influence on motor function, cell apoptosis or angiogenesis. These data indicate that CELSR1 has a neuroprotective effect on cerebral ischemia injury by reducing cell apoptosis in the peri-infarct cerebral cortex and promoting neurogenesis and angiogenesis, mainly through the Wnt/PKC pathway.
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Affiliation(s)
- Li-Hong Wang
- Department of Cell Biology, School of Basic Medical Sciences, Shandong University, Jinan 250012, Shandong, China; (L.-H.W.); (X.-Y.L.); (A.P.); (H.-Y.R.); (T.L.)
| | - Geng-Lin Zhang
- Key Laboratory for Biotech-Drugs Ministry of Health and Key Laboratory for Rare & Uncommon Diseases of Shandong Province, Shandong Medicinal Biotechnology Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan 250062, Shandong, China;
| | - Xing-Yu Liu
- Department of Cell Biology, School of Basic Medical Sciences, Shandong University, Jinan 250012, Shandong, China; (L.-H.W.); (X.-Y.L.); (A.P.); (H.-Y.R.); (T.L.)
| | - Ai Peng
- Department of Cell Biology, School of Basic Medical Sciences, Shandong University, Jinan 250012, Shandong, China; (L.-H.W.); (X.-Y.L.); (A.P.); (H.-Y.R.); (T.L.)
| | - Hai-Yuan Ren
- Department of Cell Biology, School of Basic Medical Sciences, Shandong University, Jinan 250012, Shandong, China; (L.-H.W.); (X.-Y.L.); (A.P.); (H.-Y.R.); (T.L.)
| | - Shu-Hong Huang
- Institute of Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan 250062, Shandong, China;
| | - Ting Liu
- Department of Cell Biology, School of Basic Medical Sciences, Shandong University, Jinan 250012, Shandong, China; (L.-H.W.); (X.-Y.L.); (A.P.); (H.-Y.R.); (T.L.)
| | - Xiao-Jing Wang
- Department of Cell Biology, School of Basic Medical Sciences, Shandong University, Jinan 250012, Shandong, China; (L.-H.W.); (X.-Y.L.); (A.P.); (H.-Y.R.); (T.L.)
- Advanced Medical Research Institute, Shandong University, Jinan 250012, Shandong, China
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Yarnoff B, Khavjou O, Elmi J, Lowe-Beasley K, Bradley C, Amoozegar J, Wachtmeister D, Tzeng J, Chapel JM, Teixeira-Poit S. Estimating Costs of Implementing Stroke Systems of Care and Data-Driven Improvements in the Paul Coverdell National Acute Stroke Program. Prev Chronic Dis 2019; 16:E134. [PMID: 31580797 PMCID: PMC6795072 DOI: 10.5888/pcd16.190061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Purpose and Objectives We evaluated the costs of implementing coordinated systems of stroke care by state health departments from 2012 through 2015 to help policy makers and planners gain a sense of the potential return on investments in establishing a stroke care quality improvement (QI) program. Intervention Approach State health departments funded by the Paul Coverdell National Acute Stroke Program (PCNASP) implemented activities to support the start and proficient use of hospital stroke registries statewide and coordinate data-driven QI efforts. These efforts were aimed at improving the treatment and transition of stroke patients from prehospital emergency medical services (EMS) to in-hospital care and postacute care facilities. Health departments provided technical assistance and data to support hospitals, EMS agencies, and posthospital care agencies to carry out small, rapid, incremental QI efforts to produce more effective and efficient stroke care practices. Evaluation Methods Six of the 11 PCNASP-funded state health departments in the United States volunteered to collect and report programmatic costs associated with implementing the components of stroke systems of care. Six health departments reported costs paid directly by Centers for Disease Control and Prevention–provided funds, 5 also reported their own in-kind contributions, and 4 compiled data from a sample of their partners’ estimated costs of resources, such as staff time, involved in program implementation. Costs were analyzed separately for PCNASP-funded expenditures and in-kind contributions by the health department by resource category and program activity. In-kind contributions by partners were also analyzed separately. Results PCNASP-funded expenditures ranged from $790,123 to $1,298,160 across the 6 health departments for the 3-year funding period. In-kind contributions ranged from $5,805 to $1,394,097. Partner contributions (n = 22) ranged from $3,912 to $362,868. Implications for Public Health Our evaluation reports costs for multiple state health departments and their partners for implementing components of stroke systems of care in the United States. Although there are limitations, our findings represent key estimates that can guide future program planning and efforts to achieve sustainability.
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Affiliation(s)
- Benjamin Yarnoff
- RTI International, Public Health Economics Program, 3040 E. Cornwallis Rd, Research Triangle Park, NC 27709.
| | - Olga Khavjou
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - Joanna Elmi
- Centers for Disease Control and Prevention, Division of Heart Disease and Stroke Prevention, Atlanta, Georgia
| | - Kincaid Lowe-Beasley
- Centers for Disease Control and Prevention, Division of Heart Disease and Stroke Prevention, Atlanta, Georgia
| | - Christina Bradley
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - Jacqueline Amoozegar
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - Devon Wachtmeister
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - Janice Tzeng
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - John McCoy Chapel
- Centers for Disease Control and Prevention, Division of Heart Disease and Stroke Prevention, Atlanta, Georgia
| | - Stephanie Teixeira-Poit
- North Carolina Agricultural and Technical State University, College of Health and Human Sciences, Greensboro, North Carolina
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12
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Affiliation(s)
- Patrick D Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
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13
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Li W, Pan R, Qi Z, Liu KJ. Current progress in searching for clinically useful biomarkers of blood-brain barrier damage following cerebral ischemia. Brain Circ 2018; 4:145-152. [PMID: 30693340 PMCID: PMC6329218 DOI: 10.4103/bc.bc_11_18] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/22/2018] [Accepted: 10/02/2018] [Indexed: 11/24/2022] Open
Abstract
Ischemic stroke is a leading cause of death and disability. Fear of intracranial hemorrhage (ICH) has been the primary reason for withholding tissue plasminogen activator (tPA) and thrombectomy, the only two widely accepted treatments for ischemic stroke. Thrombolysis treatment is only allowed in a very narrow time window (within 4.5–6 h). However, so far, other than the time window guideline, there is no reliable indicator available in the clinic to predict ICH before thrombolysis treatment. Recently, extensive research efforts have been devoted to the development of reliable indicators to predict ICH and safely guide the thrombolysis treatment. Accumulating evidence suggests that ischemic brain regions with a compromised blood–brain barrier (BBB) before tPA treatment develop ICH at the later time during thrombolytic reperfusion. Assessing BBB damage before thrombolysis could potentially help predict the risk of ICH after thrombolysis. This article reviews the literature reports on BBB damage biomarkers that have been developed in recent years, including biochemical markers such as BBB structural proteins, circulating brain microvascular endothelial cells, plasma albumin, and brain parenchyma proteins, as well as image markers such as magnetic resonance imaging assessment for BBB damage.
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Affiliation(s)
- Weili Li
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Rong Pan
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Zhifeng Qi
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Ke Jian Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China.,Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Karhi S, Nerg O, Miettinen T, Mäkipaakkanen E, Taina M, Manninen H, Vanninen R, Jäkälä P. Mechanical Thrombectomy of Large Artery Occlusion Is Beneficial in Octogenarians. In Vivo 2018; 32:1223-1230. [PMID: 30150448 PMCID: PMC6199581 DOI: 10.21873/invivo.11368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/22/2018] [Accepted: 05/29/2018] [Indexed: 12/26/2022]
Abstract
AIM Recent trials have established the benefit of endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) due to large artery occlusion (LAO). However, older patients were often excluded from trials. EVT outcomes were retrospectively compared between octogenarians and younger patients treated for LAO in a tertiary hospital. PATIENTS AND METHODS A total of 199 consecutive patients with anterior circulation AIS that underwent EVT between 2009 and 2015 in the Kuopio University Hospital were included. Patients were dichotomized into younger (<80 years, N=162) and older (≥80 years, N=37) groups. Baseline, imaging, and procedural characteristics, the 3-month modified Rankin Scale (mRS), and 1-year mortality were assessed. To conduct a number-needed-to-treat (NNT) analysis, data on age-dichotomized control groups from a meta-analysis were acquired. RESULTS Compared to younger patients, older patients exhibited atrial fibrillation (57% vs. 21%, p<0.01) and coronary artery disease (49% vs. 20%, p<0.01) more frequently and Internal Carotid Artery (ICA) occlusion less frequently (22% vs. 55%, p<0.01). Similar proportions of patients received preprocedural intravenous recombinant tissue-type plasminogen activator (r-tPA; 57% vs. 67%), general anesthesia (35% vs. 41%), and reperfusion (Thrombolysis in Cerebral Infarction scale 2b/3; 76% vs. 75%). Older patients had more complications during hospitalization (41% vs. 24%, p=0.034), higher 3-month mRS values (4.0±2.3 vs. 2.8±1.9, p<0.01), fewer favorable mRS values (mRS≤2: 27% vs. 52%, p<0.01), and higher 3-month (46% vs. 10% p<0.01) and 1-year mortality (49% vs. 11%, p<0.01). The NNT to achieve an additional patient with an independent outcome (mRS≤2) was 12 among older and six among younger patients. CONCLUSION Despite a poor recovery rate, octogenarians benefitted from EVT for AIS, with a NNT comparable to that of younger patients treated with intravenous r-tPA.
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Affiliation(s)
- Simo Karhi
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ossi Nerg
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | - Tuuli Miettinen
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | - Emmi Mäkipaakkanen
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | - Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Hannu Manninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Pekka Jäkälä
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
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Hsieh YS, Kwon S, Lee HS, Seol GH. Linalyl acetate prevents hypertension-related ischemic injury. PLoS One 2018; 13:e0198082. [PMID: 29799836 PMCID: PMC5969747 DOI: 10.1371/journal.pone.0198082] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/14/2018] [Indexed: 01/01/2023] Open
Abstract
Ischemic stroke remains an important cause of disability and mortality. Hypertension is a critical risk factor for the development of ischemic stroke. Control of risk factors, including hypertension, is therefore important for the prevention of ischemic stroke. Linalyl acetate (LA) has been reported to have therapeutic effects in ischemic stroke by modulating intracellular Ca2+ concentration and having anti-oxidative properties. The preventive efficacy of LA has not yet been determined. This study therefore investigated the preventive efficacy of LA in rat aortas exposed to hypertension related-ischemic injury, and the mechanism of action of LA.Hypertension was induced in vivo following ischemic injury to the aorta induced by oxygen-glucose deprivation and reoxygenation in vitro. Effects of LA were assayed by western blotting, by determining concentrations of lactate dehydrogenase (LDH) and reactive oxygen species (ROS) and by vascular contractility assays. LA significantly reduced systolic blood pressure in vivo. In vitro, LA suppressed ischemic injury-induced expression of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase subunit p47phox, as well as ROS production, LDH release, and ROS-induced endothelial nitric oxide synthase suppression. These findings indicate that LA has anti-hypertensive properties that can prevent hypertension-related ischemic injury and can prevent NADPH oxidase-induced production of ROS.
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Affiliation(s)
- Yu Shan Hsieh
- Department of Basic Nursing Science, School of Nursing, Korea University, Seoul, Republic of Korea
| | - Soonho Kwon
- Department of Basic Nursing Science, School of Nursing, Korea University, Seoul, Republic of Korea
| | - Hui Su Lee
- Department of Basic Nursing Science, School of Nursing, Korea University, Seoul, Republic of Korea
| | - Geun Hee Seol
- Department of Basic Nursing Science, School of Nursing, Korea University, Seoul, Republic of Korea
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16
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Li J, Hu XS, Zhou FF, Li S, Lin YS, Qi WQ, Qi CF, Zhang X. Limb remote ischemic postconditioning protects integrity of the blood-brain barrier after stroke. Neural Regen Res 2018; 13:1585-1593. [PMID: 30127119 PMCID: PMC6126140 DOI: 10.4103/1673-5374.237122] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Integrity of the blood-brain barrier structure is essential for maintaining the internal environment of the brain. Development of cerebral infarction and brain edema is strongly associated with blood-brain barrier leakage. Therefore, studies have suggested that protecting the blood-brain barrier may be an effective method for treating acute stroke. To examine this possibility, stroke model rats were established by middle cerebral artery occlusion and reperfusion. Remote ischemic postconditioning was immediately induced by three cycles of 10-minute ischemia/10-minute reperfusion of bilateral hind limbs at the beginning of middle cerebral artery occlusion reperfusion. Neurological function of rat models was evaluated using Zea Longa’s method. Permeability of the blood-brain barrier was assessed by Evans blue leakage. Infarct volume and brain edema were evaluated using 2,3,5-triphenyltetrazolium chloride staining. Expression of matrix metalloproteinase-9 and claudin-5 mRNA was determined by real-time quantitative reverse transcription-polymerase chain reaction. Expression of matrix metalloproteinase-9 and claudin-5 protein was measured by western blot assay. The number of matrix metalloproteinase-9- and claudin-5-positive cells was analyzed using immunohistochemistry. Our results showed that remote ischemic postconditioning alleviated disruption of the blood-brain barrier, reduced infarct volume and edema, decreased expression of matrix metalloproteinase-9 mRNA and protein and the number of positive cells, increased expression of claudin-5 mRNA and protein and the number of positive cells, and remarkably improved neurological function. These findings confirm that by suppressing expression of matrix metalloproteinase-9 and claudin-5 induced by acute ischemia/reperfusion, remote ischemic postconditioning reduces blood-brain barrier injury, mitigates ischemic injury, and exerts protective effects on the brain.
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Affiliation(s)
- Juan Li
- Experiment Technology Center of Preclinical Medicine of Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Xiao-Song Hu
- Experiment Technology Center of Preclinical Medicine of Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Fang-Fang Zhou
- Experiment Technology Center of Preclinical Medicine of Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Shuai Li
- Experiment Technology Center of Preclinical Medicine of Chengdu Medical College, Chengdu, Sichuan Province, China
| | - You-Sheng Lin
- Experiment Technology Center of Preclinical Medicine of Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Wen-Qian Qi
- Experiment Technology Center of Preclinical Medicine of Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Cun-Fang Qi
- Department of Anatomy, Qinghai University, Xining, Qinghai Province, China
| | - Xiao Zhang
- Experiment Technology Center of Preclinical Medicine of Chengdu Medical College, Chengdu, Sichuan Province, China
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17
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Kamal N, Smith EE, Jeerakathil T, Hill MD. Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review. Int J Stroke 2017; 13:268-276. [PMID: 29140185 DOI: 10.1177/1747493017743060] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.
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Affiliation(s)
- Noreen Kamal
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Michael D Hill
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada.,4 Department of Medicine, University of Calgary, Calgary, Canada.,5 Department of Radiology, University of Calgary, Calgary, Canada
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18
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Tilley BC, Mainous AG, Smith DW, McKee MD, Amorrortu RP, Alvidrez J, Diaz V, Ford ME, Fernandez ME, Hauser RA, Singer C, Landa V, Trevino A, DeSantis SM, Zhang Y, Daniels E, Tabor D, Vernon SW. Design of a cluster-randomized minority recruitment trial: RECRUIT. Clin Trials 2017; 14:286-298. [PMID: 28545336 PMCID: PMC5448312 DOI: 10.1177/1740774517690146] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Racial/ethnic minority groups remain underrepresented in clinical trials. Many strategies to increase minority recruitment focus on minority communities and emphasize common diseases such as hypertension. Scant literature focuses on minority recruitment to trials of less common conditions, often conducted in specialty clinics and dependent on physician referrals. We identified trust/mistrust of specialist physician investigators and institutions conducting medical research and consequent participant reluctance to participate in clinical trials as key-shared barriers across racial/ethnic groups. We developed a trust-based continuous quality improvement intervention to build trust between specialist physician investigators and community minority-serving physicians and ultimately potential trial participants. To avoid the inherent biases of non-randomized studies, we evaluated the intervention in the national Randomized Recruitment Intervention Trial (RECRUIT). This report presents the design of RECRUIT. Specialty clinic follow-up continues through April 2017. METHODS We hypothesized that specialist physician investigators and coordinators trained in the trust-based continuous quality improvement intervention would enroll a greater proportion of minority participants in their specialty clinics than specialist physician investigators in control specialty clinics. Specialty clinic was the unit of randomization. Using continuous quality improvement, the specialist physician investigators and coordinators tailored recruitment approaches to their specialty clinic characteristics and populations. Primary analyses were adjusted for clustering by specialty clinic within parent trial and matching covariates. RESULTS RECRUIT was implemented in four multi-site clinical trials (parent trials) supported by three National Institutes of Health institutes and included 50 associated specialty clinics from these parent trials. Using current data, we have 88% power or greater to detect a 0.15 or greater difference from the currently observed control proportion adjusting for clustering. We detected no differences in baseline matching criteria between intervention and control specialty clinics (all p values > 0.17). CONCLUSION RECRUIT was the first multi-site randomized control trial to examine the effectiveness of a trust-based continuous quality improvement intervention to increase minority recruitment into clinical trials. RECRUIT's innovations included its focus on building trust between specialist investigators and minority-serving physicians, the use of continuous quality improvement to tailor the intervention to each specialty clinic's specific racial/ethnic populations and barriers to minority recruitment, and the use of specialty clinics from more than one parent multi-site trial to increase generalizability. The effectiveness of the RECRUIT intervention will be determined after the completion of trial data collection and planned analyses.
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Affiliation(s)
- Barbara C Tilley
- Department of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Arch G Mainous
- Department of Health Services Research Management and Policy, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Daniel W Smith
- National Crime Victims Research and Treatment Center, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - M Diane McKee
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Rossybelle P Amorrortu
- Department of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | | | - Vanessa Diaz
- Department of Family Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Marvella E Ford
- Department of Public Health Sciences and Cancer Disparities, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Maria E Fernandez
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Robert A Hauser
- Departments of Neurology, Molecular Pharmacology and Physiology, College of Medicine, University of South Florida, Tampa, FL, USA
| | - Carlos Singer
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Veronica Landa
- Department of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Aron Trevino
- Department of Epidemiology & Biostatistics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Stacia M DeSantis
- Department of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Yefei Zhang
- Department of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Elvan Daniels
- Cancer Control and Prevention, American Cancer Society, Inc., Atlanta, GA, USA
| | | | - Sally W Vernon
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
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19
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Threlkeld ZD, Kozak B, McCoy D, Cole S, Martin C, Singh V. Collaborative Interventions Reduce Time-to-Thrombolysis for Acute Ischemic Stroke in a Public Safety Net Hospital. J Stroke Cerebrovasc Dis 2017; 26:1500-1505. [PMID: 28396187 DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/03/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Shorter time-to-thrombolysis in acute ischemic stroke (AIS) is associated with improved functional outcome and reduced morbidity. We evaluate the effect of several interventions to reduce time-to-thrombolysis at an urban, public safety net hospital. METHODS All patients treated with tissue plasminogen activator for AIS at our institution between 2008 and 2015 were included in a retrospective analysis of door-to-needle (DTN) time and associated factors. Between 2011 and 2014, we implemented 11 distinct interventions to reduce DTN time. Here, we assess the relative impact of each intervention on DTN time. RESULTS The median DTN time pre- and postintervention decreased from 87 (interquartile range: 68-109) minutes to 49 (interquartile range: 39-63) minutes. The reduction was comprised primarily of a decrease in median time from computed tomography scan order to interpretation. The goal DTN time of 60 minutes or less was achieved in 9% (95% confidence interval: 5%-22%) of cases preintervention, compared with 70% (58%-81%) postintervention. Interventions with the greatest impact on DTN time included the implementation of a stroke group paging system, dedicated emergency department stroke pharmacists, and the development of a stroke code supply box. CONCLUSIONS Multidisciplinary, collaborative interventions are associated with a significant and substantial reduction in time-to-thrombolysis. Such targeted interventions are efficient and achievable in resource-limited settings, where they are most needed.
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Affiliation(s)
- Zachary D Threlkeld
- Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, California; Department of Neurology, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Kozak
- School of Medicine, University of California, San Francisco, San Francisco, California
| | - David McCoy
- Department of Radiology, University of California, San Francisco, San Francisco, California
| | - Sara Cole
- Department of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Christine Martin
- Department of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Vineeta Singh
- Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, California.
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Abstract
AbstractBackground:Thrombolysis in acute ischemic stroke is usually performed in comprehensive stroke centres. Lack of stroke expertise in remote small hospitals may preclude thrombolysis. Telemedicine allows such management opportunities in distant hospitals.Methods:We report our experience in managing acute stroke over a two-year time period with telestroke. The University of Alberta Hospital acted as the ‘hub’ and seven remote hospitals as ‘spoke’. The neurologist at the ‘hub’ provided stroke expertise to the local physician using either a two-way video link or telephone. Cranial CT scans were transmitted to ‘hub’. Education sessions were held before the initiation of the program.Results:Of 210 patients 44 (21%) received thrombolysis at the ‘spoke’ sites. In 34/44 (77%) two-way video link was available while in 10/44 (23%) telephone was used. Five (11.4%) patients experienced intracranial hemorrhage after thrombolysis, 2 (4.5%) were symptomatic. Favorable (mRS=0-1) outcome at three months was 16/40 (40%) and mortality was 9/40 (22.5%). Four patients were lost to follow-up. There was no significant three months outcome difference between two-way video link and telephone consultation (P = 0.689). Over two years the number of acute stroke transfers decreased from 144 to 15 at one of the ‘spoke’ sites, a 92.5% decline.Conclusion:It is possible to successfully treat patients with acute ischemic stroke at remote sites through videoconferencing or telephone consultation. Telestroke can also lead to a significant reduction in the number of patients requiring transfer to a tertiary care centre.
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Abstract
Stroke is the third leading cause of death of people in the world today and the highest cause of disability and handicap, producing a huge burden on individuals and society more broadly. Yet unlike its counterpart acute myocardial infarction (AMI), little has been done to promote early intervention in evolving strokes. Recommendations from the American Heart Association and more recently the European Stroke Initiative are available; however, in Australia (as with many other countries) practice guidelines are scarce and clinicians largely operate in an ad hoc manner with little awareness of ‘best practice’. The controversial role of thrombolysis with limitations in respect to selecting appropriate patients, in addition to a small window of opportunity for therapeutic beneficial effects and a high risk for haemorrhage, has inhibited its widespread application. As such, emergent stroke management clearly lags behind that of AMI–both with respect to the range of treatment options and the application of best practice. This paper reviews the literature regarding best practice management of evolving stroke and the crucial role of nurses in triaging and managing patients to deliver optimal outcomes within the Australian context.
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22
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Balucani C, Levine SR, Khoury JC, Khatri P, Saver JL, Broderick JP. Acute Ischemic Stroke with Very Early Clinical Improvement: A National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Trials Exploratory Analysis. J Stroke Cerebrovasc Dis 2016; 25:894-901. [PMID: 26825352 DOI: 10.1016/j.jstrokecerebrovasdis.2015.10.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 09/22/2015] [Accepted: 10/27/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND A high proportion of patients excluded from recombinant tissue plasminogen activator (rt-PA) treatment because of rapid improvement occurring before treatment decision had incomplete recovery. The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Trials dataset allows for systematic analyses of very early postrandomization improvement (VEPRIM) in stroke severity as a National Institutes of Health Stroke Scale (NIHSS) score was available for all subjects enrolled in the study at baseline (NIHSSB) and at 2 hours after randomization (NIHSS2H). We explored various definitions of VEPRIM to characterize predictive values for clinical outcomes. METHODS Post hoc analyses of the NINDS rt-PA Stroke Trials were conducted. VEPRIM was defined as the difference between the NIHSSB and the NIHSS2H scores using 3 approaches: raw, percent, and normalized change. We assessed the association between VEPRIM and 3-month favorable outcome (mRS score of 0-1), symptomatic intracerebral hemorrhage (sICH), and death. RESULTS In the 624 subjects, every VEPRIM definition was independently associated with an increased probability of favorable outcome: for each unit of change within the VEPRIM definitions, there were 2%-24% (all P < .05) relative increased probability of favorable outcome, 2%-15% (all P < .05) decreased likelihood of death, and 2%-13% (all P < .05) decreased likelihood of sICH. Adjusting for NIHSSB and prestroke mRS scores, there was a significant rt-PA treatment effect for improvement seen for all 3 VEPRIM definitions. CONCLUSIONS VEPRIM predicted favorable outcomes independent of definition and treatment arm. Patients with VEPRIM by any definition, while doing better than patients without VEPRIM, also derived increased clinical benefit when treated with rt-PA compared to placebo. Even with VEPRIM, a substantial percentage of patients had unfavorable outcomes.
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Affiliation(s)
- Clotilde Balucani
- Downstate Medical Center, The State University of New York, Brooklyn, New York.
| | - Steven R Levine
- Downstate Medical Center, The State University of New York, Brooklyn, New York; Departments of Neurology and Emergency Medicine, Kings County Medical Center, Brooklyn, New York
| | - Jane C Khoury
- Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles, Los Angeles, California
| | - Joseph P Broderick
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio
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25
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Wang W, Li M, Chen Q, Wang J. Hemorrhagic Transformation after Tissue Plasminogen Activator Reperfusion Therapy for Ischemic Stroke: Mechanisms, Models, and Biomarkers. Mol Neurobiol 2014; 52:1572-1579. [PMID: 25367883 DOI: 10.1007/s12035-014-8952-x] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 10/20/2014] [Indexed: 01/29/2023]
Abstract
Intracerebral hemorrhagic transformation (HT) is well recognized as a common cause of hemorrhage in patients with ischemic stroke. HT after acute ischemic stroke contributes to early mortality and adversely affects functional recovery. The risk of HT is especially high when patients receive thrombolytic reperfusion therapy with tissue plasminogen activator, the only available treatment for ischemic stroke. Although many important publications address preclinical models of ischemic stroke, there are no current recommendations regarding the conduct of research aimed at understanding the mechanisms and prediction of HT. In this review, we discuss the underlying mechanisms for HT after ischemic stroke, provide an overview of the models commonly used for the study of HT, and discuss biomarkers that might be used for the early detection of this challenging clinical problem.
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Affiliation(s)
- Wei Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, People's Republic of China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, People's Republic of China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, People's Republic of China.
| | - Jian Wang
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370B, Baltimore, MD, 21205, USA.
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Kim A, Lee JS, Kim JE, Paek YM, Chung K, Park JH, Cho YJ, Hong KS. Trends in yield of a code stroke program for enhancing thrombolysis. J Clin Neurosci 2014; 22:73-8. [PMID: 25282392 DOI: 10.1016/j.jocn.2014.05.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 05/23/2014] [Accepted: 05/27/2014] [Indexed: 11/19/2022]
Abstract
As the benefit of thrombolytic therapy in acute ischemic stroke is time-dependent, a code stroke program needs to be implemented, maintained, and improved with continuous efforts to expedite thrombolytic therapy. We analyzed the long-term yield and efficiency of our code stroke program. Using a prospective single-center registry, we assessed the rates of stroke diagnosis and thrombolysis, door-to-CT scan and door-to-needle times, and annual trends in patients with code stroke activation between May 2007 and December 2011. Of the 791 patients with code stroke activation during the 4.7 year study period, 626 (79.1%) had a stroke, with 461 (58.3%) ischemic strokes and 165 (20.9%) hemorrhagic strokes. Along with an increase of code stroke activation (from 105/year to 236/year) and thrombolytic therapy volumes (from 24/year to 77/year), the rate of thrombolytic therapy among ischemic stroke patients increased from 33.3% to 59.2% (p for trend=0.0001). However, code activations for a non-stroke case also significantly increased (p for trend=0.0001). Door-to-CT scan time (p for trend=0.0011) and proportion of CT scan initiation ⩽ 25 minutes after arrival improved (p for trend=0.0022), and were 18.4 minutes and 76.7%, respectively, in 2011. However, the door-to-needle time and proportion of door-to-needle time ⩽ 60 minutes did not significantly improve, they were (43.3 minutes and 83.1%, respectively, in 2011). Our code stroke program yielded a high rate of detecting thrombolysis candidates and a continuous increase in rates of administration of thrombolytic therapy. These findings support the stroke team members' collaborative effort to treat more patients and to treat patients faster.
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Affiliation(s)
- Ahro Kim
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Ji Sung Lee
- Biostatistical Consulting Unit, Soonchunhyang University Medical Center, Seoul, Republic of Korea
| | - Ji Eun Kim
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Young Min Paek
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Kyuyoon Chung
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Ji-Hyeon Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea.
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Kriegel J, Jehle F, Dieck M, Tuttle-Weidinger L. Optimizing patient flow in Austrian hospitals – Improvement of patient-centered care by coordinating hospital-wide patient trails. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2014. [DOI: 10.1179/2047971914y.0000000093] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Liu M, Wang HR, Liu JF, Li HJ, Chen SX, Shen S, Pan SM. Therapeutic effect of recombinant tissue plasminogen activator on acute cerebral infarction at different times. World J Emerg Med 2014; 4:205-9. [PMID: 25215120 PMCID: PMC4129846 DOI: 10.5847/wjem.j.issn.1920-8642.2013.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 07/07/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The study aimed to compare the therapeutic effect of recombinant tissue plasminogen activator (rt-PA) on the onset of acute cerebral infarction (ACI) at different time points of the first 6 hours. METHODS A retrospective analysis was conducted in 74 patients who received rt-PA thrombolysis treatment within 4.5 hours after ACI and another 15 patients who received rt-PA thrombolysis treatment between 4.5-6 hours after ACI. RESULTS National Institute of Health Stroke Scale (NIHSS) scores were statistically decreased in both groups (P>0.05) at 24 hours and 7 days after ACI. There was no significant difference in modified ranking scores and mortality at 90 days after the treatment between the two groups (P>0.05). CONCLUSIONS The therapeutic effect and mortality of rt-PA treatment in patients with ACI between 4.5-6 hours after the onset of the disease were similar to those in patients who received rt-PA within 4.5 hours after the onset of this disease. Therefore, intravenous thrombolytic therapy for ACI within 4.5-6 hours after ACI was effective and safe.
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Affiliation(s)
- Ming Liu
- Department of Emergency Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Hai-Rong Wang
- Department of Emergency Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Jia-Fu Liu
- Department of Emergency Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Hao-Jun Li
- Department of Emergency Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Shen-Xing Chen
- Department of Emergency Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Sha Shen
- Department of Emergency Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Shu-Ming Pan
- Department of Emergency Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
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Intravenously Administered Tissue Plasminogen Activator Useful in Milder Strokes? A Meta-analysis. J Stroke Cerebrovasc Dis 2014; 23:2156-2162. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.04.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 04/02/2014] [Indexed: 01/03/2023] Open
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Baraniuk S, Tilley BC, del Junco DJ, Fox EE, van Belle G, Wade CE, Podbielski JM, Beeler AM, Hess JR, Bulger EM, Schreiber MA, Inaba K, Fabian TC, Kerby JD, Cohen MJ, Miller CN, Rizoli S, Scalea TM, O’Keeffe T, Brasel KJ, Cotton BA, Muskat P, Holcomb JB. Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation. Injury 2014; 45:1287-95. [PMID: 24996573 PMCID: PMC4137482 DOI: 10.1016/j.injury.2014.06.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/01/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Forty percent of in-hospital deaths among injured patients involve massive truncal haemorrhage. These deaths may be prevented with rapid haemorrhage control and improved resuscitation techniques. The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial was designed to determine if there is a difference in mortality between subjects who received different ratios of FDA approved blood products. This report describes the design and implementation of PROPPR. STUDY DESIGN PROPPR was designed as a randomized, two-group, Phase III trial conducted in subjects with the highest level of trauma activation and predicted to have a massive transfusion. Subjects at 12 North American level 1 trauma centres were randomized into one of two standard transfusion ratio interventions: 1:1:1 or 1:1:2, (plasma, platelets, and red blood cells). Clinical data and serial blood samples were collected under Exception from Informed Consent (EFIC) regulations. Co-primary mortality endpoints of 24h and 30 days were evaluated. RESULTS Between August 2012 and December 2013, 680 patients were randomized. The overall median time from admission to randomization was 26min. PROPPR enrolled at higher than expected rates with fewer than expected protocol deviations. CONCLUSION PROPPR is the largest randomized study to enrol severely bleeding patients. This study showed that rapidly enrolling and successfully providing randomized blood products to severely injured patients in an EFIC study is feasible. PROPPR was able to achieve these goals by utilizing a collaborative structure and developing successful procedures and design elements that can be part of future trauma studies.
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Affiliation(s)
- Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Barbara C. Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Deborah J. del Junco
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | | | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Jeanette M. Podbielski
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Angela M. Beeler
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | | | - Eileen M. Bulger
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington
| | - Martin A. Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University
| | - Kenji Inaba
- Division of Trauma and Critical Care, University of Southern California
| | - Timothy C. Fabian
- Division of Trauma and Surgical Critical Care, Department of Surgery, Medical School, University of Tennessee Health Science Center
| | - Jeffrey D. Kerby
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama at Birmingham
| | - Mitchell J. Cohen
- Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco
| | | | - Sandro Rizoli
- Trauma and Acute Care Surgery, St Michael’s Hospital, University of Toronto
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine
| | - Terence O’Keeffe
- Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, University of Arizona
| | - Karen J. Brasel
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin
| | - Bryan A. Cotton
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Peter Muskat
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati
| | - John B. Holcomb
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
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Abstract
BACKGROUND Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009. OBJECTIVES To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available. MAIN RESULTS We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke. AUTHORS' CONCLUSIONS Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
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Xian Y, Smith EE, Zhao X, Peterson ED, Olson DM, Hernandez AF, Bhatt DL, Saver JL, Schwamm LH, Fonarow GC. Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic Stroke. Stroke 2014; 45:1387-95. [DOI: 10.1161/strokeaha.113.003898] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background and Purpose—
The benefits of intravenous tissue-type plasminogen activator in acute ischemic stroke are time dependent, and several strategies have been reported to be associated with more rapid door-to-needle (DTN) times. However, the extent to which hospitals are using these strategies and their association with DTN times have not been well studied.
Methods—
We surveyed 304 Get With The Guidelines-Stroke hospitals joining Target: Stroke regarding their baseline use of strategies to reduce DTN times in the January 2008 to December 2009 time frame before the initiation of Target: Stroke and determined the association between hospital strategies and DTN times.
Results—
Among 5460 patients receiving tissue-type plasminogen activator within 3 hours of symptom onset in surveyed hospitals, the median DTN time was 72 minutes (interquartile range, 55–94). Reported use of the different strategies varied considerably. Of 11 hospital strategies analyzed individually by multivariable analysis, 3 strategies were independently associated with shorter DTN times. These included rapid triage/stroke team notification (209/304 [69%] hospitals, 8.1-minute reduction in DTN time), single-call activation system (190/304 [63%] hospitals, 4.3 minutes), and tissue-type plasminogen activator stored in the emergency department (189/304 [62%] hospitals, 3.5 minutes). When analyzed incrementally, hospitals that used a greater number of strategies had shorter DTN times with 1.3 minutes (adjusted mean difference) saved for each strategy implemented (14 minutes if all strategies were used).
Conclusions—
Although the majority of participating hospitals reported using some strategy to reduce delays in tissue-type plasminogen activator administration for acute ischemic stroke, the strategies applied vary considerably and those most strongly associated with shorter DTN times were applied relatively less frequently.
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Affiliation(s)
- Ying Xian
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Eric E. Smith
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Xin Zhao
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Eric D. Peterson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - DaiWai M. Olson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Adrian F. Hernandez
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Deepak L. Bhatt
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Jeffrey L. Saver
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Lee H. Schwamm
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Gregg C. Fonarow
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
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Meretoja A, Keshtkaran M, Saver JL, Tatlisumak T, Parsons MW, Kaste M, Davis SM, Donnan GA, Churilov L. Stroke thrombolysis: save a minute, save a day. Stroke 2014; 45:1053-8. [PMID: 24627114 DOI: 10.1161/strokeaha.113.002910] [Citation(s) in RCA: 208] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Stroke thrombolysis is highly time-critical, but data on long-term effects of small reductions in treatment delays have not been available. Our objective was to quantify patient lifetime benefits gained from faster treatment. METHODS Observational prospective data of consecutive stroke patients treated with intravenous thrombolysis in Australian and Finnish centers (1998-2011; n=2258) provided distributions of age, sex, stroke severity, onset-to-treatment times, and 3-month modified Rankin Scale in daily clinical practice. Treatment effects derived from a pooled analysis of thrombolysis trials were used to model the shift in 3-month modified Rankin Scale distributions with reducing treatment delays, from which we derived the expected lifetime and level of long-term disability with faster treatment. RESULTS Each minute of onset-to-treatment time saved granted on average 1.8 days of extra healthy life (95% prediction interval, 0.9-2.7). Benefit was observed in all groups: each minute provided 0.6 day in old severe (age, 80 years; National Institutes of Health Stroke Scale [NIHSS] score, 20) patients, 0.9 day in old mild (age, 80 years; NIHSS score, 4) patients, 2.7 days in young mild (age, 50 years; NIHSS score, 4) patients, and 3.5 days in young severe (age, 50 years; NIHSS score, 20) patients. Women gained slightly more than men over their longer lifetimes. In the whole cohort, each 15 minute decrease in treatment delay provided an average equivalent of 1 month of additional disability-free life. CONCLUSIONS Realistically achievable small reductions in stroke thrombolysis delays would result in significant and robust average health benefits over patients' lifetimes. The awareness of concrete importance of speed could promote practice change.
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Affiliation(s)
- Atte Meretoja
- From the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (A.M., M.K., G.A.D., L.C.); Departments of Neurology and Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (A.M., S.M.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (A.M., T.T., M.K.); UCLA Stroke Center, Los Angeles, CA (J.L.S.); John Hunter Hospital and the Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia (M.W.P.); and School of Mathematical and Geospatial Sciences, RMIT University, Melbourne, Australia (M.K., L.C.)
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Chaturvedi M, Kaczmarek L. Mmp-9 inhibition: a therapeutic strategy in ischemic stroke. Mol Neurobiol 2014; 49:563-73. [PMID: 24026771 PMCID: PMC3918117 DOI: 10.1007/s12035-013-8538-z] [Citation(s) in RCA: 219] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 08/15/2013] [Indexed: 12/16/2022]
Abstract
Ischemic stroke is a leading cause of disability worldwide. In cerebral ischemia there is an enhanced expression of matrix metallo-proteinase-9 (MMP-9), which has been associated with various complications including excitotoxicity, neuronal damage, apoptosis, blood-brain barrier (BBB) opening leading to cerebral edema, and hemorrhagic transformation. Moreover, the tissue plasminogen activator (tPA), which is the only US-FDA approved treatment of ischemic stroke, has a brief 3 to 4 h time window and it has been proposed that detrimental effects of tPA beyond the 3 h since the onset of stroke are derived from its ability to activate MMP-9 that in turn contributes to the breakdown of BBB. Therefore, the available literature suggests that MMP-9 inhibition can be of therapeutic importance in ischemic stroke. Hence, combination therapies of MMP-9 inhibitor along with tPA can be beneficial in ischemic stroke. In this review we will discuss the current status of various strategies which have shown neuroprotection and extension of thrombolytic window by directly or indirectly inhibiting MMP-9 activity. In the introductory part of the review, we briefly provide an overview on ischemic stroke, commonly used models of ischemic stroke and a role of MMP-9 in ischemia. In next part, the literature is organized as various approaches which have proven neuroprotective effects through direct or indirect decrease in MMP-9 activity, namely, using biotherapeutics, involving MMP-9 gene inhibition using viral vectors; using endogenous inhibitor of MMP-9, repurposing of old drugs such as minocycline, new chemical entities like DP-b99, and finally other approaches like therapeutic hypothermia.
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Affiliation(s)
- Mayank Chaturvedi
- Laboratory of Neurobiology, Nencki Institute, Pasteura 3, 02-093 Warsaw, Poland
| | - Leszek Kaczmarek
- Laboratory of Neurobiology, Nencki Institute, Pasteura 3, 02-093 Warsaw, Poland
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Oliveira-Filho J, Martins SCO, Pontes-Neto OM, Longo A, Evaristo EF, Carvalho JJFD, Fernandes JG, Zétola VF, Gagliardi RJ, Vedolin L, Freitas GRD. Guidelines for acute ischemic stroke treatment: part I. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 70:621-9. [PMID: 22899035 DOI: 10.1590/s0004-282x2012000800012] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Jamary Oliveira-Filho
- Rua Reitor Miguel Calmon s/n; Instituto de Ciências da Saúde / sala 455; 40110-100 Salvador BA - Brasil
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Schwamm LH. When in rome, do like the Romans: certifying stroke centers with the rod of aesculapius or the medical caduceus of hermes? J Am Heart Assoc 2013; 2:e000120. [PMID: 23557752 PMCID: PMC3647263 DOI: 10.1161/jaha.113.000120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.)
- Correspondence to: Lee H. Schwamm, MD, FAHA, Vice Chairman, Department of Neurology‐ACC 720, C. Miller Fisher Endowed Chair, Massachusetts General Hospital, Professor of Neurology, Harvard Medical School, MGH, 55 Fruit Street, Boston MA 02114. E‐mail:
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Abstract
Acute ischemic stroke is a time-critical emergency for which thrombolytic therapy is the only medical treatment. Many patients who would benefit from this treatment are deprived of it due to delays. Failure to call for help rapidly is the main obstacle, but even when the call is made in time, the prehospital evaluation, transportation, and emergency department (ED) diagnostics often take too long to treat the patient with thrombolysis. Interventions to reduce pre- and in-hospital delays have been described; although no single intervention is likely to make a major difference, a whole set of interventions needs to be implemented. The intersection of the pre- and in-hospital care is of special importance. With successful protocols and good communication between the emergency medical service and ED, delays can be significantly reduced. On the basis of our experience, 94% of patients can be treated within 60 min of arrival, based largely on using the prehospital time effectively.
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Affiliation(s)
- Atte Meretoja
- Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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Nadathur SG, Warren JR. Emergency department triaging of admitted stroke patients--a Bayesian Network analysis. Health Informatics J 2012; 17:294-312. [PMID: 22193829 DOI: 10.1177/1460458211424475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study uses hospital administrative data to ascertain the differences in the patient characteristics, process and outcomes of care between the Emergency Department (ED) triage categories of patients admitted from an ED presentation into a large metropolitan teaching hospital with a Stroke Care Unit. Bayesian Networks (BNs) derived from the administrative data were used to provide the descriptive models. Nearly half the patients in each stroke subtype were triaged as 'Urgent' (to be seen within 30 minutes). With a decrease in the urgency of triage categories, the proportion admitted within 8 hours decreased dramatically and the proportion of formal discharge increased. Notably, 45% of transient ischaemic attacks (TIAs) were categorized as 'Semi-urgent' (to be attended within 60 minutes), indicating an opportunity to improve emergency assessment of TIAs. The results illustrate the utility of hospital administrative data and the applicability of BNs for review of the current triage practices and subsequent impact.
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Zebedin D, Sorantin E, Riccabona M. Perfusion CT in childhood stroke--initial observations and review of the literature. Eur J Radiol 2011; 82:1059-66. [PMID: 22209434 DOI: 10.1016/j.ejrad.2011.11.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION To report the preliminary results of contrast-enhanced perfusion multi-detector CT for diagnoses of perfusion disturbances in children with clinical suspicion of stroke. PATIENTS AND METHODS Within the last two years emergency perfusion CT was performed in ten children (age: 8-17 years, male:female=3:7) for assessment of suspected childhood stroke. These intracranial perfusion CT, intracranial CT-digital subtraction angiography (CT-DSA) and extracranial CT-angiography (CTA) studies were retrospectively reviewed and compared with MRI, follow-up CT, catheter angiography and final clinical diagnosis. The total dose length product (DLP) for the entire examination was recorded. The image quality of perfusion CT-maps, CT-DSA and CTA were evaluated with a subjective three-point scale ranging from very good to non-diagnostic image quality rating perfusion disturbance, intracranial peripheral vessel depiction, and motion- or streak artifacts. RESULTS In nine of ten children perfusion CT showed no false positive or false negative results. In one of ten children suffering from migraine focal hypo-perfusion was read as perfusion impairment potentially indicating early stroke, but MRI and MRA follow-up were negative. Overall, perfusion-CT with CT-DSA was rated very good in 80% of cases for the detection of perfusion disturbances and vessel anatomy. CONCLUSIONS In comparison to standard CT, contrast-enhanced perfusion CT improves CTs' diagnostic capability in the emergency examination of children with a strong suspicion of ischemic cerebral infarction.
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Affiliation(s)
- D Zebedin
- Division of Pediatric Radiology, Department of Radiology, University Hospital LKH Graz, Austria.
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Fonarow GC, Smith EE, Saver JL, Reeves MJ, Hernandez AF, Peterson ED, Sacco RL, Schwamm LH. Improving door-to-needle times in acute ischemic stroke: the design and rationale for the American Heart Association/American Stroke Association's Target: Stroke initiative. Stroke 2011; 42:2983-9. [PMID: 21885841 DOI: 10.1161/strokeaha.111.621342] [Citation(s) in RCA: 266] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time-dependent, and guidelines recommend a door-to-needle time of ≤60 minutes. However, fewer than one third of acute ischemic stroke patients who receive tPA are treated within guideline-recommended door-to-needle times. This article describes the design and rationale of TARGET Stroke, a national initiative organized by the American Heart Association/American Stroke Association in partnership with other organizations to assist hospitals in increasing the proportion of tPA-treated patients who achieve guideline-recommended door-to-needle times. METHODS The initial program goal is to achieve a door-to-needle time≤60 minutes for at least 50% of acute ischemic stroke patients. Key best practice strategies previously associated with achieving faster door-to-needle times in acute ischemic stroke were identified. RESULTS The 10 key strategies chosen by TARGET Stroke include emergency medical service prenotification, activating the stroke team with a single call, rapid acquisition and interpretation of brain imaging, use of specific protocols and tools, premixing tPA, a team-based approach, and rapid data feedback. The program includes many approaches intended to promote hospital participation, implement effective strategies, share best practices, foster collaboration, and achieve stated goals. A detailed program evaluation is also included. In the first year, TARGET Stroke has enrolled over 1200 United States hospitals. CONCLUSIONS TARGET Stroke, a multidimensional initiative to improve the timeliness of tPA administration, aims to elevate clinical performance in the care of acute ischemic stroke, facilitate the more rapid integration of evidence into clinical practice, and improve outcomes.
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Affiliation(s)
- Gregg C Fonarow
- University of California, Los Angeles, Department of Neurology, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, 10833 LeConte Avenue, Room 47-123 CHS, Los Angeles, CA 90095-1679, USA.
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Shulkin DJ, Jewell KE, Alexandrov AW, Bernard DB, Brophy GM, Hess DC, Kohlbrenner J, Martin-Schild S, Mayer SA, Peacock WF, Qureshi AI, Sung GY, Lyles A. Impact of systems of care and blood pressure management on stroke outcomes. Popul Health Manag 2011; 14:267-75. [PMID: 21506730 DOI: 10.1089/pop.2010.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.
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Conduct of Stroke-Related Clinical Trials. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10060-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Khatri P, Kleindorfer DO, Yeatts SD, Saver JL, Levine SR, Lyden PD, Moomaw CJ, Palesch YY, Jauch EC, Broderick JP. Strokes with minor symptoms: an exploratory analysis of the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials. Stroke 2010; 41:2581-6. [PMID: 20814000 DOI: 10.1161/strokeaha.110.593632] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND PURPOSE The pivotal National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials excluded patients with ischemic stroke with specific minor presentations or rapidly improving symptoms. The recombinant tissue plasminogen activator product label notes that its use for minor neurological deficit or rapidly improving stroke symptoms has not been evaluated. As a result, patients with low National Institutes of Health Stroke Scale scores are not commonly treated in clinical practice. We sought to further characterize the patients with minor stroke who were included in the National Institute of Neurological Disorders and Stroke trials. METHODS Minor strokes were defined as National Institutes of Health Stroke Scale score ≤ 5 at baseline for this retrospective analysis, because this subgroup is most commonly excluded from treatment in clinical practice and trials. Clinical stroke syndromes were defined based on prespecified National Institutes of Health Stroke Scale item score clusters. Clinical outcomes were reviewed generally and within these cluster subgroups. RESULTS Only 58 cases had National Institutes of Health Stroke Scale scores of 0 to 5 in the National Institute of Neurological Disorders and Stroke trials (42 recombinant tissue plasminogen activator and 16 placebo), and 2971 patients were excluded from the trials due to "rapidly improving" or "minor symptoms" as the primary reason. No patients were enrolled with isolated motor symptoms, isolated facial droop, isolated ataxia, dysarthria, isolated sensory symptoms, or with only symptoms/signs not captured by the National Institutes of Health Stroke Scale score (ie, National Institutes of Health Stroke Scale=0). There were ≤ 3 patients with each of the other isolated deficits enrolled in the trial. CONCLUSIONS The National Institute of Neurological Disorders and Stroke trials excluded a substantial number of strokes with minor presentations, those that were included were small in number, and conclusions about outcomes based on specific syndromes cannot be drawn. Further prospective, systematic study of this subgroup is needed.
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Affiliation(s)
- Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH 45267-0525, USA.
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Abstract
BACKGROUND The majority of strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and could improve recovery after stroke. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in highly selected patients within three hours of stroke. OBJECTIVES To assess the safety and efficacy of thrombolytic agents in patients with acute ischaemic stroke. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched October 2008), MEDLINE (1966 to October 2008) and EMBASE (1980 to October 2008). We contacted researchers and pharmaceutical companies, attended relevant conferences and handsearched pertinent journals. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in patients with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria and extracted data. We assessed trial quality. We verified the extracted data with the principal investigators of all major trials. We obtained both published and unpublished data if available. MAIN RESULTS We included 26 trials involving 7152 patients. Not all trials contributed data to each outcome. The trials tested urokinase, streptokinase, recombinant tissue plasminogen activator, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke; three trials started treatment up to nine hours and one small trial up to 24 hours after stroke. About 55% of the data (patients and trials) come from trials testing intravenous tissue plasminogen activator. Very few of the patients (0.5%) were aged over 80 years. Many trials had some imbalances in key prognostic variables. Several trials did not have complete blinding of outcome assessment. Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of patients who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.81, 95% confidence interval (CI) 0.73 to 0.90). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.49, 95% CI 2.81 to 4.33) and death by three to six months after stroke (OR 1.31, 95% CI 1.14 to 1.50). Treatment within three hours of stroke appeared more effective in reducing death or dependency (OR 0.71, 95% CI 0.52 to 0.96) with no statistically significant adverse effect on death (OR 1.13, 95% CI 0.86 to 1.48). There was heterogeneity between the trials in part attributable to concomitant antithrombotic drug use (P = 0.02), stroke severity and time to treatment. Antithrombotic drugs given soon after thrombolysis may increase the risk of death. AUTHORS' CONCLUSIONS Overall, thrombolytic therapy appears to result in a significant net reduction in the proportion of patients dead or dependent in activities of daily living. This overall benefit was apparent despite an increase both in deaths (evident at seven to 10 days and at final follow up) and in symptomatic intracranial haemorrhages. Further trials are needed to identify which patients are most likely to benefit from treatment and the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh, UK, EH4 2XU
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Kashyap RS, Nayak AR, Deshpande PS, Kabra D, Purohit HJ, Taori GM, Daginawala HF. Inter-α-trypsin inhibitor heavy chain 4 is a novel marker of acute ischemic stroke. Clin Chim Acta 2009; 402:160-3. [DOI: 10.1016/j.cca.2009.01.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Quain DA, Parsons MW, Loudfoot AR, Spratt NJ, Evans MK, Russell ML, Royan AT, Moore AG, Miteff F, Hullick CJ, Attia J, McElduff P, Levi CR. Improving access to acute stroke therapies: a controlled trial of organised pre-hospital and emergency care. Med J Aust 2008; 189:429-33. [PMID: 18928434 DOI: 10.5694/j.1326-5377.2008.tb02114.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 06/19/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the effectiveness of the PAST (Pre-hospital Acute Stroke Triage) protocol in reducing pre-hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy. DESIGN Prospective cohort study using historical controls. SETTING Hunter Region of New South Wales, September 2005 to March 2006 (pre-intervention) and September 2006 to March 2007 (post-intervention). PARTICIPANTS Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital. INTERVENTION PAST protocol, comprising a pre-hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis-eligible patients, and pre-hospital notification of the acute stroke team. MAIN OUTCOME MEASURES Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA. RESULTS The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre-intervention) to 21.4% (post-intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months. CONCLUSIONS Organised pre-hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke-related disability.
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Affiliation(s)
- Debbie A Quain
- Hunter Medical Research Institute, Newcastle, NSW, Australia
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Levine SR, Adamowicz D, Johnston KC. PRIMARY STROKE CENTER CERTIFICATION. Continuum (Minneap Minn) 2008. [DOI: 10.1212/01.con.0000275643.30322.f9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25:457-507. [PMID: 18477843 DOI: 10.1159/000131083] [Citation(s) in RCA: 1673] [Impact Index Per Article: 104.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 03/27/2008] [Indexed: 12/13/2022] Open
Abstract
This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.
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LaMonte MP, Bahouth MN, Xiao Y, Hu P, Baquet CR, Mackenzie CF. Outcomes from a Comprehensive Stroke Telemedicine Program. Telemed J E Health 2008; 14:339-44. [DOI: 10.1089/tmj.2007.0062] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Yan Xiao
- Program in Trauma and Department of Anesthesiology
| | - Peter Hu
- Program in Trauma and Department of Anesthesiology
| | - Claudia R. Baquet
- Epidemiology and Preventive Medicine, University of Maryland Medical Center, Baltimore, Maryland
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Albright KC, Schott TC, Jafari N, Wohlford-Wessels MP, Finnerty EP, Jacoby MRK. Tissue plasminogen activator use: evaluation and initial management of ischemic stroke from an Iowa hospital perspective. J Stroke Cerebrovasc Dis 2008; 14:127-35. [PMID: 17904012 DOI: 10.1016/j.jstrokecerebrovasdis.2005.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2004] [Revised: 01/06/2005] [Accepted: 01/07/2005] [Indexed: 11/16/2022] Open
Abstract
Despite its efficacy for acute ischemic stroke, tissue plasminogen activator (rt-PA) is reported as used in less than 5% of patients with stroke. This study assessed the rate of intravenous rt-PA use in a community hospital and identified factors influencing rt-PA use. A retrospective chart review revealed a total of 464 patients presenting to the emergency department with a primary diagnosis of stroke from January 2000 through June 2002. Records were sorted into 3 groups: those presenting to the emergency department within 3 hours, 3 to 6 hours, and 6 hours or more of symptom onset. Each record was reviewed using National Institute of Neurologic Disorders and Stroke thrombolytic therapy criteria. Primary measures were rate of intravenous rt-PA use and reasons for not receiving rt-PA. Of the 464 patients with stroke who presented to the emergency department during the 30-month period, 99 arrived in less than 3 hours, 22 between 3 and 6 hours, and 343 greater than 6 hours. A total of 13 (2.8% of all patients with stroke or 13% of those presenting within 3 hours) received rt-PA. All patients meeting criteria received rt-PA. Rapidly improving or minor symptoms and difficult to control or elevated blood pressure were the most common reasons for not using rt-PA. Of the patients arriving within the 3-hour window, 14 were excluded by time factors. We conclude from this study that rt-PA can be effectively used in community hospitals and that use likely exceeds previously quoted national rates when based on a more appropriate measure of eligibility criteria as opposed to total presenting patients with stroke.
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Affiliation(s)
- Karen C Albright
- Des Moines University, Osteopathic Medical Center, Des Moines, Iowa, USA
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