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Jiang Y, Zhao Q, Guan J, Wang Y, Chen J, Li Y. Analyzing prehospital delays in recurrent acute ischemic stroke: Insights from interpretable machine learning. PATIENT EDUCATION AND COUNSELING 2024; 123:108228. [PMID: 38458092 DOI: 10.1016/j.pec.2024.108228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/18/2024] [Accepted: 02/24/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE This study investigates prehospital delays in recurrent Acute Ischemic Stroke (AIS) patients, aiming to identify key factors contributing to these delays to inform effective interventions. METHODS A retrospective cohort analysis of 1419 AIS patients in Shenzhen from December 2021 to August 2023 was performed. The study applied the Extreme Gradient Boosting (XGBoost) algorithm and SHapley Additive exPlanations (SHAP) for identifying determinants of delay. RESULTS Living with others and lack of stroke knowledge emerged as significant risk factors for delayed hospital presentation in recurrent AIS patients. Key features impacting delay times included residential status, awareness of stroke symptoms, presence of conscious disturbance, diabetes mellitus awareness, physical weakness, mode of hospital presentation, type of stroke, and presence of coronary artery disease. CONCLUSION Prehospital delays are similarly prevalent among both recurrent and first-time AIS patients, highlighting a pronounced knowledge gap in the former group. This discovery underscores the urgent need for enhanced stroke education and management. PRACTICE IMPLICATION The similarity in prehospital delay patterns between recurrent and first-time AIS patients emphasizes the necessity for public health initiatives and tailored educational programs. These strategies aim to improve stroke response times and outcomes for all patients.
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Affiliation(s)
- Youli Jiang
- Department of Neurology, People's Hospital of Longhua, 38 Jinglong Jianshe Road, Longhua District, Shenzhen 518109, China
| | - Qingshi Zhao
- Department of Neurology, People's Hospital of Longhua, 38 Jinglong Jianshe Road, Longhua District, Shenzhen 518109, China
| | - Jincheng Guan
- Department of Neurology, People's Hospital of Longhua, 38 Jinglong Jianshe Road, Longhua District, Shenzhen 518109, China
| | - Yuying Wang
- Department of Neurology, People's Hospital of Longhua, 38 Jinglong Jianshe Road, Longhua District, Shenzhen 518109, China
| | - Jingfang Chen
- The Third People's Hospital of Shenzhen, Shenzhen 518112, China; National Clinical Research Center for Infectious Diseases, 29 Bulan Road, Longgang District, Shenzhen 518112, China.
| | - Yanfeng Li
- Department of Neurology, People's Hospital of Longhua, 38 Jinglong Jianshe Road, Longhua District, Shenzhen 518109, China.
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Sirousinejad ZS, Dianati M, Kheiran M, Sooki Z. Delays in receiving Alteplase and related factors in patients with stroke referred to Shahid Beheshti Hospital in Kashan-Iran in 2020-2021. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2024; 13:147. [PMID: 38784291 PMCID: PMC11114574 DOI: 10.4103/jehp.jehp_1685_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 05/27/2023] [Indexed: 05/25/2024]
Abstract
BACKGROUND The benefits of using Alteplase are time-dependent. This study aimed to evaluate delays between the onset of symptoms and the administration of Alteplase and related factors in patients with acute ischemic stroke (AIS). MATERIALS AND METHODS In this cross-sectional study, 60 AIS patients receiving Alteplase were selected by census sampling from July 2020 to July 2021 from the eligible patients referred to Shahid Beheshti Hospital in Kashan, Iran. The data collection tool was a researcher-made questionnaire containing demographic information, time periods from the onset of symptoms to the injection of Alteplase, and associated factors. The required information was collected from the patients, their relatives, their health records, and Kashan Emergency Medical Service (EMS) information system. Data were analyzed in SPSS-16. RESULTS Eighty-five percent of the 60 patients participating in the study were transferred to the hospital by EMS ambulances. The mean time intervals between different phases were as follows: Onset-To-Door (OTD) time 81.35 ± 33.76 minutes; Door-To-CT (DTC) scan time 16.12 ± 17.46 minutes; Door-To-Needle (DNT) time 51.30 ± 26.14 minutes; and the overall Onset-To-Needle (ONT) time 133.75 ± 39.17 minutes. Also, the mean ONT in people transferred by EMS was about 129 minutes, and the longest prehospital delay in these patients was related to the time between the arrival of the EMS ambulance to the hospital. Marital status and geographical location where the stroke had occurred showed a significant relationship with prehospital delay and pre-hospital notification (PHN) by EMS But there was no relationship between underlying diseases or economic status and prehospital delays; also, the patient's diastolic blood pressure at the time of receiving Alteplase showed a significant relationship with in-hospital delay. CONCLUSION The findings of the study showed that the majority of people trust and use EMS ambulances to transfer to the hospital and the time spent in different stages, from the onset of symptoms to the injection of the thrombolytic drug, was in an acceptable range in the patients.
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Affiliation(s)
- Zahra Sadat Sirousinejad
- Department of Nursing, Trauma Nursing Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
| | - Mansour Dianati
- Department of Nursing, Trauma Nursing Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
| | - Mahdi Kheiran
- Department of Neurology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Zahra Sooki
- Department of Midwifery, Trauma Nursing Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
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KAZADI KABANDA I, KIANGEBENI NGONZO C, EMEKA BOWAMOU CK, DIVENGI NZAMBI JP, KIATOKO PONTE N, TUYINAMA MADODA O, NKODILA NATUHOYILA A, M’BUYAMBA-KABANGU JR, LONGO-MBENZA B, BANZULU BOMBA D, KIANU PHANZU B. Stroke signs knowledge and factors associated with a delayed hospital arrival of patients with acute stroke in Kinshasa. Heliyon 2024; 10:e28311. [PMID: 38571603 PMCID: PMC10988012 DOI: 10.1016/j.heliyon.2024.e28311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024] Open
Abstract
Background Rapid recognition and early medical intervention are essential to reduce stroke-related mortality and long-term disability. This study aimed to evaluate awareness of stroke symptoms/signs and determine factors delaying the hospital arrival of patients with acute stroke in Kinshasa. Methods Patients with stroke and/or accompanying family members were interviewed using a standard questionnaire, and their medical records were reviewed. Factors independently associated with a late arrival (≥4.5 h) to the hospital were identified using the logistic regression test in forward multivariate analysis. Results Overall, 202 patients with an average age of 57.9 ± 13.1 years were included. Only 27 (13.4%) patients immediately associated the initial symptoms with a stroke episode. Delayed hospital arrival was observed in 180 (89.1%) patients. Unmarried status (adjusted odds ratio [aOR], 2.29; 95% confidence interval [CI], 1.17-4.88; p = 0.007), low education level (aOR, 2.29; 95% CI, (1.12-5.10; p = 0,014), absence of impaired consciousness (aOR, 3.12; 95% CI, 1.52-4.43; p = 0.005), absence of a history of hypertention (aOR, 1.85; 95% CI, 1.18-3.78; p = 0.041), absence of a history of diabetes (aOR, 1.93; 95% CI, 1.15-4.58; p = 0.013), heavy alcohol consumption (aOR, 1.83; 95% CI, 1.12-2.83; p = 0.045), absence of a severe to very severe stroke (aOR, 4.93; 95% CI, 0.82-1.01; p = 0.002), and presence of ischemic stroke (aOR, 2.93; 95% CI, 1.54-4.59; p = 0.001) were identified as independent determinants of delayed hospital arrival. Conclusions This study depicted a low stroke awareness rate and a much longer prehospital delay than evidence-based guidelines recommend and identified eight factors that public health actions could target to promote the earliest management of stroke.
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Affiliation(s)
- Igor KAZADI KABANDA
- Faculty of Medicine, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | | | | | - Jean-Paul DIVENGI NZAMBI
- Department of Internal Medicine, Reference General Hospital, Kinshasa, the Democratic Republic of the Congo
| | - Nono KIATOKO PONTE
- Unit of Neurology, Centre Hospitalier Initiative Plus de Kinkole, Kinshasa, the Democratic Republic of the Congo
| | - Olivier TUYINAMA MADODA
- Emergency Unit, University Hospital of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Aliocha NKODILA NATUHOYILA
- Department of Biostatistics, Public Health School of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | | | - Benjamin LONGO-MBENZA
- Cardiology Unit, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Degani BANZULU BOMBA
- Department of Neuropsychiatry, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Bernard KIANU PHANZU
- Cardiology Unit, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
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Prust ML, Forman R, Ovbiagele B. Addressing disparities in the global epidemiology of stroke. Nat Rev Neurol 2024; 20:207-221. [PMID: 38228908 DOI: 10.1038/s41582-023-00921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.
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Affiliation(s)
- Morgan L Prust
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Rachel Forman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California-San Francisco School of Medicine, San Francisco, CA, USA
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Kim J, Olaiya MT, De Silva DA, Norrving B, Bosch J, De Sousa DA, Christensen HK, Ranta A, Donnan GA, Feigin V, Martins S, Schwamm LH, Werring DJ, Howard G, Owolabi M, Pandian J, Mikulik R, Thayabaranathan T, Cadilhac DA. Global stroke statistics 2023: Availability of reperfusion services around the world. Int J Stroke 2024; 19:253-270. [PMID: 37853529 PMCID: PMC10903148 DOI: 10.1177/17474930231210448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Disparities in the availability of reperfusion services for acute ischemic stroke are considerable globally and require urgent attention. Contemporary data on the availability of reperfusion services in different countries are used to provide the necessary evidence to prioritize where access to acute stroke treatment is needed. AIMS To provide a snapshot of published literature on the provision of reperfusion services globally, including when facilitated by telemedicine or mobile stroke unit services. METHODS We searched PubMed to identify original articles, published up to January 2023 for the most recent, representative, and relevant patient-level data for each country. Keywords included thrombolysis, endovascular thrombectomy and telemedicine. We also screened reference lists of review articles, citation history of articles, and the gray literature. The information is provided as a narrative summary. RESULTS Of 11,222 potentially eligible articles retrieved, 148 were included for review following de-duplications and full-text review. Data were also obtained from national stroke clinical registry reports, Registry of Stroke Care Quality (RES-Q) and PRE-hospital Stroke Treatment Organization (PRESTO) repositories, and other national sources. Overall, we found evidence of the provision of intravenous thrombolysis services in 70 countries (63% high-income countries (HICs)) and endovascular thrombectomy services in 33 countries (68% HICs), corresponding to far less than half of the countries in the world. Recent data (from 2019 or later) were lacking for 35 of 67 countries with known year of data (52%). We found published data on 74 different stroke telemedicine programs (93% in HICs) and 14 active mobile stroke unit pre-hospital ambulance services (80% in HICs) around the world. CONCLUSION Despite remarkable advancements in reperfusion therapies for stroke, it is evident from available patient-level data that their availability remains unevenly distributed globally. Contemporary published data on availability of reperfusion services remain scarce, even in HICs, thereby making it difficult to reliably ascertain current gaps in the provision of this vital acute stroke treatment around the world.
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Affiliation(s)
- Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Muideen T Olaiya
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Deidre A De Silva
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
| | - Bo Norrving
- Department of Clinical Sciences, Section of Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Jackie Bosch
- School of Rehabilitation Science, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Diana A De Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Hanne K Christensen
- Department of Neurology, University of Copenhagen and Bispebjerg Hospital, Copenhagen, Denmark
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, Wellington, New Zealand
| | - Geoffrey A Donnan
- Melbourne Brain Centre, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Sheila Martins
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | | | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - George Howard
- Department of Biostatistics, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mayowa Owolabi
- Center for Genomic and Precision Medicine, University of Ibadan, Ibadan, Nigeria
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Robert Mikulik
- Health Management Institute, Brno, Czech Republic
- Neurology Department, Bata Hospital, Zlin, Czech Republic
| | - Tharshanah Thayabaranathan
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
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Jiang Y, Xiong Y, Chi Y, Lin F, Zhao Q, Li Y. Healthcare-Seeking Delays in Acute Ischemic Stroke Patients: The Influence of Gender, Immigrant Status, and Educational Background. Risk Manag Healthc Policy 2024; 17:191-204. [PMID: 38264584 PMCID: PMC10803282 DOI: 10.2147/rmhp.s445001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/16/2024] [Indexed: 01/25/2024] Open
Abstract
Purpose Timely medical attention is crucial for patients with Acute Ischemic Stroke (AIS), as delays can significantly impact therapeutic outcomes. These delays are influenced by a combination of socio-cultural, educational, and clinical factors. Patients and Methods An in-depth analysis was conducted to assess the prevalence and median duration of healthcare-seeking delays in AIS patients. The study specifically investigated the independent impacts of sociocultural and clinical determinants on these delays, with a focus on immigrant status, gender disparities, and educational levels. Multivariate regression analysis was employed to identify these independent effects while controlling for potential confounding factors. Results Among 1419 AIS patients, 82.52% (n = 1171) experienced delays exceeding 2 hours from symptom onset of symptoms to hospital arrival. The median delay was 12.3 hours. Immigrant populations encountering longer delays compared to native groups. Younger males (<45 years) and elderly females were more prone to delay in healthcare-seeking. Identified independent risk factors for delay included male gender (OR = 1.65 [95% CI:1.14-2.48]), self-acknowledged diabetes (OR = 2.50 [95% CI:1.21-5.17]), small vessel (OR = 2.07 [95% CI:1.27-3.36]), and wake stroke (OR = 7.04 [95% CI:3.69-13.44]). Educational background (high school and above), GCS score with 3-8 points (OR = 0.52 [95% CI:0.09-0.69]), understanding stroke-related knowledge (OR = 0.26 [95% CI:0.09-0.44]), conscious disturbance (OR = 0.25 [95% CI:0.10-0.62]) and limb weakness (OR=0.21[95% CI:0.21-0.49]) are protective factors for timely treatment. Conclusion Immigrant populations experienced longer delays from symptom onset to hospital arrival. The crucial roles of education and knowledge about stroke underscore the need for enhanced health literacy campaigns and public awareness, with a targeted focus on younger males and elderly females.
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Affiliation(s)
- Youli Jiang
- Department of Neurology, People’s Hospital of Longhua, Shenzhen, 518109, People’s Republic of China
| | - Yao Xiong
- Department of Neurology, People’s Hospital of Longhua, Shenzhen, 518109, People’s Republic of China
| | - Yue Chi
- Department of Neurology, People’s Hospital of Longhua, Shenzhen, 518109, People’s Republic of China
| | - Fu Lin
- Department of Neurology, People’s Hospital of Longhua, Shenzhen, 518109, People’s Republic of China
| | - Qingshi Zhao
- Department of Neurology, People’s Hospital of Longhua, Shenzhen, 518109, People’s Republic of China
| | - Yanfeng Li
- Department of Neurology, People’s Hospital of Longhua, Shenzhen, 518109, People’s Republic of China
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Anees A, Panicker P, Iype T, Sreelekha KR. Assessment of onset-to-door time in acute ischemic stroke and factors associated with delay at a tertiary care center in South India. J Neurosci Rural Pract 2024; 15:86-94. [PMID: 38476422 PMCID: PMC10927050 DOI: 10.25259/jnrp_325_2023] [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: 06/14/2023] [Accepted: 06/26/2023] [Indexed: 03/14/2024] Open
Abstract
Objectives Intravenous thrombolysis is an effective treatment of acute ischemic stroke but has a narrow therapeutic time window of 3-4.5 h. Pre-hospital delay is a major barrier to patients becoming eligible for thrombolysis. This single-center study assessed the factors causing longer onset-to-door (OTD) time to identify measures that will help decrease the delay. Materials and Methods Patients with acute ischemic stroke presenting to the emergency department from August to October 2022 were included in the study. The data were collected using a structured questionnaire and was completed by interviewing the patient or the caregivers. Patients were classified as early and late arrivers with the cutoff being 3.5 h. We then analyzed the relationship between early arrival and demographic factors, clinical factors, patient response factors, and logistic factors. Results Our study consisted of 153 patients. The average OTD time was 674.33 ± 812.713 min (median: 300; interquartile range: 151-885). The pre-hospital delay was present in 66% of patients. 16.9% of patients came beyond 24 h. In the multivariate analysis, the odds of early arrival were higher among patients who perceived their symptoms as serious (odds ratio [OR]: 18.801; confidence interval [CI]: 3.728-94.803) and lower among patients who experienced a delay in reaching due to traffic (OR: 0.085; CI: 0.008-0.873). Lack of knowledge about stroke centers among both patients and health professionals also contributed to longer OTD times. Out of 52 early arrivers, 24 received thrombolytic therapy after excluding wake-up strokes and contraindications. Conclusion Pre-hospital delay continues to stand in the way of patients receiving thrombolysis. Comprehensive stroke education, increasing awareness regarding stroke centers, and promoting ambulance services are some of the interventions which could help tackle the issue.
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Affiliation(s)
- Ashika Anees
- Department of Neurology, Government Medical College Thiruvananthapuram, Kerala, India
| | - Praveen Panicker
- Department of Neurology, Government Medical College Thiruvananthapuram, Kerala, India
| | - Thomas Iype
- Department of Neurology, Government Medical College Thiruvananthapuram, Kerala, India
| | - K. R. Sreelekha
- Department of Community Medicine, Government Medical College Thiruvananthapuram, Kerala, India
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Liu Y, Wang D, Chu M, Yang Z, Luo Y, Wang D, Zhao J. Value of the stroke 1-2-0 prehospital stroke education system: the experience of a general practitioner team. BMC Neurol 2023; 23:431. [PMID: 38062426 PMCID: PMC10770900 DOI: 10.1186/s12883-023-03476-0] [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: 03/18/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Stroke is one of the leading causes of death worldwide, especially in developing countries. In China, there is an urgent need to educate people about stroke awareness and the importance of using emergency medical services (EMS) quickly after a stroke has occurred. OBJECTIVE We sought to explore the effects of the Stroke 1-2-0 Prehospital Stroke Education System based on the experience of a general practitioner team. METHOD We prospectively enrolled 119 community general practitioners to be trained in the procedures advocated by the Stroke 1-2-0 Prehospital Stroke Education System. The training content included early detection of ischemic stroke, first aid for stroke, and intravenous thrombolysis; The effects of the training were later evaluated via a before-and-after comparison. The 119 enrolled physicians formed a Stroke 1-2-0 lecturer group and taught stroke knowledge to community residents. The group remained active for 6 months, during which the medical treatment data of stroke patients (i.e., stroke onset time, prehospital delay, whether an ambulance was called, and whether thrombolytic therapy was performed) in each of 5 jurisdictions were recorded for the month before (January 2021) and that after (August 2021) the 6-month community education program. Finally, the effects of the community education program were evaluated. RESULTS The participants' understanding of intravenous thrombolysis in the treatment of acute ischemic stroke improved significantly after the training as compared with their earlier understanding (96% vs. 78.99%; P < .001), and their understanding of the time window for intravenous thrombolysis increased from 26.05% before to 72% (P < .001) after the training. Most of the participants (90% vs. 67.23%; P < .001) said that they would immediately call the 120 emergency number of China's emergency phone system if they encountered individuals who appeared to be victims of acute stroke. A total of 82 stroke patients were seen before and 67 after the community education program. As for the use of the emergency call system, more patients with stroke activated that system after the program versus before (21.95% vs. 37.31%; P = .04). The 3-hour arrival rate after the program was nearly three times higher than that before the program (62.69% vs. 19.51%; P < .001). Also, regarding receiving thrombolysis after the occurrence of a stroke, the program triggered a substantial increase compared with the total earlier (19.4% vs. 6.1%; P = .013). CONCLUSION We found that the Stroke 1-2-0 Prehospital Stroke Education System significantly improved community residents' knowledge regarding stroke.
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Affiliation(s)
- Yang Liu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
- Institute of Science and Technology for Brain-inspired Intelligence, Fudan University, Shanghai, China
| | - Daosheng Wang
- Department of Neurosurgery, Minhang Hospital, Fudan University, Shanghai, China
| | - Min Chu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Zhenzhen Yang
- Department of General Medicine, Xinzhuang Community Health Service Center, Shanghai, China
| | - Yunhe Luo
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Delong Wang
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China.
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Sarpourian F, Ahmadi Marzaleh M, Fatemi Aghda SA, Zare Z. Application of Telemedicine in the Ambulance for Stroke Patients: A Systematic Review. Prehosp Disaster Med 2023; 38:774-779. [PMID: 37877359 DOI: 10.1017/s1049023x23006519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
INTRODUCTION The use of telemedicine for the prehospital management of emergency conditions, especially stroke, is increasing day by day. Few studies have investigated the applications of telemedicine in Emergency Medical Services (EMS). A comprehensive study of the applications of this technology in stroke patients in ambulances can help to build a better understanding. Therefore, this systematic review was conducted to investigate the use of telemedicine in ambulances for stroke patients in 2023. METHODS A systematic search was conducted in PubMed, Cochrane, Scopus, ProQuest, Science Direct, and Web of Science from 2013 through March 1, 2023. The authors selected the articles based on keywords and criteria and reviewed them in terms of title, abstract, and full text. Finally, the articles that were related to the study aim were evaluated. RESULTS The initial search resulted in the extraction of 2,795 articles. After review of the articles, and applying the inclusion and exclusion criteria, seven articles were selected for the final analysis. Three (42.85%) studies were on the feasibility and intervention types. Also, randomized trials, feasibility, feasibility and prospective-observational, and feasibility and retrospective-interventional studies were each one (14.28%). Six (85.71%) of the studies were conducted in the United States. The National Institutes of Health Stroke Scale (NIHSS) and RP-Xpress were the most commonly used tools for neurological evaluations and teleconsultations. CONCLUSION Remote prehospital consultations, triage, and sending patient data before they go to the emergency department can be provided through telemedicine in ambulances. Neurological evaluations via telemedicine are reliable and accurate, and they are almost equal to in-person evaluations by a neurologist.
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Affiliation(s)
- Fatemeh Sarpourian
- PhD Candidate of Health Information Management, Student Research Committee, Department of Health Information Technology, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Milad Ahmadi Marzaleh
- Department of Health in Disasters and Emergencies, Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ali Fatemi Aghda
- PhD Candidate of Medical Informatics, Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Zare
- PhD Candidate in Health Care Management, Department of Health Care Management, School of Health Management and Information Sciences, Shiraz University of Medical Science, Shiraz, Iran
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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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Gajurel BP, Nepal G, Jaiswal V, Ang SP, Nain P, Shama N, Ruchika F, Bohara S, Kharel S, Yadav JK, Medina JRT, Shrestha AB. Utilization rates of intravenous thrombolysis for acute ischemic stroke in Asian countries:: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e35560. [PMID: 37861564 PMCID: PMC10589571 DOI: 10.1097/md.0000000000035560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Despite intravenous thrombolysis (IVT) being used for the treatment of acute ischemic stroke (AIS) for over two decades, its accessibility remains limited in various regions of the world. The Asian region, which experiences the highest age-standardized incidence of AIS, currently lacks comprehensive data on the utilization of IVT. AIMS This study aimed to provide precise estimates of IVT usage for AIS in Asian countries. METHODS A literature search was conducted on PubMed and Google using appropriate search terms. English language, peer reviewed articles published after 2010 were included in the analysis. The pooled proportion was calculated utilizing the DerSimonian and Laird random-effects model. Additionally, a subgroup analysis was conducted, taking into account factors such as the study's country, the economic status of the country, specific Asian regions, publication year (before 2015 and from 2015 onwards), study location, study setting, hospital stroke protocol, and national stroke guidelines. RESULTS 67 observational studies with 778,046 patients with AIS were included in the meta-analysis. The overall utilization rate of IVT was found to be 9.1%. High-income countries had a higher rate (11.3%) compared to lower-middle-income (8.1%) and upper-middle-income countries (9%). Central and North Asia had the highest rate (17.5%) and Southeast Asia had the lowest rate (6.8%). Studies conducted after 2015 had a higher thrombolysis rate (11.3%) compared to those before 2015 (1.5%). Presence of hospital stroke protocols (10.7%) and national stroke guidelines (10.1%) were associated with higher thrombolysis rates. CONCLUSION The overall utilization rate of IVT for AIS in Asia stood at 9.1%, showcasing noteworthy disparities across countries, regions, and income brackets. To improve thrombolysis rates in the region, addressing prehospital delays, increasing public awareness, and implementing stroke protocols and national guidelines are key strategies.
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Affiliation(s)
- Bikram Prasad Gajurel
- Department of Neurology, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Biratnagar, Nepal
| | | | - Song Peng Ang
- Division of Internal Medicine, Rutgers Health/Community Medical Center, NJ
| | - Priyanshu Nain
- Department of Medicine, Maulana Azad Medical College, New Delhi, India
| | - Nishat Shama
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka, Bangladesh
| | - F.N.U. Ruchika
- Department of Surgery, JJM Medical College, Davangere, India
| | - Sujan Bohara
- Department of Internal Medicine, Nepalese Army Institute of Health Science, Kathmandu, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | | | - Jillian Reeze T. Medina
- Manila Central University - Filemon D. Tanchoco Medical Foundation College of Medicine, Philippines
| | - Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
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Sebastian IA, Gandhi DB, Sylaja PN, Paudel R, Kalkonde YV, Yangchen Y, Gunasekara H, Injety RJ, Vijayanand PJ, Chawla NS, Oo S, Hla KM, Tenzin T, Pandian JD. Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 17:100289. [PMID: 37849930 PMCID: PMC10577144 DOI: 10.1016/j.lansea.2023.100289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/15/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023]
Abstract
The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.
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Affiliation(s)
| | - Dorcas B.C. Gandhi
- Department of Neurology and Physiotherapy, Christian Medical College and Hospital, India
| | - Padmavati N. Sylaja
- Department of Neurology, Shree Chitra Thirunal Institute, Thiruvananthapuram, Kerala, India
| | - Raju Paudel
- Grande International Hospital, Kathmandu, Nepal
| | | | | | | | - Ranjit J. Injety
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Pranay J. Vijayanand
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Nistara S. Chawla
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - San Oo
- Department of Neurology, Yangon General Hospital, Yangon, Myanmar
| | - Khin Myo Hla
- Department of Physical Medicine & Rehabilitation, Yangon General Hospital, University of Medicine, Yangon, Myanmar
| | - Tashi Tenzin
- Jigme Dorji Wangchuck National Referral Hospital, Thimpu, Bhutan
| | - Jeyaraj D. Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
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Paudel R, Tunkl C, Shrestha S, Subedi RC, Adhikari A, Thapa L, Gajurel BP, Chandra A, Kharel G, Jalan P, Phuyal S, Pokharel BR, Acharya S, Bogati K, Jha P, Kharbuja N, Gumbinger C. Stroke epidemiology and outcomes of stroke patients in Nepal: a systematic review and meta-analysis. BMC Neurol 2023; 23:337. [PMID: 37749496 PMCID: PMC10519080 DOI: 10.1186/s12883-023-03382-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND With an increasing burden of stroke, it is essential to minimize the incidence of stroke and improve stroke care by emphasizing areas that bring out the maximum impact. The care situation remains unclear in the absence of a national stroke care registry and a lack of structured hospital-based data monitoring. We conducted this systematic review and meta-analysis to assess the status of stroke care in Nepal and identify areas that need dedicated improvement in stroke care. METHODS A systematic literature review was conducted to identify all studies on stroke epidemiology or stroke care published between 2000 and 2020 in Nepal. Data analysis was done with Statistical Package for Social Sciences (SPSS) and Comprehensive Meta-analysis (CMA-3). RESULTS We identified 2533 studies after database searching, and 55 were included in quantitative and narrative synthesis. All analyses were done in tertiary care settings in densely populated central parts of Nepal. Ischemic stroke was more frequent (70.87%) than hemorrhagic (26.79%), and the mean age of stroke patients was 62,9 years. Mortality occurred in 16.9% (13-21.7%), thrombolysis was performed in 2.39% of patients, and no studies described thrombectomy or stroke unit care. CONCLUSION The provision of stroke care in Nepal needs to catch up to international standards, and our systematic review demonstrated the need to improve access to quality stroke care. Dedicated studies on establishing stroke care units, prevention, rehabilitation, and studies on lower levels of care or remote regions are required.
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Affiliation(s)
- Raju Paudel
- Grande International Hospital, Kathmandu, Nepal.
| | | | | | | | - Ayush Adhikari
- Tribhuvan Univerisity Teaching Hospital, Kathmandu, Nepal
| | | | | | - Avinash Chandra
- Annapurna Neurological Institute and Allied Sciences, Kathmandu, Nepal
| | - Ghanashyam Kharel
- National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
| | | | | | | | - Subi Acharya
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Pinky Jha
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
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Tunkl C, Paudel R, Thapa L, Tunkl P, Jalan P, Chandra A, Belson S, Prasad Gajurel B, Haji-Begli N, Bajaj S, Golenia J, Wick W, Hacke W, Gumbinger C. Are digital social media campaigns the key to raise stroke awareness in low-and middle-income countries? A study of feasibility and cost-effectiveness in Nepal. PLoS One 2023; 18:e0291392. [PMID: 37682967 PMCID: PMC10490866 DOI: 10.1371/journal.pone.0291392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/26/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Stroke is a major global health problem and was the second leading cause of death worldwide in 2020. However, the lack of public stroke awareness especially in low- and middle-income countries (LMICs) such as Nepal severely hinders the effective provision of stroke care. Efficient and cost-effective strategies to raise stroke awareness in LMICs are still lacking. This study aims to (a) explore the feasibility of a social media-based stroke awareness campaign in Nepal using a cost-benefit analysis and (b) identify best practices for social media health education campaigns. METHODS We performed a stroke awareness campaign over a period of 6 months as part of a Stroke Project in Nepal on four social media platforms (Facebook, Instagram, Twitter, TikTok) with organic traffic and paid advertisements. Adapted material based on the World Stroke Day Campaign and specifically created videos for TikTok were used. Performance of the campaign was analyzed with established quantitative social media metrics (impressions, reach, engagement, costs). RESULTS Campaign posts were displayed 7.5 million times to users in Nepal. 2.5 million individual social media users in Nepal were exposed to the campaign on average three times, which equals 8.6% of Nepal's total population. Of those, 250,000 users actively engaged with the posts. Paid advertisement on Facebook and Instagram proved to be more effective in terms of reach and cost than organic traffic. The total campaign cost was low with a "Cost to reach 1,000 users" of 0.24 EUR and a "Cost Per Click" of 0.01 EUR. DISCUSSION Social media-based campaigns using paid advertisement provide a feasible and, compared to classical mass medias, a very cost-effective approach to inform large parts of the population about stroke awareness in LMICs. Future research needs to further analyze the impact of social media campaigns on stroke knowledge.
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Affiliation(s)
- Christine Tunkl
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Raju Paudel
- Grande International Hospital, Kathmandu, Nepal
| | | | | | | | | | | | | | - Nima Haji-Begli
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sunanjay Bajaj
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Golenia
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- German Cancer Research Center, 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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15
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Liu QH, Tan JX, Hu CX, Zhang XP, Liu SY, Wan LH. Relationship of family function and pre-hospital delay among Chinese patients with recurrent ischaemic stroke and the mediation effect of stigma. Eur J Cardiovasc Nurs 2023; 22:586-593. [PMID: 36611018 DOI: 10.1093/eurjcn/zvad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 11/24/2022] [Accepted: 12/31/2022] [Indexed: 01/09/2023]
Abstract
AIMS Pre-hospital delay refers to the time span from the onset of symptoms to arrival at a hospital ≥ 3 h and is the main limitation of stroke reperfusion therapies. Family factors and stroke-related stigma may influence pre-hospital delay. However, few studies have confirmed the influence of stigma on pre-hospital delay or explored the relationships between family function, stigma, and pre-hospital delay among patients with recurrent stroke. This study aimed to explore the relationship between family function and pre-hospital delay among patients with recurrent stroke and examine the mediation role of stigma in this relationship. METHODS AND RESULTS A cross-sectional study was performed at the neurology departments of two hospitals in Guangzhou, China between July 2021 and April 2022. A total of 115 patients with recurrent stroke completed questionnaires and were included in the analysis. Data were collected using the Short Form Family Assessment Device, the Stroke Stigma Scale, and the Stroke Knowledge Questionnaire. Spearman's correlation and a structural equation model were used for data analysis. Family function directly influenced pre-hospital delay [β=0.27, P = 0.033, 95%CI = (0.02-0.51)] and indirectly influenced pre-hospital delay [β=0.17, P = 0.038, 95%CI = (0.02-0.34)] through stigma. Moreover, stigma partially mediated the effect of family function on pre-hospital delay. CONCLUSION Family function and stigma directly and indirectly influenced pre-hospital delay among patients with recurrent stroke. Future health education and interventions need to focus on strengthening and improving emotional support from family members to improve family function and reduce stigma, thereby reducing pre-hospital delay among patients with recurrent stroke.
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Affiliation(s)
- Qun-Hong Liu
- School of Nursing, Sun Yat-sen University, 74 Zhongshan Rd. 2, Guangzhou 510089, China
| | - Ju-Xiang Tan
- Department of Neurology and Stroke Center, The Third Affiliated Hospital, Sun Yat-sen University, 2693 Kaichuang Avenue, Guangzhou 510700, China
| | - Cai-Xia Hu
- Department of Neurology, Guangdong Provincial Hospital of Traditional Chinese Medicine, 111 Dade Rd., Guangzhou 510120, China
| | - Xiao-Pei Zhang
- Department of Neurology, Guangdong Provincial Hospital of Traditional Chinese Medicine, 111 Dade Rd., Guangzhou 510120, China
| | - Shu-Ying Liu
- Department of Neurology, Guangdong Provincial Hospital of Traditional Chinese Medicine, 111 Dade Rd., Guangzhou 510120, China
| | - Li-Hong Wan
- School of Nursing, Sun Yat-sen University, 74 Zhongshan Rd. 2, Guangzhou 510089, China
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Shin J, Kim H, Jeong HJ, Lee J, Moon J, Ko KP, Kim Y. Trends in Prehospital Visits as a Cause of Delayed Admission in Korean Stroke Patients over a 10-Year Period: A National Health Insurance Claims Data Study. Rev Cardiovasc Med 2023; 24:83. [PMID: 39077504 PMCID: PMC11264022 DOI: 10.31083/j.rcm2403083] [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: 09/08/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 07/31/2024] Open
Abstract
Background A prehospital delay from symptom onset to hospital arrival resulted in stroke-related complications or in-hospital deaths in acute stroke patients. We aimed to investigate trends in prehospital visits as a cause of prehospital delay using data from the Korean Health Insurance Service. Methods This nationwide, population-based, retrospective cohort study included 524,524 newly-diagnosed stroke patients admitted via the emergency departments of secondary and tertiary hospitals. We obtained the prehospital visits rate from 2010 to 2019 and identified the related characteristics. Results Prehospital visits were observed in 111,465 patients (21.3%). The prehospital visits rate decreased from 25.1% in 2010 to 17.8% in 2019, but the number of patients increased from 11,255 cases in 2010 to 11,747 cases in 2019. Fortunately, the rate of delayed admission for more than one day decreased from 26.7% to 21.3%. However, 10.4% of patients were diagnosed more than two days later. Young, females, or patients with higher income status and living in low urbanization areas exhibited a higher rate of prehospital visits. Conclusions Prehospital visits in Korean stroke patients decreased from 25.1% in 2010 to 17.8% in 2019. However, more than 10,000 patients still visited other medical institutions before admission to treatment.
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Affiliation(s)
- Jinyoung Shin
- Department of Family Medicine, Konkuk University School of Medicine, 05030 Seoul, Republic of Korea
| | - Hyeongsu Kim
- Department of Preventive Medicine, Konkuk University School of Medicine, 05030 Seoul, Republic of Korea
| | - Ho Jin Jeong
- Department of Preventive Medicine, Konkuk University School of Medicine, 05030 Seoul, Republic of Korea
| | - Jeehye Lee
- National Emergency Medical Center, National Medical Center, 04564 Seoul, Republic of Korea
| | - Jusun Moon
- Department of Neurology, National Medical Center, 04564 Seoul, Republic of Korea
| | - Kwang-Pil Ko
- Clinical Preventive Medicine Center, Seoul National University Bundang Hospital, 13620 Gyeonggi-do, Republic of Korea
| | - Youngtaek Kim
- Department of Preventive Medicine, Chungnam National University Hospital, 35015 Daejeon, Republic of Korea
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Zeng X, Balikuddembe JK, Liang P. Impact of community-based rehabilitation on the physical functioning and activity of daily living of stroke patients: a systematic review and meta-analysis. Disabil Rehabil 2023; 45:403-414. [PMID: 35200068 DOI: 10.1080/09638288.2022.2037755] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE This study aimed at establishing the impact of community-based rehabilitation (CBR) on the physical functioning and activity of daily living (ADL) of patients with stroke (PWS). MATERIALS AND METHODS Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, an electronic search was conducted in five databases, including PubMed, OVID Embase, OVID Medline, Cochrane Library, and Web of Science between May 2010 and 2020. Meta-analysis was performed using the Comprehensive Meta-Analysis Version 2 software to establish whether the studies were sufficiently homogenous. RESULTS Twenty studies out of 828 publications were included in the present systematic review. A significant difference between CBR intervention and control groups was identified about the physical functional capacity in mobility, 6-metre walk test (6MWT) (g = 0.351, 95% CI (0.110, 0.592)), community walking test (g= -0.473, 95% CI (-0.926, -0.020)) and on the other hand a significant improvement in ADL was found (g = 0.138, 95% CI(0.051, 0.224)). CONCLUSIONS CBR is revealed to be effective in improving the physical functioning and ADL for PWS and is drawn based on eligible studies which were conducted in high-income countries (HICs). This highlights a gap between developed and less-resourced countries as far as CBR for PWS is concerned and calls for a further study. Protocol Registration: CRD42020159683Implication for rehabilitationCommunity-based rehabilitation (CBR) is recommended as one of the best programme for treating stroke patients with stroke (PWS) after they are discharged from hospitals.CBR is effective in improving the physical functioning and activity of daily living of PWS.Further research should be carried out to compare between CBR and institution-based rehabilitation for PWS, especially the less-resourced settings which are grappling with a challenge of limited skilled rehabilitation professionals.
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Affiliation(s)
- Xinglin Zeng
- Rehabilitation Department, West China Medical School, Sichuan University, Chengdu, PR China
| | - Joseph K Balikuddembe
- Institute for Disaster Management and Reconstruction, Sichuan University and Hong-Kong Polytechnic University, Chengdu, PR China
| | - Ping Liang
- Cardiac Rehabilitation Center, Fuwai Hospital, Beijing, China
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Yang H, Wu Z, Huang X, Zhang M, Fu Y, Wu Y, Liu L, Li Y, Wang HHX. In-Hospital Emergency Treatment Delay Among Chinese Patients with Acute Ischaemic Stroke: Relation to Hospital Arrivals and Implications for Triage Pathways. Int J Gen Med 2023; 16:57-68. [PMID: 36636715 PMCID: PMC9829982 DOI: 10.2147/ijgm.s371687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/18/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Timely access to emergency treatment during in-hospital care phase is critical for managing the onset of acute ischaemic stroke (AIS), particularly in developing countries. We aimed to explore in-hospital emergency treatment delay and the relation of door-to-needle (DTN) time to ambulance arrivals vs walk-in arrivals. Methods Data were collected from 1276 Chinese AIS patients admitted to a general, tertiary-level hospital for intravenous thrombolysis. Information on patients' characteristics and time taken during in-hospital emergency treatment was retrieved from the hospital registry data and medical records. Ambulance arrival was defined as being transported by emergency ambulance services, while walk-in arrival was defined as arriving at hospital by regular vehicle. In-hospital emergency treatment delay occurred when the DTN time exceeded 60 minutes. We performed multivariable logistic regression analysis to explore the association between hospital arrivals (by ambulance vs by walk-in) and treatment delay after adjustment for age, sex, education, marital status, residence, medical insurance, number of symptoms, clinical severity and survival outcome. Results Over half (53.76%) of patients aged over 60 years. Around one-fifth (20.61%) of patients admitted to hospital through emergency ambulance services, while their counterparts arrived by regular vehicle. Overall, the median time taken from the hospital door to treatment initiation was 86.0 minutes. Patients arrived by ambulance (adjusted odds ratio [aOR] = 1.744, 95% confidence interval [CI] = 1.185-2.566, p = 0.005), had higher socio-economic status (aOR = 1.821, 95% CI = 1.251-2.650; p = 0.002), or paid out-of-pocket (aOR = 2.323, 95% CI = 1.764-3.060; p < 0.001) had an increased likelihood of in-hospital emergency treatment delays. Conclusion In-hospital emergency treatment delay is common in China, and occurs throughout the entire emergency treatment journey. Having a triage pathway involving hospital arrival by ambulance seems to be more likely to experience in-hospital emergency treatment delay. Further efforts to improve triage pathways may require qualitative evidence on provider- and institutional-level factors associated with in-hospital emergency treatment delay.
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Affiliation(s)
- Huajie Yang
- School of Health Technology, Guangdong Open University (Guangdong Polytechnic Institute), Guangzhou, People’s Republic of China
| | - Zhuohua Wu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Xiang Huang
- Sanxiang Community Health Service Centre of Zhongshan, Zhongshan, People’s Republic of China,Faculty of Medicine, Macau University of Science and Technology, Macau SAR, People’s Republic of China
| | - Man Zhang
- Sanxiang Community Health Service Centre of Zhongshan, Zhongshan, People’s Republic of China
| | - Yu Fu
- School of Public Health, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Yijuan Wu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Lei Liu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Yiheng Li
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People’s Republic of China,Yiheng Li, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China, Tel +86 20 83062721, Email
| | - Harry H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, People’s Republic of China,Correspondence: Harry HX Wang, School of Public Health, Sun Yat-Sen University, Guangzhou, 510080, People’s Republic of China, Tel +86 20 87330672, Email
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Revathi S, Kavitha MS, Shankar V. Factors Associated with Prehospital Delay in Patients with Acute Stroke in South India. Indian J Community Med 2023; 48:82-90. [PMID: 37082411 PMCID: PMC10112740 DOI: 10.4103/ijcm.ijcm_213_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 09/21/2022] [Indexed: 12/03/2022] Open
Abstract
Background Early hospital presentation is critical in the management of acute ischemic stroke. The effectiveness of stroke treatment is highly dependent on the amount of time lapsed between onset of symptoms and treatment. This study was aimed to identify the factors associated with prehospital delay in patients with acute stroke. Material and Methods A cross-sectional descriptive study was conducted in Sri Ramachandra University Hospital, India. A total of 210 patients hospitalized in the stroke unit were included. Patients' data were obtained by interviewing the patient and/or accompanying family member and by reviewing their medical records using a standard questionnaire. Associations were determined between prehospital delay (≥4.5 h) and variables of interest by using univariate and multivariate logistic regression analyses. Results The prehospital delay was observed in 154 patients (73.3%) and the median prehospital delay was 11.30 h. The following are the factors significantly (P < 0.05) attributed for the delay in presenting to the hospital: contextual factors like using public transport (bus), taxi, time of onset of symptoms, 7 pm-3 am; family history of stroke, perceived cognitive and behavioral factors like, wishing or praying for the symptoms to subside on its own, hesitation to travel due to long distance, delay in arranging transport, and arranging money for admission and wasting time by shopping for general practitioners, nursing homes, and hospitals. The presence of stroke symptom, headache, significantly decreased the prehospital delay. Conclusions Prehospital delay is high in South India and influenced by clinical, contextual, and cognitive/behavioral factors.
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Affiliation(s)
- S Revathi
- Professor, Faculty of Nursing, Northern Border University, Arar, KSA
- Department of Community Health Nursing, College of Nursing, Sri Ramachandra University, Chennai, Tamil Nadu, India
| | - M S Kavitha
- Department of Community Health Nursing, College of Nursing, Sri Ramachandra University, Chennai, Tamil Nadu, India
| | - V Shankar
- Department of Neurology, Sri Ramachandra University, Chennai, Tamil Nadu, India
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Botelho A, Rios J, Fidalgo AP, Ferreira E, Nzwalo H. Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192316357. [PMID: 36498429 PMCID: PMC9735885 DOI: 10.3390/ijerph192316357] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS. METHODOLOGY Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale. RESULTS A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART. CONCLUSIONS Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.
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Affiliation(s)
- Ana Botelho
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Jonathan Rios
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Ana Paula Fidalgo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Eugénia Ferreira
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
| | - Hipólito Nzwalo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, 8005-139 Faro, Portugal
- Algarve Biomedical Research Institute, 8005-139 Faro, Portugal
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21
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Kharel S, Nepal G, Joshi PR, Yadav JK, Shrestha TM. Safety and efficacy of low-cost alternative urokinase in acute ischemic stroke: A systematic review and meta-analysis. J Clin Neurosci 2022; 106:103-109. [PMID: 36274296 DOI: 10.1016/j.jocn.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/03/2022] [Accepted: 09/20/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Use of intravenous thrombolysis (IVT) for treatment of acute ischemic stroke (AIS) varies greatly between countries, ranging from 10% to 15% in high-income countries to less than 2% in low- and middle income countries (LMICs). This is because alteplase is expensive and has been cited as one of the most common barriers to IVT in LMICs. Urokinase (UK) is a thrombolytic agent which is almost 50 times cheaper with easier production and purification than alteplase. UK may become a cost-effective option for IVT in LMICs if it is found to be safe and effective. We conducted this study to assess the existing evidence on the safety and efficacy of UK vs alteplase for IVT in AIS. METHODS The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Systematic literature search was done in PubMed, EMBASE, and Google Scholar for English literature published from 2010 to 2021. RESULTS A total of 4061 participants in the alteplase and 2062 participants in the UK group were included in the final statistical analysis. After IVT, a good functional outcome at last follow-up was found among 80.57 % of patients in the alteplase group compared to 73.79 % of patients in the UK group (OR: 1.11; 95 % CI: 0.95- 1.31; I2 = 0 %; P = 0.18). Symptomatic Intracerebral Hemorrhage (sICH) was found among 1.77 % of patients in the alteplase group compared to 2.83 % of patients in the UK group (OR: 0.84; 95 % CI: 0.56- 1.26; I2 = 0 %; P = 0.41). Similarly, mortality was found among 5.03 % of patients in the alteplase group compared to 5.42 % of patients in the UK group (OR: 0.87; 95 % CI: 0.66-1.14; I2 = 0 %; P = 0.30). CONCLUSION Our meta-analysis found that intravenous UK is not inferior to alteplase in terms of safety and efficacy and can be a viable alternative for IVT in AIS patients in LMICs.
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Affiliation(s)
- Sanjeev Kharel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Gaurav Nepal
- Rani Primary Health Care Centre, Biratnagar, Nepal.
| | - Padam Raj Joshi
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Jayant Kumar Yadav
- Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal.
| | - Tirtha Man Shrestha
- Department of General Practice, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
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22
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Hansen KL, Bratholm Å, Pradhan M, Mikkelsen S, Milling L. Physicians’ experiences and perceived challenges working in an emergency setting in Bharatpur, Nepal: a qualitative study. Int J Emerg Med 2022; 15:61. [DOI: 10.1186/s12245-022-00466-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Background
Emergency medical care, including prehospital treatment, forms an important component of any healthcare system. Like most low-middle-income countries, Nepal has an emergency medical system that can be described as underdeveloped. Emergency physicians navigating this system may experience challenges or barriers in their treatment of patients. This study aimed to investigate physicians’ perspectives on emergency and prehospital patient management in a low-income country, Nepal, and to understand the challenges and barriers they perceive in emergency treatment including both the prehospital treatment and the immediate in-hospital treatment at the emergency department.
Methods
Using a qualitative study, eight semi-structured interviews with physicians working in a Nepalese emergency department were performed. The interviews were conducted between September and November 2021 and were audio-recorded and transcribed verbatim. Data were subsequently analyzed using the systematic text condensation method.
Results
Four main themes and associated sub-themes were identified: (1) patients’ sociocultural, educational, and financial factors (such as financial issues and financial inequality) and regional differences; (2) emergency department’s organization and resources concerning human and material resources, protocols, and guidelines; (3) problems with the emergency department (ED) service’s qualities and availability caused by an insufficient integration of the ED and the EMS, prehospital resources, and financial interests in the EMS; and (4) surrounding healthcare system’s impact on the ED where, especially, the levels of organized primary care, governmental responsibilities, and healthcare structure were addressed.
Conclusions
The physicians identified numerous regularly encountered challenges and barriers. These challenges stretched beyond the ED and into various aspects of society. The patients’ financial problems were described as the greatest problem, restricting the treatment due to a given patient’s inability or unwillingness to pay for the required procedures. The physicians were thus restricted in completing their duties to the desired levels. The low quality of prehospital care and a lack of education and awareness of common diseases and symptoms in a significant proportion of patients were identified by many participants as being significant issues. The aforementioned challenges or barriers directly resulted in patients arriving in critical conditions that could have been avoided if the disease were treated earlier.
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Gao Z, Liu Q, Yang L, Zhu X. Identification of high-risk factors for prehospital delay for patients with stroke using the risk matrix methods. Front Public Health 2022; 10:858926. [PMID: 36438229 PMCID: PMC9691690 DOI: 10.3389/fpubh.2022.858926] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Stroke has become a leading cause of mortality and adult disability in China. The key to treating acute ischemic stroke (AIS) is to open the obstructed blood vessels as soon as possible and save the ischemic penumbra. However, the thrombolytic rate in China is only 2.5%. Research has been devoted to investigating the causes of prehospital delay, but the exact controllable risk factors for prehospital delay remain uncertain, and a consensus is lacking. We aimed to develop a risk assessment tool to identify the most critical risk factors for prehospital delay for AIS patients. Methods From November 2018 to July 2019, 450 patients with AIS were recruited. Both qualitative and quantitative data were collected. The Delphi technique was used to obtain expert opinions about the importance of the risk indices in two rounds of Delphi consultation. Then, we used the risk matrix to identify high-risk factors for prehospital delay for AIS patients. Results The risk matrix identified the following five critical risk factors that account for prehospital delay after AIS: living in a rural area; no bystanders when stroke occurs; patients and their families lacking an understanding of the urgency of stroke treatment; patients and their families not knowing that stroke requires thrombolysis or that there is a thrombolysis time window; and the patient self-medicating, unaware of the seriousness of the symptoms, and waiting for spontaneous remission. Conclusions The risk analysis tool used during this study may help prevent prehospital delays for patients with AIS.
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Affiliation(s)
- Zihan Gao
- School of Nursing, Qingdao University, Qingdao, China
| | - Qinqin Liu
- School of Nursing, Peking University, Beijing, China
| | - Li Yang
- School of Nursing, Qingdao University, Qingdao, China,*Correspondence: Li Yang
| | - Xuemei Zhu
- School of Nursing, Harbin Medical University, Heilongjiang, China
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Nepal G, Kharel S, Kumar Yadav J, Kumar Yadav S, Bhagat R, Ka Shing Y, Coghlan M, Lal Bhattarai S, Sigdel K, Chandra Mahat B. Low-dose alteplase for the management of acute ischemic stroke in South Asians: A systematic review on cost, efficacy and safety. J Clin Neurosci 2022; 103:92-99. [PMID: 35853390 DOI: 10.1016/j.jocn.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION South Asia is responsible for more than 40% of the stroke burden and stroke mortality in the developing world. South Asia, which is home to one-fourth of the world's population, is the most densely populated and one of the poorest regions. The majority of patients in this region are unable to afford intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). If low-dose alteplase proves effective and safe in South Asians, it may be a more cost-effective treatment option. METHODS The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Researchers searched PubMed, EMBASE, and Google Scholar for English literature from 2005 to 2021. END, ENI, good functional outcome, SICH, and all-cause mortality were used to assess efficacy and safety. RESULTS In the low-dose alteplase treated patients, different studies reported 32 to 57% ENI 24 h after IVT, and 7% to 9.7% END. At 3 months follow-up, good functional outcome was achieved by 48%-76.92% of low-dose alteplase treated patients. SICH rates ranged from 0% to 16.6% across studies. Asymptomatic ICH occurred in 5-14% of patients. The mortality rate in all included studies varied from none to 25%. CONCLUSION Our systematic review demonstrates that the use of low-dose alteplase for AIS in the South Asians offer comparable efficacy and reduced risk of SICH at a significantly lower cost than standard alteplase dose. Future well-randomized clinical trials are necessary to validate the findings of our study.
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Affiliation(s)
- Gaurav Nepal
- Rani Primary Health Care Centre, Biratnagar, Nepal.
| | - Sanjeev Kharel
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Jayant Kumar Yadav
- Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal.
| | - Sushil Kumar Yadav
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore, Singapore.
| | - Megan Coghlan
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Kaushal Sigdel
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - Bishow Chandra Mahat
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Amani F, Fattahzadeh-Ardalani G, Sharghi A, Jafarizadeh R. Using Multiple Logistic Regression to Determine Factors Affecting Delaying Hospital Arrival of Patients with Acute Ischemic Stroke. Neurol India 2022; 70:1548-1553. [PMID: 36076657 DOI: 10.4103/0028-3886.355102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Early treatment of ischemic stroke patients who arrive at the hospital ≤4.5 hours after the onset of symptoms with recombinant tissue plasminogen activator is more beneficial and very important. Objective This study is aimed to investigate the factors delaying the hospital arrival of patients with acute ischemic stroke by using multiple logistic regression analysis. Methods and Materials This descriptive cross-sectional study was done on patients diagnosed with acute ischemic stroke who were referred to Ardabil city Training and Research hospital at 2018. All patients and/or patient relatives were interviewed and data were collected through a checklist including demographic and clinical data of patients to explore the involved factors delaying hospital arrival of patients and then analyzed using multiple logistic regression analysis. Results Of all included patients, only 25.3% arrived at the hospital in ≤ 4.5 hours. By using multivariate logistic regression analysis, living in cities (P = 0.007), cigarette consumption (P = 0.032), having valvular heart disease (P = 0.008), and gender (P = 0.049) were factors associated with an early arrival to the hospital. Conclusions Results showed that most of the patients had a considerable delay in arriving at the hospital in ≤ 4.5 hours. Thus, providing health promotion strategies to improve society awareness of early symptoms of stroke, training of local physicians about the importance of early arrival of stroke patients, and more extended ambulance services in all cities and rural areas are necessary for better management of acute stroke patients in this area.
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Affiliation(s)
- Firouz Amani
- Department of Community Medicine, Faculty of Medicine, Ardabil University of Medical Science, Ardabil, Iran
| | | | - Afshan Sharghi
- Department of Community Medicine, Faculty of Medicine, Ardabil University of Medical Science, Ardabil, Iran
| | - Raana Jafarizadeh
- Department of Medicine, Ardabil Branch, Islamic Azad University, Ardabil, Iran
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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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Yadav JK, Nepal G, Shing YK, Banerji RR, Gajurel BP. An opportunity to improve Acute Ischemic Stroke care in the South Asian region through telestroke services. Ann Med Surg (Lond) 2021; 72:103115. [PMID: 34888047 PMCID: PMC8636765 DOI: 10.1016/j.amsu.2021.103115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/21/2021] [Indexed: 11/13/2022] Open
Abstract
The South Asian region accounts for more than 40% of the stroke burden of the developing world and is the highest contributor to global stroke mortality. Despite proven treatment guidelines, the limited number of neurologists, the number of dedicated stroke centers and the fact that most of these facilities are urban-centric renders poor access to thrombolysis in this region, especially in the rural areas. Studies have shown that thrombolysis using telestroke services are comparable to face-to-face thrombolysis. Telestroke, conducted through low-cost media such as smartphones or laptops, may form a cost-effective solution to improve access to appropriate stroke care in a resource-limited setting such as that of the South Asian region.
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Affiliation(s)
- Jayant Kumar Yadav
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore
| | - Rohit Raman Banerji
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Basnet B, Yadav JK, Gajurel BP, Shing YK, Kandel B, Nepal G. Role of female community health volunteers in ischemic stroke prevention, identification, referral and rehabilitation in Nepal. Ann Med Surg (Lond) 2021; 72:102893. [PMID: 34992775 PMCID: PMC8712991 DOI: 10.1016/j.amsu.2021.102893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/26/2021] [Indexed: 01/01/2023] Open
Abstract
For the past three decades, female community health volunteers (FCHVs) have been at the forefront of Nepal's health map and have contributed significantly to its improving health indicators such as maternal mortality rate and infant mortality rate. Given the changing epidemiology of Nepal and the shift of burden from communicable to non-communicable diseases (NCDs), it is important to revitalize their role with the changing times. The prevalence of ischemic stroke in Nepal is on the rise. However, very few people make it to the hospital within the time frame for thrombolysis and the patient's knowledge about ischemic stroke seems to play a major part. FCHVs can play a significant role in improving ischemic stroke care by raising awareness about the condition, its risk factors, and informing the public about the need for timely treatment. They can help screen for common risk factors such as obesity, hypertension and diabetes as well as monitor for treatment in previously diagnosed individuals. Randomized controlled trials have shown to yield favorable results in NCDs with engagement of FCHVs. With proper training and support, they can play an important role in improving ischemic stroke care in low- and middle-income countries like Nepal.
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Affiliation(s)
- Babin Basnet
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Jayant Kumar Yadav
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Yow Ka Shing
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Bipin Kandel
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Gaurav Nepal
- Rani Primary Health Care Center, Biratnagar 56613, Morang, Nepal
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Melak AD, Wondimsigegn D, Kifle ZD. Knowledge, Prevention Practice and Associated Factors of Stroke Among Hypertensive and Diabetic Patients - A Systematic Review. Risk Manag Healthc Policy 2021; 14:3295-3310. [PMID: 34408515 PMCID: PMC8364969 DOI: 10.2147/rmhp.s324960] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/03/2021] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Because of the inadequate level of public awareness of the disease, the incidence of stroke has been sharply rising. Eventually, due to the prehospital delay, many stroke cases could not be eligible for thrombolysis thereby poor rehabilitative outcome has been tremendously increased. Thus, this study aimed to review the level of knowledge, prevention practice, and associated factors of stroke among hypertensive and diabetic patients. METHODS A systematic review of primarily published articles (2010-2020) related to knowledge and prevention practices of stroke was performed by searching online electronic databases like PubMed, Google Scholar, Refseek, Science direct, ResearchGate, and manual Google search by using the keywords and MeSH terms. Studies conducted on knowledge and prevention practices amongst hypertensive and/or diabetic patients were included. RESULTS Out of 531 searched studies, 42 articles were identified to be reviewed. The reported overall knowledge of stroke was ranging from 4.4% to 79%. Knowledge to the signs/symptoms of stroke was 23.6% to 87%. However, 15% to 77% of subjects were also reported that they did not know any sign of stroke. The range of risk factor knowledge was 10.5% to 86.6%. The reported level of stroke prevention practice was 2.4% to 72% but physical activity and weight reduction practice were relatively low. Inadequate level of knowledge and prevention practice of stroke was related to elderly, female gender, uneducated, unmarried, rural residents, economically low, comorbidity and unemployed individuals. CONCLUSION The current finding revealed that the level of knowledge and prevention practice of stroke was inadequate. Hence, the finding highlights health educational programs should be planned as an important avenue to enhance stroke awareness among the high-risk populations.
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Affiliation(s)
- Abreham Degu Melak
- University of Gondar, College of Medicine and Health Science, School of Pharmacy, Department of Pharmacology, Gondar, Ethiopia
| | - Dawit Wondimsigegn
- University of Gondar, College of Medicine and Health Science, School of Pharmacy, Department of Pharmaceutics and Social Pharmacy, Gondar, Ethiopia
| | - Zemene Demelash Kifle
- University of Gondar, College of Medicine and Health Science, School of Pharmacy, Department of Pharmacology, Gondar, Ethiopia
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Kharbach A, Obtel M, Achbani A, Aasfara J, Hassouni K, Lahlou L, Razine R. Ischemic stroke in Morocco: Prehospital delay and associated factors. Rev Epidemiol Sante Publique 2021; 69:345-359. [PMID: 34148762 DOI: 10.1016/j.respe.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study aimed to estimate prehospital delay and to identify the factors associated with the late arrival of patients with ischemic stroke at the Souss Massa Regional Hospital Center in Morocco. PATIENTS AND METHODS An observational, prospective, cross-sectional study was conducted from March 2019 to September 2019 in the Souss Massa regional hospital center, which is a public hospital structure. A questionnaire was administered to patients with ischemic stroke and to bystanders (family or others), while clinical and paraclinical data were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify the factors associated with delayed arrival at emergency department. RESULTS A total of 197 patients and 197 bystanders who fulfilled the criteria for the study were included. The median time from symptom onset to hospital arrival was 6hours (IQR, 4-16). Multiple regression analysis showed that illiteracy (OR 38.58; CI95%: 3.40-437.27), waiting for symptoms to disappear (patient behavior) (OR 11.24; CI95%: 1.57-80.45), deciding to go directly to the hospital (patient behavior) (OR 0.07; CI95%: 0.01-0.57), bystander's knowledge that stroke is a disease requiring urgent care within a limited therapeutic window (OR 0.005; CI95%: 0.00-0.36), and direct admission without reference (OR 0.005; CI95%: 0.00-0.07), were independently associated with late arrival (>4.5hours) of patients with acute ischemic stroke. In addition, illiteracy (OR 24.62; CI95%: 4.37-138.69), vertigo and disturbance of balance or coordination (OR 0.14; CI95%: 0.03-0.73), the relative's knowledge that stroke is a disease requiring urgent care and within a limited therapeutic window (OR 0.03; CI95%: 0.00-0.22), calling for an ambulance (relative's behavior) (OR 0.16; CI95%: 0.03-0.80), distance between 50 and 100km (OR 10.16; CI95%: 1.16-89.33), and direct admission without reference (OR 0.03; CI95%: 0.00-0.14), were independently associated with late arrival (>6hours) of patients with acute ischemic stroke. CONCLUSION Patient behavior, bystander knowledge and direct admission to the competent hospital for stroke care are modifiable factors potentially useful for reducing onset-to-door time, and thereby increasing the implementation rates of acute stroke therapies.
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Affiliation(s)
- A Kharbach
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
| | - M Obtel
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Laboratory of Social Medicine (Public Health, Hygiene and Preventive Medicine), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
| | - A Achbani
- Laboratory of Cell Biology and Molecular Genetics (LBCGM), Department of Biology, Faculty of Sciences, University Ibn Zohr Agadir, Rabat, Morocco.
| | - J Aasfara
- Department of Neurology, International Cheikh Khalifa University Hospital, Mohammed VI University of Health Sciences (UM6SS) Casablanca, Rabat, Morocco.
| | - K Hassouni
- International School of Public Health, Mohammed VI University of Health Sciences (UM6SS) Casablanca, Rabat, Morocco.
| | - L Lahlou
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco.
| | - R Razine
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Laboratory of Social Medicine (Public Health, Hygiene and Preventive Medicine), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
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Pradhan RR, Jha A, Bhandari S, Ojha S, Karn R. Knowledge, attitude, and practice of stroke and thrombolysis among students preparing for undergraduate medical entrance examination in Kathmandu, Nepal. Health Sci Rep 2021; 4:e268. [PMID: 33842697 PMCID: PMC8020573 DOI: 10.1002/hsr2.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/29/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Stroke is a major disabling disease, especially for low and middle-income countries like Nepal. The aim of our study is to assess knowledge, attitude, and practice (KAP) among the students preparing for undergraduate medical entrance examination regarding risk factors, warning signs and symptoms, and management of stroke. METHODS A cross-sectional, single staged study using self-structured questionnaire intended to assess KAP about stroke and thrombolysis was conducted. RESULTS A total of 378 students participated in our study (53% male; mean age = 18.12 ± 0.97). Majority of the participants (88.4%) had heard about stroke. The more common risk factors identified by them were hypertension (86.2%), oily food (48%), alcohol (37.8%), and smoking (32.8%). Limb weakness, slurring of speech and facial weakness as symptoms and signs of stroke were indicated by 43.4%, 30.2%, and 18.8% of the participants, respectively. Only 23.8% of the participants had heard about thrombolysis and 10% of all could rightly mention the window period of thrombolysis. Male participants had better knowledge about smoking [86 (43.0) vs 38 (21.3); P < .001] and oily food [108 (54.0) vs 73 (41.0); P = .012] being risk factors and facial weakness [50 (37.6) vs 21 (11.8); P = .001] being symptom of stroke compared with females. Similarly, male participants had heard more about thrombolysis than females [68 (34.0) vs 22 (12.4); P < .001]. CONCLUSION Knowledge regarding risk factors and signs and symptoms of stroke was adequate among the students preparing for undergraduate medical entrance examination. However, knowledge about thrombolysis was poor. Male participants had better knowledge about risk factors, warning signs and symptoms of stroke, and thrombolysis compared with female.
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Affiliation(s)
| | - Ashish Jha
- Institute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
| | | | - Sujan Ojha
- Institute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
| | - Ragesh Karn
- Institute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
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Wang R, Wang Z, Yang D, Wang J, Gou C, Zhang Y, Xian L, Wang Q. Early Hospital Arrival After Acute Ischemic Stroke Is Associated With Family Members' Knowledge About Stroke. Front Neurol 2021; 12:652321. [PMID: 34122301 PMCID: PMC8187751 DOI: 10.3389/fneur.2021.652321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background and Purpose: Prehospital delay is the major factor limiting intravenous thrombolysis and mechanical thrombectomy in acute ischemic stroke (AIS). This study aimed to: (1) identify factors related to prehospital delay and (2) determine the impact of recognition and behavior of family members on patient delay. Methods: A cross-sectional, multicenter study was conducted at six teaching hospitals in China between December 1, 2018 and November 30, 2019. Patients who experienced AIS within 7 days of onset were interviewed. Results: Of 1,782 consecutive patients (male, 57.97%; mean age, 66.3 ± 9.65 years) who had an AIS, 267 (14.98%) patients arrived within 4.5 h and 722 (40.52%) patients arrived within 6 h of stroke onset. Among patients who arrived within 4.5 h, 103 (38.6%) received thrombolysis. Age over 65 years (OR, 2.009; 95% CI, 1.014-3.982), prior stroke (OR, 3.478; 95% CI, 1.311-9.229), blurred vision (OR, 3.95; 95% CI, 1.71-9.123), and patients deciding to seek medical help (OR, 3.097; 95% CI, 1.417-6.769) were independently associated with late arrival. In contrast, sudden onset of symptoms (OR, 0.075; 95% CI, 0.028-0.196), the National Institutes of Health Stroke Scale 7-15 (OR, 0.093; 95% CI, 0.035-0.251), consciousness disturbance (OR, 0.258; 95% CI, 0.091-0.734), weakness (OR, 0.265; 95% CI, 0.09-0.784), arrival by ambulance (OR, 0.102; 95% CI, 0.049-0.211), decision time <30 min (OR, 0.008; 95% CI, 0.003-0.018), and family member understanding stroke requires early treatment (OR, 0.224; 95% CI, 0.109-0.462) were independently associated with early arrival. Conclusions: The prehospital delay in China lags behind Western countries. Recognition and behavior of stroke patients' family members may play a key role in early arrival.
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Affiliation(s)
- Rongyu Wang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhiqiang Wang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dongdong Yang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jian Wang
- Department of Neurology, Yaan People's Hospital, Yaan, China
| | - Chongji Gou
- Department of Neurology, Pengzhou People's Hospital, Pengzhou, China
| | - Yaodan Zhang
- Department of Neurology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Liulin Xian
- Department of Neurology, Nanbu Traditional Chinese Medicine, Nanbu, China
| | - Qingsong Wang
- Department of Neurology, The General Hospital of Western Theater Command, Chengdu, China
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Mackay E, Theron E, Stassen W. The barriers and facilitators to the telephonic application of the FAST assessment for stroke in a private emergency dispatch centre in South Africa. Afr J Emerg Med 2021; 11:15-19. [PMID: 33318913 PMCID: PMC7724157 DOI: 10.1016/j.afjem.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Stroke is one of the leading contributors to morbidity and mortality globally. The incidence of stroke is on the increase in Sub-Saharan countries such as South Africa. As stroke is a time-sensitive condition, emergency medical services (EMS) play an important role in the early recognition of stroke. The telephonic application of the FAST (Face, Arm, Speech, Time) assessment has been suggested to screen patients for stroke, but this is not applied consistently. This study aimed to identify the barriers and facilitators to the telephonic application of the FAST assessment. METHODS This retrospective, exploratory study sampled 20 randomly selected emergency calls to a private EMS in South Africa, with suspected stroke. After verbatim self-transcription, data were analysed using inductive content analysis to identify the barriers and facilitators to the application of the FAST assessment. Results were arranged according to themes. RESULTS Results indicated that in 15/20 (75%) of the calls, the FAST assessment was successfully applied. Eight barriers under three themes (practical barriers, emotionality, and knowledge and understanding) and three facilitators under one theme (clear communication) were identified. Most notably, language discordance, lack of empathy and caller frustration featured prominently as barriers while caller cooperation and clear instructions were prominent facilitators. CONCLUSION With the barriers known, methods to address these may be constructed. Additional training and credentialing for call-takers may be a reasonable first step. These lessons can likely be applied to other telephonic acuity and recognition algorithms.
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Affiliation(s)
- Ethan Mackay
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Elzarie Theron
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Yang L, Liu Q, Zhao Q, Zhu X, Wang L. Machine learning is a valid method for predicting prehospital delay after acute ischemic stroke. Brain Behav 2020; 10:e01794. [PMID: 32812396 PMCID: PMC7559608 DOI: 10.1002/brb3.1794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES This study aimed to identify the influencing factors associated with long onset-to-door time and establish predictive models that could help to assess the probability of prehospital delay in populations with a high risk for stroke. MATERIALS AND METHODS Patients who were diagnosed with acute ischemic stroke (AIS) and hospitalized between 1 November 2018 and 31 July 2019 were interviewed, and their medical records were extracted for data analysis. Two machine learning algorithms (support vector machine and Bayesian network) were applied in this study, and their predictive performance was compared with that of the classical logistic regression models after using several variable selection methods. Timely admission (onset-to-door time < 3 hr) and prehospital delay (onset-to-door time ≥ 3 hr) were the outcome variables. We computed the area under curve (AUC) and the difference in the mean AUC values between the models. RESULTS A total of 450 patients with AIS were enrolled; 57 (12.7%) with timely admission and 393 (87.3%) patients with prehospital delay. All models, both those constructed by logistic regression and those by machine learning, performed well in predicting prehospital delay (range mean AUC: 0.800-0.846). The difference in the mean AUC values between the best performing machine learning model and the best performing logistic regression model was negligible (0.014; 95% CI: 0.013-0.015). CONCLUSIONS Machine learning algorithms were not inferior to logistic regression models for prediction of prehospital delay after stroke. All models provided good discrimination, thereby creating valuable diagnostic programs for prehospital delay prediction.
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Affiliation(s)
- Li Yang
- School of Nursing, Qingdao University, Qingdao, China
| | - Qinqin Liu
- School of Nursing, The second Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Qiuli Zhao
- School of Nursing, The second Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Xuemei Zhu
- School of Nursing, The second Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Ling Wang
- School of Nursing, The second Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
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Gajurel BP. Nepal: the pain of stroke treatment. Pract Neurol 2020:practneurol-2020-002663. [PMID: 32820059 DOI: 10.1136/practneurol-2020-002663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Bikram Prasad Gajurel
- Neurology, Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
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Factors Associated with Pre-Hospital Delay and Intravenous Thrombolysis in China. J Stroke Cerebrovasc Dis 2020; 29:104897. [PMID: 32430238 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104897] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/18/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pre-hospital delay was a critical factor affecting stroke patients receiving intravenous thrombolytic therapy. The aim of this study was to explore the factors associated with pre-hospital delay and thrombolysis in China. METHODS Patient data were obtained from emergency department (ED), and the factors of patient pre-hospital delay were recorded through a well-designed form. RESULTS A total of 630 patients were eventually included in the study. 317 patients were admitted to the ED during the thrombolysis time window, and only 105 patients received intravenous thrombolytic therapy. In the univariate analysis, transportation (OR: 0.15; 95% CI: 0.44 - 0.518; p = 0.001), atrial fibrillation (OR: 0.555; 95% CI: 0.372-0.828; p = 0.004) and response of symptoms (OR: 0.002; 95% CI: 0.000-0.013; p = 0.000) were associated with early arrival. Speech disturbances (OR: 2.095; 95% CI: 1.294-3.391; p = 0.002), smoking (OR: 2.563; 95% CI: 1.527-4.304; p = 0.000), alcohol consumption (OR: 2.155; 95% CI: 1.159-4.005; p = 0.014) and referral presentation (OR: 2.837; 95% CI: 1.584-5.082; p = 0.000) were associated with thrombolysis. In the logistic regression analysis, direct visiting to the hospital after onset and rushing to emergency after onset were independent predictor of early arrival of AIS and intravenous thrombolytic. CONCLUSIONS The pre-hospital delay of acute ischemic stroke in China was still serious. Strengthening the ability to identify stroke-related symptoms and establishing a mutual referral medical support service model between lower and upper hospitals may effectively shorten the pre-hospital delay of stroke patients.
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Endovascular management of acute ischaemic stroke in Nepal. LANCET GLOBAL HEALTH 2020; 8:e635-e636. [PMID: 32353306 DOI: 10.1016/s2214-109x(20)30071-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 11/21/2022]
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Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature. J Neurol 2020; 268:2723-2734. [PMID: 32206899 DOI: 10.1007/s00415-020-09803-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery. METHODS A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy. RESULTS One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model. CONCLUSION Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
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Haki C, Cetiner M, Kaya H. Factors affecting the arrival time to hospital of patients with acute ischemic stroke. SANAMED 2020. [DOI: 10.24125/sanamed.v15i2.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective: It is known that intravenous thrombolytic therapy in ischemic stroke is beneficial in selected patients who arrived within the first 4.5 hours after the onset of the symptoms and the effectiveness of the treatment depends on early arrival to the hospital. The more patients arrival to the hospital within this time zone, the more they will have the chance to receive thrombolytic therapy. This study aims to investigate the factors that cause delay in the arrival of patients with ischemic stroke to the hospital. Methods: Patients diagnosed with acute ischemic stroke who applied to the neurology outpatient clinic and emergency room between February and May 2019 were included in the study. A direct interview survey was conducted to investigate the factors that delay the arrival to patients or relatives of the patients arrival to Bursa Yuksek Ihtisas Training and Research Hospital due to acute stroke. According to the time of arrival to the hospital after the onset of stroke symptoms, patients were classified as early ( 4.5 hours) and late arrival (> 4.5 hours). Based on this grouping, factors causing delay in patients' access to hospital were compared statistically. Results: A total of 251 patients and / or patient relatives who arrived to the emergency and neurology outpatient clinic were interviewed. Of the 251 patients included in the study, 119 (47.4%) were female and the mean age was 70 (34-94) years. Approximately 72.5% of the patients were arrived in the first 4.5-hour slice after the onset of stroke symptoms. Factors causing late arrival were determined as being female, having low NIHSS score and not using ambulance in transportation. Conclusion: Due to the delay in arrival of 27.5% of the patients, there is no chance to apply thrombolytic therapy to eligible ones. The factors resulting in the delay were discovered as female gender, low severity of the stroke and transportation without ambulance. In this respect, community-oriented trainings are required.
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