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Shkoruta DP, Senkiv V, Vovchuk V, Popadynets O, Kotyk T. Impact of war on stroke incidence in Ivano-Frankivsk, Ukraine. Sci Rep 2024; 14:18996. [PMID: 39152236 PMCID: PMC11329696 DOI: 10.1038/s41598-024-70270-4] [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: 06/08/2024] [Accepted: 08/14/2024] [Indexed: 08/19/2024] Open
Abstract
Stroke is an extensive health problem in Ukraine, the prominence and effects of which are aggravated by the burden of the ongoing Russo-Ukrainian War. In this study, we aimed to holistically examine the overall stroke epidemiology in Ivano-Frankivsk using data from a secondary healthcare center in the city. We determine an increasing trend in stroke admissions since 2020, with a notable 22.4% increase in 2023, mainly due to ischemic stroke occurrence. In the same year, a significant non-linear relationship between stroke incidence and frequency of news about attacks was observed. Ordinal regression analysis of general sociodemographic, clinical, and healthcare-related factors influencing outcomes for intravenous thrombolysis-treated patients, revealed the significance of the 24-h National Institutes of Health Stroke Scale score (0.32 ± 0.03) and interaction of age and Door-to-Needle Time (- 0.28 ± 0.08). However, the extension of the latter independently is not significantly correlated with patient outcomes. In conclusion, war-induced stress, intranational migrations, and lack of adequate chronic cardiovascular disease management are primarily responsible for these results. Modulations and improvements to the current healthcare system, including managing chronic diseases and early stroke symptom recognition, are necessary to optimize patient outcomes.
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Affiliation(s)
- Dominika Paula Shkoruta
- Department of Human Anatomy, Ivano-Frankivsk National Medical University, Halytska 2, Ivano-Frankivsk, 76018, Ukraine
| | - Vasylyna Senkiv
- Department of Human Anatomy, Ivano-Frankivsk National Medical University, Halytska 2, Ivano-Frankivsk, 76018, Ukraine
| | - Volodymyr Vovchuk
- Ivano-Frankivsk Central City Clinical Hospital, Mazepy 114, Ivano-Frankivsk, 76018, Ukraine
- Department of Social Medicine and Public Health, Ivano-Frankivsk National Medical University, Halytska 2, Ivano-Frankivsk, 76018, Ukraine
| | - Oksana Popadynets
- Department of Human Anatomy, Ivano-Frankivsk National Medical University, Halytska 2, Ivano-Frankivsk, 76018, Ukraine
| | - Taras Kotyk
- Department of Human Anatomy, Ivano-Frankivsk National Medical University, Halytska 2, Ivano-Frankivsk, 76018, Ukraine.
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Uchida K, Yamagami H, Sakai N, Shirakawa M, Beppu M, Toyoda K, Matsumaru Y, Matsumoto Y, Todo K, Hayakawa M, Shindo S, Ota S, Morimoto M, Takeuchi M, Imamura H, Ikeda H, Tanaka K, Ishihara H, Kakita H, Sano T, Araki H, Nomura T, Sakakibara F, Yoshimura S. Endovascular therapy for acute intracranial large vessel occlusion due to atherothrombosis: Multicenter historical registry. J Neurointerv Surg 2024; 16:884-891. [PMID: 37648433 DOI: 10.1136/jnis-2023-020670] [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: 06/06/2023] [Accepted: 08/04/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Atherothrombotic stroke-related large vessel occlusion (AT-LVO) is caused by two etiologies, the intracranial artery occlusion due to in situ occlusion (intracranial group) or due to embolism from cervical carotid occlusion or stenosis (tandem group). The prognosis and reocclusion rate of each etiology after endovascular therapy (EVT) is unclear. METHODS We conducted a historical multicenter registry study at 51 Japanese centers to compare the prognoses of AT-LVO between two etiologies. The primary outcome was the incidence of recurrent ischemic stroke or reocclusion of the treated vessels within 90 days after EVT. Each of the primary outcome means the incidence of recurrent ischemic stroke and reocclusion of the treated vessels within 90 days after EVT. RESULTS We analyzed 582 patients (338 in the intracranial group and 244 in the tandem group). Patients in the intracranial group were younger (mean 71.9 vs 74.5, p=0.003), more of them were female and fewer of them were current smokers than those in the tandem group. In the tandem group, the patients' National Institutes of Health Stroke Scale score on admission was higher (13 vs 15, p=0.006), onset to puncture time was shorter (299 [145-631] vs 232 [144-459] minutes, p=0.03) and Alberta Stroke Program Early CT Score (ASPECTS) was lower (8 [7-9] vs 8 [6-9], p=0.0002). The primary outcome was higher in the intracranial group (22.5% vs 8.2%, p<0.0001). However, any ICH and death were not significantly different in the two groups. CONCLUSIONS The incidence of recurrent ischemic stroke or reocclusion after EVT for AT-LVO was higher in the intracranial group.
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Affiliation(s)
- Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Nobuyuki Sakai
- Neurovascular Research & Neuroendovascular Therapy, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Mikiya Beppu
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasushi Matsumoto
- Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Sendai, Japan
| | - Kenichi Todo
- Stroke Center, Osaka University Graduate School of Medicine, Suita, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Seigo Shindo
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
- Department of Neurology, Kumamoto University, Kumamoto, Japan
| | - Shinzo Ota
- Department of Neurosurgery, Brain Attack Center Ota Memorial Hospital, Fukuyama, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | | | - Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
| | - Hiroto Kakita
- Department of Neurosurgery, Shimizu Hospital, Kyoto, Japan
| | - Takanori Sano
- Department of Neurosurgery, Japanese Red Cross Ise Hospital, Ise, Japan
| | - Hayato Araki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan
| | - Tatsufumi Nomura
- Neuroendovasucular Therapy Center, Ohkawara Neurosurgical Hospital, Muroran, Japan
| | | | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
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Smith FS, Whisenant M, Johnson CM, Burnett J, Savitz SI, Beauchamp JES. Development of an Acute Stroke Care Seeking Framework. J Neurosci Nurs 2024:01376517-990000000-00100. [PMID: 39133535 DOI: 10.1097/jnn.0000000000000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
ABSTRACT BACKGROUND: A multitude of variables influence an individual's decision to seek care in emergency situations. By recognizing these variables and their impact on the timeline of an individual seeking care for a stroke, nurses have an opportunity to positively affect the outcomes of stroke within the community. The purpose of this narrative review was to develop a research framework describing the variables involved in care seeking during an acute stroke. METHODS: Using a theory synthesis methodology that included variable identification and the establishment of relationships between variables based on existing literature, a framework describing variables relevant to acute stroke care seeking behavior was developed. RESULTS: Fourteen recently published studies reported significant variables related to seeking emergency medical care during the hyperacute phase of a stroke. Eight variables were identified and characterized as either promoters or distractors. Promoters led an individual to seek acute stroke care earlier, such as perceived symptom severity, stroke knowledge, and the presence of others. Distractors led an individual to delay seeking acute stroke care and resulted in later hospital arrival times, such as a lack of social network or resources, comorbid conditions, and incongruity with the local health system. CONCLUSION: Although individual decision making is exceedingly complex and varies by individual and situation, the developed acute stroke care seeking framework may provide a basis on which to develop stroke awareness programs and interventions targeted at individuals at risk for delayed acute stroke care.
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Yazıcı R, Güner M, Basa Kalafat AF, Tapkan RB, Kaya H, Yeniyurt B, Fettahoğlu S, Kalafat UM, Bala ED, Doğan S. Evaluation of Hemoglobin and Eosinophil Count in Patients Receiving Thrombolytic Treatment. Cureus 2024; 16:e64575. [PMID: 39144905 PMCID: PMC11323790 DOI: 10.7759/cureus.64575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Background and aim Stroke ranks among the primary contributors to disability and mortality on a global scale. Recent advances in ischemic stroke pathophysiology emphasize the significant role of the immune system in both stroke-related damage and neuroprotection. This article investigates the relationship between hemoglobin level and white blood cell count. Materials and methods From January 1, 2019, to April 1, 2022, all patients aged 18 years and over who were diagnosed with acute ischemic stroke in the emergency department of Kanuni Sultan Süleyman Training and Research Hospital and treated with intravenous recombinant tissue plasminogen activator (r-tPA) within 4.5 hours of stroke onset were included in this cross-sectional retrospective study. Gender, age, onset of symptoms, complaints, National Institutes of Health Stroke Scale (NIHSS) score, stroke-affected area, as well as leukocyte, neutrophil, platelet, eosinophil, lymphocyte, and hemoglobin levels were recorded and compared between mortality and survivor groups. Results A total of 61 people, including 33 men and 28 women, were included in the study. Four patients died during follow-ups. The mean duration of symptoms upon admission was 86.23 ± 56.37 minutes. The mean NIHSS score of patients was found to be 9.16 ± 3.88 (minimum: 4, maximum: 18). There was a statistically significant positive correlation between age and symptom duration (p < 0.002, r: 0.391). A statistically significant negative correlation was found between eosinophil count and NIHSS score (p < 0.012, r: -0.321) and between eosinophil count and symptom duration (p < 0.042, r: -0.261). There was a negative correlation between hemoglobin levels and mortality (p < 0.013, r: -0.318). A statistically significant negative correlation was observed between the eosinophil-to-neutrophil ratio (ENR) and NIHSS score (p < 0.017, r: -0.305) as well as between ENR and symptom duration (p < 0.034, r: -0.271). Hemoglobin is a significant predictor of mortality in the logistic regression model (p < 0.05, CI: 0.253-0.942). For each one-unit increase in hemoglobin, the odds of mortality decrease by a factor of 0.488. Conclusion Certain blood cell types (neutrophils, eosinophils, and lymphocytes) play an active role in determining stroke prognosis. A detailed explanation of the role of leukocyte types lays the foundation for "immunomodulation," which could be a promising novel treatment modality for future stroke patients.
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Affiliation(s)
- Ramiz Yazıcı
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Muhammed Güner
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Ayşe F Basa Kalafat
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Rabia B Tapkan
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Hilmi Kaya
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Bilal Yeniyurt
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Salih Fettahoğlu
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Utku M Kalafat
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Efe D Bala
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
| | - Serkan Doğan
- Emergency Medicine, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, İstanbul, TUR
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Liao Y, Qi W, Li S, Shi X, Wu X, Chi F, Xia R, Qin L, Cao L, Ren L. Analysis of onset-to-door time and its influencing factors in Chinese patients with acute ischemic stroke during the 2020 COVID-19 epidemic: a preliminary, prospective, multicenter study. BMC Health Serv Res 2024; 24:615. [PMID: 38730381 PMCID: PMC11084012 DOI: 10.1186/s12913-024-11088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Pre-hospital delay in China is a serious issue with unclear relevant reasons, seriously impeding the adoption of appropriate measures. Herein, we analyzed the onset-to-door time (ODT) in Chinese patients with acute ischemic stroke (AIS) and its influencing factors. METHODS We prospectively recruited 3,459 patients with AIS from nine representative tertiary general hospitals in China between January and June 2022. Patients were divided into ODT ≤ 3 h and ODT > 3 h groups. Following single-factor analysis, binary logistic regression analysis was performed to evaluate the risk factors leading to pre-hospital delay. RESULTS In total, 763 (21.83%) patients arrived at the hospital within 3 h of onset. After adjusting for confounding factors, the risk factors for ODT were residence in rural areas (odds ratio [OR]: 1.478, 95% credibility interval [CI]: 1.024-2.146) and hospital transfer (OR: 7.479, 95% CI: 2.548-32.337). The protective factors for ODT were location of onset ≤ 20 km from the first-visit hospital (OR: 0.355, 95% CI: 0.236-0.530), transportation by emergency medical services (OR: 0.346, 95% CI: 0.216-0.555), history of atrial fibrillation (OR: 0.375, 95% CI: 0.207-0.679), moderate stroke (OR: 0.644, 95% CI: 0.462-0.901), and severe stroke (OR: 0.506, 95% CI: 0.285-0.908). CONCLUSIONS Most patients with AIS fail to reach a hospital within the critical 3-h window. The following measures are recommended to reduce pre-hospital delays: reasonable distribution of hospitals accessible to nearby residents, minimizing interhospital transfer, paying attention to patients with mild stroke, and encouraging patients to use ambulance services. Pre-hospital delays for patients can be reduced by implementing these measures, ultimately improving the timeliness of treatment and enhancing patient prognosis. This study was carried out amid the COVID-19 pandemic, which presented challenges and constraints.
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Affiliation(s)
- Yuqi Liao
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Wenwei Qi
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuting Li
- School of Statistics, Shandong Technology and Business University, Yantai, China
| | - Xin Shi
- School of Statistics, Shandong Technology and Business University, Yantai, China
- School of Health Management, China Medical University, Shenyang, China
| | - Xiaohong Wu
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Feng Chi
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Runyu Xia
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Limin Qin
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China.
- Hunan Provincial Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China.
| | - Lijie Ren
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
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Rossis C, Michail KA, Middleton N, Karanikola M, Papathanassoglou E, Mpouzika M. Knowledge on Stroke Recognition and Management among Emergency Department Healthcare Professionals in the Republic of Cyprus. Healthcare (Basel) 2023; 12:77. [PMID: 38200983 PMCID: PMC10778653 DOI: 10.3390/healthcare12010077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
Stroke is a global leading cause of death and disability. Knowledge of related guidelines is crucial for emergency department (ED) staff, influencing early diagnosis and timely treatment. We investigated Greek Cypriot ED healthcare professionals' (nurses and physicians) knowledge in recognizing and managing stroke. A descriptive cross-sectional study spanned November 2019 to April 2020, encompassing four private and seven public EDs in the Republic of Cyprus. The data were collected through a self-reported questionnaire developed by the research team, consisting of 37 questions. Eight questions focused on sociodemographic and employment characteristics, twenty-eight assessed knowledge in stroke recognition and management (each item was equally weighted without deliberate prioritization), and one question addressed self-assessment of knowledge in stroke care. A total of 255 nurses (response rate (RR): 74.1%) and 26 physicians (RR: 47.3%) completed the questionnaire. The average correct response rate was 12.9 out of 28 statements (SD: 4.2), with nurses and physicians scoring 12.6 (SD: 4.1) and 15.7 (SD: 4), respectively. Work experience significantly influenced stroke knowledge, with all groups demonstrating superiority over those with less than one year of experience. Participants with previous training scored an average of 1.45 additional correct answers while educational attainment did not significantly influence stroke knowledge. Investigating stroke knowledge among emergency department nurses and physicians in the Republic of Cyprus revealed significant deficits. This study stresses targeted interventions, including education, yearly examinations, workshops with hands-on training, and repeated training, to address these gaps and enhance the overall stroke care capabilities of the healthcare professionals.
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Affiliation(s)
| | - Koralia A. Michail
- Department of Nursing, Cyprus University of Technology, 3041 Limassol, Cyprus; (K.A.M.); (N.M.); (M.K.)
| | - Nicos Middleton
- Department of Nursing, Cyprus University of Technology, 3041 Limassol, Cyprus; (K.A.M.); (N.M.); (M.K.)
| | - Maria Karanikola
- Department of Nursing, Cyprus University of Technology, 3041 Limassol, Cyprus; (K.A.M.); (N.M.); (M.K.)
| | | | - Meropi Mpouzika
- Department of Nursing, Cyprus University of Technology, 3041 Limassol, Cyprus; (K.A.M.); (N.M.); (M.K.)
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Liu Y, Wang D, Chu M, Yang Z, Luo Y, Wang D, Zhao J. Value of the stroke 1-2-0 prehospital stroke education system: the experience of a general practitioner team. BMC Neurol 2023; 23:431. [PMID: 38062426 PMCID: PMC10770900 DOI: 10.1186/s12883-023-03476-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Stroke is one of the leading causes of death worldwide, especially in developing countries. In China, there is an urgent need to educate people about stroke awareness and the importance of using emergency medical services (EMS) quickly after a stroke has occurred. OBJECTIVE We sought to explore the effects of the Stroke 1-2-0 Prehospital Stroke Education System based on the experience of a general practitioner team. METHOD We prospectively enrolled 119 community general practitioners to be trained in the procedures advocated by the Stroke 1-2-0 Prehospital Stroke Education System. The training content included early detection of ischemic stroke, first aid for stroke, and intravenous thrombolysis; The effects of the training were later evaluated via a before-and-after comparison. The 119 enrolled physicians formed a Stroke 1-2-0 lecturer group and taught stroke knowledge to community residents. The group remained active for 6 months, during which the medical treatment data of stroke patients (i.e., stroke onset time, prehospital delay, whether an ambulance was called, and whether thrombolytic therapy was performed) in each of 5 jurisdictions were recorded for the month before (January 2021) and that after (August 2021) the 6-month community education program. Finally, the effects of the community education program were evaluated. RESULTS The participants' understanding of intravenous thrombolysis in the treatment of acute ischemic stroke improved significantly after the training as compared with their earlier understanding (96% vs. 78.99%; P < .001), and their understanding of the time window for intravenous thrombolysis increased from 26.05% before to 72% (P < .001) after the training. Most of the participants (90% vs. 67.23%; P < .001) said that they would immediately call the 120 emergency number of China's emergency phone system if they encountered individuals who appeared to be victims of acute stroke. A total of 82 stroke patients were seen before and 67 after the community education program. As for the use of the emergency call system, more patients with stroke activated that system after the program versus before (21.95% vs. 37.31%; P = .04). The 3-hour arrival rate after the program was nearly three times higher than that before the program (62.69% vs. 19.51%; P < .001). Also, regarding receiving thrombolysis after the occurrence of a stroke, the program triggered a substantial increase compared with the total earlier (19.4% vs. 6.1%; P = .013). CONCLUSION We found that the Stroke 1-2-0 Prehospital Stroke Education System significantly improved community residents' knowledge regarding stroke.
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Affiliation(s)
- Yang Liu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
- Institute of Science and Technology for Brain-inspired Intelligence, Fudan University, Shanghai, China
| | - Daosheng Wang
- Department of Neurosurgery, Minhang Hospital, Fudan University, Shanghai, China
| | - Min Chu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Zhenzhen Yang
- Department of General Medicine, Xinzhuang Community Health Service Center, Shanghai, China
| | - Yunhe Luo
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Delong Wang
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China.
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Peng Z. Efficacy and safety of Agatroban in improving the prognosis of ischemic stroke patients. Am J Transl Res 2023; 15:5699-5706. [PMID: 37854211 PMCID: PMC10579034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/28/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE To explore and analyze the efficacy and safety of combined treatment of Agatroban and Aspirin in improving short-term and long-term prognosis of ischemic stroke patients. METHODS In this retrospective study, the clinical data of patients with ischemic stroke admitted to the Department of Neurology, Songjiang Sijing Hospital from June 2021 to April 2023 were analyzed. A total of 108 patients were selected according to the inclusion and exclusion criteria, including 54 patients treated with Aspirin only, named the control group, and 54 patients treated with Agatroban plus Aspirin, named the study group. RESULTS Compared with the control group, the study group had a higher effective rate (P=0.047). There was no significant difference in MIESSS and daily living ability scores between the two groups before treatment (P>0.05). After treatment, compared with the control group, the study group had a lower MIESSS score and a higher daily living ability score (P=0.035; P=0.044). There was no significant difference in coagulation indicators between the two groups before treatment (P>0.05). After treatment, compared with the control group, the study group had lower platelet count, fibrinogen, and D-dimer levels (P=0.031; P=0.042; P=0.047). There was no significant difference in inflammatory cytokines between the two groups before treatment (P>0.05). After treatment, compared with the control group, the study group showed significantly decreased tumor necrosis factor (TNF)-α, interleukin-6 (IL-6) and interleukin-8 (IL-8) (P=0.041; P=0.038; P=0.046). Compared with the control group, the incidence of adverse reactions in the study group was lower (P=0.033), while the prognosis was better (P=0.029; P=0.033; P=0.048). CONCLUSION Compared with Aspirin alone, Argatroban plus Aspirin can optimize coagulation parameters to a greater extent and reduce the level of cellular inflammatory factors, further improve the body's neurological functions, remarkably reduce the occurrence of adverse prognosis, and enhance the patient's ability of daily living, with remarkable therapeutic effect.
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Affiliation(s)
- Zhifang Peng
- Internal Medicine-Neurology, Shanghai Songjiang Sijing Hospital Shanghai 201601, China
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Zhang Y, Jing Y, Zhu Y, Jiang T, Tang X, Yi W. Radio frequency identification technology reduce intravenous thrombolysis time in acute ischemic stroke. PLoS One 2023; 18:e0288207. [PMID: 37467248 DOI: 10.1371/journal.pone.0288207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023] Open
Abstract
PURPOSE To inspect whether time management with radio frequency identification technology (RFID) reduces symptom onset-to-intravenous thrombolysis time (OTT) in acute ischemic stroke (AIS). METHODS In the retrospective study, patients with AIS, transferred by Emergency Medical Services (EMS) to Hunan Provincial People's Hospital between September 2019 to June 2022, divided into three groups, as traditional group, in-hospital RFID group and whole process RFID group. Baseline characteristics and time metrics were compared. RESULTS After the whole emergency process applied with RFID time management, Door to intravenous thrombolysis time (DNT) was reduced from 125.00±43.16 min to 32.59±25.45 min (F = 121.857, p<0.001), and OTT was reduced from 235.53±57.27 min to 144.31±47.96 min (F = 10.377, p<0.001). CONCLUSIONS Time management with RFID is effective in reducing OTT in AIS patients with thrombolysis treatment.
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Affiliation(s)
- Yixiong Zhang
- The First People's Hospital of Huaihua, Huaihua City, China
| | - Yingxia Jing
- Poisoning Research Laboratory, Institute of Emergency Medicine, Hunan Provincial People's Hospital, The First Affiliate Hospital of Hunan Normal University, Changsha City, China
| | - Yimin Zhu
- Poisoning Research Laboratory, Institute of Emergency Medicine, Hunan Provincial People's Hospital, The First Affiliate Hospital of Hunan Normal University, Changsha City, China
| | - Tao Jiang
- The First People's Hospital of Huaihua, Huaihua City, China
| | - Xianyi Tang
- Poisoning Research Laboratory, Institute of Emergency Medicine, Hunan Provincial People's Hospital, The First Affiliate Hospital of Hunan Normal University, Changsha City, China
| | - Weichen Yi
- The First People's Hospital of Huaihua, Huaihua City, China
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Alonso-Alonso ML, Sampedro-Viana A, Rodríguez-Yáñez M, López-Dequidt I, Pumar JM, Mosqueira AJ, Fernández-Rodicio S, Bazarra-Barreiros M, Sobrino T, Campos F, Castillo J, Hervella P, Iglesias-Rey R. Influence of Temperature Chronobiology on Stroke Outcome. Int J Mol Sci 2023; 24:ijms24043746. [PMID: 36835156 PMCID: PMC9967262 DOI: 10.3390/ijms24043746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
The circadian system regulates numerous physiological variables, including body temperature. Additionally, a circadian patter has been described in stroke onset. Considering this, we hypothesised that the chronobiology of temperature may have an impact on stroke onset and functional outcomes. We also studied the variation of blood biomarkers according to stroke onset time. This is a retrospective observational study. Of the patients included, 2763 had a stroke between midnight and 8:00 h; 1571 between 8:00-14:00 h; and 655 between 14:00 h and midnight. Axillary temperature was measured at admission. At this time, blood samples were collected for biomarker analysis (TNF-α, IL-1β, IL-6, IL-10, and glutamate). Temperature was higher in patients admitted from 8:00 h to midnight (p < 0.0001). However, the percentage of poor outcome at 3 months was highest in patients from midnight to 8:00 h (57.7%, p < 0.001). The association between temperature and mortality was highest during night time (OR: 2.79; CI 95%: 2.36-3.28; p < 0.001). These patients exhibited high glutamate (220.2 ± 140.2 µM), IL-6 (32.8 ± 14.3 pg/mL) and low IL-10 (9.7 ± 14.3 pg/mL) levels. Therefore, temperature chronobiology could have a significant impact on stroke onset and functional outcome. Superficial body hyperthermia during sleep seems to be more dangerous than during wakefulness. Further studies will be necessary to confirm our data.
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Affiliation(s)
- Maria Luz Alonso-Alonso
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Ana Sampedro-Viana
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Manuel Rodríguez-Yáñez
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Iria López-Dequidt
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - José M. Pumar
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Department of Neuroradiology, Hospital Clínico Universitario, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Antonio J. Mosqueira
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Department of Neuroradiology, Hospital Clínico Universitario, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Sabela Fernández-Rodicio
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Marcos Bazarra-Barreiros
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Tomás Sobrino
- NeuroAging Group (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Francisco Campos
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - José Castillo
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Pablo Hervella
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Ramón Iglesias-Rey
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Correspondence:
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11
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Shin J, Kim H, Kim Y, Moon J, Lee J, Jung S, Hwang R, Kim MY. Association between Prehospital Visits and Poor Health Outcomes in Korean Acute Stroke Patients: A National Health Insurance Claims Data Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2488. [PMID: 36767860 PMCID: PMC9915235 DOI: 10.3390/ijerph20032488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 06/18/2023]
Abstract
This study aimed to determine whether prehospital visits to other medical institutions before admission are associated with prolonged hospital stay, readmission, or mortality rates in acute stroke patients. Using the claims data from the Korean Health Insurance Service, a cross-sectional study was conducted on 58,418 newly diagnosed stroke patients aged ≥ 20 years from 1 January 2019 to 31 December 2019. Extended hospital stay (≥7 days; median value) following initial admission, readmission within 180 days after discharge, and all-cause mortality within 30 days were measured as health outcomes using multiple logistic regression analysis after adjusting for age, sex, income, residential area, and medical history. Stroke patients with a prehospital visit (10,992 patients, 18.8%) had a higher risk of long hospitalization (odds ratio = 1.06; 95% confidence interval = 1.02-1.10), readmission (1.19; 1.14-1.25), and mortality (1.23; 1.13-1.33) compared with patients without a prehospital visit. Female patients and those under 65 years of age had increased unfavorable outcomes (p < 0.05). Prehospital visits were associated with unfavorable health outcomes.
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Affiliation(s)
- Jinyoung Shin
- Department of Family Medicine, School of Medicine, Konkuk University, Seoul 05029, Republic of Korea
| | - Hyeongsu Kim
- Department of Preventive Medicine, School of Medicine, Konkuk University, Seoul 05029, Republic of Korea
| | - Youngtaek Kim
- Department of Preventive Medicine, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Jusun Moon
- Department of Neurology, National Medical Center, Seoul 04564, Republic of Korea
| | - Jeehye Lee
- National Emergency Medical Center, National Medical Center, Seoul 04564, Republic of Korea
| | - Sungwon Jung
- Department of Nursing, Fareast University, Eumseong 27601, Republic of Korea
| | - Rahil Hwang
- Department of Nursing, College of Nursing, Shinhan University, Uijeongbu 11644, Republic of Korea
| | - Mi Young Kim
- Department of Nursing, College of Nursing, Hanyang University, Seoul 15588, Republic of Korea
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12
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Revathi S, Kavitha MS, Shankar V. Factors Associated with Prehospital Delay in Patients with Acute Stroke in South India. Indian J Community Med 2023; 48:82-90. [PMID: 37082411 PMCID: PMC10112740 DOI: 10.4103/ijcm.ijcm_213_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 09/21/2022] [Indexed: 12/03/2022] Open
Abstract
Background Early hospital presentation is critical in the management of acute ischemic stroke. The effectiveness of stroke treatment is highly dependent on the amount of time lapsed between onset of symptoms and treatment. This study was aimed to identify the factors associated with prehospital delay in patients with acute stroke. Material and Methods A cross-sectional descriptive study was conducted in Sri Ramachandra University Hospital, India. A total of 210 patients hospitalized in the stroke unit were included. Patients' data were obtained by interviewing the patient and/or accompanying family member and by reviewing their medical records using a standard questionnaire. Associations were determined between prehospital delay (≥4.5 h) and variables of interest by using univariate and multivariate logistic regression analyses. Results The prehospital delay was observed in 154 patients (73.3%) and the median prehospital delay was 11.30 h. The following are the factors significantly (P < 0.05) attributed for the delay in presenting to the hospital: contextual factors like using public transport (bus), taxi, time of onset of symptoms, 7 pm-3 am; family history of stroke, perceived cognitive and behavioral factors like, wishing or praying for the symptoms to subside on its own, hesitation to travel due to long distance, delay in arranging transport, and arranging money for admission and wasting time by shopping for general practitioners, nursing homes, and hospitals. The presence of stroke symptom, headache, significantly decreased the prehospital delay. Conclusions Prehospital delay is high in South India and influenced by clinical, contextual, and cognitive/behavioral factors.
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Affiliation(s)
- S Revathi
- Professor, Faculty of Nursing, Northern Border University, Arar, KSA
- Department of Community Health Nursing, College of Nursing, Sri Ramachandra University, Chennai, Tamil Nadu, India
| | - M S Kavitha
- Department of Community Health Nursing, College of Nursing, Sri Ramachandra University, Chennai, Tamil Nadu, India
| | - V Shankar
- Department of Neurology, Sri Ramachandra University, Chennai, Tamil Nadu, India
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13
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di Biase L, Bonura A, Caminiti ML, Pecoraro PM, Di Lazzaro V. Neurophysiology tools to lower the stroke onset to treatment time during the golden hour: microwaves, bioelectrical impedance and near infrared spectroscopy. Ann Med 2022; 54:2658-2671. [PMID: 36154386 PMCID: PMC9542520 DOI: 10.1080/07853890.2022.2124448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reperfusion therapy administration timing in acute ischaemic stroke is the main determinant of patients' mortality and long-term disability. Indeed, the first hour from the stroke onset is defined the "golden hour", in which the treatment has the highest efficacy and lowest side effects. Delayed ambulance transport, inappropriate triage and difficulty in accessing CT scans lead to delayed onset to treatment time (OTT) in clinical practice. To date brain CT scan is needed to rule out intracranial haemorrhage, which is a major contraindication to thrombolytic therapy. The availability, dimension and portability make CT suitable mainly for intrahospital use, determining further delays in the therapies administration. This review aims at evaluating portable neurophysiology technologies developed with the scope of speeding up the diagnostic phase of acute stroke and, therefore, the initiation of intravenous thrombolysis. Medline databases were explored for studies concerning near infrared spectroscopy (NIRS), bioelectrical impedance spectroscopy (BIS) and Microwave imaging (MWI) as methods for stroke diagnosis. A total of 1368 articles were found, and 12 of these fit with our criteria and were included in the review. For each technology, the following parameters were evaluated: diagnostic accuracy, ability to differentiate ischaemic and haemorrhagic stroke, diagnosis time from stroke onset, portability and technology readiness level (TRL). All the described methods seem to be able to identify acute stroke even though the number of studies is very limited. Low cost and portability make them potentially usable during ambulance transport, possibly leading to a reduction of stroke OTT along with the related huge benefits in terms of patients outcome and health care costs. In addition, unlike standard imaging techniques, neurophysiological techniques could allow continuous monitoring of patients for timely intrahospital stroke diagnosis.KEY MESSAGESFirst hour from the stroke onset is defined the "golden hour", in which the treatment has the highest efficacy and lowest side effects.The delay for stroke onset to brain imaging time is one of the major reasons why only a minority of patients with acute ischaemic stroke are eligible to reperfusion therapies.Neurophysiology techniques (NIRS, BIS and MWI) could have a potential high impact in reducing the time to treatment in stroke patients.
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Affiliation(s)
- Lazzaro di Biase
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy.,Brain Innovations Laboratory, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Adriano Bonura
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Maria Letizia Caminiti
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Pasquale Maria Pecoraro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
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14
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Kuang J, Zhu X, Yang L, Gao Z, Wei X, Zhou K, Xu M. Factors influencing alertness to premonitory symptoms in stroke patients with pre-hospital delay. Public Health Nurs 2022; 39:1204-1212. [PMID: 35714655 DOI: 10.1111/phn.13108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 05/01/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose was to explore the alertness of premonitory symptoms in stroke patients with prehospital delay, and to analyze the influencing factors. DESIGN AND SAMPLE A cross-sectional study using the convenience sampling method was conducted in the neurology department of a general hospital between November 2018 and July 2019. A total of 352 stroke patients were participated in the survey. MEASURES A hierarchical multiple regression was performed to analyze the factors related to the alertness of premonitory symptoms (0-9 scores) in stroke patients with prehospital delay. RESULTS The alertness score was 6.53 ± 2.377. The lowest score of 0.55 ± 0.498 was for "Continuous yawning occurs continuously despite no tiredness or lack of sleep is okay, and need not be treated." The hierarchical regression results revealed that symptom onset, symptom change before admission, knowledge, social support were the influencing factors delaying the alertness of premonitory symptoms. Knowledge and support from friends could improve the alertness, while support from family and other support had a notable negative impact. CONCLUSIONS Stroke patients need to be more alert toward premonitory symptoms. This alertness is related to stroke knowledge and social support. Nurses should formulate interventions and advise stroke patients to improve their stroke knowledge and expand their social network.
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Affiliation(s)
- Jinke Kuang
- School of Nursing, Qingdao University, Qingdao, Shandong Province, China
| | - Xuemei Zhu
- School of Nursing, Harbin Medical University/The 2nd Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Li Yang
- School of Nursing, Qingdao University, Qingdao, Shandong Province, China
| | - Zihan Gao
- School of Nursing, Qingdao University, Qingdao, Shandong Province, China
| | - Xiao Wei
- School of Nursing, Qingdao University, Qingdao, Shandong Province, China
| | - Kexin Zhou
- School of Nursing, Qingdao University, Qingdao, Shandong Province, China
| | - Mengfan Xu
- School of Nursing, Qingdao University, Qingdao, Shandong Province, China
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15
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Kaloss AM, Theus MH. Leptomeningeal anastomoses: Mechanisms of pial collateral remodeling in ischemic stroke. WIREs Mech Dis 2022; 14:e1553. [PMID: 35118835 PMCID: PMC9283306 DOI: 10.1002/wsbm.1553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 12/13/2022]
Abstract
Arterial collateralization, as determined by leptomeningeal anastomoses or pial collateral vessels, is a well‐established vital player in cerebral blood flow restoration and neurological recovery from ischemic stroke. A secondary network of cerebral collateral circulation apart from the Circle of Willis, exist as remnants of arteriole development that connect the distal arteries in the pia mater. Recent interest lies in understanding the cellular and molecular adaptations that control the growth and remodeling, or arteriogenesis, of these pre‐existing collateral vessels. New findings from both animal models and human studies of ischemic stroke suggest a multi‐factorial and complex, temporospatial interplay of endothelium, immune and vessel‐associated cell interactions may work in concert to facilitate or thwart arteriogenesis. These valuable reports may provide critical insight into potential predictors of the pial collateral response in patients with large vessel occlusion and may aid in therapeutics to enhance collateral function and improve recovery from stroke. This article is categorized under:Neurological Diseases > Molecular and Cellular Physiology
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Affiliation(s)
- Alexandra M Kaloss
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
| | - Michelle H Theus
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA.,School of Neuroscience, Virginia Tech, Blacksburg, Virginia, USA.,Center for Regenerative Medicine, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
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