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1.
Chao Lin Nan Li Kang Wang Xin Zhao Bai-Qiang Li Lei Sun Yi-Xing Lin Jie-Mei Fan Miao Zhang Hai-Chen Sun 《PloS one》2013,8(10)
Background and Purpose
Although endovascular therapy (ET) is increasingly used in patients with moderate to severe acute ischemic stroke, its efficacy and safety remains controversial. We performed a meta-analysis aiming to compare the benefits and safety of endovascular treatment and intravenous thrombolysis in the treatment of acute ischemic stroke.Methods
We systematically searched PubMed, Embase, Science direct and Springer unitil July, 2013. The primary outcomes included good outcome (mRS ≤ 2) and excellent outcome (mRS ≤ 1) at 90 days or at trial end point. Secondary outcomes were occurrence of symptomatic hemorrhage and all-cause mortality.Results
Using a prespecified search strategy, 5 RCTs with 1106 patients comparing ET and intravenous thrombolysis (IVT) were included in the meta-analysis. ET and IVT were associated with similar good (43.06% vs 41.78%; OR=1.14; 95% CI, 0.77 to 1.69; P=0.52;) and excellent (30.43% vs 30.42%; OR=1.05; 95% CI, 0.80 to 1.38; P=0.72;) outcome. For additional end points, ET was not associated with increased occurrence of symptomatic hemorrhage (6.25% vs. 6.22%; OR=1.03; 95% CI, 0.62 to 1.69; P=0.91;), or all-cause mortality (18.45% vs. 17.35%; OR=1.00; 95% CI, 0.73 to 1.39; P=0.99;).Conclusions
Formal meta-analysis indicates that there are similar safety outcomes and functional independence with endovascular therapy and intravenous thrombolysis for acute ischemic stroke. 相似文献2.
Shuolin Wu Yuzhi Shi Chunxue Wang Qian Jia Ning Zhang Xingquan Zhao Gaifen Liu Yilong Wang Liping Liu Yongjun Wang On Behalf of the Investigators for the Survey on Abnormal Glucose Regulation in Patients With Acute Stroke Across China 《PloS one》2013,8(11)
Objective
Hyperglycemia is related to stroke. Glycated hemoglobin (HbA1c) can reflect pre-stroke glycaemia status. However, the information on the direct association between HbA1c and recurrence after non-cardioembolic acute ischemic strokes is rare and there is no consistent conclusion.Methods
The ACROSS-China database comprised of 2186 consecutive first-ever acute ischemic stroke patients with baseline HbA1c values. After excluding patients who died from non-stroke recurrence and patients lost to follow up, 1817 and 1540 were eligible for 3-month and 1-year analyses, respectively. Multivariate Cox regression was performed to evaluate the associations between HbA1c and 3-month and 1-year stroke recurrence.Results
The HbA1c values at admission were divided into 4 levels by quartiles: Q1 (<5.5%); Q2 (5.5 to <6.1%); Q3 (6.1% to <7.2%); and Q4 (≥7.2%). The cumulative recurrence rates were 8.3% and 11.0% for 3 months and 1 year, respectively. In multivariate analyses, when compared with Q1, the adjusted hazard ratios (AHRs) were 2.83 (95% confidence interval (CI) 1.28-6.26) in Q3 and 3.71(95% CI 1.68-8.21) in Q4 for 3-month stroke recurrence; 3.30 (95% CI 1.31-8.34) in Q3 and 3.35 (95% CI 1.36-8.21) in Q4 for 1-year stroke recurrence. Adding fasting plasma glucose in the multivariate analyses did not modify the association: AHRs were 2.75 (95% CI 1.24-6.11) in Q3 and 3.67 (95% CI 1.59-8.53) in Q4 for 3-month analysis; AHRs were 3.08 (95% CI 1.10-8.64) in Q3 and 3.31(95% CI 1.35-8.14) in Q4 for 1-year analysis.Conclusions
A higher “normal” HbA1c level reflecting pre-stroke glycaemia status independently predicts stroke recurrence within one year after non-cardioembolic acute ischemic stroke onset. HbA1c is recommended as a routine test in acute ischemic stroke patients. 相似文献3.
Darren Flynn Gary A. Ford Helen Rodgers Christopher Price Nick Steen Richard G. Thomson 《PloS one》2014,9(8)
Objective
In February 2009, the Department of Health in England launched the Face, Arm, Speech, and Time (FAST) mass media campaign, to raise public awareness of stroke symptoms and the need for an emergency response. We aimed to evaluate the impact of three consecutive phases of FAST using population-level measures of behaviour in England.Methods
Interrupted time series (May 2007 to February 2011) assessed the impact of the campaign on: access to a national stroke charity''s information resources (Stroke Association [SA]); emergency hospital admissions with a primary diagnosis of stroke (Hospital Episode Statistics for England); and thrombolysis activity from centres in England contributing data to the Safe Implementation of Thrombolysis in Stroke UK database.Results
Before the campaign, emergency admissions (and patients admitted via accident and emergency [A&E]) and thrombolysis activity was increasing significantly over time, whereas emergency admissions via general practitioners (GPs) were decreasing significantly. SA webpage views, calls to their helpline and information materials dispatched increased significantly after phase one. Website hits/views, and information materials dispatched decreased after phase one; these outcomes increased significantly during phases two and three. After phase one there were significant increases in overall emergency admissions (505, 95% CI = 75 to 935) and patients admitted via A&E (451, 95% CI = 26 to 875). Significantly fewer monthly emergency admissions via GPs were reported after phase three (−19, 95% CI = −29 to −9). Thrombolysis activity per month significantly increased after phases one (3, 95% CI = 1 to 6), and three (3, 95% CI = 1 to 4).Conclusions
Phase one had a statistically significant impact on information seeking behaviour and emergency admissions, with additional impact that may be attributable to subsequent phases on information seeking behaviour, emergency admissions via GPs, and thrombolysis activity. Future campaigns should be a0ccompanied by evaluation of impact on clinical outcomes such as reduced stroke-related morbidity and mortality. 相似文献4.
Nasar Ahmad Sanjeev Nayak Changez Jadun Indira Natarajan Palbha Jain Christine Roffe 《PloS one》2013,8(12)
Background and Purpose
Endovascular treatments have the potential to accelerate reperfusion in acute ischaemic stroke with large vessel occlusion. In the UK only a few stroke centres offer this interventional option. The University Hospital of North Staffordshire (UHNS) has treated the largest number of cases in the UK. Results of the first 106 endovascular treatments (EVT) are presented here.Methods
All patients treated with EVT (intra-arterial thrombolysis (IAT), mechanical thrombectomy (MT) or both, or an attempt at intervention) for acute stroke at UHNS, Stoke-on-Trent, UK, were entered into a prospective register. Baseline demographic and clinical data, the National Institutes for Health Stroke Scale (NIHSS), imaging results including Thrombolysis in Cerebral Infarction (TICI) score, and complications were recorded. Mortality, and modified Rankin score (mRS) were assessed at 90 days.Results
From December 2009 to January 2013 106 patients (mean age 64 years, median baseline NIHSS 18) were treated with EVT (thrombectomy ± IAT 83%, IAT alone 13%, neither 4%). Seventy-eight per cent of occlusions were in the anterior circulation. Intravenous bridging thrombolysis was performed in 81%. Revascularization was successful (TICI 2b/3) in 84%. The median time from stroke onset to the end of the procedure was 6 h 03 min. A good outcome (mRS≤2) at 90 days was achieved in 48% with a mortality of 15%. Fatal or nonfatal symptomatic intracranial haemorrhage (sICH) within 10 days occurred in 9%. The median length of stay was 14 days (31% discharged home ≤7 days).Conclusions
EVT led to good clinical outcomes in almost 50% of patients with severe strokes. 相似文献5.
Walter S Kostpopoulos P Haass A Helwig S Keller I Licina T Schlechtriemen T Roth C Papanagiotou P Zimmer A Viera J Vierra J Körner H Schmidt K Romann MS Alexandrou M Yilmaz U Grunwald I Kubulus D Lesmeister M Ziegeler S Pattar A Golinski M Liu Y Volk T Bertsch T Reith W Fassbender K 《PloS one》2010,5(10):e13758
Background
Early treatment with rt-PA is critical for favorable outcome of acute stroke. However, only a very small proportion of stroke patients receive this treatment, as most arrive at hospital too late to be eligible for rt-PA therapy.Methods and Findings
We developed a “Mobile Stroke Unit”, consisting of an ambulance equipped with computed tomography, a point-of-care laboratory system for complete stroke laboratory work-up, and telemedicine capabilities for contact with hospital experts, to achieve delivery of etiology-specific and guideline-adherent stroke treatment at the site of the emergency, well before arrival at the hospital. In a departure from current practice, stroke patients could be differentially treated according to their ischemic or hemorrhagic etiology even in the prehospital phase of stroke management. Immediate diagnosis of cerebral ischemia and exclusion of thrombolysis contraindications enabled us to perform prehospital rt-PA thrombolysis as bridging to later intra-arterial recanalization in one patient. In a complementary patient with cerebral hemorrhage, prehospital diagnosis allowed immediate initiation of hemorrhage-specific blood pressure management and telemedicine consultation regarding surgery. Call-to-therapy-decision times were 35 minutes.Conclusion
This preliminary study proves the feasibility of guideline-adherent, etiology-specific and causal treatment of acute stroke directly at the emergency site. 相似文献6.
7.
Background
Long-term disability following stroke can lead to participation restrictions in complex and social everyday activities, yet information is lacking on to what extent stroke survivors return to their pre-stroke levels of participation.Objectives
The objectives of this study were to investigate the level of participation in complex and social everyday activities 6 years after stroke, to compare this with pre-stroke participation and to identify predictors of returning to pre-stroke levels of participation.Method
All patients admitted to Karolinska University Hospital''s stroke units during a 1-year period were eligible to participate and 349 patients were recruited. Assessments were made at base-line, 3 months and 6 years using self-reported outcome measures. Participation was assessed using the Frenchay Activities Index (FAI). The 6-year score for each participant was compared to the pre-stroke score, both for the total score and for each domain (domestic chores, leisure/work and outdoor activities). Predictors of having the same or better level of participation at 6 years were identified using logistic regression.Results
At 6 years, 121 participants were followed up, 166 were deceased, 44 declined to take part and 18 could not be traced. At 6 years 84% could be described as active (FAI≥15). The same level of participation or better than pre-stroke was found in 35% of participants, in 65% the level was lower. Similar predictors were identified for achieving the same or better level of participation at 6 years for FAI total and the three domains; ability to walk without aids and a lower age at stroke onset, and perceived mobility, participation and recovery at 3 months.Conclusion
Six years after stroke, 35% of participants had the same or better level of participation as pre-stroke. Rehabilitation after stroke to improve walking ability and participation might improve long-term participation in complex and social everyday activities. 相似文献8.
Ning-Ping Foo Jer-Hao Chang Shih-Bin Su Kow-Tong Chen Ching-Fa Cheng Pei-Chung Chen Tsung-Yi Lin How-Ran Guo 《PloS one》2014,9(10)
Background
The survival rate of patients with out-of-hospital cardiac arrest is low, and measures to improve the quality of cardiopulmonary resuscitation (CPR) during ambulance transportation are desirable. We designed a stabilization device, and in a randomized crossover trial we found performing CPR in a moving ambulance with the device (MD) could achieve better efficiency than that without the device (MND), but the efficiency was lower than that in a non-moving ambulance (NM).Purpose
To evaluate whether a modified version of the stabilization device, can promote further the quality of CPR during ambulance transportation.Methods
Participants of the previous study were recruited, and they performed CPR for 10 minutes in a moving ambulance with the modified version of the stabilization device (MVSD). The primary outcomes were effective chest compressions and no-flow fraction recorded by a skill-reporter manikin. The secondary outcomes included back pain, physiological parameters, and the participants'' rating about the device after performing CPR.Results
The overall effective compressions in 10 minutes were 86.4±17.5% for NM, 60.9±14.6% for MND, 69.7±22.4% for MD, and 86.6%±13.2% for MVSD (p<0.001). Whereas changes in back pain severity and physiology parameters were similar under all conditions, MVSD had the lowest no-flow fraction. Differences in effective compressions and the no-flow fraction between MVSD and NM did not reach statistical significance.Conclusions
The use of the modified device can improve quality of CPR in a moving ambulance to a level similar to that in a non-moving condition without increasing the severity of back pain. 相似文献9.
Mikko Taina Ritva Vanninen Marja Hedman Pekka J?k?l? Satu K?rkk?inen Tero Tapiola Petri Sipola 《PloS one》2013,8(11)
Background
Ischemic strokes without a well-defined etiology are labeled as cryptogenic, and account for 30–40% of strokes in stroke registries. The left atrial appendage (LAA) is the most typical origin for intracardiac thrombus formation when associated with atrial fibrillation. Here, we examined whether increased LAA volume detected with cardiac computed tomography (cCT) constitutes a risk factor in cryptogenic stroke patients.Methods
This study included 82 stroke/TIA patients (57 males; mean age, 58 years) with a diagnosis of cryptogenic stroke after extensive radiological and cardiological investigations. Cases were classified using the TOAST criteria modified by European Association of Echocardiography recommendations for defining cardiac sources of embolism. Forty age- and gender-matched control subjects without cardiovascular diseases were selected for pair-wise comparisons (21 males; mean age, 54 years). LAA volume adjusted for body surface area was measured three dimensionally by tracing the LAA borders on electrocardiogram-gated CT slices.Results
In control subjects, mean LAA volume was 3.4±1.1 mL/m2. Mean+2SD, which was considered the upper limit for normal LAA volume was 5.6 mL/m2. In paired Student t-test between the patient group and matched controls, LAA volume was 67% larger in cryptogenic stroke/TIA patients (5.7±2.0 mL/m2 vs. 3.4±1.1 mL/m2; P<0.001). Forty-five (55%) patients with cryptogenic stroke/TIA had enlarged LAA.Conclusion
LAA is significantly enlarged in more than half of patients with cryptogenic stroke/TIA. LAA thrombosis may contribute to the pathogenesis of stroke in patients considered to have cryptogenic stroke after conventional evaluation. 相似文献10.
Chulho Kim Min Uk Jang Mi Sun Oh Jong-Ho Park San Jung Ju-Hun Lee Kyung-Ho Yu Moon-Ku Han Beom Joon Kim Tai Hwan Park Sang-Soon Park Kyung Bok Lee Jae Kwan Cha Dae-Hyun Kim Jun Lee Sung-Hun Kim Soo Joo Lee Youngchai Ko Jong-Moo Park Kyusik Kang Young-Jin Cho Keun-Sik Hong Ki-Hyun Cho Joon-Tae Kim Dong-Eog Kim Jay Chol Choi Myung Suk Jang Hee-Joon Bae Byung-Chul Lee on the behalf of CRCS- investigators 《PloS one》2014,9(8)
Background and Purpose
The time of hospital arrival may have an effect on prognosis of various vascular diseases. We examined whether off-hour admission would affect the 3-month functional outcome in acute ischemic stroke patients admitted to tertiary hospitals.Methods
We analyzed the ‘off-hour effect’ in consecutive patients with acute ischemic stroke using multi-center prospective stroke registry. Work-hour admission was defined as when the patient arrived at the emergency department between 8 AM and 6 PM from Monday to Friday and between 8 AM and 1 PM on Saturday. Off-hour admission was defined as the rest of the work-hours and statutory holidays. Multivariable logistic regression was used to analyze the association between off-hour admission and 3-month unfavorable functional outcome defined as modified Rankin Scale (mRS) 3–6. Multivariable model included age, sex, risk factors, prehospital delay time, intravenous thrombolysis, stroke subtypes and severity as covariates.Results
A total of 7075 patients with acute ischemic stroke were included in this analysis: mean age, 67.5 (±13.0) years; male, 58.6%. In multivariable analysis, off-hour admission was not associated with unfavorable functional outcome (OR, 0.89; 95% CI, 0.72–1.09) and mortality (OR, 1.09; 95% CI, 0.77–1.54) at 3 months. Moreover, off-hour admission did not affect a statistically significant shift of 3-month mRS distributions (OR, 0.90; 95% CI, 0.78–1.05).Conclusions
‘Off-hour’ admission is not associated with an unfavorable 3-month functional outcome in acute ischemic stroke patients admitted to tertiary hospitals in Korea. This finding indicates that the off-hour effects could be overcome with well-organized stroke management strategies. 相似文献11.
Chih-Hao Chen Sung-Chun Tang Li-Kai Tsai Shin-Joe Yeh Kai-Hsiang Chen Chen-Hua Li Yu-Jen Hsiao Yu-Wei Chen Bak-Sau Yip Jiann-Shing Jeng 《PloS one》2013,8(11)
Background and Purpose
Patients with low estimated glomerular filtration rate (eGFR) and proteinuria may be at increased risk for stroke. This study investigated whether low eGFR and proteinuria are outcome predictors in stroke patients treated with intravenous thrombolysis.Methods
We studied 432 consecutive stroke patients who received thrombolysis from January 2006 to December 2012, in Taiwan. Unfavorable outcome was defined as modified Rankin scale ≥2 at 3 months after stroke. Proteinuria was classified as negative or trace, mild, and moderate to severe. Using logistic regression analysis, we identified independent factors for unfavorable outcome after thrombolysis.Results
Of all patients, 32.7% had proteinuria. Patients with proteinuria were older, had higher frequencies of diabetes mellitus, hyperlipidemia, atrial fibrillation, lower eGFR, and greater severity of stroke upon admission than those without proteinuria. Proteinuria, not low eGFR, was an independent predictor for unfavorable outcome for stroke (OR = 2.00 for mild proteinuria, p = 0.035; OR = 2.54 for moderate to severe proteinuria, p = 0.035). However, no clear relationship was found between proteinuria and symptomatic hemorrhage after thrombolysis.Conclusions
Proteinuria is an independent predictor of unfavorable outcome for acute ischemic stroke in patients treated with intravenous thrombolysis, indicating the crucial role of chronic kidney disease on the effectiveness of thrombolysis. 相似文献12.
Won Young Kim Myoung Kwan Kwak Byuk Sung Ko Jae Chol Yoon Chang Hwan Sohn Kyoung Soo Lim Lars W. Andersen Michael W. Donnino 《PloS one》2014,9(11)
Objectives
Emergency tracheal intubation has achieved high success and low complication rates in the emergency department (ED). The objective of this study was to evaluate the incidence of post-intubation CA and determine the clinical factors associated with this complication.Methods
A matched case-control study with a case to control ratio of 1∶3 was conducted at an urban tertiary care center between January 2007 and December 2011. Critically ill adult patients requiring emergency airway management in the ED were included. The primary endpoint was post-intubation CA, defined as CA within 10 minutes after tracheal intubation. Clinical variables were compared between patients with post-intubation CA and patients without CA who were individually matched based on age, sex, and pre-existing comorbidities.Results
Of 2,403 patients who underwent emergency tracheal intubation, 41 patients (1.7%) had a post-intubation CA within 10 minutes of the procedure. The most common initial rhythm was pulseless electrical activity (78.1%). Patients experiencing CA had higher in-hospital mortality than patients without CA (61.0% vs. 30.1%; p<0.001). Systolic hypotension prior to intubation, defined as a systolic blood pressure ≤90 mmHg, was independently associated with post-intubation CA (OR, 3.67 [95% CI, 1.58–8.55], p = 0.01).Conclusion
Early post-intubation CA occurred with an approximate 2% frequency in the ED. Systolic hypotension before intubation is associated with this complication, which has potentially significant implications for clinicians at the time of intubation. 相似文献13.
Barry S. Peters Melissa Perry Anthony S. Wierzbicki Lisa E. Wolber Glen M. Blake Nishma Patel Richard Hoile Alastair Duncan Ranjababu Kulasegaram Frances M. K. Williams 《PloS one》2013,8(10)
Objective
To determine comparative fracture risk in HIV patients compared with uninfected controls.Design
A randomised cross-sectional study assessing bone mineral density (BMD), fracture history and risk factors in the 2 groups.Setting
Hospital Outpatients.Subbbjects
222 HIV infected patients and an equal number of age-matched controls. Assessments: Fracture risk factors were assessed and biochemical, endocrine and bone markers measured. BMD was assessed at hip and spine. 10-year fracture probability (FRAX) and remaining lifetime fracture probability (RFLP) were calculated.Main Outcome Measures
BMD, and history of fractures.Results
Reported fractures occurred more frequently in HIV than controls, (45 vs. 16; 20.3 vs. 7%; OR=3.27; p=0.0001), and unsurprisingly in this age range, non-fragility fractures in men substantially contributed to this increase. Osteoporosis was more prevalent in patients with HIV (17.6% vs. 3.6%, p<0.0001). BMD was most reduced, and predicted fracture rates most increased, at the spine. Low BMD was associated with antiretroviral therapy (ART), low body mass index and PTH. 10-year FRAX risk was <5% for all groups. RLFP was greater in patients with HIV (OR=1.22; p=0.003) and increased with ART (2.4 vs. 1.50; OR= 1.50; p=0.03).Conclusions
The increased fracture rate in HIV patients in our relatively youthful population is partly driven by fractures, including non-fragility fractures, in men. Nonetheless, these findings may herald a rise in osteoporotic fractures in HIV patients. An appropriate screening and management response is required to assess these risks and identify associated lifestyle factors that are also associated with other conditions such as cardiovascular disease and diabetes. 相似文献14.
Background
Current guidelines recommend withholding antithrombotic therapy (ATT) for at least 24 h in patients with acute ischemic stroke treated with thrombolytic therapy. Herein, we report a retrospective analysis of a single-centre experience on the safety and efficacy of antithrombotic therapy (ATT) started before or after 24 h of intravenous thrombolysis in a cohort of acute ischemic stroke patients.Methods
A total of 139 patients (Rapid ATT group) received antithrombotic therapy before 24 h of thrombolysis, and 33 patients (Standard ATT group) after 24 h. The brain parenchyma and vessel status were assessed using simple CT scan on admission, multimodal CT scan at the end of thrombolysis, and angio-CT/MRI scan at day 3. Functional outcome was scored using the modified Rankin Scale (mRS) at day 90.Results
The two ATT groups had similar demographics, stroke subtypes, baseline NIHSS, thrombolytic strategies, vessel-patency rates at the end of thrombolysis, and incidence of bleeding complications at follow up. At day 3, the Rapid ATT group had a non-significant improved vessel-patency rate than the Standard ATT group. At day 90, a greater proportion of patients in the rapid ATT group had shifted down the mRS, and had improved in the NIHSS score.Conclusions
ATT initiated before 24 h of intravenous thrombolytic therapy in acute stroke patients disclosed no safety concerns compared with a conventional antithrombotic therapy delay of 24 h and showed better functional outcome at follow up. The value of early initiation of ATT after thrombolysis deserves further assessment in randomized controlled trials. 相似文献15.
Xabier Urra Helena Ari?o Laura Llull Sergio Amaro Víctor Obach álvaro Cervera ángel Chamorro 《PloS one》2013,8(3)
Introduction
In up to one third of patients with mild stroke suitable to receive systemic thrombolysis the treatment is not administered because the treating physicians estimate a good spontaneous recovery. However, it is not settled whether the fate of these patients is equivalent to those who are thrombolysed.Methods
We analyzed 203 consecutive patients (134 men and 69 women, mean age 69±14 years) without premorbid disability and a NIHSS score ≤5 at admission [median 3 (IQR 2–4)]. Intravenous thrombolysis was administered within 4.5 hours from stroke onset (n = 119), or it was withheld (n = 84) whenever the treating physician predicted a spontaneous recovery. The baseline risk factors, clinical course, infarction volume, bleeding complications, and functional outcome at 3 months were analyzed and declared to a Web-based registry which was accessible to the local Health Authorities.Results
Expectedly, not thrombolysed patients had the mildest strokes at admission [median 2 (IQR 1–3.75)]. At day 2 to 5, the infarct volume on DWI-MRI was similar in both groups. There were no symptomatic cerebral bleedings in the study. An ordinal regression model adjusted for baseline stroke severity showed that thrombolysis was associated with a greater proportion of patients who shifted down on the modified Rankin Scale score at 3 months (OR 2.66; 95% CI 1.49–4.74, p = 0.001).Conclusions
Intravenous thrombolysis seems to be safe in patients with mild stroke and may be associated with improved outcome compared with untreated patients. These results support the evaluation of the efficacy of intravenous thrombolysis in mild stroke patients in randomized clinical trials. 相似文献16.
Maarten M. H. Lahr Durk-Jouke van der Zee Patrick C. A. J. Vroomen Gert-Jan Luijckx Erik Buskens 《PloS one》2013,8(11)
Background
Various studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. It remains largely unclear how to improve thrombolysis rate in decentralized care. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model.Methods
Based on a prospectively collected dataset of 1084 ischemic stroke patients, simulation was used to replicate current practice and estimate the effect of re-organizing decentralized stroke care to resemble a centralized model. Factors simulated included symptom onset call to help, emergency medical services transportation, and in-hospital diagnostic workup delays. Primary outcome was proportion of patients treated with thrombolysis; secondary endpoints were good functional outcome at 90 days, Onset-Treatment-Time (OTT), and OTT intervals, respectively.Results
Combining all factors might increase thrombolysis rate by 7.9%, of which 6.6% ascribed to pre-hospital and 1.3% to in-hospital factors. Good functional outcome increased by 11.4%, 8.7% ascribed to pre-hospital and 2.7% to in-hospital factors. The OTT decreased 17 minutes, 7 minutes ascribed to pre-hospital and 10 minutes to in-hospital factors. An increase was observed in the proportion thrombolyzed within 1.5 hours; increasing by 14.1%, of which 5.6% ascribed to pre-hospital and 8.5% to in-hospital factors.Conclusions
Simulation technique may target opportunities for improving thrombolysis rates in acute stroke. Pre-hospital factors proved to be the most promising for improving thrombolysis rates in an implementation study. 相似文献17.
Objectives
To examine the association of individual income and end of life (EOL) care in older cancer decedents in Taiwan.Design
Retrospective cohort study.Setting
National Health Insurance Research Database (NHIRD) in Taiwan.Participants
28,978 decedents >65 years were diagnosed with cancer and died during 2009-2011 in Taiwan. Of these decedents, 10941, 16535, and 1502 were categorized by individual income as having low, moderate, and high SES, respectively.Main outcome measures
Indicators of aggressiveness of EOL care: chemotherapy use before EOL, more than one emergency department (ER) visit, more than one hospital admission, hospital length of stay >14 days, intensive care unit (ICU) admission, and dying in a hospital.Results
Low individual income was associated with more aggressive EOL treatment (estimate -0.30 for moderate income, -0.27 for high income, both p<0.01). The major source of aggressiveness was the tendency for older decedents with low income to die in the acute care hospital. The indicators had an increasing trend from 2009 to 2011, except for hospital stay >14 days.Conclusions
Low individual income is associated with more aggressive EOL treatment in older cancer decedents. Public health providers should make available appropriate education and hospice resources to these decedents and their families, to reduce the amount of aggressive terminal care such decedents receive. 相似文献18.
Osthoff M Katan M Fluri F Schuetz P Bingisser R Kappos L Steck AJ Engelter ST Mueller B Christ-Crain M Trendelenburg M 《PloS one》2011,6(6):e21338
Background
The Mannose-binding lectin (MBL) pathway of complement plays a pivotal role in the pathogenesis of ischemia/reperfusion (I/R) injury after experimental ischemic stroke. As comparable data in human ischemic stroke are limited, we investigated in more detail the association of MBL deficiency with infarction volume and functional outcome in a large cohort of patients receiving intravenous thrombolysis or conservative treatment.Methodology/Principal Findings
In a post hoc analysis of a prospective cohort study, admission MBL concentrations were determined in 353 consecutive patients with an acute ischemic stroke of whom 287 and 66 patients received conservative and thrombolytic treatment, respectively. Stroke severity, infarction volume, and functional outcome were studied in relation to MBL concentrations at presentation to the emergency department. MBL levels on admission were not influenced by the time from symptom onset to presentation (p = 0.53). In the conservative treatment group patients with mild strokes at presentation, small infarction volumes or favorable outcomes after three months demonstrated 1.5 to 2.6-fold lower median MBL levels (p = 0.025, p = 0.0027 and p = 0.046, respectively) compared to patients with more severe strokes. Moreover, MBL deficient patients (<100 ng/ml) were subject to a considerably decreased risk of an unfavorable outcome three months after ischemic stroke (adjusted odds ratio 0.38, p<0.05) and showed smaller lesion volumes (mean size 0.6 vs. 18.4 ml, p = 0.0025). In contrast, no association of MBL concentration with infarction volume or functional outcome was found in the thrombolysis group. However, the small sample size limits the significance of this observation.Conclusions
MBL deficiency is associated with smaller cerebral infarcts and favorable outcome in patients receiving conservative treatment. Our data suggest an important role of the lectin pathway in the pathophysiology of cerebral I/R injury and might pave the way for new therapeutic interventions. 相似文献19.