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Adeniji O, Adeleye O, Akinyemi J, Otubogun F, Ogunde G, Ogunrombi M, Adesina D, Wahab A, Ogunlana M, Alimi T, Akinyemi R. Organized multi-disciplinary stroke team care improves acute stroke outcomes in resource limited settings; Results of a retrospective study from a Nigerian tertiary hospital. J Stroke Cerebrovasc Dis 2023; 32:107307. [PMID: 37633206 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107307] [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: 03/30/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Evidence for the impact of organized stroke multidisciplinary teams (MDTs) on outcomes in Africa is sparse. AIM To compare stroke outcomes, before and after the establishment (September 16, 2016) of a pioneer MDT at a tertiary hospital in southern Nigeria. METHODS Using a retrospective, observational study design, the in-patient record of all stroke patients admitted between September 2014 to September 2018 was retrieved and rigorously reviewed. 155 patients seen 2 years before the MDT were compared with 169 stroke patients seen 2 years after the MDT. Stroke severity at admission and functioning at discharge were assessed using the Stroke Levity Scale (SLS) and the modified Rankin scale (mRS). RESULTS Mean ages (in years) were 60 pre-MDT vs 59.57 post MDT (p = 0.754). There were more males, 51% pre-MDT vs 54.2% post MDT (p = 0.565). SLS and mRS were not significantly different; severe SLS and mRS pre-MDT, 52.9% vs post-MDT, 49.4% (p = 0.727) and pre-MDT 19.4% vs post-MDT 19.5% (p = 0.685) respectively. More post-MDT patients were discharged alive, pre-MDT,56.8% vs 79.2% post MDT (p < 0.001); had swallow tests, pre-MDT 9.23% vs post-MDT 33.5% (p < 0.001); on secondary prevention, pre-MDT 67.7% vs post-MDT 78.9% (p = 0.023); had more clinic visits, pre-MDT,0.7% vs post-MDT 38.3% (p < 0.001). MDT was independently associated with lower in-hospital mortality on multivariable regression, adjusted odds ratio (OR) (95% Confidence interval CI) 0.17 (0.09-0.32). CONCLUSION Our results suggest that an organized MDT may improve acute outcomes and reduce mortality in resource constrained settings where there may be no stroke units. These findings need further prospective validation.
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Affiliation(s)
- Olaleye Adeniji
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria.
| | - Osi Adeleye
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Joshua Akinyemi
- Department of Medical Statistics and Epidemiology, College of Medicine, University College hospital Ibadan, Oyo State, Nigeria
| | - Folajimi Otubogun
- Neurology unit, Federal Medical center, Ebute Meta, Lagos State, Nigeria
| | - Gabriel Ogunde
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Postal Address: PMB 017 GPO, General Post Office, Ibadan, Oyo State, Nigeria
| | - Mayowa Ogunrombi
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Deborah Adesina
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Ahmed Wahab
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Michael Ogunlana
- Department of Physiotherapy, Federal Medical Center, Abeokuta, Ogun State, Nigeria
| | - Talayo Alimi
- Department of Physiotherapy, Federal Medical Center, Abeokuta, Ogun State, Nigeria
| | - Rufus Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Postal Address: PMB 017 GPO, General Post Office, Ibadan, Oyo State, Nigeria
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2
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Habibi J, Bosch J, Bidulka P, Belson S, DePaul V, Gandhi D, Kumurenzi A, Melifonwu R, Pandian J, Langhorne P, Solomon JM, Dawar D, Carroll S, Urimubenshi G, Kaddumukasa M, Hamilton L. Strategies for specialty training of healthcare professionals in low-resource settings: a systematic review on evidence from stroke care. BMC MEDICAL EDUCATION 2023; 23:442. [PMID: 37328888 PMCID: PMC10273731 DOI: 10.1186/s12909-023-04431-w] [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] [Received: 08/24/2022] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND The greatest mortality and disability from stroke occurs in low- and middle-income countries. A significant barrier to implementation of best stroke care practices in these settings is limited availability of specialized healthcare training. We conducted a systematic review to determine the most effective methods for the provision of speciality stroke care education for hospital-based healthcare professionals in low-resource settings. METHODS We followed the PRISMA guidelines for systematic reviews and searched PubMed, Web of Science and Scopus for original clinical research articles that described or evaluated stroke care education for hospital-based healthcare professionals in low-resource settings. Two reviewers screened titles/abstracts and then full text articles. Three reviewers critically appraised the articles selected for inclusion. RESULTS A total of 1,182 articles were identified and eight were eligible for inclusion in this review; three were randomized controlled trials, four were non-randomized studies, and one was a descriptive study. Most studies used several approaches to education. A "train-the-trainer" approach to education was found to have the most positive clinical outcomes (lower overall complications, lengths of stay in hospital, and clinical vascular events). When used for quality improvement, the "train-the-trainer" approach increased patient reception of eligible performance measures. When technology was used to provide stroke education there was an increased frequency in diagnosis of stroke and use of antithrombotic treatment, reduced door-to-needle times, and increased support for decision making in medication prescription was reported. Task-shifting workshops for non-neurologists improved knowledge of stroke and patient care. Multidimensional education demonstrated an overall care quality improvement and increased prescriptions for evidence-based therapies, although, there were no significant differences in secondary prevention efforts, stroke reoccurrence or mortality rates. CONCLUSIONS The "train the trainer" approach is likely the most effective strategy for specialist stroke education, while technology is also useful if resources are available to support its development and use. If resources are limited, basic knowledge education should be considered at a minimum and multidimensional training may not be as beneficial. Research into communities of practice, led by those in similar settings, may be helpful to develop educational initiatives with relevance to local contexts.
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Affiliation(s)
- Junaid Habibi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Jackie Bosch
- Population Health Research Institute, Hamilton, ON, Canada
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Patrick Bidulka
- London School of Hygiene and Tropical Medicine, London, England, UK
| | | | - Vincent DePaul
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
| | - Dorcas Gandhi
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Anne Kumurenzi
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Peter Langhorne
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - John M Solomon
- Department of Physiotherapy, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dimple Dawar
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Sandra Carroll
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Gerard Urimubenshi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Martin Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Leah Hamilton
- Population Health Research Institute, Hamilton, ON, Canada
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3
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Kayola G, Mataa MM, Asukile M, Chishimba L, Chomba M, Mortel D, Nutakki A, Zimba S, Saylor D. Stroke Rehabilitation in Low- and Middle-Income Countries: Challenges and Opportunities. Am J Phys Med Rehabil 2023; 102:S24-S32. [PMID: 36634327 PMCID: PMC9846582 DOI: 10.1097/phm.0000000000002128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
ABSTRACT Stroke remains the second leading cause of global disability with 87% of stroke-related disability occurring in low- and middle-income countries. In low- and middle-income countries, access to acute stroke interventions is often limited, making effective poststroke rehabilitation potentially the best available intervention to promote poststroke recovery. Here, we build on our experience as an illustrative example of barriers individuals with stroke face in accessing rehabilitation services and review the literature to summarize challenges to providing effective rehabilitation in low- and middle-income countries. First, we focus on barriers individuals with stroke face in accessing rehabilitation in low- and middle-income countries, including health system barriers, such as lack of national guidelines, low prioritization of rehabilitation services, and inadequate numbers of skilled rehabilitation specialists, as well as patient factors, including limited health literacy, financial constraints, and transportation limitations. Next, we highlight consequences of this lack of rehabilitation access, including higher mortality, poorer functional outcomes, financial burden, caregiver stress, and loss of gross domestic product at a national level. Finally, we review possible strategies that could improve access and quality of rehabilitation services in low- and middle-income countries, including creation of inpatient stroke units, increased training opportunities for rehabilitation specialists, task shifting to available healthcare workers or caregivers, telerehabilitation, and community-based rehabilitation services.
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Affiliation(s)
- Grace Kayola
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | | | - Melody Asukile
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Lorraine Chishimba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Mashina Chomba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Dominique Mortel
- Department of Neurology, Johns Hopkins University School of Medicine
| | | | - Stanley Zimba
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Deanna Saylor
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
- Department of Neurology, Johns Hopkins University School of Medicine
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4
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Smit S, Hagemeister DT, van Rooyen C. Clinical review of stroke care at National District Hospital, Bloemfontein. S Afr Fam Pract (2004) 2023; 65:e1-e7. [PMID: 36744481 PMCID: PMC9983283 DOI: 10.4102/safp.v65i1.5608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Stroke is a leading cause of morbidity and mortality affecting sub-Saharan Africa. Studies show that dedicated stroke units improve patient outcomes. National District Hospital (NDH) manages strokes, with the potential of becoming a dedicated stroke unit in Bloemfontein, South Africa. The study aimed to describe the clinical characteristics, management and outcomes of patients presenting with stroke at NDH. METHODS In this retrospective descriptive study, emergency department registers were used to identify patients presenting with symptoms of a stroke between 01 January 2019 and 31 March 2019. Relevant data were extracted from hospital files. RESULTS Of the 106 identified patients, 53 were included in the study. The median age was 61 years (range 28-89 years), with an almost equal split between genders. The most common risk factor was hypertension (81.3%). The median time from symptom onset to presentation at NDH was 9 h. No patient received thrombolysis. One patient received neurosurgical intervention. The most prescribed secondary preventative drugs were antihypertensive medication, statins, anticoagulation and antiretroviral therapy. Half (52.8%) of the patients received rehabilitation as in-patients. Final diagnoses were ischaemic strokes (26/53, 49.0%), transient ischaemic attacks (10/56, 22.7%) and haemorrhagic strokes (6/56, 13.6%). The 6-month post-infarct mortality rate was 37.5%. CONCLUSION Patient outcomes were comparable to similar South African studies. Time delays in stroke management remain a major obstacle. Identified action points include community education, improving emergency medical services and establishing a dedicated stroke unit.Contribution: This study underlines the importance of stroke and cardiovascular disease prevention and stresses the value of establishing dedicated stroke units.
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Affiliation(s)
- Selma Smit
- Department of Family Medicine, Faculty of Health Science, University of the Free State, Bloemfontein.
| | - Dirk T. Hagemeister
- Department of Family Medicine, Faculty of Health Science, University of the Free State, Bloemfontein, South Africa
| | - Cornel van Rooyen
- Department of Family Medicine, Faculty of Health Science, University of the Free State, Bloemfontein, South Africa
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5
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Ndondo AP, Hammond CK. Management of Pediatric Stroke - Challenges and Perspectives from Resource-limited Settings. Semin Pediatr Neurol 2022; 44:100996. [PMID: 36456038 DOI: 10.1016/j.spen.2022.100996] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 10/14/2022]
Abstract
Childhood stroke is not as common as adult stroke, but it is underrecognized the world over. Diagnosis is often delayed due to lack of awareness not only by the lay public but also by emergency and front-line health care workers. Despite the relative rarity of childhood stroke, the impact on morbidity, mortality and the economic burden for families and society is high, especially in poorly resourced settings. The risk factors for stroke in children differ from the adult population where lifestyle factors play a more important role. The developmental aspects of the pediatric cerebral vasculature and hematological maturational biology affects the clinical presentation, investigation, management and outcomes of childhood stroke in a different way compared to adults. The management of childhood stroke is currently based on expert guidelines and evidence extrapolated from adult studies. Hyperacute therapies that have revolutionized the treatment of stroke in adults cannot be easily applied to children at this stage due to the diagnostic delays, diverse risk factors and developmental considerations mentioned above. Much has been achieved in the understanding of genetic, acquired, preventable and recurrent stroke risk factors in the past decade through international collaborative efforts like the International Pediatric Stroke Study. Evidence for the prevention and treatment of childhood stroke remains elusive. Even more elusive are relevant and achievable management guidelines for pediatric stroke in resource-limited settings. This narrative review focusses on the current management practices globally, emphasizing the challenges, and gaps in knowledge of pediatric stroke in low- and middle-income countries and other areas with limited resources. Priorities and some potential solutions at national and local level are suggested for these settings.
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Affiliation(s)
- Alvin Pumelele Ndondo
- Department of Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.
| | - Charles K Hammond
- Department of Child Health, Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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6
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Nepal G. Low-cost alternatives for the management of acute ischemic stroke in low and middle-income countries. Ann Med Surg (Lond) 2021; 72:102969. [PMID: 34992776 PMCID: PMC8712992 DOI: 10.1016/j.amsu.2021.102969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/16/2021] [Accepted: 10/16/2021] [Indexed: 11/20/2022] Open
Abstract
Acute ischemic stroke (AIS) patients arriving within a suitable time frame are treated with recanalization therapy i.e. intravenous thrombolysis (IVT) with alteplase and/or mechanical thrombectomy (MT). IVT with alteplase is indicated in AIS patients presenting within 4.5 hours of onset regardless of vascular territory involved. MT is indicated in AIS patients presenting within 24 hours of onset with large vessel occlusion in the anterior circulation. However, MT is ludicrously expensive and requires exorbitant setup, devices, and expertise which is not currently feasible in LMICs. Therefore, in LMICs the only feasible recanalization option left for AIS patients is IVT. The cost of IVT varies across the LMICs, however, most of them cost around 2000-5000 USD. Apart from IVT, patients with AIS often have other significant medical costs including those for neuroimaging, intensive care, and prolonged rehabilitative treatment. In LMICs, these costs can only be afforded by a handful of patients. The majority of the LMICs have health insurance in their infancy and family members of AIS patients opt-out IVT due to the economic burden. In general, the current treatment guidelines for AIS are not very useful in LMICs because of cost-related issues among several other factors. In this editorial, we discuss evidence for alternative treatment strategies that can help tackle the rising epidemic of AIS in poor countries by improvising on existing clinical guidelines and seeking alternative treatment regimens.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, 44600, Nepal
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7
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van Niekerk SM, Kamalakannan S, Inglis-Jassiem G, Charumbira MY, Fernandes S, Webster J, English R, Louw QA, Smythe T. Towards universal health coverage for people with stroke in South Africa: a scoping review. BMJ Open 2021; 11:e049988. [PMID: 34824111 PMCID: PMC8627414 DOI: 10.1136/bmjopen-2021-049988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore the opportunities and challenges within the health system to facilitate the achievement of universal health coverage (UHC) for people with stroke (PWS) in South Africa (SA). SETTING SA. DESIGN Scoping review. SEARCH METHODS We conducted a scoping review of opportunities and challenges to achieve UHC for PWS in SA. Global and Africa-specific databases and grey literature were searched in July 2020. We included studies of all designs that described the healthcare system for PWS. Two frameworks, the Health Systems Dynamics Framework and WHO Framework, were used to map data on governance and regulation, resources, service delivery, context, reorientation of care and community engagement. A narrative approach was used to synthesise results. RESULTS Fifty-nine articles were included in the review. Over half (n=31, 52.5%) were conducted in Western Cape province and most (n=41, 69.4%) were conducted in urban areas. Studies evaluated a diverse range of health system categories and various outcomes. The most common reported component was service delivery (n=46, 77.9%), and only four studies (6.7%) evaluated governance and regulation. Service delivery factors for stroke care were frequently reported as poor and compounded by context-related limiting factors. Governance and regulations for stroke care in terms of government support, investment in policy, treatment guidelines, resource distribution and commitment to evidence-based solutions were limited. Promising supporting factors included adequately equipped and staffed urban tertiary facilities, the emergence of Stroke units, prompt assessment by health professionals, positive staff attitudes and care, two clinical care guidelines and educational and information resources being available. CONCLUSION This review fills a gap in the literature by providing the range of opportunities and challenges to achieve health for all PWS in SA. It highlights some health system areas that show encouraging trends to improve service delivery including comprehensiveness, quality and perceptions of care.
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Affiliation(s)
- Sjan-Mari van Niekerk
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Sureshkumar Kamalakannan
- SACDIR Indian Institute of Public Health Hyderabad, Public Health Foundation of India, New Delhi, India
- International Center for Evidence in Disability, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Gakeemah Inglis-Jassiem
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Maria Yvonne Charumbira
- Rehabilitation Sciences, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Silke Fernandes
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Tropical Health and Medicine, London, UK
| | - Rene English
- Global Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Quinette A Louw
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Tracey Smythe
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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8
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John L, William A, Dawar D, Khatter H, Singh P, Andrias A, Mochahari C, Langhorne P, Pandian J. Implementation of a Physician-Based Stroke Unit in a Remote Hospital of North-East India-Tezpur Model. J Neurosci Rural Pract 2021; 12:356-361. [PMID: 33927525 PMCID: PMC8064833 DOI: 10.1055/s-0041-1723099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective
The study aims to determine the effects of implementing stroke unit (SU) care in a remote hospital in North-East India.
Materials and Methods
This before-and-after implementation study was performed at the Baptist Christian Mission Hospital, Tezpur, Assam between January 2015 and December 2017. Before the implementation of stroke unit care (pre-SU), we collected information on usual stroke care and 1-month outcome of 125 consecutive stroke admissions. Staff was then trained in the delivery of SU care for 1 month, and the same information was collected in a second (post-SU) cohort of 125 patients.
Statistical Analysis
Chi-square and Mann–Whitney U test were used to compare group differences. The loss to follow-up was imputed by using multiple imputations using the Markov Chain Monto Carlo method. The sensitivity analysis was also performed by using propensity score matching of the groups for baseline stroke severity (National Institute of Health Stroke Scale) using the nearest neighbor approach to control for confounding, and missing values were imputed by using multiple imputations. The adjusted odds ratio was calculated in univariate and multivariate regression analysis after adjusting for baseline variables. All the analysis was done by using SPSS, version 21.0., IBM Corp and R version 4.0.0., Armonk, New York, United States.
Results
The pre-SU and post-SU groups were age and gender matched. The post-SU group showed higher rates of swallow assessment (36.8 vs. 0%,
p
< 0.001), mobility assessment, and re-education (100 vs. 91.5%,
p
= 0.037). The post-SU group also showed reduced complications (28 vs. 45%,
p
= 0.006) and a shorter length of hospital stay (4 ± 2.16 vs. 5 ± 2.68 days,
p
= 0.026). The functional outcome (modified ranking scale) at 1-month showed no difference between the groups, good outcome in post-SU (39.6%) versus pre-SU (35.7%),
p
= 0.552.
Conclusion
The implementation of this physician-based SU care model in a remote hospital in India shows improvements in quality measures, complications, and possibly patient outcomes.
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Affiliation(s)
- Lydia John
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India
| | - Akanksha William
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Dimple Dawar
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Himani Khatter
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Pratibha Singh
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India
| | - Anjana Andrias
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India
| | | | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, Royal Infirmary Hospital, Glasgow, United Kingdom
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
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9
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Abstract
Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.
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10
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Baatiema L, de‐Graft Aikins A, Sarfo FS, Abimbola S, Ganle JK, Somerset S. Improving the quality of care for people who had a stroke in a low-/middle-income country: A qualitative analysis of health-care professionals' perspectives. Health Expect 2020; 23:450-460. [PMID: 31967387 PMCID: PMC7104640 DOI: 10.1111/hex.13027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/06/2019] [Accepted: 12/27/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Efforts to improve the adoption of evidence-based interventions for optimal patient outcomes in low-/middle-income countries (LMICs) are persistently hampered by a plethora of barriers. Yet, little is known about strategies to address such barriers to improve quality stroke care. This study seeks to explore health professionals' views on strategies to improve quality stroke care for people who had a stroke in a LMIC. METHODS A qualitative interview study design was adopted. A semi-structured interview guide was used to conduct in-depth interviews among forty stroke care providers in major referral centres in Ghana. Participants were from nursing, medical, specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical settings. A thematic analysis approach was utilized to inductively analyse the data. RESULTS A number of overarching themes of strategies to improve quality stroke care were identified: computerization and digitization of medical practice, allocation of adequate resources, increase the human resource capacity to deliver stroke care, development of clinical guideline/treatment protocols, institutionalization of multidisciplinary care and professional development opportunities. These strategies were however differentially prioritized among different categories of stroke care providers. CONCLUSION Closing the gap between existing knowledge on how to improve quality of stroke care in LMICs has the potential to be successful if unique and context-specific measures from the views of stroke care providers are considered in developing quality improvement strategies and health systems and policy reforms. However, for optimal outcomes, further research into the effectiveness and feasibility of the proposed strategies by stroke care providers is needed.
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Affiliation(s)
- Leonard Baatiema
- Noguchi Memorial Institute for Medical ResearchUniversity of GhanaLegonGhana
| | | | - Fred S. Sarfo
- Kwame Nkrumah University of Science & TechnologyKumasiGhana
- Department of MedicineKomfo Anokye Teaching HospitalKumasiGhana
| | - Seye Abimbola
- School of Public HealthUniversity of SydneySydneyNSWAustralia
| | - John K. Ganle
- School of Public HealthUniversity of GhanaLegonGhana
| | - Shawn Somerset
- Faculty of HealthUniversity of CanberraCanberraACTAustralia
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11
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Chimatiro GL, Rhoda AJ. Scoping review of acute stroke care management and rehabilitation in low and middle-income countries. BMC Health Serv Res 2019; 19:789. [PMID: 31684935 PMCID: PMC6829977 DOI: 10.1186/s12913-019-4654-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 10/17/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Stroke is a major public health concern, affecting millions of people worldwide. Care of the condition however, remain inconsistent in developing countries. The purpose of this scoping review was to document evidence of stroke care and service delivery in low and middle-income countries to better inform development of a context-fit stroke model of care. METHODS An interpretative scoping literature review based on Arksey and O'Malley's five-stage-process was executed. The following databases searched for literature published between 2010 and 2017; Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, Cumulative Index to Nursing and Allied Health Literature (CINNAHL), Academic Search Complete, and Google Scholar. Single combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, low and middle-income countries. RESULTS A total of 177 references were identified. Twenty of them, published between 2010 and 2017, were included in the review. Applying the Donebedian Model of quality of care, seven dimensions of stroke-care structure, six dimensions of stroke care processes, and six dimensions of stroke care outcomes were identified. Structure of stroke care included availability of a stroke unit, an accident and emergency department, a multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. Stroke care processes that emerged were assessment and diagnosis, referrals, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies. Stroke-care outcomes included quality of stroke-care practice, functional independence level, length of stay, mortality, living at home, and institutionalization. CONCLUSIONS There is lack of uniformity in the way stroke care is advanced in low and middle-income countries. This is reflected in the unsatisfactory stroke care structure, processes, and outcomes. There is a need for stroke care settings to adopt quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke. Stroke Units and Recombinant Tissue Plasminogen Activator (rtPA) administration could be considered as both a structural and process necessity towards improvement of outcomes of patients with stroke in the LMICs.
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Affiliation(s)
- George Lameck Chimatiro
- University of the Western Cape, Cape Town, South Africa
- Medical Rehabilitation College, Box 256, Blantyre, Malawi
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Abstract
Background: Stroke is the second leading cause of death and adult-onset disability globally. Although its incidence is reducing in developed countries, low- and middle-income countries, especially African countries, are witnessing an increase in cases of stroke, leading to high morbidity and mortality. Evidently, a new paradigm is needed on the continent to tackle this growing burden of stroke in its preventative and treatment aspects. Aims and Objectives: The aim of this study was to determine the scope of stroke care services, where they exist, and their relationship with currently existing health systems. Methods: A detailed literature search was undertaken referring to PubMed and Google Scholar for articles from January 1960 to March 2018, using a range of search terms. Of 93 publications, 45 papers were shortlisted, and 21 reviewed articles on existing stroke services were included. Results: The literature on models of stroke services in Africa is sparse. We identified focused systems of care delivery in the hyperacute, acute, and rehabilitative phases of stroke in a few African countries. There is a continent-wide paucity of data on the organization of prehospital stroke services. Only 3 African countries (South Africa, Egypt, and Morocco) reported experiences on thrombolysis. Also, the uptake of dedicated stroke units appears limited across the continent. Encouragingly, there are large-scale secondary prevention models on the continent, mostly within the context of experimental research projects, albeit with promising results. We found only 1 article on the interventional aspects of stroke care in our review, and this was a single-center report. Conclusions: The literature on the organization of stroke services is sparse in Africa. Dedicated action at policy, population, community, and hospital-based levels is urgently needed toward the organization of stroke services to tame the burgeoning burden of stroke on the African continent.
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Affiliation(s)
- Rufus O. Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Neurology Unit, Department of Medicine, University College Hospital,Ibadan, Nigeria
- Division of Neurology, Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Olaleye A. Adeniji
- Division of Neurology, Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria
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Fuhs AK, LaGrone LN, Moscoso Porras MG, Rodríguez Castro MJ, Ecos Quispe RL, Mock CN. Assessment of Rehabilitation Infrastructure in Peru. Arch Phys Med Rehabil 2018; 99:1116-1123. [PMID: 29162468 PMCID: PMC5962371 DOI: 10.1016/j.apmr.2017.10.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess rehabilitation infrastructure in Peru in terms of the World Health Organization (WHO) health systems building blocks. DESIGN Anonymous quantitative survey; questions were based on the WHO's Guidelines for Essential Trauma Care and rehabilitation professionals' input. SETTING Large public hospitals and referral centers and an online survey platform. PARTICIPANTS Convenience sample of hospital personnel working in rehabilitation and neurology (N=239), recruited through existing contacts and professional societies. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Outcome measures were for 4 WHO domains: health workforce, health service delivery, essential medical products and technologies, and health information systems. RESULTS Regarding the domain of health workforce, 47% of physical therapists, 50% of occupational therapists, and 22% of physiatrists never see inpatients. Few reported rehabilitative nurses (15%) or prosthetist/orthotists (14%) at their hospitals. Even at the largest hospitals, most reported ≤3 occupational therapists (54%) and speech-language pathologists (70%). At hospitals without speech-language pathologists, physical therapists (49%) or nobody (34%) perform speech-language pathology roles. At hospitals without occupational therapists, physical therapists most commonly (59%) perform occupational therapy tasks. Alternate prosthetist/orthotist task performers are occupational therapists (26%), physical therapists (19%), and physicians (16%). Forty-four percent reported interdisciplinary collaboration. Regarding the domain of health services, the most frequent inpatient and outpatient rehabilitation barriers were referral delays (50%) and distance/transportation (39%), respectively. Regarding the domain of health information systems, 28% reported rehabilitation service data collection. Regarding the domain of essential medical products and technologies, electrophysical agents (88%), gyms (81%), and electromyography (76%) were most common; thickened liquids (19%), swallow studies (24%), and cognitive training tools (28%) were least frequent. CONCLUSIONS Rehabilitation emphasis is on outpatient services, and there are comparatively adequate numbers of physical therapists and physiatrists relative to rehabilitation personnel. Financial barriers seem low for accessing existing services. There appear to be shortages of inpatient rehabilitation, specialized services, and interdisciplinary collaboration. These may be addressed by redistributing personnel and investing in education and equipment for specialized services. Further examination of task sharing's role in Peru's rehabilitation services is necessary to evaluate its potential to address deficiencies.
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Affiliation(s)
| | | | - Miguel G Moscoso Porras
- School of Physical Therapy, Peruvian University of Applied Sciences, Lima, Peru; Association for the Development of Student Research in Health Sciences, San Marcos Major National University, Lima, Peru
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Urimubenshi G, Cadilhac DA, Kagwiza JN, Wu O, Langhorne P. Stroke care in Africa: A systematic review of the literature. Int J Stroke 2018; 13:797-805. [DOI: 10.1177/1747493018772747] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited. Aim To describe the status of stroke care in Africa. Summary of review We undertook a systematic search of the published literature to identify recent (1 January 2006–20 June 2017) publications that described stroke care in any African country. Our initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for our review, the proportion of stroke patients reported to arrive at hospital within 3 h from stroke onset varied between 10% and 43%. The median time interval between stroke onset and hospital admission was 31 h. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa. Conclusions This review provides an overview of stroke care in Africa, and highlights the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access, to organized stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e., registries or audits) are also needed to inform policy and practice.
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Affiliation(s)
- Gerard Urimubenshi
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Clayton, Australia
- Stroke Division, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeanne N Kagwiza
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Khatib R, Jawaada AM, Arevalo YA, Hamed HK, Mohammed SH, Huffman MD. Implementing Evidence-Based Practices for Acute Stroke Care in Low- and Middle-Income Countries. Curr Atheroscler Rep 2017; 19:61. [PMID: 29119348 DOI: 10.1007/s11883-017-0694-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Most strokes occur in low- and middle-income countries where resources to manage patients are limited. We explore the resources required to providing optimal acute stroke care and review barriers to implementing evidence-based stroke care in settings with limited resources using the World Stroke Organization's Global Stroke Services Action Plan framework. RECENT FINDINGS Major advances have been made during the past few decades in stroke prevention, treatment, and rehabilitation. These advances have been translated into practice in many high-income countries, but their uptake remains suboptimal in low- and middle-income countries. The review highlights the resources required to providing optimal acute stroke care in settings with limited resources. These resource levels were divided into minimal, essential, and advanced resources depending on the availability of stroke expertise, diagnostics, and facilities. Resources were described for the three stages of acute care: early diagnosis and management, acute management and prevention of complications, and early discharge and rehabilitation. Barriers to providing acute care at each of these stages in low- and middle-income countries are reviewed, explaining that some barriers persist in essential or advanced settings where some aspects of organized stroke units are available.
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Affiliation(s)
- Rasha Khatib
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Assef M Jawaada
- Department of General Surgery, Palestine Medical Complex, Ramallah, Palestine
- Faculty of Pharmacy, Nursing and Health Professions, Birzeit University, Ramallah, Palestine
| | - Yurany A Arevalo
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hiba K Hamed
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, Palestine
| | - Sukayna H Mohammed
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, Palestine
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite1400, Chicago, IL, USA.
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Baatiema L, Chan CKY, Sav A, Somerset S. Interventions for acute stroke management in Africa: a systematic review of the evidence. Syst Rev 2017; 6:213. [PMID: 29065915 PMCID: PMC5655819 DOI: 10.1186/s13643-017-0594-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 10/02/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The past decades have witnessed a rapid evolution of research on evidence-based acute stroke care interventions worldwide. Nonetheless, the evidence-to-practice gap in acute stroke care remains variable with slow and inconsistent uptake in low-middle income countries (LMICs). This review aims to identify and compare evidence-based acute stroke management interventions with alternative care on overall patient mortality and morbidity outcomes, functional independence, and length of hospital stay across Africa. METHODS This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. An electronic search was conducted in six databases comprising MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Academic Search Complete and Cochrane Library for experimental and non-experimental studies. Eligible studies were abstracted into evidence tables and their methodological quality appraised using the Joanna Briggs Institute checklist. Data were analysed and presented narratively with reference to observed differences in patient outcomes, reporting p values and confidence intervals for any possible relationship. RESULTS Initially, 1896 articles were identified and 37 fully screened. Four non-experimental studies (three cohort and one case series studies) were included in the final review. One study focused on the clinical efficacy of a stroke unit whilst the remaining three reported on thrombolytic therapy. The results demonstrated a reduction in patient deaths attributed to stroke unit care and thrombolytic therapy. Thrombolytic therapy was also associated with reductions in symptomatic intracerebral haemorrhage (SICH). However, the limited eligible studies and methodological limitations compromised definitive conclusions on the extent of and level of efficacy of evidence-based acute stroke care interventions across Africa. CONCLUSION Evidence from this review confirms the widespread assertion of low applicability and uptake of evidence-based acute stroke care in LMICs. Despite the limited eligible studies, the overall positive patient outcomes following such interventions demonstrate the applicability and value of evidence-based acute stroke care interventions in Africa. Health policy attention is thus required to ensure widespread applicability of such interventions for improved patients' outcomes. The review findings also emphasises the need for further research to unravel the reasons for low uptake. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016051566.
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Affiliation(s)
- Leonard Baatiema
- Regional Institute for Population Studies, University of Ghana, Legon, Accra, Ghana. .,School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia.
| | - Carina K Y Chan
- School of Psychology, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - Adem Sav
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - Shawn Somerset
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
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Pandian JD, William AG, Kate MP, Norrving B, Mensah GA, Davis S, Roth GA, Thrift AG, Kengne AP, Kissela BM, Yu C, Kim D, Rojas-Rueda D, Tirschwell DL, Abd-Allah F, Gankpé F, deVeber G, Hankey GJ, Jonas JB, Sheth KN, Dokova K, Mehndiratta MM, Geleijnse JM, Giroud M, Bejot Y, Sacco R, Sahathevan R, Hamadeh RR, Gillum R, Westerman R, Akinyemi RO, Barker-Collo S, Truelsen T, Caso V, Rajagopalan V, Venketasubramanian N, Vlassovi VV, Feigin VL. Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review. Neuroepidemiology 2017; 49:45-61. [DOI: 10.1159/000479518] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/11/2017] [Indexed: 01/10/2023] Open
Abstract
Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. Aims and Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.
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Pandian JD, Gandhi DB, Lindley RI, Bettger JP. Informal Caregiving. Stroke 2016; 47:3057-3062. [DOI: 10.1161/strokeaha.116.013701] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 09/29/2016] [Accepted: 10/14/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Jeyaraj D. Pandian
- From the Department of Neurology (J.D.P.) and College of Physiotherapy (D.B.C.G.), Christian Medical College, Ludhiana, Punjab, India; Neurological and Mental Health Division, The George Institute for Global Health and Sydney Medical School, University of Sydney, NSW, Australia (R.I.L.); and Director of Health Policy and Implementation Science, Duke Clinical Research Institute, Duke Global Health Institute, Duke University School of Medicine Durham, NC (J.P.B.)
| | - Dorcas B.C. Gandhi
- From the Department of Neurology (J.D.P.) and College of Physiotherapy (D.B.C.G.), Christian Medical College, Ludhiana, Punjab, India; Neurological and Mental Health Division, The George Institute for Global Health and Sydney Medical School, University of Sydney, NSW, Australia (R.I.L.); and Director of Health Policy and Implementation Science, Duke Clinical Research Institute, Duke Global Health Institute, Duke University School of Medicine Durham, NC (J.P.B.)
| | - Richard I. Lindley
- From the Department of Neurology (J.D.P.) and College of Physiotherapy (D.B.C.G.), Christian Medical College, Ludhiana, Punjab, India; Neurological and Mental Health Division, The George Institute for Global Health and Sydney Medical School, University of Sydney, NSW, Australia (R.I.L.); and Director of Health Policy and Implementation Science, Duke Clinical Research Institute, Duke Global Health Institute, Duke University School of Medicine Durham, NC (J.P.B.)
| | - Janet P. Bettger
- From the Department of Neurology (J.D.P.) and College of Physiotherapy (D.B.C.G.), Christian Medical College, Ludhiana, Punjab, India; Neurological and Mental Health Division, The George Institute for Global Health and Sydney Medical School, University of Sydney, NSW, Australia (R.I.L.); and Director of Health Policy and Implementation Science, Duke Clinical Research Institute, Duke Global Health Institute, Duke University School of Medicine Durham, NC (J.P.B.)
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Nakibuuka J, Sajatovic M, Nankabirwa J, Ssendikadiwa C, Kalema N, Kwizera A, Byakika-Tusiime J, Furlan AJ, Kayima J, Ddumba E, Katabira E. Effect of a 72 Hour Stroke Care Bundle on Early Outcomes after Acute Stroke: A Non Randomised Controlled Study. PLoS One 2016; 11:e0154333. [PMID: 27145035 PMCID: PMC4856379 DOI: 10.1371/journal.pone.0154333] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 04/11/2016] [Indexed: 12/31/2022] Open
Abstract
Background Integrated care pathways (ICP) in stroke management are increasingly being implemented to improve outcomes of acute stroke patients. We evaluated the effect of implementing a 72 hour stroke care bundle on early outcomes among patients admitted within seven days post stroke to the national referral hospital in Uganda. Methods In a one year non-randomised controlled study, 127 stroke patients who had ‘usual care’ (control group) were compared to 127 stroke patients who received selected elements from an ICP (intervention group). Patients were consecutively enrolled (controls first, intervention group second) into each group over 5 month periods and followed to 30-days post stroke. Incidence outcomes (mortality and functional ability) were compared using chi square test and adjusted for potential confounders. Kaplan Meier survival estimates and log rank test for comparison were used for time to death analysis for all strokes and by stroke severity categories. Secondary outcomes were in-hospital mortality, median survival time and median length of hospital stay. Results Mortality within 7 days was higher in the intervention group compared to controls (RR 13.1, 95% CI 3.3–52.9). There was no difference in 30-day mortality between the two groups (RR 1.2, 95% CI 0.5–2.6). There was better 30-day survival in patients with severe stroke in the intervention group compared to controls (P = 0.018). The median survival time was 30 days (IQR 29–30 days) in the control group and 30 days (IQR 7–30 days) in the intervention group. In the intervention group, 41patients (32.3%) died in hospital compared to 23 (18.1%) in controls (P < 0.001). The median length of hospital stay was 8 days (IQR 5–12 days) in the controls and 4 days (IQR 2–7 days) in the intervention group. There was no difference in functional outcomes between the groups (RR 0.9, 95% CI 0.4–2.2). Conclusions While implementing elements of a stroke-focused ICP in a Ugandan national referral hospital appeared to have little overall benefit in mortality and functioning, patients with severe stroke may benefit on selected outcomes. More research is needed to better understand how and when stroke protocols should be implemented in sub-Saharan African settings. Trial Registration Pan African Clinical Trials Registry PACTR201510001272347
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Affiliation(s)
- Jane Nakibuuka
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Mulago National referral hospital, Kampala, Uganda
- * E-mail:
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, Cleveland, Ohio, United States of America
| | - Joaniter Nankabirwa
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Nelson Kalema
- Department of Medicine, Mulago National referral hospital, Kampala, Uganda
| | - Arthur Kwizera
- Department of Anaesthesia and critical care, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jayne Byakika-Tusiime
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Anthony J. Furlan
- University Hospitals Case Medical Center, Neurological Institute, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - James Kayima
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Edward Ddumba
- Department of Medicine, St Raphael of St Francis Nsambya Hospital, Nkozi University, Kampala, Uganda
| | - Elly Katabira
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Akhtar N, Kamran S, Singh R, Cameron P, D'Souza A, Imam Y, Bourke P, Joseph S, Khan R, Santos M, Deleu D, El-Zouki A, Abou-Samra A, Butt AA, Shuaib A. Beneficial Effects of Implementing Stroke Protocols Require Establishment of a Geographically Distinct Unit. Stroke 2015; 46:3494-501. [PMID: 26493677 DOI: 10.1161/strokeaha.115.010552] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 09/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Usefulness of multidisciplinary stroke units in acute stroke patients is well established. There is extensive western literature on usefulness of stroke units in outcome, but limited evidence from the rest of the world. We aim to evaluate the impact of establishing a stroke unit on outcome in patients presenting to a tertiary care facility. METHODS This is a retrospective study of 1003 patients with acute stroke admitted to Hamad General Hospital, Qatar, between January 2014 and February 2015. Patients directly admitted to intensive care unit (132) were excluded. We compared outcomes of pre- and poststroke ward (SW) establishment and in SW patients versus those of general medical wards. RESULTS Before the establishment of the SW, 175 patients were admitted to the hospital. From April 2014 to February 2015, 696 patients were admitted (SW, 545; medical ward, 151). There was a significant reduction in length of stay from 14.7±27.7 to 6.2±20.2 days (P=0.0001) and incidence of complications (23.6% versus 6.4%, P=0.0001) after implementation of stroke-specific protocols. Prognosis at discharge (modified Rankin Scale 0-2 in 56.0% versus 70.4%, P=0.001) and at 90 days (modified Rankin Scale 0-2 in 70.6% versus 95.0%, P=0.001) also significantly improved. Compared with medical ward patients, outcome was significantly better in SW patients with fewer complications (10.9% versus 5.0%, P=0.013) and shorter length of stay (8.9±30.7 versus 5.4±16.1 days, P=0.05). CONCLUSIONS Establishing a distinct SW is essential for achieving full benefits of stroke protocols implementation. SW patients have significantly fewer complications and better prognosis when compared with patients in medical wards.
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Affiliation(s)
- Naveed Akhtar
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Peter Cameron
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Atlantic D'Souza
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Yahya Imam
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Paula Bourke
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Sujatha Joseph
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Rabia Khan
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Mark Santos
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Abdel El-Zouki
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Abdul Abou-Samra
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Adeel A Butt
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- From the Neuroscience Institute (Stroke Center of Excellence) (N.A., S.K., A.D., Y.I., P.B., S.J., R.K., M.S., D.D., A.S.), Departments of Emergency Medicine (P.C.), Internal Medicine (A.E.-Z., A.A.-S.), Cardiology Research Center (R.S.), and Hamad Healthcare Quality Institute (A.A.B.), Hamad Medical Corporation, Doha, Qatar.
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Toward a Modern Delivery of Stroke Care in Emerging Economies. J Stroke Cerebrovasc Dis 2013; 22:e1-3. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 02/29/2012] [Accepted: 03/03/2012] [Indexed: 01/22/2023] Open
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23
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Navigating the Poststroke Continuum of Care. J Stroke Cerebrovasc Dis 2013; 22:1-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2011.05.021] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 05/19/2011] [Accepted: 05/21/2011] [Indexed: 11/20/2022] Open
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Bryer A, Connor MD, Haug P, Cheyip B, Staub H, Tipping B, Duim WB, Pinkney-Atkinson V. The South African Guideline for the Management of Ischemic Stroke and Transient Ischemic Attack: Recommendations for a Resource-Constrained Health Care Setting. Int J Stroke 2011; 6:349-54. [DOI: 10.1111/j.1747-4949.2011.00629.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alan Bryer
- Department of Medicine, Division of Neurology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Myles D. Connor
- Queen Margaret Hospital, NHS Fife, and University of Edinburgh, Edinburgh, UK
| | - Peter Haug
- Milnerton MediClinic, Cape Town, South Africa
| | | | - Hugh Staub
- Entabeni Hospital, Life Healthcare Rehabilitation Unit, Durban, South Africa
| | - Brent Tipping
- Division of Geriatric Medicine, Donald Gordon Medical Centre and University of the Witwatersrand, Johannesburg, South Africa
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26
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Pandian JD, Joy SA, Justin M, Premkumar AJ, John J, George AD, Paul P. Impact of Stroke Unit Care: An Indian Perspective. Int J Stroke 2011; 6:372-3. [DOI: 10.1111/j.1747-4949.2011.00626.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jeyaraj Durai Pandian
- Department of Neurology, Betty Cowan Research and Innovation Centre, Christian Medical College and Hospital, Ludhiana, Punjab, India
- Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Sneha Anna Joy
- Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Melbha Justin
- Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | | | - Jubin John
- Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Anjali David George
- Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Priya Paul
- Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
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27
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Ghandehari K. Barriers of thrombolysis therapy in developing countries. Stroke Res Treat 2011; 2011:686797. [PMID: 21603174 PMCID: PMC3095908 DOI: 10.4061/2011/686797] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 01/31/2011] [Accepted: 02/13/2011] [Indexed: 11/20/2022] Open
Abstract
The developing world carries the highest burden of stroke mortality and stroke-related disability. The number of stroke patients receiving r-tPA in the developing world is extremely low. Prehospital delay, financial constraints, and lack of infrastructure are main barriers of thrombolysis therapy in developing countries. Until a cheaper thrombolytic agent and the proper infrastructure for utilization of thrombolytic therapy is available, developing countries should focus on primary and secondary stroke prevention strategies. However, governments and health systems of developing countries should efforts exerb for promotion of their infrastructure of stroke care.
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Affiliation(s)
- Kavian Ghandehari
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, P.O. Box: 91766-99199, Iran
- Department of Neurology, Ghaem Hospital, Ahmadabad Street, Mashhad, P.O. Box: 91766-99199, Iran
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28
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Hachinski V, Donnan GA, Gorelick PB, Hacke W, Cramer SC, Kaste M, Fisher M, Brainin M, Buchan AM, Lo EH, Skolnick BE, Furie KL, Hankey GJ, Kivipelto M, Morris J, Rothwell PM, Sacco RL, Smith SC, Wang Y, Bryer A, Ford GA, Iadecola C, Martins SCO, Saver J, Skvortsova V, Bayley M, Bednar MM, Duncan P, Enney L, Finklestein S, Jones TA, Kalra L, Kleim J, Nitkin R, Teasell R, Weiller C, Desai B, Goldberg MP, Heiss WD, Saarelma O, Schwamm LH, Shinohara Y, Trivedi B, Wahlgren N, Wong LK, Hakim A, Norrving B, Prudhomme S, Bornstein NM, Davis SM, Goldstein LB, Leys D, Tuomilehto J. Stroke: working toward a prioritized world agenda. Int J Stroke 2010; 5:238-56. [PMID: 20636706 DOI: 10.1111/j.1747-4949.2010.00442.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke. METHODS Preliminary work was performed by seven working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium. RESULTS Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent 'silo' mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science. Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (eg, social media/marketing) techniques. Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks. Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery. Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries. Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care. Educate and energize professionals, patients, the public and policy makers by using a 'Brain Health' concept that enables promotion of preventive measures. CONCLUSIONS To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.
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29
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Bruno A, Waddell MJ, Potter DJ, Kongable GL, Golas A, Carroll JT, Juneja R. Opportunity to lower hyperglycaemia faster in patients with acute ischaemic stroke and diabetes. Int J Stroke 2010; 5:338-9. [PMID: 20636722 DOI: 10.1111/j.1747-4949.2010.00450.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hachinski V, Donnan GA, Gorelick PB, Hacke W, Cramer SC, Kaste M, Fisher M, Brainin M, Buchan AM, Lo EH, Skolnick BE, Furie KL, Hankey GJ, Kivipelto M, Morris J, Rothwell PM, Sacco RL, Smith SC, Wang Y, Bryer A, Ford GA, Iadecola C, Martins SCO, Saver J, Skvortsova V, Bayley M, Bednar MM, Duncan P, Enney L, Finklestein S, Jones TA, Kalra L, Kleim J, Nitkin R, Teasell R, Weiller C, Desai B, Goldberg MP, Heiss WD, Saarelma O, Schwamm LH, Shinohara Y, Trivedi B, Wahlgren N, Wong LK, Hakim A, Norrving B, Prudhomme S, Bornstein NM, Davis SM, Goldstein LB, Leys D, Tuomilehto J. Stroke: working toward a prioritized world agenda. Stroke 2010; 41:1084-99. [PMID: 20498453 DOI: 10.1161/strokeaha.110.586156] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND PURPOSE The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke. METHODS Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium. RESULTS Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent "silo" mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science. Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (eg, social media/marketing) techniques. Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks. Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery. Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries. Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care. Educate and energize professionals, patients, the public and policy makers by using a "Brain Health" concept that enables promotion of preventive measures. CONCLUSIONS To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.
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Affiliation(s)
- Vladimir Hachinski
- University of Western Ontario, University Hospital, 339 Windermere Road, London, Ontario, Canada N6A 5A5, USA.
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Hachinski V, Donnan GA, Gorelick PB, Hacke W, Cramer SC, Kaste M, Fisher M, Brainin M, Buchan AM, Lo EH, Skolnick BE, Furie KL, Hankey GJ, Kivipelto M, Morris J, Rothwell PM, Sacco RL, Smith SC, Wang Y, Bryer A, Ford GA, Iadecola C, Martins SCO, Saver J, Skvortsova V, Bayley M, Bednar MM, Duncan P, Enney L, Finklestein S, Jones TA, Kalra L, Kleim J, Nitkin R, Teasell R, Weiller C, Desai B, Goldberg MP, Heiss WD, Saarelma O, Schwamm LH, Shinohara Y, Trivedi B, Wahlgren N, Wong LK, Hakim A, Norrving B, Prudhomme S, Bornstein NM, Davis SM, Goldstein LB, Leys D, Tuomilehto J. Stroke: working toward a prioritized world agenda. Cerebrovasc Dis 2010; 30:127-47. [PMID: 20516682 DOI: 10.1159/000315099] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke. METHODS Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium. RESULTS Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent 'silo' mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science. Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (e.g., social media/marketing) techniques. Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks. Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery. Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries. Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care. Educate and energize professionals, patients, the public and policy makers by using a 'Brain Health' concept that enables promotion of preventive measures. CONCLUSIONS To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.
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Affiliation(s)
- Vladimir Hachinski
- Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, and St. Joseph's Healthcare London, Ontario, Canada
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Current challenges of stroke treatment. Curr Opin Neurol 2010; 23:29-30. [DOI: 10.1097/wco.0b013e32833539c5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Banzi R, Moja L, Liberati A, Gensini GF, Gusinu R, Conti AA. Measuring the impact of evidence: the Cochrane systematic review of organised stroke care. Intern Emerg Med 2009; 4:507-10. [PMID: 19888638 DOI: 10.1007/s11739-009-0323-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Rita Banzi
- Italian Cochrane Centre, Mario Negri Institute for Pharmacological Research, Via La Masa, 19, 20156, Milan, Italy
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