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Röhrs KJ, Audebert H. Pre-Hospital Stroke Care beyond the MSU. Curr Neurol Neurosci Rep 2024; 24:315-322. [PMID: 38907812 PMCID: PMC11258185 DOI: 10.1007/s11910-024-01351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 06/24/2024]
Abstract
PURPOSE OF REVIEW Mobile stroke units (MSU) have established a new, evidence-based treatment in prehospital stroke care, endorsed by current international guidelines and can facilitate pre-hospital research efforts. In addition, other novel pre-hospital modalities beyond the MSU are emerging. In this review, we will summarize existing evidence and outline future trajectories of prehospital stroke care & research on and off MSUs. RECENT FINDINGS The proof of MSUs' positive effect on patient outcomes is leading to their increased adoption in emergency medical services of many countries. Nevertheless, prehospital stroke care worldwide largely consists of regular ambulances. Advancements in portable technology for detecting neurocardiovascular diseases, telemedicine, AI and large-scale ultra-early biobanking have the potential to transform prehospital stroke care also beyond the MSU concept. The increasing implementation of telemedicine in emergency medical services is demonstrating beneficial effects in the pre-hospital setting. In synergy with telemedicine the exponential growth of AI-technology is already changing and will likely further transform pre-hospital stroke care in the future. Other promising areas include the development and validation of miniaturized portable devices for the pre-hospital detection of acute stroke. MSUs are enabling large-scale screening for ultra-early blood-based biomarkers, facilitating the differentiation between ischemia, hemorrhage, and stroke mimics. The development of suitable point-of-care tests for such biomarkers holds the potential to advance pre-hospital stroke care outside the MSU-concept. A multimodal approach of AI-supported telemedicine, portable devices and blood-based biomarkers appears to be an increasingly realistic scenario for improving prehospital stroke care in regular ambulances in the future.
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Affiliation(s)
- Kian J Röhrs
- Department of Neurology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Heinrich Audebert
- Department of Neurology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Krothapalli N, Hasan D, Lusk J, Poli S, Hussain S, de Havenon A, Grotta J, Grory BM. Mobile stroke units: Beyond thrombolysis. J Neurol Sci 2024; 463:123123. [PMID: 38981417 DOI: 10.1016/j.jns.2024.123123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
In the last decade, mobile stroke units (MSUs) have shown the potential to transform prehospital stroke care, marking a paradigm shift in delivering ultra-rapid thrombolysis and streamlining triage processes. These units bring acute stroke care directly to patients, significantly shortening treatment times. This review outlines the rationale for MSU care and discusses the potential applications beyond the original purpose of delivering thrombolysis, including large vessel occlusion detection, intracerebral hemorrhage management, and innovative forms of prehospital research.
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Affiliation(s)
- Neeharika Krothapalli
- Department of Neurology, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - David Hasan
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA; Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Jay Lusk
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Shazam Hussain
- Department of Neurology, Cleveland Clinic Health Foundation, Cleveland, OH, USA
| | - Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT, USA
| | - James Grotta
- Department of Neurology, University of Texas Health Science Center, Houston, TX, USA
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
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Hagrass AI, Elsayed SM, Doheim MF, Mostafa MA, Elfil M, Al-Kafarna M, Almaghary BK, Fayoud AM, Hamdallah A, Hasan MT, Ragab KM, Nourelden AZ, Zaazouee MS, Medicherla C, Lerario M, Czap AL, Chong J, Nour M, Al-Mufti F. Mobile Stroke Units in Acute Ischemic Stroke: A Comprehensive Systematic Review and Meta-Analysis of 5 "T Letter" Domains. Cardiol Rev 2024; 32:297-313. [PMID: 38602410 DOI: 10.1097/crd.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Intravenous thrombolysis (IVT) may be administered to stroke patients requiring immediate treatment more quickly than emergency medical services if certain conditions are met. These conditions include the presence of mobile stroke units (MSUs) with on-site treatment teams and a computed tomography scanner. We compared clinical outcomes of MSU conventional therapy by emergency medical services through a systematic review and meta-analysis. We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 and 90 days. The secondary outcomes included the modified Rankin Scale score at 90 days, alarm to IVT or intra-arterial recanalization, and time from symptom onset or last known well to thrombolysis. We included 19 controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90-day mortality significantly decreased in the MSU group compared with the conventional care group [risk ratio = 0.82; 95% confidence interval (CI), 0.71-0.95], while there was no significant difference at 7 days (risk ratio = 0.89; 95% CI, 0.69-1.15). MSU achieved greater functional independence (modified Rankin Scale = 0-2) at 90 days (risk ratio = 1.08; 95% CI, 1.01-1.16). MSU was associated with shorter alarm to IVT or intra-arterial recanalization time (mean difference = -29.69; 95% CI, -34.46 to -24.92), treating patients in an earlier time window, as shown through symptom onset or last known well to thrombolysis (mean difference = -36.79; 95% CI, -47.48 to -26.10). MSU-treated patients had a lower rate of 90-day mortality and better 90-day functional outcomes by earlier initiation of IVT compared with conventional care.
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Affiliation(s)
| | | | - Mohamed Fahmy Doheim
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | | | | | | | | | | | | - Mackenzie Lerario
- Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Alexandra L Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, Valhalla, NY
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla, NY
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Schiele P, König AN, Meyer A, Falk V, Nienaber CA, Kurz SD. Modelling years of life lost due to acute type A aortic dissection in the German healthcare setting: a predictive study. BMJ Open 2024; 14:e078398. [PMID: 38925695 PMCID: PMC11202649 DOI: 10.1136/bmjopen-2023-078398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 05/23/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVES This study aimed to develop a patient-centred approach to the burden of acute type A aortic dissection (ATAAD) through modelling. The main objective was to identify potential improvements in managing this life-threatening cardiovascular condition and to provide evidence-based recommendations to optimise outcomes. DESIGN We developed a predictive model along patient pathways to estimate the burden of ATAAD through the years of life lost (YLLs) metric. The model was created based on a systematic review of the literature and was parameterised using demographic data from the German healthcare environment. The model was designed to allow interactive simulation of different scenarios resulting from changes in key impact factors. SETTING The study was conducted using data from the German healthcare environment and results from the literature review. PARTICIPANTS The study included a comprehensive modelling of ATAAD cases in Germany but did not directly involve participants. INTERVENTIONS There were no specific interventions applied in this study based on the modelling design. PRIMARY AND SECONDARY OUTCOME MEASURES The single outcome measure was the estimation of YLL due to ATAAD in Germany. RESULTS Our model estimated 102 791 YLL per year for ATAAD in Germany, with 62 432 and 40 359 YLL for men and women, respectively. Modelling an improved care setting yielded 93 191 YLL or 9.3% less YLL compared with the current standard while a worst-case scenario resulted in 113 023 or 10.0% more YLL. The model is accessible at https://acuteaorticdissection.com/ to estimate custom scenarios. CONCLUSIONS Our study provides an evidence-based approach to estimating the burden of ATAAD and identifying potential improvements in the management of pathways. This approach can be used by healthcare decision-makers to inform policy changes aimed at optimising patient outcomes. By considering patient-centred approaches in any healthcare environment, the model has the potential to improve efficient care for patients suffering from ATAAD.
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Affiliation(s)
- Philipp Schiele
- Department of Statistics, Ludwig-Maximilians-Universität München, München, Germany
| | - Adriana N König
- Munich School of Management and Munich Center of Health Sciences, Ludwig-Maximilians-Universität München, München, Germany
| | - Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Christoph A Nienaber
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiology and Aortic Centre, The Royal Brompton & Harefield Hospitals as part of Guys' and St. Thomas' NHS Foundation Trust, London, UK
| | - Stephan D Kurz
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Schwabauer E, Piccininni M, Freitag E, Ebinger M, Geisler F, Harmel P, Hille A, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Kurth T, Rohmann JL, Endres M, Schlunk F, Weber J, Wendt M, Audebert HJ. Effects of Mobile Stroke Unit dispatch on blood pressure management and outcomes in patients with intracerebral haematoma: Results from the Berlin_Prehospital Or Usual Care Delivery in acute Stroke (B_PROUD) controlled intervention study. Eur Stroke J 2024; 9:366-375. [PMID: 38014623 DOI: 10.1177/23969873231213156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION In patients with acute intracerebral haemorrhage (ICH) and elevated systolic blood pressure (BP), guidelines suggest that systolic BP reduction to <140 mmHg should be rapidly initiated. Compared with conventional care, Mobile Stroke Units (MSUs) allow for earlier ICH diagnosis through prehospital imaging and earlier BP lowering. PATIENTS AND METHODS ICH patients were prospectively evaluated as a cohort of the controlled B_PROUD-study in which MSU availability alone determined MSU dispatch in addition to conventional ambulance. We used inverse probability of treatment weighting to adjust for confounding to estimate the effect of additional MSU dispatch in ICH patients. Outcomes of interest were 7-day mortality (primary), systolic BP (sBP) at hospital arrival, dispatch-to-imaging time, largest haematoma volume, anticoagulation reversal, length of in-hospital stay, 3-month functional outcome. RESULTS Between February 2017 and May 2019, MSUs were dispatched to 95 (mean age: 72 ± 13 years, 45% female) and only conventional ambulances to 78 ICH patients (mean age: 71 ± 12 years, 44% female). After adjusting for confounding, we found shorter dispatch-to-imaging time (mean difference: -17.75 min, 95% CI: -27.16 to -8.21 min) and lower sBP at hospital arrival (mean difference = -16.31 mmHg, 95% CI: -30.64 to -6.19 mmHg) in the MSU group. We found no statistically significant difference for the other outcomes, including 7-day mortality (adjusted odds ratio: 1.43, 95% CI: 0.68 to 3.31) or favourable outcome (adjusted odds ratio = 0.67, 95% CI: 0.27 to 1.67). CONCLUSIONS Although MSU dispatch led to sBP reduction and lower dispatch-to-imaging time compared to conventional ambulance care, we found no evidence of better outcomes in the MSU dispatch group.
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Affiliation(s)
- Eugen Schwabauer
- Klinik für Neurologie mit Stroke Unit; Vivantes Klinikum Neukölln, Berlin, Germany
| | - Marco Piccininni
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Erik Freitag
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Frederik Geisler
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Annegret Hille
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica L Rohmann
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Frieder Schlunk
- Berlin Institute of Health (BIH), Berlin, Germany
- Institut für Neuroradiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Weber
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | | | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Wolcott ZC, English SW. Artificial intelligence to enhance prehospital stroke diagnosis and triage: a perspective. Front Neurol 2024; 15:1389056. [PMID: 38756217 PMCID: PMC11096539 DOI: 10.3389/fneur.2024.1389056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition, accurate diagnosis, and efficient triage to improve outcomes after stroke. Emergency medical services (EMS) personnel currently rely heavily on dispatch accuracy, stroke screening tools, bypass protocols and prehospital notification to care for patients with suspected stroke, but novel tools including mobile stroke units and telemedicine-enabled ambulances are already changing the landscape of prehospital stroke care. Herein, the authors provide our perspective on the current state of prehospital stroke diagnosis and triage including several of these emerging trends. Then, we provide commentary to highlight potential artificial intelligence (AI) applications to improve stroke detection, improve accurate and timely dispatch, enhance EMS training and performance, and develop novel stroke diagnostic tools for prehospital use.
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Piccininni M, Stensrud MJ. Using Negative Control Populations to Assess Unmeasured Confounding and Direct Effects. Epidemiology 2024; 35:313-319. [PMID: 38465949 DOI: 10.1097/ede.0000000000001724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Sometimes treatment effects are absent in a subgroup of the population. For example, penicillin has no effect on severe symptoms in individuals infected by resistant Staphylococcus aureus , and codeine has no effect on pain in individuals with certain polymorphisms in the CYP2D6 enzyme. Subgroups where a treatment is ineffective are often called negative control populations or placebo groups. They are leveraged to detect bias in different disciplines. Here we present formal criteria that justify the use of negative control populations to rule out unmeasured confounding and mechanistic (direct) causal effects. We further argue that negative control populations, satisfying our formal conditions, are available in many settings, spanning from clinical studies of infectious diseases to epidemiologic studies of public health interventions. Negative control populations can also be used to rule out placebo effects in unblinded randomized experiments. As a case study, we evaluate the effect of mobile stroke unit dispatches on functional outcomes at discharge in individuals with suspected stroke, using data from a large trial. Our analysis supports the hypothesis that mobile stroke units improve functional outcomes in these individuals.
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Affiliation(s)
- Marco Piccininni
- From the Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Digital Health-Machine Learning Research Group, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
| | - Mats Julius Stensrud
- Department of Mathematics, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
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Bluhm S, Schramm P, Spreen-Ledebur Y, Bluhm S, Münte TF, Eiersted MR, Wolfram F, van Hooff RJR, Wienecke T, Royl G. Potential effects of a mobile stroke unit on time to treatment and outcome in patients treated with thrombectomy or thrombolysis: A Danish-German cross-border analysis. Eur J Neurol 2024:e16298. [PMID: 38682808 DOI: 10.1111/ene.16298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND PURPOSE A mobile stroke unit (MSU) reduces delays in stroke treatment by allowing thrombolysis on board and avoiding secondary transports. Due to the beneficial effect in comparison to conventional emergency medical services, current guidelines recommend regional evaluation of MSU implementation. METHODS In a descriptive study, current pathways of patients requiring a secondary transport for mechanical thrombectomy were reconstructed from individual patient records within a Danish (n = 122) and an adjacent German region (n = 80). Relevant timestamps included arrival times (on site, primary hospital, thrombectomy centre) as well as the initiation of acute therapy. An optimal MSU location for each region was determined. The resulting time saving was translated into averted disability-adjusted life years (DALYs). RESULTS For each region, the optimal MSU location required a median driving time of 35 min to a stroke patient. Time savings in the German region (median [Q1; Q3]) were 7 min (-15; 31) for thrombolysis and 35 min (15; 61) for thrombectomy. In the Danish region, the corresponding time savings were 20 min (8; 30) and 43 min (25; 66). Assuming 28 thrombectomy cases and 52 thrombolysis cases this would translate to 9.4 averted DALYs per year justifying an annual net MSU budget of $0.8M purchasing power parity dollars (PPP-$) in the German region. In the Danish region, the MSU would avert 17.7 DALYs, justifying an annual net budget of PPP-$1.7M. CONCLUSION The effects of an MSU can be calculated from individual patient pathways and reflect differences in the hospital infrastructure between Denmark and Germany.
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Affiliation(s)
- Susanna Bluhm
- Department of Neurology, University of Lübeck, Lübeck, Germany
- St Vinzenz-Hospital, Köln, Germany
| | - Peter Schramm
- Department of Neuroradiology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
| | | | | | - Thomas F Münte
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
| | | | - Frauke Wolfram
- Department of Radiology, Zealand University Hospital, Roskilde, Denmark
| | - Robbert-Jan Roderick van Hooff
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Troels Wienecke
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Georg Royl
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
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Fang H, Bo Y, Hao Z, Mang G, Jin J, Wang H. A promising frontier: targeting NETs for stroke treatment breakthroughs. Cell Commun Signal 2024; 22:238. [PMID: 38654328 PMCID: PMC11036592 DOI: 10.1186/s12964-024-01563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/07/2024] [Indexed: 04/25/2024] Open
Abstract
Stroke is a prevalent global acute cerebrovascular condition, with ischaemic stroke being the most frequently occurring type. After a stroke, neutrophils accumulate in the brain and subsequently generate and release neutrophil extracellular traps (NETs). The accumulation of NETs exacerbates the impairment of the blood‒brain barrier (BBB), hampers neovascularization, induces notable neurological deficits, worsens the prognosis of stroke patients, and can facilitate the occurrence of t-PA-induced cerebral haemorrhage subsequent to ischaemic stroke. Alternative approaches to pharmacological thrombolysis or endovascular thrombectomy are being explored, and targeting NETs is a promising treatment that warrants further investigation.
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Affiliation(s)
- Huijie Fang
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Yunfei Bo
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Zhongfei Hao
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Ge Mang
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiaqi Jin
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
| | - Hongjun Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China.
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Wen R, Wang M, Bian W, Zhu H, Xiao Y, Zeng J, He Q, Wang Y, Liu X, Shi Y, Hong Z, Xu B. Effectiveness of the acute stroke care map program in reducing in-hospital delay for acute ischemic stroke in a Chinese urban area: an interrupted time series analysis. Front Neurol 2024; 15:1364952. [PMID: 38699054 PMCID: PMC11063247 DOI: 10.3389/fneur.2024.1364952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024] Open
Abstract
Background Timely intravenous thrombolysis (IVT) is crucial for improving outcomes in acute ischemic stroke (AIS) patients. This study evaluates the effectiveness of the Acute Stroke Care Map (ASCaM) initiative in Shenyang, aimed at reducing door-to-needle times (DNT) and thus improving the timeliness of care for AIS patients. Methods An retrospective cohort study was conducted from April 2019 to December 2021 in 30 hospitals participating in the ASCaM initiative in Shenyang. The ASCaM bundle included strategies such as EMS prenotification, rapid stroke triage, on-call stroke neurologists, immediate neuroimaging interpretation, and the innovative Pre-hospital Emergency Call and Location Identification feature. An interrupted time series analysis (ITSA) was used to assess the impact of ASCaM on DNT, comparing 9 months pre-intervention with 24 months post-intervention. Results Data from 9,680 IVT-treated ischemic stroke patients were analyzed, including 2,401 in the pre-intervention phase and 7,279 post-intervention. The ITSA revealed a significant reduction in monthly DNT by -1.12 min and a level change of -5.727 min post-ASCaM implementation. Conclusion The ASCaM initiative significantly reduced in-hospital delays for AIS patients, demonstrating its effectiveness as a comprehensive stroke care improvement strategy in urban settings. These findings highlight the potential of coordinated care interventions to enhance timely access to reperfusion therapies and overall stroke prognosis.
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Affiliation(s)
- Rui Wen
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Miaoran Wang
- Affiliated Central Hospital of Shenyang Medical College, Shenyang Medical College, Shenyang, China
| | - Wei Bian
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Haoyue Zhu
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Ying Xiao
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Jing Zeng
- ChongQing Medical University, ChongQing, China
| | - Qian He
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Yu Wang
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Xiaoqing Liu
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Yangdi Shi
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Zhe Hong
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Bing Xu
- Shenyang Tenth People’s Hospital, Shenyang, China
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11
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Lam TJR, Liu Z, Tan BYQ, Ng YY, Tan CK, Wong XY, Venketasubramanian N, Yeo LLL, Ho AFW, Ong MEH. Prehospital stroke care in Singapore. Singapore Med J 2024:00077293-990000000-00102. [PMID: 38449072 DOI: 10.4103/singaporemedj.smj-2023-066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/03/2023] [Indexed: 03/08/2024]
Abstract
ABSTRACT Due to the narrow window of opportunity for stroke therapeutics to be employed, effectiveness of stroke care systems is predicated on the efficiency of prehospital stroke systems. A robust prehospital stroke system of care that provides a rapid and well-coordinated response maximises favourable poststroke outcomes, but achieving this presents a unique set of challenges dependent on demographic and geographical circumstances. Set in the context of a highly urbanised first-world nation with a rising burden of stroke, Singapore's prehospital stroke system has evolved to reflect the environment in which it operates. This review aims to characterise the current state of prehospital stroke care in Singapore, covering prehospital aspects of the stroke survival chain from symptom onset till arrival at the emergency department. We identify areas for improvement and innovation, as well as provide insights into the possible future of prehospital stroke care in Singapore.
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Affiliation(s)
| | - Zhenghong Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Yih Ying Ng
- Department of Preventive and Population Medicine, Tan Tock Seng Hospital, Singapore
- Ministry of Home Affairs, Singapore Civil Defence Force, Singapore
| | - Colin Kaihui Tan
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | - Xiang Yi Wong
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | | | | | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
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12
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Italiano D, Johns H, Campbell B, Turc G, Churilov L. Reporting and analysis of process-of-care time measures in clinical trials for hyperacute stroke interventions: a scoping review protocol. JBI Evid Synth 2024; 22:489-497. [PMID: 38099923 DOI: 10.11124/jbies-23-00136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVE The objective of this scoping review is to investigate the reporting and comparison of process-of-care time measures in hyperacute stroke trials and systematic reviews of trials (subsequently referred to as "studies"). INTRODUCTION Stroke is a leading cause of death and disability worldwide. A crucial factor in determining the effectiveness of stroke care in improving patient outcomes is time; therefore, time measures are frequently reported in studies of hyperacute stroke interventions. However, there is inconsistency in how these measures are reported and compared. Furthermore, there is a lack of clarity in how compatible the reporting methods are with the statistical analysis methods. INCLUSION CRITERIA This scoping review will include studies that report and/or compare time measures between key events of interest in the delivery of hyperacute stroke care. Studies of thrombolytic therapy and/or thrombectomy, as well as controlled trials of mobile stroke unit interventions, will be included. METHODS The scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and the JBI methodology for scoping reviews. The search will be executed in MEDLINE (PubMed), Embase (Ovid), and clinical trial registries ANZCTR, ISRCTN, and ClinicalTrials.gov. Title and abstract screening will be followed by full-text screening and subsequent data extraction from eligible studies. The results from this scoping review will be presented in tables and narratively summarized. REVIEW REGISTRATION Open Science Framework https://osf.io/y98wz.
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Affiliation(s)
- Dominic Italiano
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Australian Stroke Alliance, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Hannah Johns
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Australian Stroke Alliance, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Bruce Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Paris, France
- Inserm, Paris, France
- FHU NeuroVasc, Paris, France
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Australian Stroke Alliance, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
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13
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Rink JS, Tollens F, Tschalzev A, Bartelt C, Heinzl A, Hoffmann J, Schoenberg SO, Marzina A, Sandikci V, Wiegand C, Hoyer C, Szabo K. Establishing an MSU service in a medium-sized German urban area-clinical and economic considerations. Front Neurol 2024; 15:1358145. [PMID: 38487327 PMCID: PMC10938346 DOI: 10.3389/fneur.2024.1358145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
Background and purpose Mobile stroke units (MSU) have been demonstrated to improve prehospital stroke care in metropolitan and rural regions. Due to geographical, social and structural idiosyncrasies of the German city of Mannheim, concepts of established MSU services are not directly applicable to the Mannheim initiative. The aim of the present analysis was to identify major determinants that need to be considered when initially setting up a local MSU service. Methods Local stroke statistics from 2015 to 2021 were analyzed and circadian distribution of strokes and local incidence rates were calculated. MSU patient numbers and total program costs were estimated for varying operating modes, daytime coverage models, staffing configurations which included several resource sharing models with the hospital. Additional case-number simulations for expanded catchment areas were performed. Results Median time of symptom onset of ischemic stroke patients was 1:00 p.m. 54.3% of all stroke patients were admitted during a 10-h time window on weekdays. Assuming that MSU is able to reach 53% of stroke patients, the average expected number of ischemic stroke patients admitted to MSU would be 0.64 in a 10-h shift each day, which could potentially be increased by expanding the MSU catchment area. Total estimated MSU costs amounted to € 815,087 per annum. Teleneurological assessment reduced overall costs by 11.7%. Conclusion This analysis provides a framework of determinants and considerations to be addressed during the design process of a novel MSU program in order to balance stroke care improvements with the sustainable use of scarce resources.
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Affiliation(s)
- Johann S. Rink
- Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Fabian Tollens
- Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Andrej Tschalzev
- Institute for Enterprise Systems, University of Mannheim, Mannheim, Germany
| | - Christian Bartelt
- Institute for Enterprise Systems, University of Mannheim, Mannheim, Germany
| | | | - Jens Hoffmann
- Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Stefan O. Schoenberg
- Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Annika Marzina
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Vesile Sandikci
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Carla Wiegand
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Carolin Hoyer
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
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14
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Kaffes M, Bondi F, Geisler F, Grittner U, Haacke L, Ihl T, Lorenz M, Schehadat MS, Schwabauer E, Wendt M, Zuber M, Kübler-Weller D, Lorenz-Meyer I, Sanchez JC, Montaner J, Audebert HJ, Weber JE. Optimization of sensitivity and specificity of a biomarker-based blood test (LVOCheck-Opti): A protocol for a multicenter prospective observational study of patients suspected of having a stroke. Front Neurol 2024; 14:1327348. [PMID: 38371304 PMCID: PMC10870936 DOI: 10.3389/fneur.2023.1327348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Introduction Acute ischemic stroke (AIS) is a time-critical medical emergency. For patients with large-vessel occlusions (LVO), mechanical thrombectomy (MT) is the gold-standard treatment. Mobile Stroke Units (MSUs) provide on-site diagnostic capabilities via computed tomography (CT) and have been shown to improve functional outcomes in stroke patients, but are cost-efficient only in urban areas. Blood biomarkers have recently emerged as possible alternative to cerebral imaging for LVO diagnosis. Prehospital LVO diagnosis offers the potential to transport patients directly to centers that have MT treatment available. In this study, we assess the accuracy of combining two biomarkers, HFABP and NT-proBNP, with clinical indicators to detect LVO using ultra-early prehospital blood samples. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00030399). Methods and analysis We plan a multicenter prospective observational study with 800 patients with suspected stroke enrolled within 24 h of symptom onset. Study participants will be recruited at three sites (MSUs) in Berlin, Germany. Blood-samples will be taken pre-hospitally at the scene and tested for HFABP and NT-proBNP levels. Additional clinical data and information on final diagnosis will be collected and documented in an electronic case report form (eCRF). Sensitivity and specificity of the combination will be calculated through iterative permutation-response calculations. Discussion This study aims to evaluate the diagnostic capabilities of a combination of the biomarkers HFABP and NT-proBNP in LVO prediction. In contrast to most other biomarker studies to date, by employing MSUs as study centers, ultra-early levels of biomarkers can be analyzed. Point-of-care LVO detection in suspected stroke could lead to faster treatment in both urban and rural settings and thus improve functional outcomes on a broader scale. Clinical trial registration Deutsches Register klinischer Studien https://drks.de/search/de/trial/DRKS00030399, DRKS00030399.
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Affiliation(s)
- Maximilian Kaffes
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fulvio Bondi
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Frederik Geisler
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lisa Haacke
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Ihl
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maren Lorenz
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marc S. Schehadat
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eugen Schwabauer
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Martina Zuber
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dorothee Kübler-Weller
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jean-Charles Sanchez
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joan Montaner
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
- Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Heinrich J. Audebert
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joachim E. Weber
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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15
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Xia Y, Li L, Li Y, Hu M, Zhang T, Feng Q, Li W, Zhu Y, Wu M. Association of fasting blood glucose level with 90-day unfavorable outcome in acute ischemic stroke patients. Clin Neurol Neurosurg 2024; 236:108049. [PMID: 37989034 DOI: 10.1016/j.clineuro.2023.108049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVES Fasting blood glucose (FBG) is a risk factor for Acute Ischemic Stroke (AIS). We aimed to systematically assess the association of FBG level and 90-day unfavorable outcome in AIS patients. METHODS FBG levels and related information of the patients were collected at admission. The unfavorable outcome was defined as 90-day mRS 3-6. FBG levels were analyzed as continuous variables and tertiles (Q1-Q3). Odds ratios and 95% confidence intervals were calculated by using multivariate logistic regression analysis. RESULTS Overall, 677 AIS patients were included. FBG were significantly associated with unfavorable outcome at 90 days (adjusted OR 1.15 [95%Cl, 1.05-1.25], P = 0.002). Participants were categorized based on the FBG tertile cut-off points, the Odds ratios was 2.55-fold higher in Q3 than those in Q1 after adjusting (OR 2.55[95%Cl, 1.23-5.3], p = 0.012). Threshold effect analysis showed when FBG ≥ 5.5 mmol/L, the correlation between FBG and 90-day unfavorable outcome increased significantly. Subgroup analysis showed that there was no significant interaction between FBG and 90-day unfavorable outcome. Non-diabetic AIS patients with hyperglycemia (FBG ≥ 7 mmol/L) have a worse prognosis in comparison to those with normal glucose (FBG ˂ 5.6 mmol/L) (OR 8.59 [ 95%Cl, 2.24-32.97], p = 0.002). CONCLUSION FBG is an independent predictor of 90-day unfavorable outcome after stroke in AIS patients. When FBG ≥ 5.5 mmol/L, the risk of 90-day unfavorable outcome increases significantly.
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Affiliation(s)
- Yangjingyi Xia
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Li Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Yunze Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Manyan Hu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Tianrui Zhang
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Qinghua Feng
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Wenlei Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Yuan Zhu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Minghua Wu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China.
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16
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Capirossi C, Laiso A, Renieri L, Capasso F, Limbucci N. Epidemiology, organization, diagnosis and treatment of acute ischemic stroke. Eur J Radiol Open 2023; 11:100527. [PMID: 37860148 PMCID: PMC10582298 DOI: 10.1016/j.ejro.2023.100527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/21/2023] Open
Abstract
The management of acute ischemic stroke is changing. Over the period of 2010-2050, the number of incident strokes is expected to be more than double. Rapid access to mechanical thrombectomy for patients with large vessel occlusion is critically associated with their functional outcome. Moreover, patients with first pass effect had a better clinical outcome, lower mortality, and fewer procedural adverse events. We discuss some advances in acute ischemic stroke regarding the organization, the diagnosis and the treatment.
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Affiliation(s)
- Carolina Capirossi
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Antonio Laiso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Francesco Capasso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
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17
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Samaniego EA, Boltze J, Lyden PD, Hill MD, Campbell BCV, Silva GS, Sheth KN, Fisher M, Hillis AE, Nguyen TN, Carone D, Favilla CG, Deljkich E, Albers GW, Heit JJ, Lansberg MG. Priorities for Advancements in Neuroimaging in the Diagnostic Workup of Acute Stroke. Stroke 2023; 54:3190-3201. [PMID: 37942645 PMCID: PMC10841844 DOI: 10.1161/strokeaha.123.044985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/03/2023] [Indexed: 11/10/2023]
Abstract
STAIR XII (12th Stroke Treatment Academy Industry Roundtable) included a workshop to discuss the priorities for advancements in neuroimaging in the diagnostic workup of acute ischemic stroke. The workshop brought together representatives from academia, industry, and government. The participants identified 10 critical areas of priority for the advancement of acute stroke imaging. These include enhancing imaging capabilities at primary and comprehensive stroke centers, refining the analysis and characterization of clots, establishing imaging criteria that can predict the response to reperfusion, optimizing the Thrombolysis in Cerebral Infarction scale, predicting first-pass reperfusion outcomes, improving imaging techniques post-reperfusion therapy, detecting early ischemia on noncontrast computed tomography, enhancing cone beam computed tomography, advancing mobile stroke units, and leveraging high-resolution vessel wall imaging to gain deeper insights into pathology. Imaging in acute ischemic stroke treatment has advanced significantly, but important challenges remain that need to be addressed. A combined effort from academic investigators, industry, and regulators is needed to improve imaging technologies and, ultimately, patient outcomes.
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Affiliation(s)
- Edgar A. Samaniego
- Department of Neurology, Radiology and Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Johannes Boltze
- School of Life Sciences, The University of Warwick, Coventry, United Kingdom
| | - Patrick D. Lyden
- Zilkha Neurogenetic Institute of the Keck School of Medicine at USC, Los Angeles, California, United States
| | - Michael D. Hill
- Department of Clinical Neuroscience & Hotchkiss Brain Institute, University of Calgary & Foothills Medical Centre, Calgary, Canada
| | - Bruce CV Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, United States
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Argye E. Hillis
- Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United Stated
| | - Thanh N. Nguyen
- Department of Neurology, Boston Medical Center, Massachusetts, United States
| | - Davide Carone
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Christopher G. Favilla
- Department of Neurology, University of Pennsylvania Philadelphia, Pennsylvania, Unites States
| | | | - Gregory W. Albers
- Department of Neurology, Stanford University, Stanford, California, United States
| | - Jeremy J. Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, California, United States
| | - Maarten G Lansberg
- Department of Neurology, Stanford University, Stanford, California, United States
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18
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Wechsler LR, Adeoye O, Alemseged F, Bahr-Hosseini M, Deljkich E, Favilla C, Fisher M, Grotta J, Hill MD, Kamel H, Khatri P, Lyden P, Mirza M, Nguyen TN, Samaniego E, Schwamm L, Selim M, Silva G, Yavagal DR, Yenari MA, Zachrison KS, Boltze J, Yaghi S. Most Promising Approaches to Improve Stroke Outcomes: The Stroke Treatment Academic Industry Roundtable XII Workshop. Stroke 2023; 54:3202-3213. [PMID: 37886850 DOI: 10.1161/strokeaha.123.044279] [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: 06/20/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023]
Abstract
The Stroke Treatment Academic Industry Roundtable XII included a workshop to discuss the most promising approaches to improve outcome from acute stroke. The workshop brought together representatives from academia, industry, and government representatives. The discussion examined approaches in 4 epochs: pre-reperfusion, reperfusion, post-reperfusion, and access to acute stroke interventions. The participants identified areas of priority for developing new and existing treatments and approaches to improve stroke outcomes. Although many advances in acute stroke therapy have been achieved, more work is necessary for reperfusion therapies to benefit the most possible patients. Prioritization of promising approaches should help guide the use of resources and investigator efforts.
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Affiliation(s)
- Lawrence R Wechsler
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, PA (L.R.W.)
| | - Opeolu Adeoye
- Washington University School of Medicine, St. Louis, MO (O.A.)
| | | | | | | | | | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | | | | | - Hooman Kamel
- Weill Cornel School of Medicine, New York, NY (H.K.)
| | - Pooja Khatri
- University of Cincinnati Medical Center, OH (P.K.)
| | - Patrick Lyden
- University of Southern California, Los Angeles, CA (P.L.)
| | | | | | | | - Lee Schwamm
- Massachusetts General Hospital, Boston (L.S.)
| | - Magdy Selim
- Beth Israel Deaconess Medical Center, Boston, MA (M.S.)
| | | | | | | | | | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, United Kingdom (J.B.)
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19
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Pirlog BO, Jacob AP, Rajan SS, Yamal JM, Parker SA, Wang M, Bowry R, Czap A, Bratina PL, Gonzalez MO, Singh N, Zou J, Gonzales NR, Jones WJ, Alexandrov AW, Alexandrov AV, Navi BB, Nour M, Spokoyny I, Mackey J, Silnes K, Fink ME, Pisarro Sherman C, Willey J, Saver JL, English J, Barazangi N, Ornelas D, Volpi J, Pv Rao C, Griffin L, Persse D, Grotta JC. Outcomes of patients with pre-existing disability managed by mobile stroke units: A sub-analysis of the BEST-MSU study. Int J Stroke 2023; 18:1209-1218. [PMID: 37337357 DOI: 10.1177/17474930231185471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Few data exist on acute stroke treatment in patients with pre-existing disability (PD) since they are usually excluded from clinical trials. A recent trial of mobile stroke units (MSUs) demonstrated faster treatment and improved outcomes, and included PD patients. AIM To determine outcomes with tissue plasminogen activator (tPA), and benefit of MSU versus management by emergency medical services (EMS), for PD patients. METHODS Primary outcomes were utility-weighted modified Rankin Scale (uw-mRS). Linear and logistic regression models compared outcomes in patients with versus without PD, and PD patients treated by MSU versus standard management by EMS. Time metrics, safety, quality of life, and health-care utilization were compared. RESULTS Of the 1047 tPA-eligible ischemic stroke patients, 254 were with PD (baseline mRS 2-5) and 793 were without PD (baseline mRS 0-1). Although PD patients had worse 90-day uw-mRS, higher mortality, more health-care utilization, and worse quality of life than non-disabled patients, 53% returned to at least their baseline mRS, those treated faster had better outcome, and there was no increased bleeding risk. Comparing PD patients treated by MSU versus EMS, 90-day uw-mRS was 0.42 versus 0.36 (p = 0.07) and 57% versus 46% returned to at least their baseline mRS. There was no interaction between disability status and MSU versus EMS group assignment (p = 0.67) for 90-day uw-mRS. CONCLUSION PD did not prevent the benefit of faster treatment with tPA in the BEST-MSU study. Our data support inclusion of PD patients in the MSU management paradigm.
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Affiliation(s)
- Bianca O Pirlog
- Department of Neuroscience, County Emergency Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Asha P Jacob
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Suja S Rajan
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Stephanie A Parker
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mengxi Wang
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ritvij Bowry
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alexandra Czap
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Patti L Bratina
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Michael O Gonzalez
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Noopur Singh
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jinhao Zou
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicole R Gonzales
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William J Jones
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anne W Alexandrov
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Babak B Navi
- Feil Family and Brain Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - May Nour
- Department of Neurology, Ronald Reagan University of California, Los Angeles Medical Center, Los Angeles, CA, USA
| | - Ilana Spokoyny
- Department of Neurology, Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kelly Silnes
- University of Buckingham Medical School, Buckingham, UK
| | - Matthew E Fink
- Feil Family and Brain Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Carla Pisarro Sherman
- Feil Family and Brain Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Josh Willey
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan University of California, Los Angeles Medical Center, Los Angeles, CA, USA
| | - Joey English
- Department of Neurology, Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - Nobl Barazangi
- Department of Neurology, Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - David Ornelas
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jay Volpi
- Department of Neurology, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Chethan Pv Rao
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | | | - David Persse
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - James C Grotta
- Mobile Stroke Unit, Memorial Hermann Texas Medical Center, Houston, TX, USA
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Ospel JM, Dmytriw AA, Regenhardt RW, Patel AB, Hirsch JA, Kurz M, Goyal M, Ganesh A. Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment. J Neurointerv Surg 2023; 15:1065-1071. [PMID: 36241225 DOI: 10.1136/jnis-2021-018547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
Abstract
Triage describes the assignment of resources based on where they can be best used, are most needed, or are most likely to achieve success. Triage is of particular importance in time-critical conditions such as acute ischemic stroke. In this setting, one of the goals of triage is to minimize the delay to endovascular thrombectomy (EVT), without delaying intravenous thrombolysis or other time-critical treatments including patients who cannot benefit from EVT. EVT triage is highly context-specific, and depends on availability of financial resources, staff resources, local infrastructure, and geography. Furthermore, the EVT triage landscape is constantly changing, as EVT indications evolve and new neuroimaging methods, EVT technologies, and adjunctive medical treatments are developed and refined. This review provides an overview of recent developments in EVT triage at both the pre-hospital and in-hospital stages. We discuss pre-hospital large vessel occlusion detection tools, transport paradigms, in-hospital workflows, acute stroke neuroimaging protocols, and angiography suite workflows. The most important factor in EVT triage, however, is teamwork. Irrespective of any new technology, EVT triage will only reach optimal performance if all team members, including paramedics, nurses, technologists, emergency physicians, neurologists, radiologists, neurosurgeons, and anesthesiologists, are involved and engaged. Thus, building sustainable relationships through continuous efforts and hands-on training forms an integral part in ensuring rapid and efficient EVT triage.
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Affiliation(s)
- Johanna M Ospel
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martin Kurz
- Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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21
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Zheng B, Li Y, Gu G, Yang J, Jiang J, Chen Z, Fan Y, Wang S, Pei H, Wang J. Comparing 5G mobile stroke unit and emergency medical service in patients acute ischemic stroke eligible for t-PA treatment: A prospective, single-center clinical trial in Ya'an, China. Brain Behav 2023; 13:e3231. [PMID: 37632149 PMCID: PMC10636411 DOI: 10.1002/brb3.3231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/12/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND This study aims to assess and compare the functional outcomes of patients with acute ischemic stroke (AIS) eligible for tissue plasminogen activator (t-PA) treatment who received care from either a fifth-generation(5G) mobile stroke unit (MSU) or traditional emergency medical service (EMS). METHOD The study recruited patients between February 2020 and January 2022, with the final 90-day follow-up concluded in April 2022. Prior to enrollment, patients were assigned to either EMS or MSU care based on predetermined rules. The primary outcome measure was the Modified Rankin Scale (mRS) score at 90 days, with secondary outcome measures including time metrics, mRS and National Institutes of Health Stroke Scale scores at 7-day follow-up, and hospitalization costs. RESULTS Of the 2281 enrolled patients, 207 were eligible for t-PA treatment, with 101 allocated to MSU care and 106 to EMS care. The percentage of patients achieving a favorable mRS score (0-2) at 90 days was 82.2% in the MSU group compared to 72.6% in the EMS group (p < .05). Median times from symptom onset to thrombolysis were 146 min in the MSU group and 204 min in the EMS group, while median times from ambulance alert to computed tomography (CT) completion were 53 and 128 min, respectively. Hospitalization charges averaged approximately $3592 in the MSU group and $4800 in the EMS group. CONCLUSIONS Our findings indicate that 5G MSU care significantly reduces the time from symptom onset to stroke diagnosis and intravenous thrombolysis in patients with AIS, resulting in improved functional outcomes compared to EMS care. As China continues its deployment of 5G technology and other digital infrastructures, the adoption of 5G MSU care on a broader scale may eventually supplant traditional stroke treatment approaches.
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Affiliation(s)
- Bo Zheng
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Yan Li
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Gangfeng Gu
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Jian Yang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Junyao Jiang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Zhao Chen
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Yang Fan
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Sheng Wang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Han Pei
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Jian Wang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
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22
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Donoso-Calero MI, Sanz-García A, Polonio-López B, Maestre Miquel C, Durantez Fernández C, Mordillo-Mateos L, Mohedano-Moriano A, Conty-Serrano R, Otero-Agra M, Jorge-Soto C, Martín-Conty JL, Martín-Rodríguez F. Clinical outcome prediction of acute neurological patients admitted to the emergency department: Sequential Organ Failure Assessment score and modified SOFA score. Front Public Health 2023; 11:1264159. [PMID: 37965516 PMCID: PMC10642972 DOI: 10.3389/fpubh.2023.1264159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/16/2023] [Indexed: 11/16/2023] Open
Abstract
Background The aim of this study was to determine the ability of the Sequential Organ Failure Assessment score (SOFA) and modified SOFA score (mSOFA) as predictive tools for 2-day and 28-day mortality and ICU admission in patients with acute neurological pathology treated in hospital emergency departments (EDs). Methods An observational, prospective cohort study in adults with acute neurological disease transferred by ambulance to an ED was conducted from 1 January 2019 to 31 August 2022 in five hospitals in Castilla-León (Spain). Score discrimination was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve of the score. Results A total of 640 adult patients with neurological disease were included. For the prediction of 2-day mortality (all-cause), mSOFA presented a higher AUC than SOFA (mSOFA = 0.925 vs. SOFA = 0.902). This was not the case for 28-day mortality, for which SOFA was higher than mSOFA (mSOFA = 0.852 vs. SOFA = 0.875). Finally, ICU admission showed that SOFA was higher than mSOFA (mSOFA = 0.834 vs. SOFA = 0.845). Conclusion Both mSOFA and SOFA presented similar predictive ability, with mSOFA being the best predictor for short-term mortality and SOFA being the best predictor for medium-term mortality, as well as for ICU admission. These results in a cohort of patients with acute neurological pathology pave the way for the use of both predictive tools in the ED. The inclusion of these tools could improve the clinical assessment and further treatment of neurological patients, who commonly present the worst outcomes.
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Affiliation(s)
- María I. Donoso-Calero
- Faculty of Health Sciences, Universidad de Castilla-la Mancha, Talavera de la Reina, Spain
| | - Ancor Sanz-García
- Faculty of Health Sciences, Universidad de Castilla-la Mancha, Talavera de la Reina, Spain
- Technological Innovation Applied to Health Research Group (ITAS), Faculty of Health Sciences, University of Castilla-La Mancha, Talavera de la Reina, Spain
| | - Begoña Polonio-López
- Faculty of Health Sciences, Universidad de Castilla-la Mancha, Talavera de la Reina, Spain
- Technological Innovation Applied to Health Research Group (ITAS), Faculty of Health Sciences, University of Castilla-La Mancha, Talavera de la Reina, Spain
| | - Clara Maestre Miquel
- Faculty of Health Sciences, Universidad de Castilla-la Mancha, Talavera de la Reina, Spain
| | | | - Laura Mordillo-Mateos
- Faculty of Health Sciences, Universidad de Castilla-la Mancha, Talavera de la Reina, Spain
- Technological Innovation Applied to Health Research Group (ITAS), Faculty of Health Sciences, University of Castilla-La Mancha, Talavera de la Reina, Spain
| | - Alicia Mohedano-Moriano
- Faculty of Health Sciences, Universidad de Castilla-la Mancha, Talavera de la Reina, Spain
- Technological Innovation Applied to Health Research Group (ITAS), Faculty of Health Sciences, University of Castilla-La Mancha, Talavera de la Reina, Spain
| | | | - Martin Otero-Agra
- School of Nursing from Pontevedra, Universidade de Vigo, Pontevedra, Spain
| | - Cristina Jorge-Soto
- Faculty of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José L. Martín-Conty
- Faculty of Health Sciences, Universidad de Castilla-la Mancha, Talavera de la Reina, Spain
- Technological Innovation Applied to Health Research Group (ITAS), Faculty of Health Sciences, University of Castilla-La Mancha, Talavera de la Reina, Spain
| | - Francisco Martín-Rodríguez
- Prehospital Early Warning Scoring-System Investigation Group, Valladolid, Spain
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
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23
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English SW, Chhabra N, Hanus AE, Basharath R, Miller M, Butterfield RJ, Zhang N, Demaerschalk BM. Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network. J Telemed Telecare 2023:1357633X231204066. [PMID: 37899587 DOI: 10.1177/1357633x231204066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Prehospital telestroke evaluations may improve stroke triage compared to paramedic-applied large vessel occlusion scales, but ambulance-based video National Institutes of Health Stroke Scale assessments are challenging. The accuracy of telestroke-administered large vessel occlusion scales has not been investigated, so we sought to evaluate this further. METHODS This retrospective study included all in-hospital telestroke encounters in a large academic telestroke network from 2019 to 2020. We retrospectively calculated seven large vessel occlusion scales using the in-hospital telestroke National Institutes of Health Stroke Scale (Rapid Arterial oCclusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Prehospital Acute Stroke Severity, Vision-Aphasia-Neglect, and Gaze-Face-Arm-Speech-Time). Diagnostic performance was assessed via sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy using established scale thresholds. These results were compared to the National Institutes of Health Stroke Scale at thresholds of 6, 8, and 10. The area under curve was calculated using c-statistics by treating scales as continuous variables. RESULTS A total of 625 patients were included; 111 (17.8%) patients had an anterior large vessel occlusion, 118 (18.9%) patients had any large vessel occlusion, and 182 (29.1%) patients had stroke mimic diagnosis. The mean age (SD) was 67.9 (15.9), 48.3% were female, and 93.4% were white. The Mean National Institutes of Health Stroke Scale (SD) was 14.9 (8.4) for patients with anterior large vessel occlusion, 4.7 (5.0) for patients with non-large vessel occlusion ischemic stroke, and 4.4 (5.8) for stroke mimic (p < 0.001). Compared to the National Institutes of Health Stroke Scale, Field Assessment Stroke Triage for Emergency Destination, and Rapid Arterial oCclusion Evaluation scales demonstrated higher accuracy and area under curve for large vessel occlusion detection. DISCUSSION Both the Field Assessment Stroke Triage for Emergency Destination and Rapid Arterial oCclusion Evaluation scales outperformed the National Institutes of Health Stroke Scale for large vessel occlusion detection in patients evaluated by in-hospital telestroke. These scales may be valid alternatives to the National Institutes of Health Stroke Scale examination in this setting.
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Affiliation(s)
- Stephen W English
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Nikita Chhabra
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
| | - Abigail E Hanus
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Rida Basharath
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Monet Miller
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | | | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, AZ, USA
| | - Bart M Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
- Center for Digital Health, Mayo Clinic, Rochester, MI, USA
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Fladt J, Ospel JM, Singh N, Saver JL, Fisher M, Goyal M. Optimizing Patient-Centered Stroke Care and Research in the Prehospital Setting. Stroke 2023; 54:2453-2460. [PMID: 37548010 DOI: 10.1161/strokeaha.123.044169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Over the past decades, continuous technological advances and the availability of novel therapies have enabled treatment of more acute medical conditions than ever before. Many of these treatments, such as intravenous thrombolysis and mechanical thrombectomy for acute ischemic stroke, are highly time sensitive. This has raised interest in shifting advanced acute care from hospitals to the prehospital setting. Key objectives of advanced prehospital stroke care may include (1) early targeted treatments in the prehospital setting, for example, intravenous thrombolysis for acute stroke, and (2) advanced prehospital diagnostics such as prehospital large vessel occlusion and intracranial hemorrhage detection, to help inform patient triage and potentially reduce subsequent workload in emergency departments. Major challenges that may hamper a swift transition to more advanced prehospital care are related to conducting clinical trials in the prehospital setting to provide sufficient evidence for emergency interventions, as well as ambulance design, infrastructure, emergency medical service personnel training and workload, and cost barriers. Utilizing new technologies such as telemedicine, mobile stroke units and portable diagnostic devices, customized software applications, and smart storage space management may help surmount these challenges and establish efficient, targeted care strategies that are achievable in the prehospital setting. In this article, we delineate the paradigm of shifting advanced stroke care to the prehospital setting and outline future directions in providing evidence-based, patient-centered prehospital care. While we use acute stroke as an illustrative example, these principles are not limited to stroke patients and can be applied to prehospital triage for any time-critical disease.
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Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (J.F.)
| | - Johanna M Ospel
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
| | - Nishita Singh
- Department of Neurology, University of Manitoba, Winnipeg, Canada (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
| | - Mayank Goyal
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
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25
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Piccininni M, Kurth T, Audebert HJ, Rohmann JL. The Effect of Mobile Stroke Unit Care on Functional Outcomes: An Application of the Front-door Formula. Epidemiology 2023; 34:712-720. [PMID: 37462471 DOI: 10.1097/ede.0000000000001642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
BACKGROUND The Berlin-based B_PROUD study was designed to assess the effect of mobile stroke unit (MSU) dispatch among ischemic stroke and transient ischemic attack (TIA) patients without contraindications to reperfusion treatments. However, a large proportion of patients for whom the MSU was dispatched did not ultimately receive MSU care. We estimated the causal effect of additional MSU care on 3-month functional outcomes among B_PROUD patients for whom an MSU was dispatched. METHODS We used data from the B_PROUD study (1 February 2017-8 May 2019). Given the presence of exposure-outcome unmeasured confounding, we used the front-door formula to identify the distribution of modified Rankin scale (mRS) outcomes under two hypothetical interventions: (1) receiving additional MSU care and (2) only receiving conventional care. We considered the time from dispatch to thrombolysis as the full mediator and adjusted for exposure-mediator and mediator-outcome confounding. We used a parametric estimator to estimate the common odds ratio (cOR) and 95% bootstrapped confidence intervals (CI). RESULTS We included in total 768 ischemic stroke/TIA patients with MSU dispatch. The MSU was canceled for 180 (23%) patients, whereas 588 (77%) received MSU care. The unadjusted association between the care group and mRS favored conventional care (cOR = 1.7; 95% CI = 1.2, 2.3); however, after applying the front-door formula, the mRS distribution favored MSU care (cOR = 0.88; 95% CI = 0.81, 0.96). CONCLUSIONS Receiving MSU care was associated with better functional outcomes than conventional care only, compatible with the hypothesized beneficial effect of MSU care on poststroke outcomes, among stroke and TIA patients without contraindications to reperfusion treatments.
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Affiliation(s)
- Marco Piccininni
- From the Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Kurth
- From the Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica L Rohmann
- From the Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
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26
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Reuken PA, Besteher B, Finke K, Fischer A, Holl A, Katzer K, Lehmann-Pohl K, Lemhöfer C, Nowka M, Puta C, Walter M, Weißenborn C, Stallmach A. Longterm course of neuropsychological symptoms and ME/CFS after SARS-CoV-2-infection: a prospective registry study. Eur Arch Psychiatry Clin Neurosci 2023:10.1007/s00406-023-01661-3. [PMID: 37587244 DOI: 10.1007/s00406-023-01661-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/31/2023] [Indexed: 08/18/2023]
Abstract
A significant proportion of patients after SARS-CoV-2 infection suffer from long-lasting symptoms. Although many different symptoms are described, the majority of patients complains about neuropsychological symptoms. Additionally, a subgroup of patients fulfills diagnostic criteria for ME/CFS. We analyzed a registry of all patients presenting in the out-patients clinic at a German university center. For patients with more than one visit, changes in reported symptoms from first to second visit were analyzed. A total of 1022 patients were included in the study, 411 of them had more than one visit. 95.5% of the patients reported a polysymptomatic disease. At the first visit 31.3% of the patients fulfilled ME/CFS criteria after a median time of 255 days post infection and and at the second visit after a median of 402 days, 19.4% still suffered from ME/CFS. Self-reported fatigue (83.7-72.7%) and concentration impairment (66.2-57.9%) decreased from first to second visit contrasting non-significant changes in the structured screening. A significant proportion of SARS-CoV-2 survivors presenting with ongoing symptoms present with ME/CFS. Although the proportion of subjective reported symptoms and their severity reduce over time, a significant proportion of patients suffer from long-lasting symptoms necessitating new therapeutic concepts.
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Affiliation(s)
- P A Reuken
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital/Friedrich-Schiller-University Jena, Am Klinikum 1, 07743, Jena, Germany.
| | - B Besteher
- Department of Psychiatry and Psychotherapy, Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany
| | - K Finke
- Department of Neurology, Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany
| | - A Fischer
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital/Friedrich-Schiller-University Jena, Am Klinikum 1, 07743, Jena, Germany
| | - A Holl
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital/Friedrich-Schiller-University Jena, Am Klinikum 1, 07743, Jena, Germany
| | - K Katzer
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital/Friedrich-Schiller-University Jena, Am Klinikum 1, 07743, Jena, Germany
| | - K Lehmann-Pohl
- Center for Sepsis Control and Care (CSCC), Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany
| | - C Lemhöfer
- Institute of Physical and Rehabilitation Medicine, Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany
| | - M Nowka
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital/Friedrich-Schiller-University Jena, Am Klinikum 1, 07743, Jena, Germany
| | - C Puta
- Center for Sepsis Control and Care (CSCC), Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany
- Department of Sports Medicine and Health Promotion, Friedrich-Schiller-University Jena, Jena, Germany
- Center for Interdisciplinary Prevention of Diseases Related to Professional Activities, Jena, Germany
| | - M Walter
- Department of Psychiatry and Psychotherapy, Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany
| | - C Weißenborn
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital/Friedrich-Schiller-University Jena, Am Klinikum 1, 07743, Jena, Germany
| | - A Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital/Friedrich-Schiller-University Jena, Am Klinikum 1, 07743, Jena, Germany
- Center for Sepsis Control and Care (CSCC), Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany
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Geisler F, Haacke L, Lorenz M, Schwabauer E, Wendt M, Bernhardt L, Dashti E, Freitag E, Kunz A, Hofmann-Shen C, Zuber M, Waldschmidt C, Kandil FI, Kappert K, Dang-Heine C, Lorenz-Meyer I, Audebert HJ, Weber JE. Prospective collection of blood plasma samples to identify potential biomarkers for the prehospital stroke diagnosis (ProGrEss-Bio): study protocol for a multicenter prospective observational study. Front Neurol 2023; 14:1201130. [PMID: 37483444 PMCID: PMC10359480 DOI: 10.3389/fneur.2023.1201130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/09/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are well-established, evidence-based, time-critical therapies that reduce morbidity and mortality in acute ischemic stroke (AIS) patients. The exclusion of intracerebral hemorrhage (ICH) is mandatory and has been performed by cerebral imaging to date. Mobile stroke units (MSUs) have been shown to improve functional outcomes by bringing cerebral imaging and IVT directly to the patient, but they have limited coverage. Blood biomarkers clearly distinguishing between AIS, ICH, and stroke mimics (SM) could provide an alternative to cerebral imaging if concentration changes are detectable in the hyperacute phase after stroke with high diagnostic accuracy. In this study, we will take blood samples in a prehospital setting to evaluate potential biomarkers. The study was registered in the German Clinical Trials Register (https://drks.de/search/de) with the identifier DRKS00023063. Methods and analysis We plan a prospective, observational study involving 300 patients with suspected stroke and symptom onset of ≤4.5 h before the collection of biomarkers. Study participants will be recruited from three sites in Berlin, Germany during MSU deployments. The focus of the study is the collection of blood samples from participants at the prehospital scene and from participants with AIS or ICH at a second-time point. All samples will be analyzed using targeted and untargeted analytical approaches. Study-related information about participants, including medical information and discharge diagnoses from the subsequent treating hospital, will be collected and documented in an electronic case report form (eCRF). Discussion This study will evaluate whether a single blood biomarker or a combination of biomarkers can distinguish patients with AIS and ICH from patients with stroke and SM in the early phase after symptom onset in the prehospital setting. In addition, the kinetics of blood biomarkers in AIS and ICH patients will be investigated. Our goal is to evaluate new ways to reliably diagnose stroke in the prehospital setting and thus accelerate the application of evidence-based therapies to stroke patients.
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Affiliation(s)
- Frederik Geisler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lisa Haacke
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maren Lorenz
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eugen Schwabauer
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Lydia Bernhardt
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Eman Dashti
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erik Freitag
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Kunz
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christina Hofmann-Shen
- Kliniken Beelitz, Teaching Hospital of Brandenburg Medical School Theodor Fontane, Beelitz-Heilstätten, Germany
| | - Martina Zuber
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Farid I. Kandil
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kai Kappert
- Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chantip Dang-Heine
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heinrich J. Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joachim E. Weber
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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Bösel J, Hubert GJ, Jesser J, Möhlenbruch MA, Ringleb PA. Access to and application of recanalizing therapies for severe acute ischemic stroke caused by large vessel occlusion. Neurol Res Pract 2023; 5:19. [PMID: 37198694 DOI: 10.1186/s42466-023-00245-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Groundbreaking study results since 2014 have dramatically changed the therapeutic options in acute therapy for severe ischemic stroke caused by large vessel occlusion (LVO). The scientifically proven advances in stroke imaging and thrombectomy techniques have allowed to offer the optimal version or combination of best medical and interventional therapy to the selected patient, yielding favorable or even excellent clinical outcomes within time windows unheard of before. The provision of the best possible individual therapy has become a guideline-based gold standard, but remains a great challenge. With geographic, regional, cultural, economic and resource differences worldwide, optimal local solutions have to be strived for. AIM This standard operation procedure (SOP) is aimed to give a suggestion of how to give patients access to and apply modern recanalizing therapy for acute ischemic stroke caused by LVO. METHOD The SOP was developed based on current guidelines, the evidence from the most recent trials and the experience of authors who have been involved in the above-named development at different levels. RESULTS This SOP is meant to be a comprehensive, yet not too detailed template to allow for freedom in local adaption. It comprises all relevant stages in providing care to the patient with severe ischemic stroke such as suspicion and alarm, prehospital acute measures, recognition and grading, transport, emergency room workup, selective cerebral imaging, differential treatment by recanalizing therapies (intravenous thrombolysis, endovascular stroke treatmet, or combined), complications, stroke unit and neurocritical care. CONCLUSIONS The challenge of giving patients access to and applying recanalizing therapies in severe ischemic stroke may be facilitated by a systematic, SOP-based approach adapted to local settings.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Gordian J Hubert
- TEMPiS Telestroke Center, Department of Neurology, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Munich, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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30
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Fuchs A, Huber M, Riva T, Becker S, Albrecht R, Greif R, Pietsch U. Factors influencing on-scene time in a physician-staffed helicopter emergency medical service (HEMS): a retrospective observational study. Scand J Trauma Resusc Emerg Med 2023; 31:20. [PMID: 37060088 PMCID: PMC10105469 DOI: 10.1186/s13049-023-01085-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/06/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND For helicopter emergency service systems (HEMS), the prehospital time consists of response time, on-scene time and transport time. Little is known about the factors that influence on-scene time or about differences between adult and paediatric missions in a physician-staffed HEMS. METHODS We analysed the HEMS electronic database of Swiss Air-Rescue from 01-01-2011 to 31-12-2021 (N = 110,331). We included primary missions and excluded missions with National Advisory Committee for Aeronautics score (NACA) score 0 or 7, resulting in 68,333 missions for analysis. The primary endpoint 'on-scene time' was defined as first physical contact with the patient until take-off to the hospital. A multivariable linear regression model was computed to examine the association of diagnosis, type and number of interventions and monitoring, and patient's characteristics with the primary endpoint. RESULTS The prehospital time and on-scene time of the missions studied were, respectively, 50.6 [IQR: 41.0-62.0] minutes and 21.0 [IQR: 15.0-28.6] minutes. Helicopter hoist operations, resuscitation, airway management, critical interventions, remote location, night-time, and paediatric patients were associated with longer on-scene times. CONCLUSIONS Compared to adult patients, the adjusted on-scene time for paediatric patients was longer. Besides the strong impact of a helicopter hoist operation on on-scene time, the dominant factors contributing to on-scene time are the type and number of interventions and monitoring: improving individual interventions or performing them in parallel may offer great potential for reducing on-scene time. However, multiple clinical interventions and monitoring interact and are not single interventions. Compared to the impact of interventions, non-modifiable factors, such as NACA score, type of diagnosis and age, make only a minor contribution to overall on-scene time.
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
- Swiss Air-Rescue (Rega), Zurich, Switzerland.
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | | | - Roland Albrecht
- Swiss Air-Rescue (Rega), Zurich, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Robert Greif
- University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
- European Resuscitation Council (ERC) Research NET, Niel, Belgium
| | - Urs Pietsch
- Swiss Air-Rescue (Rega), Zurich, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Bagot KL, Purvis T, Hancock S, Zhao H, Coote S, Easton D, Campbell BCV, Davis SM, Donnan GA, Foster S, Langenberg F, Smith K, Stephenson M, Bernard S, McGowan S, Yan B, Mitchell P, Middleton S, Cadilhac DA. Sustaining a New Model of Acute Stroke Care: A Mixed-Method Process Evaluation of the Melbourne Mobile Stroke Unit. Int J Health Policy Manag 2023; 12:7716. [PMID: 37579413 PMCID: PMC10461847 DOI: 10.34172/ijhpm.2023.7716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/21/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Internationally, Mobile Stroke Unit (MSU) ambulances have changed pre-hospital acute stroke care delivery. MSU clinical and cost-effectiveness studies are emerging, but little is known about important factors for achieving sustainability of this innovative model of care. METHODS Mixed-methods study from the Melbourne MSU (operational since November 2017) process evaluation. Participant purposive sampling included clinical, operational and executive/management representatives from Ambulance Victoria (AV) (emergency medical service provider), the MSU clinical team, and receiving hospitals. Sustainability was defined as ongoing MSU operations, including MSU workforce and future model considerations. Theoretically-based on-line survey with Unified Theory of Acceptance and Use of Technology (UTAUT), Self Determination Theory (SDT, Intrinsic Motivation), and open-text questions targeting barriers and benefits was administered (June-September 2019). Individual/group interviews were conducted, eliciting improvement suggestions and requirements for ongoing use. Descriptive and regression analyses (quantitative data) and directed content and thematic analysis (open text and interview data) were conducted. RESULTS There were 135 surveys completed. Identifying that the MSU was beneficial to daily work (β=0.61), not experiencing pressure/tension about working on the MSU (β=0.17) and thinking they did well working within the team model (β=0.17) were significantly associated with wanting to continue working within the MSU model [R2=0.76; F(15, 60)=12.76, P<.001]. Experiences varied between those on the MSU team and those working with the MSU. Advantages were identified for patients (better, faster care) and clinicians (interdisciplinary learning). Disadvantages included challenges integrating into established systems, and establishing working relationships. Themes identified from 35 interviews were MSU team composition, MSU vehicle design and layout, personnel recruitment and rostering, communication improvements between organisations, telemedicine options, MSU operations and dispatch specificity. CONCLUSION Important factors affecting the sustainability of the MSU model of stroke care emerged. A cohesive team approach, with identifiable benefits and good communication between participating organisations is important for clinical and operational sustainability.
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Affiliation(s)
- Kathleen L. Bagot
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, VIC, Australia
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Shaun Hancock
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, VIC, Australia
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Ambulance Victoria, Melbourne, VIC, Australia
| | - Skye Coote
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Damien Easton
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Bruce CV Campbell
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Ambulance Victoria, Melbourne, VIC, Australia
- Stroke Foundation, Melbourne, VIC, Australia
| | - Stephen M. Davis
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Geoff A. Donnan
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, VIC, Australia
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | | | - Francesca Langenberg
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Ambulance Victoria, Melbourne, VIC, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Department of Paramedicine Monash University, Melbourne, Melbourne, VIC, Australia
- Discipline of Emergency Medicine, University of Western Australia, Perth, WA, Australia
| | - Michael Stephenson
- Ambulance Victoria, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Department of Paramedicine Monash University, Melbourne, Melbourne, VIC, Australia
| | - Stephen Bernard
- Ambulance Victoria, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Department of Paramedicine Monash University, Melbourne, Melbourne, VIC, Australia
| | | | - Bernard Yan
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Peter Mitchell
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Sandy Middleton
- St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
- Nursing Research Institute, Australian Catholic University, Melbourne, VIC, Australia
| | - Dominique A. Cadilhac
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, VIC, Australia
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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Bagot KL, Purvis T, Hancock S, Zhao H, Coote S, Easton D, Campbell BCV, Davis SM, Donnan GA, Foster S, Langenberg F, Smith K, Stephenson M, Bernard S, McGowan S, Yan B, Mitchell P, Middleton S, Cadilhac DA. Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: A qualitative process evaluation. J Eval Clin Pract 2023; 29:495-512. [PMID: 36648226 DOI: 10.1111/jep.13803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023]
Abstract
RATIONALE Mobile stroke units (MSUs) are increasingly being implemented to provide acute stroke care in the prehospital environment, but a comprehensive implementation evaluation has not been undertaken. AIM To identify successes and challenges in the pre- and initial operations of the first Australian MSU service from an interdisciplinary perspective. METHODS Process evaluation of the Melbourne MSU with a mixed-methods design. Purposive sampling targeted key stakeholder groups. Online surveys (administered June-September 2019) and semistructured interviews (October-November 2019) explored experiences. Directed content analysis (raters' agreement 85%) and thematic analysis results are presented using the Interactive Sociotechnical Analysis framework. RESULTS Participants representing executive/program operations, MSU clinicians and hospital-based clinicians completed 135 surveys and 38 interviews. Results converged, with major themes addressing successes and challenges: stakeholders, vehicle, knowledge, training/education, communication, work processes and working relationships. CONCLUSIONS Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments.
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Affiliation(s)
- Kathleen L Bagot
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Shaun Hancock
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Skye Coote
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Damien Easton
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia.,Stroke Foundation, Melbourne, Victoria, Australia
| | - Steve M Davis
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff A Donnan
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Shane Foster
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Francesca Langenberg
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.,Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Michael Stephenson
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | | | - Bernard Yan
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Mitchell
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Sandy Middleton
- St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Nursing Research Institute, Australian Catholic University, Melbourne, Victoria, Australia
| | - Dominique A Cadilhac
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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Rajendram P, Ikram A, Fisher M. Combined Therapeutics: Future Opportunities for Co-therapy with Thrombectomy. Neurotherapeutics 2023; 20:693-704. [PMID: 36943636 PMCID: PMC10275848 DOI: 10.1007/s13311-023-01369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/23/2023] Open
Abstract
Stroke is an urgent public health issue with millions of patients worldwide living with its devastating effects. The advent of thrombolysis and endovascular thrombectomy has transformed the hyperacute care of these patients. However, a significant proportion of patients receiving these therapies still goes on to have unfavorable outcomes and many more remain ineligible for these therapies based on our current guidelines. The future of stroke care will depend on an expansion of the scope of thrombolysis and endovascular thrombectomy to patients outside traditional time windows, more distal occlusions, and large vessel occlusions with mild clinical deficits, for whom clinical trial results have not proven therapeutic efficacy. Novel cytoprotective therapies targeting the ischemic cascade and reperfusion injury therapy, in combination with our existing treatment modalities, should be explored to further improve outcomes for these patients with acute ischemic stroke. In this review, we will review the current status of thrombolysis and thrombectomy, suggest additional data that is needed to enhance these therapies, and discuss how cytoprotection might be combined with thrombectomy.
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Affiliation(s)
- Phavalan Rajendram
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA.
| | - Asad Ikram
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA
| | - Marc Fisher
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA
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Pajor MJ, Adeoye OM. Evolving Stroke Systems of Care: Stroke Diagnosis and Treatment in the Post-Thrombectomy Era. Neurotherapeutics 2023; 20:655-663. [PMID: 36977818 PMCID: PMC10047478 DOI: 10.1007/s13311-023-01371-7] [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] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Thrombectomy became the gold-standard treatment of acute ischemic stroke caused by large-vessel occlusions (LVO) in 2015 after five clinical trials published that year demonstrated significantly improved patient outcomes. In subsequent years, advances in stroke systems of care have centered around improving access to and expanding patient eligibility for thrombectomy. The prehospital and acute stroke treatment settings have had the greatest emphasis. Numerous prehospital stroke scales now provide emergency medical services with focused physical exams to identify LVOs, and many devices to non-invasively detect LVO are undergoing clinical testing. Mobile stroke units deployed throughout Western Europe and the USA also show promising results by bringing elements of acute stroke care directly to the patient. Numerous clinical trials since 2015 have aimed to increase candidates for thrombectomy by expanding indications and the eligibility time window. Further optimizations of thrombectomy treatment have focused on the role of thrombolytics and other adjunctive therapies that may promote neuroprotection and neurorecovery. While many of these approaches require further clinical investigation, the next decade shows significant potential for further advances in stroke care.
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Affiliation(s)
- Michael J. Pajor
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
| | - Opeolu M. Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
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Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
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Grotta JC. Intravenous Thrombolysis for Acute Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:425-442. [PMID: 37039403 DOI: 10.1212/con.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE This article reviews the history of IV thrombolysis, its current indications and implementation, the duality of the "time is brain" versus "tissue clock" approaches, the impact of endovascular thrombectomy on IV thrombolysis, the emergence of tenecteplase, and future research directions. LATEST DEVELOPMENTS The growing use of factor Xa inhibitors has increasingly caused patients with stroke to be excluded from treatment with IV thrombolysis. Important geographic, socioeconomic, sex, race, and ethnic disparities have been identified in the implementation of IV thrombolysis and need to be overcome. IV thrombolysis substantially improves outcomes when provided within the first golden hour after stroke onset in patients treated in mobile stroke units, supporting the "time is brain" concept and encouraging the possible value of more widespread implementation of the mobile stroke unit approach. At the same time, other studies have shown that IV thrombolysis can be successful in patients whose "tissue clock" is still ticking up to 9 hours after stroke onset or in patients who awaken with their stroke, as demonstrated by favorable imaging profiles. These considerations, along with the emergence of endovascular thrombectomy, have fostered examination of our care systems, including the "drip and ship" versus direct to comprehensive or endovascular thrombectomy stroke center approaches, as well as the possibility of skipping IV thrombolysis in certain patients treated with endovascular thrombectomy. Data suggesting that tenecteplase is at least noninferior to alteplase, as well as its more convenient dosing, has led to its increased use. Ongoing studies are evaluating newer thrombolytics and adding antithrombotic therapy to IV thrombolysis. ESSENTIAL POINTS IV thrombolysis remains the most common acute stroke treatment. Advances in acting faster to treat stroke have increased its efficacy, and advances in imaging have expanded its use. However, implementing these advances and overcoming disparities in IV thrombolysis use remain major challenges.
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Nilanont Y, Chanyagorn P, Shukij K, Pengtong W, Kongmuangpuk M, Wongmayurachat K, Nittayaboon K, Wongsawat Y, Sirovetnukul R, Chakorn T, Riyapan S, Kaveeta C, Chotik-Anuchit S, Tongdee T, Thabmontian P, Saeheng P, Nopmaneejumruslers C, Vamvanij V. Comparing performance measures and clinical outcomes between mobile stroke units and usual care in underserved areas. Neurol Sci 2023; 44:1261-1271. [PMID: 36515765 PMCID: PMC10023765 DOI: 10.1007/s10072-022-06550-6] [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: 08/30/2022] [Accepted: 12/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy of mobile stroke units (MSUs) in improving acute ischemic stroke (AIS) care in developing countries is unknown. We compared performance measures and stroke outcomes in AIS patients between MSU and usual care: emergency medical services (EMS) and walk-in. METHODS We enrolled patients > 18 years of age with an AIS within 4.5 h after onset. Demographic data, types, and time of reperfusion therapies and clinical outcomes were recorded. A favorable outcome was defined as a modified Rankin Scale (mRS) 0-2 at 3 months. RESULTS A total of 978 AIS patients (MSU = 243, EMS = 214, walk-in = 521) were enrolled between June 1, 2018, and April 30, 2021. The mean age (± SD) was 66 (± 14) years, and 510 (52.1%) were male. AIS time metrics were the shortest in the MSU with a mean (± SD) door to needle (DN) time of 20 (± 7), 29 (± 13), and 35 (± 16) min (p < 0.001) and door to puncture (DP) time of 73 ± 19, 86 ± 33, and 101 ± 42 min (p < 0.001) in MSU, EMS, and walk-in, respectively. Participants in the MSU (56.8%) received higher rate of reperfusion therapie(s) when compared to the EMS (51.4%) and walk-in (31.5%) (p < 0.001). After adjustment for any potential confounders and using the EMS as a reference, the MSU has the highest likelihood of achieving a favorable outcome (adjusted OR 2.15; 95% CI 1.39-3.32). CONCLUSIONS In underserved populations, MSUs significantly reduced DN time, increased the likelihood of receiving reperfusion treatment, and achieved independency at 3 months when compared to usual care.
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Affiliation(s)
- Yongchai Nilanont
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Pornchai Chanyagorn
- Department of Electrical Engineering, Faculty of Engineering, Mahidol University, Nakhon Pathom, Thailand
| | - Karuna Shukij
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Waitayaporn Pengtong
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mananchaya Kongmuangpuk
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanokkarn Wongmayurachat
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kittiya Nittayaboon
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yodchanan Wongsawat
- Department of Biomedical Engineering, Faculty of Engineering, Mahidol University, Nakhon Pathom, Thailand
| | - Ronnachai Sirovetnukul
- Department of Industrial Engineering, Faculty of Engineering, Mahidol University, Nakhon Pathom, Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sattha Riyapan
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chitapa Kaveeta
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Songkram Chotik-Anuchit
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Trongtum Tongdee
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ploypailin Thabmontian
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Porntep Saeheng
- Bangkok Emergency Medical Service, Medical Service Department, Bangkok, Thailand
| | - Cherdchai Nopmaneejumruslers
- Office of the Director of Siriraj Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Visit Vamvanij
- Office of the Director of Siriraj Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Fassbender K, Lesmeister M, Merzou F. Prehospital stroke management and mobile stroke units. Curr Opin Neurol 2023; 36:140-146. [PMID: 36794965 PMCID: PMC9994848 DOI: 10.1097/wco.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW Delayed presentation at the hospital contributes to poorer patient outcomes and undertreatment of acute stroke patients. This review will discuss recent developments in prehospital stroke management and mobile stroke units aimed to improve timely access to treatment within the past 2 years and will point towards future directions. RECENT FINDINGS Recent progress in research into prehospital stroke management and mobile stroke units ranges from interventions aimed at improving patients' help-seeking behaviour, to the education of emergency medical services team members, to the use of innovative referral methods, such as diagnostic scales, and finally to evidence of improved outcomes by the use of mobile stroke units. SUMMARY Understanding is increasing about the need for optimizing stroke management over the entire stroke rescue chain with the goal of improving access to highly effective time-sensitive treatment. In the future, we can expect that novel digital technologies and artificial intelligence will become relevant in effective interaction between prehospital and in-hospital stroke-treating teams, with beneficial effects on patients' outcomes.
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Affiliation(s)
- Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
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Beauchamp NJ, Bryan RN, Bui MM, Krestin GP, McGinty GB, Meltzer CC, Neumaier M. Integrative diagnostics: the time is now-a report from the International Society for Strategic Studies in Radiology. Insights Imaging 2023; 14:54. [PMID: 36995467 PMCID: PMC10063732 DOI: 10.1186/s13244-023-01379-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 03/31/2023] Open
Abstract
Enormous recent progress in diagnostic testing can enable more accurate diagnosis and improved clinical outcomes. Yet these tests are increasingly challenging and frustrating; the volume and diversity of results may overwhelm the diagnostic acumen of even the most dedicated and experienced clinician. Because they are gathered and processed within the "silo" of each diagnostic discipline, diagnostic data are fragmented, and the electronic health record does little to synthesize new and existing data into usable information. Therefore, despite great promise, diagnoses may still be incorrect, delayed, or never made. Integrative diagnostics represents a vision for the future, wherein diagnostic data, together with clinical data from the electronic health record, are aggregated and contextualized by informatics tools to direct clinical action. Integrative diagnostics has the potential to identify correct therapies more quickly, modify treatment when appropriate, and terminate treatment when not effective, ultimately decreasing morbidity, improving outcomes, and avoiding unnecessary costs. Radiology, laboratory medicine, and pathology already play major roles in medical diagnostics. Our specialties can increase the value of our examinations by taking a holistic approach to their selection, interpretation, and application to the patient's care pathway. We have the means and rationale to incorporate integrative diagnostics into our specialties and guide its implementation in clinical practice.
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Affiliation(s)
| | - R Nick Bryan
- University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Marilyn M Bui
- Moffitt Cancer Center and Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Gabriel P Krestin
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Carolyn C Meltzer
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Neumaier
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Gao L, Parsons M, Churilov L, Zhao H, Campbell BCV, Yan B, Mitchell P, Coote S, Langenberg F, Smith K, Anderson D, Stephenson M, Davis SM, Donnan G, Easton D, Bivard A. Cost-effectiveness of tenecteplase versus alteplase for stroke thrombolysis evaluation trial in the ambulance. Eur Stroke J 2023; 8:448-455. [DOI: 10.1177/23969873231165086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Background: Tenecteplase administered to patients with ischaemic stroke in a mobile stroke unit (MSU) has been shown to reduce the perfusion lesion volumes and result in ultra-early recovery. We now seek to assess the cost-effectiveness of tenecteplase in the MSU. Methods: A within-trial (TASTE-A) economic analysis and a model-based long-term cost-effectiveness analysis were performed. This post hoc within-trial economic analysis utilised the patient-level data (intention to treat, ITT) prospectively collected over the trial to calculate the difference in both healthcare costs and quality-adjusted life years (QALYs, estimated from modified Rankin scale score). A Markov microsimulation model was developed to simulate the long-term costs and benefits. Results: In total, there were 104 patients with ischaemic stroke randomised to tenecteplase ( n = 55) or alteplase ( n = 49) treatment groups, respectively in the TASTE-A trial. The ITT-based analysis showed that treatment with tenecteplase was associated with non-signficantly lower costs (A$28,903 vs A$40,150 ( p = 0.056)) and greater benefits (0.171 vs 0.158 ( p = 0.457)) than that for the alteplase group over the first 90 days post the index stroke. The long-term model showed that tenecteplase led to greater savings in costs (−A$18,610) and more health benefits (0.47 QALY or 0.31 LY gains). Tenecteplase-treated patients had reduced costs for rehospitalisation (−A$1464), nursing home care (−A$16,767) and nonmedical care (−A$620) per patient. Conclusions: Treatment of ischaemic stroke patients with tenecteplase appeared to be cost-effective and improve QALYs in the MSU setting based on Phase II data. The reduced total cost from tenecteplase was driven by savings from acute hospitalisation and reduce need for nursing home care.
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Thrombolysis for acute ischaemic stroke: current status and future perspectives. Lancet Neurol 2023; 22:418-429. [PMID: 36907201 DOI: 10.1016/s1474-4422(22)00519-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 03/14/2023]
Abstract
Alteplase is currently the only approved thrombolytic agent for treatment of acute ischaemic stroke, but interest is burgeoning in the development of new thrombolytic agents for systemic reperfusion with an improved safety profile, increased efficacy, and convenient delivery. Tenecteplase has emerged as a potential alternative thrombolytic agent that might be preferred over alteplase because of its ease of administration and reported efficacy in patients with large vessel occlusion. Ongoing research efforts are also looking at potential improvements in recanalisation with the use of adjunct therapies to intravenous thrombolysis. New treatment strategies are also emerging that aim to reduce the risk of vessel reocclusion after intravenous thrombolysis administration. Other research endeavors are looking at the use of intra-arterial thrombolysis after mechanical thrombectomy to induce tissue reperfusion. The growing implementation of mobile stroke units and advanced neuroimaging could boost the number of patients who can receive intravenous thrombolysis by shortening onset-to-treatment times and identifying patients with salvageable penumbra. Continued improvements in this area will be essential to facilitate the ongoing research endeavors and to improve delivery of new interventions.
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García-Tornel Á, Flores A, Terceño M, Cardona P, Amaro S, Gomis M, Zaragoza J, Krupinski J, Gómez-Choco M, Mas N, Cocho D, Catena E, Purroy F, Deck M, Rubiera M, Pagola J, Rodriguez-Luna D, Juega J, Rodríguez-Villatoro N, Molina CA, Soro C, Jimenez X, Salvat-Plana M, Dávalos A, Jovin TG, Abilleira S, Pérez de la Ossa N, Ribó M. Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia. Stroke 2023; 54:770-780. [PMID: 36848432 DOI: 10.1161/strokeaha.122.041013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020. METHODS We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am-8:59 pm) and nighttime (9:00 pm-7:59 am). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated. RESULTS We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020-2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680-1.163]; P
interaction=0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548-1.072]; nighttime, acOR, 1.785 [95% CI, 1.024-3.112] ; P
interaction<0.01); no heterogeneity was observed for other stroke subtypes (P
interaction>0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers. CONCLUSIONS Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02795962.
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Affiliation(s)
- Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Alan Flores
- Department of Neurology, Hospital Universitari Joan XXIII, Tarragona, Spain (A.F.)
| | - Mikel Terceño
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T.)
| | - Pedro Cardona
- Stroke Unit, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Spain (P.C.)
| | - Sergi Amaro
- Stroke Unit, Hospital Clínic, Barcelona, Spain (S.A.)
| | - Meritxell Gomis
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Josep Zaragoza
- Department of Neurology, Hospital Verge de la Cinta, Tortosa, Spain (J.Z.)
| | - Jerzy Krupinski
- Department of Neurology, Hospital Mútua Terrassa, Spain (J.K.)
| | - Manuel Gómez-Choco
- Department of Neurology, Hospital Moisés Broggi, Sant Joan Despí, Spain (M.G.-C.)
| | - Natalia Mas
- Department of Neurology, Hospital Sant Joan de Déu - Fundació Althaia, Manresa, Spain (N.M.)
| | - Dolores Cocho
- Department of Neurology, Hospital General Granollers, Spain (D.C.)
| | - Esther Catena
- Department of Neurology, Consorci Sanitari Alt Penedès-Garraf, Spain (E.C.)
| | - Francesc Purroy
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P.)
| | - Matias Deck
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Jesús Juega
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Cristina Soro
- Sistema d'Emergències Mèdiques, Barcelona, Spain (C.S., X.J.)
| | - Xavier Jimenez
- Sistema d'Emergències Mèdiques, Barcelona, Spain (C.S., X.J.)
| | - Mercè Salvat-Plana
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain (M.S.-P., S.A.)
| | - Antoni Dávalos
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Tudor G Jovin
- Neurological Institute, Cooper University Hospital, Camden, NJ (T.G.J.)
| | - Sonia Abilleira
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain (M.S.-P., S.A.)
| | - Natalia Pérez de la Ossa
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Marc Ribó
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
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Shimada T, Matsubara K, Koyama D, Matsukawa M, Ohsaki M, Kobayashi Y, Saito K, Yamagami H. Development of evaluation system for cerebral artery occlusion in emergency medical services: noninvasive measurement and utilization of pulse waves. Sci Rep 2023; 13:3339. [PMID: 36849592 PMCID: PMC9971203 DOI: 10.1038/s41598-023-30229-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 02/19/2023] [Indexed: 03/01/2023] Open
Abstract
Rapid reperfusion therapy can reduce disability and death in patients with large vessel occlusion strokes (LVOS). It is crucial for emergency medical services to identify LVOS and transport patients directly to a comprehensive stroke center. Our ultimate goal is to develop a non-invasive, accurate, portable, inexpensive, and legally employable in vivo screening system for cerebral artery occlusion. As a first step towards this goal, we propose a method for detecting carotid artery occlusion using pulse wave measurements at the left and right carotid arteries, feature extraction from the pulse waves, and occlusion inference using these features. To meet all of these requirements, we use a piezoelectric sensor. We hypothesize that the difference in the left and right pulse waves caused by reflection is informative, as LVOS is typically caused by unilateral artery occlusion. Therefore, we extracted three features that only represented the physical effects of occlusion based on the difference. For inference, we considered that the logistic regression, a machine learning technique with no complex feature conversion, is a reasonable method for clarifying the contribution of each feature. We tested our hypothesis and conducted an experiment to evaluate the effectiveness and performance of the proposed method. The method achieved a diagnostic accuracy of 0.65, which is higher than the chance level of 0.43. The results indicate that the proposed method has potential for identifying carotid artery occlusions.
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Affiliation(s)
- Takuma Shimada
- grid.255178.c0000 0001 2185 2753Faculty of Science and Engineering, Doshisha University, Kyoto, Japan
| | - Kazumasa Matsubara
- grid.255178.c0000 0001 2185 2753Faculty of Science and Engineering, Doshisha University, Kyoto, Japan
| | - Daisuke Koyama
- grid.255178.c0000 0001 2185 2753Faculty of Science and Engineering, Doshisha University, Kyoto, Japan
| | - Mami Matsukawa
- Faculty of Science and Engineering, Doshisha University, Kyoto, Japan.
| | - Miho Ohsaki
- grid.255178.c0000 0001 2185 2753Faculty of Science and Engineering, Doshisha University, Kyoto, Japan
| | - Yasuyo Kobayashi
- grid.410814.80000 0004 0372 782XDepartment of Neurology, Nara Medical University, Nara, Japan
| | - Kozue Saito
- grid.410814.80000 0004 0372 782XDepartment of Neurology, Nara Medical University, Nara, Japan
| | - Hiroshi Yamagami
- grid.416803.80000 0004 0377 7966Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
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Mackey J, Yamal JM, Parker SA, Silnes K, Rajan SS, Jacob AP, Wang M, Singh N, Jones WJ, Spokoyny I, Navi BB, Saver JL, Grotta JC. Golden Hour Treatment With tPA (Tissue-Type Plasminogen Activator) in the BEST-MSU Study. Stroke 2023; 54:415-425. [PMID: 36689579 DOI: 10.1161/strokeaha.122.039821] [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: 04/27/2022] [Accepted: 09/19/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Treatment of patients with acute ischemic stroke on mobile stroke units (MSUs) improves outcomes compared with management by standard emergency medical services ambulances and is associated with more patients treated with intravenous tPA (tissue-type plasminogen activator) in the first golden hour after last known normal. We explored the predictors and outcomes of first-hour treatment (FHT) compared with later treatment in an alternating-week cluster-controlled trial of MSUs. METHODS We analyzed all patients treated with intravenous tPA in the BEST-MSU Study (Benefits of Stroke Treatment Delivered by a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services). After stratifying by treatment timeframe, we identified factors associated with FHT. We performed adjusted analyses of the association between FHT and clinical outcome and modeled the shape of the relationship between last known normal-to-treatment time and excellent outcome. RESULTS Among 941 tPA-treated patients, 206 (21.8%) had lytic started within 60 minutes. Treatment on the MSU, older age, male sex, alert by 911, faster arrival on-scene and imaging, more severe stroke, atrial fibrillation, and absence of heart failure and pretreatment antihypertensive treatment were associated with FHT. Compared with later treatment, FHT was associated with higher adjusted odds ratio for 90-day modified Rankin Scale score of 0 to 1 (odds ratio, 1.87 [95% CI, 1.25-2.84]; P=0.003). Among FHT patients, 68% achieved a 90-day modified Rankin Scale of 0 or 1 or returned to their baseline status. FHT was not associated with higher risk of hemorrhage and was associated with reduced risk of treating neurovascular mimics. CONCLUSIONS FHT almost doubles the odds of excellent clinical outcome without increased risk compared with later treatment, which supports the use of MSUs.
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Affiliation(s)
- Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis (J.M., K.S.)
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, University of Texas School of Public Health, Houston (J.-M.Y., S.S.R., M.W., N.S.)
| | - Stephanie A Parker
- Department of Neurology, University of Texas McGovern Medical School, Houston (S.A.P., A.P.J.)
| | - Kelly Silnes
- Department of Neurology, Indiana University School of Medicine, Indianapolis (J.M., K.S.)
- University of Buckingham Medical School, United Kingdom (K.S.)
| | - Suja S Rajan
- Department of Biostatistics and Data Science, University of Texas School of Public Health, Houston (J.-M.Y., S.S.R., M.W., N.S.)
| | - Asha P Jacob
- Department of Neurology, University of Texas McGovern Medical School, Houston (S.A.P., A.P.J.)
| | - Mengxi Wang
- Department of Biostatistics and Data Science, University of Texas School of Public Health, Houston (J.-M.Y., S.S.R., M.W., N.S.)
| | - Noopur Singh
- Department of Biostatistics and Data Science, University of Texas School of Public Health, Houston (J.-M.Y., S.S.R., M.W., N.S.)
| | - William J Jones
- Department of Neurology, University of Colorado, Aurora (W.J.J.)
| | - Ilana Spokoyny
- Department of Neurology, Mills Peninsula Medical Center, Burlingame, CA (I.S.)
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, NY (B.B.N.)
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center (J.L.S.)
| | - James C Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston (J.C.G.)
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Tanaka K, Reeves MJ. Mobile Stroke Units and Pursuit of Intravenous Tissue-Type Plasminogen Activator Treatment in the Golden Hour. Stroke 2023; 54:426-429. [PMID: 36689589 DOI: 10.1161/strokeaha.122.041391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
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Gou LK, Li C. Qixue Shuangbu decoction and acupuncture combined with Western medicine in acute severe stroke patients. World J Clin Cases 2023; 11:556-565. [PMID: 36793635 PMCID: PMC9923850 DOI: 10.12998/wjcc.v11.i3.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/18/2022] [Accepted: 12/21/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Stroke is a common and frequently occurring disease of the nervous system and one of the three major diseases leading to human death. The incidence and mortality of stroke in China increase with age. Overall, 70 % of patients with stroke have serious disability, which results in heavy burden to their families and the society.
AIM To analyze the effects of Qixue Shuangbu decoction and acupuncture combined with Western medicine on immune indexes and digestive tract function in patients with acute severe stroke.
METHODS A total of 68 patients with acute severe stroke admitted to Lanzhou Second People’s Hospital between March 2018 and September 2021 were selected and divided into the control and observation groups according to a random number table method. The control group was administered routine Western medicine treatment, such as dehydration, lowering intracranial pressure, anticoagulation, improving cerebral blood circulation and cerebral nerve protection according to the “Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke in China.” The observation group was administered Qixue Shuangbu decoction via nasal feeding tube on the basis of the routine Western medicine treatment with simultaneous acupuncture. The two groups were compared.
RESULTS The acute physiology and chronic health evaluation II, organ dysfunction syndrome score, National Institutes of Health Stroke Scale, and traditional Chinese medicine syndrome scores of the two groups were significantly decreased compared with those measured before treatment, and the complements C3 and C4, and immunoglobulins (Ig) M and G were significantly increased compared with those observed before treatment (P < 0.05). After treatment, the scores of the observation group were lower than those of the control group, and the complement and Ig levels were higher than those of the control group (P < 0.05). The levels of diamine oxidase (DAO), D-lactic acid (D-LA), and calcitonin gene-related peptide (CGRP) in the two groups were significantly higher than those before treatment, while the levels of lipopolysaccharide, ubiquitin carboxyl-terminal hydrolase 1 (UCH-L1), tumor necrosis factor-α (TNF-α), interleukin (IL) -2, and IL-8 were significantly lower than those before treatment (P < 0.05). After treatment, DAO, D-LA, and CGRP were higher in the observation group than in the control group, while lipopolysaccharide, UCH-L1, TNF-α, IL-2, and IL-8 were lower than in the control group (P < 0.05). The hospitalization time of individuals in the observation group was shorter than that of the control group (P < 0.05).
CONCLUSION Qixue Shuangbu decoction and acupuncture combined with Western medicine for the treatment of acute severe stroke can regulate intestinal flora, reduce inflammation, improve intestinal mucosal barrier function and immune function related indicators, and promote recovery.
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Affiliation(s)
- Li-Kun Gou
- Department of Critical Care Medicine, Lanzhou Second People’s Hospital, Lanzhou 730046, Gansu Province, China
| | - Chun Li
- Department of Critical Care Medicine, Lanzhou Second People’s Hospital, Lanzhou 730046, Gansu Province, China
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Wong JZW, Park PSW, Frost T, Stephens K, Newk-Fon Hey Tow FK, Garcia PG, Senanayake C, Choi PMC. Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study. BMJ Open 2023; 13:e067816. [PMID: 36697041 PMCID: PMC9884893 DOI: 10.1136/bmjopen-2022-067816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE 'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors. DESIGN Continuous observation workflow time study. SETTING AND PARTICIPANTS Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team. MAIN OUTCOME MEASURES The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models. RESULTS 100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration. CONCLUSIONS Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.
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Affiliation(s)
- Joseph Zhi Wen Wong
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
- Departments of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Peter Si Woo Park
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Tanya Frost
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Karen Stephens
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | | | - Pamela Gayle Garcia
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Channa Senanayake
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
- Eastern Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Clayton, Victoria, Australia
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Agrawal D, Dhillon P, Siow I, Lee KS, Spooner O, Yeo L, Bhogal P. Prehospital technologies for early stroke detection - A review. Interv Neuroradiol 2023:15910199231152372. [PMID: 36654460 DOI: 10.1177/15910199231152372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The rate of neural circuitry loss in a typical large vessel occlusion well emphasizes that 'Time is Brain'. Every untreated minute in a large vessel ischaemic stroke results in loss of 1.9 million neurons and 13.8 billion synapses. As such, it is essential to optimize the flow-limiting steps in delivering the current standard of care. The current diagnostic model involves recognition of symptoms by patients, followed by access to Emergency Medical Services and subsequent physical examination and neuroimaging in the Emergency Department. With more than 50% of stroke patients using Emergency Medical Services as the first point of care contact, it can be deduced that the outcome of the 'stroke chain of survival' can be improved by addressing the bottleneck of prehospital stroke diagnosis. Here we present a review of the existing technologies.
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Affiliation(s)
- Deepsha Agrawal
- Department of Radiology, 6397Oxford University Hospitals NHS Trust, Oxford, UK
| | - Permesh Dhillon
- Department of Interventional Neuroradiology, 105590Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Isabel Siow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Oliver Spooner
- Department of Stroke Medicine, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Leonard Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
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Rohmann JL, Huerta-Gutierrez R, Audebert HJ, Kurth T, Piccininni M. Adjusted horizontal stacked bar graphs (“Grotta bars”) for consistent presentation of observational stroke study results. Eur Stroke J 2023; 8:370-379. [PMID: 37021164 PMCID: PMC10069225 DOI: 10.1177/23969873221149464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
Background: Modified Rankin Scale (mRS) scores are used to measure functional outcomes after stroke. Researchers create horizontal stacked bar graphs (nicknamed “Grotta bars”) to illustrate distributional differences in scores between groups. In well-conducted randomized controlled trials, Grotta bars have a causal interpretation. However, the common practice of exclusively presenting unadjusted Grotta bars in observational studies can be misleading in the presence of confounding. We demonstrated this problem and a possible solution using an empirical comparison of 3-month mRS scores among stroke/TIA patients discharged home versus elsewhere after hospitalization. Patients and methods: Using data from the Berlin-based B-SPATIAL registry, we estimated the probability of being discharged home conditional on prespecified measured confounding factors and generated stabilized inverse probability of treatment (IPT) weights for each patient. We visualized mRS distributions by group with Grotta bars for the IPT-weighted population in which measured confounding was removed. We then used ordinal logistic regression to quantify unadjusted and adjusted associations between being discharged home and the 3-month mRS score. Results: Of 3184 eligible patients, 2537 (79.7%) were discharged home. In the unadjusted analyses, those discharged home had considerably lower mRS compared with patients discharged elsewhere (common odds ratio, cOR = 0.13, 95% CI: 0.11–0.15). After removing measured confounding, we obtained substantially different mRS distributions, visually apparent in the adjusted Grotta bars. No statistically significant association was found after confounding adjustment (cOR = 0.82, 95% CI: 0.60–1.12). Discussion and conclusion: The practice of presenting only unadjusted stacked bar graphs for mRS scores together with adjusted effect estimates in observational studies can be misleading. IPT weighting can be implemented to create Grotta bars that account for measured confounding, which are more consistent with the presentation of adjusted results in observational studies.
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Affiliation(s)
- Jessica L Rohmann
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Rodrigo Huerta-Gutierrez
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Kurth
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Piccininni
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
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50
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Oliveira Gonçalves AS, Rohmann JL, Piccininni M, Kurth T, Ebinger M, Endres M, Freitag E, Harmel P, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Busse R, Audebert HJ. Economic Evaluation of a Mobile Stroke Unit Service in Germany. Ann Neurol 2023; 93:942-951. [PMID: 36637359 DOI: 10.1002/ana.26602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Lower global disability and higher quality of life among ischemic stroke patients was found to be associated with the dispatch of mobile stroke units (MSUs) among patients eligible for recanalizing treatments in the Berlin_Prehospital Or Usual Delivery of stroke care (B_PROUD) study. The current study assessed the cost-utility and cost-effectiveness of additional MSU dispatch using data from this prospective, controlled, intervention study. METHODS Outcomes considered in the economic evaluation included quality-adjusted life years (QALYs) derived from the 3-level version of EQ-5D (EQ-5D-3L) and modified Rankin Scale (mRS) scores for functional outcomes 3-months after stroke. Costs were prospectively collected during the study by the MSU provider (Berlin Fire Brigade) and the B_PROUD research team. We focus our results on the societal perspective. As we aimed to determine the economic consequences of the intervention beyond the study's follow-up period, both care costs and QALYs were extrapolated over 5 years. RESULTS The additional MSU dispatch resulted in an incremental €40,984 per QALY. The best-case scenario and the worst-case scenario yielded additional costs of, respectively, €24,470.76 and €61,690.88 per QALY. In the cost-effectiveness analysis, MSU dispatch resulted in incremental costs of €81,491 per survival without disability. The best-case scenario and the worst-case scenario yielded additional costs of, respectively, €44,455.30 and €116,491.15 per survival without disability. INTERPRETATION Among patients eligible for recanalizing treatments in ischemic stroke, MSU dispatch was associated with both higher QALYs and higher costs and is cost-effective when considering internationally accepted thresholds ranging from an additional €40,000 to €80,000 per QALY. ANN NEUROL 2023.
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Affiliation(s)
- Ana Sofia Oliveira Gonçalves
- Institute of Public Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Jessica L Rohmann
- Institute of Public Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Marco Piccininni
- Institute of Public Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Erik Freitag
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Ira Rohrpasser-Napierkowski
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Berlin University of Technology, Berlin, Germany.,European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
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