The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction: The optimal choice of the thrombolytic drug for emergency revascularization in patients with acute coronary syndrome (ACS) still remains to be defined. Percutaneous coronary intervention is a more safe and effective method of reperfusion compared with thrombolytic therapy, that’s why the last is relatively not common nowadays. But in the COVID-19 era in a number of cases some patients with ACS can’t be quickly hospitalized due to different reasons like the absence of the nearest available cardiovascular center, or lack of an ambulance. A long period of chest pain forces the doctors to use systemic thrombolytic therapy. Purpose This study investigates the efficacy and safety of Alteplase, Prourokinase, Tenecteplase, and Streptokinase in patients with acute coronary syndrome. Methods A retrospective, open, non-randomized cohort study was conducted. We have analysed 600 patients with ACS, who underwent systemic thrombolytic therapy at the prehospital and in-hospital stages from 2009 to 2011. Patients were divided into several groups according to the thrombolytic agent administered: Alteplase (254 patients), Prourokinase (309 patients), Tenecteplase (6 patients), Streptokinase (31 patients). Treatments were to be given as soon as possible. The ECG reperfusion criterion was a decrease in the ST segment by 50% or more from the initial elevation. Results Among 600 patients (mean age, 61 years (SD = 20); 119 women [19.7%]), 440 had successful reperfusion. The median time from chest pain onset to the start of treatment was 3 hours (P < 0.001). The percentages of successful thrombolysis for each agent were similar: Alteplase 74,4% Prourokinase 71,2%, Tenecteplase 83%, Streptokinase 74,2%. No statistical differences were observed in thrombolytic results among these groups (OR: 0.60, 95% CI: 0,2868 to 1,217; P = 0.17). At the same time, the hospital treatment with prourokinase was more effective than prehospital care with prourokinase: 110 successful reperfusions in 138 patients (79.7%) and 110 successful reperfusions in 171 patients (64.3%), respectively. Regardless of the onset of the attack (OR: 0.45, 95% CI: 0,2004 to 0,9913; P = 0.05). The effectiveness of the other thrombolytics cannot be compared between prehospital care and hospital treatment due to the rare use at the hospital stage in our cases. In the study, there was also no statistical difference in complication rates among the treatment groups. Among all patients, there were 9 fatal outcomes (1.5%): Alteplase 3,15% Prourokinase 1,9%, Streptokinase 3,22%. Conclusion(s): In patients with ACS, all thrombolytic drugs showed similar effectiveness. There is no difference in the safety and efficacy among the agents in our study, but there is a difference in cost and route of administration. However, upcoming prospective trials with long follow-up periods might be expected to determine the most appropriate systemic thrombolytic drug.

Download Full-text

Treatment decisions and mortality in HIV-positive presumptive smear-negative TB in the Xpert® MTB/RIF era: a cohort study

BMC Infectious Diseases ◽

10.1186/s12879-017-2534-2 ◽

2017 ◽

Vol 17 (1) ◽

Cited By ~ 5

Author(s):

Sabine M. Hermans ◽

Juliet A. Babirye ◽

Olive Mbabazi ◽

Francis Kakooza ◽

Robert Colebunders ◽

...

Keyword(s):

Cohort Study ◽

Treatment Decisions ◽

Hiv Positive ◽

Smear Negative

Download Full-text

Implications of Hidradenitis Suppurativa Phenotypes in Cardiovascular Risk and Treatment Decisions: A Retrospective Cohort Study

Dermatology ◽

10.1159/000513044 ◽

2021 ◽

pp. 1-6

Author(s):

Carlos Cuenca-Barrales ◽

Trinidad Montero-Vilchez ◽

Luis Salvador-Rodríguez ◽

Manuel Sánchez-Díaz ◽

Salvador Arias-Santiago ◽

...

Keyword(s):

Cohort Study ◽

Cardiovascular Risk ◽

Disease Severity ◽

Retrospective Cohort Study ◽

Therapeutic Approach ◽

Retrospective Cohort ◽

Hidradenitis Suppurativa ◽

Severe Disease ◽

Treatment Decisions ◽

Lesion Pattern

Background: New integrative hidradenitis suppurativa (HS) lesion pattern phenotypes have been proposed, an inflammatory phenotype (IP) and a follicular phenotype (FP). They are characterized by different lesion patterns, symptoms, and risks of disease progression. Objectives: To evaluate whether lesion pattern phenotypes (1) have a different cardiovascular risk factor profile, and (2) are associated with a different therapeutic approach in the setting of an HS clinic. Methods: A retrospective cohort study was conducted on 233 patients with HS. They were classified according to lesion pattern phenotype criteria. Data regarding cardiovascular risk factors and treatment decisions were gathered. Results: One hundred and seventeen HS patients (50.21%) were classified as FP and 112 (48.07%) as IP. IP was associated with more severe disease and greater impairment of quality of life. Regardless of disease severity, patients with IP may have a higher cardiovascular risk, assessed according to higher C-reactive protein (CRP) levels (12.75 vs. 5.89, p = 0.059). The lesion pattern phenotype also influenced treatment decisions regardless of disease severity. Patients with IP were more likely to be treated with systemic corticosteroids and adalimumab, showing that lesion pattern phenotypes are associated with different therapeutic approaches. Conclusions: IP is associated with higher CRP values, suggesting a greater cardiovascular risk in these patients and also a different therapeutic approach. This information could help guide dermatologists in the management of HS patients and help to determine future treatment recommendations.

Download Full-text

An Investigation of the Glucose Monitoring Practices of Nurses in Stroke Care: A Descriptive Cohort Study

Nursing Research and Practice ◽

10.1155/2013/715802 ◽

2013 ◽

Vol 2013 ◽

pp. 1-7

Author(s):

Elizabeth Ann Laird ◽

Vivien E. Coates ◽

Assumpta A. Ryan ◽

Mark O. McCarron ◽

Diane Lyttle ◽

...

Keyword(s):

Diabetes Mellitus ◽

Cohort Study ◽

Acute Stroke ◽

Glucose Monitoring ◽

Positive Association ◽

Stroke Care ◽

Routine Practice ◽

Full Potential ◽

Significant Positive Association ◽

History Of

Glucose derangement is commonly observed among adults admitted to hospital with acute stroke. This paper presents the findings from a descriptive cohort study that investigated the glucose monitoring practices of nurses caring for adults admitted to hospital with stroke or transient ischaemic attack. We found that a history of diabetes mellitus was strongly associated with initiation of glucose monitoring and higher frequency of that monitoring. Glucose monitoring was continued for a significantly longer duration of days for adults with a history of diabetes mellitus, when compared to the remainder of the cohort. As glucose monitoring was not routine practice for adults with no history of diabetes mellitus, the detection and treatment of hyperglycaemia and hypoglycaemia events could be delayed. There was a significant positive association between the admission hospital that is most likely to offer stroke unit care and the opportunity for glucose monitoring. We concluded that adults with acute stroke, irrespective of their diabetes mellitus status prior to admission to hospital, are vulnerable to both hyperglycaemic and hypoglycaemic events. This study suggests that the full potential of nurses in the monitoring of glucose among hospitalised adults with stroke has yet to be realised.

Download Full-text

ROLE OF COMPUTED TOMOGRAPHY SCAN IN EVALUATION OF NEUROLOGICAL MANIFESTATIONS IN COVID 19 POSITIVE PATIENTS AND ITS CORRELATION WITH D-DIMER VALUE AND GCS: A RETROSPECTIVE COHORT STUDY IN A TERTIARY CARE HOSPITAL IN CENTRAL INDIA

10.36106/gjra/2900769 ◽

2021 ◽

pp. 17-21

Author(s):

Debraj Saha ◽

Aarti Anand ◽

Jawahar Rathod ◽

Prajwaleet Gour ◽

Shivprasad Jaybhay ◽

...

Keyword(s):

Cohort Study ◽

Acute Stroke ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Neurological Symptoms ◽

Government Medical College ◽

Stroke Patients ◽

Medical College ◽

Neuro Imaging ◽

D Dimer

Objective: To investigate the incidence and spectrum of neuroimaging ndings and their prognostic role in hospitalized COVID-19 patients in Government Medical College Nagpur along with their correlation with D-Dimer Values and GCS . Methods: This is a retrospective cohort study of 774 COVID-19 conrmed patients admitted to Government Medical College st st Nagpur between 1 April 2020 and 31 October 2020. Clinical data were extracted from electronic medical records, and particularly data of all neurological symptoms were extracted from the imaging reports. Four neuro-radiologists evaluated all neuroimaging studies for acute neuroimaging ndings related to COVID-19. Plasma D-dimer levels were measured using a particle-enhanced, immunoturbidimetric assay on admission in the 116 patients who came for evaluation of neurological symptoms. Moreover ,the patients were classied into different groups as mild, moderate and severe based on their GCS scores and was assessed with respect to their neuro-imaging ndings. Results: 15 % of the admitted patients suffered from neurological symptoms. Acute stroke was the most common nding in the patients with positive neuroimaging ndings resulting in 34.4% of the patients with positive neuroimaging ndings. Other ndings were subacute infarcts (13.8%), Chronic lacunar infarcts (20.6%) , Intraparenchymal hemorrhage in 10.4 %, hypertensive encephalopathy in 7 % and subarachanoid hemorrhage in 3.4 %. Plasma median D-dimer levels were signicantly (P฀ =฀ 0.000) higher in Acute stroke patients as compared to COVID 19 positive patients who had negative CT scan imaging features(0.88; interquartile range [IQR], 0.28–2.11 mg/L and 0.31; IQR, 0.17–0.74 mg/L). Patients who have positive neuroimaging ndings presented with a lower GCS whereas patients who had negative neuroimaging ndings presented with a higher GCS. Conclusions: Our study demonstrates acute stroke is the most common neuroloimaging nding in hospitalized COVID 19 Patients. Moreover D-Dimer values are highly predictive of acute ischemic stroke. Patients with positive neuro-imaging ndings have poor GCS scores.

Download Full-text

Electrocardiographic changes and serum troponin levels in patients with acute stroke, a prospective Cohort study in Sudan

Journal of the Neurological Sciences ◽

10.1016/j.jns.2021.119707 ◽

2021 ◽

Vol 429 ◽

pp. 119707

Author(s):

Etedal Ibrahim ◽

Salma Taha ◽

Khabab Mohamed Ahmed ◽

Mohammed Eltahier Omer

Keyword(s):

Cohort Study ◽

Acute Stroke ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Electrocardiographic Changes

Download Full-text

May ultrasonography be considered a useful tool for bedside screening of dysphagia in patients with acute stroke? A cohort study

Minerva Medica ◽

10.23736/s0026-4806.20.06571-4 ◽

2021 ◽

Vol 112 (3) ◽

Author(s):

Alessandro PICELLI ◽

Angela MODENESE ◽

Elena POLETTO ◽

Valentina BUSINARO ◽

Valentina VARALTA ◽

...

Keyword(s):

Cohort Study ◽

Acute Stroke

Download Full-text

Abstract P153: SARS-CoV-2 (COVID-19) Protection Efforts on Acute Stroke Treatment

Stroke ◽

10.1161/str.52.suppl_1.p153 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Jessica Greenwood ◽

Starlie Belnap ◽

Rodney Bedgio ◽

Guilherme Dabus ◽

Italo Linfante ◽

...

Keyword(s):

Stroke Volume ◽

Endovascular Treatment ◽

Acute Stroke ◽

Symptom Onset ◽

Onset Time ◽

Fold Increase ◽

Medical Attention ◽

Hospital Treatment ◽

Significant Delay ◽

The Impact

Introduction: It is unclear how the interventions designed to restrict community and in-hospital exposure to the SARS-CoV-2 virus affected the care for stroke patients seeking acute treatment. The objective of the following study was to determine the impact COVID-19 has had on the treatment times for patients evaluated as acute stroke alerts at Baptist Hospital of Miami (BHM). A co-primary objective of the study was to assess the risk of contracting SARS-CoV-2 within 2 weeks from hospital discharge. Methods: This retrospective, two phase study was conducted between December 2019 and April 2020. In phase one, we assessed time from symptom onset to hospital arrival, number of strokes with witnessed onset, and in-hospital treatment times pre & post implementation of Covid-19 preventive exposure measures. In phase two of the study, a telephone survey was conducted on the post implementation group to assess the risk of patients developing symptoms or testing positive for SARS-CoV-2 from hospital admission up to two weeks post discharge. Results: Phase I demonstrated there was a 40% decline in stroke volume, but no significant delay to seek medical attention post implementation of the SARS prevention strategies. On average individuals in the pre-group (n=155) waited approximately 260 minutes (SE=24) to seek medical attention vs. 203 minutes (SE=27) minutes for the post-group (n=87). However, there was nearly a six-fold increase in the percentage of cases with unknown symptom onset post implementation of COVID-19 safety precautions. There was significant delay in administering IV alteplase, increasing from 24 mins (n=16) to 33 mins (n=21) post implementation; delays observed for endovascular treatment were not significant (pre, n=13 mean= 73 mins, post n=12 mean= 82 mins). The volume of patients treated with either IV alteplase and/or endovascular treatment remained similar. Phase II of the study is on-going, results will be available for the ISC. Discussion: The COVID-19 crisis in our community was associated with a six-fold increase in the percentage of cases with unknown stroke onset time. Besides a marked decrease in stroke volume, we did not evidence significant delays to either seek or provide acute stroke care outside a modest increase in door to needle time.

Download Full-text

Acute Stroke Presentation, Care, and Outcomes in Community Hospitals in Northern California During the COVID-19 Pandemic

Stroke ◽

10.1161/strokeaha.120.031099 ◽

2020 ◽

Vol 51 (10) ◽

pp. 2918-2924 ◽

Cited By ~ 7

Author(s):

Mai N. Nguyen-Huynh ◽

Xian Nan Tang ◽

David R. Vinson ◽

Alexander C. Flint ◽

Janet G. Alexander ◽

...

Keyword(s):

Cohort Study ◽

Ischemic Stroke ◽

Acute Stroke ◽

Temporal Trends ◽

Patient Characteristics ◽

Large Vessel ◽

Critical Conditions ◽

Care Seeking ◽

Northern California ◽

Inpatient Mortality

Background and Purpose: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. Methods: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. Results: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P <0.001). Stroke discharges also dropped, in concordance with acute stroke alerts decrease. In total, 9120 patients were included: 8337 in pre- and 783 in post-SIP cohorts. There were no differences in patient demographics. Compared with pre-SIP, post-SIP patients had higher National Institutes of Health Stroke Scale scores ( P =0.003), lower comorbidity score ( P <0.001), and arrived more often by ambulance ( P <0.001). Post-SIP, more patients had large vessel occlusions ( P =0.03), and there were fewer stroke mimics ( P =0.001). Discharge outcomes were similar for post-SIP and pre-SIP cohorts. Conclusions: In this cohort study, regional stroke alert and ischemic stroke discharge volumes decreased significantly in the early COVID-19 pandemic. Compared with pre-SIP, the post-SIP population showed no significant demographic differences but had lower comorbidity scores, more severe strokes, and more large vessel occlusions. The inpatient mortality was similar in both cohorts. Further studies are needed to understand the causes and implications of care avoidance to patients and healthcare systems.

Download Full-text

Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions

Cerebrovascular Diseases ◽

10.1159/000508910 ◽

2020 ◽

Vol 49 (4) ◽

pp. 388-395

Author(s):

Iris Q. Grunwald ◽

Daniel J. Phillips ◽

David Sexby ◽

Viola Wagner ◽

Martin Lesmeister ◽

...

Keyword(s):

Hospital Admission ◽

Acute Stroke ◽

Stroke Unit ◽

Hospital Admissions ◽

Hospital Treatment ◽

Stroke Patients ◽

Transient Ischaemic Attacks ◽

Accident And Emergency ◽

Mobile Stroke Unit ◽

The Uk

Background: Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay. Objective: The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions. Methods: Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward, and stroke management metrics were assessed. Results: In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40–60). Conclusion: This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.

Download Full-text