ABSTRACT
Background and Aims: Timely administration of recombinant tissue plasminogen activator (r-tPA) improves clinical outcomes in acute ischemic stroke patients. This study aims to explore the influence of the systematic presence on site of a neurologist compared with telestroke management on door-to-needle time in acute ischemic stroke outside of working hours (OWH). Methods: This retrospective cohort study included all r-tPA-treated patients in the emergency rooms of two Swiss stroke units, Nyon Hospital [Groupement Hospitalier de l'Ouest Lémanique (GHOL)] and Fribourg Hospital [Hôpital de Fribourg (HFR)], between February 2014 and September 2018. Door-to-needle time was analyzed for patients admitted during working hours (WH' weekdays 08:00-18:00) and OWH (weekdays 18:00-08:00, weekends, and public holidays). The latter was compared between centers; OWH, every patient was evaluated prior to thrombolysis by a neurologist on site in GHOL, while HFR adopted distance neurological supervision with teleradiology, performed by telephone evaluation of relevant clinical information with online real-time access to brain imaging. Results: Data were analyzed for 157 patients in HFR and 101 patients in GHOL. No statistically significant differences in baseline characteristics were found for the 258 r-tPA-treated acute ischemic stroke patients, in terms of age, gender, cardiovascular risk factors (hypertension, diabetes, and atrial fibrillation), and pre-Modified Rankin Scale (pre-mRs) between centers, with the exception of smoking and anticoagulation status. Patients in HFR presented with more severe strokes {median National Institutes of Health Stroke Scale (NIHSS) [6 (SD 6.88) (GHOL), 8 (SD 6.98) (HFR), p = 0.005]}. No significant differences in baseline characteristics were found as per admission time independently of the center. Door-to-needle time was significantly longer in the HFR cohort when compared with GHOL, irrespective of admission time. Both centers demonstrated significantly longer median door-to-needle time OWH. However, analysis of the door-to-needle time differences between WH and OWH showed no significant interaction using robust ANCOVA WRS2 analysis (p = 0.952) and a Bayesian model (BF01 = 3.97). Conclusions: On-site systematic evaluation by a neurologist did not appear to influence door-to-needle time OWH, suggesting distance supervision may be time-efficient in thrombolysis. This supports existing prospective studies in hyperacute telestroke management. The relevance lies in optimizing resource use considering the increasing demand for emergency neurological management.
ABSTRACT
Dramatic advances in recent years have changed the care of stroke patients. Creation of stroke hubs with centers and units achieved a significant reduction in mortality and morbidity. The indications for acute therapies such as intravenous thrombolysis and endovascular treatment target an increasing proportion of stroke patients. Early rehabilitation and multidisciplinary approaches have become part of the gold standard in stroke care. The creation of additional stroke units and strengthening local synergies should continue in order to propose the best medical treatments for all stroke patients.
La prise en charge des patients souffrant d'accident vasculaire cérébral (AVC) a connu des avancées spectaculaires dans les dernières années. Le développement de réseaux de « stroke units ¼ et « stroke centers ¼ a permis une nette diminution de mortalité et morbidité. Les indications aux traitements aigus, tels que la thrombolyse intraveineuse et le traitement endovasculaire, visent une proportion croissante de patients. La rééducation précoce et la prise en charge multidisciplinaire font désormais partie des traitements de référence. Les efforts de création d'unités spécialisées et le renforcement des synergies locales devront être poursuivis afin de proposer les meilleurs traitements disponibles à l'ensemble de la population.
Subject(s)
Hospitals, Community , Stroke , Humans , Stroke/therapyABSTRACT
No disponible
Subject(s)
Humans , Female , Middle Aged , Valproic Acid/adverse effects , Epilepsy/complications , Epilepsy/drug therapy , Mood Disorders/complications , Neuropsychological TestsABSTRACT
OBJECTIVE: The goal of the study described here was to determine if executive dysfunction and impulsivity are related to risk for suicide and suicide attempts in patients with temporal lobe epilepsy. METHOD: Forty-two patients with temporal lobe epilepsy were recruited. A detailed medical history, neurological examination, serial EEGs, Mini-International Neuropsychiatric Interview, executive function, and MRI were assessed. Multiple regression analysis was carried out to examine predictive associations between clinical variables and Wisconsin Card Sorting Test measures. RESULTS: Patients' scores on the Risk for Suicide Scale (n=24) were greater than 7, which means they had the highest relative risk for suicide attempts. Family history of psychiatric disease, current major depressive episode, left temporal lobe epilepsy, and perseverative responses and total errors on the Wisconsin Card Sorting Test increased by 6.3 and 7.5 suicide risk and suicide attempts, respectively. Executive dysfunction (specifically perseverative responses and more total errors) contributed greatly to suicide risk. CONCLUSION: Executive performance has a major impact on suicide risk and suicide attempts in patients with temporal lobe epilepsy.
Subject(s)
Epilepsy, Temporal Lobe/complications , Epilepsy, Temporal Lobe/psychology , Executive Function/physiology , Impulsive Behavior/etiology , Neuropsychological Tests , Suicide, Attempted/psychology , Adolescent , Adult , Atrophy , Depression/etiology , Electroencephalography/methods , Epilepsy, Temporal Lobe/pathology , Female , Hippocampus/pathology , Humans , Logistic Models , Magnetic Resonance Imaging/methods , Male , Middle Aged , Neurologic Examination/methods , Psychiatric Status Rating Scales , Retrospective Studies , Risk , Severity of Illness Index , Young AdultABSTRACT
Contexto: el sangramiento digestivo alto, problema de salud de elevada frecuencia en todo el mundo y causa mayor de morbilidad y mortalidad en todos los grupos etáreos, reviste una gran importancia clínica y sanitaria, a pesar de los cambios que han existido en los últimos años en el conocimiento y manejo de esta patología. La mortalidad por la misma no ha variado sustancialmente comportándose en nuestro país de forma similar al resto del mundo por lo que representa un relevante problema de salud. Objetivo: caracterizar clínicamente a los pacientes a los cuales se les realizó esofagogastroduodenoscopía por presentar sangramiento digestivo alto valorando edad, sexo, antecedentes patológicos personales, forma de presentación del sangrado y causas más frecuentes que conllevan al mismo. Universo: constituido por todos los pacientes a los cuales se les realizó esofagogastroduodenoscopía por presentar sangramiento digestivo alto en los servicios de Gastroenterología de los hospitales clínicos quirúrgicos 10 de octubre y Miguel Enríquez en el periodo comprendido entre abril-octubre de 2002. Muestra: correspondió al total de pacientes que conforman el universo. Resultados: el sangramiento digestivo predominó en el sexo femenino (64,11%) y en el grupo de pacientes con edades de 60 años y más (48,32%). La causa más frecuentes de hemorragia fue la úlcera duodenal (38,27%), siendo más frecuente la melena (50,7%). El estadio de Forrest que predominó en pacientes con úlcera fue el II c y un gran número de pacientes presentó antecedentes personales, predominando dentro de estos la ingestión de anti-inflamatorios no esteroides (AINES) en días previos al sangrado lo que representó un 39,13%, seguido de la ingestión de bebidas alcohólicas (23,44%). Conclusiones: la hemorragia digestiva alta es más frecuente en épocas tardías de la vida y se asocia frecuentemente a la ingestión previa de AINES y bebidas alcohólicas...
