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.

Gender differences in lung cancer mortality trends in Andalusia 1975-2008: a joinpoint regression analysis.

Death rates from lung cancer in men are higher in Andalusia than in other Spanish regions. This study describes lung cancer mortality rates and their trends in Andalusia from 1975 through 2008. Data on lung cancer mortality were obtained from the Death Registry of Andalusia. For each gender, age group-specific and standardized (overall and truncated) rates were calculated by the direct method using the world standard population. Joinpoint regression analysis was used to identify points where a significant change in trends occurred. In men, short-term trends for age-standardized mortality rates (ASMRs) declined significantly from 2004 through 2008 for each age group < 80 years old. In women, the segmented joinpoint analysis showed a decrease from 1975 through 1998 in ASMRs (overall) (-0.6%, P < 0.05), followed by a marked increase (4.6%, P < 0.05). A decrease in male versus female mortality due to lung cancer is evident in Andalusia (Spain).

[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)

[False diagnoses of strokes in emergency departments]. / Falsos diagnósticos de ictus en los servicios de urgencias.

INTRODUCTION: Diagnosing a stroke can sometimes be difficult. There are a number of mimic conditions that can lead to false diagnoses. AIM: To examine false diagnoses of acute stroke. PATIENTS AND METHODS: We reviewed the medical histories with diagnoses of acute stroke -i.e. ischaemic or haemorrhagic stroke and transient ischaemic attack (TIA)- for a three-month period. Alternative diagnoses were established in doubtful stroke cases (without meeting the World Health Organisation stroke criteria). RESULTS: Altogether there were 358 patients: 110 TIA, 191 ischaemics and 57 haemorrhagics. In all, 65 false diagnoses were selected, which represented 18.2% of the total number (41.8% of the cases of TIA) and 31.8% of the strokes admitted in the emergency department. The subtypes of false diagnoses were: 46 TIA (70.8%), 18 ischaemics (27.7%) and one haemorrhagic (1.5%). The alternative diagnoses were the following: syncope/pre-syncope in 10.8% of cases (n = 7); confusional syndrome/disorientation in 21.5% (n = 14); lowered level of consciousness in 27.7% (n = 18); generalised weakness in 6.2% (n = 4); dizziness/vertigo in 3.1% (n = 2); isolated dysarthria in 10.8% (n = 7); epileptic seizure in 6.2% (n = 4); and others in 13.8% (n = 9). A total of 71.7% could be attributed to systemic causes. The mean age was 79 years and 64.6% were females (n = 42). Computerised tomography of the head was performed in 70.8% of the cases (n = 46). A neurologist assessed 7.7% of them (n = 5). The destination on being discharged was: primary care (53.3%), visit to neurology department (31.7%), visit internal medicine department (6.7%), hospitalisation in neurology department (1.7%), hospitalisation in other specialties (1.7%), transfer (1.7%) and death (3.3%). CONCLUSIONS: False diagnoses of cerebrovascular diseases are common. In emergency departments almost half of the diagnoses of TIA may be wrong. Most false diagnoses refer to TIA (70%) and occur in elderly patients, can be attributed to systemic causes, have not been assessed by a neurologist and are referred to primary care. Hospital stroke registries that include emergency patients may be overestimated, especially in the number of cases of TIA.

Temporal trends in asthma mortality over 30 years.

BACKGROUND: Bronchial asthma is an important cause of morbidity and mortality worldwide. There is limited availability of updated information on asthma mortality trends. In this context, further investigation of asthma mortality trends is necessary. OBJECTIVE: We aimed to assess trends in asthma mortality trends in the Autonomous Community of Andalusia (over 7 million inhabitants), Spain, during the period 1975-2005. METHOD: Official population estimates and data on asthma deaths were obtained from official authorities. Crude and age-adjusted death rates for different age and gender groups were calculated. Joinpoint regression analysis was used for trend analysis. RESULTS: Age-adjusted death rates for asthma have fallen 2.9% for females and 7.7% for males from 1975 to 2005. This trend has not been constant but has varied during the study period. After a non-significant increase from 1975 to 1981 (4.5% for females and 3.8% for males), adjusted asthma mortality rates have been declining 3.7% for females and 9.6% for males (both p values < 0.05) since 1981. Age-group analysis revealed that the downturn in asthma mortality rates occurred in all age groups above 45 years for males and 35 years for females. CONCLUSIONS: During the last decades, significant variation in asthma mortality was found in Andalusia. This variation has not been constant during the study period. Currently, the decreasing trend initiated in 1981 continues.

[Lung cancer mortality trends in Spain between 1980 and 2005]. / Mortalidad por cáncer de pulmón en España. Evolución en 25 años (1980-2005).

OBJECTIVE: To describe trends in lung cancer mortality in Spain between 1980 and 2005. MATERIAL AND METHODS: Data on deaths from lung cancer during the study period were obtained from the Spanish National Institute of Statistics. Global and truncated (35 to 64 years) age-specific and gender-specific mortality rates were calculated and expressed as rates per 100,000 person-years. Trends were analyzed using joinpoint regression models. RESULTS: In 2005 in Spain, 16 647 men and 2471 women died from lung cancer, accounting for 26.6% and 6.6%, respectively, of all cancer deaths. In men, truncated mortality rates initially increased in the 1980-1992 period (3.1% per year; P<.05) but began to decrease in the 1992-2005 period (-0.8% per year, P<.05). Starting in the 1990s, age-specific mortality rates showed a statistically significant decrease in patients aged less than 85 years. For women, after an initial stable period, truncated mortality rates increased significantly from 1992 onward by 6.3% per year. The analysis by age groups showed that the rates increased in all age groups, except for patients aged 25 to 34 years and patients aged 75 to 84 years, in whom they remained stable. CONCLUSIONS: While lung cancer mortality began to decrease slightly among Spanish men 15 years ago, it increased significantly among women during the same period.

Mortalidad por cáncer de pulmón en España. Evolución en 25 años (1980-2005) / Lung cancer mortality trends in Spain between 1980 and 2005

Objetivo: Describir la evolución de la mortalidad por cáncer de pulmón en España durante el período 1980-2005. Material y métodos: Las defunciones por cáncer de pulmón durante el período de estudio se obtuvieron del Instituto Nacional de Estadística. Se calcularon las tasas específicas globales y truncadas (35-64 años) por grupos de edad y sexo, que se expresan como tasas por 100.000 personas-año. Para el análisis de tendencias de las tasas se utilizaron modelos de regresión joinpoint. Resultados: En 2005 se produjeron en España 16.647 defunciones por cáncer de pulmón en varones y 2.471 en mujeres, lo que representó el 26,6 y el 6,6% de la mortalidad por tumores, respectivamente. En los varones las tasas truncadas, tras un período de incremento (1980-1992, un 3,1% anual; p < 0,05), comienzan a descender (1992-2005, un ­0,8% anual; p < 0,05). Las tasas específicas por grupos de edad muestran un descenso estadísticamente significativo por debajo de los 85 años que comienza en la década de los noventa. En las mujeres las tasas truncadas, tras un período inicial en que permanecen estables, se incrementan significativamente a partir de 1992 un 6,3% anual. El análisis por grupos de edad muestra que las tasas se han incrementado en todos ellos, excepto en los grupos de 25-34 y 75-84 años, donde permanecen estables. Conclusiones: Mientras que la tendencia de mortalidad por cáncer de pulmón en los varones españoles comenzó a descender ligeramente hace 15 años, en las mujeres se observa un aumento llamativo durante el mismo período

Objective: To describe trends in lung cancer mortality in Spain between 1980 and 2005. Material and methods: Data on deaths from lung cancer during the study period were obtained from the Spanish National Institute of Statistics. Global and truncated (35 to 64 years) age­specific and gender­specific mortality rates were calculated and expressed as rates per 100 000 person-years. Trends were analyzed using joinpoint regression models. Results: In 2005 in Spain, 16 647 men and 2471 women died from lung cancer, accounting for 26.6% and 6.6%, respectively, of all cancer deaths. In men, truncated mortality rates initially increased in the 1980-1992 period (3.1% per year; P<.05) but began to decrease in the 1992-2005 period (­0.8% per year, P<.05). Starting in the 1990s, age­specific mortality rates showed a statistically significant decrease in patients aged less than 85 years. For women, after an initial stable period, truncated mortality rates increased significantly from 1992 onward by 6.3% per year. The analysis by age groups showed that the rates increased in all age groups, except for patients aged 25 to 34 years and patients aged 75 to 84 years, in whom they remained stable. Conclusions: While lung cancer mortality began to decrease slightly among Spanish men 15 years ago, it increased significantly among women during the same period

Effect of age, birth cohort and period of death on skin melanoma mortality in Spain, 1975 through 2004.

Recent statistics cohort analysis of mortality reveals that skin melanoma rates are dropping in the younger cohorts. Therefore, the aim of this study is to provide up-to-date information and to analyze recent changes in skin melanoma mortality trends in Spain during the period of 1975-2004 using joinpoint regression and age-period-cohort models. Between 1975 and 2004, the age-standardized (overall) mortality rates for skin melanoma increased from 0.3 to 1.3 per 100,000 person-years for males and from 0.2 to 0.8 per 100,000 person-years for females, with an estimated annual percentage of change of 4.8 and 4.3%, respectively. In men and women, the best fit was found for the full model, which simultaneously considered the effects of age, period and cohort. The risks among both males and females increased in each successive birth cohort born between 1895 and 1950. Thereafter, the risks declined through the most recent birth cohort born in 1970. Examination of the mortality trends by age group and birth cohort revealed that the recent less rapidly rising (men) or stabilizing (women) age-adjusted skin melanoma mortality rates in Spain were a result of declining mortality in the younger age groups and more recent birth cohorts. The particularly favorable trends in young people suggest that a further decline in mortality from skin melanoma in Spain is likely to occur within the next few years.

Antibodies against glutathione S-transferase T1 in non-solid organ transplanted patients.

BACKGROUND: This article describes the presence of antibodies against glutathione S-transferase T1 (GSTT1) in a group of patients who never received a solid organ graft. These antibodies have been previously detected in liver and kidney transplant subjects with donor-recipient mismatch for this enzyme at the genetic level. In liver-grafted subjects, the appearance of these antibodies correlated with de novo immune hepatitis. STUDY DESIGN AND METHODS: To obtain some insights in this phenomenon, the clinical records of these patients were reviewed, and the possible causes leading to the production of these antibodies and possible clinical consequences were analyzed. RESULTS: The clinical situation of these patients was very heterogeneous, but they had in common the need for transfusions or a previous pregnancy. GSTT1 antigen is present in red blood cells, liver, kidney, and other tissues. Because the presence of the GSTT1-null allele in seven of these patients has been demonstrated, it can be hypothesized that both GSTT1-positive transfusions or pregnancy of a GSTT1-positive fetus could induce these antibodies. Because the recipient is allele-null, no adverse effects in the host are expected to occur. The longest follow-up (5 years) shows no antibody-derived diseases. CONCLUSION: It is concluded that anti-GSTT1 can appear in a context different from the previously published alloreactivity after liver and kidney transplantation, as a consequence of transfusions and pregnancies. So far, no adverse clinical outcomes in our patients have been observed.