Time Window for Acute Stroke Management: A Cross-Sectional Study Among Community Healthcare Practitioners in Primary Care

Crosstalk between Nrf2 signaling pathway and inflammation in ischemic stroke: Mechanisms of action and therapeutic implications

One of the major causes of long-term disability and mortality is ischemic stroke that enjoys limited treatment approaches. On the one hand, oxidative stress, induced by excessive generation of reactive oxygen species (ROS), plays a critical role in post-stroke inflammatory response. Increased ROS generation is one of the basic factors in the progression of stroke-induced neuroinflammation. Moreover, intravenous (IV) thrombolysis using recombinant tissue plasminogen activator (rtPA) as the only medication approved for patients with acute ischemic stroke who suffer from some clinical restrictions it could not cover the complicated episodes that happen after stroke. Thus, identifying novel therapeutic targets is crucial for successful preparation of new medicines. Recent evidence indicates that the transcription factor Nuclear factor erythroid 2-related factor 2 (Nrf2) contributes significantly to regulating the antioxidant production in cytosol, which causes antiinflammatory effects on neurons. New findings have shown a relationship between activation of the Nrf2 and glial cells, nuclear factor kappa B (NF-κB) pathway, the nucleotide-binding domain (NOD)-like receptor family pyrin domain containing 3 (NLRP3) inflammasome signaling, and expression of inflammatory markers, suggesting induction of Nrf2 activation can represent a promising therapeutic alternative as the modulators of Nrf2 dependent pathways for targeting inflammatory responses in neural tissue. Hence, this review addresses the relationship of Nrf2 signaling with inflammation and Nrf2 activators' potential as therapeutic agents. This review helps to improve required knowledge for focused therapy and the creation of modern and improved treatment choices for patients with ischemic stroke.

Value of the stroke 1-2-0 prehospital stroke education system: the experience of a general practitioner team

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.

Assessment of stroke knowledge and awareness among primary healthcare providers: A cross-sectional survey from the Kezhou quality improvement in acute stroke care project

Objective

Acute stroke care is a highly complex type of emergency medical service (EMS) involving patient-centered care in a highly unpredictable and stressful environment with the help of several busy providers. The ability of primary healthcare providers (PHPs) to identify stroke onset early and further manage referrals to higher-level hospitals becomes critical.

Methods

We conducted a cross-sectional survey about stroke knowledge and awareness among PHPs in China from September 2021 to December 2021. A total of 289 PHPs were divided into two groups, the stroke treatment window (STW) Aware group vs. the STW Unaware group according to their knowledge on the time window for acute ischemic stroke (AIS) management. Logistic regression analysis was performed to explore the predictors associated with knowledge of the time window for acute stroke management.

Results

Of 289 PHPs surveyed during the study period, 115 (39.7%) participants were aware of the time window for stroke management and were in the STW Aware group, while 174 (60.2%) were in the STW Unaware group. Forty percent of PHPs in the STW Aware group were familiar with the secondary stroke prevention goal of &lt;140/90 mmHg, compared with 27.01% in the Unaware group (P &lt; 0.05). PHPs were not sufficiently aware of loss of consciousness also a symptom of stroke in two groups (75.7 vs. 62.6%, P &lt; 0.05). A higher proportion of PHPs in the STW Aware group believed that thrombolysis was an effective treatment for AIS (96.5 vs. 79.9%, P &lt; 0.01). Endovascular therapy is indicated for AIS was perceived by a higher proportion of PHPs in the STW Aware group than that in the Unaware group (62.6 vs. 6.9%, P &lt; 0.01). Eighty percent of PHPs in the STW Aware group reported attending training on stroke management compared with 58.1% in the Unaware group (P &lt; 0.01). Logistic regression results showed that the predictors of stroke knowledge and awareness among PHPs included sex (OR: 2.3, 95% CI, 1.2–4.6), received training (OR: 2.9, 95% CI, 1.60–5.1), and times of training per year (OR: 0.70, 95% CI, 0.6–0.9).

Conclusions

PHPs present with a mild to moderate level of stroke management knowledge in northwest China. Strategies to help increase stroke knowledge and awareness among PHPs should be considered in order to help improve the stroke related health service system.

In-Hospital Emergency Treatment Delay Among Chinese Patients with Acute Ischaemic Stroke: Relation to Hospital Arrivals and Implications for Triage Pathways

Introduction

Timely access to emergency treatment during in-hospital care phase is critical for managing the onset of acute ischaemic stroke (AIS), particularly in developing countries. We aimed to explore in-hospital emergency treatment delay and the relation of door-to-needle (DTN) time to ambulance arrivals vs walk-in arrivals.

Methods

Data were collected from 1276 Chinese AIS patients admitted to a general, tertiary-level hospital for intravenous thrombolysis. Information on patients' characteristics and time taken during in-hospital emergency treatment was retrieved from the hospital registry data and medical records. Ambulance arrival was defined as being transported by emergency ambulance services, while walk-in arrival was defined as arriving at hospital by regular vehicle. In-hospital emergency treatment delay occurred when the DTN time exceeded 60 minutes. We performed multivariable logistic regression analysis to explore the association between hospital arrivals (by ambulance vs by walk-in) and treatment delay after adjustment for age, sex, education, marital status, residence, medical insurance, number of symptoms, clinical severity and survival outcome.

Results

Over half (53.76%) of patients aged over 60 years. Around one-fifth (20.61%) of patients admitted to hospital through emergency ambulance services, while their counterparts arrived by regular vehicle. Overall, the median time taken from the hospital door to treatment initiation was 86.0 minutes. Patients arrived by ambulance (adjusted odds ratio [aOR] = 1.744, 95% confidence interval [CI] = 1.185-2.566, p = 0.005), had higher socio-economic status (aOR = 1.821, 95% CI = 1.251-2.650; p = 0.002), or paid out-of-pocket (aOR = 2.323, 95% CI = 1.764-3.060; p < 0.001) had an increased likelihood of in-hospital emergency treatment delays.

Conclusion

In-hospital emergency treatment delay is common in China, and occurs throughout the entire emergency treatment journey. Having a triage pathway involving hospital arrival by ambulance seems to be more likely to experience in-hospital emergency treatment delay. Further efforts to improve triage pathways may require qualitative evidence on provider- and institutional-level factors associated with in-hospital emergency treatment delay.