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Bulmer T, Volders D, Blake J, Kamal N. Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals. Front Neurol 2021; 12:746404. [PMID: 34777215 PMCID: PMC8586711 DOI: 10.3389/fneur.2021.746404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements. Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site. Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively. Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.
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Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional and Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - John Blake
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
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Fulop NJ, Ramsay AIG, Hunter RM, McKevitt C, Perry C, Turner SJ, Boaden R, Papachristou I, Rudd AG, Tyrrell PJ, Wolfe CDA, Morris S. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background
Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes.
Objective
To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented.
Design
Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; ≈210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes.
Results
Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality [–1.1%, 95% confidence interval (CI) –2.1% to –0.1%], resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% (95% CI 65.6% to 67.1%); comparator = 54.4% (95% CI 53.6% to 55.1%)]. Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS (–2.0 days, 95% CI –2.8 to –1.2 days) only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS (–1.5 days, 95% CI –2.5 to –0.4 days) and clinical interventions [e.g. SU within 4 hours: GMB = 79.1% (95% CI 77.9% to 80.4%); comparator = 53.4% (95% CI 53.0% to 53.7%)] but not on mortality (–1.3%, 95% CI –2.7% to 0.01%; p = 0.05, accounting for reductions observed in RoE); however, there was a significant effect when examining GMB HASUs only (–1.8%, 95% CI –3.4% to –0.2%), resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context.
Limitations
The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views.
Conclusions
Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Angus IG Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Christopher McKevitt
- Department of Population Health Sciences, School of Population Health & Environmental Sciences Research, King’s College London, London, UK
| | - Catherine Perry
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Simon J Turner
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Ruth Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | - Anthony G Rudd
- Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
| | - Pippa J Tyrrell
- Stroke and Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Charles DA Wolfe
- Department of Population Health Sciences, School of Population Health & Environmental Sciences Research, King’s College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
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Morris S, Ramsay AIG, Boaden RJ, Hunter RM, McKevitt C, Paley L, Perry C, Rudd AG, Turner SJ, Tyrrell PJ, Wolfe CDA, Fulop NJ. Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data. BMJ 2019; 364:l1. [PMID: 30674465 PMCID: PMC6334718 DOI: 10.1136/bmj.l1] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To investigate whether further centralisation of acute stroke services in Greater Manchester in 2015 was associated with changes in outcomes and whether the effects of centralisation of acute stroke services in London in 2010 were sustained. DESIGN Retrospective analyses of patient level data from the Hospital Episode Statistics (HES) database linked to mortality data from the Office for National Statistics, and the Sentinel Stroke National Audit Programme (SSNAP). SETTING Acute stroke services in Greater Manchester and London, England. PARTICIPANTS 509 182 stroke patients in HES living in urban areas admitted between January 2008 and March 2016; 218 120 stroke patients in SSNAP between April 2013 and March 2016. INTERVENTIONS Hub and spoke models for acute stroke care. MAIN OUTCOME MEASURES Mortality at 90 days after hospital admission; length of acute hospital stay; treatment in a hyperacute stroke unit; 19 evidence based clinical interventions. RESULTS In Greater Manchester, borderline evidence suggested that risk adjusted mortality at 90 days declined overall; a significant decline in mortality was seen among patients treated at a hyperacute stroke unit (difference-in-differences -1.8% (95% confidence interval -3.4 to -0.2)), indicating 69 fewer deaths per year. A significant decline was seen in risk adjusted length of acute hospital stay overall (-1.5 (-2.5 to -0.4) days; P<0.01), indicating 6750 fewer bed days a year. The number of patients treated in a hyperacute stroke unit increased from 39% in 2010-12 to 86% in 2015/16. In London, the 90 day mortality rate was sustained (P>0.05), length of hospital stay declined (P<0.01), and more than 90% of patients were treated in a hyperacute stroke unit. Achievement of evidence based clinical interventions generally remained constant or improved in both areas. CONCLUSIONS Centralised models of acute stroke care, in which all stroke patients receive hyperacute care, can reduce mortality and length of acute hospital stay and improve provision of evidence based clinical interventions. Effects can be sustained over time.
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Affiliation(s)
- Stephen Morris
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
| | - Ruth J Boaden
- Alliance Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK
| | - Christopher McKevitt
- Department of Population Health Sciences, School of Population Heath and Environmental Sciences, King's College London, London SE1 1UL, UK
| | - Lizz Paley
- Stroke Programme, Royal College of Physicians, London, UK
| | - Catherine Perry
- Alliance Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Anthony G Rudd
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Simon J Turner
- Health Policy, Politics and Organisation (HiPPO) Research Group, Centre for Primary Care, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Pippa J Tyrrell
- Stroke and Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford M6 8HD, UK
| | - Charles D A Wolfe
- Department of Population Health Sciences, School of Population Heath and Environmental Sciences, King's College London, London SE1 1UL, UK
- National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London SE1 9RT, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
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Liu X, Wen S, Zhao S, Yan F, Zhao S, Wu D, Ji X. Mild Therapeutic Hypothermia Protects the Brain from Ischemia/Reperfusion Injury through Upregulation of iASPP. Aging Dis 2018; 9:401-411. [PMID: 29896428 PMCID: PMC5988595 DOI: 10.14336/ad.2017.0703] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/03/2017] [Indexed: 11/16/2022] Open
Abstract
Mild therapeutic hypothermia, a robust neuroprotectant, reduces neuronal apoptosis, but the precise mechanism is not well understood. Our previous study showed that a novel inhibitor of an apoptosis-stimulating protein of p53 (iASPP) might be involved in neuronal death after stroke. The aim of this study was to confirm the role of iASPP after stroke treated with mild therapeutic hypothermia. To address this, we mimicked ischemia/reperfusion injury in vitro by using oxygen-glucose deprivation/reperfusion (OGD/R) in primary rat neurons. In our in vivo approach, we induced middle cerebral artery occlusion (MCAO) for 60 min in C57/B6 mice. From the beginning of ischemia, focal mild hypothermia was applied for two hours. To evaluate the role of iASPP, small interfering RNA (siRNA) was injected intracerebroventricularly. Our results showed that mild therapeutic hypothermia increased the expression of iASPP and decreased the expression of its targets, Puma and Bax, and an apoptosis marker, cleaved caspase-3, in primary neurons under OGD/R. Increased iASPP expression and decreased ASPP1/2 expression were observed under hypothermia treatment in MCAO mice. iASPP siRNA (iASPPi) or hypothermia plus iASPPi application increased infarct volume, apoptosis and aggravated the neurological deficits in MCAO mice. Furthermore, iASPPi downregulated iASPP expression, and upregulated the expression of proapoptotic effectors, Puma, Bax and cleaved caspase-3, in mice after stroke treated with mild therapeutic hypothermia. In conclusion, mild therapeutic hypothermia protects against ischemia/reperfusion brain injury in mice by upregulating iASPP and thus attenuating apoptosis. iASPP may be a potential target in the therapy of stroke.
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Affiliation(s)
- Xiangrong Liu
- 1China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,2 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China.,3Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shaohong Wen
- 1China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,2 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China.,3Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shunying Zhao
- 1China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Yan
- 2 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China.,3Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shangfeng Zhao
- 4Department of Neurosurgery, Beijing Tongren Hospital, Capital University of Medical Sciences, Beijing, China
| | - Di Wu
- 1China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,2 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Xunming Ji
- 1China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,2 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China.,3Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China.,5Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
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Halvorsrud K, Flynn D, Ford GA, McMeekin P, Bhalla A, Balami J, Craig D, White P. A Delphi study and ranking exercise to support commissioning services: future delivery of Thrombectomy services in England. BMC Health Serv Res 2018; 18:135. [PMID: 29471828 PMCID: PMC5824465 DOI: 10.1186/s12913-018-2922-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/06/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Intra-arterial thrombectomy is the gold standard treatment for large artery occlusive stroke. However, the evidence of its benefits is almost entirely based on trials delivered by experienced neurointerventionists working in established teams in neuroscience centres. Those responsible for the design and prospective reconfiguration of services need access to a comprehensive and complementary array of information on which to base their decisions. This will help to ensure the demonstrated effects from trials may be realised in practice and account for regional/local variations in resources and skill-sets. One approach to elucidate the implementation preferences and considerations of key experts is a Delphi survey. In order to support commissioning decisions, we aimed using an electronic Delphi survey to establish consensus on the options for future organisation of thrombectomy services among physicians with clinical experience in managing large artery occlusive stroke. METHODS A Delphi survey was developed with 12 options for future organisation of thrombectomy services in England. A purposive sampling strategy established an expert panel of stroke physicians from the British Association of Stroke Physicians (BASP) Clinical Standards and/or Executive Membership that deliver 24/7 intravenous thrombolysis. Options with aggregate scores falling within the lowest quartile were removed from the subsequent Delphi round. Options reaching consensus following the two Delphi rounds were then ranked in a final exercise by both the wider BASP membership and the British Society of Neuroradiologists (BSNR). RESULTS Eleven stroke physicians from BASP completed the initial two Delphi rounds. Three options achieved consensus, with subsequently wider BASP (97%, n = 43) and BSNR members (86%, n = 21) assigning the highest approval rankings in the final exercise for transferring large artery occlusive stroke patients to nearest neuroscience centre for thrombectomy based on local CT/CT Angiography. CONCLUSIONS The initial Delphi rounds ensured optimal reduction of options by an expert panel of stroke physicians, while subsequent ranking exercises allowed remaining options to be ranked by a wider group of experts within stroke to reach consensus. The preferred implementation option for thrombectomy is investigating suspected acute stroke patients by CT/CT Angiography and secondary transfer of large artery occlusive stroke patients to the nearest neuroscience (thrombectomy) centre.
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Affiliation(s)
- Kristoffer Halvorsrud
- Institute of Health and Society Newcastle University, Newcastle Upon Tyne, UK
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Darren Flynn
- Institute of Health and Society Newcastle University, Newcastle Upon Tyne, UK
| | - Gary A. Ford
- Institute of Neuroscience, Newcastle University, 3-4, Claremont Terrace, Newcastle upon Tyne, NE2 4AX UK
- Oxford University Hospitals NHS Trust and Oxford University, Oxford, UK
| | - Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle Upon Tyne, UK
| | - Ajay Bhalla
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Joyce Balami
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - Dawn Craig
- Institute of Health and Society Newcastle University, Newcastle Upon Tyne, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, 3-4, Claremont Terrace, Newcastle upon Tyne, NE2 4AX UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Liu X, Wu D, Wen S, Zhao S, Xia A, Li F, Ji X. Mild therapeutic hypothermia protects against cerebral ischemia/reperfusion injury by inhibiting miR-15b expression in rats. Brain Circ 2017; 3:219-226. [PMID: 30276328 PMCID: PMC6057705 DOI: 10.4103/bc.bc_15_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/10/2017] [Accepted: 07/24/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Mild hypothermia has a protective effect on ischemic stroke, but the mechanisms remain elusive. Here, we investigated microRNA (miRNA) profiles and the specific role of miRNAs in ischemic stroke treated with mild hypothermia. MATERIALS AND METHODS Male adult Sprague Dawley rats were subjected to focal transient cerebral ischemia. Mild hypothermia was induced by applying ice packs around the neck and head of the animals. miRNAs expression profiles were detected in ischemic stroke treated with mild therapeutic hypothermia through miRNA chips. Reverse transcription-polymerase chain reaction (RT-PCR) was used to verify the change of miRNA array. Western blot and adenosine triphosphate (ATP) assay kits were used to detect the changes of protein expression and ATP levels, respectively. miR-15b mimic and its control were injected into the right lateral ventricle 60 min before the induction of ischemia. RESULTS The results showed that mild hypothermia affected miRNAs profiles expression. We verified the expression of miR-15b and miR-598-3p by miRNA RT-PCR. miR-15b mimic inhibited the expression of its target, ADP ribosylation factor-like 2 (Arl2) protein, and decreased ATP levels in PC12 cells. Compared with the control, miR-15b mimic increased the infarct volume and aggravated the neurological function under normothermia or hypothermia treatment. Furthermore, the expression of Arl2 was decreased in the miR-15b mimic group under normothermia or hypothermia treatment. CONCLUSIONS Mild therapeutic hypothermia affected miRNA profiles and protected against cerebral ischemia/reperfusion by inhibiting miR-15b expression in rats. miR-15b may be a potential target for therapeutic intervention in stroke.
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Affiliation(s)
- Xiangrong Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, PR China
- China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing 100053, PR China
| | - Di Wu
- China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing 100053, PR China
| | - Shaohong Wen
- China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing 100053, PR China
| | - Shunying Zhao
- China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing 100053, PR China
| | - Ao Xia
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, PR China
- China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Fang Li
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, PR China
- China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, PR China
- China-America Joint Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing 100053, PR China
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, PR China
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Guillon B, Bourcier R, Toulgoat F, de Gaalon S, Gaultier-Lintia A, Sévin M. Gestione dell’infarto cerebrale acuto. Neurologia 2016. [DOI: 10.1016/s1634-7072(16)80382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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9
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Morris S, Hunter RM, Ramsay AIG, Boaden R, McKevitt C, Perry C, Pursani N, Rudd AG, Schwamm LH, Turner SJ, Tyrrell PJ, Wolfe CDA, Fulop NJ. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014; 349:g4757. [PMID: 25098169 PMCID: PMC4122734 DOI: 10.1136/bmj.g4757] [Citation(s) in RCA: 154] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate whether centralisation of acute stroke services in two metropolitan areas of England was associated with changes in mortality and length of hospital stay. DESIGN Analysis of difference-in-differences between regions with patient level data from the hospital episode statistics database linked to mortality data supplied by the Office for National Statistics. SETTING Acute stroke services in Greater Manchester and London, England. PARTICIPANTS 258,915 patients with stroke living in urban areas and admitted to hospital in January 2008 to March 2012. INTERVENTIONS "Hub and spoke" model for acute stroke care. In London hyperacute care was provided to all patients with stroke. In Greater Manchester hyperacute care was provided to patients presenting within four hours of developing symptoms of stroke. MAIN OUTCOME MEASURES Mortality from any cause and at any place at 3, 30, and 90 days after hospital admission; length of hospital stay. RESULTS In London there was a significant decline in risk adjusted mortality at 3, 30, and 90 days after admission. At 90 days the absolute reduction was -1.1% (95% confidence interval -2.1 to -0.1; relative reduction 5%), indicating 168 fewer deaths (95% confidence interval 19 to 316) during the 21 month period after reconfiguration in London. In both areas there was a significant decline in risk adjusted length of hospital stay: -2.0 days in Greater Manchester (95% confidence interval -2.8 to -1.2; 9%) and -1.4 days in London (-2.3 to -0.5; 7%). Reductions in mortality and length of hospital stay were largely seen among patients with ischaemic stroke. CONCLUSIONS A centralised model of acute stroke care, in which hyperacute care is provided to all patients with stroke across an entire metropolitan area, can reduce mortality and length of hospital stay.
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Affiliation(s)
- Stephen Morris
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
| | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
| | - Ruth Boaden
- Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Christopher McKevitt
- Division of Health and Social Care Research, School of Medicine, King's College London, London SE1 3QD, UK
| | - Catherine Perry
- Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Nanik Pursani
- King's College London Stroke Research Patients and Family Group, Division of Health and Social Care Research, School of Medicine, King's College London, London SE1 3QD, UK
| | - Anthony G Rudd
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Simon J Turner
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
| | - Pippa J Tyrrell
- University of Manchester Stroke and Vascular Centre, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford M6 8HD, UK
| | - Charles D A Wolfe
- Division of Health and Social Care Research, School of Medicine, King's College London, London SE1 3QD, UK National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
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van Dishoeck AM, Dippel DWJ, Dirks M, Looman CWN, Mackenbach JP, Steyerberg EW. Measuring Quality Improvement in Acute Ischemic Stroke Care: Interrupted Time Series Analysis of Door-to-Needle Time. Cerebrovasc Dis Extra 2014; 4:149-55. [PMID: 25076959 PMCID: PMC4105950 DOI: 10.1159/000363535] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/08/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of acute stroke treatment, and is reflected in the widely used performance indicator 'door-to-needle time' (DNT). DNT measures the time from the moment the patient enters the emergency department until he/she receives intravenous rtPA. The purpose of the study was to measure quality improvement from the first implementation of thrombolysis in stroke patients in a university hospital in the Netherlands. We further aimed to identify specific interventions that affect DNT. METHODS We included all patients with acute ischemic stroke consecutively admitted to a large university hospital in the Netherlands between January 2006 and December 2012, and focused on those treated with thrombolytic therapy on admission. Data were collected routinely for research purposes and internal quality measurement (the Erasmus Stroke Study). We used a retrospective interrupted time series design to study the trend in DNT, analyzed by means of segmented regression. RESULTS Between January 2006 and December 2012, 1,703 patients with ischemic stroke were admitted and 262 (17%) were treated with rtPA. Patients treated with thrombolysis were on average 63 years old at the time of the stroke and 52% were male. Mean age (p = 0.58) and sex distribution (p = 0.98) did not change over the years. The proportion treated with thrombolysis increased from 5% in 2006 to 22% in 2012. In 2006, none of the patients were treated within 1 h. In 2012, this had increased to 81%. In a logistic regression analysis, this trend was significant (OR 1.6 per year, CI 1.4-1.8). The median DNT was reduced from 75 min in 2006 to 45 min in 2012 (p < 0.001 in a linear regression model). In this period, a 12% annual decrease in DNT was achieved (CI from 16 to 8%). We could not find a significant association between any specific intervention and the trend in DNT. CONCLUSION AND IMPLICATIONS The DNT steadily improved from the first implementation of thrombolysis. Specific explanations for this improvement require further study, and may relate to the combined impact of a series of structural and logistic interventions. Our results support the use of performance measures for internal communication. Median DNT should be used on a monthly or quarterly basis to inform all professionals treating stroke patient of their achievements.
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Affiliation(s)
- Anne Margreet van Dishoeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maaike Dirks
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Caspar W N Looman
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan P Mackenbach
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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