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Erkelens DC, Zwart DL, van der Meer GH, Wouters LT, De Groot E, Damoiseaux RA, Hoes AW, Rutten FH. Is the time of calling helpful for differentiating transient ischaemic attack and stroke from mimics in primary care out-of-hours services? A cross-sectional study. BMJ Open 2020; 10:e041408. [PMID: 33334837 PMCID: PMC7747588 DOI: 10.1136/bmjopen-2020-041408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Telephone triage of patients suspected of transient ischaemic attack (TIA) or stroke is challenging. Both TIA and stroke more likely occur during daytime, with a peak in the morning hours. Thus, the time of calling might be a helpful determinant during telephone triage. We assessed the time of calling in patients with stroke-like symptoms who called the out-of-hours services in primary care (OHS-PC), and evaluated whether the time of calling differed between patients with TIA or stroke compared with those with mimics. DESIGN Cross-sectional study. SETTING Six OHS-PC locations in the Netherlands. PARTICIPANTS 1269 telephone triage recordings of patients calling the OHS-PC because of stroke-like symptoms. We collected information on patient characteristics, symptoms, time of calling and urgency allocation. The final diagnosis related to each triage call was based on letters from the neurologist (retrieved from the patient's general practitioner). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measures were the time of calling hourly and 4 hourly, and the risk of TIA or stroke/hour. The secondary outcome measure was the risk ratio of TIA or stroke in the morning (08:00-12:00h) versus other hours. RESULTS Mean age was 68.6 (SD±18.5) years, 56.9% were women and 50.0% had a TIA or stroke. The risk ratio of TIA or stroke among people calling with stroke-like symptoms between 08:00-12:00h versus other hours was 1.13 (95% CI 1.00 to 1.28, p=0.070). After correction for age and sex, the adjusted risk ratio was 0.94 (95% CI 0.80 to 1.10, p=0.434). CONCLUSION In patients who called the OHS-PC because of stroke-like symptoms, the time of calling did not differ between patients with TIA or stroke and patients with mimics. TRIAL REGISTRATION NUMBER The Netherlands National Trial Registry (NTR7331).
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Affiliation(s)
- Daphne Ca Erkelens
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dorien L Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gerben H van der Meer
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Loes Tcm Wouters
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Esther De Groot
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger Amj Damoiseaux
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Penn AM, Bibok MB, Saly VK, Coutts SB, Lesperance ML, Balshaw RF, Votova K, Croteau NS, Trivedi A, Jackson AM, Hegedus J, Klourfeld E, Yu AYX, Zerna C, Modi J, Barber PA, Hoag G, Borchers CH. Validation of a proteomic biomarker panel to diagnose minor-stroke and transient ischaemic attack: phase 2 of SpecTRA, a large scale translational study. Biomarkers 2018; 23:793-803. [PMID: 30010432 DOI: 10.1080/1354750x.2018.1499130] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To validate our previously developed 16 plasma-protein biomarker panel to differentiate between transient ischaemic attack (TIA) and non-cerebrovascular emergency department (ED) patients. METHOD Two consecutive cohorts of ED patients prospectively enrolled at two urban medical centers into the second phase of SpecTRA study (training, cohort 2A, n = 575; test, cohort 2B, n = 528). Plasma samples were analyzed using liquid chromatography/multiple reaction monitoring-mass spectrometry. Logistic regression models which fit cohort 2A were validated on cohort 2B. RESULTS Three of the panel proteins failed quality control and were removed from the panel. During validation, panel models did not outperform a simple motor/speech (M/S) deficit variable. Post-hoc analyses suggested the measured behaviour of L-selectin and coagulation factor V contributed to poor model performance. Removal of these proteins increased the external performance of a model containing the panel and the M/S variable. CONCLUSIONS Univariate analyses suggest insulin-like growth factor-binding protein 3 and serum paraoxonase/lactonase 3 are reliable and reproducible biomarkers for TIA status. Logistic regression models indicated L-selectin, apolipoprotein B-100, coagulation factor IX, and thrombospondin-1 to be significant multivariate predictors of TIA. We discuss multivariate feature subset analyses as an exploratory technique to better understand a panel's full predictive potential.
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Affiliation(s)
- Andrew M Penn
- a Department of Neurosciences , Stroke Rapid Assessment Clinic, Island Health Authority , Victoria , Canada
| | - Maximilian B Bibok
- b Department of Research and Capacity Building , Island Health Authority , Victoria , Canada
| | - Viera K Saly
- a Department of Neurosciences , Stroke Rapid Assessment Clinic, Island Health Authority , Victoria , Canada
| | - Shelagh B Coutts
- c Departments of Clinical Neurosciences, Radiology, and Community Health Services , University of Calgary , Calgary , Canada
| | - Mary L Lesperance
- d Department of Mathematics and Statistics , University of Victoria , Victoria , Canada
| | - Robert F Balshaw
- e George & Fay Yee Centre for Healthcare Innovation , University of Manitoba , Winnipeg , Canada
| | - Kristine Votova
- b Department of Research and Capacity Building , Island Health Authority , Victoria , Canada.,f Division of Medical Sciences , University of Victoria , Victoria , Canada
| | - Nicole S Croteau
- b Department of Research and Capacity Building , Island Health Authority , Victoria , Canada.,d Department of Mathematics and Statistics , University of Victoria , Victoria , Canada
| | - Anurag Trivedi
- a Department of Neurosciences , Stroke Rapid Assessment Clinic, Island Health Authority , Victoria , Canada
| | - Angela M Jackson
- g Genome British Columbia Proteomics Centre, University of Victoria , Victoria , Canada
| | - Janka Hegedus
- c Departments of Clinical Neurosciences, Radiology, and Community Health Services , University of Calgary , Calgary , Canada
| | - Evgenia Klourfeld
- c Departments of Clinical Neurosciences, Radiology, and Community Health Services , University of Calgary , Calgary , Canada
| | - Amy Y X Yu
- h Department of Medicine , University of Toronto , Toronto , Canada
| | - Charlotte Zerna
- c Departments of Clinical Neurosciences, Radiology, and Community Health Services , University of Calgary , Calgary , Canada
| | - Jayesh Modi
- i Department of Radiology , Foothills Medical Centre , Calgary , Canada
| | - Philip A Barber
- j Department of Clinical Neurosciences , University of Calgary , Calgary , Canada
| | - Gordon Hoag
- k Department of Laboratory Medicine, Pathology & Medical Genetics , Island Health Authority , Victoria , Canada
| | - Christoph H Borchers
- g Genome British Columbia Proteomics Centre, University of Victoria , Victoria , Canada.,l Department of Biochemistry and Microbiology , University of Victoria , Victoria , Canada.,m Gerald Bronfman Department of Oncology , McGill University , Montreal , Canada.,n Proteomics Centre, Segal Cancer Centre , Lady Davis Institute , Montreal , Canada
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Reducing time-to-unit among patients referred to an outpatient stroke assessment unit with a novel triage process: a prospective cohort study. BMC Health Serv Res 2018; 18:142. [PMID: 29482544 PMCID: PMC6389093 DOI: 10.1186/s12913-018-2952-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 02/21/2018] [Indexed: 11/30/2022] Open
Abstract
Background To evaluate the performance of a novel triage system for Transient Ischemic Attack (TIA) units built upon an existent clinical prediction rule (CPR) to reduce time to unit arrival, relative to the time of symptom onset, for true TIA and minor stroke patients. Differentiating between true and false TIA/minor stroke cases (mimics) is necessary for effective triage as medical intervention for true TIA/minor stroke is time-sensitive and TIA unit spots are a finite resource. Methods Prospective cohort study design utilizing patient referral data and TIA unit arrival times from a regional fast-track TIA unit on Vancouver Island, Canada, accepting referrals from emergency departments (ED) and general practice (GP). Historical referral cohort (N = 2942) from May 2013–Oct 2014 was triaged using the ABCD2 score; prospective referral cohort (N = 2929) from Nov 2014–Apr 2016 was triaged using the novel system. A retrospective survival curve analysis, censored at 28 days to unit arrival, was used to compare days to unit arrival from event date between cohort patients matched by low (0–3), moderate (4–5) and high (6–7) ABCD2 scores. Results Survival curve analysis indicated that using the novel triage system, prospectively referred TIA/minor stroke patients with low and moderate ABCD2 scores arrived at the unit 2 and 1 day earlier than matched historical patients, respectively. Conclusions The novel triage process is associated with a reduction in time to unit arrival from symptom onset for referred true TIA/minor stroke patients with low and moderate ABCD2 scores. Electronic supplementary material The online version of this article (10.1186/s12913-018-2952-x) contains supplementary material, which is available to authorized users.
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