Prehospital Phase of the Stroke Chain of Survival: A Prospective Observational Study.
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ABSTRACT:
SUBMITTER: Puolakka T
PROVIDER: S-EPMC4889170 | biostudies-other | 2016 May
REPOSITORIES: biostudies-other
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Project description:IntroductionThe efficacy of both intravenous treatment (IVT) and endovascular treatment (EVT) for patients with acute ischaemic stroke strongly declines over time. Only a subset of patients with ischaemic stroke caused by an intracranial large vessel occlusion (LVO) in the anterior circulation can benefit from EVT. Several prehospital stroke scales were developed to identify patients that are likely to have an LVO, which could allow for direct transportation of EVT eligible patients to an endovascular-capable centre without delaying IVT for the other patients. We aim to prospectively validate these prehospital stroke scales simultaneously to assess their accuracy in predicting LVO in the prehospital setting.Methods and analysisPrehospital triage of patients with suspected stroke symptoms (PRESTO) is a prospective multicentre observational cohort study in the southwest of the Netherlands including adult patients with suspected stroke in the ambulance. The paramedic will assess a combination of items from five prehospital stroke scales, without changing the normal workflow. Primary outcome is the clinical diagnosis of an acute ischaemic stroke with an intracranial LVO in the anterior circulation. Additional hospital data concerning the diagnosis and provided treatment will be collected by chart review. Logistic regression analysis will be performed, and performance of the prehospital stroke scales will be expressed as sensitivity, specificity and area under the receiver operator curve.Ethics and disseminationThe Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) is not applicable. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. The best performing scale, or the simplest scale in case of clinical equipoise, will be integrated in a decision model with other clinical characteristics and real-life driving times to improve prehospital triage of suspected stroke patients.Trial registration numberNTR7595.
| S-EPMC6615792 | biostudies-literature
Project description:The outcome of stroke patients is complex and multidimensional. We evaluated the impact of acute-phase variables, including clinical state, complications, resource use and interventions, on 6-month survival after first-ever stroke, taking into account baseline conditions exerting a possible effect on outcome. As part of a National Research Program, we performed a prospective observational study of acute stroke patients in four Italian Regions. Consecutive patients admitted for a period of 3 months to the emergency rooms of participating hospitals were included. A total of 1030 patients were enrolled (median age 76.0 years, 52.1% males). At 6 months, 816 (79.2%) were alive, and 164 (15.9%) deceased. Survival status at the 6-month follow-up was missing for 50 (4.9%). Neurological state in the acute phase was significantly worse in patients deceased at 6 months, who showed also higher frequency of acute-phase complications. Cox regression analysis adjusted for demographics, pre-stroke function, baseline diseases and risk factors, indicated as significant predictors of 6-month death altered consciousness (HR, 1.70; 95% CI, 1.14-2.53), total anterior circulation infarct (HR, 2.13; 95% CI, 1.44-3.15), hyperthermia (HR, 1.70; 95% CI, 1.18-2.45), pneumonia (HR, 1.76; 95% CI, 1.18-2.61), heart failure (HR, 2.87; 95% CI, 1.34-6.13) and nasogastric feeding (HR, 2.35; 95% CI, 1.53-3.60), while antiplatelet therapy during acute phase (HR, 0.56; 95% CI, 0.39-0.79), and early mobilisation (HR, 0.55; 95% CI, 0.36-0.84) significantly increased 6-month survival. In a prospective observational study, stroke severity and some acute-phase complications, potentially modifiable, significantly increased the risk of 6-month death, independently of baseline variables. Early mobilisation positively affected survival, highlighting the role of early rehabilitation after stroke.
| S-EPMC5865737 | biostudies-literature
Project description:BackgroundFew studies have investigated the patient compartment temperatures during ambulance missions or its relation to admission hypothermia. Still hypothermia is a known risk factor for increased mortality and morbidity in both trauma and disease. This has special relevance to our sub-arctic region's pre-hospital services, and we prospectively studied the environmental temperature in the patient transport compartment in both ground and air ambulances.MethodsWe recorded cabin temperature during patient transport in two ground ambulances and one ambulance helicopter in the catchment area of the University Hospital of North Norway using automatic temperature loggers. The data were collected for one month in each of the four seasons. We calculated the sum of degrees Celsius below 18 min by minute to describe the patient exposure to unfavourably low cabin temperature, and present the data as box plots. The statistical differences between transport mode and season were analysed with ANCOVA.ResultsThe recorded cabin temperatures were higher during the summer than the other three seasons. However, we also found that helicopter transports were performed at lower cabin temperatures and with significantly more exposure to unfavourably low temperatures than the ground ambulance transports. Furthermore, the helicopter cabin reached the final temperature much slower than the ground ambulance cabins did or remained at a lower than comfortable temperature.ConclusionsHelicopter cabin temperature during ambulance missions should be monitored closer, particularly for patients at risk for developing admission hypothermia.
| S-EPMC7359238 | biostudies-literature
Project description:BackgroundDiagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy.MethodsProspective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea.ResultsIn total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%-69%) before POCUS compared to 65% (95% CI 53%-75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66-0.78) before POCUS compared to 0.79 (0.73-0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82-0.91) before POCUS and 0.93 (0.88-0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%-94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%-100%).ConclusionSupplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure.Trial registrationRegistered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1 .
| S-EPMC9899351 | biostudies-literature
Project description:Background. Patients with sepsis benefit from early diagnosis and treatment. Accurate paramedic recognition of sepsis is important to initiate care promptly for patients who arrive by Emergency Medical Services. Methods. Prospective observational study of adult patients (age ? 16 years) transported by paramedics to the emergency department (ED) of a Canadian tertiary hospital. Paramedic identification of sepsis was assessed using a novel prehospital sepsis screening tool developed by the study team and compared to blind, independent documentation of ED diagnoses by attending emergency physicians (EPs). Specificity, sensitivity, accuracy, positive and negative predictive value, and likelihood ratios were calculated with 95% confidence intervals. Results. Overall, 629 patients were included in the analysis. Sepsis was identified by paramedics in 170 (27.0%) patients and by EPs in 71 (11.3%) patients. Sensitivity of paramedic sepsis identification compared to EP diagnosis was 73.2% (95% CI 61.4-83.0), while specificity was 78.8% (95% CI 75.2-82.2). The accuracy of paramedic identification of sepsis was 78.2% (492/629, 52 true positive, 440 true negative). Positive and negative predictive values were 30.6% (95% CI 23.8-38.1) and 95.9% (95% CI 93.6-97.5), respectively. Conclusion. Using a novel prehospital sepsis screening tool, paramedic recognition of sepsis had greater specificity than sensitivity with reasonable accuracy.
| S-EPMC4804076 | biostudies-literature
Project description:Rapid and precise prehospital recognition of acute coronary syndrome (ACS) is key to improving clinical outcomes. The aim of this study was to investigate a predictive power for predicting ACS using the machine learning-based prehospital algorithm. We conducted a multicenter observational prospective study that included 10 participating facilities in an urban area of Japan. The data from consecutive adult patients, identified by emergency medical service personnel with suspected ACS, were analyzed. In this study, we used nested cross-validation to evaluate the predictive performance of the model. The primary outcomes were binary classification models for ACS prediction based on the nine machine learning algorithms. The voting classifier model for ACS using 43 features had the highest area under the receiver operating curve (AUC) (0.861 [95% CI 0.775-0.832]) in the test score. After validating the accuracy of the model using the external cohort, we repeated the analysis with a limited number of selected features. The performance of the algorithms using 17 features remained high AUC (voting classifier, 0.864 [95% CI 0.830-0.898], support vector machine (radial basis function), 0.864 [95% CI 0.829-0.887]) in the test score. We found that the machine learning-based prehospital algorithms showed a high predictive power for predicting ACS.
| S-EPMC9418242 | biostudies-literature
Project description:Stroke, characterized by sudden loss of cerebral function, is among one of the leading cause of death and disability world over. The newer treatment modalities have changed the landscape of stroke treatment but are very much time bound.To characterize pre-hospital and in-hospital factors affecting acute stroke management thus defining lacunae in stroke management.A prospective observational study, conducted at the emergency department of a tertiary care center in southern India from August 2015 to July 2016. All stroke patients presenting within first 24 hours of onset were included. A pre -defined Knowledge-Attitude-Practice (KAP) questionnaire was used.Total of 133 patients were eligible out of which 28 were excluded for various reasons. Majority were >60 years age and male (61%). About 60% arrived within window. Distance from the hospital was one of the major factors for arrival within the window period. When compared by KAP questionnaire, bystanders of those arriving within window period had better awareness of stroke symptoms.Improving awareness of stroke symptoms and increasing availability of EMS is likely increase chances of stroke patients receiving appropriate acute management.
| S-EPMC5879854 | biostudies-other
Project description:ObjectiveIschemic stroke (IS) in young patients may differ in etiology and prognosis from later-life IS, which is much more common. A number of single-center and population-based cohorts of affected individuals have been published, but information on the long-term prognosis of these patients is limited.MethodsIS patients (≤55 years), discharged over a 10-year period, were evaluated and prospectively followed. Subgroups were evaluated for type of stroke, antecedent risk factors (RF), long-term outcomes, and occupational status over several years of follow-up.Results178 IS individuals from 2001-2010 were divided into older (46-55, n = 118) and younger (18-45, n = 60) age groups. Traditional RF-hypertension, diabetes mellitus, hyperlipidemia-were significantly associated with IS, and increased with age. The distribution and type of IS were similar in both groups, except for an increase in small vessel IS among the older subgroup (p = .003). Of the evaluable patients at 5.1 ± 2.5 years of follow-up (n = 138), a similar proportion of patients in both subgroups had a recurrent IS, but no significant differences were found in most disability indices. Approximately one third of patients suffered from moderate to severe disability, and were unable to return to their prior work.ConclusionsYounger and older IS patients are generally predisposed from the same traditional RF which progress with age. Long-term disabilities tend to worsen over time due to recurrent vascular events. These data emphasize the need for a strategy for early identification of the already well-known stroke RF in younger stroke patients.
| S-EPMC8442588 | biostudies-literature
Project description:BACKGROUND:Earlier use of in-hospital plasma, platelets, and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter. METHODS:Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from January to November 2015. Five helicopter systems had plasma and/or RBCs, whereas the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high-risk criteria were analyzed. Patients receiving PHT were compared with patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores. RESULTS:Twenty-five thousand one hundred eighteen trauma patients were admitted, 2,341 (9%) were transported by helicopter, of which 1,058 (45%) met the highest-risk criteria. Five hundred eighty-five of 1,058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and Glasgow Coma Scale (7 vs 14) was significantly lower, whereas median Injury Severity Score was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 hours (8.4% vs 3.6%), 24 hours (12.6% vs 8.9%), and 30 days (19.3% vs 13.3%). Twenty-four percent of eligible patients received a PHT. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs, and 69% received both. In the propensity score matching analysis (n = 109), PHT was not significantly associated with mortality at any time point, although only 10% of the high-risk sample were able to be matched. CONCLUSION:Because of the unexpected imbalance in systolic blood pressure, Glasgow Coma Scale, and Injury Severity Score between systems with and without blood products on helicopters, matching was limited, and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population. LEVEL OF EVIDENCE:Level II.
| S-EPMC5562146 | biostudies-literature
Project description:BackgroundThe western medical arsenal for treating stroke is rather limited, and the only treatments shown to improve outcomes are not accessible to most in the third world. Even in the developed world, many patients present too late to receive thrombolysis or thrombectomy. Stroke patients in India commonly use Ayurvedic therapies, but there are no published data regarding the efficacy or safety of these therapies, the latter being of particular concern in acute ischemic stroke (AIS).ObjectiveTo obtain preliminary data on the safety and efficacy of stand-alone whole-system Ayurvedic treatment in AIS.MethodsWe present here an observational study prospectively comparing outcomes in 2 cohorts of AIS patients treated with whole-system classical Ayurveda (n = 13) or conservative (nonthrombolytic, noninterventional) western biomedicine (n = 20).ResultsPooled analysis of outcomes did not show statistically significant differences in mortality (15.38% vs 15%, P = 1.00), nonfatal adverse event rates (15.38% vs 30%, P = .4), or functional disability measures. A paired analysis performed using a matching algorithm to reduce baseline disparities between the cohorts also showed no statistically significant differences in outcomes.ConclusionsThe safety profiles of classical Ayurveda and conservative western biomedicine in AIS are similar. This is the first ever report of stand-alone Ayurvedic therapy in AIS. Our results support the conduct of a randomized controlled trial to study the efficacy of Ayurvedic treatment of AIS.
| S-EPMC6545648 | biostudies-literature