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Tunkl C, Paudel R, Bajaj S, Thapa L, Tunkl P, Chandra A, Shah B, Karmacharya B, Subedi A, Jalan P, Ghimire P, Ghimire MR, Dorje G, Begli NH, Golenia J, Gajurel BP, Shreyan S, Sharma N, Krauss A, Pandian J, Fischer T, van der Merwe J, Wick W, Hacke W, Gumbinger C. Implementing stroke care in a lower-middle-income country: results and recommendations based on an implementation study within the Nepal Stroke Project. Front Neurol 2023; 14:1272076. [PMID: 37941574 PMCID: PMC10628475 DOI: 10.3389/fneur.2023.1272076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/22/2023] [Indexed: 11/10/2023] Open
Abstract
Background Globally, the majority of strokes affect people residing in lower- and lower-middle-income countries (LMICs), but translating evidence-based knowledge into clinical practice in regions with limited healthcare resources remains challenging. As an LMIC in South Asia, stroke care has remained a healthcare problem previously unaddressed at a national scale in Nepal. The Nepal Stroke Project (NSP) aims to improve acute stroke care in the tertiary healthcare sector of Nepal. We hereby describe the methods applied and analyze the barriers and facilitators of the NSP after 18 months. Methods The NSP follows a four-tier strategy: (1) quality improvement by training healthcare professionals in tertiary care centers; (2) implementation of in-hospital stroke surveillance and quality monitoring system; (3) raising public awareness of strokes; and (4) collaborating with political stakeholders to facilitate public funding for stroke care. We performed a qualitative, iterative analysis of observational data to analyze the output indicators and identify best practices. Results Both offline and online initiatives were undertaken to address quality improvement and public awareness. More than 1,000 healthcare professionals across nine tertiary care hospitals attended 26 stroke-related workshops conducted by Nepalese and international stroke experts. Monthly webinars were organized, and chat groups were made for better networking and cross-institutional case sharing. Social media-based public awareness campaigns reached more than 3 million individuals. Moreover, live events and other mass media campaigns were instituted. For quality monitoring, the Registry of Stroke Care Quality (RES-Q) was introduced. Collaboration with stakeholders (both national and international) has been initiated. Discussion We identified six actions that may support the development of tertiary care centers into essential stroke centers in a resource-limited setting. We believe that our experiences will contribute to the body of knowledge on translating evidence into practice in LMICs, although the impact of our results must be verified with process indicators of stroke care.
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Affiliation(s)
- Christine Tunkl
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Raju Paudel
- Department of Neurology, Grande International Hospital, Kathmandu, Nepal
| | - Sunanjay Bajaj
- Department of Neurology, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, United States
| | - Lekhjung Thapa
- Department of Neurology, National Neuro Center, Kathmandu, Nepal
| | - Patrick Tunkl
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Avinash Chandra
- Department of Neurology, Annapurna Neurological Institute, Kathmandu, Nepal
| | - Bhupendra Shah
- Department of Neurology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Balgopal Karmacharya
- Department of Neurosurgery and Emergency Medicine, Manipal Teaching Hospital, Pokhara, Nepal
| | - Ashim Subedi
- Department of Neurosurgery and Emergency Medicine, Manipal Teaching Hospital, Pokhara, Nepal
| | - Pankaj Jalan
- Department of Neurology, Norvic International Hospital, Kathmandu, Nepal
| | | | - Mahesh Raj Ghimire
- Department of Neurology, National Neuro Center, Kathmandu, Nepal
- Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Nima Haji Begli
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Golenia
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Nooma Sharma
- Department of Neurology, National Neuro Center, Kathmandu, Nepal
| | - Alexandra Krauss
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Thomas Fischer
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Wolfgang Wick
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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2
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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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Pandian JD, Kalkonde Y, Sebastian IA, Felix C, Urimubenshi G, Bosch J. Stroke systems of care in low-income and middle-income countries: challenges and opportunities. Lancet 2020; 396:1443-1451. [PMID: 33129395 DOI: 10.1016/s0140-6736(20)31374-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/18/2020] [Accepted: 06/09/2020] [Indexed: 12/27/2022]
Abstract
The burden of stroke is higher in low-income and middle-income countries (LMICs) than in high-income countries and is rising. Even though there are global policies and guidelines for implementing stroke care, there are many challenges in setting up stroke services in LMICs. Despite these challenges, there are many models of stroke care available in LMICs-eg, multidisciplinary team care led by a stroke neurologist, specialist-led care by neurologists, physician-led care, hub and spoke models incorporating stroke telemedicine (ie, telestroke), and task sharing involving community health workers. Alternative strategies have been developed, such as reorganising the existing hospital infrastructure by training health professionals to implement protocol-driven care. The future challenge is to identify what elements of organised stroke care can be implemented to make the largest gain. Simple interventions such as swallowing assessments, bowel and bladder care, mobility assessments, and consistent secondary prevention can prove to be key elements to improving post-discharge morbidity and mortality in LMICs.
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Affiliation(s)
- Jeyaraj D Pandian
- Department of Neurology, Christian Medical College, Ludhiana, India.
| | | | | | - Cynthia Felix
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gerard Urimubenshi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda; Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jackie Bosch
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
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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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William AG, Pannu A, Kate MP, Jaison V, Gupta L, Bose S, Sahonta R, Sebastian I, Pandian JD. Quality Indicators of Intravenous Thrombolysis from North India. Ann Indian Acad Neurol 2017; 20:393-398. [PMID: 29184343 PMCID: PMC5682744 DOI: 10.4103/aian.aian_277_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Data on intravenous (IV) thrombolysis using tissue plasminogen activator (tPA) are limited from low- and middle-income countries. We aimed to assess the quality indicators of IV thrombolysis in our stroke unit. Methods: All stroke patients admitted in our hospital from October 2008 to April 2017 were included in this study. Data were collected prospectively by trained research staff in a detailed case record form. Outcome was assessed using modified Rankin Scale (mRS, 0–1 good outcome). Results: Of the total 4720 stroke patients seen, 944 (20%) came within window period (<4.5 h). Of these, 214 (4.5%) were eligible for thrombolysis and 170 (3.6%) were thrombolysed, relatives of 23 (23/214, 10.7%) patients denied consent, and 21 (9.8%) patients could not afford tPA. The mean age of thrombolysed patients was 58.4 (range 19–95) years. Median NIHSS at admission was 12 (interquartile range 2–24). Average onset-to-door (O-D) time was 76.8 (5–219) min, door-to-examination (D-E) time was 17.8 (5–105) min, door-to-CT (D-CT) time was 48 (1–205) min, and door-to-needle (D-N) time was 90 (20–285) min. At 6 months, 110 (64.7%) patients were contactable and 82 (74.5%) patients had good outcome (mRS 0–1). Conclusion: Thrombolysis rate has steadily increased at the center without undue adverse effects even in the elderly. D-E and D-CT times have reduced, but O-D and D-N times need further improvement. More patients could be thrombolysed if the cost of tPA is reduced and the consent process is waived.
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Affiliation(s)
| | - Aman Pannu
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | | | - Vineeth Jaison
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Leenu Gupta
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Smrithi Bose
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Rajeshwar Sahonta
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Ivy Sebastian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
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7
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Padma VM, Bhatia R, Kuruttukulam G, Alurkar A, Talwar KK, Khurana D, Kaul S, Suri V, Singh G, Huded V. A call for neurologists to take up stroke intervention. Ann Indian Acad Neurol 2016; 19:429-432. [PMID: 27994348 PMCID: PMC5144460 DOI: 10.4103/0972-2327.194408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Recent data have provided overwhelming evidence in favor of benefits of emergent endovascular intervention in large vessel acute ischemic stroke (AIS). India with its large population has a huge burden of AIS. Hence, neurologists need to gear up to the new challenge of providing interventional care to huge populations of AIS in the country. The best way to cover this unprecedented unmet need is to encourage neurologists to take up interventional subspecialty interests through new but sound training pathways.
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Affiliation(s)
- Vasantha M Padma
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anand Alurkar
- Department of Neurology, KEM Hospital, Pune, Maharashtra, India
| | | | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Kaul
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Vinit Suri
- Department of Neurology, Apollo Hospital, New Delhi, India
| | - Gagandeep Singh
- Department of Neurology, Dayanand Medical College, Ludhiana, Punjab, India
| | - Vikram Huded
- NH institute of Neurosciences, Bangalore, Karnataka, India
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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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9
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Pandian JD, Bhullar RS, Kaur P, Dhillon S, Toor G, Singh Y. Trends in the use of intravenous recombinant tissue plasminogen activator from northwest India. Int J Stroke 2012; 7:363-4. [PMID: 22583526 DOI: 10.1111/j.1747-4949.2012.00793.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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