Factors associated with the administration of tissue plasminogen activator for acute ischemic stroke

Public and outpatients’ awareness of calling emergency medical services immediately by acute stroke in an upper middle-income country: a cross-sectional questionnaire study in greater Gaborone, Botswana

Objectives

In this cross-sectional study from Botswana, we investigated awareness of calling emergency medical services (EMS) and seeking immediate medical assistance by acute stroke among stroke risk outpatients and public.

Method

Closed-ended questionnaires on awareness of calling EMS and seeking immediate medical assistance by acute stroke, were administered by research assistants to a representative selection of outpatients and public.

Results

The response rate was 96.0% (93.0% for public (2013) and 96.6% for outpatients (795)). Public respondents had mean age of 36.1 ± 14.5 years (age range 18–90 years) and 54.5% were females, while outpatients had mean age of 37.4 ± 12.7 years (age range 18–80 years) and 58.1% were females.

Awareness of calling EMS (78.3%), and of seeking immediate medical assistance (93.1%) by stroke attack was adequate. For calling EMS by acute stroke, outpatients had higher awareness than the public (p < 0.05) among those with unhealthy diet (90.9% vs 71.1%), family history of both stroke and heart diseases (90.7% vs 61.2%), no history of psychiatric diseases (93.2% vs 76.0%) and sedentary lifestyle (87.5% vs 74.8%).

Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight.

Male gender, ≥50 years age, primary education, family history of both stroke and heart diseases, current smoking, no history of HIV/AIDS, and light physical activity were predictors of low awareness of need for calling EMS.

Conclusion

Results call for educational campaigns on awareness of calling EMS and seeking immediate medical assistance among those with high risk factor levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02859-z.

• This is the first study comparing awareness of calling EMS among outpatients and public in sub-Saharan Africa

• Awareness of calling EMS or seeking immediate medical services by acute stroke was adequate among both outpatients and public

• Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight

• Results call for educational campaigns on awareness of calling EMS/ seeking immediate medical assistance by stroke.

A Clinical Observation of Intravenous Thrombolysis in Acute Ischemic Stroke with Minor Trauma

OBJECTIVE

This study aimed to observe the curative effect of intravenous thrombolysis with alteplase in patients with acute ischemic stroke and minor trauma.

METHODS

The data of 25 patients with minor trauma who were treated in our department from January to December 2018 were analyzed retrospectively (observation group), and during the same period, 25 thrombolytic patients were enrolled as the control group. Brain computed tomography (CT) was performed before and at three days after thrombolysis. NIHSS scores were recorded before thrombolysis and at one, three, and seven days after thrombolysis. Additionally, bleeding rate after thrombolysis and 90-day mRS scores were recorded.

RESULTS

The differences in 1-day, 3-day, and 7-day NIHSS scores and 90-day mRS scores between the two groups were not statistically significant (P>0.05). The bleeding rate was higher in the observation group than in the control group, and this was statistically significant (P<0.05).

CONCLUSION

Intravenous thrombolysis with alteplase has a good curative effect in acute ischemic stroke patients with minor trauma. The bleeding rate was significantly higher than in the control group, but there was no significant difference in the long-term curative effect.

Cerebral Thrombolysis in Rural Residents Aged ≥ 80

Purpose

The proportion of older people in Poland is higher in rural areas than in urban areas. Thus, we aimed to evaluate treatment rate and factors associated with outcome and safety of intravenous thrombolysis (IVT) in rural residents aged ≥80 years admitted to primary stroke centers.

Patients and Methods

This study was a retrospective, observational cohort study of 873 patients treated with recombinant tissue plasminogen activator (rt-PA) in primary stroke centers between February 1, 2009 and December 31, 2017. Among them were 527 rural residents and 231 (26.5%) were ≥80 years of age. The analyses between rural and urban patients aged ≥80 and between rural patients aged <80 and aged ≥80 were performed.

Results

The proportion of patients aged ≥80 treated with rt-PA was comparable in rural and urban residents (27.9% vs 24.3% p = 0.24). Rural patients aged ≥80 were also characterized by lower incidence of cardiovascular risk factors and better patients’ conditions on admission to hospital. Symptomatic intracerebral hemorrhage rate among ≥80-year-old stroke patients was lower in those living in rural areas than in those living in urban areas (5.4% vs 14.3%, p = 0.02); there were no differences regarding mortality and 3-month functional outcome between both populations. The older group of rural patients was characterized by a higher 3-month mortality (28.5% vs 12.6%, p < 0.001) and lower functional independence rate (34.0% vs 50.5%, p < 0.001) than rural younger patients. Antiplatelet (OR 2.43, 95% CI 1.04–5.66, p = 0.04) and anticoagulant therapy before stroke (OR 3.64, 95% CI 1.21–10.99, p = 0.022), early ischemic changes in baseline computerized tomograprpahy (OR 2.65, 95% CI 1.03–6.82, p = 0.043) were associated with unfavorable outcome; and higher National Institute of Health Stroke Scale score on admission (OR 1.01, 95% CI 1.01–1.20, p = 0.039), higher baseline count of white blood cells (OR 1.33, 95% CI 1.10–0.62, p = 0.003) were associated with mortality in rural patients over 80.

Conclusion

We suggest that rural patients aged ≥80 may be safely treated with IVT in routine practice. However, lower efficacy and a higher mortality must be considered in former use of Vitamin K antagonist and antiplatelet or high white blood cells count.

Sex differences in IV thrombolysis treatment for acute ischemic stroke

Objective

A prior meta-analysis of reports published between 2000 and 2008 found that women were 30% less likely to receive IV recombinant tissue plasminogen activator (rtPA) treatment for stroke than men; we updated this meta-analysis to determine if this sex difference persisted.

Methods

We identified studies that reported sex-specific IV rtPA treatment rates for acute ischemic stroke published between 2008 and 2018. Eligible studies included representative populations of patients with ischemic stroke from hospital-based, registry-based, or administrative data. Random effects odds ratios (ORs) were generated to quantify sex differences.

Results

Twenty-four eligible studies were identified during this 10-year period. The summary unadjusted OR based on 17 studies with data on all ischemic stroke patients was 0.87 (95% confidence interval [CI], 0.82–0.93), indicating that women had 13% lower odds of receiving IV rtPA treatment than men. However, substantial between-study variability existed. Lower treatment odds in women were also observed in 7 studies that provided data on the subgroup of patients eligible for IV rtPA treatment, although the summary OR of 0.95 (95% CI, 0.88–1.02) was not statistically significant. Examination of time trends across 33 studies published between 2000 and 2018 found evidence that the sex difference had narrowed in more recent years.

Conclusions

Although there is considerable variability in the findings of individual studies, pooled data from recent studies show that women with acute stroke are less likely to be treated with IV thrombolysis compared with men. However, the size of this difference has narrowed compared to studies published before 2008.

Use of emergency medical transport and impact on time to care in patients with ischaemic stroke

INTRODUCTION

According to numerous studies, using emergency medical services (EMS) to transport stroke patients to hospitals decreases diagnostic and treatment delays.

OBJECTIVES

To determine the frequency of use of EMS by stroke patients in Bizkaia (Spain), analyse the factors associated with using EMS, and study the impact of EMS on time to care.

METHODS

We gathered data from 545 patients hospitalised for acute ischaemic stroke and recruited consecutively. Data were obtained from the patients' medical histories and interviews with the patients themselves or their companions. We studied the following variables: previous health status, stroke symptoms and severity (NIHSS), type of transport, and time to medical care. Univariate and multivariate analyses were performed to identify factors associated with use of EMS and care delays.

RESULTS

Patients transported to hospital by the EMS accounted for 47.2% of the total. Greater stroke severity, arriving at the hospital at night, and poor functional status at baseline were found to be independently associated with use of EMS. Use of EMS was linked to earlier arrival at the hospital. Door-to-imaging times were shorter in the EMS group; however, this association disappeared after adjusting for stroke severity. Revascularisation was more frequent among patients transported by the EMS.

CONCLUSIONS

EMS transport was associated with shorter prehospital delays. Effective health education programmes should be developed to promote EMS transport for patients with stroke symptoms. In-hospital stroke management should also be improved to reduce time to medical care.

How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care

BACKGROUND

Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke.

METHODS

Published original English-language research from four electronic databases spanning 1997-2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted.

RESULTS

Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio = 2.1, p = 0.05).

CONCLUSIONS

In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients.

The effect of centralization of health care services on travel time and its equality

OBJECTIVES

To analyze the regional variations in travel time between patient residences and medical facilities for the treatment of ischemic heart disease and breast cancer, and to simulate the effects of health care services centralization on travel time and equality of access.

METHODS

We used medical insurance claims data for inpatients and outpatients for the two target diseases that had been filed between September 2008 and May 2009 in Kyoto Prefecture, Japan. Using a geographical information system, patient travel times were calculated based on the driving distance between patient residences and hospitals via highways and toll roads. Locations of residences and hospital locations were identified using postal codes. We then conducted a simulation analysis of centralization of health care services to designated regional core hospitals. The simulated changes in potential spatial access to care were examined.

RESULTS

Inequalities in access to care were examined using Gini coefficients, which ranged from 0.4109 to 0.4574. Simulations of health care services centralization showed reduced travel time for most patients and overall improvements in equality of access, except in breast cancer outpatients.

CONCLUSION

Our findings may contribute to the decision-making process in policies aimed at improving the potential spatial access to health care services.