scholarly journals Discrepancies between current and ideal endovascular stroke treatment practice in Europe and North America: Results from UNMASK EVT, a multidisciplinary survey

2020 ◽  
Vol 26 (4) ◽  
pp. 420-424 ◽  
Author(s):  
Johanna M Ospel ◽  
Nima Kashani ◽  
Francis Turjman ◽  
Urs Fischer ◽  
Blaise Baxter ◽  
...  
Keyword(s):  
North America ◽  
Acute Stroke ◽  
Endovascular Therapy ◽  
North American ◽  
Systems Of Care ◽  
European Countries ◽  
Acute Stroke Care ◽  
Stroke Treatment ◽  
Local Resources ◽  
American States

Background Since 2015, endovascular therapy has been established as a standard of care for acute stroke. This has caused major challenges regarding the organization of systems of care, which have to meet the increasing demand for thrombectomies. This study aims to evaluate how endovascular therapy decisions made by European and North American physicians under their current local resources differ from those made under assumed ideal conditions. Methods In an international, multidisciplinary survey, physicians involved in acute stroke care were asked to give their treatment decisions to 10 out of 22 randomly assigned stroke case-scenarios. Participants stated (a) their treatment approach under assumed ideal conditions (without any external limitations) and (b) the treatment they would pursue under their current local resources. Resources gaps (ideal minus current endovascular therapy rates) were calculated for different countries/states/provinces and correlated to economic and healthcare key metrics (gross domestic product-per-capita, public or private health insurance coverage, etc.). Results A total of 607 physicians, among them 218 from North America and 136 from 25 European countries, responded to the survey. Resources gaps in the majority of North American states/provinces and European countries were small (<5%). The highest gaps were observed among few European countries, namely Poland (30%) and the United Kingdom (33%). The magnitude of the resources gap did not correlate to national economic or healthcare metrics. Discussion and conclusion In the majority of North American states/provinces and European countries covered in this study, the discrepancy between endovascular therapy decisions under current local resources and assumed ideal conditions seems to be small, even in countries with a limited economic status and healthcare infrastructure.

Coccomyces papillatus. [Descriptions of Fungi and Bacteria].

2001 ◽  
Author(s):  
D. W. Minter
Keyword(s):  
North America ◽  
Geographical Distribution ◽  
North American ◽  
European Countries ◽  
Native North American ◽  
Pinus Wallichiana

Abstract A description is provided for Coccomyces papillatus. Information is included on the disease caused by the organism, its transmission, geographical distribution, and hosts. DISEASE: The ecology of this fungus is completely unknown. SHERWOOD (1980) noted strong similarities with Coccomyces strobi (IMI Descriptions No. 1292), which is known to occur on brittle dead attached twigs of native North American five-needled pines in North America and some European countries to which they have been introduced. This habitat is often associated with endobionts involved in self-pruning ecosystems which later fruit on dead twigs, best exemplified by Colpoma quercinum on Quercus and C. crispum on Picea (IMI Descriptions Nos 942. 1333), and Therrya fuckelii and T. pini on Pinus (IMI Descriptions Nos 1297, 1298) and it is tempting to speculate that C. papillatus too will prove to occupy this sort of niche. HOSTS: Pinus wallichiana (twig). GEOGRAPHICAL DISTRIBUTION: ASIA: Pakistan. TRANSMISSION: Not known. Presumably by air-borne ascospores released in humid conditions.

Abstract W MP60: Atrial Fibrillation is Associated with Worse Collaterals in Acute Stroke: Angiography in the ENDOSTROKE Registry

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Christian H Nolte ◽  
Georg Bohner ◽  
Tobias Neumann-Haefelin ◽  
Erich Hofmann ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Acute Stroke ◽  
Endovascular Therapy ◽  
Cardioembolic Stroke ◽  
Baseline Risk ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Stroke Etiology ◽  
The Impact

Background: Risk factors for stroke may alter hemodynamics or invoke ischemic preconditioning, yet the impact of such factors on response to acute stroke treatment and the potential relationship with collateral circulation remains unknown. Methods: Consecutive cases enrolled in the International Multicenter Registry for Mechanical Recanalization Procedures in Acute Stroke (ENDOSTROKE) were analyzed with respect to collateral status on baseline angiography before endovascular therapy. ASITN/SIR collateral grade (0-1/2/3-4) was scored by the core lab, blind to all other data. Collateral grade was analyzed with respect to numerous baseline risk factors, demographics and outcomes after endovascular intervention. Results: 109 patients (median age 69 years (25 th , 75 th percentiles: 56, 77); 51% women; median baseline NIHSS 15 (13, 18)) with complete (TICI 0) anterior circulation occlusions (M1, n=71; ICA, n=28; M2, n=10) at baseline were evaluated based on collateral grade (0-1, n=12; 2, n=41; 3-4, n=56). Worse collaterals were noted in patients with atrial fibrillation (ASITN grades 0-1/2/3-4: 21%/30%/49%) as compared to patients without atrial fibrillation (5%/42%/53%, p=0.024), yet cardioembolic stroke etiology was unrelated. Other baseline features such as age, gender, time to presentation, other co-morbidities and labs were unrelated to collateral grade. Post-procedure reperfusion (TICI 2b-3) was significantly associated with better collaterals (OR 2.58 (1.343-4.957, p=0.004). Similarly, final infarct size was significantly smaller in those with better collaterals. Good clinical outcomes (mRS 0-2 at day 90) were less frequent in those with poorer collaterals (OR 0.403 (0.199-0.813, p=0.011). Conclusions: Atrial fibrillation, but not cardioembolic stroke etiology, is associated with worse collaterals. Hemodynamic implications, such as diminished cardiac output due to atrial fibrillation, may result in less favorable outcomes after endovascular therapy for acute stroke.

Abstract TMP86: Telestroke Improves Guideline-Based Comprehensive Stroke Care: The TELECAST Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher D Streib ◽  
Oladi Bentho ◽  
Kathryn Bard ◽  
Eric Jaton ◽  
Sarah Engkjer ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Composite Score ◽  
Stroke Recurrence ◽  
Acute Stroke Care ◽  
Specialist Service ◽  
Stroke Treatment ◽  
Chi Squared ◽  
Secondary Outcomes ◽  
The Impact

Introduction: Limited access to stroke specialist expertise produces disparities in inpatient stroke treatment. The impact of telestroke on the remote delivery of guideline-based inpatient stroke care is yet to be comprehensively studied. The TELECAST trial (NCT03672890) prospectively examined the impact of a 24-7 telestroke specialist service dedicated to inpatient acute stroke care spanning admission to discharge. Methods: AHA stroke guidelines were used to derive outcome metrics in the following acute stroke inpatient care categories: diagnostic stroke evaluation (DSE), secondary stroke prevention (SSP), health screening and evaluation (HSE), and stroke education (SE). Adherence to AHA guidelines for stroke inpatients pre-telestroke (July 1, 2016-June 30, 2018) and post-telestroke intervention (July 1, 2018-June 30, 2019) were studied. The primary outcome was a composite score of all guideline-based stroke care. Secondary outcomes consisted of subcategory composite scores in DSE, SSP, HSE, and SE. Chi-squared tests were utilized to assess primary and secondary outcomes. Statistical analysis was performed using STATA 15.0. Results: Following institution of a comprehensive inpatient telestroke service, overall adherence to guideline-based metrics improved (composite score: 85% vs 94%, p<0.01) as did adherence to DSE guidelines (subgroup score: 90 vs 95%, p<0.01). SSP, HSE, and SE subgroup scores were not significantly different. See Table 1. Conclusion: The implementation of a 24-7 inpatient telestroke service improved adherence to AHA guidelines for inpatient acute stroke care. Dedicated inpatient telestroke specialist coverage may improve inpatient stroke care and reduce stroke recurrence in hospitals without access to stroke specialists.

Abstract P278: Improving Stroke Systems of Care in Nebraska

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Marco A Gonzalez Castellon ◽  
James A BOBENHOUSE ◽  
David Franco ◽  
Beth L Malina ◽  
Mindy Cook ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Rural Areas ◽  
Systems Of Care ◽  
Stroke Care ◽  
The United States ◽  
Advisory Council ◽  
Management Tool ◽  
Acute Stroke Care ◽  
Stroke Systems Of Care ◽  
Get With The Guidelines

Introduction: Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska. Purpose: To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas. Methods: The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access). Results: The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in < 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019. Conclusion: Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program

Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

2021 ◽  
pp. 1-11
Author(s):  
Anna Alegiani ◽  
Michael Rosenkranz ◽  
Leonie Schmitz ◽  
Susanne Lezius ◽  
Günter Seidel ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Quality Indicators ◽  
Metropolitan Area ◽  
Stroke Care ◽  
Care Quality ◽  
Acute Stroke Care ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Acute Stroke Treatment ◽  
Over Time

<b><i>Background and Purpose:</i></b> Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. <b><i>Methods:</i></b> In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. <b><i>Results:</i></b> From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (<i>p</i> &#x3c; 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (<i>p</i> &#x3c; 0.001). <b><i>Conclusions:</i></b> Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

Abstract 184: Drivers of Costs Associated With Reperfusion Therapy in Acute Stroke: The IMS III Trial

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kit N Simpson ◽  
Annie N Simpson ◽  
Patrick D Mauldin ◽  
Michael D Hill ◽  
Sharon D Yeatts ◽  
...  
Keyword(s):  
Acute Stroke ◽  
General Anesthesia ◽  
Endovascular Therapy ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Hospital Charges ◽  
Acute Stroke Care ◽  
Initial Hospital ◽  
Initial Hospitalization ◽  
Mean Cost

Importance: The annual costs of stroke to the nation have been estimated to be over $38 billion, with nearly $22 billion attributed to direct medical costs. Objective: To understand cost drivers during the initial hospitalization for acute ischemic stroke subjects in the IMS III Trial. Design, Setting and Participants: Prospective cost analysis of subjects from U.S. centers treated with IV t-PA alone or IV t-PA followed by endovascular therapy in the IMS III trial. Cost of initial hospital admission was estimated from the actual hospital charges on UB04 billing forms provided by the treating hospitals. Cost profiles of the IMS III treatment groups were compared to profiles of a sample of US patients from the HCUP National Inpatient Sample (NIS) for 2010. Interventions: IV t-PA alone as compared to IV t-PA followed by endovascular therapy. Main Outcome Measure: Costs of hospitalization for acute stroke subjects. Results: The adjusted cost of a stroke admission in the study was $35,130 for subjects treated with endovascular therapy following IV t-PA and $25,630 for subjects treated with IV t-PA alone (p<0.0001). The higher cost in the endovascular therapy following IV t-PA treatment arm was largely explained by the costs of the devices. Significant factors related to costs included treatment group (higher costs with endovascular therapy), baseline NIH Stroke Scale (higher costs with higher severity), time from stroke onset to IV t-PA (lower costs with earlier treatment), age (higher costs with older age), stroke location (higher cost with right hemispheric location) and comorbid diabetes (higher costs with diabetes). The mean cost for subjects who had routine use of general anesthesia as part of endovascular therapy was $46,444 as compared to $30,350 for those who did not have general anesthesia. The costs of embolectomy for IMS III subjects and patients from the NIS cohort exceeded the Medicare DRG payment in more than 75% of hospitalized patients. Conclusions and Relevance: Changing the processes of acute stroke care, such as minimizing the time to start of IV t-PA and decreasing the use of routine general anesthesia, may improve the cost-effectiveness of medical and endovascular therapy for acute stroke.

Abstract 352: Early Data From an Implementation Science Study Suggests the Need for Identification and Adoption of Best Practices to Improve the Timeliness of Stroke Treatment

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Lisa M Monk
Keyword(s):  
Best Practices ◽  
Acute Stroke ◽  
Care Delivery ◽  
Stroke Care ◽  
Early Data ◽  
Screening Tools ◽  
Stroke Severity ◽  
Ct Scanner ◽  
Acute Stroke Care ◽  
Stroke Treatment

There is a disconnect from discovery of best treatment options and application into clinical practice in a timely manner. The I M plementation of best Pr actices f O r acute stroke care-de v eloping and optimizing regional systems of Stroke Care (IMPROVE Stroke Care) goal is to develop a regional integrated stroke system that identifies, classifies, and treats patients with acute ischemic stroke more rapidly and effectively with reperfusion therapy. These improvements in acute stroke care delivery are expected to result in lower mortality, fewer recurrent strokes, and improved long term functional outcomes. Recent discoveries in stroke care and advancement in technology extends the window for both TPA administration and mechanical thombectomy. The challenge of implementing these latest advances are difficult considering the ability of hospitals to implement the original American Heart Association (AHA) Systems of Stroke Care recommendations. Early data from this project shows that the challenges continue to exist in recommendations that have been in place as early as 2005. EMS is not utilizing pre-hospital stroke screening tools, only 5% of the time, stroke severity tools, only 7% of the time, lytic checklists, 0% of the time, destination decision changed due to severity score, 0% of the time, and pre-notifying emergency rooms, only 63% of the time. Emergency departments door to CT <45 minutes, only 55% of the time, Lytic given in CT scanner, only 35% of the time, Door to lytic therapy< 45 minutes, 77% of the time, Door to Groin puncture, 81% of the time, and Door to TICI Flow 2c/3 flow <90 minutes, 39% of the time. The Systems of Stroke Care have recommendations that will improve time to treatment and outcomes for patients. This project is working to provide tools, guidance, data, and feedback to improve application of these recommendations and identify best practices and solutions to barriers.

The demography of grandparenthood in 16 European countries and two North American countries

2018 ◽  
pp. 23-42
Author(s):  
Rachel Margolis ◽  
Bruno Arpino
Keyword(s):  
North America ◽  
Young Children ◽  
North American ◽  
Labour Force ◽  
Family Members ◽  
Intergenerational Relationships ◽  
Labour Force Participation ◽  
Population Characteristics ◽  
European Countries ◽  
The Future

Intergenerational relationships between grandparents and grandchildren can offer tremendous benefits to family members of each generation. The demography of grandparenthood – the timing, length and population characteristics – shape the extent to which young children have grandparents available, how many grandparents are alive, and the duration of overlap with grandparents. In this chapter, we examine how the demography of grandparenthood varies across 16 countries in Europe and two countries in North America, and why it is changing. Next, we examine variation in two key determinants of intergenerational relationships – the labour force participation and health of grandparents. Last, we comment on some important changes in the demography of grandparenthood that may come in the future.

scholarly journals Modeling the Optimal Transportation for Acute Stroke Treatment

Stroke ◽  
2020 ◽  
Vol 51 (1) ◽  
pp. 275-281 ◽  
Author(s):  
Marielle Ernst ◽  
Eckhard Schlemm ◽  
Jessalyn K. Holodinsky ◽  
Noreen Kamal ◽  
Götz Thomalla ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Endovascular Therapy ◽  
Catchment Area ◽  
Treatment Time ◽  
Intravenous Thrombolysis ◽  
Probability Models ◽  
Stroke Treatment ◽  
Federal States ◽  
Medical Response ◽  
Stroke Center

Background and Purpose— Health systems are faced with the challenge of ensuring fast access to appropriate therapy for patients with acute stroke. The paradigms primarily discussed are mothership and drip and ship. Less attention has been focused on the drip-and-drive (DD) paradigm. Our aim was to analyze whether and under what conditions DD would predict the greatest probability of good outcome for patients with suspected ischemic stroke in Northwestern Germany. Methods— Conditional probability models based on the decay curves for endovascular therapy and intravenous thrombolysis were created to determine the best transport paradigm, and results were displayed using map visualizations. Our study area consisted of the federal states of Lower Saxony, Hamburg, and Schleswig-Holstein in Northwestern Germany covering an area of 64 065 km 2 with a population of 12 703 561 in 2017 (198 persons per km 2 ). In several scenarios, the catchment area, that is, the region that would result in the greatest probability of good outcomes, was calculated for each of the mothership, drip-and-ship, and the DD paradigms. Several different treatment time parameters were varied including onset-to-first-medical-response time, ambulance-on-scene time, door-to-needle time at primary stroke center, needle-to-door time, door-to-needle time at comprehensive stroke center, door-to-groin-puncture time, needle-to-interventionalist-leave time, and interventionalist-arrival-to-groin-puncture time. Results— The mothership paradigm had the largest catchment area; however, the DD catchment area was larger than the drip-and-ship catchment area so long as the needle-to-interventionalist-leave time and the interventionalist-arrival-to-groin-puncture time remain <40 minutes each. A slowed workflow in the DD paradigm resulted in a decrease of the DD catchment area to 1221 km 2 (2%). Conclusions— Our study suggests the largest catchment area for the mothership paradigm and a larger catchment area of DD paradigm compared with the drip-and-ship paradigm in Northwestern Germany in most scenarios. The existence of different paradigms allows the spread of capacities, shares the cost and hospital income, and gives primary stroke centers the possibility to provide endovascular therapy services 24/7.

scholarly journals Influence of Guidelines in Endovascular Therapy Decision Making in Acute Ischemic Stroke

Stroke ◽  
2019 ◽  
Vol 50 (12) ◽  
pp. 3578-3584 ◽  
Author(s):  
Nima Kashani ◽  
Johanna M. Ospel ◽  
Bijoy K. Menon ◽  
Gustavo Saposnik ◽  
Mohammed Almekhlafi ◽  
...  
Keyword(s):  
Decision Making ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Endovascular Therapy ◽  
American Heart Association ◽  
American Heart ◽  
Heart Association ◽  
Early Management ◽  
Stroke Treatment ◽  
Local Resources

Background and Purpose— The American Heart Association and the American Stroke Association guidelines for early management of patients with ischemic stroke offer guidance to physicians involved in acute stroke care and clarify endovascular treatment indications. The purpose of this study was to assess concordance of physicians’ endovascular treatment decision-making with current American Heart Association and the American Stroke Association stroke treatment guidelines using a survey-approach and to explore how decision-making in the absence of guideline recommendations is approached. Methods— In an international cross-sectional survey (UNMASK-EVT), physicians were randomly assigned 10 of 22 case scenarios (8 constructed with level 1A and 11 with level 2B evidence for endovascular treatment and 3 scenarios without guideline coverage) and asked to declare their treatment approach (1) under their current local resources and (2) assuming there were no external constraints. The proportion of physicians offering endovascular therapy (EVT) was calculated. Subgroup analysis was performed for different specialties, geographic regions, with regard to physicians’ age, endovascular, and general stroke treatment experience. Results— When facing level 1A evidence, participants decided in favor of EVT in 86.8% under current local resources and in 90.6% under assumed ideal conditions, that is, 9.4% decided against EVT even under assumed ideal conditions. In case scenarios with level 2B evidence, 66.3% decided to proceed with EVT under current local resources and 69.7% under assumed ideal conditions. Conclusions— There is potential for improving thinking around the decision to offer endovascular treatment, since physicians did not offer EVT even under assumed ideal conditions in 9.4% despite facing level 1A evidence. A majority of physicians would offer EVT even for level 2B evidence cases.

Sign in / Sign up

Export Citation Format

Share Document