Mobile platform for treatment of stroke: A case study of tele-assistance.

This article presents the technological solution of a tele-assistance process for stroke patients in acute phase in the Seville metropolitan area. The main objective of this process is to reduce time from symptom onset to treatment of acute phase stroke patients by means of telemedicine, regarding mobility between an intensive care unit ambulance and an expert center and activating the pre-hospital care phase. The technological platform covering the process has been defined following an interoperability model based on standards and with a focus on service-oriented architecture focus. Messaging definition has been designed according to the reference model of the CEN/ISO 13606, messages content follows the structure of archetypes. An XDS-b (Cross-Enterprise Document Sharing-b) transaction messaging has been designed according to Integrating the Healthcare Enterprise profile for archetype notifications and update enquiries.This research has been performed by a multidisciplinary group. The Virgen del Rocío University Hospital acts as Reference Hospital and the Public Company for Healthcare as mobility surroundings.

El control estricto de la presión arterial tras un ictus isquémico se asocia con la aparición de episodios de hipotensión nocturna / Tight control of blood pressure after ischemic stroke is associated with nocturnal hypotension episodes

Objetivo. Evaluar si un control más estricto de la presión arterial (PA) en pacientes con ictus isquémico reciente se asocia con la presencia de episodios de hipotensión nocturna (HPN). Pacientes y métodos. Se incluyeron 100 pacientes consecutivos que habían sido dados de alta por ictus isquémico en los seis meses previos. Para evaluar el buen control de la PA en estos pacientes, se utilizaron valores de la PA en consulta y monitorización ambulatoria de la PA de 24 horas. Resultados. Se estudiaron 63 varones y 37 mujeres; la media de edad fue de 69 ± 11 años. Se incluyeron 68 ictus lacunares y 32 no lacunares. Se observaron episodios de HPN en 59 pacientes. La hipertensión clínica estuvo presente en 34 pacientes. Un patrón anormal del ritmo circadiano de la PA estaba presente en 72 sujetos. Sólo 18 pacientes tenían la PA dentro de límites normales. Los episodios de HPN fueron más frecuentes en los pacientes con buen control de la PA en comparación con los pacientes con mal control: 88,8% y 52,4%, respectivamente (p = 0,007). La presencia de episodios de HPN también estaba inversamente relacionada con el número de parámetros de PA alterados (p = 0,001). Conclusiones. El control estricto de la PA tras un ictus isquémico se asocia con una alta frecuencia de episodios de HPN. Es probable que una reducción intensiva de los niveles de la PA dentro del rango de la normalidad tras un ictus isquémico pueda no ser beneficiosa, en particular en los pacientes ancianos (AU)

Aim. To evaluate whether a tighter blood pressure (BP) control in patients with recent ischemic stroke is associated with the presence of nocturnal hypotension (NHP) episodes. Patients and methods. We included one hundred consecutive patients who had been discharged for ischemic stroke in the previous six months. To evaluate adequacy of BP control in these patients office BP and 24-h ambulatory BP monitoring values were used. Results. We studied 63 males and 37 females; mean age was 69 ± 11 years. Sixty-eight lacunar and 32 non-lacunar strokes were included. Episodes of NHP were observed in 59 patients. Clinical hypertension was present in 34 patients. An abnormal pattern of circadian rhythm of BP was present in 72 subjects. Only 18 patients had BP within normal limits. Episodes of NHP were more frequent in subjects with good BP control versus patients with bad BP control: 88.8% and 52.4 % respectively (p = 0.007). The presence of NHP episodes was also inversely related to number of BP parameters altered (p = 0.001). Conclusions. Tight control of BP after ischemic stroke is associated with a high frequency of NHP episodes. It is likely that aggressively lowering BP levels within the normal range after an ischemic stroke may be not beneficial, particularly in elderly patients (AU)

Dislipemia aterogénica y riesgo residual en pacientes con ictus isquémico / Atherogenic dyslipidemia and residual risk in patients with ischemic stroke

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[Hemicrania continua and paroxysmal hemicrania: clinical and therapeutic characteristics in a series of 23 patients]. / Hemicránea continua y paroxística: características clínicas y terapéuticas en una serie de 23 pacientes.

INTRODUCTION: Hemicranias are an uncommon type of headache characterised by strictly unilateral pain, either as a continuous, although fluctuating, headache in hemicrania continua (HC) or in the form of recurring attacks in paroxysmal hemicrania (PH). In both types of headache, an absolute response to indomethacin is reported. AIMS. To analyse the fulfilment of current diagnostic criteria for HC and PH and the recent introduction of HC within the group of trigeminal-autonomic cephalgias. PATIENTS AND METHODS: The clinical and therapeutic characteristics of patients diagnosed with HC or PH were evaluated retrospectively. Demographic and symptomatological information as well as data regarding the analogical pain scale and response to indomethacin were included. RESULTS: A sample of 12 HC (four males and eight females) was evaluated from a total of 520 cases (2.3%). Mean age at onset: 47.1 ± 16.4 years. Baseline pain intensity: 3.3 ± 1,9. Exacerbations: 9.2 ± 1.1. Eight cases (66.7%) presented autonomic symptoms, four (33.3%) followed a time pattern, and two (16.7%) did not respond to indomethacin. We evaluated a sample of 11 PH (100% females) from 520 cases (2.1%). Mean age at onset: 37.0 ± 13.9 years. Pain intensity: 8.7 ± 2.7. Nine cases (81.8%) presented autonomic symptoms, three (27.3%) followed a time pattern and one (9.1%) did not respond to indomethacin. CONCLUSIONS: Hemicranias are not frequently diagnosed in day-to-day clinical practice. Their diagnosis requires the fulfilment of certain criteria that are sometimes not fully satisfied. We believe that the criteria need revising and we also support the recent inclusion of HC within the group of trigeminal-autonomic cephalgias.

TITLE: Hemicranea continua y paroxistica: caracteristicas clinicas y terapeuticas en una serie de 23 pacientes.Introduccion. Las hemicraneas son cefaleas raras caracterizadas por dolor estrictamente unilateral, bien como una cefalea continua, aunque fluctuante, en la hemicranea continua (HC), o en forma de ataques recurrentes en la hemicranea paroxistica (HP). En ambos tipos de cefalea se describe una respuesta absoluta a la indometacina. Objetivo. Analizar el cumplimiento de los criterios diagnosticos actuales para HC y HP, y la reciente introduccion de la HC en el grupo de las cefaleas trigeminoautonomicas. Pacientes y metodos. Evaluamos retrospectivamente las caracteristicas clinicas y terapeuticas de pacientes diagnosticados de HC o HP. Incluimos informacion demografica, sintomatologia, escala analogica de dolor y respuesta a la indometacina. Resultados. Evaluamos una muestra de 12 pacientes con HC (cuatro hombres y ocho mujeres) de un total de 520 casos (2,3%). Edad media de inicio: 47,1 ± 16,4 años. Intensidad de dolor basal: 3,3 ± 1,9. Exacerbaciones: 9,2 ± 1,1. Ocho casos (66,7%) presentaban sintomas autonomicos, cuatro (33,3%) tenian patron horario y dos (16,7%) no respondieron a la indometacina. Evaluamos una muestra de 11 pacientes con HP (100% mujeres) de 520 casos (2,1%). Edad media de inicio: 37,0 ± 13,9 años. Intensidad de dolor: 8,7 ± 2,7. Nueve casos (81,8%) presentaban sintomas autonomicos, tres (27,3%) tenian patron horario y uno (9,1%) no respondio a la indometacina. Conclusiones. Las hemicraneas son diagnosticos infrecuentes en consultas de cefalea. Su diagnostico requiere el cumplimiento de unos criterios que a veces no se cumplen en su totalidad. Pensamos que se precisa una revision de los criterios y apoyamos que la HC se haya introducido recientemente en el grupo de las cefaleas trigeminoautonomicas.

Hemicránea continua y paroxística: características clínicas y terapéuticas en una serie de 23 pacientes / Hemicrania continua and paroxysmal hemicrania: clinical and therapeutic characteristics in a series of 23 patients

Introducción. Las hemicráneas son cefaleas raras caracterizadas por dolor estrictamente unilateral, bien como una cefalea continua, aunque fluctuante, en la hemicránea continua (HC), o en forma de ataques recurrentes en la hemicránea paroxística (HP). En ambos tipos de cefalea se describe una respuesta absoluta a la indometacina. Objetivo. Analizar el cumplimiento de los criterios diagnósticos actuales para HC y HP, y la reciente introducción de la HC en el grupo de las cefaleas trigeminoautonómicas. Pacientes y métodos. Evaluamos retrospectivamente las características clínicas y terapéuticas de pacientes diagnosticados de HC o HP. Incluimos información demográfica, sintomatología, escala analógica de dolor y respuesta a la indometacina. Resultados. Evaluamos una muestra de 12 pacientes con HC (cuatro hombres y ocho mujeres) de un total de 520 casos (2,3%). Edad media de inicio: 47,1 ± 16,4 años. Intensidad de dolor basal: 3,3 ± 1,9. Exacerbaciones: 9,2 ± 1,1. Ocho casos (66,7%) presentaban síntomas autonómicos, cuatro (33,3%) tenían patrón horario y dos (16,7%) no respondieron a la indometacina. Evaluamos una muestra de 11 pacientes con HP (100% mujeres) de 520 casos (2,1%). Edad media de inicio: 37,0 ± 13,9 años. Intensidad de dolor: 8,7 ± 2,7. Nueve casos (81,8%) presentaban síntomas autonómicos, tres (27,3%) tenían patrón horario y uno (9,1%) no respondió a la indometacina. Conclusiones. Las hemicráneas son diagnósticos infrecuentes en consultas de cefalea. Su diagnóstico requiere el cumplimiento de unos criterios que a veces no se cumplen en su totalidad. Pensamos que se precisa una revisión de los criterios y apoyamos que la HC se haya introducido recientemente en el grupo de las cefaleas trigeminoautonómicas (AU)

Introduction. Hemicranias are an uncommon type of headache characterised by strictly unilateral pain, either as a continuous, although fluctuating, headache in hemicrania continua (HC) or in the form of recurring attacks in paroxysmal hemicrania (PH). In both types of headache, an absolute response to indomethacin is reported. Aims. To analyse the fulfilment of current diagnostic criteria for HC and PH and the recent introduction of HC within the group of trigeminal-autonomic cephalgias. Patients and methods. The clinical and therapeutic characteristics of patients diagnosed with HC or PH were evaluated retrospectively. Demographic and symptomatological information as well as data regarding the analogical pain scale and response to indomethacin were included. Results. A sample of 12 HC (four males and eight females) was evaluated from a total of 520 cases (2.3%). Mean age autonomic symptoms, four (33.3%) followed a time pattern, and two (16.7%) did not respond to indomethacin. We evaluated a sample of 11 PH (100% females) from 520 cases (2.1%). Mean age at onset: 37.0 ± 13.9 years. Pain intensity: 8.7 ± 2.7. Nine cases (81.8%) presented autonomic symptoms, three (27.3%) followed a time pattern and one (9.1%) did not respond to indomethacin. Conclusions. Hemicranias are not frequently diagnosed in day-to-day clinical practice. Their diagnosis requires the fulfilment of certain criteria that are sometimes not fully satisfied. We believe that the criteria need revising and we also support the recent inclusion of HC within the group of trigeminal-autonomic cephalgias (AU)

Atención prehospitalaria del ictus agudo: ¿hemos mejorado realmente? / Pre-hospital care of acute stroke: have we really improved?

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Ictus cardioembólico por fibrilación auricular y nuevos criterios de anticoagulación: un reto terapéutico / Cardioembolic stroke in atrial fibrillation and new anticoagulation criteria: a therapeutic dare

Introducción. La fibrilación auricular (FA) aumenta por cinco el riesgo de ictus. El nuevo esquema de estratificación de riesgo para instauración de anticoagulación oral CHA2-DS2-VASc obtiene mejores resultados en la estratificación del riesgo de ictus frente a la previa escala CHADS2. Objetivo. Evaluar en pacientes con FA conocida e ictus cardioembólico la indicación de anticoagulación oral conforme al riesgo previo embolígeno según la escala CHADS2 y la nueva clasificación CHA2-DS2-VASc, valorando el riesgo hemorrá- gico con la escala HAS-BLED. Pacientes y métodos. Se incluyeron 164 pacientes con FA e ictus cardioembólico, 87 de los cuales tenían FA conocida. Se registró tratamiento precedente anticoagulante y criterios de anticoagulación previos según las escalas CHADS2 y CHA2- DS2-VASc, incluyendo la escala de riesgo hemorrágico HAS-BLED. En anticoagulados se registró un nivel de índice internacional normalizado (INR) en fase aguda del ictus. Resultados. No hubo diferencias significativas en características basales según anticogulación previa, excepto mayor porcentaje de ictus en anticogulados (47%). El 41,3% con FA conocida estaba anticoagulado antes del ictus. De los 52 pacientes no anticoagulados, el 61,5% tenía criterios de anticoagulación previos al ictus según la CHADS2. Usando la CHA2-DS2- VASc, dicho porcentaje aumentó al 94,2% (p < 0,001). El 78,8% de los no anticoagulados presentaba bajo riesgo de sangrado según la escala HAS-BLED. En pacientes anticoagulados, el 67,6% presentaba INR infraterapéutico en el momento del ictus. Conclusión. En nuestro medio, detectamos bajo cumplimiento de escalas de estratificación de riesgo tromboembólico en pacientes con FA para una estrategia óptima de tratamiento. Es preciso su mayor uso para la prevención primaria del ictus y la optimización del tratamiento anticoagulante en pacientes con FA (AU)

Aim. To evaluate in patients with known AF and cardioembolic stroke, the indication of oral anticoagulation under previous risk embolism according to the CHADS2 scale and new classification CHA2-DS2-VASc, assessing the risk of bleeding with HAS-BLED scale. Patients and methods. We included 164 patients with atrial fibrillation and cardioembolic stroke, 87 of them with known AF. It was recorded previous anticoagulant treatment and criteria for prior anticoagulation taking into account CHADS2 scales and CHA2-DS2-VASc, including hemorrhagic risk scale HAS-BLED. In anticoagulated patients INR level was recorded in acute stroke phase. Results. There were no significant differences in baseline patients characteristics according to previous anticoagulation, except higher percentage of previous stroke in anticoagulated patients (47%). 41.3% were anticoagulated with known AF prior to stroke. From 52 non-anticoagulated patients, 61.5% met criteria for anticoagulation prior to stroke as CHADS2. Using CHA2-DS2-VASc, this percentage increased to 94.2% (p <0.001). 78.8% of non-anticoagulated had a low risk of bleeding according to the scale HAS-BLED. In anticoagulated patients, 67.6% had suboptimal INR at the time of stroke. Conclusion. In our study, we found low compliance scales of thromboembolic risk stratification in patients with AF for an optimal treatment strategy. It should be increased its use for primary prevention of stroke and optimization of anticoagulant therapy in patients with AF (AU)

Development, Implementation, and Evaluation of a Telemedicine Service for the Treatment of Acute Stroke Patients: TeleStroke.

BACKGROUND: Health care service based on telemedicine can reduce both physical and time barriers in stroke treatments. Moreover, this service connects centers specializing in stroke treatment with other centers and practitioners, thereby increasing accessibility to neurological specialist care and fibrinolytic treatment. OBJECTIVE: Development, implementation, and evaluation of a care service for the treatment of acute stroke patients based on telemedicine (TeleStroke) at Virgen del Rocío University Hospital. METHODS: The evaluation phase, conducted from October 2008 to January 2011, involved patients who presented acute stroke symptoms confirmed by the emergency physician; they were examined using TeleStroke in two hospitals, at a distance of 16 and 110 kilometers from Virgen del Rocío University Hospital. We analyzed the number of interconsultation sheets, the percentage of patients treated with fibrinolysis, and the number of times they were treated. To evaluate medical professionals' acceptance of the TeleStroke system, we developed a web-based questionnaire using a Technology Acceptance Model. RESULTS: A total of 28 patients were evaluated through the interconsultation sheet. Out of 28 patients, 19 (68%) received fibrinolytic treatment. The most common reasons for not treating with fibrinolysis included: clinical criteria in six out of nine patients (66%) and beyond the time window in three out of nine patients (33%). The mean "onset-to-hospital" time was 69 minutes, the mean time from admission to CT image was 33 minutes, the mean "door-to-needle" time was 82 minutes, and the mean "onset-to-needle" time was 150 minutes. Out of 61 medical professionals, 34 (56%) completed a questionnaire to evaluate the acceptability of the TeleStroke system. The mean values for each item were over 6.50, indicating that respondents positively evaluated each item. This survey was assessed using the Cronbach alpha test to determine the reliability of the questionnaire and the results obtained, giving a value of 0.97. CONCLUSIONS: The implementation of TeleStroke has made it possible for patients in the acute phase of stroke to receive effective treatment, something that was previously impossible because of the time required to transfer them to referral hospitals.

¿Debemos cambiar el tratamiento de la presión arterial en la fase aguda del ictus, tras los resultados del estudio SCAST? / In view of the findings of the SCAST study, must the treatment of arterial pressure in the acute phase of stroke be changed?

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[Factors that affect time delays to fibrinolytic treatment in ischaemic stroke]. / Factores que influyen en la demora del tratamiento fibrinolitico en el ictus isquémico.

INTRODUCTION: Extending the thrombolytic therapy window in ischaemic stroke to 4.5 hours has proved to be useful and safe, but a prompt response remains a decisive factor. AIM: To analyse the factors that delay treatment. PATIENTS AND METHODS: After activating the Stroke Code procedure, the consecutive cases of stroke attended in the emergency department throughout the year 2006 were recorded; data included their clinical and epidemiological features, origin, means of transport and delay times in the process. RESULTS: Of the total number of patients with ischaemic stroke, 10.1% finished the emergency study with a median of 1 hour to decide to carry out treatment within 3 hours, and 13.1% of them between 3 and 4.5 hours, with a median of 2 hours and 6 minutes. For the analysis of all the variables, 498 patients were selected; 39% were admitted to hospital within the first 3 hours and 11.2% between 3 and 4.5 hours of the onset of symptoms. The use of the emergency telephone system, transport by mobile ICU or ambulance and an impaired level of consciousness, sight or, to a lesser extent, language or speech were related to shorter delay times. CONCLUSIONS: The factors that depended on the actual patient, in general, did not shorten the delay time. Clinical severity, the presence of informants and activating the emergency system shortened intervention times.

Factores que influyen en la demora del tratamiento fibrinolítico en el ictus isquémico / Factors that affect time delays to fibrinolytic treatment in ischaemic stroke

Introducción. Ampliar la ventana terapéutica trombolítica del ictus isquémico hasta las 4,5 horas se ha demostrado útil y seguro, pero la celeridad en la respuesta sigue siendo determinante. Objetivo. Analizar los factores que demoran el tratamiento. Pacientes y métodos. Tras activar el dispositivo Código Ictus, se registraron los casos consecutivos de ictus atendidos en urgencias durante el año 2006, sus características clínicas, epidemiológicas, procedencia, modo de traslado y demoras del proceso. Resultados. Del total de pacientes con ictus isquémico, el 10,1% concluyó el estudio de urgencias con una mediana de 1 hora para decidir tratar en las 3 horas y el 13,1%, entre las 3 y 4,5 horas con una mediana de 2 horas y 6 minutos. Para el análisis de todas las variables se seleccionó a 498 pacientes; el 39% ingresó en las primeras 3 horas y el 11,2% entre las 3 y 4,5 horas del inicio de los síntomas. El uso del sistema telefónico de emergencias, el traslado en UCI móvil o ambulancia y el déficit en el nivel de conciencia, visual o, en menor grado, del lenguaje o habla incidieron en una demora menor. Conclusiones. Los factores dependientes del propio paciente, en general, no disminuyeron la demora. La gravedad clínica, la presencia de informadores y la activación del sistema de emergencias acortaron los tiempos en las actuaciones (AU)

Introduction. Extending the thrombolytic therapy window in ischaemic stroke to 4.5 hours has proved to be useful and safe, but a prompt response remains a decisive factor. Aim. To analyse the factors that delay treatment. Patients and methods. After activating the Stroke Code procedure, the consecutive cases of stroke attended in the emergency department throughout the year 2006 were recorded; data included their clinical and epidemiological features, origin, means of transport and delay times in the process. Results. Of the total number of patients with ischaemic stroke, 10.1% finished the emergency study with a median of 1 hour to decide to carry out treatment within 3 hours, and 13.1% of them between 3 and 4.5 hours, with a median of 2 hours and 6 minutes. For the analysis of all the variables, 498 patients were selected; 39% were admitted to hospital within the first 3 hours and 11.2% between 3 and 4.5 hours of the onset of symptoms. The use of the emergency telephone system, transport by mobile ICU or ambulance and an impaired level of consciousness, sight or, to a lesser extent, language or speech were related to shorter delay times. Conclusions. The factors that depended on the actual patient, in general, did not shorten the delay time. Clinical severity, the presence of informants and activating the emergency system shortened intervention times (AU)

Ecocardiografía en el ictus. Nuevos argumentos para el debate / Echocardiography in strokes: new arguments for the debate

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La mortalidad en el ‘cinturón del ictus’ español: algunas claves andaluzas. Réplica / Mortality in the Spanish ‘stroke belt’: some key points in Andalusia. Reply

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El ‘cinturón del ictus’ español: un nuevo concepto para una vieja realidad / No disponible

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