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Lee EJ, Kim DJ, Kang DW, Yang W, Jeong HY, Kim JM, Ko SB, Lee SH, Yoon BW, Cho JY, Jung KH. Targeted Metabolomic Biomarkers for Stroke Subtyping. Transl Stroke Res 2024; 15:422-432. [PMID: 36764997 DOI: 10.1007/s12975-023-01137-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/11/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke is a heterogeneous disease with various etiologies. The current subtyping process is complicated, time-consuming, and costly. Metabolite-based biomarkers have the potential to improve classification and deliver optimal treatments. We here aimed to identify novel, targeted metabolomics-based biomarkers to discriminate between large-artery atherosclerosis (LAA) and cardioembolic (CE) stroke. METHODS We acquired serum samples and clinical data from a hospital-based acute stroke registry (ischemic stroke within 3 days from symptom onset). We included 346 participants (169 LAA, 147 CE, and 30 healthy older adults) and divided them into training and test sets. Targeted metabolomic analysis was performed using quantitative and quality-controlled liquid chromatography with tandem mass spectrometry. A multivariate regression model using metabolomic signatures was created that could independently distinguish between LAA and CE strokes. RESULTS The training set (n = 193) identified metabolomic signatures that were different in patients with LAA and CE strokes. Six metabolomic biomarkers, i.e., lysine, serine, threonine, kynurenine, putrescine, and lysophosphatidylcholine acyl C16:0, could discriminate between LAA and CE stroke after adjusting for sex, age, body mass index, stroke severity, and comorbidities. The enhanced diagnostic power of key metabolite combinations for discriminating between LAA and CE stroke was validated using the test set (n = 123). CONCLUSIONS We observed significant differences in metabolite profiles in LAA and CE strokes. Targeted metabolomics may provide enhanced diagnostic yield for stroke subtypes. The pathophysiological pathways of the identified metabolites should be explored in future studies.
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Affiliation(s)
- Eung-Joon Lee
- Department of Neurology, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Da Jung Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
- Metabolomics Core Facility, Department of Transdisciplinary Research and Collaboration, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong-Wan Kang
- Department of Neurology, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Wookjin Yang
- Department of Neurology, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Han-Yeong Jeong
- Department of Neurology, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Jeong-Min Kim
- Department of Neurology, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Seung-Hoon Lee
- Department of Neurology, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Byung-Woo Yoon
- Department of Neurology, Uijeongbu Eulji Medical Center, Uijeongbu-si, Republic of Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea.
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea.
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea.
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2
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Silva GS, Rocha E. Developing Systems of Care for Stroke in Resource-limited Settings. Semin Neurol 2024; 44:119-129. [PMID: 38513704 DOI: 10.1055/s-0044-1782617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.
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Affiliation(s)
- Gisele Sampaio Silva
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Neurology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eva Rocha
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
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3
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Burton E, Quinn R, Crosbie-Staunton K, Deasy C, Masterson S, O'Donnell C, Merwick Á, Willis D, Kearney PM, Mc Carthy VJC, Buckley CM. Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study. BMJ Open 2024; 14:e078168. [PMID: 38508613 PMCID: PMC10961584 DOI: 10.1136/bmjopen-2023-078168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021. DESIGN We conducted a secondary data analysis with a quasi-experimental design. SETTING We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'. PRIMARY AND SECONDARY OUTCOME MEASURES We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis. PARTICIPANTS We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021. RESULTS 40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001). CONCLUSIONS A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.
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Affiliation(s)
- Edel Burton
- School of Public Health, University College Cork, Cork, Ireland
| | - Rory Quinn
- National Ambulance Service, Health Service Executive, Dublin, Ireland
| | | | - Conor Deasy
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Siobhan Masterson
- National Ambulance Service, Health Service Executive, Dublin, Ireland
- College of Medicine and Health, University College Cork, Cork, Ireland
- Discipline of General Practice, University of Galway, Galway, Ireland
| | - Cathal O'Donnell
- National Ambulance Service, Health Service Executive, Dublin, Ireland
| | - Áine Merwick
- Neurology Department, Cork University Hospital, Cork, Ireland
| | - David Willis
- National Ambulance Service, Health Service Executive, Dublin, Ireland
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4
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Dixon M, Appleton JP, Siriwardena AN, Williams J, Bath PM. A systematic review of ambulance service-based randomised controlled trials in stroke. Neurol Sci 2023; 44:4363-4378. [PMID: 37405524 PMCID: PMC10641071 DOI: 10.1007/s10072-023-06910-w] [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: 01/02/2023] [Accepted: 06/12/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Treatment for stroke is time-dependent, and ambulance services play a vital role in the early recognition, assessment and transportation of stroke patients. Innovations which begin in ambulance services to expedite delivery of treatments for stroke are developing. However, research delivery in ambulance services is novel, developing and not fully understood. AIMS To synthesise literature encompassing ambulance service-based randomised controlled interventions for acute stroke with consideration to the characteristics of the type of intervention, consent modality, time intervals and issues unique to research delivery in ambulance services. Online searches of MEDLINE, EMBASE, Web of Science, CENTRAL and WHO IRCTP databases and hand searches identified 15 eligible studies from 538. Articles were heterogeneous in nature and meta-analysis was partially available as 13 studies reported key time intervals, but terminology varied. Randomised interventions were evident across all points of contact with ambulance services: identification of stroke during the call for help, higher dispatch priority assigned to stroke, on-scene assessment and clinical interventions, direct referral to comprehensive stroke centres and definitive care delivery at scene. Consent methods ranged between informed patient, waiver and proxy modalities with country-specific variation. Challenges unique to the prehospital setting comprise the geographical distribution of ambulance resources, low recruitment rates, prolonged recruitment phases, management of investigational medicinal product and incomplete datasets. CONCLUSION Research opportunities exist across all points of contact between stroke patients and ambulance services, but randomisation and consent remain novel. Early collaboration and engagement between trialists and ambulance services will alleviate some of the complexities reported. REGISTRATION NUMBER PROSPERO 2018CRD42018075803.
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Affiliation(s)
- Mark Dixon
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Julia Williams
- Department of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK.
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.
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5
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Han X, Qin Y, Mei C, Jiao F, Khademolqorani S, Nooshin Banitaba S. Current trends and future perspectives of stroke management through integrating health care team and nanodrug delivery strategy. Front Cell Neurosci 2023; 17:1266660. [PMID: 38034591 PMCID: PMC10685387 DOI: 10.3389/fncel.2023.1266660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/25/2023] [Indexed: 12/02/2023] Open
Abstract
Stroke is accounted as the second-most mortality and adult disability factor in worldwide, while causes the bleeding promptly and lifetime consequences. The employed functional recovery after stroke is highly variable, allowing to deliver proper interventions to the right stroke patient at a specific time. Accordingly, the multidisciplinary nursing team, and the administrated drugs are major key-building-blocks to enhance stroke treatment efficiency. Regarding the healthcare team, adequate continuum of care have been declared as an integral part of the treatment process from the pre-hospital, in-hospital, to acute post-discharge phases. As a curative perspective, drugs administration is also vital in surviving at the early step and reducing the probability of disabilities in later. In this regard, nanotechnology-based medicinal strategy is exorbitantly burgeoning. In this review, we have highlighted the effectiveness of current clinical care considered by nursing teams to treat stroke. Also, the advancement of drugs through synthesis of miniaturized nanodrug formations relating stroke treatment is remarked. Finally, the remained challenges toward standardizing the healthcare team and minimizing the nanodrugs downsides are discussed. The findings ensure that future works on normalizing the healthcare nursing teams integrated with artificial intelligence technology, as well as advancing the operative nanodrugs can provide value-based stroke cares.
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Affiliation(s)
- Xuelu Han
- Nursing Clinic, Affiliated Hospital of Jilin Medical University, Jilin, China
| | - Yingxin Qin
- Department of Nursing, Affiliated Hospital of Jilin Medical University, Jilin, China
| | - Chunli Mei
- Nursing College, Beihua University, Jilin, China
| | - Feitong Jiao
- Nursing Training Center, School of Nursing, Jilin Medical University, Jilin, China
| | - Sanaz Khademolqorani
- Department of Textile Engineering, Isfahan University of Technology, Isfahan, Iran
- Emerald Experts Laboratory, Isfahan Science and Technology Town, Isfahan, Iran
| | - Seyedeh Nooshin Banitaba
- Emerald Experts Laboratory, Isfahan Science and Technology Town, Isfahan, Iran
- Department of Textile Engineering, Amirkabir University of Technology, Tehran, Iran
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6
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Kowark A, Felzen M, Ziemann S, Wied S, Czaplik M, Beckers SK, Brokmann JC, Hilgers RD, Rossaint R. Telemedical support for prehospital emergency medical service in severe emergencies: an open-label randomised non-inferiority clinical trial. Crit Care 2023; 27:256. [PMID: 37391836 PMCID: PMC10311733 DOI: 10.1186/s13054-023-04545-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND A tele-emergency medical service with a remote emergency physician for severe prehospital emergencies may overcome the increasing number of emergency calls and shortage of emergency medical service providers. We analysed whether routine use of a tele-emergency medical service is non-inferior to a conventional physician-based one in the occurrence of intervention-related adverse events. METHODS This open-label, randomised, controlled, parallel-group, non-inferiority trial included all routine severe emergency patients aged ≥ 18 years within the ground-based ambulance service of Aachen, Germany. Patients were randomised in a 1:1 allocation ratio to receive either tele-emergency medical service (n = 1764) or conventional physician-based emergency medical service (n = 1767). The primary outcome was the occurrence of intervention-related adverse events with suspected causality to the group assignment. The trial was registered with ClinicalTrials.gov (NCT02617875) on 30 November 2015 and is reported in accordance with the CONSORT statement for non-inferiority trials. RESULTS Among 3531 randomised patients, 3220 were included in the primary analysis (mean age, 61.3 years; 53.8% female); 1676 were randomised to the conventional physician-based emergency medical service (control) group and 1544 to the tele-emergency medical service group. A physician was not deemed necessary in 108 of 1676 cases (6.4%) and 893 of 1544 cases (57.8%) in the control and tele-emergency medical service groups, respectively. The primary endpoint occurred only once in the tele-emergency medical service group. The Newcombe hybrid score method confirmed the non-inferiority of the tele-emergency medical service, as the non-inferiority margin of - 0.015 was not covered by the 97.5% confidence interval of - 0.0046 to 0.0025. CONCLUSIONS Among severe emergency cases, tele-emergency medical service was non-inferior to conventional physician-based emergency medical service in terms of the occurrence of adverse events.
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Affiliation(s)
- Ana Kowark
- Department of Anaesthesiology, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Marc Felzen
- Department of Anaesthesiology, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | - Sebastian Ziemann
- Department of Anaesthesiology, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | - Stephanie Wied
- Department of Medical Statistics, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Czaplik
- Department of Anaesthesiology, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | - Stefan K Beckers
- Department of Anaesthesiology, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | - Jörg C Brokmann
- Emergency Department, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | - Ralf-Dieter Hilgers
- Department of Medical Statistics, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany.
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7
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Budinčević H, Meštrović A, Demarin V. Stroke Scales as Assessment Tools in Emergency Settings: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1541. [PMID: 36363498 PMCID: PMC9696547 DOI: 10.3390/medicina58111541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/15/2022] [Accepted: 10/21/2022] [Indexed: 10/14/2023]
Abstract
In the last 20 years, substantial improvements have been made in stroke recanalization treatment. Good outcomes after modern reperfusion treatment require the rapid and accurate identification of stroke patients. Several stroke rating scales are available or have been proposed for the early recognition of stroke and the evaluation of stroke severity and outcome. This review aims to provide an overview of commonly used stroke scales in emergency and clinical settings. The most commonly used scale in a prehospital setting for stroke recognition is the Face, Arms, Speech, Time (FAST) test. Among many prehospital stroke scales, the Los Angeles Prehospital Stroke Screen has the highest sensitivity and specificity for confirming stroke diagnosis. The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for the evaluation of stroke patients in hospital settings and research, and it has two variants: the shortened NIHSS for Emergency Medical Service and the modified NIHSS. The evaluation of comatose patients usually involves assessment with the Glasgow Coma Scale, which is very useful in patients with hemorrhagic stroke or traumatic brain injury. In patients with subarachnoid hemorrhage, the outcome is usually accessed with the Hunt and Hess scale. A commonly used tool for stroke outcome evaluation in clinical/hospital settings and research is the modified Rankin scale. The tools for disability evaluation are the Barthel Index and Functional Independence Measure.
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Affiliation(s)
- Hrvoje Budinčević
- Department of Neurology, Sveti Duh University Hospital, 10000 Zagreb, Croatia
- Department of Neurology and Neurosurgery, Faculty of Medicine, J.J. Strossmayer University of Osijek, 31000 Osijek, Croatia
| | - Andrija Meštrović
- Department of Neurology, Sveti Duh University Hospital, 10000 Zagreb, Croatia
| | - Vida Demarin
- International Institute for Brain Health, 10000 Zagreb, Croatia
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8
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Ghozy S, Reda A, Varney J, Elhawary AS, Shah J, Murry K, Sobeeh MG, Nayak SS, Azzam AY, Brinjikji W, Kadirvel R, Kallmes DF. Neuroprotection in Acute Ischemic Stroke: A Battle Against the Biology of Nature. Front Neurol 2022; 13:870141. [PMID: 35711268 PMCID: PMC9195142 DOI: 10.3389/fneur.2022.870141] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/21/2022] [Indexed: 12/22/2022] Open
Abstract
Stroke is the second most common cause of global death following coronary artery disease. Time is crucial in managing stroke to reduce the rapidly progressing insult of the ischemic penumbra and the serious neurologic deficits that might follow it. Strokes are mainly either hemorrhagic or ischemic, with ischemic being the most common of all types of strokes. Thrombolytic therapy with recombinant tissue plasminogen activator and endovascular thrombectomy are the main types of management of acute ischemic stroke (AIS). In addition, there is a vital need for neuroprotection in the setting of AIS. Neuroprotective agents are important to investigate as they may reduce mortality, lessen disability, and improve quality of life after AIS. In our review, we will discuss the main types of management and the different modalities of neuroprotection, their mechanisms of action, and evidence of their effectiveness after ischemic stroke.
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Affiliation(s)
- Sherief Ghozy
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, United States.,Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC Program), Oxford University, Oxford, United Kingdom
| | - Abdullah Reda
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Joseph Varney
- School of Medicine, American University of the Caribbean, Philipsburg, Sint Maarten
| | | | - Jaffer Shah
- Medical Research Center, Kateb University, Kabul, Afghanistan
| | | | - Mohamed Gomaa Sobeeh
- Faculty of Physical Therapy, Sinai University, Cairo, Egypt.,Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Sandeep S Nayak
- Department of Internal Medicine, NYC Health + Hospitals/Metropolitan, New York, NY, United States
| | - Ahmed Y Azzam
- Faculty of Medicine, October 6 University, Giza, Egypt
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic Rochester, Rochester, MN, United States
| | | | - David F Kallmes
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, United States
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9
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Turc G, Hadziahmetovic M, Walter S, Churilov L, Larsen K, Grotta JC, Yamal JM, Bowry R, Katsanos AH, Zhao H, Donnan G, Davis SM, Hussain MS, Uchino K, Helwig SA, Johns H, Weber JE, Nolte CH, Kunz A, Steiner T, Sacco S, Ebinger M, Tsivgoulis G, Faßbender K, Audebert HJ. Comparison of Mobile Stroke Unit With Usual Care for Acute Ischemic Stroke Management: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:281-290. [PMID: 35129584 PMCID: PMC8822443 DOI: 10.1001/jamaneurol.2021.5321] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography scanner, point-of-care laboratory, and neurological expertise) use leads to better functional outcomes compared with usual care. OBJECTIVE To determine with a systematic review and meta-analysis of the literature whether MSU use is associated with better functional outcomes in patients with acute ischemic stroke (AIS). DATA SOURCES MEDLINE, Cochrane Library, and Embase from 1960 to 2021. STUDY SELECTION Studies comparing MSU deployment and usual care for patients with suspected stroke were eligible for analysis, excluding case series and case-control studies. DATA EXTRACTION AND SYNTHESIS Independent data extraction by 2 observers, following the PRISMA and MOOSE reporting guidelines. The risk of bias in each study was determined using the ROBINS-I and RoB2 tools. In the case of articles with partially overlapping study populations, unpublished disentangled results were obtained. Data were pooled in random-effects meta-analyses. MAIN OUTCOMES AND MEASURES The primary outcome was excellent outcome as measured with the modified Rankin Scale (mRS; score of 0 to 1 at 90 days). RESULTS Compared with usual care, MSU use was associated with excellent outcome (adjusted odds ratio [OR], 1.64; 95% CI, 1.27-2.13; P < .001; 5 studies; n = 3228), reduced disability over the full range of the mRS (adjusted common OR, 1.39; 95% CI, 1.14-1.70; P = .001; 3 studies; n = 1563), good outcome (mRS score of 0 to 2: crude OR, 1.25; 95% CI, 1.09-1.44; P = .001; 6 studies; n = 3266), shorter onset-to-intravenous thrombolysis (IVT) times (median reduction, 31 minutes [95% CI, 23-39]; P < .001; 13 studies; n = 3322), delivery of IVT (crude OR, 1.83; 95% CI, 1.58-2.12; P < .001; 7 studies; n = 4790), and IVT within 60 minutes of symptom onset (crude OR, 7.71; 95% CI, 4.17-14.25; P < .001; 8 studies; n = 3351). MSU use was not associated with an increased risk of all-cause mortality at 7 days or at 90 days or with higher proportions of symptomatic intracranial hemorrhage after IVT. CONCLUSIONS AND RELEVANCE Compared with usual care, MSU use was associated with an approximately 65% increase in the odds of excellent outcome and a 30-minute reduction in onset-to-IVT times, without safety concerns. These results should help guideline writing committees and policy makers.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France,Université de Paris, Paris, France,INSERM U1266, Paris, France,FHU Neurovasc, Paris, France
| | | | - Silke Walter
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Leonid Churilov
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - James C. Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital–Texas Medical Center, Houston
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, School of Public Health, Houston
| | - Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University Population Health Research Institute, Hamilton, Ontario, Canada,Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Geoffrey Donnan
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Stephen M. Davis
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Muhammad S. Hussain
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Hannah Johns
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Joachim E. Weber
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
| | - Alexander Kunz
- Klinik für Neurologie, Neurologische Intensivmedizin, Zentrum für Hirngefäßerkrankungen, Asklepios Fachklinikum Brandenburg, Brandenburg, Germany
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Martin Ebinger
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany,Klinik für Neurologie Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Klaus Faßbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
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10
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Ebinger M, Audebert HJ. Shifting acute stroke management to the prehospital setting. Curr Opin Neurol 2022; 35:4-9. [PMID: 34799513 DOI: 10.1097/wco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The earlier the treatment, the better the outcomes after acute ischemic stroke. Optimizing prehospital care bears potential to shorten treatment times. We here review the recent literature on mothership vs. drip-and-ship as well as mobile stroke unit concepts. RECENT FINDINGS Mobile stroke units result in the shortest onset-to-treatment times in mostly urban settings. SUMMARY Future research should focus on further streamlining processes around mobile stroke units, especially improving dispatch algorithms and improve referral for endovascular therapy.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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11
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Osuegbu OI, Adeniji FO, Owhonda GC, Kanee RB, Aigbogun EO. Exploring the Essential Stroke Care Structures in Tertiary Healthcare Facilities in Rivers State, Nigeria. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580211067939. [PMID: 35049398 PMCID: PMC8785286 DOI: 10.1177/00469580211067939] [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] [Indexed: 11/15/2022]
Abstract
This study evaluated the essential stroke care structure available in the two Tertiary Health Facilities in Rives State, Nigeria. This was a descriptive survey involving the Stroke Care Survey and Assessment Tool (checklist/questionnaire) developed by the World Stroke Organisation to obtain information about the available essential stroke care structure (facilities, equipment, personnel and management protocol) at the two tertiary health facilities (RSUTH & UPTH). The study gathered relevant information, which was summarised into tables and graphs using Microsoft Excel 2016. From the results, although facilities had A and E departments, dedicated stroke units (fixed or mobile) were unavailable, and there was no locally developed protocol to support rapid triage of stroke patients. The facilities and equipment were either unavailable or insufficient. Only one health facility (RSUTH) provided 24 hrs/7 days laboratory services. The workforces were a mix between regular clinical staff and some specialists. Tissue plasminogen activator (tPA) use was non-existent, though specialists were trained on its administration. There was no locally developed or adopted stroke-specific clinical guidelines. In conclusion, the structural services available for stroke care within the studied tertiary health facilities were poor, unavailable or grossly insufficient. The state facility (RSUTH) suffered the most in terms of unavailable national support and staff development.
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Affiliation(s)
- Osborne Ikechuckwu Osuegbu
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | - Foluke Olukemi Adeniji
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | | | - Rogers Bariture Kanee
- Institute of Geo-Science and Space Technology, 108005Rivers State University, Oroworukwo, Nigeria
| | - Eric Osamudiamwen Aigbogun
- Department of Public Health, Faculty of Sciences and Technology, 248428Cavendish University Uganda, Kampala, Uganda
- Center for Occupational Health and Safety, Institute of Petroleum Studies, 327041University of Port Harcourt, Choba, Nigeria
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12
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Shahrestani S, Strickland BA, Bakhsheshian J, Mack WJ, Toga AW, Sanossian N, Tai YC, Zada G. Transcranial eddy current damping sensors for detection and imaging of hemorrhagic stroke: feasibility in benchtop experimentation. Neurosurg Focus 2021; 51:E15. [PMID: 34198251 DOI: 10.3171/2021.4.focus21121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spontaneous intracerebral hemorrhage occurs in an estimated 10% of stroke patients, with high rates of associated mortality. Portable diagnostic technologies that can quickly and noninvasively detect hemorrhagic stroke may prevent unnecessary delay in patient care and help rapidly triage patients with ischemic versus hemorrhagic stroke. As such, the authors aimed to develop a rapid and portable eddy current damping (ECD) hemorrhagic stroke sensor for proposed in-field diagnosis of hemorrhagic stroke. METHODS A tricoil ECD sensor with microtesla-level magnetic field strengths was constructed. Sixteen gelatin brain models with identical electrical properties to live brain tissue were developed and placed within phantom skull replicas, and saline was diluted to the conductivity of blood and placed within the brain to simulate a hemorrhage. The ECD sensor was used to detect modeled hemorrhages on benchtop models. Data were saved and plotted as a filtered heatmap to represent the lesion location. The individuals performing the scanning were blinded to the bleed location, and sensors were tangentially rotated around the skull models to localize blood. Data were also used to create heatmap images using MATLAB software. RESULTS The sensor was portable (11.4-cm maximum diameter), compact, and cost roughly $100 to manufacture. Scanning time was 2.43 minutes, and heatmap images of the lesion were produced in near real time. The ECD sensor accurately predicted the location of a modeled hemorrhage in all (n = 16) benchtop experiments with excellent spatial resolution. CONCLUSIONS Benchtop experiments demonstrated the proof of concept of the ECD sensor for rapid transcranial hemorrhagic stroke diagnosis. Future studies with live human participants are warranted to fully establish the feasibility findings derived from this study.
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Affiliation(s)
- Shane Shahrestani
- Departments of1Neurological Surgery and.,2Department of Medical Engineering, California Institute of Technology, Pasadena, California
| | | | | | | | - Arthur W Toga
- 3Laboratory of NeuroImaging (LONI), USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles; and
| | | | - Yu-Chong Tai
- 2Department of Medical Engineering, California Institute of Technology, Pasadena, California
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13
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Mayampurath A, Parnianpour Z, Richards CT, Meurer WJ, Lee J, Ankenman B, Perry O, Mendelson SJ, Holl JL, Prabhakaran S. Improving Prehospital Stroke Diagnosis Using Natural Language Processing of Paramedic Reports. Stroke 2021; 52:2676-2679. [PMID: 34162217 DOI: 10.1161/strokeaha.120.033580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
| | - Zahra Parnianpour
- Department of Neurology (Z.P., S.J.M., J.L.H., S.P.), University of Chicago, IL
| | | | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, IL (W.J.M.)
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (J.L.)
| | - Bruce Ankenman
- Department of Industrial Engineering and Management Studies, Northwestern University (B.A., O.P.)
| | - Ohad Perry
- Department of Industrial Engineering and Management Studies, Northwestern University (B.A., O.P.)
| | - Scott J Mendelson
- Department of Neurology (Z.P., S.J.M., J.L.H., S.P.), University of Chicago, IL
| | - Jane L Holl
- Department of Neurology (Z.P., S.J.M., J.L.H., S.P.), University of Chicago, IL
| | - Shyam Prabhakaran
- Department of Neurology (Z.P., S.J.M., J.L.H., S.P.), University of Chicago, IL
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14
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Mansour OY, Ramadan I, Elfatatry A, Hamdi M, Abudu A, Hassan T, Eldeeb H, Marouf H, Mogahed M, Farouk M, Abas M, Hamed M, Afify M, Abdallah T, Zaidat O. Using ESN-Smartphone Application to Maximize AIS Reperfusion Therapy in Alexandria Stroke Network: A Stroke Chain of Survival Organizational Model. Front Neurol 2021; 12:597717. [PMID: 33708169 PMCID: PMC7940834 DOI: 10.3389/fneur.2021.597717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/22/2021] [Indexed: 12/18/2022] Open
Abstract
Background: In developing countries like Egypt, the clinical workflow of stroke management is poorly established due to the lack of awareness of the stroke patients concerning their need of therapeutic intervention and the poor identification of facilities equipped to treat stroke. Hence, establishing a stroke system of care in developing countries that can efficiently and rapidly triage patients to the appropriate reperfusion therapy center is imperative to improving stroke management and outcomes. Aims: To evaluate a pilot experience in stroke hospital identification and expediting decision-making in AIS treatment through the Alexandria stroke network and Egyptian Stroke Network (ESN)-app. Methods: Between 2017 and 2019, seven hospitals registered themselves on the AS-Network as pilot hospitals. The ESN-application was used to detect stroke type, tele-connect stroke teams and hospitals, track triage of patients to equipped facility in real time, and streamline stroke workflow. The quality of and time required for stroke management were compared between 84 patients with acute ischemic stroke (AIS) whose treatment involved the ESN-app and 276 patients whose treatment did not. Results: During this pilot study, 360 AIS cases received reperfusion therapy, 84 of which were indicated by the ESN-app. The use of the application was associated with the significant drop in time metrics for the reperfusion AIS-patients (door-in-door-out time; 56 ± 34 min vs. 96 ± 45 min, door-to-groin puncture time; 50 ± 7 min vs. 120 ± 25 min, door-to-needle time; 55 ± 12 min vs. 78 ± 16 min with p < 0.0001). Its use was also associated with higher rates of excellent outcomes at the 90-day follow-up (without ESN-app vs. with ESN-app, 67.9 vs. 47.1%, p = 0.001) but no difference in 90-day mortality or symptomatic intracerebral hemorrhage (without ESN-app vs. with ESN-app, 9.5 vs. 11.2% and 4.8 vs. 5.1%, p > 0.05). Conclusion: Our pilot experience demonstrated that the use of the ESN-app expedited the stroke treatment workflow and facilitated tele-connection between registered stroke facilities. Additionally, its use might be associated with achieving higher rates of excellent outcomes at 90 days, where a larger scale study is needed for more confirmation.
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Affiliation(s)
- Ossama Yassin Mansour
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt.,Louran Comprehensive Stroke Center, Alexandria, Egypt.,Mabaret Elasafra Hospital, Alexandria, Egypt.,Shark el Madina Ministry of Health Hospital, Alexandria, Egypt.,Department of Neurology, Damanhur Medical National Institute, Damanhur, Egypt.,Elandalusia General Hospital, Alexandria, Egypt
| | - Ismail Ramadan
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt
| | - Amer Elfatatry
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt
| | - Mohamed Hamdi
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt
| | - Ashraf Abudu
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt
| | - Tamer Hassan
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Louran Comprehensive Stroke Center, Alexandria, Egypt
| | - Hany Eldeeb
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt.,Mabaret Elasafra Hospital, Alexandria, Egypt
| | - Hazem Marouf
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt.,Mabaret Elasafra Hospital, Alexandria, Egypt
| | | | - Mohamed Farouk
- Shark el Madina Ministry of Health Hospital, Alexandria, Egypt
| | - Mohamed Abas
- Department of Neurology, Damanhur Medical National Institute, Damanhur, Egypt
| | - Mervat Hamed
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt.,Elandalusia General Hospital, Alexandria, Egypt
| | | | - Tamer Abdallah
- Stroke Center, Semouha Emergency University Hospital, Alexandria, Egypt.,Stroke Unit, Elhadara University Hospital, Alexandria, Egypt.,Louran Comprehensive Stroke Center, Alexandria, Egypt
| | - Osama Zaidat
- Bon Secours Mercy Health System, Neuroscience Institute, St. Vincent Hospital, Toledo, OH, United States
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15
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Asaithambi G, Tong X, Lakshminarayan K, Coleman King SM, George MG, Odom EC. Emergency Medical Services Utilization for Acute Stroke Care: Analysis of the Paul Coverdell National Acute Stroke Program, 2014-2019. PREHOSP EMERG CARE 2021; 26:326-332. [PMID: 33464940 DOI: 10.1080/10903127.2021.1877856] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: Emergency medical service (EMS) transportation after acute stroke is associated with shorter symptom-to-arrival times and more rapid medical attention when compared to patient transportation by private vehicle. Methods: We analyzed data from the Paul Coverdell National Acute Stroke Program from 2014 to 2019 among stroke (ischemic and hemorrhagic) and transient ischemic attack (TIA) patients to examine patterns in EMS utilization. Results: Of 500,829 stroke and TIA patients (mean age 70.9 years, 51.3% women) from 682 participating hospitals during the study period, 60% arrived by EMS. Patients aged 18-64 years vs. ≥65 years (AOR 0.67) were less likely to utilize EMS. Severe stroke patients (AOR 2.29, 95%CI, 2.15-2.44) and hemorrhagic stroke patients vs. ischemic stroke patients (AOR 1.47, 95% CI, 1.43-1.51) were more likely to utilize EMS. Medicare (AOR 1.35, 95% CI, 1.32-1.38) and Medicaid (AOR 1.41, 95% CI, 1.37-1.45) beneficiaries were more likely than privately insured patients to utilize EMS, but no difference was found between no insurance/self-pay patients and privately insured patients on EMS utilization. Overall, there was a decreasing trend in the utilization of EMS (59.6% to 59.3%, p = 0.037). The decreasing trend was identified among ischemic stroke (p < 0.0001) patients but not among TIA (p = 0.89) or hemorrhagic stroke (p = 0.44) patients. There was no observed trend in pre-notification among stroke patients' arrival by EMS across the study period (56.9% to 56.5%, p = 0.99). Conclusions: Strategies to help increase stroke awareness and utilization of EMS among those with symptoms of stroke should be considered in order to help improve stroke outcomes.
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Affiliation(s)
- Ganesh Asaithambi
- Received November 15, 2020 from United Hospital Department of Neurosciences, Allina Health, St. Paul, Minnesota, USA (GA); Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA (XT, SMCK, MGG; ECO); Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA (KL); Department of Neurology, University of Minnesota Medical School, Minneapolis, Minnesota, USA (KL). Revision received January 14, 2021; accepted for publication January 14, 2021
| | - Xin Tong
- Received November 15, 2020 from United Hospital Department of Neurosciences, Allina Health, St. Paul, Minnesota, USA (GA); Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA (XT, SMCK, MGG; ECO); Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA (KL); Department of Neurology, University of Minnesota Medical School, Minneapolis, Minnesota, USA (KL). Revision received January 14, 2021; accepted for publication January 14, 2021
| | - Kamakshi Lakshminarayan
- Received November 15, 2020 from United Hospital Department of Neurosciences, Allina Health, St. Paul, Minnesota, USA (GA); Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA (XT, SMCK, MGG; ECO); Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA (KL); Department of Neurology, University of Minnesota Medical School, Minneapolis, Minnesota, USA (KL). Revision received January 14, 2021; accepted for publication January 14, 2021
| | - Sallyann M Coleman King
- Received November 15, 2020 from United Hospital Department of Neurosciences, Allina Health, St. Paul, Minnesota, USA (GA); Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA (XT, SMCK, MGG; ECO); Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA (KL); Department of Neurology, University of Minnesota Medical School, Minneapolis, Minnesota, USA (KL). Revision received January 14, 2021; accepted for publication January 14, 2021
| | - Mary G George
- Received November 15, 2020 from United Hospital Department of Neurosciences, Allina Health, St. Paul, Minnesota, USA (GA); Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA (XT, SMCK, MGG; ECO); Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA (KL); Department of Neurology, University of Minnesota Medical School, Minneapolis, Minnesota, USA (KL). Revision received January 14, 2021; accepted for publication January 14, 2021
| | - Erika C Odom
- Received November 15, 2020 from United Hospital Department of Neurosciences, Allina Health, St. Paul, Minnesota, USA (GA); Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA (XT, SMCK, MGG; ECO); Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA (KL); Department of Neurology, University of Minnesota Medical School, Minneapolis, Minnesota, USA (KL). Revision received January 14, 2021; accepted for publication January 14, 2021
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16
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Current Methods for the Prehospital Detection of Large Vessel Occlusion (LVO) Ischemic Stroke. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021. [DOI: 10.1007/s40138-020-00224-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Bath PM, Appleton JP, England T. The Hazard of Negative (Not Neutral) Trials on Treatment of Acute Stroke: A Review. JAMA Neurol 2020; 77:114-124. [PMID: 31790551 DOI: 10.1001/jamaneurol.2019.4107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance While there are a limited number of beneficial treatments for acute stroke (eg, stroke units, reperfusion, aspirin, hemicraniectomy), there are more negative (as opposed to neutral) interventions spanning multiple different mechanisms of action. To reduce the risk of future negative studies, it is vital to understand why previous interventions appeared to cause harm. Observations The limited number of beneficial treatments for acute ischemic stroke are far outnumbered by negative (not neutral) interventions that worsened outcomes in randomized clinical trials (RCTs), including those with putative neuroprotectant, anticoagulant, anti-inflammatory, free radical-scavenging, hemorrhagic, or vasoactive activity. Other agents reduced thrombolytic efficiency or exhibited neuropsychiatric or cardiac toxicity. In intracerebral hemorrhage, platelet transfusion was hazardous. Although reperfusion treatments should be given as soon as possible, very early intervention with other strategies may instead be hazardous, as has been seen with physical therapy and vasodepressors. Conclusions and Relevance The lessons learned from negative stroke RCTs are vital for designing future studies. Multicenter preclinical studies are necessary, and animals that die must be included in analyses. Randomized clinical trials must assess multiple neurological, vascular, cardiac, and general safety effects, whether these are on target or off target. All preclinical trials and RCTs must be published in full. Learning from the past will help to reduce the number of negative stroke RCTs in the future.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, England.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, England.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England
| | - Timothy England
- Vascular Medicine, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, England
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18
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Wessell AP, Carvalho HDP, Le E, Cannarsa G, Kole MJ, Stokum JA, Chryssikos T, Miller TR, Chaturvedi S, Gandhi D, Yarbrough K, Satti SR, Jindal G. A Critical Assessment of the Golden Hour and the Impact of Procedural Timing in Stroke Thrombectomy. AJNR Am J Neuroradiol 2020; 41:822-827. [PMID: 32414902 DOI: 10.3174/ajnr.a6556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/04/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies in acute ischemic stroke have demonstrated the importance of minimizing delays to endovascular treatment and keeping thrombectomy procedural times at <30-60 minutes. The purpose of this study was to investigate the impact of thrombectomy procedural times on clinical outcomes. MATERIALS AND METHODS We retrospectively compared 319 patients having undergone thrombectomy according to procedural time (<30 minutes, 30-60 minutes, and >60 minutes) and time from stroke onset to endovascular therapy (≤6 or >6 hours). Clinical characteristics of patients with postprocedural intracranial hemorrhage were also assessed. Logistic regression was used to determine independent predictors of poor outcome at 90 days (mRS ≥3). RESULTS Greater age (OR, 1.03; 95% CI, 1.01-1.06; P = .016), higher admission NIHSS score (OR, 1.10; 95% CI, 1.04-1.16; P = .001), history of diabetes mellitus (OR, 1.96; 95% CI, 1.05-3.65; P = .034), and postprocedural intracranial hemorrhage were independently associated with greater odds of poor outcome. Modified TICI scale scores of 2c (OR, 0.11; 95% CI, 0.04-0.28; P < .001) and 3 (OR, 0.15; 95% CI, 0.06-0.38; P < .001) were associated with reduced odds of poor outcome. Although not statistically significant on univariate analysis, onset to endovascular therapy of >6 hours was independently associated with increased odds of poor outcome (OR, 2.20; 95% CI, 1.11-4.36; P = .024) in the final multivariate model (area under the curve = 0.820). Procedural time was not independently associated with clinical outcome in the final multivariate model (P > .05). CONCLUSIONS Thrombectomy procedural times beyond 60 minutes are associated with lower revascularization rates and worse 90-day outcomes. Procedural time itself was not an independent predictor of outcome. While stroke thrombectomy procedures should be performed rapidly, our study emphasizes the significance of achieving revascularization despite the requisite procedural time. However, the potential for revascularization must be weighed against the risks associated with multiple thrombectomy attempts.
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Affiliation(s)
- A P Wessell
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - H D P Carvalho
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| | - E Le
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| | - G Cannarsa
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - M J Kole
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - J A Stokum
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - T Chryssikos
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - T R Miller
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| | - S Chaturvedi
- Neurology (S.C., K.Y.), University of Maryland Medical Center, Baltimore, Maryland
| | - D Gandhi
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| | - K Yarbrough
- Neurology (S.C., K.Y.), University of Maryland Medical Center, Baltimore, Maryland
| | - S R Satti
- Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, Delaware
| | - G Jindal
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
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19
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Harpaz D, Seet RCS, Marks RS, Tok AIY. Blood-Based Biomarkers Are Associated with Different Ischemic Stroke Mechanisms and Enable Rapid Classification between Cardioembolic and Atherosclerosis Etiologies. Diagnostics (Basel) 2020; 10:E804. [PMID: 33050269 PMCID: PMC7600601 DOI: 10.3390/diagnostics10100804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 12/22/2022] Open
Abstract
Stroke is a top leading cause of death, which occurs due to interference in the blood flow of the brain. Ischemic stroke (blockage) accounts for most cases (87%) and is further subtyped into cardioembolic, atherosclerosis, lacunar, other causes, and cryptogenic strokes. The main value of subtyping ischemic stroke patients is for a better therapeutic decision-making process. The current classification methods are complex and time-consuming (hours to days). Specific blood-based biomarker measurements have promising potential to improve ischemic stroke mechanism classification. Over the past decades, the hypothesis that different blood-based biomarkers are associated with different ischemic stroke mechanisms is increasingly investigated. This review presents the recent studies that investigated blood-based biomarker characteristics differentiation between ischemic stroke mechanisms. Different blood-based biomarkers are specifically discussed (b-type natriuretic peptide, d-dimer, c-reactive protein, tumor necrosis factor-α, interleukin-6, interleukin-1β, neutrophil-lymphocyte ratio, total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein and apolipoprotein A), as well as the different cut-off values that may be useful in specific classifications for cardioembolic and atherosclerosis etiologies. Lastly, the structure of a point-of-care biosensor device is presented, as a measuring tool on-site. The information presented in this review will hopefully contribute to the major efforts to improve the care for stroke patients.
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Affiliation(s)
- Dorin Harpaz
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Raymond C. S. Seet
- Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore;
| | - Robert S. Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Alfred I. Y. Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
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20
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Harpaz D, Seet RCS, Marks RS, Tok AIY. B-Type Natriuretic Peptide as a Significant Brain Biomarker for Stroke Triaging Using a Bedside Point-of-Care Monitoring Biosensor. BIOSENSORS 2020; 10:E107. [PMID: 32859068 PMCID: PMC7559708 DOI: 10.3390/bios10090107] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/23/2020] [Accepted: 08/24/2020] [Indexed: 05/12/2023]
Abstract
Stroke is a widespread condition that causes 7 million deaths globally. Survivors suffer from a range of disabilities that affect their everyday life. It is a complex condition and there is a need to monitor the different signals that are associated with it. Stroke patients need to be rapidly diagnosed in the emergency department in order to allow the admission of the time-limited treatment of tissue plasminogen activator (tPA). Stroke diagnostics show the use of sophisticated technologies; however, they still contain limitations. The hidden information and technological advancements behind the utilization of biomarkers for stroke triaging are significant. Stroke biomarkers can revolutionize the way stroke patients are diagnosed, monitored, and how they recover. Different biomarkers indicate different cascades and exhibit unique expression patterns which are connected to certain pathologies in the human body. Over the past decades, B-type natriuretic peptide (BNP) and its derivative N-terminal fragment (NT-proBNP) have been increasingly investigated and highlighted as significant cardiovascular biomarkers. This work reviews the recent studies that have reported on the usefulness of BNP and NT-proBNP for stroke triaging. Their classification association is also presented, with increased mortality in stroke, correlation with cardioembolic stroke, and an indication of a second stroke recurrence. Moreover, recent scientific efforts conducted for the technological advancement of a bedside point-of-care (POC) device for BNP and NT-proBNP measurements are discussed. The conclusions presented in this review may hopefully assist in the major efforts that are currently being conducted in order to improve the care of stroke patients.
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Affiliation(s)
- Dorin Harpaz
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Raymond C. S. Seet
- Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore;
| | - Robert S. Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Alfred I. Y. Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
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21
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A Novel Use of Prehospital Telemedicine to Decrease Door to Computed Tomography Results in Acute Strokes. J Healthc Qual 2019; 42:264-268. [PMID: 31725488 DOI: 10.1097/jhq.0000000000000229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Timely emergency department (ED) recognition of acute strokes reduces morbidity and mortality and improves outcomes. Prehospital telehealth evaluation rapidly assesses patients with stroke symptoms and mobilizes resources before ED arrival, decreasing ED arrival to computed tomography (CT) result times. Expediting CT results reduces the decision time to determining thrombolytic therapy eligibility. METHODS Seventeen ambulances in our region were supplied with equipment to perform a nonrecordable video examination with an ED physician. Emergency Medical Service requested a physician video examination on patients with a positive prehospital Cincinnati Stroke Scale. The physician and paramedic conducted an NIH-8 scale, and, based on the assessment, the patients were placed directly on the CT scanner table. RESULTS Four time intervals that impact CT acquisition and thrombolytic decision-making were measured. There was improvement in all time intervals. Time from ED arrival to CT order decreased 1.7 minutes. Time from arrival to study start decreased 5.7 minutes. Time from CT order to result decreased 3.89 minutes and time from ED arrival to CT result decreased 5.6 minutes. DISCUSSION Prehospital telehealth consults with paramedics, and the receiving hospital for acute strokes significantly decreased times for all metrics studied including the time from ED arrival to CT result.
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22
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Winter B, Wendt M, Waldschmidt C, Rozanski M, Kunz A, Geisler F, Grittner U, Kaczmarek S, Ebinger M, Audebert HJ. 4G versus 3G-enabled telemedicine in prehospital acute stroke care. Int J Stroke 2019; 14:620-629. [DOI: 10.1177/1747493019830303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Time to reperfusion treatment is closely related to outcome in ischemic stroke. Prehospital stroke work-up in CT-equipped mobile stroke units is effective in reducing time to thrombolytic treatment. Current evidence predominantly comes from mobile stroke units staffed with neurologists but telemedicine-guided management may be acceptable for providing neurological expertise in ambulances. With unsatisfactory experiences in third-generation (3G)-based approaches, fourth-generation (4G) networks may provide adequate audio-visual quality but systematic comparisons of technological parameters and decision-making are lacking. Methods Trained actors presented stroke symptoms and paramedics assisted the remotely guided extended National Institutes of Health Stroke Scale (eNIHSS) assessment on the mobile stroke unit in Berlin, Germany. We compared technical parameters of 4G and 3G connections, assessed audio-visual quality of examination, and analyzed reliability of neurological assessment and treatment decisions made by the remote neurologist versus the mobile stroke unit neurologist. Results 4G and 3G connections were evaluated in 40 scenarios each. Connectivity was not available in 17% of 4G- and 15% of 3G-attempts with 6% simultaneous unavailability of both networks. The remote examiners graded audio and video quality in 4G better than in 3G with slightly shorter assessment duration in 4G (mean: 9 (SD:5) vs. mean 11 (SD:3) min, p = 0.10). Reliability of the eNIHSS sum scores was high with intraclass correlation coefficients of 0.99 (95% CI: 0.987–1.00) for 4G and 0.98 (95% CI: 0.96–0.99) for 3G. None of the remote treatment decisions differed from onsite decisions. Conclusions 4G mobile communications provided higher quality of video-examination and allowed reliable remote assessment of stroke symptoms but coverage was still incomplete in both networks.
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Affiliation(s)
- B Winter
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, St. Josefs-Krankenhaus Potsdam-Sanssouci, Potsdam, Germany
| | - M Wendt
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- Unfallkrankenhaus Berlin, Berlin, Germany
| | - C Waldschmidt
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - M Rozanski
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - A Kunz
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - F Geisler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - U Grittner
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - M Ebinger
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - HJ Audebert
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
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Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial. Lancet 2019. [PMID: 30738649 PMCID: PMC6497986 DOI: 10.1016/s0140-6736(19)30194-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND High blood pressure is common in acute stroke and is a predictor of poor outcome; however, large trials of lowering blood pressure have given variable results, and the management of high blood pressure in ultra-acute stroke remains unclear. We investigated whether transdermal glyceryl trinitrate (GTN; also known as nitroglycerin), a nitric oxide donor, might improve outcome when administered very early after stroke onset. METHODS We did a multicentre, paramedic-delivered, ambulance-based, prospective, randomised, sham-controlled, blinded-endpoint, phase 3 trial in adults with presumed stroke within 4 h of onset, face-arm-speech-time score of 2 or 3, and systolic blood pressure 120 mm Hg or higher. Participants were randomly assigned (1:1) to receive transdermal GTN (5 mg once daily for 4 days; the GTN group) or a similar sham dressing (the sham group) in UK-based ambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment, whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure of functional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis was hierarchical, first in participants with a confirmed stroke or transient ischaemic attack (cohort 1), and then in all participants who were randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. This trial is registered with ISRCTN, number ISRCTN26986053. FINDINGS Between Oct 22, 2015, and May 23, 2018, 516 paramedics from eight UK ambulance services recruited 1149 participants (n=568 in the GTN group, n=581 in the sham group). The median time to randomisation was 71 min (IQR 45-116). 597 (52%) patients had ischaemic stroke, 145 (13%) had intracerebral haemorrhage, 109 (9%) had transient ischaemic attack, and 297 (26%) had a non-stroke mimic at the final diagnosis of the index event. In the GTN group, participants' systolic blood pressure was lowered by 5·8 mm Hg compared with the sham group (p<0·0001), and diastolic blood pressure was lowered by 2·6 mm Hg (p=0·0026) at hospital admission. We found no difference in mRS between the groups in participants with a final diagnosis of stroke or transient ischaemic stroke (cohort 1): 3 (IQR 2-5; n=420) in the GTN group versus 3 (2-5; n=408) in the sham group, adjusted common odds ratio for poor outcome 1·25 (95% CI 0·97-1·60; p=0·083); we also found no difference in mRS between all patients (cohort 2: 3 [2-5]; n=544, in the GTN group vs 3 [2-5]; n=558, in the sham group; 1·04 [0·84-1·29]; p=0·69). We found no difference in secondary outcomes, death (treatment-related deaths: 36 in the GTN group vs 23 in the sham group [p=0·091]), or serious adverse events (188 in the GTN group vs 170 in the sham group [p=0·16]) between treatment groups. INTERPRETATION Prehospital treatment with transdermal GTN does not seem to improve functional outcome in patients with presumed stroke. It is feasible for UK paramedics to obtain consent and treat patients with stroke in the ultra-acute prehospital setting. FUNDING British Heart Foundation.
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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: 33] [Impact Index Per Article: 6.6] [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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25
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Larsen K, Bache KG, Franer E, Tveit LH, Hov MR, Lund CG, Solyga V, Lossius HM. Pre-hospital thrombolysis of ischemic stroke in the emergency service system-A case report from the Treat-NASPP trial. Acta Anaesthesiol Scand 2019; 63:410-413. [PMID: 30426474 PMCID: PMC6587768 DOI: 10.1111/aas.13285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/27/2018] [Indexed: 01/21/2023]
Affiliation(s)
- Karianne Larsen
- The Norwegian Air Ambulance Foundation; Oslo Norway
- Institute of Basic Medical Sciences; University of Oslo; Oslo Norway
| | - Kristi G. Bache
- The Norwegian Air Ambulance Foundation; Oslo Norway
- Institute of Basic Medical Sciences; University of Oslo; Oslo Norway
| | - Eirik Franer
- The Norwegian Air Ambulance Foundation; Oslo Norway
- Department of Anesthesiology; Østfold Hospital; Kalnes Norway
| | - Lars H. Tveit
- Department of Neurology; Østfold Hospital; Kalnes Norway
| | - Maren R. Hov
- The Norwegian Air Ambulance Foundation; Oslo Norway
- Department of Neurology; Oslo University Hospital; Oslo Norway
| | - Christian G. Lund
- The Norwegian Air Ambulance Foundation; Oslo Norway
- Department of Neurology; Oslo University Hospital; Oslo Norway
| | - Volker Solyga
- Department of Neurology; Østfold Hospital; Kalnes Norway
| | - Hans Morten Lossius
- The Norwegian Air Ambulance Foundation; Oslo Norway
- Department of Health Science; University of Stavanger; Stavanger Norway
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26
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The frequency, characteristics and aetiology of stroke mimic presentations: a narrative review. Eur J Emerg Med 2019; 26:2-8. [DOI: 10.1097/mej.0000000000000550] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Calderon VJ, Kasturiarachi BM, Lin E, Bansal V, Zaidat OO. Review of the Mobile Stroke Unit Experience Worldwide. INTERVENTIONAL NEUROLOGY 2018; 7:347-358. [PMID: 30410512 DOI: 10.1159/000487334] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 01/31/2018] [Indexed: 11/19/2022]
Abstract
Background The treatment of stroke is dependent on a narrow therapeutic time window that requires interventions to be emergently pursued. Despite recent "FAST" initiatives that have underscored "time is brain," many patients still fail to present within the narrow time window to receive maximum treatment benefit from advanced stroke therapies, including recombinant tissue plasminogen activator (tPA) and mechanical thrombectomy. The convergence of emergency medical services, telemedicine, and mobile technology, including transportable computed tomography scanners, has presented a unique opportunity to advance patient stroke care in the prehospital field by shortening time to hyperacute stroke treatment with a mobile stroke unit (MSU). Summary In this review, we provide a look at the evolution of the MSU into its current status as well as future directions. Our summary statement includes historical and implementation information, economic cost, and published clinical outcome and time metrics, including the utilization rate of thrombolysis. Key Messages Initially hypothesized in 2003, the first MSUs were launched in Germany and adopted worldwide in acute, prehospital stroke management. These specialized ambulances have made the diagnosis and treatment of many neurological emergencies, in addition to ischemic and hemorrhagic stroke, possible at the emergency site. Providing treatment as early as possible, including within the prehospital phase of stroke management, improves patient outcomes. As MSUs continue to collect data and improve their methods, shortened time metrics are expected, resulting in more patients who will benefit from faster treatment of their acute neurological emergencies in the prehospital field.
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Affiliation(s)
| | | | - Eugene Lin
- Mercy Health-St. Vincent Medical Center, Toledo, Ohio, USA
| | - Vibhav Bansal
- Mercy Health-St. Rita Medical Center, Lima, Ohio, USA
| | - Osama O Zaidat
- Mercy Health-St. Vincent Medical Center, Toledo, Ohio, USA
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28
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Liu X, Kiss GK, Mellender SJ, Weiss HR, Chi OZ. Activation of Akt by SC79 decreased cerebral infarct in early cerebral ischemia-reperfusion despite increased BBB disruption. Neurosci Lett 2018; 681:78-82. [PMID: 29859325 DOI: 10.1016/j.neulet.2018.05.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/02/2023]
Abstract
Activation of Akt has been suggested to produce neuronal protection in cerebral ischemia. Decreasing blood-brain barrier (BBB) disruption has been associated with a better neuronal outcome in cerebral ischemia. We hypothesized that activation of Akt would decrease BBB disruption and contribute to decreasing the size of infarct in the early stage of cerebral ischemia-reperfusion within the therapeutic window. Transient middle cerebral artery occlusion (MCAO) was performed in rats under isoflurane anesthesia with controlled ventilation. Rats were treated with SC79 (a selective Akt activator which is cell and BBB permeable) 0.05 mg/kg × 3 i.p. or vehicle i.p. perioperatively. After one hour of MCAO and two hours of reperfusion, the transfer coefficient (Ki) of 14C-α-aminoisobutyric acid (14C-AIB, molecular weight 104 Da) and the volume of 3H-dextran (molecular weight 70,000 Da) distribution were determined to measure the degree of BBB disruption. At the same time point, the size of infarction was determined using tetrazolium staining. In an additional group of rats, a higher dose of SC79 (0.5 mg/kg × 3) was administered to determine the size of infarct. Administration of SC79 increased the Ki in the ischemic-reperfused cortex (IR-C, +32%, p < 0.05) as well as in the contralateral cortex (CC, +35%, p < 0.05) when compared with the untreated animals with MCAO/reperfusion. The volume of dextran distribution was not significantly changed by SC79. SC79 treatment significantly produced a decrease in the percentage of cortical infarct out of total cortical area (12.7 ± 1.7% vs 6.9 ± 0.9%, p < 0.001). Increasing the dose of SC79 by ten times did not significantly affect the size of cortical infarct. Contrary to our hypothesis, our data demonstrated that SC79 decreased the size of the infarct in the ischemic-reperfused cortex despite an increase in BBB disruption. Our data suggest the importance of activation of Akt for neuronal survival in the early stage of cerebral ischemia-reperfusion within the therapeutic window and that the mechanism of neuroprotection may not be related to the BBB effects of SC79.
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Affiliation(s)
- Xia Liu
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Geza K Kiss
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Scott J Mellender
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Harvey R Weiss
- Department of Neuroscience and Cell Biology, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Oak Z Chi
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA.
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Alotaibi NM, Sarzetto F, Guha D, Lu M, Bodo A, Gupta S, Dyer E, Howard P, da Costa L, Swartz RH, Boyle K, Nathens AB, Yang VXD. Impact of Smartphone Applications on Timing of Endovascular Therapy for Ischemic Stroke: A Preliminary Study. World Neurosurg 2017; 107:678-683. [PMID: 28823672 DOI: 10.1016/j.wneu.2017.08.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/05/2017] [Accepted: 08/08/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND The metrics of imaging-to-puncture and imaging-to-reperfusion were recently found to be associated with the clinical outcomes of endovascular thrombectomy for acute ischemic stroke. However, measures for improving workflow within hospitals to achieve better timing results are largely unexplored for endovascular therapy. The aim of this study was to examine our experience with a novel smartphone application developed in house to improve our timing metrics for endovascular treatment. METHODS We developed an encrypted smartphone application connecting all stroke team members to expedite conversations and to provide synchronized real-time updates on the time window from stroke onset to imaging and to puncture. The effects of the application on the timing of endovascular therapy were evaluated with a secondary analysis of our single-center cohort. Our primary outcome was imaging-to-puncture time. We assessed the outcomes with nonparametric tests of statistical significance. RESULTS Forty-five patients met our criteria for analysis among 66 consecutive patients with acute ischemic stroke who received endovascular therapy at our institution. After the implementation of the smartphone application, imaging-to-puncture time was significantly reduced (preapplication median time, 127 minutes; postapplication time, 69 minutes; P < 0.001). Puncture-to-reperfusion time was not affected by the application use (42 minutes vs. 36 minutes). CONCLUSION The use of smartphone applications may reduce treatment times for endovascular therapy in acute ischemic stroke. Further studies are needed to confirm our findings.
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Affiliation(s)
- Naif M Alotaibi
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Francesca Sarzetto
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Daipayan Guha
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael Lu
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andre Bodo
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shaurya Gupta
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erin Dyer
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter Howard
- Department of Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Richard H Swartz
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karl Boyle
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Victor X D Yang
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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30
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Byrne D, Sugrue G, Stanley E, Walsh JP, Murphy S, Kavanagh EC, MacMahon PJ. Improved Detection of Anterior Circulation Occlusions: The "Delayed Vessel Sign" on Multiphase CT Angiography. AJNR Am J Neuroradiol 2017; 38:1911-1916. [PMID: 28798219 DOI: 10.3174/ajnr.a5317] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/27/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Multiphase CTA, a technique to dynamically assess the vasculature in acute ischemic stroke, was primarily developed to evaluate collateral filling. We have observed that it is also useful in identifying distal anterior circulation occlusions due to delayed anterior circulation opacification on multiphase CTA, an observation we term the "delayed vessel sign." We aimed to determine the usefulness of this sign by comparing multiphase CTA with single-phase CTA. MATERIALS AND METHODS All 23 distal anterior circulation occlusions during a 2-year period were included. Ten M1-segment occlusions and 10 cases without a vessel occlusion were also included. All patients had follow-up imaging confirming the diagnosis. Initially, the noncontrast CT and first phase of the multiphase CTA study for each patient were blindly evaluated (2 neuroradiologists, 2 radiology trainees) for an anterior circulation occlusion. Readers' confidence, speed, and sensitivity of detection were recorded. Readers were then educated on the "delayed vessel sign," and each multiphase CTA study was re-examined for a vessel occlusion after at least 14 days. RESULTS There was significant improvement in the sensitivity of detection of distal anterior circulation vessel occlusions (P < .001), overall confidence (P < .001), and time taken to interpret (P < .001) with multiphase CTA compared with single-phase CTA. Readers preferred MIP images compared with source images in >90% of cases. CONCLUSIONS The delayed vessel sign is a reliable indicator of anterior circulation vessel occlusion, particularly in cases involving distal branches. Assessment of the later phases of multiphase CTA for the delayed vessel sign leads to a significant improvement in the speed and confidence of interpretation, compared with single-phase CTA.
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Affiliation(s)
- D Byrne
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.)
| | - G Sugrue
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.)
| | - E Stanley
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.)
| | - J P Walsh
- Department of Radiology (J.P.W.), St. James's Hospital, Dublin, Ireland
| | - S Murphy
- Stroke Medicine (S.M.), Mater Misericordiae University Hospital, Dublin, Ireland.,School of Medicine (S.M., E.C.K., P.J.M.), University College Dublin, Dublin, Ireland.,Royal College of Surgeons in Ireland Medical School (S.M.), Dublin, Ireland
| | - E C Kavanagh
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.).,School of Medicine (S.M., E.C.K., P.J.M.), University College Dublin, Dublin, Ireland
| | - P J MacMahon
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.).,School of Medicine (S.M., E.C.K., P.J.M.), University College Dublin, Dublin, Ireland
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Harpaz D, Eltzov E, Seet RCS, Marks RS, Tok AIY. Point-of-Care-Testing in Acute Stroke Management: An Unmet Need Ripe for Technological Harvest. BIOSENSORS 2017; 7:E30. [PMID: 28771209 PMCID: PMC5618036 DOI: 10.3390/bios7030030] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 12/20/2022]
Abstract
Stroke, the second highest leading cause of death, is caused by an abrupt interruption of blood to the brain. Supply of blood needs to be promptly restored to salvage brain tissues from irreversible neuronal death. Existing assessment of stroke patients is based largely on detailed clinical evaluation that is complemented by neuroimaging methods. However, emerging data point to the potential use of blood-derived biomarkers in aiding clinical decision-making especially in the diagnosis of ischemic stroke, triaging patients for acute reperfusion therapies, and in informing stroke mechanisms and prognosis. The demand for newer techniques to deliver individualized information on-site for incorporation into a time-sensitive work-flow has become greater. In this review, we examine the roles of a portable and easy to use point-of-care-test (POCT) in shortening the time-to-treatment, classifying stroke subtypes and improving patient's outcome. We first examine the conventional stroke management workflow, then highlight situations where a bedside biomarker assessment might aid clinical decision-making. A novel stroke POCT approach is presented, which combines the use of quantitative and multiplex POCT platforms for the detection of specific stroke biomarkers, as well as data-mining tools to drive analytical processes. Further work is needed in the development of POCTs to fulfill an unmet need in acute stroke management.
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Affiliation(s)
- Dorin Harpaz
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
| | - Evgeni Eltzov
- Agriculture Research Organization (ARO), Volcani Centre, Rishon LeTsiyon 15159, Israel.
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore.
| | - Robert S Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- The National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- The Ilse Katz Centre for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
| | - Alfred I Y Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
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Hov MR, Zakariassen E, Lindner T, Nome T, Bache KG, Røislien J, Gleditsch J, Solyga V, Russell D, Lund CG. Interpretation of Brain CT Scans in the Field by Critical Care Physicians in a Mobile Stroke Unit. J Neuroimaging 2017; 28:106-111. [PMID: 28766306 PMCID: PMC5811888 DOI: 10.1111/jon.12458] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/23/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE In acute stroke, thromboembolism or spontaneous hemorrhage abruptly reduces blood flow to a part of the brain. To limit necrosis, rapid radiological identification of the pathological mechanism must be conducted to allow the initiation of targeted treatment. The aim of the Norwegian Acute Stroke Prehospital Project is to determine if anesthesiologists, trained in prehospital critical care, may accurately assess cerebral computed tomography (CT) scans in a mobile stroke unit (MSU). METHODS In this pilot study, 13 anesthesiologists assessed unselected acute stroke patients with a cerebral CT scan in an MSU. The scans were simultaneously available by teleradiology at the receiving hospital and the on‐call radiologist. CT scan interpretation was focused on the radiological diagnosis of acute stroke and contraindications for thrombolysis. The aim of this study was to find inter‐rater agreement between the pre‐ and in‐hospital radiological assessments. A neuroradiologist evaluated all CT scans retrospectively. Statistical analysis of inter‐rater agreement was analyzed with Cohen's kappa. RESULTS Fifty‐one cerebral CT scans from the MSU were included. Inter‐rater agreement between prehospital anesthesiologists and the in‐hospital on‐call radiologists was excellent in finding radiological selection for thrombolysis (kappa .87). Prehospital CT scans were conducted in median 10 minutes (7 and 14 minutes) in the MSU, and median 39 minutes (31 and 48 minutes) before arrival at the receiving hospital. CONCLUSION This pilot study shows that anesthesiologists trained in prehospital critical care may effectively assess cerebral CT scans in an MSU, and determine if there are radiological contraindications for thrombolysis.
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Affiliation(s)
- Maren Ranhoff Hov
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik Zakariassen
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, Uni Research Health, Bergen, Norway
| | - Thomas Lindner
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,The Regional Centre for Emergency Medical Research and Development, Stavanger, Norway
| | - Terje Nome
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Kristi G Bache
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Jo Røislien
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway
| | | | - Volker Solyga
- Department of Neurology, Østfold Hospital, Kalnes, Norway
| | - David Russell
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Faculty of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christian G Lund
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
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- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway
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Mattila OS, Harve H, Pihlasviita S, Ritvonen J, Sibolt G, Pystynen M, Strbian D, Curtze S, Kuisma M, Tatlisumak T, Lindsberg PJ. Ultra-acute diagnostics for stroke: Large-scale implementation of prehospital biomarker sampling. Acta Neurol Scand 2017; 136:17-23. [PMID: 27642014 DOI: 10.1111/ane.12687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Blood-based biomarkers could enable early and cost-effective diagnostics for acute stroke patients in the prehospital setting to support early initiation of treatments. To facilitate development of ultra-acute biomarkers, we set out to implement large-scale prehospital blood sampling and determine feasibility and diagnostic timesavings of this approach. MATERIALS AND METHODS Emergency medical services (EMS) personnel of the Helsinki metropolitan area were trained to collect prehospital blood samples from thrombolysis candidates using a cannula adapter technique. Time delays, sample quality, and logistics were investigated between May 20, 2013 and May 19, 2014. RESULTS Prehospital blood sampling and study recruiting were successfully performed for 430 thrombolysis candidates, of which 50% had ischemic stroke, 14.4% TIA, 13.5% hemorrhagic stroke, and 22.1% stroke mimics. A total of 66.3% of all samples were collected during non-office hours. The median (interquartile range) emergency call to prehospital sample time was 33 minutes (25-41), and the median time from reported symptom onset or wake-up to prehospital sample was 53 minutes (38-85; n=394). Prehospital sampling was performed 31 minutes (25-42) earlier than hospital admission blood sampling and 37 minutes (30-47) earlier than admission neuroimaging. Hemolysis rate in serum and plasma samples was 6.5% and 9.3% for EMS samples, and 0.7% and 1.6% for admission samples. CONCLUSIONS Prehospital biomarker sampling can be implemented in all EMS units and provides a median timesaving of more than 30 minutes to first blood sample. Large prehospital sample sets will enable development of novel ambulance biomarkers to improve early differential diagnosis and treatment of thrombolysis candidates.
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Affiliation(s)
- O. S. Mattila
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Molecular Neurology; Research Programs Unit; University of Helsinki; Helsinki Finland
| | - H. Harve
- Emergency Medical Services; Department of Emergency Care; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - S. Pihlasviita
- Molecular Neurology; Research Programs Unit; University of Helsinki; Helsinki Finland
| | - J. Ritvonen
- Molecular Neurology; Research Programs Unit; University of Helsinki; Helsinki Finland
| | - G. Sibolt
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - M. Pystynen
- Emergency Medical Services; Department of Emergency Care; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - D. Strbian
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - S. Curtze
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - M. Kuisma
- Emergency Medical Services; Department of Emergency Care; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - T. Tatlisumak
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- The Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
- Department of Neurology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - P. J. Lindsberg
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Molecular Neurology; Research Programs Unit; University of Helsinki; Helsinki Finland
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Yu IC, Kuo PC, Yen JH, Paraiso HC, Curfman ET, Hong-Goka BC, Sweazey RD, Chang FL. A Combination of Three Repurposed Drugs Administered at Reperfusion as a Promising Therapy for Postischemic Brain Injury. Transl Stroke Res 2017. [PMID: 28624878 DOI: 10.1007/s12975-017-0543-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cerebral ischemia leads to multifaceted injury to the brain. A polytherapeutic drug that can be administered immediately after reperfusion may increase protection to the brain by simultaneously targeting multiple deleterious cascades. This study evaluated efficacy of the combination of three clinically approved drugs: lamotrigine, minocycline, and lovastatin, using two mouse models: global and focal cerebral ischemia induced by transient occlusion of the common carotid arteries or the middle cerebral artery, respectively. In vitro, the combination drug, but not single drug, protected neurons against oxygen-glucose deprivation (OGD)-induced cell death. The combination drug simultaneously targeted cell apoptosis and DNA damage induced by ischemia. Besides acting on neurons, the combination drug suppressed inflammatory processes in microglia and brain endothelial cells induced by ischemia. In a transient global ischemia model, the combination drug, but not single drug, suppressed microglial activation and inflammatory cytokine production, and reduced neuronal damage. In a transient focal ischemia model, the combination drug, but not single drug, attenuated brain infarction, suppressed infiltration of peripheral neutrophils, and reduced neurological deficits following ischemic stroke. In summary, the combination drug confers a broad-spectrum protection against ischemia/reperfusion (I/R) injury and could be a promising approach for early neuroprotection after out-of-hospital cardiac arrest or ischemic stroke.
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Affiliation(s)
- I-Chen Yu
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA.
| | - Ping-Chang Kuo
- Department of Microbiology and Immunology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Jui-Hung Yen
- Department of Microbiology and Immunology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Hallel C Paraiso
- Department of Biology, Indiana University-Purdue University Fort Wayne, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Eric T Curfman
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Benecia C Hong-Goka
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Robert D Sweazey
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Fen-Lei Chang
- Department of Neurology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA.
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35
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Chi OZ, Kiss GK, Mellender SJ, Liu X, Weiss HR. Rapamycin decreased blood-brain barrier permeability in control but not in diabetic rats in early cerebral ischemia. Neurosci Lett 2017. [PMID: 28625574 DOI: 10.1016/j.neulet.2017.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diabetes causes functional and structural changes in blood-brain barrier (BBB). The mammalian target of rapamycin (mTOR) has been associated with glucose metabolism, diabetes, and altering BBB permeability. Since there is only a narrow therapeutic window (3h) for stroke victims, it is important to investigate BBB disruption in the early stage of cerebral ischemia. We compared the degree of BBB disruption in diabetic and in control rats at two hours of reperfusion after one hour of middle cerebral artery (MCA) occlusion with or without inhibition of mTOR. Two weeks after streptozotocin ip to induce diabetes, MCA occlusion was performed. In half of the rats, an mTOR inhibitor, rapamycin was given for 2days before MCA occlusion. After one hour of MCA occlusion and two hours of the reperfusion, the transfer coefficient (Ki) of 14C-α-aminoisobutyric acid was determined to quantify degree of BBB disruption. Ischemia-reperfusion increased the Ki in the control animals. Streptozotocin increased the Ki in the ischemic-reperfused (IR-C, +22%) as well as in the contralateral cortex (CC, +40%). Rapamycin decreased the Ki in the IR-C (-32%) as well as in the CC (-26%) in the control rats. However, rapamycin did not affect Ki in the IR-C or in the CC in the diabetic rats. Our data demonstrated a greater BBB disruption in diabetes in the ischemic as well as non-ischemic cortex even in the early stage of cerebral ischemia-reperfusion and that acute administration of rapamycin did not significantly affect BBB permeability in diabetes. From our quantitative analysis of BBB disruption, the vulnerability of BBB in diabetes has been emphasized in the early stage of cerebral ischemia-reperfusion and a less important role of the mTOR pathway is suggested in altering BBB permeability in diabetes.
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Affiliation(s)
- Oak Z Chi
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ 08901, USA.
| | - Geza K Kiss
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ 08901, USA
| | - Scott J Mellender
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ 08901, USA
| | - Xia Liu
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ 08901, USA
| | - Harvey R Weiss
- Department of Neuroscience and Cell Biology, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854, USA
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36
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Dong Q, Dong Y, Liu L, Xu A, Zhang Y, Zheng H, Wang Y. The Chinese Stroke Association scientific statement: intravenous thrombolysis in acute ischaemic stroke. Stroke Vasc Neurol 2017; 2:147-159. [PMID: 28989804 PMCID: PMC5628383 DOI: 10.1136/svn-2017-000074] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/20/2017] [Accepted: 03/22/2017] [Indexed: 12/30/2022] Open
Abstract
The most effective medical treatment for acute ischaemic stroke (AIS) is to offer intravenous thrombolysis during the ultra-early period of time after the onset. Even based on the Consensus of Chinese Experts on Intravenous Thrombolysis for AIS in 2012 and 2014 Chinese Guidelines on the Diagnosis and Treatment of AIS, the rate of thrombolysis for AIS in China remained around 2.4%, and the rate of intravenous tissue plasminogen activator usage was only about 1.6% in real world. The indication of thrombolysis for AIS has been expanded, and contraindications have been reduced with recently published studies. In order to facilitate the standardisation of treating AIS, improve the rate of thrombolysis and benefit patients who had a stroke, Chinese Stroke Association has organised and developed this scientific statement.
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Affiliation(s)
- Qiang Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Yi Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Anding Xu
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Yusheng Zhang
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
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37
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Sinawang PD, Harpaz D, Fajs L, Seet RCS, Tok AIY, Marks RS. Electrochemical impedimetric detection of stroke biomarker NT-proBNP using disposable screen-printed gold electrodes. EUROBIOTECH JOURNAL 2017. [DOI: 10.24190/issn2564-615x/2017/02.09] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Stroke is the second top leading cause of death globally. It is caused by an abrupt interruption of blood flow to the brain. In that course, brain natriuretic peptide (BNP) and its derivative N-terminal pro b-type natriuretic peptide (NT-proBNP), neurohormones produced mainly by the heart ventricles in response to excessive stretching of cardiomyocytes (heart muscle cells), are proven to be good biomarkers for heart failure diagnosis. Moreover, there is growing clinical interest of the use of NT-proBNP for stroke diagnosis and prognosis because it is significantly associated with cardioembolic stroke and secondary stroke reoccurrence, with sensitivity >90% and specificity >80%. However, in diagnostic settings, there is still a need to address the encountered analytical problems, particularly assay specificity and set up. In this study, a novel approach for NT-proBNP detection is demonstrated using an electrochemical immunoassay method. A label-free impedimetry immunosensor for stroke biomarker was developed using modified disposable screen-printed gold electrodes (SPGE) hosting specific anti-NT-proBNP capture antibody. The performance of our immunosensor was studied in the presence of NT-proBNP in both buffered and mock (porcine) plasma samples. A linear relation between the relative total resistance (ΔRtot) responses and the NT-proBNP concentrations in buffer was observed in a range from 0.1 to 5 ng mL-1 with a correlation coefficient (R2) of 0.94656. Overall, the biosensor has demonstrated the capability to quantitate NT-proBNP and differentiate such concentrations in a low concentration range, especially among 0, 0.1, 0.5, 1, and 3 ng mL-1 in plasma samples within 25 min. This range is valuable not only for classifying cardioembolic stroke (higher or equal to 0.5 ng mL-1), but also predicting the risk of secondary stroke reoccurrence (higher than 0.255 ng mL-1). Our biosensor has the potential to be used as an easy-to-use point-of-care test that is both accurate and affordable.
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Affiliation(s)
- Prima Dewi Sinawang
- School of Materials Science and Engineering, Nanyang Technological University, Singapore
- Biosensorix Pte. Ltd., 1 Raffles Place, Singapore 048616, Singapore
| | - Dorin Harpaz
- School of Materials Science and Engineering, Nanyang Technological University, Singapore
- The Avram and Stella Goldstein-Goren Department of Biotechnology Engineering, Ben-Gurion University of the Negev , Israel
- Institute for Sports Research, Nanyang Technological University, Singapore
| | - Luka Fajs
- School of Materials Science and Engineering, Nanyang Technological University, Singapore
- Biosensorix Pte. Ltd., 1 Raffles Place, Singapore 048616, Singapore
| | - Raymond Chee Seong Seet
- Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore , Singapore
| | - Alfred Iing Yoong Tok
- School of Materials Science and Engineering, Nanyang Technological University, Singapore
- Institute for Sports Research, Nanyang Technological University, Singapore
| | - Robert S. Marks
- School of Materials Science and Engineering, Nanyang Technological University, Singapore
- The Avram and Stella Goldstein-Goren Department of Biotechnology Engineering, Ben-Gurion University of the Negev , Israel
- The National Institute for Biotechnology, The Ilse Katz Center for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev , Israel
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Dancer S, Brown AJ, Yanase LR. National Institutes of Health Stroke Scale in Plain English Is Reliable for Novice Nurse Users with Minimal Training. J Emerg Nurs 2017; 43:221-227. [DOI: 10.1016/j.jen.2016.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/06/2016] [Accepted: 09/07/2016] [Indexed: 11/28/2022]
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Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience. J Neurol Sci 2017; 376:102-105. [DOI: 10.1016/j.jns.2017.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/19/2017] [Accepted: 03/02/2017] [Indexed: 11/22/2022]
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Babadjouni RM, Walcott BP, Liu Q, Tenser MS, Amar AP, Mack WJ. Neuroprotective delivery platforms as an adjunct to mechanical thrombectomy. Neurosurg Focus 2017; 42:E4. [PMID: 28366053 DOI: 10.3171/2017.1.focus16514] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Despite the success of numerous neuroprotective strategies in animal and preclinical stroke models, none have effectively translated to clinical medicine. A multitude of influences are likely responsible. Two such factors are inefficient recanalization strategies for large vessel occlusions and suboptimal delivery methods/platforms for neuroprotective agents. The recent endovascular stroke trials have established a new paradigm for large vessel stroke treatment. The associated advent of advanced mechanical revascularization devices and new stroke technologies help address each of these existing gaps. A strategy combining effective endovascular revascularization with administration of neuroprotective therapies is now practical and could have additive, if not synergistic, effects. This review outlines past and current neuroprotective strategies assessed in acute stroke trials. The discussion focuses on delivery platforms and their potential applicability to endovascular stoke treatment.
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Affiliation(s)
| | - Brian P Walcott
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Matthew S Tenser
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Arun P Amar
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William J Mack
- Zilkha Neurogenetic Institute and.,Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Chi OZ, Mellender SJ, Kiss GK, Liu X, Weiss HR. Blood -brain barrier disruption was less under isoflurane than pentobarbital anesthesia via a PI3K/Akt pathway in early cerebral ischemia. Brain Res Bull 2017; 131:1-6. [PMID: 28238830 DOI: 10.1016/j.brainresbull.2017.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/19/2017] [Accepted: 02/21/2017] [Indexed: 01/07/2023]
Abstract
One of the important factors altering the degree of blood-brain barrier (BBB) disruption in cerebral ischemia is the anesthetic used. The phosphoinositide 3-kinase (PI3K)/Akt signaling pathway has been reported to be involved in modulating BBB permeability and in isoflurane induced neuroprotection. This study was performed to compare the degree of BBB disruption in focal cerebral ischemia under isoflurane vs pentobarbital anesthesia and to determine whether inhibition of PI3K/Akt would affect the disruption in the early stage of focal cerebral ischemia. Permanent middle cerebral artery (MCA) occlusion was performed in rats under 1.4% isoflurane or pentobarbital (50mg/kg i.p.) anesthesia with controlled ventilation. In half of each group LY294002, which is a PI3K/Akt inhibitor, was applied on the ischemic cortex immediately after MCA occlusion. After one hour of MCA occlusion, the transfer coefficient (Ki) of 14C-α-aminoisobutyric acid (14C-AIB) was determined to quantify the degree of BBB disruption. MCA occlusion increased the Ki both in the isoflurane and pentobarbital anesthetized rats. However, the value of Ki was lower under isoflurane (11.5±6.0μL/g/min) than under pentobarbital (18.3±7.1μL/g/min) anesthesia. The Ki of the contralateral cortex of the pentobarbital group was higher (+74%) than that of the isoflurane group. Application of LY294002 on the ischemic cortex increased the Ki (+99%) only in the isoflurane group. The degree of BBB disruption by MCA occlusion was significantly lower under isoflurane than pentobarbital anesthesia in the early stage of cerebral ischemia. Our data demonstrated the importance of choice of anesthetics and suggest that PI3K/Akt signaling pathway plays a significant role in altering BBB disruption in cerebral ischemia during isoflurane but not during pentobarbital anesthesia.
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Affiliation(s)
- Oak Z Chi
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA.
| | - Scott J Mellender
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Geza K Kiss
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Xia Liu
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Harvey R Weiss
- Department of Neuroscience and Cell Biology, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ, 08854, USA
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Szentes T, Kovács L, Óváry C. New hospital structure in the twenty-first century: the position of level III (tertiary) neurological and stroke care in a changing healthcare system. SPRINGERPLUS 2016; 5:2039. [PMID: 27995016 PMCID: PMC5127917 DOI: 10.1186/s40064-016-3710-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 11/21/2016] [Indexed: 11/10/2022]
Abstract
AIM The determination of the necessary capacity and number of neurology wards of level III progressivity that can be defined in the system of criteria detailed in this article and which possess optimal operating conditions in Hungarian terms. METHODS We used the National Health Insurance Company's database to calculate case numbers and capacity for different levels of neurological and stroke care. We also revised the allocation of advanced diagnostic and therapeutic technologies, and proposed changes, based on health insurance data. We also discussed these propositions with clinical experts to test their viability. RESULTS We determined the adequate number of organisational units capable of providing special neurological healthcare services on the basis of the basic data of the Hungarian healthcare system, specifying this number as 6 instead of the current 11. CONCLUSIONS In our study, we have identified significant bias in the nationwide level of neurological and stroke care organisation, which needs revised allocation of healthcare resources. Naturally, this can only be carried out through the restructuring of the emergency care system and the expansion of pre-hospital care.
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Affiliation(s)
- Tamás Szentes
- National Healthcare Service Center, Budapest, Hungary
- National Public Health and Medical Officer Service, Budapest, Hungary
- Department of Public Health, Faculty of Medicine,, Semmelweis University, Budapest, Hungary
- ÁNTSZ Országos Tisztifőorvosi Hivatal, Albert Flórián út 2, 1097 Budapest, Hungary
| | | | - Csaba Óváry
- National Institute of Clinical Neurosciences, Budapest, Hungary
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Wechsler LR, Demaerschalk BM, Schwamm LH, Adeoye OM, Audebert HJ, Fanale CV, Hess DC, Majersik JJ, Nystrom KV, Reeves MJ, Rosamond WD, Switzer JA. Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 48:e3-e25. [PMID: 27811332 DOI: 10.1161/str.0000000000000114] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Telestroke is one of the most frequently used and rapidly expanding applications of telemedicine, delivering much-needed stroke expertise to hospitals and patients. This document reviews the current status of telestroke and suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance delivery of care. METHODS A literature search was undertaken to examine the current status of telestroke and relevant quality indicators. The members of the writing committee contributed to the review of specific quality and outcome measures with specific suggestions for metrics in telestroke networks. The drafts were circulated and revised by all committee members, and suggestions were discussed for consensus. RESULTS Models of telestroke and the role of telestroke in stroke systems of care are reviewed. A brief description of the science of quality monitoring and prior experience in quality measures for stroke is provided. Process measures, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology are reviewed, and suggestions are provided for quality metrics. Additional topics include licensing, credentialing, training, and documentation.
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Reiff T, Michel P. Reasons and evolution of non-thrombolysis in acute ischaemic stroke. Emerg Med J 2016; 34:219-226. [PMID: 27797870 PMCID: PMC5502245 DOI: 10.1136/emermed-2015-205140] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/23/2016] [Accepted: 10/02/2016] [Indexed: 11/16/2022]
Abstract
Introduction Despite increasing evidence of its efficacy in advanced age or in mild or severe strokes, intravenous thrombolysis remains underused for acute ischaemic stroke (AIS). Our aim was to obtain an updated view of reasons for non-thrombolysis and to identify its changing patterns over time. Methods This is a retrospective study of prospectively collected data from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) from the years 2003–2011. Patients admitted with acute stroke in the past 24 hours who had not had thrombolysis were identified; reasons for non-thrombolysis documented in the prospectively entered data were tabulated and analysed for the group as a whole. Data were analysed for the years 2003–2006 and 2007 forward because of changes in contraindications. A subgroup of patients who arrived within the treatment window ≤180 min was separately analysed for reasons for non-thrombolysis. Predictors of non-thrombolysis were investigated via multivariate regression analyses. Results In the 2019 non-thrombolysed patients the most frequent reasons for non-thrombolysis were admission delays (66.3%), stroke severity (mostly mild) (47.9%) and advanced age (14.1%); 55.9% had more than one exclusion criterion. Among patients arriving ≤180 min after onset, the main reasons were stroke severity and advanced age. After 2006, significantly fewer patients were excluded because of age (OR 2.65, p<0.001) or (mostly mild) stroke severity (OR 10.56, p=0.029). Retrospectively, 18.7% of all non-thrombolysed patients could have been treated because they only had relative contraindications. Conclusion Onset-to-admission delays remain the main exclusion criterion for thrombolysis. Among early arrivals, relative contraindications such as minor stroke severity and advanced age were frequent. Thrombolysis rate increased with the reduction of thrombolysis restrictions (eg, age and stroke severity).
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Affiliation(s)
- T Reiff
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - P Michel
- Stroke Center, Neurology Service, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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Zock E, Kerkhoff H, Kleyweg RP, van de Beek D. Intrinsic factors influencing help-seeking behaviour in an acute stroke situation. Acta Neurol Belg 2016; 116:295-301. [PMID: 26732617 PMCID: PMC4989004 DOI: 10.1007/s13760-015-0555-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/12/2015] [Indexed: 02/03/2023]
Abstract
The proportion of stroke patients eligible for intravenous or intra-arterial treatment is still limited because many patients do not seek medical help immediately after stroke onset. The aim of our study was to explore which intrinsic factors and considerations influence help-seeking behaviour of relatively healthy participants, confronted with stroke situations. Semi-structured interviews were conducted with 25 non-stroke participants aged 50 years or older. We presented 5 clinical stroke situations as if experienced by the participants themselves. Recognition and interpretation of symptoms were evaluated and various factors influencing help-seeking behaviour were explored in-depth. We used the thematic synthesis method for data analysis. Five themes influencing help-seeking behaviour in a stroke situation were identified: influence of knowledge, views about seriousness, ideas about illness and health, attitudes towards others and beliefs about the emergency medical system. A correct recognition of stroke symptoms or a correct interpretation of the stroke situations did not automatically result in seeking medical help. Interestingly, similar factors could lead to different types of actions between participants. Many intrinsic, as well as social and environmental factors are of influence on help-seeking behaviour in an acute stroke situation. All these factors seem to play a complex role in help-seeking behaviour with considerable inter-individual variations. Accomplishing more patients eligible for acute stroke treatment, future research should focus on better understanding of all factors at various levels grounded in a theory of help-seeking behaviour.
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Blacker DJ. The future of stroke is small. FUTURE NEUROLOGY 2016. [DOI: 10.2217/fnl-2016-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- David J Blacker
- The Western Australian Neuroscience Research Institute, Nedlands, Australia
- Sir Charles Gairdner Hospital, Nedlands, Australia
- University of Western Australia, Crawley, Australia
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Chi OZ, Mellender SJ, Barsoum S, Liu X, Damito S, Weiss HR. Effects of rapamycin pretreatment on blood-brain barrier disruption in cerebral ischemia-reperfusion. Neurosci Lett 2016; 620:132-6. [PMID: 27037216 DOI: 10.1016/j.neulet.2016.03.053] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/12/2016] [Accepted: 03/28/2016] [Indexed: 02/06/2023]
Abstract
The mammalian target of rapamycin (mTOR) pathway is essential in neuronal survival and repair in cerebral ischemia. Decreases in blood-brain barrier (BBB) disruption are associated with a decrease in neuronal damage in cerebral ischemia. This study was performed to investigate how pre-inhibition of the mTOR pathway with rapamycin would affect BBB disruption and the size of the infarcted cortical area in the early stage of focal cerebral ischemia-reperfusion using quantitative analysis of BBB disruption. Rats were treated with 20mg/kg of rapamycin i.p. once a day for 2days (Rapamycin Group) or vehicle (Control Group) before transient middle cerebral artery (MCA) occlusion. After one hour of MCA occlusion and two hours of reperfusion, the transfer coefficient (Ki) of (14)C-α-aminoisobutyric acid ((14)C-AIB) to measure the degree of BBB disruption and the size of the cortical infarct were determined. Ischemia-reperfusion increased the Ki in the Rapamycin treated (+15%) as well as in the untreated control group (+13%). However, rapamycin pretreatment moderately decreased Ki in the contralateral (-30%) as well as in the ischemic-reperfused (-29%) cortex when compared with the untreated control group. Rapamycin pretreatment substantially increased the percentage of cortical infarct compared with the control group (+56%). Our data suggest that activation of mTOR pathway is necessary for neuronal survival in the early stage of cerebral ischemia-perfusion and that the reason for the enlarged cortical infarct by rapamycin pretreatment may be related to its non-BBB effects on the mTOR pathway.
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Affiliation(s)
- Oak Z Chi
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Scott J Mellender
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sylviana Barsoum
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Xia Liu
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Stacey Damito
- Department of Neuroscience and Cell Biology, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Harvey R Weiss
- Department of Neuroscience and Cell Biology, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
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Weber J, Ebinger M, Audebert HJ. Prehospital stroke care: telemedicine, thrombolysis and neuroprotection. Expert Rev Neurother 2016; 15:753-61. [PMID: 26109228 DOI: 10.1586/14737175.2015.1051967] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last 15 years, new approaches regarding neuroprotective and thrombolytic strategies in stroke management have been evaluated in the prehospital setting. These efforts have provided exciting new potentials of hyperacute stroke care. Trials have shown that the use of specialized stroke ambulances increases the proportion of patients receiving intravenous thrombolysis and shortens alarm-to-treatment time by approximately half an hour compared to standard care. Intravenous thrombolysis within the ultra-early time window of the 'golden hour' has become a realistic scenario. However, direct effects of prehospital stroke care on functional outcome have yet to be shown and other approaches such as neuroprotective treatments could not demonstrate clinical benefit so far. There is a clear need for systematic research in the prehospital field to test the clinical effectiveness and cost-effectiveness of new therapeutic strategies. It will be necessary to test various components of prehospital stroke care alone and in combination.
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Affiliation(s)
- Joachim Weber
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Henninger N, Fisher M. Extending the Time Window for Endovascular and Pharmacological Reperfusion. Transl Stroke Res 2016; 7:284-93. [DOI: 10.1007/s12975-015-0444-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/13/2015] [Accepted: 12/14/2015] [Indexed: 01/07/2023]
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Sun J, Guo Y, Wang X, Zeng Q. mHealth For Aging China: Opportunities and Challenges. Aging Dis 2016; 7:53-67. [PMID: 26816664 DOI: 10.14336/ad.2015.1011] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 10/11/2015] [Indexed: 12/17/2022] Open
Abstract
The aging population with chronic and age-related diseases has become a global issue and exerted heavy burdens on the healthcare system and society. Neurological diseases are the leading chronic diseases in the geriatric population, and stroke is the leading cause of death in China. However, the uneven distribution of caregivers and critical healthcare workforce shortages are major obstacles to improving disease outcome. With the advancement of wearable health devices, cloud computing, mobile technologies and Internet of Things, mobile health (mHealth) is rapidly developing and shows a promising future in the management of chronic diseases. Its advantages include its ability to improve the quality of care, reduce the costs of care, and improve treatment outcomes by transferring in-hospital treatment to patient-centered medical treatment at home. mHealth could also enhance the international cooperation of medical providers in different time zones and the sharing of high-quality medical service resources between developed and developing countries. In this review, we focus on trends in mHealth and its clinical applications for the prevention and treatment of diseases, especially aging-related neurological diseases, and on the opportunities and challenges of mHealth in China. Operating models of mHealth in disease management are proposed; these models may benefit those who work within the mHealth system in developing countries and developed countries.
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Affiliation(s)
- Jing Sun
- 1Department of International Inpatient, Chinese PLA General Hospital, Beijing 100853, China
| | - Yutao Guo
- 2Department of Geriatric Cardiology, Institute of Health Management, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiaoning Wang
- 3The State Key Laboratory and Normal Aging, Chinese PLA General Hospital, Beijing 100853, China
| | - Qiang Zeng
- 1Department of International Inpatient, Chinese PLA General Hospital, Beijing 100853, China
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