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Saceleanu VM, Toader C, Ples H, Covache-Busuioc RA, Costin HP, Bratu BG, Dumitrascu DI, Bordeianu A, Corlatescu AD, Ciurea AV. Integrative Approaches in Acute Ischemic Stroke: From Symptom Recognition to Future Innovations. Biomedicines 2023; 11:2617. [PMID: 37892991 PMCID: PMC10604797 DOI: 10.3390/biomedicines11102617] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023] Open
Abstract
Among the high prevalence of cerebrovascular diseases nowadays, acute ischemic stroke stands out, representing a significant worldwide health issue with important socio-economic implications. Prompt diagnosis and intervention are important milestones for the management of this multifaceted pathology, making understanding the various stroke-onset symptoms crucial. A key role in acute ischemic stroke management is emphasizing the essential role of a multi-disciplinary team, therefore, increasing the efficiency of recognition and treatment. Neuroimaging and neuroradiology have evolved dramatically over the years, with multiple approaches that provide a higher understanding of the morphological aspects as well as timely recognition of cerebral artery occlusions for effective therapy planning. Regarding the treatment matter, the pharmacological approach, particularly fibrinolytic therapy, has its merits and challenges. Endovascular thrombectomy, a game-changer in stroke management, has witnessed significant advances, with technologies like stent retrievers and aspiration catheters playing pivotal roles. For select patients, combining pharmacological and endovascular strategies offers evidence-backed benefits. The aim of our comprehensive study on acute ischemic stroke is to efficiently compare the current therapies, recognize novel possibilities from the literature, and describe the state of the art in the interdisciplinary approach to acute ischemic stroke. As we aspire for holistic patient management, the emphasis is not just on medical intervention but also on physical therapy, mental health, and community engagement. The future holds promising innovations, with artificial intelligence poised to reshape stroke diagnostics and treatments. Bridging the gap between groundbreaking research and clinical practice remains a challenge, urging continuous collaboration and research.
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Affiliation(s)
- Vicentiu Mircea Saceleanu
- Neurosurgery Department, Sibiu County Emergency Hospital, 550245 Sibiu, Romania;
- Neurosurgery Department, “Lucian Blaga” University of Medicine, 550024 Sibiu, Romania
| | - Corneliu Toader
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (A.B.); (A.D.C.); (A.V.C.)
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 020022 Bucharest, Romania
| | - Horia Ples
- Centre for Cognitive Research in Neuropsychiatric Pathology (NeuroPsy-Cog), “Victor Babes” University of Medicine and Pharmacy, 300736 Timisoara, Romania
- Department of Neurosurgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Razvan-Adrian Covache-Busuioc
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (A.B.); (A.D.C.); (A.V.C.)
| | - Horia Petre Costin
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (A.B.); (A.D.C.); (A.V.C.)
| | - Bogdan-Gabriel Bratu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (A.B.); (A.D.C.); (A.V.C.)
| | - David-Ioan Dumitrascu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (A.B.); (A.D.C.); (A.V.C.)
| | - Andrei Bordeianu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (A.B.); (A.D.C.); (A.V.C.)
| | - Antonio Daniel Corlatescu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (A.B.); (A.D.C.); (A.V.C.)
| | - Alexandru Vlad Ciurea
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (A.B.); (A.D.C.); (A.V.C.)
- Neurosurgery Department, Sanador Clinical Hospital, 010991 Bucharest, Romania
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De Rubeis G, Fabiano S, Bertaccini L, Wlderk A, Pezzella FR, Anticoli S, Saba L, Gasperini C, Pampana E. Is Mechanical Thrombectomy or Thrombolysis Universally Cost-Effective? A Systematic Review of the Literature. World Neurosurg 2023; 169:e29-e39. [PMID: 36202340 DOI: 10.1016/j.wneu.2022.09.127] [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: 07/25/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Thrombolysis (rTPA) and mechanical thrombectomy (MT) are cost-effective treatments for ischemic stroke. However, little is known about the impact of different types of health systems (HSs) on the outcome and cost of ischemic stroke. METHODS Literature search was performed on PubMed/OVID for studies without time limits. The year of publication, type of HS, cost of intervention treatment (rTPA/MT), cost of control strategy (conservative treatment or rTPA), quality-adjusted life years (QALYs) gained, and percentage of gross domestic product spent on health were recorded. The inclusion criteria were English literature, cost-effectiveness, and cost-utility analyses. The exclusion criterion was the absence of geographic coherence between the derived QALYs and the costs. The costs were inflated to 2021 and then converted to US dollar/euro. An analysis of variance or Kruskal-Wallis test was used to compare the percentage of cost reduction and the QALYs gained. Gross domestic product percentage was correlated with the QALYs gained. RESULTS Thirty-five studies were analyzed. No significant differences in the percentage of cost reduction were found among the different types of HS (Beveridge -14.74% [95% confidence interval {CI} -57.94/53.08] vs. Bismarck -2.27% [95% CI -122.73/118.18] vs. national insurance -0.015% [95% CI -16.96/51.00] vs. private insurance -4.05% [95% CI -32.62/13.18]). No differences were found in QALYs gained among the different HS (Beveridge 1021 [95% CI -36.37/1705.04] vs. Bismarck 440 [95% CI -2290.68/3870.68] vs. national insurance 643 [95% CI -137.54/2366.21] vs. private insurance 550 [95% CI 131.54/1128.06]). No differences were found among the QALYs gained between rTPA/conservative treatment versus rTPA/MT and rtPA + MT/MT. The percentage of gross domestic product spent on health did not correlate with the QALYs gained (rho = -0.16; P = 0.56). CONCLUSIONS MT and rTPA are independently cost-effective among different HS.
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Affiliation(s)
- Gianluca De Rubeis
- Department of Diagnostic, UOC of Diagnostic and Interventional Neuroradiology, San Camillo-Forlanini Hospital, Rome, Italy.
| | - Sebastiano Fabiano
- Department of Diagnostic, UOC of Diagnostic and Interventional Neuroradiology, San Camillo-Forlanini Hospital, Rome, Italy
| | - Luca Bertaccini
- Department of Diagnostic, UOC of Diagnostic and Interventional Neuroradiology, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Wlderk
- Department of Diagnostic, UOC of Diagnostic and Interventional Neuroradiology, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Sabrina Anticoli
- Emergency Department, UOSD Stroke Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Luca Saba
- Department of Medical Imaging, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari-Polo di Monserrato, Cagliari, Italy
| | - Claudio Gasperini
- Department of Neuroscience, UOC Neurology, S Camillo Forlanini Hospital, Rome, Italy
| | - Enrico Pampana
- Department of Diagnostic, UOC of Diagnostic and Interventional Neuroradiology, San Camillo-Forlanini Hospital, Rome, Italy
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Terecoasă EO, Radu RA, Negrilă A, Enache I, Cășaru B, Tiu C. Pre-Hospital Delay in Acute Ischemic Stroke Care: Current Findings and Future Perspectives in a Tertiary Stroke Center from Romania-A Cross-Sectional Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1003. [PMID: 36013470 PMCID: PMC9415394 DOI: 10.3390/medicina58081003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 12/16/2022]
Abstract
Background and objectives: The time interval between stroke onset and hospital arrival is a major barrier for reperfusion therapies in acute ischemic stroke and usually accounts for most of the onset-to-treatment delay. The present study aimed to analyze the pre-hospital delays for patients with acute ischemic stroke admitted to a tertiary stroke center in Romania and to identify the factors associated with a late hospital arrival. Material and methods: The study population consisted of 770 patients hospitalized with the diagnosis of acute ischemic stroke in the University Emergency Hospital Bucharest during a 6-month period, between 1 January and 30 June 2018. Data regarding pre-hospital delays were prospectively collected and analyzed together with the demographic and clinical characteristics of the patients. Results: In total, 31.6% of patients arrived at the hospital within 4.5 h from stroke onset and 4.4% in time intervals between 4.5 and 6 h from the onset, and 28.7% of the patients reached the hospital more than 24 h after onset of symptoms. Transport to hospital by own means was the only factor positively associated with arrival to hospital > 4.5 h from stroke onset and more than doubled the odds of late arrival. Factors negatively associated with hospital arrival > 4.5 h after stroke onset were prior diagnosis of atrial fibrillation, initial National Institute of Health Stroke Scale (NIHSS) score ≥ 16 points, presence of hemianopsia, facial palsy and sensory disturbance. Factors increasing the odds of hospital arrival after 24 h from stroke onset were living alone and living in rural areas. Conclusions: Almost one in three ischemic stroke patients presenting to our center reaches hospital more than 24 h after onset of symptoms. These findings highlight the need for urgent measures to improve not only stroke awareness but also pre-hospital protocols in order to provide timely and appropriate care for our stroke patients.
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Affiliation(s)
- Elena Oana Terecoasă
- Department of Neurology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania; (E.O.T.); (A.N.); (I.E.); (B.C.); (C.T.)
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania
| | - Răzvan Alexandru Radu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania
| | - Anca Negrilă
- Department of Neurology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania; (E.O.T.); (A.N.); (I.E.); (B.C.); (C.T.)
| | - Iulian Enache
- Department of Neurology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania; (E.O.T.); (A.N.); (I.E.); (B.C.); (C.T.)
| | - Bogdan Cășaru
- Department of Neurology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania; (E.O.T.); (A.N.); (I.E.); (B.C.); (C.T.)
| | - Cristina Tiu
- Department of Neurology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania; (E.O.T.); (A.N.); (I.E.); (B.C.); (C.T.)
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania
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Albart SA, Yusof Khan AHK, Abdul Rashid A, Wan Zaidi WA, Bidin MZ, Looi I, Hoo FK. Knowledge of acute stroke management and the predictors among Malaysian healthcare professionals. PeerJ 2022; 10:e13310. [PMID: 35469195 PMCID: PMC9034705 DOI: 10.7717/peerj.13310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/30/2022] [Indexed: 01/13/2023] Open
Abstract
Background Despite rapid advances in acute ischaemic stroke (AIS) management, many healthcare professionals (HCPs) might not be aware of the latest recommended management of AIS patients. Therefore, we aimed to determine the level and factors associated with AIS management knowledge among Malaysian HCPs. Methods This cross-sectional online questionnaire study was conducted nationwide among 627 HCPs in Malaysia using the Acute Stroke Management Questionnaire (ASMaQ). Multiple logistic regression was used to predict the relationship between the independent variables (age, gender, years of service, profession, work setting, work sector, seeing stroke patients in daily practice, and working with specialists) and the outcome variable (good vs poor knowledge). Results Approximately 76% (95% CI [73-79%]) of HCPs had good overall knowledge of stroke. The highest proportion of HCPs with good knowledge was noted for General Stroke Knowledge (GSK) [88.5% (95% CI [86-91%])], followed by Advanced Stroke Management (ASM) [61.2% (95% CI [57-65%])] and Hyperacute Stroke Management (HSM) [58.1% (95% CI [54-62%])]. The odds of having poor knowledge of stroke were significantly higher among non-doctor HCPs [adjusted OR = 3.46 (95% CI [1.49-8.03]), P = 0.004]; among those not seeing stroke patients in daily practice [adjusted OR = 2.67 (95% CI [1.73-4.10]), P < 0.001]; and among those working without specialists [adjusted OR = 2.41 (95% CI [1.38-4.18]), P = 0.002]. Conclusions Stroke education should be prioritised for HCPs with limited experience and guidance. All HCPs need to be up-to-date on the latest AIS management and be able to make a prompt referral to an appropriate facility. Therefore, more stroke patients will benefit from advanced stroke care.
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Affiliation(s)
- Stephenie Ann Albart
- Clinical Research Centre, Ministry of Health Malaysia, Hospital Seberang Jaya, Seberang Jaya, Penang, Malaysia
| | - Abdul Hanif Khan Yusof Khan
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Aneesa Abdul Rashid
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Wan Asyraf Wan Zaidi
- Department of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohammad Zulkarnain Bidin
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Irene Looi
- Clinical Research Centre, Ministry of Health Malaysia, Hospital Seberang Jaya, Seberang Jaya, Penang, Malaysia,Department of Medicine, Ministry of Health Malaysia, Hospital Seberang Jaya, Seberang Jaya, Penang, Malaysia
| | - Fan Kee Hoo
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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Olavarría VV, Hoffmeister L, Vidal C, Brunser AM, Hoppe A, Lavados PM. Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression. Front Neurol 2022; 13:851498. [PMID: 35463124 PMCID: PMC9028765 DOI: 10.3389/fneur.2022.851498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/02/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions. Methods We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria. Results A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4–15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1–10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window. Conclusions The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend.
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Affiliation(s)
- Verónica V. Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Lorena Hoffmeister
- Escuela de Salud Pública, Facultad de Medicina, Universidad Mayor, Santiago, Chile
| | - Carolina Vidal
- Escuela de Salud Pública, Facultad de Medicina, Universidad Mayor, Santiago, Chile
| | - Alejandro M. Brunser
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Arnold Hoppe
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Pablo M. Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
- Unidad de Investigación y Ensayos Clínicos, Departamento de Desarrollo Académico e Investigación, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Santiago, Universidad del Desarrollo, Santiago, Chile
- *Correspondence: Pablo M. Lavados
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Masiliūnas R, Vilionskis A, Bornstein NM, Rastenytė D, Jatužis D. The impact of a comprehensive national policy on improving acute stroke patient care in Lithuania. Eur Stroke J 2022; 7:134-142. [PMID: 35647307 PMCID: PMC9134776 DOI: 10.1177/23969873221089158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/05/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction: Reperfusion therapy (RT) is a mainstay treatment for acute ischemic stroke (AIS). We aimed to evaluate the impact of a comprehensive national policy (CNP) to improve access to RT for AIS patients across Lithuania. Patients and methods: Aggregated anonymized data on AIS cases treated in Lithuanian hospitals between 2006 and 2019 were retrospectively obtained from the Institute of Hygiene and the Stroke Integrated Care Management Committee. Through an interrupted time series analysis, we examined the trends in AIS hospital admissions, RT, and in-hospital case fatality rates prior to the enactment of CNP in 2014, changes immediately after the intervention, and differences in trends between the pre- and post-intervention periods. Mean yearly door-to-needle times were calculated post-intervention. Results: 114,436 cases were treated for AIS in Lithuanian hospitals before, and 65,084 after the government intervention. We observed a significant decreasing post-intervention trend change in AIS hospital admission rate per 100,000 population (regression coefficient ± standard error: β = –16.47 ± 3.95, p = 0.002) and an increasing trend change in the proportion of AIS patients who received reperfusion treatment: intravenous thrombolysis (β = 1.42 ± 0.96, p < 0.001) and endovascular therapy (β = 0.85 ± 0.05, p < 0.001). The proportion of patients treated in stroke centers increased immediately after the intervention (β = 4.95 ± 1.14, p = 0.001), but the long-term post-intervention trend did not change. In addition, there was a significant decreasing trend in all cause in-hospital case fatality rate within primary and comprehensive stroke centers after the intervention (β = –0.60 ± 0.18, p = 0.008) despite its prompt initial immediate increase (β = 1.68 ± 0.73, p = 0.043). The mean countrywide door-to-needle time decreased from 68 min in 2014 to 43 min in 2019. Conclusion: The comprehensive national stroke patient care policy could be associated with an immediate increase in stroke center treatment rate, increased access to RT, and improved stroke care performance measures.
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Affiliation(s)
| | - Aleksandras Vilionskis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Natan M Bornstein
- Neurological Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Daiva Rastenytė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Dalius Jatužis
- Center of Neurology, Vilnius University, Vilnius, Lithuania
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Ryan A, Paul CL, Cox M, Whalen O, Bivard A, Attia J, Bladin C, Davis SM, Campbell BCV, Parsons M, Grimley RS, Anderson C, Donnan GA, Oldmeadow C, Kuhle S, Walker FR, Hood RJ, Maltby S, Keynes A, Delcourt C, Hatchwell L, Malavera A, Yang Q, Wong A, Muller C, Sabet A, Garcia-Esperon C, Brown H, Spratt N, Kleinig T, Butcher K, Levi CR. TACTICS - Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship: evaluating the effectiveness of an 'implementation intervention' in providing better patient access to reperfusion therapies: protocol for a non-randomised controlled stepped wedge cluster trial in acute stroke. BMJ Open 2022; 12:e055461. [PMID: 35149571 PMCID: PMC8845197 DOI: 10.1136/bmjopen-2021-055461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Stroke reperfusion therapies, comprising intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), are best practice treatments for eligible acute ischemic stroke patients. In Australia, EVT is provided at few, mainly metropolitan, comprehensive stroke centres (CSC). There are significant challenges for Australia's rural and remote populations in accessing EVT, but improved access can be facilitated by a 'drip and ship' approach. TACTICS (Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship) aims to test whether a multicomponent, multidisciplinary implementation intervention can increase the proportion of stroke patients receiving EVT. METHODS AND ANALYSIS This is a non-randomised controlled, stepped wedge trial involving six clusters across three Australian states. Each cluster comprises one CSC hub and a minimum of three primary stroke centre (PSC) spokes. Hospitals will work in a hub and spoke model of care with access to a multislice CT scanner and CT perfusion image processing software (MIStar, Apollo Medical Imaging). The intervention, underpinned by behavioural theory and technical assistance, will be allocated sequentially, and clusters will move from the preintervention (control) period to the postintervention period. PRIMARY OUTCOME Proportion of all stroke patients receiving EVT, accounting for clustering. SECONDARY OUTCOMES Proportion of patients receiving IVT at PSCs, proportion of treated patients (IVT and/or EVT) with good (modified Rankin Scale (mRS) score 0-2) or poor (mRS score 5-6) functional outcomes and European Quality of Life Scale scores 3 months postintervention, proportion of EVT-treated patients with symptomatic haemorrhage, and proportion of reperfusion therapy-treated patients with good versus poor outcome who presented with large vessel occlusion at spokes. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Hunter New England Human Research Ethics Committee (18/09/19/4.13, HREC/18/HNE/241, 2019/ETH01238). Trial results will be disseminated widely through published manuscripts, conference presentations and at national and international platforms regardless of whether the trial was positive or neutral. TRIAL REGISTRATION NUMBER ACTRN12619000750189; UTNU1111-1230-4161.
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Affiliation(s)
- Annika Ryan
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Christine L Paul
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Martine Cox
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Olivia Whalen
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Andrew Bivard
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - John Attia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Christopher Bladin
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mark Parsons
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Department of Neurology, Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Rohan S Grimley
- Queensland State-wide Stroke Clinical Network, Healthcare Improvement Unit, Queensland Health, Herston, Queensland, Australia
- School of Medicine, Griffith University, Southport, Queensland, Australia
| | - Craig Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher Oldmeadow
- Data Sciences, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Sarah Kuhle
- Queensland State-wide Stroke Clinical Network, Healthcare Improvement Unit, Queensland Health, Herston, Queensland, Australia
| | - Frederick R Walker
- Centre for Advanced Training Systems, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Rebecca J Hood
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Centre for Advanced Training Systems, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Steven Maltby
- Centre for Advanced Training Systems, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Angela Keynes
- Centre for Advanced Training Systems, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Luke Hatchwell
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Alejandra Malavera
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Qing Yang
- Apollo Medical Imaging Technology Pty Ltd, Melbourne, Victoria, Australia
| | - Andrew Wong
- Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Claire Muller
- Queensland State-wide Stroke Clinical Network, Healthcare Improvement Unit, Queensland Health, Herston, Queensland, Australia
- Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Arman Sabet
- School of Medicine, Griffith University, Southport, Queensland, Australia
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Carlos Garcia-Esperon
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Area Administration, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Helen Brown
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Neil Spratt
- Division of Medicine, Department of Neurology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, Translational Stroke Laboratory, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ken Butcher
- Department of Neurology, Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Clinical Neuroscience, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Area Administration, Hunter New England Local Health District, New Lambton, New South Wales, Australia
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8
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Kumi F, Bugri AA, Adjei S, Duorinaa E, Aidoo M. Quality of acute ischemic stroke care at a tertiary Hospital in Ghana. BMC Neurol 2022; 22:28. [PMID: 35039001 PMCID: PMC8762857 DOI: 10.1186/s12883-021-02542-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Information on the quality of acute ischemic stroke care provided in lower-to-middle income countries is limited. Objective This study was undertaken to examine the quality of acute ischemic stroke care provided at Tamale Teaching Hospital in Ghana. Methods The medical records of patients admitted into the medical ward of the hospital between January to October 2021 were reviewed retrospectively. Extent of compliance to 15 stroke performance indicators were determined. Results Under the study period, 105 patients were admitted at the hospital with acute ischemic stroke. The mean (±SD) age was 65 ± 12 years; 38.1% were males; 65.7% had National Health Insurance Scheme coverage. Glasgow Coma Scale was the only functional stroke rating scale used by physicians to rate stroke severity. About a quarter of the patients had CT scan performed within 24 h of admission. Less than a quarter of the patients had a last known well time documented. Rate of thrombolytic administration was 0%. Less than a quarter of the patients were prescribed venous thromboembolism prophylaxis on the day of admission or day after. Only 13.8% of patients had documented reasons for not being prescribed venous thromboembolism prophylaxis. Antiplatelet therapy was prescribed to 33.3% of the patients by the end of day 2 of admission. Anticoagulation was prescribed to all patients who had comorbid condition of atrial fibrillation as part of the discharge medications. More than half of the patients were discharged to go home with statin medications. Documented stroke education was provided to 31.4% caretakers or patients. Slightly less than half of the patients were assessed for or received rehabilitation. Less than a quarter had documented dysphagia screening within 24 h of admission. None of the patient had their stroke severity rated with National Institutes of Health Stroke Scale on arrival. No patient obtained carotid imaging assessment by end of day 2. Conclusion There were several gaps in the quality of acute ischemic stroke care provided to patients at the Tamale Teaching Hospital. With the exception of discharging patients on statin medications, there was poor adherence to all other stroke performance indicators.
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Affiliation(s)
- Frank Kumi
- Pharmacy Unit, King's Medical Center, Tamale, Ghana.
| | - Amos A Bugri
- Pharmacy Directorate, Tamale Teaching Hospital, Tamale, Ghana
| | - Stephen Adjei
- Pharmacy Directorate, Tamale Teaching Hospital, Tamale, Ghana
| | - Elvis Duorinaa
- Pharmacy Directorate, Tamale Teaching Hospital, Tamale, Ghana
| | - Matthew Aidoo
- Department of Pharmacology, University for Development Studies, Tamale, Ghana
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9
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Barbour J, Hushen P, Newman GC, Vidal J. Impact of an emergency medicine pharmacist on door to needle alteplase time and patient outcomes in acute ischemic stroke. Am J Emerg Med 2022; 51:358-362. [PMID: 34823191 DOI: 10.1016/j.ajem.2021.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/17/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Time is a critical metric in the emergency department (ED) for acute ischemic stroke and thrombolytic therapy. National guidelines have emphasized tracking time from stroke onset to treatment and decreasing door to needle (DTN) time [1, 2]. Multidisciplinary teamwork is encouraged but, there is limited evidence demonstrating the value of the pharmacist on the stroke response team. The goal of this study is to compare DTN times in the ED with or without a pharmacist at bedside and examine the impact on subsequent patient outcomes. METHODS This was a single-center retrospective cohort study. Investigators identified patients who presented to the ED between August 2016 - May 2020 with signs of ischemic stroke and subsequently received intravenous alteplase. Patients were excluded if they refused alteplase or received alteplase off-campus before being transferred. Pharmacist documentation of clinical interventions was used to identify participation on the stroke response team. The primary outcome was median DTN time. Secondary outcomes included severity of deficits measured by the National Institutes of Health Stroke Scale (NIHSS), hospital length of stay (LOS), 90-day Modified Rankin Scale (mRS), incidence of intracranial hemorrhage (ICH), and inpatient all-cause mortality. RESULTS Of the 164 patients included, 31 had an emergency medicine pharmacist at bedside (EMP group) and 133 did not (No EMP group). The median DTN time was significantly shorter at 35 min EMP [interquartile range (IQR) 29-44] vs 42 min No EMP [IQR 34-55]; p = 0.003. The number of cases achieving a DTN time of 30 min or less was significantly higher when a pharmacist was involved (35.5% vs.16.5%; p = 0.018) as well as the number of patients receiving alteplase within 45 min (80.7% vs. 57.1%; p = 0.015). NIHSS scores at discharge were lower in the EMP group (2 [IQR 0-5] vs. 4 [IQR 0-8.25]; p = 0.049). In patients with magnetic resonance imaging (MRI) confirmed stroke, a difference was not observed in the secondary outcomes. CONCLUSION Patients with an emergency medicine pharmacist as part of their stroke response team had significantly lower DTN times. A higher proportion of these cases met benchmark DTN times less than 45 min and 30 min. An emergency medicine pharmacist on a stroke response team has the potential to improve patient care.
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Affiliation(s)
- Julia Barbour
- Department of Pharmacy, Einstein Medical Center Philadelphia, Philadelphia, PA, United States.
| | - Patricia Hushen
- Department of Neurology, Einstein Medical Center Philadelphia, Philadelphia, PA, United States
| | - George C Newman
- Department of Neurology, Einstein Medical Center Philadelphia, Philadelphia, PA, United States
| | - Jennifer Vidal
- Department of Pharmacy, Einstein Medical Center Philadelphia, Philadelphia, PA, United States
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10
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O’Connell N, O’Connor K, McGrath D, Vagge L, Mockler D, Jennings R, Darker CD. Early Intervention in Psychosis services: A systematic review and narrative synthesis of the barriers and facilitators to implementation. Eur Psychiatry 2021; 65:e2. [PMID: 34913421 PMCID: PMC8792869 DOI: 10.1192/j.eurpsy.2021.2260] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early intervention in psychosis (EIP) services target the early manifestation of psychosis and provide multidisciplinary care. They demonstrate effectiveness and cost-effectiveness. Implementation of EIP services is inconsistent and piecemeal. This systematic review and narrative synthesis aims to identify barriers and facilitators to EIP service implementation. METHODS We conducted an electronic search of databases (EMBASE, Medline, Web of Science, and PsychINFO) to detect papers reporting EIP service implementation findings and associated barriers and facilitators. The search occurred between June to August 2020, and again in January 2021. Articles meeting inclusion criteria were extracted and narratively synthesized. A quality assessment was conducted using the Mixed Methods Appraisal Tool. RESULTS Twenty-three studies were selected. The most common study design was descriptive accounts of implementation. Patient age ranged varied from 14 to 35 years. We identified three barrier and facilitator domains: (a) system; (b) services; and (c) staff, and a range of subdomains. The most frequent subdomains were "funding" and "strength of collaboration and communication between EIP and outside groups and services". Associations between domains and subdomains were evident, particularly between systems and services. CONCLUSIONS A range of barriers and facilitators to EIP implementation exist. Some of these are generic factors germane across health systems and services, while others are specific to EIP services. A thorough prior understanding of these challenges and enablers are necessary before implementation is attempted. Accounting for these issues within local and national contexts may help predict and increase the likelihood of services' success, stability, and longevity.
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Affiliation(s)
- N. O’Connell
- Discipline of Public Health and Primary Care, Institute of Population
Health, School of Medicine, Trinity College Dublin,
Dublin, Ireland
| | - K. O’Connor
- National Clinical Programme for Early Intervention in Psychosis,
Health Service ExecutiveDublin, Ireland
- Rise, South Lee Mental Health Services, Cork & Department of
Psychiatry, University College Cork
| | - D. McGrath
- Discipline of Public Health and Primary Care, Institute of Population
Health, School of Medicine, Trinity College Dublin,
Dublin, Ireland
| | - L. Vagge
- Discipline of Public Health and Primary Care, Institute of Population
Health, School of Medicine, Trinity College Dublin,
Dublin, Ireland
| | - D. Mockler
- Rise, South Lee Mental Health Services, Cork & Department of
Psychiatry, University College Cork
- Trinity College Dublin Library, Trinity College
Dublin, Dublin, Ireland
| | - R. Jennings
- National Clinical Programme for Early Intervention in Psychosis,
Health Service ExecutiveDublin, Ireland
| | - C. D. Darker
- Discipline of Public Health and Primary Care, Institute of Population
Health, School of Medicine, Trinity College Dublin,
Dublin, Ireland
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11
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Hood RJ, Maltby S, Keynes A, Kluge MG, Nalivaiko E, Ryan A, Cox M, Parsons MW, Paul CL, Garcia-Esperon C, Spratt NJ, Levi CR, Walker FR. Development and Pilot Implementation of TACTICS VR: A Virtual Reality-Based Stroke Management Workflow Training Application and Training Framework. Front Neurol 2021; 12:665808. [PMID: 34858305 PMCID: PMC8631764 DOI: 10.3389/fneur.2021.665808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Delays in acute stroke treatment contribute to severe and negative impacts for patients and significant healthcare costs. Variability in clinical care is a contributor to delayed treatment, particularly in rural, regional and remote (RRR) areas. Targeted approaches to improve stroke workflow processes improve outcomes, but numerous challenges exist particularly in RRR settings. Virtual reality (VR) applications can provide immersive and engaging training and overcome some existing training barriers. We recently initiated the TACTICS trial, which is assessing a "package intervention" to support advanced CT imaging and streamlined stroke workflow training. As part of the educational component of the intervention we developed TACTICS VR, a novel VR-based training application to upskill healthcare professionals in optimal stroke workflow processes. In the current manuscript, we describe development of the TACTICS VR platform which includes the VR-based training application, a user-facing website and an automated back-end data analytics portal. TACTICS VR was developed via an extensive and structured scoping and consultation process, to ensure content was evidence-based, represented best-practice and is tailored for the target audience. Further, we report on pilot implementation in 7 Australian hospitals to assess the feasibility of workplace-based VR training. A total of 104 healthcare professionals completed TACTICS VR training. Users indicated a high level of usability, acceptability and utility of TACTICS VR, including aspects of hardware, software design, educational content, training feedback and implementation strategy. Further, users self-reported increased confidence in their ability to make improvements in stroke management after TACTICS VR training (post-training mean ± SD = 4.1 ± 0.6; pre-training = 3.6 ± 0.9; 1 = strongly disagree, 5 = strongly agree). Very few technical issues were identified, supporting the feasibility of this training approach. Thus, we propose that TACTICS VR is a fit-for-purpose, evidence-based training application for stroke workflow optimisation that can be readily deployed on-site in a clinical setting.
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Affiliation(s)
- Rebecca J Hood
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Steven Maltby
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Angela Keynes
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Murielle G Kluge
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Eugene Nalivaiko
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Annika Ryan
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Martine Cox
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Christine L Paul
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Carlos Garcia-Esperon
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,Department of Neurology, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Neil J Spratt
- School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,Department of Neurology, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Department of Neurology, John Hunter Hospital, New Lambton Heights, NSW, Australia.,The Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Sydney, NSW, Australia
| | - Frederick R Walker
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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12
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Virta JJ, Strbian D, Putaala J, Korja M. Risk of Aneurysm Rupture After Thrombolysis in Patients With Acute Ischemic Stroke and Unruptured Intracranial Aneurysms. Neurology 2021; 97:e1790-e1798. [PMID: 34615686 DOI: 10.1212/wnl.0000000000012771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Unruptured intracranial aneurysms (UIAs) are considered to be a relative contraindication for IV thrombolysis (IVT) in acute ischemic stroke (AIS). Currently, however, data are limited on the risk of UIA rupture after IVT. Our objective was to assess whether IVT for AIS can lead to a UIA rupture and intracranial hemorrhages (ICHs) in patients with unruptured UIAs. METHODS This was a prospective cohort study of consecutive patients treated in a comprehensive stroke center between 2005 and 2019. We assessed radiology reports and records at the Finnish Care Register for Health Care to identify patients with UIAs among all patients with AIS treated with IVT at the center. We analyzed patient angiograms for aneurysm characteristics and other brain imaging studies for ICHs after IVT. The main outcome was in-hospital ICHs attributable to a UIA rupture after IVT. Secondary outcomes were in-hospital symptomatic ICHs (European-Australian Cooperative Acute Stroke Study [ECASS-2] criteria, i.e., NIH Stroke Scale score increase ≥4 points) and any in-hospital ICHs. RESULTS A total of 3,953 patients were treated with IVT during the 15-year study period. One hundred thirty-two (3.3%) of the 3,953 patients with AIS had a total of 155 UIAs (141 saccular and 14 fusiform). The mean diameter of UIAs was 4.7 ± 3.8 mm, with 18.7% being ≥7 mm and 9.7% ≥10 mm in diameter. None of the 141 saccular UIAs ruptured after IVT. Three patients (2.3%, 95% confidence interval [CI] 0.6%-5.8%) with large fusiform basilar artery UIAs had a fatal rupture at 27 hours, 43 hours, and 19 days after IVT. All 3 were administered anticoagulation treatments after IVT, and anticoagulation took effect during the UIA rupture. Any ICHs and symptomatic ICHs were detected in 18.9% (95% CI 12.9%-26.2%) and 8.3% (95% CI 4.4%-13.8%) of all patients with AIS, respectively. DISCUSSION IVT appears to be safe in patients with AIS with saccular UIAs, including larges UIAs (≥10 mm). Anticoagulation after AIS in patients with large fusiform posterior circulation UIAs may increase the risk of aneurysm rupture.
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Affiliation(s)
- Jyri Juhani Virta
- From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland.
| | - Daniel Strbian
- From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland
| | - Jukka Putaala
- From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland
| | - Miikka Korja
- From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland
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13
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Study the effect of static magnetic field intensity on drug delivery by magnetic nanoparticles. Sci Rep 2021; 11:18056. [PMID: 34508159 PMCID: PMC8433372 DOI: 10.1038/s41598-021-97499-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/06/2021] [Indexed: 11/14/2022] Open
Abstract
Employing the magnets in therapy has a long history of treating diseases, and currently new applications such as drug delivery by magnetic nanoparticles are gaining more attention. This research tried to study the effect of static magnetic field intensity on drug delivery by magnetic nanoparticles carrying thrombolytic agents. In this research, Fe3O4@SiO2 nanoparticles carrying streptokinase were applied. The efficiency of thrombolysis and micro-CT-scan images are utilized to study the effect of different magnetic fields (0.1, 0.2, 0.3 and 0.5 T) on thrombolysis. The results confirm that increasing the static magnetic field intensity accelerated the thrombolysis. Increasing the intensity of the magnetic field from 0.1 to 0.3 T leads to an increase in clot dissolution rate from 55 to 89%, respectively. Moreover, micro-CT-scan images revealed that magnetic nanoparticles carrying a thrombolytic agent penetrated deeper into the mesh-like structure of clot as the magnetic field intensities increased, which could lead to further dissolution of the clot.
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14
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Wen JY, Zhang J, Chen S, Chen Y, Zhang Y, Ma ZY, Zhang F, Xie WM, Fan YF, Duan JS, Chen ZW. Endothelium-derived hydrogen sulfide acts as a hyperpolarizing factor and exerts neuroprotective effects via activation of large-conductance Ca 2+ -activated K + channels. Br J Pharmacol 2021; 178:4155-4175. [PMID: 34216027 DOI: 10.1111/bph.15607] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/15/2021] [Accepted: 06/18/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND PURPOSE Endothelium-derived hyperpolarizing factor (EDHF) has been suggested as a therapeutic target for vascular protection against ischaemic brain injury. However, the molecular entity of EDHF and its action on neurons remains unclear. This study was undertaken to demonstrate whether the hydrogen sulfide (H2 S) acts as EDHF and exerts neuroprotective effect via large-conductance Ca2+ -activated K+ (BKCa /KCa 1.1) channels. EXPERIMENTAL APPROACH The whole-cell patch-clamp technology was used to record the changes of BKCa currents in rat neurons induced by EDHF. The cerebral ischaemia/reperfusion model of mice and oxygen-glucose deprivation/reoxygenation (OGD/R) model of neurons were used to explore the neuroprotection of EDHF by activating BKCa channels in these neurons. KEY RESULTS Increases of BKCa currents and membrane hyperpolarization in hippocampal neurons induced by EDHF could be markedly inhibited by BKCa channel inhibitor iberiotoxin or endothelial H2 S synthase inhibitor propargylglycine. The H2 S donor, NaHS-induced BKCa current and membrane hyperpolarization in neurons were also inhibited by iberiotoxin, suggesting that H2 S acts as EDHF and activates the neuronal BKCa channels. Besides, we found that the protective effect of endothelium-derived H2 S against mice cerebral ischaemia/reperfusion injury was disrupted by iberiotoxin. Importantly, the inhibitory effect of NaHS or BKCa channel opener on OGD/R-induced neuron injury and the increment of intracellular Ca2+ level could be inhibited by iberiotoxin but enhanced by co-application with L-type but not T-type calcium channel inhibitor. CONCLUSION AND IMPLICATIONS Endothelium-derived H2 S acts as EDHF and exerts neuroprotective effects via activating the BKCa channels and then inhibiting the T-type calcium channels in hippocampal neurons.
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Affiliation(s)
- Ji-Yue Wen
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Jie Zhang
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Shuo Chen
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Ye Chen
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Yang Zhang
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Zi-Yao Ma
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Fang Zhang
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Wei-Ming Xie
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Yi-Fei Fan
- Department of Physiology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Jing-Si Duan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhi-Wu Chen
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
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15
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Hamilton H, Dale S, McElduff B, Craig LE, Fasugba O, McInnes E, Alexandrov AW, Cadilhac DA, Lightbody E, Watkins DC, Middleton S. The role of stroke nurses in thrombolysis administration in Australia and the United Kingdom: A cross-sectional survey of current practice. J Clin Nurs 2021; 31:158-166. [PMID: 34075640 DOI: 10.1111/jocn.15892] [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: 01/12/2021] [Revised: 04/27/2021] [Accepted: 05/04/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The role of stroke nurses in patient selection and administration of recombinant tissue plasminogen activator (rt-PA) for acute ischaemic stroke is evolving. OBJECTIVES To compare differences in stroke nurses' practices related to rt-PA administration in Australia and the United Kingdom (UK) and to examine whether these differences influence rt-PA treatment rates. METHODS A cross-sectional, self-administered questionnaire administered to a lead stroke clinician from hospitals known to provide rt-PA for acute ischaemic stroke. Chi-square tests were used to analyse between-country differences in ten pre-specified rt-PA practices. Non-parametric equality of medians test was used to assess within-country differences for likelihood of undertaking practices and association with rt-PA treatment rates. Reporting followed STROBE checklist. RESULTS Response rate 68%; (Australia: 74% [n = 63/85]; UK: 65% [n = 93/144]). There were significant differences between countries for 7/10 practices. UK nurses were more likely to: request CT scan; screen patient for rt-PA suitability; gain informed consent; use telemedicine to assess, diagnose or treat; assist in the decision for rt-PA with Emergency Department physician or neurologist; and undergo training in rt-PA administration. Reported median hospital rt-PA treatment rates were 12% in the UK and 7.8% in Australia: (7.8%). In Australia, there was an association between higher treatment rates and nurses involvement in 5/10 practices; read and interpret CT scans; screen patient for rt-PA suitability; gain informed consent; assess suitability for rt-PA with neurologist/stroke physician; undergo training in rt-PA administration. There was no relationship between UK treatment rates and likelihood of a stroke nurse to undertake any of the ten rt-PA practices. CONCLUSION Stroke nurses' active role in rt-PA administration can improve rt-PA treatment rates. Models of care that broaden stroke nurses' scope of practice to maximise rt-PA treatment rates for ischaemic stroke patients are needed. RELEVANCE TO CLINICAL PRACTICE This study demonstrates that UK and Australian nurses play an important role in thrombolysis practices; however, they are underused. Formalising and extending the role of stroke nurses in rt-PA administration could potentially increase thrombolysis rates with clinical benefits for patients.
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Affiliation(s)
- Helen Hamilton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, North Sydney, NSW, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, North Sydney, NSW, Australia
| | - Benjamin McElduff
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, North Sydney, NSW, Australia
| | - Louise E Craig
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, North Sydney, NSW, Australia
| | - Oyebola Fasugba
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, North Sydney, NSW, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, North Sydney, NSW, Australia
| | - Anne W Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dominique A Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences, Monash University, Clayton, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Elizabeth Lightbody
- Faculty of Health and Care, University of Central Lancashire, Lancashire, UK
| | | | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, North Sydney, NSW, Australia
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16
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Choi JC, Kim JG, Kang CH, Bae HJ, Kang J, Lee SJ, Park JM, Park TH, Cho YJ, Lee KB, Lee J, Kim DE, Cha JK, Kim JT, Lee BC, Lee JS, Kim AS. Effect of Transport Time on the Use of Reperfusion Therapy for Patients with Acute Ischemic Stroke in Korea. J Korean Med Sci 2021; 36:e77. [PMID: 33754510 PMCID: PMC7985286 DOI: 10.3346/jkms.2021.36.e77] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/11/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND We investigated the association between geographic proximity to hospitals and the administration rate of reperfusion therapy for acute ischemic stroke. METHODS We identified patients with acute ischemic stroke who visited the hospital within 12 hours of symptom onset from a prospective nationwide multicenter stroke registry. Reperfusion therapy was classified as intravenous thrombolysis (IVT), endovascular therapy (EVT), or combined therapy. The association between the proportion of patients who were treated with reperfusion therapy and the ground transport time was evaluated using a spline regression analysis adjusted for patient-level characteristics. We also estimated the proportion of Korean population that lived within each 30-minute incremental service area from 67 stroke centers accredited by the Korean Stroke Society. RESULTS Of 12,172 patients (mean age, 68 ± 13 years; men, 59.7%) who met the eligibility criteria, 96.5% lived within 90 minutes of ground transport time from the admitting hospital. The proportion of patients treated with IVT decreased significantly when stroke patients lived beyond 90 minutes of the transport time (P = 0.006). The proportion treated with EVT also showed a similar trend with the transport time. Based on the residential area, 98.4% of Korean population was accessible to 67 stroke centers within 90 minutes. CONCLUSION The use of reperfusion therapy for acute stroke decreased when patients lived beyond 90 minutes of the ground transport time from the hospital. More than 95% of the South Korean population was accessible to 67 stroke centers within 90 minutes of the ground transport time.
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Affiliation(s)
- Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
- Institute of Medical Science, Jeju National University, Jeju, Korea.
| | - Joong Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Chul Hoo Kang
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Hee Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Jong Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Yong Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea
| | - Dong Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jae Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Joon Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Byung Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Anthony S Kim
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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17
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Zheng S, Lyu TJ, Li Z, Gu H, Yang X, Wang C, Li H, Jiang Y, Shen H, Wang Y. GRP per capita and hospital characteristics associated with intravenous tissue plasminogen activator adherence rate: evidence from the Chinese Stroke Center Alliance. Stroke Vasc Neurol 2021; 6:337-343. [PMID: 33431514 PMCID: PMC8485228 DOI: 10.1136/svn-2020-000633] [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: 09/16/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022] Open
Abstract
Background Timely delivery of intravenous tissue plasminogen activator (IV-rt PA) is pivotal to eligible patients who had a stroke while achieving higher rates of IV-rt PA has been problematic. This paper focuses on investigating influential factors associated with the administration of IV-rt PA, primarily per capita gross regional product (GRP) and healthcare system factors. Methods The study included 980 hospitals in the Chinese Stroke Center Alliance where 158 003 patients who had an acute ischaemic stroke received IV-rt PA between August 2015 and August 2019. The adherence rate to IV-rt PA within 4.5 hours time window in each hospital was the primary outcome. Influential factors were grouped into two categories: macroeconomic status and hospital characteristics. The outcome was analysed using multivariable linear regression. Results GRP per capita (β=2.37, p<0.001), hospital stroke centre certification (β=3.77, p<0.001), number of neurologists (β=0.12, p<0.001), existence of emergency services for neurological treatment (β=7.43, p=0.014), presence of emergency department (β=10.03, p=0.019) and cooperating with emergency centre (β=4.65, p=0.029) were significantly positively associated with the adherence rate to IV-rt PA. Conclusions Higher GRP per capita, affluent neurological personnel, well-equipped emergency services for neurological treatment and routine cooperation with the emergency centre were important for enhancing the adherence rate to IV-rt PA among patients who had an acute ischaemic stroke in China.
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Affiliation(s)
- Suxi Zheng
- Innvotion and Information Management, HKU Business School, The University of Hong Kong, Hong Kong, China
| | - Tian Jie Lyu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Chinese Institute for Brain Research, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunjuan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haipeng Shen
- Innvotion and Information Management, HKU Business School, The University of Hong Kong, Hong Kong, China .,Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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18
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Maeda M, Fukuda H, Matsuo R, Kiyuna F, Ago T, Kitazono T, Kamouchi M. Nationwide temporal trend analysis of reperfusion therapy utilization and mortality in acute ischemic stroke patients in Japan. Medicine (Baltimore) 2021; 100:e24145. [PMID: 33429791 PMCID: PMC7793441 DOI: 10.1097/md.0000000000024145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/07/2020] [Indexed: 01/05/2023] Open
Abstract
This study aimed to elucidate nationwide trends in reperfusion therapy utilization and subsequent 30-day mortality in acute ischemic stroke patients in Japan. The analysis focused on intravenous recombinant tissue plasminogen activator (IV rt-PA) and endovascular thrombectomy (EVT). Using health insurance claims data, we calculated the age- and sex-adjusted monthly number of acute ischemic stroke patients who received IV rt-PA and/or EVT in Japan from April 2010 to March 2016, and investigated the 30-day all-cause mortality rates after undergoing these therapies. Through an interrupted time-series analysis, we examined the: (1).. trends prior to extension of the IV rt-PA therapeutic time window from 3 hours to 4.5 hours in September 2012, (2).. changes that occurred immediately after the extension, and (3).. differences in trends between the pre- and post-extension periods. During the study period, 69,920 patients with acute ischemic stroke (mean age ± standard deviation: 74.9 ± 12.0 years; 41.4% women) received IV rt-PA and/or EVT. The age- and sex-adjusted number of patients receiving IV rt-PA monotherapy increased immediately after the time window extension (<rk-italic > P < .001), but did not change during the pre- (P = .90) and post-extension (P = .58) periods. In contrast, the number of patients receiving EVT with or without IV rt-PA continuously increased during the pre-extension period (P < .001), and further increased during the post-extension period (P <.001); however, this number decreased immediately after the extension (P < .001). There were no significant changes in 30-day all-cause mortality during the pre- (P = .40) and post-extension (P = .64) periods, as well as immediately after the extension (P = .53). The extension of the IV rt-PA therapeutic time window and progressively widespread use of EVT in Japan have increased the number of acute ischemic stroke patients eligible for reperfusion therapy. These trends were not accompanied by a higher risk of post-reperfusion mortality.
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Affiliation(s)
- Megumi Maeda
- Department of Health Care Administration and Management
| | - Haruhisa Fukuda
- Department of Health Care Administration and Management
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University
| | - Ryu Matsuo
- Department of Health Care Administration and Management
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University
| | - Fumi Kiyuna
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Takanari Kitazono
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University
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19
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Mindel E, Weiss R, Bushi D, Gera O, Orion D, Chapman J, Shavit-Stein E. Increased brain plasmin levels following experimental ischemic stroke in male mice. J Neurosci Res 2020; 99:966-976. [PMID: 33296953 DOI: 10.1002/jnr.24764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 10/29/2020] [Accepted: 11/15/2020] [Indexed: 12/19/2022]
Abstract
Many coagulation factor proteases are increased in the brain during ischemic stroke. One of these proteases is plasmin. In this study we established a novel method for direct quantitative measurement of plasmin activity in male mouse brain slices using a sensitive fluorescent substrate in the presence of specific protease inhibitors. In both the ischemic and contralateral hemispheres, plasmin activity increased 3, 6, and 24 hr following stroke in comparison to healthy mice (F(3, 72) = 39.5, p < 0.0001, repeated measures ANOVA) after the induction of permanent middle cerebral artery occlusion (PMCAo). Plasmin activity was higher in the ischemic hemisphere (F(1,36) = 9.1, p = 0.005) and there was a significant interaction between time and ischemic hemisphere (F(3,36) = 4.4, p = 0.009). Plasmin activity was correlated with infarct volume (R2 = 0.5289, p = 0.0009 by Spearman). The specificity of the assay was verified utilizing tissue-type plasminogen activator (tPA)-deficient mice which, as expected, had significantly lower levels of plasmin 24 hr following ischemia compared to wild-type mice (ischemic (0.6 ± 0.23 and 1.94 ± 0.5, respectively), p = 0.049 and contralateral hemispheres (0.13 ± 0.14 and 0.75 ± 0.10, respectively), p = 0.018 by t test). There is a time-dependent increase in plasmin levels and an association of higher levels of plasmin with larger infarct volumes in an experimental stroke model. This suggests caution in the use of recombinant tPA (rtPA) and that plasmin inhibition in the brain may be a therapeutic target in acute ischemic stroke.
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Affiliation(s)
- Ekaterina Mindel
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Weiss
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Doron Bushi
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Comprehensive Stroke Center, Department of Neurology, Sackler Faculty of Medicine, Sheba Medical Center, Ramat Gan, Israel
| | - Orna Gera
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Orion
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Comprehensive Stroke Center, Department of Neurology, Sackler Faculty of Medicine, Sheba Medical Center, Ramat Gan, Israel
| | - Joab Chapman
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Robert and Martha Harden Chair in Mental and Neurological Diseases, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Shavit-Stein
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Hasnain MG, Attia JR, Akter S, Rahman T, Hall A, Hubbard IJ, Levi CR, Paul CL. Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis. Implement Sci 2020; 15:98. [PMID: 33148294 PMCID: PMC7641813 DOI: 10.1186/s13012-020-01054-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates-mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed. METHOD The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness. RESULTS Results from 77 studies were included. Five behaviour change wheel interventions, 'Education', 'Persuasion', 'Training', 'Environmental restructuring' and 'Enablement', were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified. CONCLUSION There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.
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Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - John R. Attia
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
- John Hunter Hospital, New Lambton Heights, New South Wales Australia
| | - Shahinoor Akter
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Department of Anthropology, Jagannath University, Dhaka, Bangladesh
| | - Tabassum Rahman
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Centre for Development, Economics and Sustainability, Monash University, Melbourne, Victoria Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
| | - Isobel J. Hubbard
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - Christopher R. Levi
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, New South Wales Australia
| | - Christine L. Paul
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
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21
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Wagner TH, Yoon J, Jacobs JC, So A, Kilbourne AM, Yu W, Goodrich DE. Estimating Costs of an Implementation Intervention. Med Decis Making 2020; 40:959-967. [PMID: 33078681 DOI: 10.1177/0272989x20960455] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Health care systems frequently have to decide whether to implement interventions designed to reduce gaps in the quality of care. A lack of information on the cost of these interventions is often cited as a barrier to implementation. In this article, we describe methods for estimating the cost of implementing a complex intervention. We review methods related to the direct measurement of labor, supplies and space, information technology, and research costs. We also discuss several issues that affect cost estimates in implementation studies, including factor prices, fidelity, efficiency and scale of production, distribution, and sunk costs. We examine case studies for stroke and depression, where evidence-based treatments exist and yet gaps in the quality of care remain. Understanding the costs for implementing strategies to reduce these gaps and measuring them consistently will better inform decision makers about an intervention's likely effect on their budget and the expected costs to implement new interventions.
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Affiliation(s)
- Todd H Wagner
- Health Economics Resource Center, US Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, CA, USA.,Department of Surgery, Stanford University, Stanford, CA, USA
| | - Jean Yoon
- Health Economics Resource Center, US Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, CA, USA
| | - Josephine C Jacobs
- Health Economics Resource Center, US Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, CA, USA
| | - Angela So
- Health Economics Resource Center, US Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, CA, USA
| | - Amy M Kilbourne
- US Department of Veterans Affairs (VA) Quality Enhancement Research Initiative, Washington, DC, USA.,University of Michigan Medical School, Department of Learning Health Sciences, Ann Arbor, MI, USA
| | - Wei Yu
- Health Economics Resource Center, US Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, CA, USA
| | - David E Goodrich
- Center for Evaluation and Implementation Resources, US Department of Veterans Affairs (VA), Ann Arbor, MI, USA.,Center for Clinical Management Research, US Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, MI, USA
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22
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Sobolewski P, Brola W, Wilczyński J, Szczuchniak W, Wójcik T, Wach-Klink A, Kos M, Kozera G. Cerebral Thrombolysis in Rural Residents Aged ≥ 80. Clin Interv Aging 2020; 15:1737-1751. [PMID: 33061326 PMCID: PMC7522422 DOI: 10.2147/cia.s256070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/05/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose The proportion of older people in Poland is higher in rural areas than in urban areas. Thus, we aimed to evaluate treatment rate and factors associated with outcome and safety of intravenous thrombolysis (IVT) in rural residents aged ≥80 years admitted to primary stroke centers. Patients and Methods This study was a retrospective, observational cohort study of 873 patients treated with recombinant tissue plasminogen activator (rt-PA) in primary stroke centers between February 1, 2009 and December 31, 2017. Among them were 527 rural residents and 231 (26.5%) were ≥80 years of age. The analyses between rural and urban patients aged ≥80 and between rural patients aged <80 and aged ≥80 were performed. Results The proportion of patients aged ≥80 treated with rt-PA was comparable in rural and urban residents (27.9% vs 24.3% p = 0.24). Rural patients aged ≥80 were also characterized by lower incidence of cardiovascular risk factors and better patients’ conditions on admission to hospital. Symptomatic intracerebral hemorrhage rate among ≥80-year-old stroke patients was lower in those living in rural areas than in those living in urban areas (5.4% vs 14.3%, p = 0.02); there were no differences regarding mortality and 3-month functional outcome between both populations. The older group of rural patients was characterized by a higher 3-month mortality (28.5% vs 12.6%, p < 0.001) and lower functional independence rate (34.0% vs 50.5%, p < 0.001) than rural younger patients. Antiplatelet (OR 2.43, 95% CI 1.04–5.66, p = 0.04) and anticoagulant therapy before stroke (OR 3.64, 95% CI 1.21–10.99, p = 0.022), early ischemic changes in baseline computerized tomograprpahy (OR 2.65, 95% CI 1.03–6.82, p = 0.043) were associated with unfavorable outcome; and higher National Institute of Health Stroke Scale score on admission (OR 1.01, 95% CI 1.01–1.20, p = 0.039), higher baseline count of white blood cells (OR 1.33, 95% CI 1.10–0.62, p = 0.003) were associated with mortality in rural patients over 80. Conclusion We suggest that rural patients aged ≥80 may be safely treated with IVT in routine practice. However, lower efficacy and a higher mortality must be considered in former use of Vitamin K antagonist and antiplatelet or high white blood cells count.
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Affiliation(s)
- Piotr Sobolewski
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland.,Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Waldemar Brola
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland.,Department of Neurology and Stroke Unit, Saint Lukas Hospital in Końskie, Końskie, Poland
| | | | - Wiktor Szczuchniak
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Tomasz Wójcik
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Aleksandra Wach-Klink
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Marek Kos
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland.,Department of Public Health, Medical University of Lublin, Lublin, Poland
| | - Grzegorz Kozera
- Medical Simulation Center, Medical University of Gdańsk, Gdańsk, Poland
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23
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Dwyer M, Peterson GM, Gall S, Francis K, Ford KM. Health care providers' perceptions of factors that influence the provision of acute stroke care in urban and rural settings: A qualitative study. SAGE Open Med 2020; 8:2050312120921088. [PMID: 32435489 PMCID: PMC7223863 DOI: 10.1177/2050312120921088] [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] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 03/26/2020] [Indexed: 01/19/2023] Open
Abstract
Objectives Individuals living in rural areas have comparatively less access to acute stroke care than their urban counterparts. Understanding the local barriers and facilitators to the use of current best practice for acute stroke may inform efforts to reduce this disparity. Methods A qualitative study featuring semi-structured interviews and focus groups was conducted in the Australian state of Tasmania. Clinical staff from a range of disciplines involved in acute stroke care were recruited from three of the state's four major public hospitals (one urban and two rural). A semi-structured interview guide based on the findings of an earlier quantitative study was used to elicit discussion about the barriers and facilitators associated with providing acute stroke care. An inductive process of thematic analysis was then used to identify themes and subthemes across the data set. Results Two focus groups and five individual interviews were conducted. Four major themes were identified from analysis of the data: systemic issues, clinician factors, additional support and patient-related factors. Acute stroke care within the study's urban hospital was structured and comprehensive, aided by the hospital's acute stroke unit and specialist nursing support. In contrast, care provided in the study's rural hospitals was somewhat less comprehensive, and often constrained by an absence of infrastructure or poor access to existing resources. Conclusion The identified factors help to characterise acute stroke care within urban and rural hospitals and will assist quality improvement efforts in Tasmania's hospitals.
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Affiliation(s)
- Mitchell Dwyer
- School of Nursing, University of Tasmania, Hobart, TAS, Australia
| | | | - Seana Gall
- School of Nursing, University of Tasmania, Hobart, TAS, Australia
| | - Karen Francis
- School of Nursing, University of Tasmania, Hobart, TAS, Australia
| | - Karen M Ford
- Tasmanian Health Service, Hobart, TAS, Australia
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24
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Levi CR, Attia JA, D'Este C, Ryan AE, Henskens F, Kerr E, Parsons MW, Sanson‐Fisher RW, Bladin CF, Lindley RI, Middleton S, Paul CL. Cluster-Randomized Trial of Thrombolysis Implementation Support in Metropolitan and Regional Australian Stroke Centers: Lessons for Individual and Systems Behavior Change. J Am Heart Assoc 2020; 9:e012732. [PMID: 31973599 PMCID: PMC7033885 DOI: 10.1161/jaha.119.012732] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/15/2019] [Indexed: 12/21/2022]
Abstract
Background Intravenous thrombolytic therapy (IVT) with tissue plasminogen activator for acute ischemic stroke is underutilized in many parts of the world. Randomized trials to test the effectiveness of thrombolysis implementation strategies are limited. Methods and Results This study aimed to test the effectiveness of a multicomponent, multidisciplinary tissue plasminogen activator implementation package in increasing the proportion of thrombolyzed cases while maintaining accepted benchmarks for low rates of intracranial hemorrhage and high rates of functional outcomes at 3 months. A cluster randomized controlled trial of 20 hospitals in the early stages of thrombolysis implementation across 3 Australian states was undertaken. Monitoring of IVT rates during the baseline period allowed hospitals (the unit of randomization) to be grouped into 3 baseline IVT strata-very low rates (0% to ≤4.0%); low rates (>4.0% to ≤10.0%); and moderate rates (>10.0%). Hospitals were randomized to an implementation package (experimental group) or usual care (control group) using a 1:1 ratio. The 16-month intervention was based on behavioral theory and analysis of the steps, roles, and barriers to rapid assessment for thrombolysis eligibility and involved comprehensive strategies addressing individual and system-level change. The primary outcome was the difference in tissue plasminogen activator proportions between the 2 groups postintervention. The absolute difference in postintervention IVT rates between intervention and control hospitals adjusted for baseline IVT rate and stratum was not significant (primary outcome rate difference=1.1% (95% CI -1.5% to 3.7%; P=0.38). Rates of intracranial hemorrhage remained below international benchmarks. Conclusions The implementation package resulted in no significant change in tissue plasminogen activator implementation, suggesting that ongoing support is needed to sustain initial modifications in behavior. Clinical Trial Registration URL: www.anzctr.org.au Unique identifiers: ACTRN12613000939796 and U1111-1145-6762.
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Affiliation(s)
- Christopher R. Levi
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
- Hunter New England HealthNew Lambton HeightsAustralia
| | - John A. Attia
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
| | - Cate D'Este
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- National Centre for Epidemiology and Population HealthThe Australian National UniversityActonAustralia
| | - Annika E. Ryan
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
| | - Frans Henskens
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
| | - Erin Kerr
- Hunter New England HealthNew Lambton HeightsAustralia
| | | | - Robert W. Sanson‐Fisher
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
| | | | - Richard I. Lindley
- The George Institute for Global HealthSydneyAustralia
- The University of SydneyDarlingtonAustralia
| | - Sandy Middleton
- Nursing Research InstituteAustralian Catholic University and St Vincent's Health AustraliaSydney and DarlinghurstAustralia
| | - Christine L. Paul
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
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Craig LE, Middleton S, Hamilton H, Cudlip F, Swatzell V, Alexandrov AV, Lightbody E, Watkins DC, Philip S, Cadilhac DA, McInnes E, Dale S, Alexandrov AW. Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA. INTERVENTIONAL NEUROLOGY 2020; 8:1-12. [PMID: 32231690 PMCID: PMC7098288 DOI: 10.1159/000493020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/16/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Strict criteria for recombinant tissue plasminogen activator (rtPA) eligibility are stipulated on licences for use in ischaemic stroke; however, practitioners may also add non-standard rtPA criteria. We examined eligibility criteria variation in 3 English-speaking countries including use of non-standard criteria, in relation to rtPA treatment rates. METHODS Surveys were mailed to 566 eligible hospitals in Australia (AUS), the UK, and the USA. Criteria were pre-classified as standard (approved indication and contraindications) or non-standard (approved warning or researcher "decoy"). Percentage for criterion selection was calculated/compared; linear regression was used to assess the association between use of non-standard criteria and rtPA treatment rates, and to identify factors associated with addition of non-standard criteria. RESULTS Response rates were 74% AUS, 65% UK, and 68% USA; mean rtPA treatment rates were 8.7% AUS, 12.7% UK, and 8.7% USA. Median percentage of non-standard inclusions was 33% (all 3 countries) and included National Institutes of Health Stroke Scale (NIHSS) scores > 4, computed tomography (CT) angiography documented occlusion, and favourable CT perfusion. Median percentage of non-standard exclusions was 25% AUS, 28% UK, and 60% USA, and included depressed consciousness, NIHSS > 25, and use of antihypertensive infusions. No AUS or UK sites selected 100% of standard exclusions. CONCLUSIONS Non-standard criteria for rtPA eligibility were evident in all three countries and could, in part, explain comparably low use of rtPA. Differences in the use of standard criteria may signify practitioner intolerance for those derived from original efficacy studies that are no longer relevant.
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Affiliation(s)
- Louise E Craig
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Robina, Queensland, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Helen Hamilton
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Fern Cudlip
- Stroke Team, Good Samaritan Comprehensive Stroke Center, San Jose, California, USA
| | - Victoria Swatzell
- Mobile Stroke Unit, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, USA
| | - Elizabeth Lightbody
- College of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom
| | - Dame Caroline Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom
| | - Sheeba Philip
- East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom
| | - Dominique A Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Anne W Alexandrov
- Mobile Stroke Unit, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, USA
- College of Medicine, Department of Neurology & College of Nursing, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, USA
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Yu AYX, Fang J, Kapral MK. One-Year Home-Time and Mortality After Thrombolysis Compared With Nontreated Patients in a Propensity-Matched Analysis. Stroke 2019; 50:3488-3493. [PMID: 31570086 DOI: 10.1161/strokeaha.119.026922] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Intravenous thrombolysis with r-tPA (recombinant tissue-type plasminogen activator) is associated with improved early functional outcome after stroke, but its long-term effects are less understood. We aimed to determine the association between r-tPA and 1-year outcomes after stroke. Methods- We used the Ontario Stroke Registry to identify patients diagnosed with ischemic stroke between 2002 and 2013 in Ontario, Canada, their baseline characteristics, and whether they received r-tPA. We used propensity score methods to match patients treated with r-tPA to nontreated patients. The primary outcome was 1-year home-time, defined as the number of days spent outside of any healthcare institutions in the first 365 days after the index date of admission. Secondary outcomes were admission to a nursing home and all-cause mortality in the first year. Outcomes were determined using linked administrative data. We used paired t tests to compare mean home-time days and Cox proportional hazards models for mortality and nursing home admission to estimate hazard ratios and 95% CI. Results- All 4449 patients treated with r-tPA in the registry were matched to nontreated patients. Compared with nontreated patients, those treated with r-tPA experienced more time at home in the first year (mean±SD was 248.9 days±137.2 treated versus 239.4 days±139.0 nontreated, P=0.005) and were less likely to be admitted to nursing homes (9.4% treated versus 12.2% nontreated; hazard ratio, 0.84; 95% CI, 0.78-0.91). One-year all-cause mortality was similar between the 2 groups (13.2% treated versus 12.4% nontreated; hazard ratio, 1.07; 95% CI, 0.96-1.20). Conclusions- Despite similar mortality, patients who received r-tPA spent more time at home and were less likely to require nursing home admission in the first year after stroke compared with nontreated patients, suggesting long-term benefits and safety of this treatment.
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Affiliation(s)
- Amy Y X Yu
- From the Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, ON, Canada (A.Y.X.Y.).,ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.)
| | - Moira K Kapral
- ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.).,Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, ON, Canada (M.K.K.)
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27
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Damani RH, Anand S, Asgarisabet P, Bissell C, Savitz S, Suarez JI. Regional Intervention of Stroke Care to Increase Thrombolytic Therapy for Acute Ischemic Stroke. Stroke 2019; 49:2008-2010. [PMID: 29991653 DOI: 10.1161/strokeaha.118.021109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose- The aims of this study were to investigate the effect of an intervention to unblind data on r-tPA (recombinant tissue-type plasminogen activator) administration and sharing data with chief executive officers of participating hospitals, on r-tPA administration rates postintervention and on potential healthcare cost savings implemented at 26 Southeast Texas Regional Advisory Council hospitals. Methods- Retrospective analysis of prospective data on thrombolytic therapy from 26 Southeast Texas Regional Advisory Council hospitals, collected between April 2014 and June 2016. The control (blinded) period (Q2-2014 to Q2-2015) was followed by unblinding (Q3-2015). Results- Intervention was associated with 21.1% increase in r-tPA administration rates, with 38.5% increase in r-tPA administration with door-to-needle time ≤60 minutes. An absolute increase in r-tPA administration of 2.1% was seen with an average lifetime cost savings of $3.6 million. Conclusions- Transparent regional data sharing was associated with improved r-tPA administration and healthcare cost savings.
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Affiliation(s)
- Rahul H Damani
- From the Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, Houston, TX (R.H.D., S.A.)
| | - Samyuktha Anand
- From the Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, Houston, TX (R.H.D., S.A.)
| | - Parisa Asgarisabet
- University of Texas Health Science Center at Houston School of Public Health (P.A.)
| | | | - Sean Savitz
- Department of Neurology, McGovern School of Medicine, Houston, TX (S.S.)
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine (J.I.S.).,Department of Neurology (J.I.S.).,Department of Neurosurgery (J.I.S.), Johns Hopkins University School of Medicine, Baltimore, MD
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28
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Ng SHX, Wong AWK, Chen CH, Tan CS, Müller-Riemenschneider F, Chan BPL, Baum MC, Lee JM, Venketasubramanian N, Koh GCH. Stroke Factors Associated with Thrombolysis Use in Hospitals in Singapore and US: A Cross-Registry Comparative Study. Cerebrovasc Dis 2019; 47:291-298. [PMID: 31434100 PMCID: PMC6759403 DOI: 10.1159/000502278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/23/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This paper aims to describe and compare the characteristics of 2 stroke populations in Singapore and in St. Louis, USA, and to document thrombolysis rates and contrast factors associated with its uptake in both populations. METHODS The stroke populations described were from the Singapore Stroke Registry (SSR) in -Singapore and the Cognitive Rehabilitation Research Group Stroke Registry (CRRGSR) in St. Louis, MO, USA. The registries were compared in terms of demographics and stroke risk factor history. Logistic regression was used to determine factors associated with thrombolysis uptake. RESULTS A total of 39,323 and 8,106 episodes were recorded in SSR and CRRGSR, respectively, from 2005 to 2012. Compared to CRRGSR, patients in SSR were older, male, and from the ethnic majority. Thrombolysis rates in SSR and CRRGSR were 2.5 and 8.2%, respectively, for the study period. History of ischemic heart disease or atrial fibrillation was associated with increased uptake in both populations, while history of stroke was associated with lower uptake. For SSR, younger age and males were associated with increased uptake, while having a history of smoking or diabetes was associated with decreased uptake. For CRRGSR, ethnic minority status was associated with decreased uptake. CONCLUSIONS The comparison of stroke populations in Singapore and St Louis revealed distinct differences in clinicodemographics of the 2 groups. Thrombolysis uptake was driven by nonethnicity demographics in Singapore. Ethnicity was the only demographic driver of uptake in the CRRGSR population, highlighting the need to target ethnic minorities in increasing access to thrombolysis.
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Affiliation(s)
- Sheryl Hui-Xian Ng
- Saw Swee Hock School of Public Health, National University Health System, Singapore, Singapore
| | - Alex W K Wong
- Department of Neurology, Program in Occupational Therapy, Washington University in St Louis, St. Louis, Missouri, USA
| | - Cynthia Huijun Chen
- Saw Swee Hock School of Public Health, National University Health System, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University Health System, Singapore, Singapore
| | - Falk Müller-Riemenschneider
- Saw Swee Hock School of Public Health, National University Health System, Singapore, Singapore
- Institute for Social Medicine, Epidemiology and Health Economics, Charite University Medical Centre, Berlin, Germany
| | - Bernard P L Chan
- Division of Neurology, National University Hospital, National University Health System, Singapore, Singapore
| | - M Carolyn Baum
- Department of Neurology, Program in Occupational Therapy, Washington University in St Louis, St. Louis, Missouri, USA
| | - Jin-Moo Lee
- Department of Neurology, Washington University in St Louis, St. Louis, Missouri, USA
| | | | - Gerald Choon-Huat Koh
- Saw Swee Hock School of Public Health, National University Health System, Singapore, Singapore,
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29
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McVerry F, Hunter A, Dynan K, Matthews M, McCormick M, Wiggam I, Vahidassr D, McErlean F, Stevenson M, Hopkins E, McKee J, Kelly J, Kennedy F, McCarron MO. Country-Wide Analysis of Systemic Factors Associated With Acute Ischemic Stroke Door to Needle Time. Front Neurol 2019; 10:676. [PMID: 31297081 PMCID: PMC6606974 DOI: 10.3389/fneur.2019.00676] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/10/2019] [Indexed: 01/19/2023] Open
Abstract
Objective: Pre-hospital, in-hospital, and patient factors are associated with variation in door to needle (DTN) time in acute ischemic stroke (AIS). Publications are usually from large single centers or multicenter registries with less reporting on national results. Materials and methods: All AIS patients treated with intravenous tissue plasminogen activator (iv-tPA) over 4 years (2013–2016) in Northern Ireland were recorded prospectively, including patient demographics, pre-hospital care, thrombolysis rate, and DTN time. Logistic regression was performed to identify factors associated with DTN time. Results: One thousand two hundred and one patients from 10,556 stroke admissions (11.4%) were treated with iv-tPA. Median NIHSS was 10 (IQR 6-17). Median DTN time was 54 min (IQR 36-77) with 61% treated < 60 min from arrival at hospital. National thrombolysis numbers increased over time with improving DTN time (P = 0.002). Arrival method at hospital (ambulance OR 2.3 CI1.4-3.8) pre-alert from ambulance (pre-alert OR = 5.3 CI3.5-8.1) and time of day (out of hours, n = 650, OR 0.20 CI 0.22-0.38) all P < 0.001, were the independent factors in determining DTN time. Variation in DTN time between centers occurred but was unrelated to volume of stroke admissions. Conclusion: Ambulance transport with pre-hospital notification and time of day are associated with shorter DTN time on a national level. Most thrombolysis was delivered outside of normal working hours but these patients are more likely to experience treatment delays. Re-organization of stroke services at a whole system level with emphasis on pre-hospital care and design of stroke teams are required to improve quality and equitable care in AIS nationally.
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Affiliation(s)
- Ferghal McVerry
- Stroke Unit and Neurology Department, Altnagelvin Hospital, Derry, United Kingdom
| | - Annemarie Hunter
- Neurology Department, Royal Victoria Hospital, Belfast, United Kingdom
| | - Kevin Dynan
- Stroke Unit, Ulster Hospital, Dundonald, United Kingdom
| | | | | | - Ivan Wiggam
- Neurology Department, Royal Victoria Hospital, Belfast, United Kingdom
| | | | - Fintan McErlean
- Audit Department, Royal Victoria Hospital, Belfast, United Kingdom
| | - Mike Stevenson
- Centre for Public Health, Queen's University, Belfast, United Kingdom
| | - Emer Hopkins
- Health and Social Care Board, Belfast, United Kingdom
| | - Jacqueline McKee
- Stroke Unit and Neurology Department, Altnagelvin Hospital, Derry, United Kingdom
| | - James Kelly
- Stroke Unit, South West Acute Hospital, Enniskillen, United Kingdom
| | - Fiona Kennedy
- Neurology Department, Royal Victoria Hospital, Belfast, United Kingdom
| | - Mark O McCarron
- Stroke Unit and Neurology Department, Altnagelvin Hospital, Derry, United Kingdom
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30
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Middleton S, Dale S, Cheung NW, Cadilhac DA, Grimshaw JM, Levi C, McInnes E, Considine J, McElduff P, Gerraty R, Craig LE, Schadewaldt V, Fitzgerald M, Quinn C, Cadigan G, Denisenko S, Longworth M, Ward J, D'Este C. Nurse-Initiated Acute Stroke Care in Emergency Departments: The Triage, Treatment, and Transfer Implementation Cluster Randomized Controlled Trial. Stroke 2019; 50:1346-1355. [PMID: 31092163 DOI: 10.1161/strokeaha.118.020701] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods- A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke <48 hours from symptom onset and were admitted to the stroke unit via ED. Our nurse-initiated T3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2; (2) Treatment: tPA eligibility screening and appropriate administration; clinical protocols for managing fever, hyperglycemia, and swallowing; (3) prompt (<4 hours) stroke unit Transfer. It was implemented using (1) workshops to identify barriers and solutions; (2) face-to-face, online, and written education; (3) national and local clinical opinion leaders; and (4) email, telephone, and site visit follow-up. Outcomes were assessed at the patient level. Primary outcome: 90-day death or dependency (modified Rankin Scale score of ≥2); secondary outcomes: functional dependency (Barthel Index ≥95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale; monitoring and management of tPA, fever, hyperglycemia, swallowing; prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Results- Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P=0.24) or secondary outcomes. Conclusions- This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. Clinical Trial Registration- URL: http://www.anzctr.org.au. Unique identifier: ACTRN12614000939695.
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Affiliation(s)
- Sandy Middleton
- From the Nursing Research Institute, St Vincent's Health Australia, Sydney (S.M., S. Dale., E.M., L.E.C., V.S.)
- Australian Catholic University, Darlinghurst, NSW (S.M., S. Dale., E.M., L.E.C., V.S.)
| | - Simeon Dale
- From the Nursing Research Institute, St Vincent's Health Australia, Sydney (S.M., S. Dale., E.M., L.E.C., V.S.)
- Australian Catholic University, Darlinghurst, NSW (S.M., S. Dale., E.M., L.E.C., V.S.)
| | - N Wah Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital, NSW, Australia (N.W.C.)
- University of Sydney, NSW, Australia (N.W.C.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research Centre and Department of Medicine, Monash University, Clayton, VIC, Australia (D.A.C.)
| | | | - Chris Levi
- The Sydney Partnership for Health Education Research and Enterprise (SPHERE), University of New South Wales, Liverpool, Australia (C.L.)
| | - Elizabeth McInnes
- From the Nursing Research Institute, St Vincent's Health Australia, Sydney (S.M., S. Dale., E.M., L.E.C., V.S.)
- Australian Catholic University, Darlinghurst, NSW (S.M., S. Dale., E.M., L.E.C., V.S.)
| | - Julie Considine
- Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia (J.C.)
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, NSW, Australia (P.M., C.D.)
| | - Richard Gerraty
- Neurosciences Clinical Institute, Epworth Hospital, VIC, Australia (R.G.)
- Department of Medicine, Monash University, Richmond, VIC, Australia (R.G.)
| | - Louise Eisten Craig
- From the Nursing Research Institute, St Vincent's Health Australia, Sydney (S.M., S. Dale., E.M., L.E.C., V.S.)
- Australian Catholic University, Darlinghurst, NSW (S.M., S. Dale., E.M., L.E.C., V.S.)
| | - Verena Schadewaldt
- From the Nursing Research Institute, St Vincent's Health Australia, Sydney (S.M., S. Dale., E.M., L.E.C., V.S.)
- Australian Catholic University, Darlinghurst, NSW (S.M., S. Dale., E.M., L.E.C., V.S.)
| | - Mark Fitzgerald
- Department of Surgery and Central Clinical School, Monash University, Melbourne, VIC, Australia (M.F.)
| | - Clare Quinn
- Speech Pathology Department, Prince of Wales Hospital, Randwick, NSW, Australia (C.Q.)
| | - Greg Cadigan
- Statewide Stroke Clinical Network, Brisbane, QLD, Australia (G.C.)
| | - Sonia Denisenko
- Victorian Stroke Clinical Network, Safer Care Victoria, Australia (S. Denisenko)
| | - Mark Longworth
- NSW Agency for Clinical Innovation, Chatswood, NSW, Australia (M.L.)
| | - Jeanette Ward
- Nulungu Research Institute, University of Notre Dame, Broome, WA, Australia (J.W.)
| | - Catherine D'Este
- School of Medicine and Public Health, University of Newcastle, NSW, Australia (P.M., C.D.)
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, ACT (C.D.)
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Zupan M, Zaletel M, Žvan B. Enhancement of Intravenous Thrombolysis by Nationwide Telestroke Care in Slovenia: A Model of Care for Middle-Income Countries. Telemed J E Health 2019; 26:462-467. [PMID: 31140945 DOI: 10.1089/tmj.2019.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Stroke expertise is critical for timely and appropriate intravenous thrombolysis (IVT) and affects IVT use. Introduction: In Slovenia, IVT is administered in general hospitals, which often lack on-site neurologic expertise. To overcome this obstacle, a national telestroke network, TeleKap, has been implemented. The aim of the study was to determine whether TeleKap is associated with enhanced IVT use. Materials and Methods: This investigation was a retrospective observational study comparing the number of acute ischemic stroke (AIS) patients and the use of IVT during the first 3 consecutive years. TeleKap, a decentralized hub-and-spoke telestroke model covering the entire nation, consists of one comprehensive stroke center and 12 spokes classified according to the availability of on-site neurologic expertise. Results: During the observation period, we treated a total of 1,316 patients with AIS, of which 508 (38.6%) received IVT. We found statistically significant positive trends in the number of IVT patients (142 in 2015, 158 in 2016, and 208 in 2017; B = 4.39, standard error (SE) = 1.59, p = 0.01) and the number of AIS patients (326 in 2015, 424 in 2016, and 566 in 2017; B = 14.42, SE = 5.19, p = 0.01) for all spokes. The trend in the IVT rate was numerically negative but did not reach statistical significance (43.5% in 2015, 37.3% in 2016, and 36.7% in 2017; p = 0.30). Discussion: TeleKap enhanced IVT use regardless of on-site neurologic expertise. Conclusions: TeleKap proved to be efficient. It could serve as a model of telestroke care for other similar countries.
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Affiliation(s)
- Matija Zupan
- Divison of Neurology, Department of Vascular Neurology, University Medical Centre Ljubljana, Slovenia
| | - Marjan Zaletel
- Divison of Neurology, Department of Vascular Neurology, University Medical Centre Ljubljana, Slovenia
| | - Bojana Žvan
- Divison of Neurology, Department of Vascular Neurology, University Medical Centre Ljubljana, Slovenia
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32
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Lachkhem Y, Rican S, Minvielle É. Understanding delays in acute stroke care: a systematic review of reviews. Eur J Public Health 2019; 28:426-433. [PMID: 29790991 DOI: 10.1093/eurpub/cky066] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Stroke is the leading cause of adult long-term disability in Western countries. Intravenous thrombolytic therapy with recombinant tissue plasminogen activator is safe and effective within the first 4.5 h after the onset of stroke. Various factors delaying acute stroke care have been identified in the literature. This review aimed to provide an overview of factors delaying acute stroke care and attempted to show how they interact in a synthetic framework. Methods We conducted a systematic review of literature reviews published in Medline and DORIS until 2016 on factors influencing acute stroke pathway timeframe. Results We analyzed 31 reviews that cover all factors of delays from stroke onset to treatment. We identified 27 factors that had a significant impact on acute stroke care and can be categorized into four distinct categories: patient-related factors, training, resources and lack of coordination. We also reported associations between factors observed in both between categories (mainly between patients and organizational/logistical factors) and within categories. Conclusion This review provides a wide overview of factors influencing acute stroke pathway. Since it was observed that the identified factors were interrelated, they needed to be analyzed in a systematic way. We hence created a synthetic framework that combines several categories of factors while assuming that factor weight varies from a study context to another. Better knowledge on underlying mechanisms between factors would provide crucial improvement of the interventions aiming at reducing delays in both pre-hospital and inhospital stages. For future research, we recommend adopting a systemic perspective on factors influencing acute stroke pathway.
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Affiliation(s)
- Yacine Lachkhem
- Equipe d'Accueil Management des Organisations de Santé, French School of Public Health, Rennes, France
| | | | - Étienne Minvielle
- Equipe d'Accueil Management des Organisations de Santé, French School of Public Health, Rennes, France.,Gustave Roussy Cancer Center, Villejuif, France
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Mathur S, Walter S, Grunwald IQ, Helwig SA, Lesmeister M, Fassbender K. Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units. Front Neurol 2019; 10:159. [PMID: 30881334 PMCID: PMC6407433 DOI: 10.3389/fneur.2019.00159] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/07/2019] [Indexed: 12/11/2022] Open
Abstract
In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs-especially in rural and remote settings-with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.
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Affiliation(s)
- Shrey Mathur
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
- Neuroscience Unit, Faculty of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Iris Q. Grunwald
- Neuroscience Unit, Faculty of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
- Department of Medicine, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, United Kingdom
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
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Bahnasy WS, Ragab OAA, Elhassanien ME. Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience. eNeurologicalSci 2019; 14:68-71. [PMID: 30671551 PMCID: PMC6330381 DOI: 10.1016/j.ensci.2019.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The use of intravenous recombinant tissue plasminogen activator (IV r-tPA) in early acute ischemic stroke (AIS) management faces a lot of difficulties in developing countries due to lessened guideline development with consecutive pre- and intra-hospital delay. OBJECTIVES The objective was to identify the barriers facing proper utilization of IV r-tPA for AIS in Tanta University Hospitals. METHODS The study was conducted on 4124 AIS patients eligible to use IV r-tPA divided to group-I consisting of 442 patients who arrived the hospital within <3.5 h from the stroke onset and group-II consisting of 3682 patients who arrived >3.5 h from the stroke onset. The former group was further subdivided to 238 patients who received IV r-tPA (group-Ia) and 204 patients who did not receive IV r-tPA (group-Ib) due to different obstacles. RESULTS The main causes of pre-hospital onset to arrival delay were stroke unawareness, long travel time, incorrect beliefs, non-available neurologists, stroke onset during sleep and multiple causes (18.2%, 20.5%, 12.7%, 9.1%, 16% and 23.5% of cases, respectively). Causes of non-administration of IV r-tPA in eligible patients includes prolonged door-to-needle time, financial restraints, minor strokes, unavailable beds and fear of complications (41.2%, 26%, 12.7%, 11.3% and 8.8%, respectively). CONCLUSION Increasing the chance of utilizing IV r-tPA for AIS patients' needs regular updating of the stroke chain of survival system to get the highest benefits from the available resources.
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Fulop NJ, Ramsay AIG, Hunter RM, McKevitt C, Perry C, Turner SJ, Boaden R, Papachristou I, Rudd AG, Tyrrell PJ, Wolfe CDA, Morris S. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background
Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes.
Objective
To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented.
Design
Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; ≈210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes.
Results
Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality [–1.1%, 95% confidence interval (CI) –2.1% to –0.1%], resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% (95% CI 65.6% to 67.1%); comparator = 54.4% (95% CI 53.6% to 55.1%)]. Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS (–2.0 days, 95% CI –2.8 to –1.2 days) only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS (–1.5 days, 95% CI –2.5 to –0.4 days) and clinical interventions [e.g. SU within 4 hours: GMB = 79.1% (95% CI 77.9% to 80.4%); comparator = 53.4% (95% CI 53.0% to 53.7%)] but not on mortality (–1.3%, 95% CI –2.7% to 0.01%; p = 0.05, accounting for reductions observed in RoE); however, there was a significant effect when examining GMB HASUs only (–1.8%, 95% CI –3.4% to –0.2%), resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context.
Limitations
The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views.
Conclusions
Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Angus IG Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Christopher McKevitt
- Department of Population Health Sciences, School of Population Health & Environmental Sciences Research, King’s College London, London, UK
| | - Catherine Perry
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Simon J Turner
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Ruth Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | - Anthony G Rudd
- Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
| | - Pippa J Tyrrell
- Stroke and Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Charles DA Wolfe
- Department of Population Health Sciences, School of Population Health & Environmental Sciences Research, King’s College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
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Andrew NE, Middleton S, Grimley R, Anderson CS, Donnan GA, Lannin NA, Stroil-Salama E, Grabsch B, Kilkenny MF, Squires JE, Cadilhac DA. Hospital organizational context and delivery of evidence-based stroke care: a cross-sectional study. Implement Sci 2019; 14:6. [PMID: 30658654 PMCID: PMC6339367 DOI: 10.1186/s13012-018-0849-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 12/07/2018] [Indexed: 01/19/2023] Open
Abstract
Background Organizational context is one factor influencing the translation of evidence into practice, but data pertaining to patients with acute stroke are limited. We aimed to determine the associations of organizational context in relation to four important evidence-based stroke care processes. Methods This was a mixed methods cross-sectional study. Among 19 hospitals in Queensland, Australia, a survey was conducted of the perceptions of stroke clinicians about their work using the Alberta Context Tool (ACT), a validated measure covering 10 concepts of organizational context, and with additional stroke-specific contextual questions. These data were linked to the Australian Stroke Clinical Registry (AuSCR) to determine the relationship with receipt of evidence-based acute stroke care (acute stroke unit admission, use of thrombolysis for those with acute ischemic stroke, receipt of a written care plan on discharge, and prescription of antihypertensive medications on discharge) using quantile regression. Exploratory cluster analysis was used to categorize hospitals into high and low context groups based on all of the 10 ACT concepts. Differences in adherence to care processes between the two groups were examined. Results A total of 215 clinicians completed the survey (50% nurses, 37% allied health staff, 10% medical practitioners), with 81% being in their current role for at least 1 year. There was good reliability (∞ 0.83) within the cohort to allow pooling of professional groups. Greater ACT scores, especially for social capital (μ 9.00, 95% confidence interval [CI] 4.86 to 13.14) and culture (μ 7.33, 95% CI 2.05 to 12.62), were associated with more patients receiving stroke unit care. There was no correlation between ACT concepts and other care processes. Working within higher compared to lower context environments was associated with greater proportions of patients receiving stroke unit care (88.5% vs. 69.0%) and being prescribed antihypertensive medication at discharge (62.5% vs. 52.0%). Staff from higher context hospitals were more likely to value medical and/or nursing leadership and stroke care protocols. Conclusions Overall organizational context, and in particular aspects of culture and social capital, are associated with the delivery of some components of evidence-based stroke care, offering insights into potential pathways for improving the implementation of proven therapies. Electronic supplementary material The online version of this article (10.1186/s13012-018-0849-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadine E Andrew
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia.,Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, Australia
| | - Rohan Grimley
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia.,Sunshine Coast Clinical School, The University of Queensland, Birtinya and Statewide Stroke Clinical Network, Queensland Health, Brisbane, Australia
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Geoffrey A Donnan
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Natasha A Lannin
- Faculty of Health Sciences, La Trobe University, Bundoora, Australia.,Occupational Therapy Department, Alfred Health, Melbourne, Australia
| | - Enna Stroil-Salama
- Australian Bronchiectasis Registry, Lung Foundation Australia, Brisbane, Australia
| | - Brenda Grabsch
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Janet E Squires
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia. .,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.
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Ebben RHA, Siqeca F, Madsen UR, Vloet LCM, van Achterberg T. Effectiveness of implementation strategies for the improvement of guideline and protocol adherence in emergency care: a systematic review. BMJ Open 2018; 8:e017572. [PMID: 30478101 PMCID: PMC6254419 DOI: 10.1136/bmjopen-2017-017572] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/21/2018] [Accepted: 10/05/2018] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Guideline and protocol adherence in prehospital and in-hospital emergency departments (EDs) is suboptimal. Therefore, the objective of this systematic review was to identify effective strategies for improving guideline and protocol adherence in prehospital and ED settings. DESIGN Systematic review. DATA SOURCES PubMed (including MEDLINE), CINAHL, EMBASE and Cochrane. METHODS We selected (quasi) experimental studies published between 2004 and 2018 that used strategies to increase guideline and protocol adherence in prehospital and in-hospital emergency care. Pairs of two independent reviewers performed the selection process, quality assessment and data extraction. RESULTS Eleven studies were included, nine of which were performed in the ED setting and two studies were performed in a combined prehospital and ED setting. For the ED setting, the studies indicated that educational strategies as sole intervention, and educational strategies in combination with audit and feedback, are probably effective in improving guideline adherence. Sole use of reminders in the ED setting also showed positive effects. The two studies in the combined prehospital and ED setting showed similar results for the sole use of educational interventions. CONCLUSIONS Our review does not allow firm conclusion on how to promote guideline and protocol adherence in prehospital emergency care, or the combination of prehospital and ED care. For ED settings, the sole use of reminders or educational interventions and the use of multifaceted strategies of education combined with audit and feedback are all likely to be effective in improving guideline adherence.
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Affiliation(s)
- Remco H A Ebben
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Flaka Siqeca
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Erasmus Scholar from the University of Prishtina, Kosovo at the KU Leuven, Leuven, Belgium
| | | | - Lilian C M Vloet
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Theo van Achterberg
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Leuven, Belgium
- Department of Public Health and Primary Care, Uppsala University, Uppsala, Sweden
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Kushwaha S, Talwar P, Chandel N, Anthony A, Maheshwari S, Khurana S. Saving the brain initiative - Developing an effective hub-and-spoke model to improve the acute stroke management pathways in urban India. J Neurol Sci 2018; 393:83-87. [PMID: 30125806 DOI: 10.1016/j.jns.2018.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 08/03/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES We aimed to develop and evaluate a hub-and-spoke model in the East Delhi by assessing knowledge and creating awareness through sensitization programs in target communities and among general physicians (GPs) along with implementation of a standard stroke management protocol (SMP) at our institute in order to extend the benefit of thrombolytic therapy. METHODS We carried out a prospective interventional study using sensitization program comprising 1046 community participants and 101 GPs under "Saving the Brain Initiative" project. Network included one hub and six nearby spoke hospitals. The pre-awareness and post-awareness data along with clinical outcome of thrombolysis collected over 2012-2017 was analyzed. RESULTS We observed lack of awareness in communities and among GPs regarding stroke symptomatology and treatment options. There was 17.3% increase in patients with stroke post-awareness programs. Door-to-door time improved as 49.3% of patients reached hospital within <2 h of onset as compared to 32.2% in pre-awareness period. 89.4% patients had good outcome and were discharged with improved NIHSS. In the post-awareness period, the rate of thrombolysis increased by 4.0%. CONCLUSIONS Sensitization of primary physicians, paramedical and medical staff along with community dwellers and implementation of SMP through hub-and-stroke model is instrumental in improving the rate of thrombolysis and its outcome.
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Affiliation(s)
- Suman Kushwaha
- Department of Neurology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi 110 095, India.
| | - Puneet Talwar
- Department of Neurology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi 110 095, India.
| | - Niketa Chandel
- Department of Neurology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi 110 095, India
| | - Aldrin Anthony
- Department of Neurology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi 110 095, India
| | - Siddharth Maheshwari
- Department of Neurology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi 110 095, India
| | - Sarbjeet Khurana
- Department of Epidemiology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi 110 095, India
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Hassankhani H, Soheili A, Vahdati SS, Mozaffari FA, Fraser JF, Gilani N. Treatment Delays for Patients With Acute Ischemic Stroke in an Iranian Emergency Department: A Retrospective Chart Review. Ann Emerg Med 2018; 73:118-129. [PMID: 30318375 DOI: 10.1016/j.annemergmed.2018.08.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 08/11/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE We evaluate the extent and nature of treatment delays and the contributing factors influencing them for patients with acute ischemic stroke, as well as main barriers to stroke care in an Iranian emergency department (ED). METHODS A retrospective chart review was conducted on 394 patients with acute ischemic stroke who were referred to the ED of a tertiary academic medical center in northwest Iran from March 21 to June 21, 2017. The steps of this review process included instrument development, medical records retrieval, data extraction, and data verification. Primary outcomes were identified treatment delays and causes of loss of eligibility for intravenous recombinant tissue plasminogen activator (r-tPA). RESULTS Of patients with acute ischemic stroke, 80.2% did not meet intravenous r-tPA eligibility; the most common cause was delayed (>4.5 hours) ED arrival after symptom onset (71.82%; n=283). Of 19.8% of subjects for whom the stroke code was activated, intravenous r-tPA was administered in only 5.3%. The average time from patients' arrival to first emergency medicine resident visit, notification of acute stroke team, presence of neurology resident, and computed tomography scan interpretation was lower for patients who met criteria of intravenous r-tPA than for those who lost eligibility for fibrinolytic therapy. The average door-to-needle time was 69 minutes (interquartile range 46 to 91 minutes). CONCLUSION Our ED and acute stroke team had a favorable clinical performance meeting established critical time goals of inhospital care for potentially eligible patients, but a poor clinical performance for the majority of patients who were not candidates for fibrinolytic therapy.
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Affiliation(s)
- Hadi Hassankhani
- Research Center for Evidence-Based Medicine, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Soheili
- Student Research Committee, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Samad S Vahdati
- Neurosciences Research Center, Department of Emergency Medicine, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farough A Mozaffari
- Department of Social Sciences, School of Law and Social Sciences, University of Tabriz, Tabriz, Iran
| | - Justin F Fraser
- Department of Neurological Surgery, Neurology, Radiology, and Neuroscience, University of Kentucky, Lexington, KY
| | - Neda Gilani
- Road Traffic Injury Research Center, Department of Statistics and Epidemiology, School of Health, Tabriz University of Medical Sciences, Tabriz, Iran
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Huang Q, Zhang JZ, Xu WD, Wu J. Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis. Medicine (Baltimore) 2018; 97:e11205. [PMID: 29924046 PMCID: PMC6024468 DOI: 10.1097/md.0000000000011205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jing-ze Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Wen-deng Xu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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Fleet R, Bussières S, Tounkara FK, Turcotte S, Légaré F, Plant J, Poitras J, Archambault PM, Dupuis G. Rural versus urban academic hospital mortality following stroke in Canada. PLoS One 2018; 13:e0191151. [PMID: 29385173 PMCID: PMC5791969 DOI: 10.1371/journal.pone.0191151] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 12/31/2017] [Indexed: 12/03/2022] Open
Abstract
Introduction Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada. Objectives To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals. Materials and methods We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate. Results A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities. Conclusion Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada’s universal health care system.
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Affiliation(s)
- Richard Fleet
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
- Research Chair in Emergency Medicine Université Laval-CHAU Hôtel-Dieu de Lévis, Lévis, QC, Canada
- * E-mail:
| | - Sylvain Bussières
- Research Chair in Emergency Medicine Université Laval-CHAU Hôtel-Dieu de Lévis, Lévis, QC, Canada
| | | | - Stéphane Turcotte
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Québec, QC, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine and Knowledge Transfer and Health Technology Assessment Group, CHU de Québec Research Centre and Evaluative Research Unit, Université Laval, Québec, QC, Canada
| | - Jeff Plant
- Faculty of Medicine, University of British Columbia and Department of Emergency Medicine, Penticton Regional Hospital, Penticton, BC, Canada
| | - Julien Poitras
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
- Research Chair in Emergency Medicine Université Laval-CHAU Hôtel-Dieu de Lévis, Lévis, QC, Canada
| | - Patrick M. Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
- Research Chair in Emergency Medicine Université Laval-CHAU Hôtel-Dieu de Lévis, Lévis, QC, Canada
- Intensive Care Division, Department of Anesthesiology, Université Laval, Quebec, QC, Canada
| | - Gilles Dupuis
- Department of Psychology, Université du Québec à Montréal, Montréal, QC, Canada
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Haesebaert J, Nighoghossian N, Mercier C, Termoz A, Porthault S, Derex L, Gueugniaud PY, Bravant E, Rabilloud M, Schott AM, Cailler S, Hénniche A, Prost S, Fournier C, Le Loch JB, Roncoroni C, Verbois F, Debas O, Tesniere M, Bontemps B, Lavignon JP, Rimet M, Trinquet P, Millot T, Dumont O, Tabyaoui S, Ziade E, Detante O, Giroud M, Cakmak S, Marcel S, Blanc-Lasserre K, Minier D, Rodier G, Philippeau F, Vallet AE. Improving Access to Thrombolysis and Inhospital Management Times in Ischemic Stroke: A Stepped-Wedge Randomized Trial. Stroke 2018; 49:405-411. [PMID: 29321338 DOI: 10.1161/strokeaha.117.018335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 12/04/2017] [Accepted: 12/07/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A suboptimal number of ischemic stroke patients eligible for thrombolysis actually receive it, partly because of extended inhospital delays. We developed a comprehensive program designed for emergency unit staff and evaluated its effectiveness for reducing intrahospital times and improving access to thrombolysis. METHODS We conducted a randomized stepped-wedge controlled trial in 18 emergency unit. The sequentially implemented training intervention, targeting emergency physicians and nurses, was based on specifically designed videos and interactive simulation workshops on intrahospital management optimization. The effectiveness was assessed on intrahospital times and thrombolysis proportion. During the study period, all consecutive patients with confirmed ischemic stroke and no contraindications to thrombolysis were included. RESULTS A total of 328 patients were enrolled in the control group and 363 in the intervention group. Mean age was 73.6 years. Overall thrombolysis proportion was 34.2% in the intervention group versus 25.6% in the control group (adjusted odds ratio, 1.42; 95% confidence interval, 1.01-2.01), thrombolysis proportion within 4 hours 30 minutes almost doubled (adjusted odds ratio, 1.9; 95% confidence interval, 1.32-2.73). Although imaging-to-stroke unit time was significantly decreased in the intervention group (39 versus 53 minutes; P=0.03), median door-to-imaging and door-to-needle times were not different between groups (P=0.70 and P=0.40, respectively). CONCLUSIONS An interactive and multifaceted training program targeting emergency professionals was significantly associated with an increased access to thrombolysis, especially within 4 hours and 30 minutes. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02814760.
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Affiliation(s)
- Julie Haesebaert
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France.
| | - Norbert Nighoghossian
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
| | - Catherine Mercier
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
| | - Anne Termoz
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
| | - Sylvie Porthault
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
| | - Laurent Derex
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
| | - Pierre-Yves Gueugniaud
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
| | - Estelle Bravant
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
| | - Muriel Rabilloud
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
| | - Anne-Marie Schott
- From the EA7425, Laboratoire HeSPeR, Lyon, France (J.H., A.T., E.B., A.-M.S.) and CNRS, UMR 5558, LBBE, Equipe Biostatistique-Santé (C.M., M.R.) Université Lyon 1, Villeurbanne, France; Pôle IMER (J.H., A.T., E.B., A.-M.S.), Stroke Center, Hôpital Pierre Wertheimer (N.N., L.D.), Service de Biostatistique et Bioinformatique (C.M., M.R.), and PAM Urgences Réanimation Médicales, Hôpital Edouard Herriot (S.P., P.-Y.G.), Hospices Civils de Lyon, France
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Induced Pluripotent Stem Cell-Derived Neural Stem Cell Therapy Enhances Recovery in an Ischemic Stroke Pig Model. Sci Rep 2017; 7:10075. [PMID: 28855627 PMCID: PMC5577218 DOI: 10.1038/s41598-017-10406-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/07/2017] [Indexed: 12/17/2022] Open
Abstract
Induced pluripotent stem cell-derived neural stem cells (iNSCs) have significant potential as an autologous, multifunctional cell therapy for stroke, which is the primary cause of long term disability in the United States and the second leading cause of death worldwide. Here we show that iNSC transplantation improves recovery through neuroprotective, regenerative, and cell replacement mechanisms in a novel ischemic pig stroke model. Longitudinal multiparametric magnetic resonance imaging (MRI) following iNSC therapy demonstrated reduced changes in white matter integrity, cerebral blood perfusion, and brain metabolism in the infarcted tissue. The observed tissue level recovery strongly correlated with decreased immune response, enhanced neuronal protection, and increased neurogenesis. iNSCs differentiated into neurons and oligodendrocytes with indication of long term integration. The robust recovery response to iNSC therapy in a translational pig stroke model with increased predictive potential strongly supports that iNSCs may be the critically needed therapeutic for human stroke patients.
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Zakaria MF, Aref H, Abd ElNasser A, Fahmy N, Tork MA, Fouad MM, ElBokl A, Roushdy T, ElFaramawy S, El-Shiekh MA, Moustafa RR. Egyptian experience in increasing utilization of reperfusion therapies in acute ischemic stroke. Int J Stroke 2017; 13:525-529. [PMID: 28585904 DOI: 10.1177/1747493017711949] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The rate of alteplase (tPA) thrombolysis utilization in acute stroke in Egypt is <1%. We report on the causes of this low rate of reperfusion therapies and take corrective action to improve it. Methods Two prospective observational studies were conducted at Ain Shams University hospitals. The first included 269 acute stroke patients admitted to the hospital over a six-month period. Obstacles to reperfusion therapy were identified, and based on the results, a corrective action plan was implemented including making alteplase(tPA) available, training, and establishing a standardized local protocol for reperfusion therapy. A second study was then conducted that included 284 acute ischemic stroke patients over another six-month period. Results In the first study, 53/269 patients (19.7%) arrived at hospital within 4.5 h and were eligible for reperfusion therapy. Of those, seven (13.2%) received alteplase(tPA), representing 2.6% of the total ischemic stroke patients admitted. The main causes for not giving thrombolytic therapy was unavailability of alteplase(tPA) (56.5%), wrong treatment decision (17.4%), missed window while performing brain imaging (15%), and unavailability of intermediate care bed (10.9%). The second study showed that out of 284 cases admitted with acute ischemic stroke, 37 were eligible for thrombolysis and 35 received alteplase(tPA) (94.3%), representing 12.3% of the total ischemic stroke admissions. Conclusion A comprehensive action plan that centers around making the drug available and training resulted in a significant improvement of reperfusion therapy utilization in Egypt.
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Affiliation(s)
- Magd Fouad Zakaria
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hany Aref
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Azza Abd ElNasser
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nagia Fahmy
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Amir Tork
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Ahmed ElBokl
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Tamer Roushdy
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sara ElFaramawy
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Ramez Reda Moustafa
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Savadi Oskouie D, Sharifipour E, Sadeghi Bazargani H, Hashemilar M, Nikanfar M, Ghazanfari Amlashi S, Abbaszade Z, Sadeghihokmabadi E, Rikhtegar R, Golzari SEJ. Efficacy of Citalopram on Acute Ischemic Stroke Outcome: A Randomized Clinical Trial. Neurorehabil Neural Repair 2017; 31:638-647. [PMID: 28454498 DOI: 10.1177/1545968317704902] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke (IS) is one of the main causes of death and disability in the adult population, and recovery from it is a major health concern worldwide. The aim of the present study was to evaluate the effectiveness of citalopram on 3-mounth outcome of nondepressed acute IS patients. METHODS In a randomized, placebo-controlled clinical trial, 144 patients with acute IS were studied for 3 months. In one group, the patients received oral citalopram 20 mg (once daily), and in the other group, they received placebo. All patients received standard care, including physiotherapy. Patients with depression were excluded throughout the study. The primary outcome of the study was set to a 50% reduction in the 3-month National Institutes of Health Stroke Scale compared with the baseline scores (Clinical Trial Registration URL: http://www.irct.ir ; Unique identifier: IRCT201203192150N2). RESULTS The mean age of patients was 66.4 years. Of 144 eligible patients, 15 patients died (4 in the citalopram and 11 in the placebo group), and 21 patients did not complete the study follow-up period (10 in the citalopram and 11 in the placebo group). The primary outcome of the study was achieved in 57 patients (79%) in the citalopram and 39 patients (54%) in the placebo group ( P < .001), with risk ratio and number needed to treat of 2 (CI = 1.2-3) and 4 (CI = 2.5-8.6), respectively. No major adverse events were found in either group. CONCLUSIONS Citalopram is a safe and tolerable medication in patients with acute IS, which could improve the outcome in these patients.
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Affiliation(s)
| | | | | | - Mazyar Hashemilar
- 1 Tabriz University of Medical Sciences, Razi Hospital, Tabriz, Iran
| | - Masoud Nikanfar
- 1 Tabriz University of Medical Sciences, Razi Hospital, Tabriz, Iran
| | | | - Zahra Abbaszade
- 1 Tabriz University of Medical Sciences, Razi Hospital, Tabriz, Iran
| | | | - Reza Rikhtegar
- 1 Tabriz University of Medical Sciences, Razi Hospital, Tabriz, Iran
| | - Samad E J Golzari
- 1 Tabriz University of Medical Sciences, Razi Hospital, Tabriz, Iran
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Craig LE, McInnes E, Taylor N, Grimley R, Cadilhac DA, Considine J, Middleton S. Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF). Implement Sci 2016; 11:157. [PMID: 27894313 PMCID: PMC5126852 DOI: 10.1186/s13012-016-0524-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background Clinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED. Methods Studies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy. Results Five qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of “environmental, context and resources” (such as stressful working conditions or lack of resources) and “knowledge” (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of “knowledge” (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and “skills” (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were “focus on past success” and “information about health consequences.” Conclusions Barriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.
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Affiliation(s)
- Louise E Craig
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia.
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia
| | - Natalie Taylor
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Rohan Grimley
- Sunshine Coast Hospital and Health Service/Sunshine Coast Clinical School, The University of Queensland, Nambour, QLD, Australia
| | - Dominique A Cadilhac
- Translational Public Health and Evaluation Division, Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Public Health: Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Julie Considine
- Deakin University, Geelong, VIC, Australia.,Eastern Health - Deakin University Nursing and Midwifery Research Centre, Box Hill, VIC, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia
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Broughton EI, Marquez L. Why Economic Analysis of Health System Improvement Interventions Matters. Front Public Health 2016; 4:218. [PMID: 27781204 PMCID: PMC5058346 DOI: 10.3389/fpubh.2016.00218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 09/21/2016] [Indexed: 11/22/2022] Open
Abstract
There is little evidence to direct health systems toward providing efficient interventions to address medical errors, defined as an unintended act of omission or commission or one not executed as intended that may or may not cause harm to the patient but does not achieve its intended outcome. We believe that lack of guidance on what is the most efficient way to reduce medical errors and improve the quality of health-care limits the scale-up of health system improvement interventions. Challenges to economic evaluation of these interventions include defining and implementing improvement interventions in different settings with high fidelity, capturing all of the positive and negative effects of the intervention, using process measures of effectiveness rather than health outcomes, and determining the full cost of the intervention and all economic consequences of its effects. However, health system improvement interventions should be treated similarly to individual medical interventions and undergo rigorous economic evaluation to provide actionable evidence to guide policy-makers in decisions of resource allocation for improvement activities among other competing demands for health-care resources.
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Affiliation(s)
- Edward Ivor Broughton
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co., LLC, Bethesda, MD, USA
| | - Lani Marquez
- USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co., LLC , Bethesda, MD , USA
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