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Weber JE, Angermaier A, Bollweg K, Erdur H, Ernst S, Flöel A, Gorski C, Kandil FI, Kinze S, Kleinsteuber K, Kurth T, Schmehl I, Theen S, Endres M, Audebert HJ. Acute neurological care in north-east Germany with telemedicine support (ANNOTeM): protocol of a multi-center, controlled, open-label, two-arm intervention study. BMC Health Serv Res 2020; 20:755. [PMID: 32807159 PMCID: PMC7430113 DOI: 10.1186/s12913-020-05576-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/23/2020] [Indexed: 11/09/2022] Open
Abstract
Background Both diagnosis and treatment of neurological emergencies require neurological expertise and are time-sensitive. The lack of fast neurological expertise in regions with underserved infrastructure poses a major barrier for state-of-the-art care of patients with acute neurological diseases and leads to disparity in provision of health care. The main purpose of ANNOTeM (acute neurological care in North East Germany with telemedicine support) is to establish effective and sustainable support structures for evidence based treatments for stroke and other neurological emergencies and to improve outcome for acute neurological diseases in these rural regions. Methods A “hub-and-spoke” network structure was implemented connecting three academic neurological centres (“hubs”) and rural hospitals (“spokes”) caring for neurological emergencies. The network structure includes (1) the establishment of a 24/7 telemedicine consultation service, (2) the implementation of standardized operating procedures (SOPs) in the network hospitals, (3) a multiprofessional training scheme, and (4) a quality management program. Data from three major health insurance companies as well as data from the quality management program are being collected and evaluated. Primary outcome is the composite of first time of receiving paid outpatient nursing care, first time of receiving care in a nursing home, or death within 90 days after hospital admission. Discussion Beyond stroke only few studies have assessed the effects of telemedically supported networks on diagnosis and outcome of neurological emergencies. ANNOTeM will provide information whether this approach leads to improved outcome. In addition, a health economic analysis will be performed. Study registration German Clinical Trials Register DRKS00013067, date of registration: November 16 th, 2017, URL: http://www.drks.de/DRKS00013068
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Affiliation(s)
- J E Weber
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany. .,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Clinical Research Unit, Berlin Institute of Health, Berlin, Germany.
| | - A Angermaier
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - K Bollweg
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany
| | - H Erdur
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - S Ernst
- Clinical Research Unit, Berlin Institute of Health, Berlin, Germany.,Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases, partner site, Rostock, Greifswald, Germany
| | - C Gorski
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - F I Kandil
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute for Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - S Kinze
- Unfallkrankenhaus Berlin, Berlin, Germany
| | - K Kleinsteuber
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - T Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - I Schmehl
- Unfallkrankenhaus Berlin, Berlin, Germany
| | - S Theen
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Excellence Cluster NeuroCure, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - H J Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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Affiliation(s)
- S. Langner
- Institute for Diagnostic Radiology and Neuroradiology, Universitymedicine Greifswald, Germany
| | - R. Buelow
- Institute for Diagnostic Radiology and Neuroradiology, Universitymedicine Greifswald, Germany
| | - S. Fleck
- Department of Neurosurgery, Universitymedicine Greifswald, Germany
| | - A. Angermaier
- Department of Neurology, Universitymedicine Greifswald, Germany
| | - M. Kirsch
- Institute for Diagnostic Radiology and Neuroradiology, Universitymedicine Greifswald, Germany
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Khaw AV, Angermaier A, Michel P, Kirsch M, Kessler C, Langner S. Inter-rater Agreement in Three Perfusion-Computed Tomography Evaluation Methods before Endovascular Therapy for Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2016; 25:960-8. [PMID: 26851212 DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 10/26/2015] [Accepted: 01/02/2016] [Indexed: 11/29/2022] Open
Abstract
PURPOSE There is ongoing debate on which method of perfusion computed tomography (PCT) evaluation in ischemic stroke is the most appropriate for improved selection of patients for endovascular treatment. We sought to test different assessment methods for inter-rater reliability. METHODS Twenty-six patients were enrolled prospectively before endovascular therapy for acute anterior circulation ischemic stroke. Three raters experienced in stroke imaging and blinded to other imaging and clinical information independently analyzed 22 technically successful PCT scans according to 3 prespecified assessment methods applied to cerebral blood flow (CBF)/cerebral blood volume (CBV) and time-to-peak (TTP) maps: (1) visual mismatch estimate (VME), (2) Alberta Stroke Program Early CT Score perfusion method (ASPECTS-PCT), and (3) quantitative perfusion ratios (qPRs): RCBF, RCBV, RTTP. Inter-rater agreement was assessed with Cohen's kappa, intraclass correlation coefficients (ICC), Bland-Altman plots, and global and descriptive statistics. RESULTS Significant differences between raters were found with VME and ASPECTS-PCT (P < .001) but with qPRs only for CBV (P = .03). Inter-rater agreement for VME was at best moderate by kappa statistics (.51); moderate by ICC for all parametric maps of ASPECTS-PCT (.56-.62), strong for RTTP (.76), and excellent for RCBF (.92) and RCBV (.86). Pairwise comparisons revealed less scattering of individual values with qPRs and less deviation of mean differences from 0, suggesting minor systematic deviation by any 1 rater as compared with VME or ASPECTS-PCT. CONCLUSION PCT evaluation methods used before endovascular therapy for acute anterior circulation stroke are subject to substantial inter-rater disagreement. QPRs in PCT evaluation had better inter-rater reliability than the often used VME and ASPECTS-PCT assessment.
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Affiliation(s)
- A V Khaw
- Department of Clinical Neurosciences, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - A Angermaier
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - P Michel
- Stroke Center, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - M Kirsch
- Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - C Kessler
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - S Langner
- Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany.
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von Podewils F, Runge U, Krüger S, Geithner J, Wang ZI, Khaw AV, Angermaier A, Gaida B, Domin M, Kessler C, Langner S. Diffusion tensor imaging abnormalities in photosensitive juvenile myoclonic epilepsy. Eur J Neurol 2015; 22:1192-200. [DOI: 10.1111/ene.12725] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 02/26/2015] [Indexed: 11/30/2022]
Affiliation(s)
- F. von Podewils
- Department of Neurology, Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - U. Runge
- Department of Neurology, Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - S. Krüger
- Department of Neurology, Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - J. Geithner
- Epilepsie-Zentrum Berlin-Brandenburg; Ev. Krankenhaus Königin Elisabeth Herzberge; Berlin Germany
| | - Z. I. Wang
- Epilepsy Center; Neurological Institute; Cleveland Clinic Foundation; Cleveland OH USA
| | - A. V. Khaw
- Department of Neurology, Epilepsy Center; University Medicine Greifswald; Greifswald Germany
- Department of Clinical Neurosciences; Schulich School of Medicine and Dentistry; London Health Sciences Centre; University of Western Ontario; London ON Canada
| | - A. Angermaier
- Department of Neurology, Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - B. Gaida
- Department of Neurology, Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - M. Domin
- Center for Diagnostic Radiology and Neuroradiology; University Medicine Greifswald; Greifswald Germany
| | - C. Kessler
- Department of Neurology, Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - S. Langner
- Center for Diagnostic Radiology and Neuroradiology; University Medicine Greifswald; Greifswald Germany
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Langner S, Khaw AV, Fretwurst T, Angermaier A, Hosten N, Kirsch M. [Endovascular treatment of acute ischemic stroke under conscious sedation compared to general anesthesia - safety, feasibility and clinical and radiological outcome]. ROFO-FORTSCHR RONTG 2013; 185:320-7. [PMID: 23420311 DOI: 10.1055/s-0032-1330361] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Vessel recanalization is an important predictor of clinical outcome in the treatment of acute ischemic stroke. Endovascular therapies are used with increasing frequency. There is no general agreement on the policy of anesthesia during endovascular therapy, ranging from general anesthesia (GA) to local anesthesia at the puncture site with conscious sedation (CS) as needed. The aim of the study was to evaluate the safety and feasibility and radiological and clinical outcome of endovascular stroke therapy under CS. MATERIALS AND METHODS We retrospectively included all patients with acute ischemic stroke who were treated with endovascular therapy over a five-year period. Data was evaluated with respect to type of sedation, conversion from CS to GA, recanalization rate, infarct volume and peri- and post-procedural complications. RESULTS There was a technical failure in 7 patients. Of the remaining 124 patients (mean age 68.8 ± 14.6 years), 65 were female (52 %). The site of occlusion was located in the anterior circulation in 94 patients (76 %) and in the posterior circulation in 30 cases (24 %). 105 patients (85 %) were treated under CS and 16 cases (13 %) primarily under GA. In 3 cases (2 %) peri-procedural conversion to GA was necessary. Primary intra-arterial thrombolysis, mechanical recanalization only, and combination therapy were performed in 60 (48 %), 27 (22 %) and 37 (30 %) patients, respectively. There were no significant differences for recanalization rate and complications between GA and CS. The mean procedure time was significantly shorter in patients treated under CS (p < 0.01). CONCLUSION Endovascular stroke therapy with CS is feasible, can be performed safely and is faster than with GA.
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Affiliation(s)
- S Langner
- Institut für Diagnostische Radiologie und Neuroradiologie, Universitätsmedizin Greifswald, Germany
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Abstract
PURPOSE Diffusion-weighted imaging (DWI) has become an important component in modern stroke imaging. This MR technique detects diffusion abnormalities, which can be quantified by computing apparent diffusion coefficient (ADC) maps. ADC values are typically calculated from a set of MR images obtained with varying degrees of diffusion weighting (b-values) using nonlinear regression. However, there is no agreement concerning the number of images needed for ADC calculation. The aim of our study was to determine how many b-values are necessary to reliably calculate ADC maps. MATERIALS AND METHODS In 100 consecutive patients with clinical signs of acute ischemic stroke, 6 identically oriented and centered diffusion data sets with different b-values were acquired. ROI analysis was performed for DWI-positive lesions, normal-appearing gray and white matter, CSF, and background noise. ADC values for each ROI were calculated using a nonlinear regression model. Additionally, the CNR and SNR were calculated for each ROI. RESULTS Acquisition time was 0:39 min for 2 b-values and up to 2:49 min for a sequence with 7 b-values. The mean ADC (× 10(-3) mm2/s) for ischemic lesions was 58.29, 58.47, 57.83, 57.81, 57.58 and 54.51 using 2, 3, 4, 5, 6, and 7 b-values. Ischemic lesions had significantly different mean ADC values only for high b-values (b = 2000 s/mm2). CONCLUSION ADC values can be reliably calculated using 2 b-values. Radiologists may use the more time-efficient 2-point method for reliably estimating ADC values and detecting ischemic lesions in the daily clinical routine.
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Affiliation(s)
- M Kuhnke
- Institut für Diagnostische Radiologie und Neuroradiologie, Universitätsmedizin Greifswald
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Reinartz G, Angermaier A, Buchfelder M, Fahlbusch R, Georgieff M. Pre- and postoperative investigations of hepatic glucose production and leucine turnover in Cushing's disease utilizing stable isotope techniques. Horm Metab Res 1995; 27:425-31. [PMID: 8557243 DOI: 10.1055/s-2007-979993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Impairment of glucose tolerance and muscle wasting indicating a disorder of glucose metabolism are characteristic features of Cushing's syndrome. We have examined glucose and amino acid metabolism in eleven patients with pituitary dependent Cushing's disease in comparison to nine healthy controls. Furthermore, the therapeutic effect of selective pituitary microsurgery was studied by repeated stable isotope measurements of hepatic glucose production and leucine turnover rates. Eight patients remitted after surgery and 3 had persistent disease. All patients were investigated prior to surgery and again 1 week and 3 months after the operation with (6,6-2H2)-glucose and (5,5,5-2H3)-leucine by means of a primed (4 mg/kg.min and 0.27 mg/kg.min), continuous (0.05 mg/kg.min and 0.005 mg/kg.min) infusion. In Cushing's disease, both the preoperatively elevated mean glucose production rate (2.34 +/- 0.63 mg/kg.min) and the reduced mean leucine turnover (0.213 +/- 0.025 mg/kg.min) were found to be linked with hepatic insulin resistance and an insulin-induced reduction in protein breakdown combined with a reduced protein synthesis. Mean glucose production and leucine flux both normalized after surgery in the remitting patients (2.18 +/- 0.15 mg/kg.min and 0.244 +/- 0.047 mg/kg.min 3 months after the operation). The metabolic disorders thus were reversible following successful correction of hormonal oversecretion by transsphenoidal surgery.
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Affiliation(s)
- G Reinartz
- Neurochirurgische Klinik der Universität Erlangen-Nürnberg, Germany
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