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Mahajan C, Kapoor I, Prabhakar H. The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries. Neurocrit Care 2024:10.1007/s12028-024-02040-z. [PMID: 38960992 DOI: 10.1007/s12028-024-02040-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/05/2024] [Indexed: 07/05/2024]
Abstract
The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. Issues related to common clinical conditions such as stroke, traumatic brain injury, myasthenia gravis, epilepsy, tubercular meningitis, and tracheostomy are also discussed. To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.
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Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Qurat Ul Ain H, Junaid Tahir M, Abbasher Hussien Mohamed Ahmed K, Ahmed F, Mohamed Ibrahim Ali M, Hassan Salih Elhaj E, Mustafa GE, Ahsan A, Yousaf Z. Tele-stroke: a strategy to improve acute stroke care in low- and middle-income countries. Ann Med Surg (Lond) 2024; 86:3808-3811. [PMID: 38989217 PMCID: PMC11230807 DOI: 10.1097/ms9.0000000000002187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 05/08/2024] [Indexed: 07/12/2024] Open
Affiliation(s)
| | | | | | | | | | | | | | - Areeba Ahsan
- Foundation University School of Health Sciences, Islamabad, Pakistan
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3
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Kolangarakath A, Chalil Madathil K, Hegde S, Agrawal S, Bian M, Simmons L, Molloseau G, Holmstedt C, LeBlanc D, Harvey J, McGeorge T, Spampinato M, Roberts D. Barriers to integrating portable Magnetic Resonance Imaging systems in emergency medical service ambulances for stroke care. ERGONOMICS 2024:1-20. [PMID: 38916114 DOI: 10.1080/00140139.2024.2367157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
This study examines the barriers to integrating portable Magnetic Resonance Imaging (MRI) systems into ambulance services to enable effective triaging of patients to the appropriate hospitals for timely stroke care and potentially reduce door-to-needle time for thrombolytic administration. The study employs a qualitative methodology using a digital twin of the patient handling process developed and demonstrated through semi-structured interviews with 18 participants, including 11 paramedics from an Emergency Medical Services system and seven neurologists from a tertiary stroke care centre. The interview transcripts were thematically analysed to determine the barriers based on the Systems Engineering Initiative for Patient Safety framework. Key barriers include the need for MRI operation skills, procedural complexities in patient handling, space constraints, and the need for training and policy development. Potential solutions are suggested to mitigate these barriers. The findings can facilitate implementing MRI systems in ambulances to expedite stroke treatment.
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Affiliation(s)
- Arvind Kolangarakath
- Department of Industrial Engineering, Clemson University, Clemson, South Carolina, USA
| | - Kapil Chalil Madathil
- Department of Industrial Engineering, Clemson University, Clemson, South Carolina, USA
| | - Sudeep Hegde
- Department of Industrial Engineering, Clemson University, Clemson, South Carolina, USA
| | - Shubham Agrawal
- Department of Psychology, Clemson University, Clemson, South Carolina, USA
| | - Mary Bian
- Department of Psychology, Clemson University, Clemson, South Carolina, USA
| | - Lauren Simmons
- Department of Genetics and Biochemistry, Clemson University, Clemson, South Carolina, USA
| | - Gabby Molloseau
- College of Medicine, Medical University of South Carolina, Clemson, South Carolina, USA
| | - Christine Holmstedt
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Dustin LeBlanc
- Department of Emergency Medicine, Medical University of South Carolina,Charleston, South Carolina, USA
| | - Jillian Harvey
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Todd McGeorge
- Charleston County Emergency Medical Services, Charleston, South Carolina, USA
| | - Maria Spampinato
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Donna Roberts
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA
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4
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Masouris I, Kellert L, Pradhan C, Wischmann J, Schniepp R, Müller R, Fuhry L, Hamann GF, Pfefferkorn T, Rémi JM, Schöberl F. Telemedical stroke care significantly improves patient outcome in rural areas: Long-term analysis of the German NEVAS network. Int J Stroke 2024; 19:577-586. [PMID: 38346936 PMCID: PMC11134988 DOI: 10.1177/17474930241234259] [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: 11/20/2023] [Accepted: 02/02/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described. AIMS This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network. METHODS In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters. RESULTS In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%. CONCLUSIONS 24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Cauchy Pradhan
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Roman Schniepp
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Robert Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - Leonard Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | | | - Jan M Rémi
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Schöberl
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
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5
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Pestka DL, Boes S, Ramezani S, Peters M, Usher MG, Koopmeiners JS, Beebe TJ, Melton GB, Streib CD. Implementing Telestroke in the Inpatient Setting: Identifying Factors for Success. Stroke 2024; 55:1517-1524. [PMID: 38639090 DOI: 10.1161/strokeaha.123.046024] [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: 11/29/2023] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Inpatient telestroke programs have emerged as a solution to provide timely stroke care in underserved areas, but their successful implementation and factors influencing their effectiveness remain underexplored. This study aimed to qualitatively evaluate the perspectives of inpatient clinicians located at spoke hospitals participating in a newly established inpatient telestroke program to identify implementation barriers and facilitators. METHODS This was a formative evaluation relying on semistructured qualitative interviews with 16 inpatient providers (physicians and nurse practitioners) at 5 spoke sites of a hub-and-spoke inpatient telestroke program. The Integrated-Promoting Action on Research Implementation in Health Services framework guided data analysis, focusing on the innovation, recipients, context, and facilitation aspects of implementation. Interviews were transcribed and coded using thematic analysis. RESULTS Fifteen themes were identified in the data and mapped to the Integrated-Promoting Action on Research Implementation in Health Services framework. Themes related to the innovation (the telestroke program) included easy access to stroke specialists, the benefits of limiting patient transfers, concerns about duplicating tests, and challenges of timing inpatient telestroke visits and notes to align with discharge workflow. Themes pertaining to recipients (care team members and patients) were communication gaps between teams, concern about the supervision of inpatient telestroke advanced practice providers and challenges with nurse empowerment. With regard to the context (hospital and system factors), providers highlighted familiarity with telehealth technologies as a facilitator to implementing inpatient telestroke, yet highlighted resource limitations in smaller facilities. Facilitation (program implementation) was recognized as crucial for education, standardization, and buy-in. CONCLUSIONS Understanding barriers and facilitators to implementation is crucial to determining where programmatic changes may need to be made to ensure the success and sustainment of inpatient telestroke services.
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Affiliation(s)
- Deborah L Pestka
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Samuel Boes
- Department of Neurology (S.B., S.R., C.D.S.), University of Minnesota, Minneapolis
| | - Solmaz Ramezani
- Department of Neurology (S.B., S.R., C.D.S.), University of Minnesota, Minneapolis
| | - Maya Peters
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Michael G Usher
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Joseph S Koopmeiners
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Division of Biostatistics and Health Data Science, School of Public Health (J.S.K.), University of Minnesota, Minneapolis
| | - Timothy J Beebe
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Division of Health Policy Management, School of Public Health (T.J.B.), University of Minnesota, Minneapolis
| | - Genevieve B Melton
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Department of Surgery (G.B.M.), University of Minnesota, Minneapolis
- Institute for Health Informatics (G.B.M.), University of Minnesota, Minneapolis
| | - Christopher D Streib
- Department of Neurology (S.B., S.R., C.D.S.), University of Minnesota, Minneapolis
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6
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Prust ML, Forman R, Ovbiagele B. Addressing disparities in the global epidemiology of stroke. Nat Rev Neurol 2024; 20:207-221. [PMID: 38228908 DOI: 10.1038/s41582-023-00921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.
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Affiliation(s)
- Morgan L Prust
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Rachel Forman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California-San Francisco School of Medicine, San Francisco, CA, USA
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7
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Zrubka Z, Champion A, Holtorf AP, Di Bidino R, Earla JR, Boltyenkov AT, Tabata-Kelly M, Asche C, Burrell A. The PICOTS-ComTeC Framework for Defining Digital Health Interventions: An ISPOR Special Interest Group Report. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:383-396. [PMID: 38569772 DOI: 10.1016/j.jval.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVES Digital health definitions are abundant, but often lack clarity and precision. We aimed to develop a minimum information framework to define patient-facing digital health interventions (DHIs) for outcomes research. METHODS Definitions of digital-health-related terms (DHTs) were systematically reviewed, followed by a content analysis using frameworks, including PICOTS (population, intervention, comparator, outcome, timing, and setting), Shannon-Weaver Model of Communication, Agency for Healthcare Research and Quality Measures, and the World Health Organization's Classification of Digital Health Interventions. Subsequently, we conducted an online Delphi study to establish a minimum information framework, which was pilot tested by 5 experts using hypothetical examples. RESULTS After screening 2610 records and 545 full-text articles, we identified 101 unique definitions of 67 secondary DHTs in 76 articles, resulting in 95 different patterns of concepts among the definitions. World Health Organization system (84.5%), message (75.7%), intervention (58.3%), and technology (52.4%) were the most frequently covered concepts. For the Delphi survey, we invited 47 members of the ISPOR Digital Health Special Interest Group, 18 of whom became the Delphi panel. The first, second, and third survey rounds were completed by 18, 11, and 10 respondents, respectively. After consolidating results, the PICOTS-ComTeC acronym emerged, involving 9 domains (population, intervention, comparator, outcome, timing, setting, communication, technology, and context) and 32 optional subcategories. CONCLUSIONS Patient-facing DHIs can be specified using PICOTS-ComTeC that facilitates identification of appropriate interventions and comparators for a given decision. PICOTS-ComTeC is a flexible and versatile tool, intended to assist authors in designing and reporting primary studies and evidence syntheses, yielding actionable results for clinicians and other decision makers.
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Affiliation(s)
- Zsombor Zrubka
- Health Economics Research Center, University Research and Innovation Center, Óbuda University, Budapest, Hungary.
| | | | | | - Rossella Di Bidino
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; The Graduate School of Health Economics and Management (ALTEMS), Rome, Italy
| | | | | | - Masami Tabata-Kelly
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Carl Asche
- Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt-Lake City, UT, USA
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8
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Alhajala H, Hendricks-Jones M, Shawver J, Amllay A, Chen JT, Hajjar M, Robbins S, Dwyer T, Sedlak E, Crayne C, Miller B, Kung V, Burgess R, Jumaa M, Zaidi SF. Expansion of Telestroke Coverage in Community Hospitals: Unifying Stroke Care and Reducing Transfer Rate. Ann Neurol 2024; 95:576-582. [PMID: 38038962 DOI: 10.1002/ana.26839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/03/2023] [Accepted: 11/10/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE Telestroke (TS) service has been shown to improve stroke diagnosis timing and accuracy, facilitate treatment decisions, and decrease interfacility transfers. Expanding TS service to inpatient units at the community hospital provides an opportunity to follow up on stroke patients and optimize medical management. This study examines the outcome of expanding TS coverage from acute emergency room triage to incorporate inpatient consultation. METHODS We studied the effect of expanding TS to inpatient consultation service at 19 regional hospitals affiliated with Promedica Stroke Network. We analyzed data pre- and post-TS expansion. We reviewed changes in TS utilization, admission rate, thrombolytic therapy, patient transfer rate, and diagnosis accuracy. RESULTS Between January 2018 and June 2022, a total of 9,756 patients were evaluated in our stroke network (4,705 in pre- and 5,051 in the post-TS expansion). In the post-TS expansion period, stroke patients' admission at the spoke hospital increased from 18/month to 40/month, and for TIA from 11/month to 16/month. TS cart use increased from 12% to 35.2%. Patient transfers to hub hospital decreased by 31%. TS service expansion did not affect intravenous thrombolytic therapy rate or door-to-needle time. There was no difference in length of stay or readmission rate, and the patients at the spoke hospitals had a higher rate of home discharge 57.38% compared with 52.58% at hub hospital. INTERPRETATION Telestroke service expansion to inpatient units helped decrease transfers and retain patients in their communities, increased stroke and TIA diagnosis accuracy, and did not compromise patients' hospitalization or outcome. ANN NEUROL 2024;95:576-582.
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Affiliation(s)
- Hisham Alhajala
- Department of Neurology, University of Toledo, Toledo, OH, USA
| | | | - Julie Shawver
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | | | - John Tuhao Chen
- Department of Statistics, Bowling Green State University, Bowling Green, OH, USA
| | - Monica Hajjar
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Sarah Robbins
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Trisha Dwyer
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Emily Sedlak
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | | | - Brian Miller
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Vieh Kung
- Department of Neurology, University of Toledo, Toledo, OH, USA
| | - Richard Burgess
- Department of Neurology, University of Toledo, Toledo, OH, USA
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo, Toledo, OH, USA
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Syed F Zaidi
- Department of Neurology, University of Toledo, Toledo, OH, USA
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
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9
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [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] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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10
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Sparling T, Iyer L, Pasquina P, Petrus E. Cortical Reorganization after Limb Loss: Bridging the Gap between Basic Science and Clinical Recovery. J Neurosci 2024; 44:e1051232024. [PMID: 38171645 PMCID: PMC10851691 DOI: 10.1523/jneurosci.1051-23.2023] [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: 06/08/2023] [Revised: 08/28/2023] [Accepted: 09/29/2023] [Indexed: 01/05/2024] Open
Abstract
Despite the increasing incidence and prevalence of amputation across the globe, individuals with acquired limb loss continue to struggle with functional recovery and chronic pain. A more complete understanding of the motor and sensory remodeling of the peripheral and central nervous system that occurs postamputation may help advance clinical interventions to improve the quality of life for individuals with acquired limb loss. The purpose of this article is to first provide background clinical context on individuals with acquired limb loss and then to provide a comprehensive review of the known motor and sensory neural adaptations from both animal models and human clinical trials. Finally, the article bridges the gap between basic science researchers and clinicians that treat individuals with limb loss by explaining how current clinical treatments may restore function and modulate phantom limb pain using the underlying neural adaptations described above. This review should encourage the further development of novel treatments with known neurological targets to improve the recovery of individuals postamputation.Significance Statement In the United States, 1.6 million people live with limb loss; this number is expected to more than double by 2050. Improved surgical procedures enhance recovery, and new prosthetics and neural interfaces can replace missing limbs with those that communicate bidirectionally with the brain. These advances have been fairly successful, but still most patients experience persistent problems like phantom limb pain, and others discontinue prostheses instead of learning to use them daily. These problematic patient outcomes may be due in part to the lack of consensus among basic and clinical researchers regarding the plasticity mechanisms that occur in the brain after amputation injuries. Here we review results from clinical and animal model studies to bridge this clinical-basic science gap.
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Affiliation(s)
- Tawnee Sparling
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814
| | - Laxmi Iyer
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland 20817
| | - Paul Pasquina
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814
| | - Emily Petrus
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland 20814
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11
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Maltby S, Garcia-Esperon C, Jackson K, Butcher K, Evans JW, O'Brien W, Dixon C, Russell S, Wilson N, Kluge MG, Ryan A, Paul CL, Spratt NJ, Levi CR, Walker FR. TACTICS VR Stroke Telehealth Virtual Reality Training for Health Care Professionals Involved in Stroke Management at Telestroke Spoke Hospitals: Module Design and Implementation Study. JMIR Serious Games 2023; 11:e43416. [PMID: 38060297 PMCID: PMC10739245 DOI: 10.2196/43416] [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: 10/30/2022] [Revised: 09/06/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Stroke management in rural areas is more variable and there is less access to reperfusion therapies, when compared with metropolitan areas. Delays in treatment contribute to worse patient outcomes. To improve stroke management in rural areas, health districts are implementing telestroke networks. The New South Wales Telestroke Service provides neurologist-led telehealth to 23 rural spoke hospitals aiming to improve treatment delivery and patient outcomes. The training of clinical staff was identified as a critical aspect for the successful implementation of this service. Virtual reality (VR) training has not previously been used in this context. OBJECTIVE We sought to develop an evidence-based VR training module specifically tailored for stroke telehealth. During implementation, we aimed to assess the feasibility of workplace deployment and collected feedback from spoke hospital staff involved in stroke management on training acceptability and usability as well as perceived training impact. METHODS The TACTICS VR Stroke Telehealth application was developed with subject matter experts. During implementation, both quantitative and qualitative data were documented, including VR use and survey feedback. VR hardware was deployed to 23 rural hospitals, and use data were captured via automated Wi-Fi transfer. At 7 hospitals in a single local health district, staff using TACTICS VR were invited to complete surveys before and after training. RESULTS TACTICS VR Stroke Telehealth was deployed to rural New South Wales hospitals starting on April 14, 2021. Through August 20, 2023, a total of 177 VR sessions were completed. Survey respondents (n=20) indicated a high level of acceptability, usability, and perceived training impact (eg, accuracy and knowledge transfer; mean scores 3.8-4.4; 5=strongly agree). Furthermore, respondents agreed that TACTICS VR increased confidence (13/18, 72%), improved understanding (16/18, 89%), and improved awareness (17/18, 94%) regarding stroke telehealth. A comparison of matched pre- and posttraining responses revealed that training improved the understanding of telehealth workflow practices (after training: mean 4.2, SD 0.6; before training: mean 3.2, SD 0.9; P<.001), knowledge on accessing stroke telehealth (mean 4.1, SD 0.6 vs mean 3.1, SD 1.0; P=.001), the awareness of stroke telehealth (mean 4.1, SD 0.6 vs mean 3.4, SD 0.9; P=.03), ability to optimally communicate with colleagues (mean 4.2, SD 0.6 vs mean 3.7, SD 0.9; P=.02), and ability to make improvements (mean 4.0, SD 0.6 vs mean 3.5, SD 0.9; P=.03). Remote training and deployment were feasible, and limited issues were identified, although uptake varied widely (0-66 sessions/site). CONCLUSIONS TACTICS VR Stroke Telehealth is a new VR application specifically tailored for stroke telehealth workflow training at spoke hospitals. Training was considered acceptable, usable, and useful and had positive perceived training impacts in a real-world clinical implementation context. Additional work is required to optimize training uptake and integrate training into existing education pathways.
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Affiliation(s)
- Steven Maltby
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Carlos Garcia-Esperon
- Hunter Medical Research Institute, New Lambton Heights, Australia
- John Hunter Hospital, New Lambton Heights, Australia
| | - Kate Jackson
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Ken Butcher
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - James W Evans
- Department of Neurosciences, Gosford Hospital, Gosford, Australia
| | - William O'Brien
- Department of Neurosciences, Gosford Hospital, Gosford, Australia
| | - Courtney Dixon
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Skye Russell
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Natalie Wilson
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Murielle G Kluge
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Annika Ryan
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Christine L Paul
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Neil J Spratt
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
- John Hunter Hospital, New Lambton Heights, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
- John Hunter Health & Innovation Precinct, New Lambton Heights, Australia
| | - Frederick Rohan Walker
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
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12
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Thilemann S, Traenka CK, Schaub F, Nussbaum L, Bonati L, Peters N, Fladt J, Nickel C, Hunziker P, Luethy M, Schädelin S, Ernst A, Engelter S, De Marchis GM, Lyrer P. Real-time video analysis allows the identification of large vessel occlusion in patients with suspected stroke: feasibility trial of a "telestroke" pathway in Northwestern Switzerland. Front Neurol 2023; 14:1232401. [PMID: 37941577 PMCID: PMC10627858 DOI: 10.3389/fneur.2023.1232401] [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: 05/31/2023] [Accepted: 09/12/2023] [Indexed: 11/10/2023] Open
Abstract
Background and aim Loss of time is a major obstacle to efficient stroke treatment. Our telestroke path intends to optimize prehospital triage using a video link connecting ambulance personnel and a stroke physician. The objectives were as follows: (1) To identify patients suffering a stroke and (2) in particular large vessel occlusion (LVO) strokes as candidates for endovascular treatment. We have chosen the Rapid Arterial Occlusion Evaluation (RACE) scale for this purpose. Methods This analysis aimed to verify the feasibility of prehospital stroke identification by video assessment. In this prospective telestroke cohort study, we included 97 subjects, in which the RACE score (items: facial palsy, arm and leg motor function, head and gaze deviation, and aphasia or agnosia) was applied, and the assessment videotaped by a trained member of the Emergency Medical Services (EMS) in the field using a mobile device. Each recorded patient video was independently assessed by three experienced stroke physicians from a certified stroke center and compared to the neuroimaging gold standard. Within this feasibility study, the stroke code was not altered by the outcome of the RACE assessment, and all patients underwent the standard procedures within the emergency unit. Results We analyzed 97 patients (median age 78 years, 53% women), of whom 51 (52.6%) suffered an acute stroke, 12 (23.5%) of which were due to an LVO and 46 patients had symptoms mimicking a stroke. The sensitivity of stroke identification was 77.8%, and specificity was 53.6%. In regard to the identification of an LVO, sensitivity was 69.4% and specificity was 84.3%. The inter-rater agreement in the RACE-score assessment was ICC = 0.82 (intraclass-correlation coefficient). Conclusion These results confirm our hypothesis that the local telestroke concept is feasible. It allows correct (i) stroke and (ii) LVO identification in the majority of the cases and thus has the potential to assist in efficient prehospital triage.
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Affiliation(s)
- Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christoph Kenan Traenka
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Fabian Schaub
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lukas Nussbaum
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Nickel
- Department of Emergency, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Patrick Hunziker
- Medical Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Marc Luethy
- Anaesthesiology, University Hospital Basel, Switzerland and Emergency Medical Service (EMS) Basel, Basel, Switzerland
| | - Sabine Schädelin
- Clinical Trial Unit, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Axel Ernst
- ICT Service and Support, University Hospital Basel, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital St Gallen, St. Gallen, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
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13
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Hendrickx L, Kuznia C, Maneval L. Use of Telestroke to Improve Access to Care for Rural Patients With Stroke Symptoms. Crit Care Nurse 2023; 43:49-56. [PMID: 37777248 DOI: 10.4037/ccn2023505] [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: 10/02/2023]
Abstract
BACKGROUND Cerebrovascular accident, or stroke, is a common cause of death or disability. Timely diagnosis and intervention are critical for improving survival rates and reducing the long-term effects of stroke. For patients with ischemic stroke, thrombolytic drugs and endovascular intervention are time-sensitive treatment options. LOCAL PROBLEM Patients living in rural areas often do not have access to rapid consultation with specialized neurologic teams for diagnosis and treatment of stroke. The use of telemedicine in the form of a telestroke consultation can improve timely diagnosis and treatment for rural patients exhibiting stroke symptoms. METHODS A telestroke program was implemented in the upper Midwest. A team of 4 interventional neurologists provided telestroke consultation to a comprehensive stroke center and 5 other acute stroke-ready rural hospitals. RESULTS A tiered stroke alert algorithm and telestroke workflow chart were developed to help health care professionals at rural sites determine eligibility for telestroke consultation. A teleneurologist connected with the originating site, and the National Institutes of Health Stroke Scale could be completed remotely with assistance from the originating site. Telestroke has increased the percentage of patients receiving thrombolytics in less than 60 minutes, and door-to-needle time has decreased. CONCLUSION Rural patients with stroke symptoms may experience a delay in care or stroke diagnosis due to distance to specialized neurologic services. Telestroke consultation is a successful method for timely diagnosis of stroke and recommendation for treatment.
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Affiliation(s)
- Lori Hendrickx
- Lori Hendrickx is a professor at South Dakota State University College of Nursing, Brookings, South Dakota, and a staff nurse at St. Mary's Essentia Health, Detroit Lakes, Minnesota
| | - Chelsey Kuznia
- Chelsey Kuznia is the stroke program manager for the Comprehensive Stroke Center, Essentia Health, Fargo, North Dakota
| | - Lindsey Maneval
- Lindsey Maneval is an emergency department supervisor and stroke coordinator, St. Mary's Essentia Health, Detroit Lakes
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14
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Rawson J, Petrone A, Adcock A. Single-step Optimization in Triaging Large Vessel Occlusion Strokes: Identifying Factors to Improve Door-to-groin Time for Endovascular Therapy. West J Emerg Med 2023; 24:737-742. [PMID: 37527384 PMCID: PMC10393444 DOI: 10.5811/westjem.59770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/27/2023] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION Although acute stroke endovascular therapy (EVT) has dramatically improved outcomes in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO), access to EVT-capable centers remains limited, particularly in rural areas. Therefore, it is essential to optimize triage systems for EVT-eligible patients. One strategy may be the use of a telestroke network that typically consists of multiple spoke sites that receive a consultation to determine appropriateness of patient transfer to an EVT-capable hub site. Standardization of AIS protocols may be necessary to achieve target door-to-groin (DTG) times of less than 60 minutes in EVT-eligible patients upon hub arrival. Specifically, the decision to obtain vascular imaging at the transferring hub site vs delaying until arrival at the hub is controversial. The purpose of this study was to identify factors associated with reduced DTG time in LVO-AIS patients. METHODS We performed a retrospective chart review for all patients treated over a 3.5-year period at our home hub institution. Patients were classified as telestroke transfers, non-telestroke transfers, and direct-to-hub presentations. We recorded demographic information, DTG time, reperfusion status, length of stay (LOS), functional status at discharge, seven-day mortality, and the site where vascular imaging- computed tomography angiography (CTA)-was obtained. We performed binary logistic regression to identify factors associated with DTG <60 minutes. RESULTS In the sample of EVT-eligible patients (n = 383), CTA was performed at the spoke site prior to transfer to the hub institution in 53% of cases. Further, 59% of telestroke transfer cases received a CTA prior to transfer compared to only 40% of non-telestroke transfers (59 vs 40%, P = 0.01). A Door-to-groin time <60 minutes was achieved in 67% of transfer patients who received pre-transfer CTA compared to only 22% of transfer patients who received CTA upon hub arrival and 17% of patients who presented directly to the hub. Ultimately, transfer patients who received CTA prior to transfer were 7.2 times more likely to have a DTG <60 minutes compared to those who did not (OR 7.2, 95% confidence interval 3.5-14.7; P < 0.001). CONCLUSION Pre-transfer computed tomography angiography was the only significant predictor of achieving target door-to-groin times of less than 60 minutes. Because DTG time has been well established as a predictor of clinical outcomes, including pre-transfer CTA in a standardized acute ischemic stroke protocol may prove beneficial. Our findings also illustrate the need to optimize direct-to-hub stroke alerts and telestroke relationships to minimize workflow disruptions, which became more apparent during the pandemic.
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Affiliation(s)
- Joshua Rawson
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Ashley Petrone
- West Virginia University, Department of Pathology, Morgantown, West Virginia
| | - Amelia Adcock
- West Virginia University, Department of Neurology; Cerebrovascular Division, Morgantown, West Virginia
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15
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Gudmundson AT, Koo A, Virovka A, Amirault AL, Soo M, Cho JH, Oeltzschner G, Edden RA, Stark C. Meta-analysis and Open-source Database for In Vivo Brain Magnetic Resonance Spectroscopy in Health and Disease. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.10.528046. [PMID: 37205343 PMCID: PMC10187197 DOI: 10.1101/2023.02.10.528046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Proton ( 1 H) Magnetic Resonance Spectroscopy (MRS) is a non-invasive tool capable of quantifying brain metabolite concentrations in vivo . Prioritization of standardization and accessibility in the field has led to the development of universal pulse sequences, methodological consensus recommendations, and the development of open-source analysis software packages. One on-going challenge is methodological validation with ground-truth data. As ground-truths are rarely available for in vivo measurements, data simulations have become an important tool. The diverse literature of metabolite measurements has made it challenging to define ranges to be used within simulations. Especially for the development of deep learning and machine learning algorithms, simulations must be able to produce accurate spectra capturing all the nuances of in vivo data. Therefore, we sought to determine the physiological ranges and relaxation rates of brain metabolites which can be used both in data simulations and as reference estimates. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, we've identified relevant MRS research articles and created an open-source database containing methods, results, and other article information as a resource. Using this database, expectation values and ranges for metabolite concentrations and T 2 relaxation times are established based upon a meta-analyses of healthy and diseased brains.
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Affiliation(s)
- Aaron T. Gudmundson
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
- F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD
| | - Annie Koo
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA
| | - Anna Virovka
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA
| | - Alyssa L. Amirault
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA
| | - Madelene Soo
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA
| | - Jocelyn H. Cho
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA
| | - Georg Oeltzschner
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
- F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD
| | - Richard A.E. Edden
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
- F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD
| | - Craig Stark
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA
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16
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Thurlow NA, Chan KM, Yeater TD, Allen KD. Effects of Repeat Test Exposure on Gait Parameters in Naïve Lewis Rats. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.19.537488. [PMID: 37131645 PMCID: PMC10153156 DOI: 10.1101/2023.04.19.537488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Rodent gait analysis has emerged as a powerful, quantitative behavioral assay to characterize the pain and disability associated with movement-related disorders. In other behavioral assays, the importance of acclimation and the effect of repeated testing have been evaluated. However, for rodent gait analysis, the effects of repeated gait testing and other environmental factors have not been thoroughly characterized. In this study, fifty-two naïve male Lewis rats ages 8 to 42 weeks completed gait testing at semi-random intervals for 31 weeks. Gait videos and force plate data were collected and processed using a custom MATLAB suite to calculate velocity, stride length, step width, percentage stance time (duty factor), and peak vertical force data. Exposure was quantified as the number of gait testing sessions. Linear mixed effects models were used to evaluate the effects of velocity, exposure, age, and weight on animal gait patterns. Relative to age and weight, repeated exposure was the dominant parameter affecting gait variables with significant effects on walking velocity, stride length, fore and hind limb step width, fore limb duty factor, and peak vertical force. From exposure 1 to 7, average velocity increased by approximately 15 cm/s. Together, these data indicate arena exposure had large effects on gait parameters and should be considered in acclimation protocols, experimental design, and subsequent data analysis of rodent gait data.
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Affiliation(s)
- Nat A. Thurlow
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Kiara M. Chan
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Department of Kinesiology, Indiana University, Bloomington, IN, USA
| | - Taylor D. Yeater
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN
| | - Kyle D. Allen
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Department of Orthopedics and Sports Medicine, University of Florida, Gainesville, FL, USA
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17
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Nguyen CP, Maas WJ, van der Zee DJ, Uyttenboogaart M, Buskens E, Lahr MMH. Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review. BMC Health Serv Res 2023; 23:315. [PMID: 36998011 PMCID: PMC10064746 DOI: 10.1186/s12913-023-09310-0] [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: 08/15/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Reducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT. METHODS A comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until January 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality. RESULTS Twenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incremental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educational interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were cost-effective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%). CONCLUSIONS A wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Existing pathways and local characteristics need to be taken along in assessing proposed improvements.
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Affiliation(s)
- Chi Phuong Nguyen
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands.
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
- Department of Pharmaceutical Administration and Economics, Hanoi University of Pharmacy, Hanoi, Vietnam.
| | - Willemijn J Maas
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Erik Buskens
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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English C, Hill K, Cadilhac DA, Hackett ML, Lannin NA, Middleton S, Ranta A, Stocks NP, Davey J, Faux SG, Godecke E, Campbell BCV. Living clinical guidelines for stroke: updates, challenges and opportunities. Med J Aust 2022; 216:510-514. [PMID: 35569098 PMCID: PMC9542680 DOI: 10.5694/mja2.51520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Dominique A Cadilhac
- Monash University Melbourne VIC
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine University of NSW Sydney NSW
- University of Central Lancashire Preston UK
| | | | - Sandy Middleton
- Nursing Research Institute Australian Catholic University and St Vincent’s Health Australia Sydney NSW
- Australian Catholic University Sydney NSW
| | | | | | | | - Steven G Faux
- St Vincent's Hospital Sydney NSW
- University of NSW Sydney NSW
| | - Erin Godecke
- Edith Cowan University Perth WA
- Sir Charles Gairdner Hospital Perth WA
| | - Bruce CV Campbell
- Melbourne Brain Centre at Royal Melbourne Hospital Melbourne VIC
- University of Melbourne Melbourne VIC
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Remote monitoring in the use of extracorporeal membrane oxygenation and acute mechanical circulatory support. Curr Opin Crit Care 2022; 28:308-314. [PMID: 35653252 DOI: 10.1097/mcc.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of the role of remote monitoring tools in management of critically-ill patients requiring acute mechanical circulatory support (MCS). RECENT FINDINGS Tele-critical care systems have received new interest during the COVID-19 pandemic, which has stretched the capacity of health systems everywhere. At the same time, utilization of MCS and extracorporeal membrane oxygenation (ECMO) technologies has increased during the pandemic. The opportunity for remote monitoring and clinical decision support for ECMO and acute MCS devices has been recognized by industry partners, with several major platforms implementing technology infrastructure for it in available products. Healthcare systems face challenges interfacing multiple devices from multiple manufacturers with each other and with their designated electronic health records. Furthermore, the availability of data must be combined with algorithms for alerting on clinical events and with implementation systems to act upon these alerts. Studies are not yet published validating remote monitoring platforms for ECMO and MCS in clinical care. SUMMARY Remote monitoring for MCS devices represents a major opportunity for further investigation to improve the utilization of these devices and better serve patients.
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Sharifi Kia A, Rafizadeh M, Shahmoradi L. Telemedicine in the emergency department: an overview of systematic reviews. ZEITSCHRIFT FUR GESUNDHEITSWISSENSCHAFTEN = JOURNAL OF PUBLIC HEALTH 2022; 31:1-15. [PMID: 35103232 PMCID: PMC8791673 DOI: 10.1007/s10389-021-01684-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
AIM There is both favorable and controversial evidence on the application of telemedicine in the emergency department (ED), which has created uncertainty regarding the effectiveness of these systems. We performed a systematic review of the literature on systematic reviews to provide an overview of the benefits and challenges to the application of telemedicine systems for the ED. SUBJECT AND METHODS PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar databases were explored for systematic reviews of telemedicine applications for the ED. Each review was critically appraised by two authors for data items to be extracted and evaluated. The most highly recommended technology, feasibility, benefits, and challenges to the application of telemedicine systems were studied and reported. RESULTS We identified 18 studies of varying methodological quality and summarized their key findings. Form these 18 studies, 12 papers yielded a high risk of bias in their investigation. Nine papers concluded that real-time video conferencing was the best method of delivery, eight papers found cost reduction as an outcome of implementing these systems, and six studies found technical and infrastructure issues as a challenge when implementing telemedicine for EDs. CONCLUSION There is strong evidence suggesting that the use of telemedicine positively impacts patient care. However, there are many challenges in implementing telemedicine that may impede the process or even impact patient safety. In conclusion, despite the high potential of telemedicine systems, there is still a need for better quality of evidence in order to confirm their feasibility in the ED.
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Affiliation(s)
- Ali Sharifi Kia
- Master of Science degree in Health Informatics, Department of Health Information Management, School of Health Management & Information Sciences, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mouna Rafizadeh
- Master of Science degree in Health Information Technology, Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Leila Shahmoradi
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences (TUMS), No. 17, Farredanesh Alley, Ghods St, Enghelab Ave, Tehran, 14177-44361 Iran
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Cifarelli DT, Weir JS, Slusser JD, Smith TM, DeWitt R, Cifarelli CP. Telemedicine for Cranial Radiosurgery Patients in a Rural U.S. Population: Patterns and Predictors of Patient Utilization. Telemed J E Health 2022; 28:1317-1323. [PMID: 35076292 DOI: 10.1089/tmj.2021.0519] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Telemedicine retains potential for increasing access to specialty providers in underserved and rural communities. COVID-19 accelerated adoption of telehealth beyond rural populations, serving as a primary modality of patient-provider encounters for many nonemergent diagnoses. Methods: From 2020 to 2021, telemedicine was incorporated in management of stereotactic radiosurgery patients. Retrospective data on diagnoses, demographics, distance to primary clinic, and encounter type were captured and statistically analyzed using descriptive measures and Cox proportional regression modeling. Graphical representation of service areas was created using geo-mapping software. Results: Patients (n = 208) completed 331 telemedicine encounters over 12 months. Metastases and meningiomas comprised 60% of diagnoses. Median age was 62 years with median household income and residential population of $44,752 and 7,634 people. The one-way mean and median travel distances were 74.6 and 66.3 miles. The total potential road mileage for all patients was 44,596 miles. A total of 118 (57%) patients completed video visits during the first encounter, whereas 90 (43%) opted for telephone encounters. At 12 months, 138 patients (66%) utilized video visits and 70 (34%) used telephone visits. Predictors of video visit use were video-enabled visit during the first encounter (hazard ratio [HR] 2.806, p < 0.001), total potential distance traveled (HR 1.681, p < 0.05), and the need for more than one visit per year (HR 2.903, p < 0.001). Discussion: Telemedicine can be effective in radiosurgery practice with predictors of video-enabled use being pre-existing patient comfort levels with videoconferencing, total annual travel distance, and number of visits per year. Age, rural population status, and household income did not impact telemedicine use in our patient cohort.
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Affiliation(s)
- Daniel T Cifarelli
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
| | - Joshua S Weir
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Jenifer D Slusser
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Tanya M Smith
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
| | - Rebecca DeWitt
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
| | - Christopher P Cifarelli
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
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22
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Goulart BNGD, Lopes-Herrera SA, Amato CADLH, Fernandes FDM, Perissinoto J, Tamanaha AC, Souza APRD, Montenegro ACDA, Segeren L, Machado FP, Molini-Avejonas DR. Brazilian phonoaudiology telepractice before and during the COVID-19 pandemic. REVISTA CEFAC 2022. [DOI: 10.1590/1982-0216/20222418721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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23
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Choi J, Petrone A, Adcock A. A Case for the Non-Neurologist Telestroke Provider. Front Neurol 2021; 12:651519. [PMID: 34421782 PMCID: PMC8377720 DOI: 10.3389/fneur.2021.651519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. We hypothesize that rates of tPA recommendation, sensitivity of final diagnosis, and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations. Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center over 1 year. Statistical analysis: Chi squared test. Results: Three hundred and three consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non-stroke-trained neurologists, and 59% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine-trained, stroke neurology-trained and other neurology- trained provider groups, respectively (p = 0.427). Sensitivity of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group. Discussion/Conclusion: Our results did not illustrate any statistically significant difference between care provided by an emergency medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore, may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.
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Affiliation(s)
- Justin Choi
- School of Medicine, West Virginia University, Morgantown, WV, United States
| | - Ashley Petrone
- Department of Neurology, West Virginia University Hospitals, Morgantown, WV, United States
| | - Amelia Adcock
- Department of Neurology, West Virginia University Hospitals, Morgantown, WV, United States.,Department of Neurology, Mayo Clinic, Phoenix, AZ, United States
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24
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Cruz MJ, Nieblas-Bedolla E, Young CC, Feroze AH, Williams JR, Ellenbogen RG, Levitt MR. United States Medicolegal Progress and Innovation in Telemedicine in the Age of COVID-19: A Primer for Neurosurgeons. Neurosurgery 2021; 89:364-371. [PMID: 34133724 PMCID: PMC8344865 DOI: 10.1093/neuros/nyab185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/03/2021] [Indexed: 01/14/2023] Open
Abstract
Telemedicine has received increased attention in recent years as a potential solution to expand clinical capability and patient access to care in many fields, including neurosurgery. Although patient and physician attitudes are rapidly shifting toward greater telemedicine use in light of the COVID-19 pandemic, there remains uncertainty about telemedicine's regulatory future. Despite growing evidence of telemedicine's utility, there remain a number of significant medicolegal barriers to its mass adoption and wider implementation. Herein, we examine recent progress in state and federal regulations in the United States governing telemedicine's implementation in quality of care, finance and billing, privacy and confidentiality, risk and liability, and geography and interstate licensure, with special attention to how these concern teleneurosurgical practice. We also review contemporary topics germane to the future of teleneurosurgery, including the continued expansion of reciprocity in interstate licensure, expanded coverage for homecare services for chronic conditions, expansion of Center for Medicare and Medicaid Services reimbursements, and protections of store-and-forward technologies. Additionally, we discuss recent successes in teleneurosurgery, stroke care, and rehabilitation as models for teleneurosurgical best practices. As telemedicine technology continues to mature and its expanse grows, neurosurgeons' familiarity with its benefits, limitations, and controversies will best allow for its successful adoption in our field to maximize patient care and outcomes.
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Affiliation(s)
- Michael J Cruz
- School of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Abdullah H Feroze
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - John R Williams
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Stroke and Applied Neurosciences Center, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Stroke and Applied Neurosciences Center, University of Washington, Seattle, Washington, USA
- Department of Radiology, University of Washington, Seattle, Washington, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
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25
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Luchowski P, Szmygin M, Wojczal J, Prus K, Sojka M, Luchowska E, Rejdak K. Stroke patients from rural areas have lower chances for long-term good clinical outcome after mechanical thrombectomy. Clin Neurol Neurosurg 2021; 206:106687. [PMID: 34015697 DOI: 10.1016/j.clineuro.2021.106687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study evaluated 3-months clinical outcome after mechanical thrombectomy (MT) in stroke patients transferred to a comprehensive stroke center (CSC) from a rural and urban areas in a Lubelskie province, the third largest province in Poland. MATERIALS AND METHODS Acute stroke patients with a premorbid modified Rankin scale (mRS) score 0-2 who were admitted within 6 h after stroke onset and treated with MT between 2016 and 2020 were retrospectively analyzed. Patients from rural and urban areas transported directly to CSC were compared regarding the onset-to-groin time, reperfusion rate, symptomatic intracranial hemorrhage (sICH) and favourable clinical outcome (modified Rankin Scale score 0-2) 3-months after MT. RESULTS A total of 398 patients were analyzed: 179 from rural areas (RA) and 219 from urban areas (UA). There was no significant difference in baseline neurological deficit expressed in The National Institutes of Health Stroke Scale (median 18.4 for RA patients versus 18.1 for UA patients, p = 0.70). Time from stroke onset to groin puncture was significantly shorter in the UA patients (median 197.3 min versus 219.6 min, p = 0.004). There was a significant difference in 3 months favourable clinical outcome between these two groups (31.3% of RA patients versus 42.5% of UA patients, p = 0.021) and full recovery rates (5.6% of RA patients versus 15.0% of UA patients, p = 0.002). The rate of sICH and 3-months mortality was similar in both groups (7.3% of RA patients versus 8.7% of UA patients, p = 0.61% and 21.8% of RA group vs. 22.4% of UA group, p = 0.88, respectively). CONCLUSION Stroke patients from RA undergoing thrombectomy had worse functional outcome compared to UA patients. Since the benefit of MT is time dependent, urban-rural differences in stroke outcome probably result from the longer time from stroke onset to reperfusion treatment in RA patients.
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Affiliation(s)
- Piotr Luchowski
- Department of Neurology, Medical University of Lublin, Poland.
| | - Maciej Szmygin
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Poland
| | - Joanna Wojczal
- Department of Neurology, Medical University of Lublin, Poland
| | - Katarzyna Prus
- Department of Neurology, Medical University of Lublin, Poland
| | - Michał Sojka
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Poland
| | - Elżbieta Luchowska
- Department of Laboratory Diagnostics, Medical University of Lublin, Poland
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Poland
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26
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Purohit A, Smith J, Hibble A. Does telemedicine reduce the carbon footprint of healthcare? A systematic review. Future Healthc J 2021; 8:e85-e91. [PMID: 33791483 DOI: 10.7861/fhj.2020-0080] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In the rapidly progressing field of telemedicine, there is a multitude of evidence assessing the effectiveness and financial costs of telemedicine projects; however, there is very little assessing the environmental impact despite the increasing threat of the climate emergency. This report provides a systematic review of the evidence on the carbon footprint of telemedicine. The identified papers unanimously report that telemedicine does reduce the carbon footprint of healthcare, primarily by reduction in transport-associated emissions. The carbon footprint savings range between 0.70-372 kg CO2e per consultation. However, these values are highly context specific. The carbon emissions produced from the use of the telemedicine systems themselves were found to be very low in comparison to emissions saved from travel reductions. This could have wide implications in reducing the carbon footprint of healthcare services globally. In order for telemedicine services to be successfully implemented, further research is necessary to determine context-specific considerations and potential rebound effects.
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27
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Lazarus G, Permana AP, Nugroho SW, Audrey J, Wijaya DN, Widyahening IS. Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis. Brain Behav 2020; 10:e01787. [PMID: 32812380 PMCID: PMC7559631 DOI: 10.1002/brb3.1787] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The potential of telestroke implementation in resource-limited areas has yet to be systematically evaluated. This study aims to investigate the implementation of telestroke on acute stroke care in rural areas. METHODS Eligible studies published up to November 2019 were included in this study. Randomized trials were further evaluated for risk of bias with Cochrane RoB 2, while nonrandomized studies with ROBINS-I tool. Random effects model was utilized to estimate effect sizes, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. RESULTS The search yielded 19 studies involving a total of 28,496 subjects, comprising of prehospital and in-hospital telestroke interventions in the form of mobile stroke units and hub-and-spoke hospitals network, respectively. Telestroke successfully increased the proportion of patients treated ≤3 hr (OR 2.15; 95% CI 1.37-3.40; I2 = 0%) and better three-month functional outcome (OR 1.29; 95% CI 1.01-1.63; I2 = 44%) without increasing symptomatic intracranial hemorrhage rate (OR 1.27; 0.65-2.49; I2 = 0%). Furthermore, telestroke was also associated with shorter onset-to-treatment time (mean difference -27.97 min; 95% CI -35.51, -20.42; I2 = 63%) and lower in-hospital mortality rate (OR 0.67; 95% CI 0.52-0.87; I2 = 0%). GRADE assessments yielded low-to-moderate certainty of body evidences. CONCLUSION Telestroke implementation in rural areas was associated with better clinical outcomes as compared to usual care. Its integration in both prehospital and in-hospital settings could help optimize emergency stroke approach. Further studies with higher-level evidence are needed to confirm these findings.
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Affiliation(s)
- Gilbert Lazarus
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Affan Priyambodo Permana
- Department of Neurosurgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Setyo Widi Nugroho
- Department of Neurosurgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Jessica Audrey
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | - Indah Suci Widyahening
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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