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Masouris I, Kellert L, Pradhan C, Wischmann J, Schniepp R, Müller R, Fuhry L, Hamann GF, Pfefferkorn T, Rémi JM, Schöberl F. Telemedical stroke care significantly improves patient outcome in rural areas: Long-term analysis of the German NEVAS network. Int J Stroke 2024; 19:577-586. [PMID: 38346936 PMCID: PMC11134988 DOI: 10.1177/17474930241234259] [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: 11/20/2023] [Accepted: 02/02/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described. AIMS This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network. METHODS In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters. RESULTS In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%. CONCLUSIONS 24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Cauchy Pradhan
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Roman Schniepp
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Robert Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - Leonard Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | | | - Jan M Rémi
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Schöberl
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
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Wang P, Zhang Q, Li GP, Xu N, Wang Z, Zhao YH, Zou YY, Liu YF, Wang LM. Effectiveness of a Teach-Back Education Program on Perioperative Pain in Patients With Lung Cancer: An Intervention Study Using Behavior Change Wheel. Pain Manag Nurs 2024:S1524-9042(24)00109-7. [PMID: 38609805 DOI: 10.1016/j.pmn.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE To assess the effect of a teach-back educational intervention using Behavior Change Wheel (BCW) framework on perioperative pain among patients with lung cancer. METHODS A prospective quasi-experimental study was conducted in 88 patients with lung cancer from a tertiary hospital in China. According to the order of admission, they were allocated to either control group or intervention group, with 44 patients in each group. Patients in the control group received routine nursing care, while patients in the intervention group were given a teach-back education program based on BCW framework. The visual analog scale (VAS) was adopted to evaluate patients' pain on the day of surgery (T0), 1 (T1), 2 (T2), and 3 (T3) days after surgery. We also recorded the use of patient-controlled analgesia (PCA), the length of hospital stay, and the degree of patients' satisfaction. RESULTS Rest pain, pain when coughing, and pain during activity that patients in the intervention group experienced were significantly less severe than those in the control group on T0 and T1. The pain when coughing in the intervention group was also significantly milder on T2 and T3. In addition, the number of self-control time, use duration, and total dose of PCA were significantly lower in the intervention group. Moreover, patients' satisfaction of nursing service was significantly higher in the intervention group. CONCLUSION A teach-back education program based on BCW framework was effective in pain management among the perioperative patients with lung cancer. This study demonstrates the application of teach-back method and the BCW in the development of patient education intervention to mitigate perioperative pain.
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Affiliation(s)
- Peng Wang
- Department of International Medical Care, Peking Union Medical College Hospital, Beijing, China
| | - Qian Zhang
- Department of International Medical Care, Peking Union Medical College Hospital, Beijing, China
| | - Gui-Ping Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Ning Xu
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zhuo Wang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yan-Hong Zhao
- Department of International Medical Care, Peking Union Medical College Hospital, Beijing, China
| | - Yi-Yan Zou
- Department of International Medical Care, Peking Union Medical College Hospital, Beijing, China
| | - Yuan-Fei Liu
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Li-Mei Wang
- Department of International Medical Care, Peking Union Medical College Hospital, Beijing, China.
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Hwong WY, Ng SW, Tong SF, Ab Rahman N, Law WC, Kaman Z, Wong SK, Puvanarajah SD, Sivasampu S. Stroke thrombolysis in a middle-income country: A case study exploring the determinants of its implementation. Front Neurol 2022; 13:1048807. [PMID: 36504666 PMCID: PMC9729841 DOI: 10.3389/fneur.2022.1048807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Translation of evidence into clinical practice for use of intravenous thrombolysis in acute stroke care has been slow, especially across low- and middle-income countries. In Malaysia where the average national uptake was poor among the public hospitals in 2018, one hospital intriguingly showed comparable thrombolysis rates to high-income countries. This study aimed to explore and provide in-depth understanding of factors and explanations for the high rates of intravenous stroke thrombolysis in this hospital. Methods This single case study sourced data using a multimethod approach: (1) semi-structured in-depth interviews and focus group discussions, (2) surveys, and (3) review of medical records. The Tailored Implementation of Chronic Diseases (TICD) framework was used as a guide to understand the determinants of implementation. Twenty-nine participants comprising the Hospital Director, neurologists, emergency physicians, radiologists, pharmacists, nurses and medical assistants (MAs) were included. Thematic analyses were conducted inductively before triangulated with quantitative analyses and document reviews. Results Favorable factors contributing to the uptake included: (1) cohesiveness of team members which comprised of positive interprofessional team dynamics, shared personal beliefs and values, and passionate leadership, and (2) facilitative work process through simplification of workflow and understanding the rationale of the sense of urgency. Patient factors was a limiting factor. Almost two third of ischemic stroke patients arrived at the hospital outside the therapeutic window time, attributing patients' delayed presentation as a main barrier to the uptake of intravenous stroke thrombolysis. One other barrier was the availability of resources, although this was innovatively optimized to minimize its impact on the uptake of the therapy. As such, potential in-hospital delays accounted for only 3.8% of patients who missed the opportunity to receive thrombolysis. Conclusions Despite the ongoing challenges, the success in implementing intravenous stroke thrombolysis as standard of care was attributed to the cohesiveness of team members and having facilitative work processes. For countries of similar settings, plans to improve the uptake of intravenous stroke thrombolysis should consider the inclusion of interventions targeting on these modifiable factors.
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Affiliation(s)
- Wen Yea Hwong
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Selangor, Malaysia,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands,*Correspondence: Wen Yea Hwong ;
| | - Sock Wen Ng
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Selangor, Malaysia
| | - Seng Fah Tong
- Department of Family Medicine, Universiti Kebangsaan Malaysia, Selangor, Malaysia
| | - Norazida Ab Rahman
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Selangor, Malaysia
| | - Wan Chung Law
- Neurology Unit, Department of Medicine, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
| | - Zurainah Kaman
- Neurology Unit, Department of Medicine, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
| | - Sing Keat Wong
- Department of Neurology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Santhi Datuk Puvanarajah
- Department of Neurology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Sheamini Sivasampu
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Selangor, Malaysia
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Sapra H. "No Time to Die" - Saving the Neurons. Indian J Crit Care Med 2022; 26:539-540. [PMID: 35719449 PMCID: PMC9160637 DOI: 10.5005/jp-journals-10071-24221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
How to cite this article: Sapra H. "No Time to Die" - Saving the Neurons. Indian J Crit Care Med 2022;26(5):539-540.
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Affiliation(s)
- Harsh Sapra
- Department of Neurocritical Care, Medanta–The Medicity, Gurugram, Haryana, India,Harsh Sapra, Department of Neurocritical Care, Medanta–The Medicity, Gurugram, Haryana, India, Phone: +91 9650898677, e-mail:
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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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Wang L, Fan X, Chen Y, Liang X, Shen W, Zhang Y. Efficacy and Safety of Xingnaojing Injection for Emergency Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:839305. [PMID: 35401232 PMCID: PMC8987164 DOI: 10.3389/fphar.2022.839305] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/21/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Xingnaojing injection (XNJ) is derived from a traditional Chinese prescription named Angong Niuhuang pill. As an adjuvant treatment widely used in acute ischemic stroke (AIS), XNJ has proven to be effective with certain clinical evidence. The aim of this study is to collect the latest evidence and evaluate efficacy and safety of XNJ for emergency treatment of AIS. Methods: We searched seven literature databases and two clinical trial registries from their inception to November 14, 2021 for randomized controlled trials (RCTs) examining the efficacy of XNJ for AIS. Two reviewers independently selected relevant trials, extracted data, and assessed the risk of bias. We pooled data into a meta-analysis using RevMan 5.4 software. Results: Thirty-eight RCTs were included in this review, with a total of 3,677 participants. XNJ plus conventional treatments (CTs) showed a significant advantage, compared with CTs alone, in improving functional independence at 14 days (RR = 1.70, 95% CI = 1.03 to 2.81, p = 0.04), neurological function (MDNIHSS < 6h = −3.81, 95% CI = −5.25 to −2.38, p < 0.00001; MDNIHSS < 24h = −3.75, 95% CI = −4.92 to −2.59, p < 0.00001; MDNIHSS < 72h = −3.74, 95% CI = −5.48 to −2.00, p < 0.0001; MDNIHSS < 14d = −1.97, 95% CI = −3.25 to −0.69, p = 0.003), and activities of daily living on the Barthel index (MDBI-14day = 9.97, 95% CI = 9.29 to 10.65, p < 0.00001; MDBI-30day = 10.04, 95% CI = 5.82, to 14.26, p < 0.00001). In addition, the results showed that XNJ plus CTs was superior to CTs alone in reducing IL-6, TNF-α, hs-CRP, and MMP-9. Regarding safety of XNJ, the incidence of adverse reactions in the XNJ group was lower than that in the control group (RR = 0.57, 95% CI = 0.38 to 0.87, p = 0.009). The certainty of evidence was evaluated as low or very low for all. Conclusion: XNJ appears to be effective and safe for emergency treatment of AIS. The first 72 h after the onset of stroke, in particular the first 6 hours, may be the optimum initiation time. However, further high-quality RCTs are warranted to determine an appropriate initiation time. Systematic Review Registration: [https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=233211], identifier [CRD42021233211].
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Affiliation(s)
| | | | | | | | - Wei Shen
- *Correspondence: Wei Shen, ; Yunling Zhang,
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Affiliation(s)
- Linda S Williams
- VA HSR&D EXTEND QUERI, Indianapolis, IN (L.S.W.).,Indiana University School of Medicine, Indianapolis, IN (L.S.W.).,Regenstrief Institute, Inc, Indianapolis, IN (L.S.W.)
| | - Barbara G Vickrey
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (B.G.V.)
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