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Choy J, Pourkazemi F, Bogaardt H, Anderson C, Chai SY, Pebdani RN. "One of the biggest grey areas": A focus group study exploring dosage of swallowing exercises from speech-language pathologist perspectives. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 26:445-456. [PMID: 37652163 DOI: 10.1080/17549507.2023.2240038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Purpose: To explore the perspectives and practices of speech-language pathologists on dosage of swallowing exercises in stroke rehabilitation.Method: Online focus groups involved 20 speech-language pathologists working in various settings across Australia. Focus group data were recorded, deidentified, and analysed using inductive thematic analysis guided by an interpretivist phenomenological approach.Result: Analysis resulted in four main themes: (1) "Getting the most bang for your buck": Importance of dosage in swallowing, (2) "No patient is identical": Personalising swallowing exercise dosage to the patient, (3) "You've got what you should do, and then what you can do": Gap between recommendations and practical application, and (4) "Not much guidance out there about dosage": More research needed to guide dosage. Speech-language pathologists agreed that dosage was theoretically important for swallowing exercises, but practical application of dosage was impacted by patient factors, limited access to resources, and lack of research-based guidelines.Conclusion: Speech-language pathologists reported trying to provide optimal care despite multiple barriers to prescribing dosages of swallowing exercises in practice. Personalising exercise dosage to the patient, creative clinician strategies, improved and equitable access to resources, and research-based guidelines on swallowing exercise dosages are needed to address these barriers.
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Affiliation(s)
- Jacinda Choy
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, NSW, Australia
- HammondCare Braeside Hospital, Prairiewood, NSW, Australia
- Royal Rehab, Ryde, NSW, Australia
| | - Fereshteh Pourkazemi
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Hans Bogaardt
- School of Allied Health Science and Practice, University of Adelaide, Adelaide, SA, Australia
| | - Caitlin Anderson
- HammondCare Braeside Hospital, Prairiewood, NSW, Australia
- Nepean Hospital, Kingswood, NSW, Australia
| | - Shing Yee Chai
- HammondCare Braeside Hospital, Prairiewood, NSW, Australia
| | - Roxanna N Pebdani
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, Centre for Disability Research and Policy, The University of Sydney, Sydney, NSW, Australia
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2
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Ozdemir H, Sagris D, Abdul-Rahim AH, Lip GYH, Shantsila E. Management of ischaemic stroke survivors in primary care setting: the road to holistic care. Intern Emerg Med 2024; 19:609-618. [PMID: 37875703 PMCID: PMC11039521 DOI: 10.1007/s11739-023-03445-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/26/2023] [Indexed: 10/26/2023]
Abstract
The management of ischaemic stroke survivors is multidisciplinary, necessitating the collaboration of numerous medical professionals and rehabilitation specialists. However, due to the lack of comprehensive and holistic follow-up, their post-discharge management may be suboptimal. Achieving this holistic, patient-centred follow-up requires coordination and interaction of subspecialties, which general practitioners can provide as the first point of contact in healthcare systems. This approach can improve the management of stroke survivors by preventing recurrent stroke through an integrated post-stroke care, including appropriate Antithrombotic therapy, assisting them to have a Better functional and physiological status, early recognition and intervention of Comorbidities, and lifestyles. For such work to succeed, close interdisciplinary collaboration between primary care physicians and other medical specialists is required in a holistic or integrated way.
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Affiliation(s)
- Hizir Ozdemir
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Azmil Husin Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Gregory Yoke Hong Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Eduard Shantsila
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK.
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3
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Wang X, Yang J, You C, Bao X, Ma L. Efficacy and Safety of Bone Marrow Derived Stem Cell Therapy for Ischemic Stroke: Evidence from Network Meta-analysis. Curr Stem Cell Res Ther 2024; 19:1102-1110. [PMID: 37612871 DOI: 10.2174/1574888x18666230823094531] [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: 03/23/2023] [Revised: 06/26/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Several types of stem cells are available for the treatment of stroke patients. However, the optimal type of stem cell remains unclear. OBJECTIVE To analyze the effects of bone marrow-derived stem cell therapy in patients with ischemic stroke by integrating all available direct and indirect evidence in network meta-analyses. METHODS We searched several databases to identify randomized clinical trials comparing clinical outcomes of bone marrow-derived stem cell therapy vs. conventional treatment in stroke patients. Pooled relative risks (RRs) and mean differences (MDs) were reported. The surface under the cumulative ranking (SUCRA) was used to rank the probabilities of each agent regarding different outcomes. RESULTS Overall, 11 trials with 576 patients were eligible for analysis. Three different therapies, including mesenchymal stem cells (MSCs), mononuclear stem cells (MNCs), and multipotent adult progenitor cells (MAPCs), were assessed. The direct analysis demonstrated that stem cell therapy was associated with significantly reduced all-cause mortality rates (RR 0.55, 95% CI 0.33 to 0.93; I2=0%). Network analysis demonstrated MSCs ranked first in reducing mortality (RR 0.42, 95% CrI 0.15 to 0.86) and improving modified Rankin Scale score (MD -0.59 95% CI -1.09 to -0.09), with SUCRA values 80%, and 98%, respectively. Subgroup analysis showed intravenous transplantation was superior to conventional therapy in reducing all-cause mortality (RR 0.53, 95% CrI 0.29 to 0.88). CONCLUSION Using stem cell transplantation was associated with reduced risk of death and improved functional outcomes in patients with ischemic stroke. Additional large trials are warranted to provide more conclusive evidence.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Jingguo Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
- West China Brain Research Centre, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
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4
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Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke 2023; 18:499-531. [PMID: 36725717 DOI: 10.1177/17474930231156753] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. AIMS To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). SUMMARY OF REVIEW Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. CONCLUSION The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
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Affiliation(s)
- Gillian E Mead
- Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.,Heart & Brain Lab, Western University, London, ON, Canada.,Robarts Research Institute, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laetitia Yperzeele
- Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.,Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - P N Sylaja
- Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kelvin Hill
- Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA
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5
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Lobo EH, Abdelrazek M, Grundy J, Kensing F, Livingston PM, Rasmussen LJ, Islam SMS, Frølich A. Caregiver Engagement in Stroke Care: Opportunities and Challenges in Australia and Denmark. Front Public Health 2021; 9:758808. [PMID: 34900907 PMCID: PMC8661098 DOI: 10.3389/fpubh.2021.758808] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/04/2021] [Indexed: 01/01/2023] Open
Abstract
Globally, there is a rise in incident cases of stroke, particularly in low- and middle-income countries, due to obesity-related and lifestyle risk factors, including health issues such as high cholesterol, diabetes and hypertension. Since the early 20th century, stroke mortality has declined due to proper management of the risk factors and improved treatment practices. However, despite the decline in mortality, there is an increase in the levels of disability that requires long-term support. In countries such as Australia and Denmark, where most care is provided within the community; family members, generally spouses, assume the role of caregiver, with little to no preparation that affects the quality of care provided to the person living with stroke. While past research has highlighted aspects to improve caregiver preparedness of stroke and its impact on care; health planning, recovery, and public health policies rarely consider these factors, reducing engagement and increasing uncertainty. Hence, there is a need to focus on improving strategies during recovery to promote caregiver engagement. In this study, we, therefore, try to understand the needs of the caregiver in stroke that limit engagement, and processes employed in countries such as Australia and Denmark to provide care for the person with stroke. Based on our understanding of these factors, we highlight the potential opportunities and challenges to promote caregiving engagement in these countries.
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Affiliation(s)
- Elton H. Lobo
- School of Information Technology, Deakin University, Geelong, VIC, Australia
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mohamed Abdelrazek
- School of Information Technology, Deakin University, Geelong, VIC, Australia
| | - John Grundy
- Faculty of Information Technology, Monash University, Clayton, VIC, Australia
| | - Finn Kensing
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Lene J. Rasmussen
- Department of Cellular and Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | | | - Anne Frølich
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Innovation and Research Centre for Multimorbidity, Slagelse Hospital, Region Zealand, Denmark
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6
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Bivard A, Levi C, Lin L, Cheng X, Aviv R, Spratt NJ, Kleinig T, Butcher K, Chen C, Dong Q, Parsons M. Assessing the Relative Value of CT Perfusion Compared to Non-contrast CT and CT Angiography in Prognosticating Reperfusion-Eligible Acute Ischemic Stroke Patients. Front Neurol 2021; 12:736768. [PMID: 34566877 PMCID: PMC8458833 DOI: 10.3389/fneur.2021.736768] [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: 07/05/2021] [Accepted: 08/19/2021] [Indexed: 11/19/2022] Open
Abstract
In the present study we sought to measure the relative statistical value of various multimodal CT protocols at identifying treatment responsiveness in patients being considered for thrombolysis. We used a prospectively collected cohort of acute ischemic stroke patients being assessed for IV-alteplase, who had CT-perfusion (CTP) and CT-angiography (CTA) before a treatment decision. Linear regression and receiver operator characteristic curve analysis were performed to measure the prognostic value of models incorporating each imaging modality. One thousand five hundred and sixty-two sub-4.5 h ischemic stroke patients were included in this study. A model including clinical variables, alteplase treatment, and NCCT ASPECTS was weak (R2 0.067, P < 0.001, AUC 0.605) at predicting 90 day mRS. A second model, including dynamic CTA variables (collateral grade, occlusion severity) showed better predictive accuracy for patient outcome (R2 0.381, P < 0.001, AUC 0.781). A third model incorporating CTP variables showed very high predictive accuracy (R2 0.488, P < 0.001, AUC 0.899). Combining all three imaging modalities variables also showed good predictive accuracy for outcome but did not improve on the CTP model (R2 0.439, P < 0.001, AUC 0.825). CT perfusion predicts patient outcomes from alteplase therapy more accurately than models incorporating NCCT and/or CT angiography. This data has implications for artificial intelligence or machine learning models.
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Affiliation(s)
- Andrew Bivard
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Christopher Levi
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Neurology, John Hunter Hospital, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia
| | - Longting Lin
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Southwestern Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Richard Aviv
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Neil J Spratt
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Neurology, John Hunter Hospital, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia
| | - Tim Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kenneth Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Chushuang Chen
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Neurology, John Hunter Hospital, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia
| | - Qiang Dong
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Southwestern Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia
| | - Mark Parsons
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Southwestern Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia
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7
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Singh TP, Velu RB, Quigley F, Golledge J. Association of chronic venous disease with major adverse cardiovascular events. J Vasc Surg Venous Lymphat Disord 2021; 10:683-688. [PMID: 34506962 DOI: 10.1016/j.jvsv.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/29/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of the present study was to examine whether severe chronic venous disease (CVD) is associated with a greater risk of major adverse cardiovascular events (MACE) compared with mild CVD. METHODS Participants with CVD were prospectively recruited from outpatient vascular departments at two hospitals in North Queensland, Australia. CVD severity was ascertained by vascular specialists using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification. MACE, defined as myocardial infarction, stroke, or cardiovascular death, were identified from the outpatient follow-up and linked medical records. Kaplan-Meier and Cox proportional hazard analyses were used to examine the association of CVD severity with the occurrence of MACE. A subanalysis was performed in which participants with CEAP C5 and C6 (severe CVD) were compared with those with CEAP C2 to C4 (mild CVD). RESULTS A total of 774 participants were included and followed up for a median of 3.09 years (interquartile range, 1.09-8.14 years). The participants with C6 CVD (n = 69) had a threefold greater risk of MACE (hazard ratio, 3.03; 95% confidence interval, 1.02-9.03; P = .046) compared with those with C2 CVD (n = 326) after adjusting for other risk factors. Participants with severe CVD had an increased risk of MACE compared with those with mild CVD (adjusted hazard ratio, 2.37; 95% confidence interval, 1.12-5.04; P = .024). CONCLUSIONS Individuals with severe CVD have an increased risk of MACE compared with those with mild CVD, independently of traditional risk factors. Further research is required to clarify the cause of the excess risk.
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Affiliation(s)
- Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Ramesh B Velu
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Frank Quigley
- The Department of Vascular and Endovascular Surgery, Mater Private Hospital, Townsville, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
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8
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Yaria J, Gil A, Makanjuola A, Oguntoye R, Miranda JJ, Lazo-Porras M, Zhang P, Tao X, Ahlgren JÁ, Bernabe-Ortiz A, Moscoso-Porras M, Malaga G, Svyato I, Osundina M, Gianella C, Bello O, Lawal A, Temitope A, Adebayo O, Lakkhanaloet M, Brainin M, Johnson W, Thrift AG, Phromjai J, Mueller-Stierlin AS, Perone SA, Varghese C, Feigin V, Owolabi MO. Quality of stroke guidelines in low- and middle-income countries: a systematic review. Bull World Health Organ 2021; 99:640-652E. [PMID: 34475601 PMCID: PMC8381090 DOI: 10.2471/blt.21.285845] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries. METHODS We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences. FINDINGS We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations. CONCLUSION Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.
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Affiliation(s)
- Joseph Yaria
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Artyom Gil
- Division of Country Health Programme, WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russia
| | | | - Richard Oguntoye
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - J Jaime Miranda
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Maria Lazo-Porras
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Puhong Zhang
- The George Institute for Global Health, Beijing, China
| | - Xuanchen Tao
- The George Institute for Global Health, Beijing, China
| | | | - Antonio Bernabe-Ortiz
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - German Malaga
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Irina Svyato
- Moscow School of Management SKOLKOVO, Moscow, Russia
| | - Morenike Osundina
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Camila Gianella
- Department of Psychology, Pontificia Universidad Católica del Perú, Lima, Peru
| | - Olamide Bello
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Abisola Lawal
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Ajagbe Temitope
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | | | | | - Michael Brainin
- Department of Neurosciences and Preventive Medicine, Danube University, Krems, Austria
| | - Walter Johnson
- Department of Neurosurgery, Loma Linda University, California, United States of America
| | - Amanda G Thrift
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | | | | | - Cherian Varghese
- Noncommunicable Disease Department, World Health Organization, Geneva, Switzerland
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Mayowa O Owolabi
- Department of Medicine, University College Hospital, 200001 Ibadan, Oyo State, Nigeria.Correspondence to Mayowa O Owolabi ()
| | - on behalf of the Stroke Experts Collaboration Group
- Department of Medicine, University College Hospital, Ibadan, Nigeria
- Division of Country Health Programme, WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russia
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- The George Institute for Global Health, Beijing, China
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Moscow School of Management SKOLKOVO, Moscow, Russia
- Department of Psychology, Pontificia Universidad Católica del Perú, Lima, Peru
- Thung Chang Hospital, Thung Chang District, Nan, Thailand
- Department of Neurosciences and Preventive Medicine, Danube University, Krems, Austria
- Department of Neurosurgery, Loma Linda University, California, United States of America
- School of Clinical Sciences, Monash University, Melbourne, Australia
- Health System Research Institute, Nonthaburi, Thailand
- Institute for Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Noncommunicable Disease Department, World Health Organization, Geneva, Switzerland
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
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9
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Zhang XL, Zhang XG, Huang YR, Zheng YY, Ying PJ, Zhang XJ, Lu X, Wang YJ, Zheng GQ. Stem Cell-Based Therapy for Experimental Ischemic Stroke: A Preclinical Systematic Review. Front Cell Neurosci 2021; 15:628908. [PMID: 33935650 PMCID: PMC8079818 DOI: 10.3389/fncel.2021.628908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
Stem cell transplantation offers promise in the treatment of ischemic stroke. Here we utilized systematic review, meta-analysis, and meta-regression to study the biological effect of stem cell treatments in animal models of ischemic stroke. A total of 98 eligible publications were included by searching PubMed, EMBASE, and Web of Science from inception to August 1, 2020. There are about 141 comparisons, involving 5,200 animals, that examined the effect of stem cell transplantation on neurological function and infarct volume as primary outcome measures in animal models for stroke. Stem cell-based therapy can improve both neurological function (effect size, −3.37; 95% confidence interval, −3.83 to −2.90) and infarct volume (effect size, −11.37; 95% confidence interval, −12.89 to −9.85) compared with controls. These results suggest that stem cell therapy could improve neurological function deficits and infarct volume, exerting potential neuroprotective effect for experimental ischemic stroke, but further clinical studies are still needed.
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Affiliation(s)
- Xi-Le Zhang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao-Guang Zhang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yan-Ran Huang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yan-Yan Zheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peng-Jie Ying
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao-Jie Zhang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao Lu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi-Jing Wang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guo-Qing Zheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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10
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Jarva E, Mikkonen K, Tuomikoski AM, Kääriäinen M, Meriläinen M, Karsikas E, Koivunen K, Jounila-Ilola P, Oikarinen A. Healthcare professionals' competence in stroke care pathways: A mixed-methods systematic review. J Clin Nurs 2021; 30:1206-1235. [PMID: 33350004 DOI: 10.1111/jocn.15612] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The challenges of caring for stroke patients are growing due to population ageing and improved survival rates. Healthcare professionals' competence development in stroke care is a necessity to ensure high-quality patient care. OBJECTIVES To identify and describe the competence areas of healthcare professionals working in the stroke patient care pathway and factors influencing these competences. DESIGN A mixed-methods systematic review. METHODS The review was conducted according to the JBI guidelines and registered in the PROSPERO database (CRD42020204062). PRISMA checklist guided the review process. Relevant original studies were identified by searching four databases-CINAHL (EBSCO), PubMed, Scopus and Medic. After researcher consensus was reached, 32 studies were selected for inclusion and subjected to content analysis and data tabulation. RESULTS Competence in care processes, clinical competence, competence in using self-management strategies, interaction skills, skills in acknowledging family and competence in integrating the available evidence base into patient care were identified as key competence areas. Organisation of services, specialisation in stroke care, continuous development and education, family and carer and training in oral care and cognitive rehabilitation were identified as factors that influence healthcare professionals' competence. CONCLUSIONS Diverse clinical and interaction competencies are needed throughout the stroke care pathway, and various factors affect healthcare professionals' competence. Further research on healthcare professionals' stroke care competence will be needed to respond to changing healthcare demand. RELEVANCE TO CLINICAL PRACTICE We recommend organisational support and formulation of stroke care patient guidelines in line with healthcare competence requirements. Focus should be added for nursing professions in developing interactive communication competence since nurses spend the majority of the time providing individual patient care. Also, organisations should integrate continuing training in specialised stroke care for healthcare professionals' competence development.
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Affiliation(s)
- Erika Jarva
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
| | - Kristina Mikkonen
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
| | - Anna-Maria Tuomikoski
- Oulu University of Applied Sciences, Oulu, Finland.,The Finnish Centre for Evidence-Based Health Care: A Joanna Briggs Institute Centre of Excellence, Helsinki, Finland
| | - Maria Kääriäinen
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland.,The Finnish Centre for Evidence-Based Health Care: A Joanna Briggs Institute Centre of Excellence, Helsinki, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Merja Meriläinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Oulu University Hospital, Oulu, Finland
| | | | | | | | - Anne Oikarinen
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
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11
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Klaic M, Galea MP. Using the Technology Acceptance Model to Identify Factors That Predict Likelihood to Adopt Tele-Neurorehabilitation. Front Neurol 2020; 11:580832. [PMID: 33343488 PMCID: PMC7738474 DOI: 10.3389/fneur.2020.580832] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/11/2020] [Indexed: 12/24/2022] Open
Abstract
Tele-neurorehabilitation has the potential to reduce accessibility barriers and enhance patient outcomes through a more seamless continuum of care. A growing number of studies have found that tele-neurorehabilitation produces equivalent results to usual care for a variety of outcomes including activities of daily living and health related quality of life. Despite the potential of tele-neurorehabilitation, this model of care has failed to achieve mainstream adoption. Little is known about feasibility and acceptability of tele-neurorehabilitation and most published studies do not use a validated model to guide and evaluate implementation. The technology acceptance model (TAM) was developed 20 years ago and is one of the most widely used theoretical frameworks for predicting an individual's likelihood to adopt and use new technology. The TAM3 further built on the original model by incorporating additional elements from human decision making such as computer anxiety. In this perspective, we utilize the TAM3 to systematically map the findings from existing published studies, in order to explore the determinants of adoption of tele-neurorehabilitation by both stroke survivors and prescribing clinicians. We present evidence suggesting that computer self-efficacy and computer anxiety are significant predictors of an individual's likelihood to use tele-neurorehabilitation. Understanding what factors support or hinder uptake of tele-neurorehabilitation can assist in translatability and sustainable adoption of this technology. If we are to shift tele-neurorehabilitation from the research domain to become a mainstream health sector activity, key stakeholders must address the barriers that have consistently hindered adoption.
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Affiliation(s)
- Marlena Klaic
- Allied Health Department, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Mary P Galea
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia
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12
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Singh TP, Wong S, Quigley F, Jenkins J, Golledge J. Association of gout with major adverse cardiovascular events and all-cause mortality in patients with peripheral artery disease. Atherosclerosis 2020; 312:23-27. [PMID: 32947223 DOI: 10.1016/j.atherosclerosis.2020.08.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/12/2020] [Accepted: 08/19/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Prior epidemiological studies have suggested that individuals with gout are at greater risk of cardiovascular events, but there have been no studies in people with peripheral artery disease (PAD). The aim of this study was to investigate the relationship between gout and major adverse cardiovascular events (MACE) and all-cause mortality in people with PAD. METHODS Participants with a range of PAD presentations, including carotid artery disease, aortic or peripheral aneurysm and lower limb PAD, were prospectively recruited from outpatient vascular departments within Australia. MACE (myocardial infarction, stroke or cardiovascular death) and all-cause mortality were identified through out-patient follow-up and linked medical records. Propensity-score matching was undertaken to generate a matched cohort of patients with and without a history of gout. Kaplan-Meier survival analysis and Cox-proportional hazard analysis were used to examine the association of gout with MACE and all-cause mortality. RESULTS A total of 4308 people with PAD, of whom 334 had a history of gout, were included and followed for a median (inter-quartile range) of 2.1 (0.1-5.9) years. In the unadjusted analyses, participants with gout were at increased risk of MACE (hazard ratio, HR 1.37, 95% confidence intervals, CI 1.09-1.71, p = 0.006) and all-cause mortality (HR 1.38, 95% 1.13-1.68, p = 0.002), however, the associations were lost in the adjusted analyses. In the propensity-score matched cohort, gout was not significantly associated with an increased risk for MACE or all-cause mortality. CONCLUSIONS Gout was not independently associated with increased cardiovascular events in PAD patients.
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Affiliation(s)
- Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Shannon Wong
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Frank Quigley
- The Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia
| | - Jason Jenkins
- Department of Vascular and Endovascular Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
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13
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Baatiema L, Abimbola S, de-Graft Aikins A, Damasceno A, Kengne AP, Sarfo FS, Charway-Felli A, Somerset S. Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries. J Neurol Sci 2020; 418:117117. [PMID: 32919367 DOI: 10.1016/j.jns.2020.117117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 12/31/2022]
Abstract
Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.
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Affiliation(s)
- Leonard Baatiema
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana.
| | - Seye Abimbola
- School of Public Health, University of Sydney, Australia.
| | | | | | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Fred S Sarfo
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Department of Medicine, Kumasi, Ghana.
| | | | - Shawn Somerset
- Faculty of Health, University of Canberra, Canberra, Australia.
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14
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Chang JC. Stroke Classification: Critical Role of Unusually Large von Willebrand Factor Multimers and Tissue Factor on Clinical Phenotypes Based on Novel "Two-Path Unifying Theory" of Hemostasis. Clin Appl Thromb Hemost 2020; 26:1076029620913634. [PMID: 32584600 PMCID: PMC7427029 DOI: 10.1177/1076029620913634] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/17/2022] Open
Abstract
Stroke is a hemostatic disease associated with thrombosis/hemorrhage caused by intracranial vascular injury with spectrum of clinical phenotypes and variable prognostic outcomes. The genesis of different phenotypes of stroke is poorly understood due to our incomplete understanding of hemostasis and thrombosis. These shortcomings have handicapped properly recognizing each specific stroke syndrome and contributed to controversy in selecting therapeutic agents. Treatment recommendation for stroke syndromes has been exclusively derived from the result of laborious and expensive clinical trials. According to newly proposed "two-path unifying theory" of in vivo hemostasis, intracranial vascular injury would yield several unique stroke syndromes triggered by 3 distinctly different thrombogenetic mechanisms depending upon level of intracranial intravascular injury and character of formed blood clots. Five major phenotypes of stroke occur via thrombogenetic paths: (1) transient ischemic attack due to focal endothelial damage limited to endothelial cells (ECs), (2) acute ischemic stroke due to localized ECs and subendothelial tissue (SET) damage extending up to the outer vascular wall, (3) thrombo-hemorrhagic stroke due to localized vascular damage involving ECs and SET and extending beyond SET to extravascular tissue, (4) acute hemorrhagic stroke due to major localized intracranial hemorrhage/hematoma into the brain tissue or space between the coverings of the brain associated with vascular anomaly or obtuse trauma, and (5) encephalopathic stroke due to disseminated endotheliopathy leading to microthrombosis within the brain. New classification of stroke phenotypes would assist in selecting rational therapeutic regimen for each stroke syndrome and designing clinical trials to improve clinical outcome.
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Affiliation(s)
- Jae C. Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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15
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Scrivener K, Pocovi N, Jones T, Dean B, Gallagher S, Henrisson W, Thorburn M, Dean C. Observations of Activity Levels in a Purpose-Built, Inpatient, Rehabilitation Facility. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2019; 12:26-38. [DOI: 10.1177/1937586718823519] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Effective rehabilitation should include high levels of physical activity. The impact of the environmental design on activity levels has had minimal consideration. Purpose: This study investigates activity levels of inpatients undergoing rehabilitation in a new rehabilitation facility with innovative design and multidisciplinary care, comparing weekday and weekend activity levels, as well as changes over a 12-month period. Method: An observational study reporting participants’ location, people present, body position, and activity type on 2 weekdays and 1 weekend day using behavior mapping techniques. Fifteen participants were observed in a mixed rehabilitation unit with neurological, orthopedic, and other health conditions. Results: Results were calculated as the proportion of observations participants spent in each location, position, and performing activities (physical, cognitive, social), and time spent alone and inactive. On average, participants were engaged in activity for 86% (standard deviation [ SD] = 9) of the day, with physical activity accounting for 51% ( SD = 11), cognitive activity 28% ( SD = 10), and social activity 42% ( SD = 16). There was more physical activity (mean difference [ MD] 8% absolute, confidence interval [CI] = [4, 12], p < .01) and less social activity ( MD −6% absolute, CI [−11, −1], p = .02) on weekdays compared to weekends. Overall, participants were alone and inactive for 12% ( SD = 9) of the day. Participants observed in 2016 displayed similar results to those observed in 2015. Conclusion: High levels of activity were achieved in this facility that underwent environmental redesign, construction of new facilities, and implementation of evidence-based strategies.
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Affiliation(s)
- Katharine Scrivener
- Department of Health Professions, Macquarie University, New South Wales, Australia
| | - Natasha Pocovi
- Department of Health Professions, Macquarie University, New South Wales, Australia
| | - Taryn Jones
- Department of Health Professions, Macquarie University, New South Wales, Australia
| | - Bridget Dean
- Department of Health Professions, Macquarie University, New South Wales, Australia
| | - Shaun Gallagher
- Department of Health Professions, Macquarie University, New South Wales, Australia
| | - Wesley Henrisson
- Department of Health Professions, Macquarie University, New South Wales, Australia
| | - Michael Thorburn
- Department of Health Professions, Macquarie University, New South Wales, Australia
| | - Catherine Dean
- Department of Health Professions, Macquarie University, New South Wales, Australia
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16
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Dave A, Cagniart K, Holtkamp MD. A Case for Telestroke in Military Medicine: A Retrospective Analysis of Stroke Cost and Outcomes in U.S. Military Health-Care System. J Stroke Cerebrovasc Dis 2018; 27:2277-2284. [PMID: 29887364 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 02/11/2018] [Accepted: 04/12/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The development of primary stroke centers has improved outcomes for stroke patients. Telestroke networks have expanded the reach of stroke experts to underserved, geographically remote areas. This study illustrates the outcome and cost differences between neurology and primary care ischemic stroke admissions to demonstrate a need for telestroke networks within the Military Health System (MHS). MATERIALS AND METHODS All adult admissions with a primary diagnosis of ischemic stroke in the MHS Military Mart database from calendar years 2010 to 2015 were reviewed. Neurology, primary care, and intensive care unit (ICU) admissions were compared across primary outcomes of (1) disposition status and (2) intravenous tissue plasminogen activator administration and for secondary outcomes of (1) total cost of hospitalization and (2) length of stay (LOS). RESULTS A total of 3623 admissions met the study's parameters. The composition was neurology 462 (12.8%), primary care 2324 (64.1%), ICU 677 (18.7%), and other/unknown 160 (4.4%). Almost all neurology admissions (97%) were at the 3 neurology training programs, whereas a strong majority of primary care admissions (80%) were at hospitals without a neurology admitting service. Hospitals without a neurology admitting service had more discharges to rehabilitation facilities and higher rates of in-hospital mortality. LOS was also longer in primary care admissions. CONCLUSIONS Ischemic stroke admissions to neurology had better outcomes and decreased LOS when compared to primary care within the MHS. This demonstrates a possible gap in care. Implementation of a hub and spoke telestroke model is a potential solution.
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Affiliation(s)
- Ajal Dave
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kendra Cagniart
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew D Holtkamp
- Department of Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas.
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17
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Singh TP, Moxon JV, Healy GN, Cadet-James Y, Golledge J. Presentation and outcomes of indigenous Australians with peripheral artery disease. BMC Cardiovasc Disord 2018; 18:94. [PMID: 29769031 PMCID: PMC5956730 DOI: 10.1186/s12872-018-0835-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/09/2018] [Indexed: 12/01/2022] Open
Abstract
Background The risk factors for peripheral artery disease (PAD) are more common in Indigenous than non-Indigenous Australians, however the presentation and outcome of PAD in Indigenous Australians has not been previously investigated. The aim of this prospective cohort study was to compare the presenting characteristics and clinical outcome of Indigenous and non-Indigenous Australians with PAD. Methods PAD patients were prospectively recruited and followed-up since 2003 from an outpatient vascular clinic in Townsville, Australia. Presenting symptoms and risk factors in Indigenous and non-Indigenous patients were compared using Pearson’s χ2 test and Mann Whitney U test. Kaplan Meier survival analysis and Cox proportional hazard analysis were used to compare the incidence of myocardial infarction (MI), stroke or death (major cardiovascular events) among Indigenous and non-Indigenous patients. Results Four hundred and one PAD patients were recruited, of which 16 were Indigenous and 385 were non-Indigenous Australians. Indigenous Australians were younger at entry (median age 63.3 [54.7–67.8] vs 69.6 [63.3–75.4]), more commonly current smokers (56.3% vs 31.4%), and more frequently had insulin-treated diabetes (18.8% vs 5.2%). During a median follow-up of 2.5 years, five and 45 major cardiovascular events were recorded amongst Indigenous and non-Indigenous Australians, respectively. Indigenous Australians were at ~ 5-fold greater risk of major cardiovascular events (adjusted hazard ratio 4.72 [95% confidence intervals 1.41–15.78], p = 0.012) compared to non-Indigenous Australians. Conclusions These findings suggest that Indigenous Australians with PAD present at a younger age, have higher rates of smoking and insulin-treated diabetes, and poorer clinical outcomes compared to non-Indigenous Australians.
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Affiliation(s)
- Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia.,The Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia.,The University of Queensland, School of Public Health, Herston, QLD, Australia
| | - Joseph V Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia
| | - Genevieve N Healy
- The University of Queensland, School of Public Health, Herston, QLD, Australia
| | | | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia. .,The Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia.
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18
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Rehabilitation Reduced Readmission and Mortality Risks in Patients With Stroke or Transient Ischemic Attack. Med Care 2018; 56:290-298. [DOI: 10.1097/mlr.0000000000000888] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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19
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Bivard A, Spratt N, Miteff F, Levi C, Parsons MW. Tissue Is More Important than Time in Stroke Patients Being Assessed for Thrombolysis. Front Neurol 2018; 9:41. [PMID: 29467716 PMCID: PMC5808281 DOI: 10.3389/fneur.2018.00041] [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: 10/24/2017] [Accepted: 01/17/2018] [Indexed: 11/26/2022] Open
Abstract
Aim The relative prognostic importance of modern imaging profiles compared with standard clinical characteristics is uncertain in acute stroke patients. In this study, we aimed to compare baseline multimodal CT imaging measures with known clinical predictors of patient outcome at 3 months [modified Rankin scale (mRS)]. Methods We collected baseline, 24 h, and day 90 clinical and imaging data from acute ischemic stroke patients being assessed for thrombolytic therapy between 2010 and 2015 at a single center as part of a retrospective analysis. Results 561 patients presenting within 4.5 h of ischemic stroke onset who were eligible for thrombolysis based on standard clinical criteria were assessed. Acute infarct core volume on CTP was the strongest univariate predictor of patient outcome (mRS 0–2, R2 0.497, p < 0.001), followed by collateral grade (mRS 0–2, R2 0.281, p < 0.001). The strongest baseline clinical predictor of outcome was National Institutes of Health Stroke Scale (NIHSS) (mRS 0–2, R2 = 0.203, p < 0.001). Time to treatment (mRS 0–2, R2 0.096, p = 0.01) and age (mRS 0–2, R2 0.027, p = 0.013) were relatively weak univariate baseline clinical predictors of 3-month outcome. In multivariate analysis, acute infarct core volume and collateral grade were the only significant baseline predictors of 3-month disability (both p < 0.001). Conclusion In patients assessed for thrombolysis by combined clinical and multimodal CT criteria within 4.5 h of onset, the size of the CTP infarct core and collateral grade on multimodal CT were highly predictive of patient outcome. Standard clinical variables, including time to treatment and NIHSS, were not as strongly predictive as multimodal CT variables.
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Affiliation(s)
- Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Mark William Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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20
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Lin SH, Dionne TP. Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary. J Particip Med 2018; 10:e3. [PMID: 33052128 PMCID: PMC7434068 DOI: 10.2196/jopm.8929] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 07/02/2017] [Indexed: 12/30/2022] Open
Abstract
Background Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke. Objective The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke. Methods Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes. Results This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors. Conclusions Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.
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Affiliation(s)
- Susan Hamady Lin
- Institute of Health Professions, Department of Occupational Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA, United States
| | - Timothy P Dionne
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY, United States
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21
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Bjartmarz I, Jónsdóttir H, Hafsteinsdóttir TB. Implementation and feasibility of the stroke nursing guideline in the care of patients with stroke: a mixed methods study. BMC Nurs 2017; 16:72. [PMID: 29213212 PMCID: PMC5709925 DOI: 10.1186/s12912-017-0262-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 11/10/2017] [Indexed: 11/14/2022] Open
Abstract
Background Nurses often have difficulties with using interdisciplinary stroke guidelines for patients with stroke as they do not focus sufficiently on nursing. Therefore, the Stroke Nursing Guideline (SNG) was developed and implemented. The aim of this study was to determine the implementation and feasibility of the SNG in terms of changes in documentation and use of the guideline in the care of stroke patients on Neurological and Rehabilitation wards, barriers and facilitators, and nurses’ and auxiliary nurses’ view of the implementation. Methods A sequential explorative mixed method design was used including pre-test post-test measures and post intervention focus groups interviews. For the quantitative part retrospective electronic record data of nursing care was collected from 78 patients and prospective measures with Barriers and Facilitators Assessment Instrument (BFAI) and Quality Indicator Tool (QIT) from 33 nursing staff including nurses and auxiliary nurses. In the qualitative part focus groups interviews were conducted with nursing staff on usefulness of the SNG and experiences with implementation. Results Improved nursing documentation was found for 23 items (N = 37), which was significant for nine items focusing mobility (p = 0.002, p = 0.024, p = 0.012), pain (p = 0.012), patient teaching (p = 0.001, p = 0.000) and discharge planning (p = 0.000, p = 0.002, p = 0.004). Improved guideline use was found for 20 QIT-items (N = 30), with significant improvement on six items focusing on mobility (p = 0.023), depression (p = 0.033, p = 0.025, p = 0.046, p = 0.046), discharge planning (p = 0.012). Facilitating characteristics for change were significantly less for two of four BFAI-subscales, namely Innovation (p = 0.019) and Context (p = 0.001), whereas no change was found for Professional and Patient subscales. The findings of the focus group interviews showed the SNG to be useful, improving and providing consistency in care. The implementation process was found to be successful as essential components of nursing rehabilitation were defined and integrated into daily care. Conclusion Nursing staff found the SNG feasible and implementation successful. The SNG improved nursing care, with increased consistency and more rigorous functional exercises than before. The SNG provides nurses and auxiliary nurses with an important means for evidence based care for patients with stroke. Several challenges of implementing this complex nursing intervention surfaced which mandates ongoing attention. Electronic supplementary material The online version of this article (10.1186/s12912-017-0262-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingibjörg Bjartmarz
- Clinical Nurse Specialist, Department of Rehabilitation, Landspítali University Hospital, Reykjavík, Iceland
| | - Helga Jónsdóttir
- Faculty of Nursing, University of Iceland, Reykjavík, Iceland.,Nursing Care for Chronically Ill Adults, Landspítali University Hospital, Reykjavík, Iceland
| | - Thóra B Hafsteinsdóttir
- Faculty of Nursing, University of Iceland, Reykjavík, Iceland.,Julius Center for Health Sciences and Primary Care, Nursing Science Department, University Medical Center Utrecht, Utrecht, The Netherlands
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Baatiema L, Otim ME, Mnatzaganian G, de-Graft Aikins A, Coombes J, Somerset S. Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review. Implement Sci 2017; 12:74. [PMID: 28583164 PMCID: PMC5460544 DOI: 10.1186/s13012-017-0599-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 05/08/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings. METHODOLOGY A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used. RESULTS Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers. CONCLUSIONS Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings. TRIAL REGISTRATION The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).
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Affiliation(s)
- Leonard Baatiema
- Regional Institute for Population Studies, University of Ghana, P.O Box LG96, Legon-Accra, Ghana.
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia.
| | - Michael E Otim
- College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - George Mnatzaganian
- College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Melbourne, Australia
| | - Ama de-Graft Aikins
- Regional Institute for Population Studies, University of Ghana, P.O Box LG96, Legon-Accra, Ghana
| | - Judith Coombes
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Shawn Somerset
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
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Eldh AC, Almost J, DeCorby-Watson K, Gifford W, Harvey G, Hasson H, Kenny D, Moodie S, Wallin L, Yost J. Clinical interventions, implementation interventions, and the potential greyness in between -a discussion paper. BMC Health Serv Res 2017; 17:16. [PMID: 28061856 PMCID: PMC5219812 DOI: 10.1186/s12913-016-1958-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/16/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. DISCUSSION To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. CONCLUSION Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.
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Affiliation(s)
- Ann Catrine Eldh
- School of Education, Health and Social Studies, Dalarna University, FALUN, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, UPPSALA, Sweden
- Department of Medical and Health Sciences, Linköping University, SE-581 83 LINKÖPING, Sweden
| | | | | | | | - Gill Harvey
- University of Adelaide, Adelaide, Australia
- University of Manchester, Manchester, United Kingdom
| | - Henna Hasson
- Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Centre for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden
| | - Deborah Kenny
- University of Colorado, Colorado Springs, Colorado, USA
| | | | - Lars Wallin
- School of Education, Health and Social Studies, Dalarna University, FALUN, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
- Department of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jennifer Yost
- School of Nursing, McMaster University, Hamilton, Canada
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Edwards JD, Kapral MK, Fang J, Saposnik G, Gladstone DJ. Underutilization of Ambulatory ECG Monitoring After Stroke and Transient Ischemic Attack: Missed Opportunities for Atrial Fibrillation Detection. Stroke 2016; 47:1982-9. [PMID: 27406109 DOI: 10.1161/strokeaha.115.012195] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/29/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Detection and treatment of atrial fibrillation is a major goal in secondary stroke prevention. Guidelines recommend at least 24 hours of ECG monitoring after stroke. However, it is unclear how often this is done in routine practice. METHODS In this longitudinal cohort study using data from the Ontario Stroke Registry, we analyzed consecutive patients presenting to designated stroke centers in Ontario, Canada (2003-2013) with a first acute ischemic stroke or transient ischemic attack (TIA) in sinus rhythm and without known atrial fibrillation. The primary outcome was the proportion of patients who received at least 24-hour Holter monitoring within 30 days after stroke/TIA. Secondary analyses assessed total duration of ECG monitoring completed within 90 days after stroke/TIA, temporal trends in monitoring use, and use of Holter monitoring relative to echocardiography. RESULTS Among 17 398 consecutive eligible patients (mean age 68.8±14.3 years), 30.6% had at least 24 hours of Holter monitoring within 30 days after stroke/TIA. Less than 1% of patients received prolonged monitoring beyond 48 hours. The median time to start monitoring was 9 days poststroke (interquartile range 3-25). Stroke/TIA patients were nearly twice as likely to receive an echocardiogram than a Holter monitor within 90 days (odds ratio 1.8, 95% confidence interval 1.67-2.01). CONCLUSIONS Less than one third of patients in our cohort received guideline-recommended 24-hour Holter monitoring, and <1% received prolonged ambulatory ECG monitoring. These findings highlight a modifiable evidence-practice gap that likely contributes to an overdiagnosis of strokes as cryptogenic, an underdiagnosis of atrial fibrillation, and missed anticoagulant treatment opportunities for secondary stroke prevention.
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Affiliation(s)
- Jodi D Edwards
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.)
| | - Moira K Kapral
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.)
| | - Jiming Fang
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.)
| | - Gustavo Saposnik
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.)
| | - David J Gladstone
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.).
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[Hypertensive emergencies and urgencies]. Presse Med 2015; 44:737-44. [PMID: 26248707 DOI: 10.1016/j.lpm.2015.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 06/22/2015] [Indexed: 11/21/2022] Open
Abstract
Hypertension is a common disease, the most common chronic disease. Hypertensive emergency is much less frequent and only affects 1 to 2 % of all hypertensive patients. The true hypertensive emergency is characterized by the serious damage of one hypertensive target organ and requires an urgent intravenous treatment. Isolated blood pressure elevation should not be regarded as a hypertensive emergency if there is no target organ damage, even if the blood pressure is very high. These situations of "false hypertensive emergency", or hypertensive urgencies, often requires an immediate treatment, but oral. Signs of visceral pain of true hypertensive emergency often are a poor general condition, severe headache, decreased visual acuity, neurological deficit of ischemic or hemorrhagic cause, confusion, dyspnea with orthopnoea revealing heart failure, angina, chest pain revealing an aortic dissection, proteinuria, acute renal failure or eclampsia. True hypertensive emergencies include several entities, namely: severe hypertension, malignant hypertension and accelerated hypertension. If malignant hypertension is not treated, the prognosis is poor with 50 % death risk in the following year.
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26
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Miller JB, Heitsch L, Siket MS, Schrock JW, Wira CR, Lewandowski C, Madsen TE, Merck LH, Wright DW. The Emergency Medicine Debate on tPA for Stroke: What Is Best for Our Patients? Efficacy in the First Three Hours. Acad Emerg Med 2015; 22:852-5. [PMID: 26113369 DOI: 10.1111/acem.12712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Joseph B. Miller
- Department of Emergency Medicine; Henry Ford Hospital; Detroit MI
| | - Laura Heitsch
- Department of Emergency Medicine; Washington University School of Medicine; St. Louis MO
| | - Matthew S. Siket
- Department of Emergency Medicine; Alpert Medical School of Brown University; Providence RI
| | - Jon W. Schrock
- Department of Emergency Medicine; Case Western Reserve University School of Medicine; Cleveland OH
| | - Charles R. Wira
- Department of Emergency Medicine; Yale School of Medicine; New Haven CT
| | | | - Tracy E. Madsen
- Department of Emergency Medicine; Alpert Medical School of Brown University; Providence RI
| | - Lisa H. Merck
- Department of Emergency Medicine; Alpert Medical School of Brown University; Providence RI
| | - David W. Wright
- Department of Emergency Medicine; Emory University; Atlanta GA
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Bivard A, Levi C, Krishnamurthy V, McElduff P, Miteff F, Spratt NJ, Bateman G, Donnan G, Davis S, Parsons M. Perfusion computed tomography to assist decision making for stroke thrombolysis. Brain 2015; 138:1919-31. [PMID: 25808369 PMCID: PMC4572482 DOI: 10.1093/brain/awv071] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/21/2015] [Indexed: 11/13/2022] Open
Abstract
The use of perfusion imaging to guide selection of patients for stroke thrombolysis remains controversial because of lack of supportive phase three clinical trial evidence. We aimed to measure the outcomes for patients treated with intravenous recombinant tissue plasminogen activator (rtPA) at a comprehensive stroke care facility where perfusion computed tomography was routinely used for thrombolysis eligibility decision assistance. Our overall hypothesis was that patients with 'target' mismatch on perfusion computed tomography would have improved outcomes with rtPA. This was a prospective cohort study of consecutive ischaemic stroke patients who fulfilled standard clinical/non-contrast computed tomography eligibility criteria for treatment with intravenous rtPA, but for whom perfusion computed tomography was used to guide the final treatment decision. The 'real-time' perfusion computed tomography assessments were qualitative; a large perfusion computed tomography ischaemic core, or lack of significant perfusion lesion-core mismatch were considered relative exclusion criteria for thrombolysis. Specific volumetric perfusion computed tomography criteria were not used for the treatment decision. The primary analysis compared 3-month modified Rankin Scale in treated versus untreated patients after 'off-line' (post-treatment) quantitative volumetric perfusion computed tomography eligibility assessment based on presence or absence of 'target' perfusion lesion-core mismatch (mismatch ratio >1.8 and volume >15 ml, core <70 ml). In a second analysis, we compared outcomes of the perfusion computed tomography-selected rtPA-treated patients to an Australian historical cohort of non-contrast computed tomography-selected rtPA-treated patients. Of 635 patients with acute ischaemic stroke eligible for rtPA by standard criteria, thrombolysis was given to 366 patients, with 269 excluded based on visual real-time perfusion computed tomography assessment. After off-line quantitative perfusion computed tomography classification: 253 treated patients and 83 untreated patients had 'target' mismatch, 56 treated and 31 untreated patients had a large ischaemic core, and 57 treated and 155 untreated patients had no target mismatch. In the primary analysis, only in the target mismatch subgroup did rtPA-treated patients have significantly better outcomes (odds ratio for 3-month, modified Rankin Scale 0-2 = 13.8, P < 0.001). With respect to the perfusion computed tomography selected rtPA-treated patients (n = 366) versus the clinical/non-contrast computed tomography selected rtPA-treated patients (n = 396), the perfusion computed tomography selected group had higher adjusted odds of excellent outcome (modified Rankin Scale 0-1 odds ratio 1.59, P = 0.009) and lower mortality (odds ratio 0.56, P = 0.021). Although based on observational data sets, our analyses provide support for the hypothesis that perfusion computed tomography improves the identification of patients likely to respond to thrombolysis, and also those in whom natural history may be difficult to modify with treatment.
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Affiliation(s)
- Andrew Bivard
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Christopher Levi
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Venkatesh Krishnamurthy
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Patrick McElduff
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Ferdi Miteff
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Neil J Spratt
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Grant Bateman
- 2 Department of Radiology, John Hunter Hospital, University of Newcastle New South Wales, Australia
| | - Geoffrey Donnan
- 3 Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen Davis
- 3 Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Mark Parsons
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
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Xie CL, Wang WW, Xue XD, Zhang SF, Gan J, Liu ZG. A systematic review and meta-analysis of Ginsenoside-Rg1 (G-Rg1) in experimental ischemic stroke. Sci Rep 2015; 5:7790. [PMID: 25600516 PMCID: PMC5379000 DOI: 10.1038/srep07790] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/15/2014] [Indexed: 01/31/2023] Open
Abstract
The neuroprotective actions of Ginsenoside-Rg1 (G-Rg1) have been documented for experimental stroke therapy. We used a systematic review and meta-analysis to assess the efficacy of G-Rg1 in experimental ischemic stroke. We identified studies describing the efficacy of G-Rg1 in animal models of focal cerebral ischemia. Primary outcomes were infarct volume and neurological function score (NFS). In all, eleven studies reported significant effects of G-Rg1 for improving the NFS when compared with the control group (P < 0.00001), and four studies reported significant effects of G-Rg1 for reducing infarct volume compared with middle cerebral artery occlusion group (P < 0.00001). Meanwhile, studies reported G-Rg1 was more efficacious than positive control drug nimodipine (0.7 or 1 mg/kg, intraperitoneal) according to NFS (P = 0.009) and infarct volume (p = 0.0002). The results demonstrate a marked efficacy of G-Rg1 in experimental acute ischemic stroke, but raise concerns that our value of effect size might be overestimate due to factors such as study quality and possible publication bias. Even so, the findings suggest G-Rg1 as a candidate neuroprotective drug for human ischemic stroke.
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Affiliation(s)
- Cheng-long Xie
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine 200092, 1665 Kongjiang Road, Shanghai, China
| | - Wen-Wen Wang
- The center of Traditional Chinese Medicine, The Second Affiliated Hospital of Wenzhou Medical College, Wenzhou 325027, China
| | - Xiao-dong Xue
- Department of Neurology, Cang Nan county hospital, Wenzhou 325800, China
| | - Su-fang Zhang
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine 200092, 1665 Kongjiang Road, Shanghai, China
| | - Jing Gan
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine 200092, 1665 Kongjiang Road, Shanghai, China
| | - Zhen-Guo Liu
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine 200092, 1665 Kongjiang Road, Shanghai, China
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Bray JE, Coughlan K, Mosley I, Barger B, Bladin C. Are suspected stroke patients identified by paramedics transported to appropriate stroke centres in Victoria, Australia? Intern Med J 2014; 44:515-8. [DOI: 10.1111/imj.12382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 09/18/2013] [Indexed: 11/29/2022]
Affiliation(s)
- J. E. Bray
- Research and Evaluation Department; Ambulance Victoria; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - K. Coughlan
- Department of Neuroscience; Box Hill Hospital; Melbourne Victoria Australia
| | - I. Mosley
- Division of Stroke Epidemiology and Public Health; Florey Institute of Neuroscience and Mental Health; Melbourne Victoria Australia
| | - B. Barger
- Research and Evaluation Department; Ambulance Victoria; Melbourne Victoria Australia
| | - C. Bladin
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Neuroscience; Box Hill Hospital; Melbourne Victoria Australia
- Division of Stroke Epidemiology and Public Health; Florey Institute of Neuroscience and Mental Health; Melbourne Victoria Australia
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Gache K, Leleu H, Nitenberg G, Woimant F, Ferrua M, Minvielle E. Main barriers to effective implementation of stroke care pathways in France: a qualitative study. BMC Health Serv Res 2014; 14:95. [PMID: 24575955 PMCID: PMC3943407 DOI: 10.1186/1472-6963-14-95] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 02/21/2014] [Indexed: 01/19/2023] Open
Abstract
Background Stroke Care Pathways (SCPs) aim to improve quality of care by providing better access to stroke units, rehabilitation centres, and home care for dependent patients. The objective of this study was to identify the main barriers to effective implementation of SCPs in France. Methods We selected 4 types of SCPs currently implemented in France that differed in terms of geographical location, population size, socio-economic conditions, and available health care facilities. We carried out 51 semi-structured interviews of 44 key health professionals involved in these SCPs and used the interview data to (i) create a typology of the organisational barriers to effective SCP implementation by axial coding, (ii) define barrier contents by vertical coding. The typology was validated by a panel of 15 stroke care professionals. Results Four main barriers to effective SCP implementation were identified: lack of resources (31/44 interviewees), coordination problems among staff (14/44) and among facilities (27/44), suboptimal professional and organisational practices (16/44), and inadequate public education about stroke (13/44). Transposition of the findings onto a generic SCP highlighted alternative care options and identified 10 to 17 barriers that could disrupt continuity of care. Conclusion Lack of resources was considered to be the chief obstacle to effective SCP implementation. However, the main weakness of existing SCPs was poor communication and cooperation among health professionals and among facilities. We intend to use this knowledge to construct a robust set of quality indicators for use in SCP quality improvement initiatives, in comparisons between SCPs, and in the assessment of the effective implementation of clinical practice guidelines.
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Affiliation(s)
| | | | - Gérard Nitenberg
- Compaq-HPST, Institut de Cancérologie Gustave Roussy, 114 rue Edouard Vaillant, Villejuif 94805, France.
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Szer J. The Journal in 2013. Intern Med J 2014. [DOI: 10.1111/imj.12332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tielbur BR, Rice Cella DE, Currie A, Roach JD, Mattingly B, Boone J, Watwood C, McGauran A, Kirshner HS, Charles PD. Discharge huddle outfitted with mobile technology improves efficiency of transitioning stroke patients into follow-up care. Am J Med Qual 2013; 30:36-44. [PMID: 24316727 DOI: 10.1177/1062860613510964] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Disjointed patient care is a well-documented problem in health care systems, often stemming from poor communication between providers, services, and follow-up care resources. A multidisciplinary discharge huddle, augmented with cellular and tablet technology, was implemented on the Neurology Stroke Service to facilitate multidisciplinary communication, improve transition of patients, and increase referrals into affiliated follow-up care. After initiating the huddle, patient length of stay decreased by 1.4 days (25%), patient flow into continuum partners increased by 10%, and the number of patients going without services after their hospital stay decreased by more than 12%. Huddle members reported that the technology was helpful, heavily utilized, and made their work more efficient. This pilot suggests that utilizing modern mobile technologies can help improve efficiency and referrals within the health care system and reduce patient length of stay.
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Affiliation(s)
| | | | | | | | | | - Jack Boone
- Vanderbilt University Medical Center, Nashville, TN
| | | | - Ann McGauran
- Vanderbilt University Medical Center, Nashville, TN
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Golledge J, Ewels C, Muller R, Walker PJ. Association of chronic kidney disease categories defined with different formulae with major adverse events in patients with peripheral vascular disease. Atherosclerosis 2013; 232:289-97. [PMID: 24468141 DOI: 10.1016/j.atherosclerosis.2013.11.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim of this study was to compare the ability of eGFR calculated by modification of diet in renal disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Lund-Malmö formulae in predicting major adverse events in peripheral vascular disease (PVD) patients. METHODS We prospectively recruited 2137 patients, measured serum creatinine to calculate eGFR using three different formulae and grouped patients into eGFR categories ≥90, 60-89, 45-59, 30-44, 15-29 and <15 ml/min/1.73 m(2). Patients were followed up for a median of 1.3 (inter-quartile range 0.3-3.6) years. The primary outcome was the combined incidence of myocardial infarction, stroke or death. The ability of eGFR categories defined with the different formulae to predict outcome was assessed using the net reclassification index. RESULTS 1450 (67.9%), 1515 (70.9%) and 1813 (84.8%) patients had eGFR <90 ml/min/1.73 m(2) according to the CKD-EPI, MDRD and Lund-Malmö formulae, respectively. Using the CKD-EPI formula 276 (12.9%) patients were reclassified to a different eGFR category in comparison to the MDRD formula and the prediction of outcome was improved (net reclassification index 0.106, p < 0.001). Using the Lund-Malmö formula 563 (26.3%) patients were reclassified to a different eGFR category in comparison to the MDRD formula and the prediction of outcome was improved (net reclassification index 0.108, p < 0.001). Classification using the CKD-EPI and Lund-Malmö formulae was equally effective at predicting outcome (net reclassification index - 0.002, p = 0.397). CONCLUSIONS eGFR categories determined with the CKD-EPI and Lund-Malmö formulae are equally effective at predicting major adverse events in patients with PVD.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia; Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Australia.
| | - Carla Ewels
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia; School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Australia
| | - Reinhold Muller
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia; School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Australia
| | - Phillip J Walker
- University of Queensland School of Medicine, Discipline of Surgery and Centre for Clinical Research, Brisbane, Australia; Department of Vascular Surgery, The Royal Brisbane and Women's Hospital, Brisbane, Australia
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Stroke mimics under the drip-and-ship paradigm. J Stroke Cerebrovasc Dis 2013; 23:844-9. [PMID: 23954600 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 06/28/2013] [Accepted: 07/07/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes. METHODS Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed. RESULTS One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS (P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital (P = .02). CONCLUSION The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS.
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Phan TG, Thrift A, Cadilhac D, Srikanth V. A plea for the use of systematic review methodology when writing guidelines and timely publication of guidelines. Intern Med J 2012; 42:1369-71; author reply 1371-2. [PMID: 23253008 DOI: 10.1111/j.1445-5994.2012.02953.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 07/16/2012] [Indexed: 12/01/2022]
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