The prevalence of cocaine-associated chest pain in a London hospital

Objectives: To determine the prevalence of cocaine misuse in patients presenting to an Accident and Emergency department with chest pain. 4 of 12 FAEM abstracts www.emjonline.co

Editor's choice : European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of acute limb ischaemia

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Ultraearly thrombolysis by an anesthesiologist in a mobile stroke unit: A prospective, controlled intervention study

Background Acute stroke treatment in mobile stroke units (MSU) is feasible and reduces time-to-treatment, but the optimal staffing model is unknown. We wanted to explore if integrating thrombolysis of acute ischemic stroke (AIS) in an anesthesiologist-based emergency medical services (EMS) reduces time-to-treatment and is safe. Methods A nonrandomized, prospective, controlled intervention study. Inclusion criteria: age ≥18 years, nonpregnant, stroke symptoms with onset ≤4 h. The MSU staffing is inspired by the Norwegian Helicopter Emergency Medical Services crew with an anesthesiologist, a paramedic-nurse and a paramedic. Controls were included by conventional ambulances in the same catchment area. Primary outcome was onset-to-treatment time. Secondary outcomes were alarm-to-treatment time, thrombolytic rate and functional outcome. Safety outcomes were symptomatic intracranial hemorrhage and mortality. Results We included 440 patients. MSU median (IQR) onset-to-treatment time was 101 (71–155) minutes versus 118 (90–176) minutes in controls, p = 0.007. MSU median (IQR) alarm-to-treatment time was 53 (44–65) minutes versus 74 (63–95) minutes in controls, p < 0.001. Golden hour treatment was achieved in 15.2% of the MSU patients versus 3.7% in the controls, p = 0.005. The thrombolytic rate was higher in the MSU (81% vs 59%, p = 0.001). MSU patients were more often discharged home (adjusted OR [95% CI]: 2.36 [1.11–5.03]). There were no other significant differences in outcomes. Conclusions Integrating thrombolysis of AIS in the anesthesiologist-based EMS reduces time-to-treatment without negatively affecting outcomes. An MSU based on the EMS enables prehospital assessment of acute stroke in addition to other medical and traumatic emergencies and may facilitate future implementation.publishedVersio

Acute Stroke Care: Strategies For Improving Diagnostics

Stroke is one of the leading causes of death and disability, with a high incidence of over 11 million cases annually worldwide. Costs of treatment and rehabilitation, loss of work, and the hardships resulting from stroke are a major burden both at the individual and at the societal level. Importantly, stroke therapies need to be initiated early for them to be effective. Thrombolytic therapy and mechanical thrombectomy are early treatment options of ischemic stroke. In hemorrhagic stroke, optimization of hemodynamic and hemostatic parameters is central, and surgery is considered in a subset of patients. Efficient treatment of stroke requires early and precise recognition of stroke at all stages of the treatment chain. This includes identification of patients with suspected acute stroke by emergency medical dispatchers and emergency medical services staff, and precise admission diagnostics by the receiving on-call stroke team. Success requires grasping the complexity of stroke symptoms that depend on the brain areas affected, and the plethora of medical conditions that can mimic stroke. The Helsinki Ultra-acute Stroke Biomarker Study includes a cohort of 1015 patients transported to hospital due to suspected acute stroke, as candidates for revascularization therapies. Based on this cohort, this thesis work has explored new avenues to improve early stroke diagnostics in all stages of the treatment chain. In a detailed investigation into the identification of stroke by emergency medical dispatchers, we analyzed emergency phone calls with missed stroke identification. We also combined data on dispatch and EMS and hospital records to identify causes for missing stroke during emergency calls. Most importantly, we found that a patient’s fall at onset and patient confusion were strongly associated with missed identification. Regarding the Face Arm Speech Test (FAST), the most likely symptom to be misidentified was acute speech disturbance. Using prehospital blood sampling of stroke patients, and ultrasensitive measurement, we investigated the early dynamics of the plasma biomarkers glial fibrillary acidic protein (GFAP) and total tau. Utilizing serial sampling, we demonstrate for the first time that monitoring the early release rate of GFAP can improve the diagnostic performance of this biomarker for early differentiation between ischemic and hemorrhagic stroke. In our analysis of early GFAP levels, we were able to differentiate with high accuracy two-thirds of all patients with acute cerebral ischemia from those with hemorrhagic stroke, supporting further investigation of this biomarker as a promising point-of-care tool for prehospital stroke diagnostics. We performed a detailed review of the admission diagnostics of our cohort of 1015 patients to explore causes and predictors of admission misdiagnosis. We then investigated the consequences of misdiagnosis on outcomes. We demonstrate in this large cohort that the highly optimized and rapid admission evaluation in our hospital district (door-to-needle times below 20 minutes) did not compromise the accuracy and safety of admission evaluation. In addition, we discovered targets for improving future diagnostics. Finally, our detailed neuropathological investigation of a case of cerebral amyloid angiopathy (CAA) -related hemorrhage after stroke thrombolysis provided unique tissue-level evidence for this common vasculopathy as a notable risk factor for intracranial hemorrhagic complications in the setting of stroke. These findings support research to improve the diagnostics of CAA, and the prediction of hemorrhagic complications associated with stroke thrombolysis. In conclusion, these proposed targets and strategies will aid in the future improvement and development of this highly important field of diagnostics. Our proof-of-concept discoveries on early GFAP kinetics help guide further study into this diagnostic approach just as highly sensitive point-of-care GFAP measurement instruments are becoming available. Finally, our results support the safety of worldwide efforts to optimize emergency department door-to- needle times when care is taken to ensure sufficient expertise is in place, highlighting the role of the on-call vascular neurologist as a central diagnostic asset.Aivohalvaus on yksi yleisimpiä kuolinsyitä ja pitkäkestoisen työkyvyttömyyden aiheuttajia. Aivohalvauksen aiheuttamat hoito- ja kuntoutuskustannukset, työkyvyn menetys ja arkielämän vaikeudet ovat mittava taakka sekä yksilön, läheisten että yhteiskunnan tasoilla. Tehokkaiden hoitojen vaatima nopeus edellyttää aivohalvauksen varhaista ja tarkkaa tunnistamista hoitoketjun kaikilla askelmilla. Tässä väitöskirjatyössä etsittiin uusia keinoja aivohalvauksen varhaisdiagnostiikan kehittämiseksi hätäkeskuksessa, ensihoidossa ja vastaanottavan sairaalan HYKS:n päivystyspoliklinikalla. Yksityiskohtainen analyysi aivohalvauksen tunnistamisesta hätäkeskuksessa osoitti, että potilaan kaatuminen ja sekavuus olivat puutteellisen tunnistamisen keskeisiä tekijöitä. Face Arm Speech Test (FAST) -seulontaoireista puhehäiriö oli todennäköisimmin väärin tunnistettu. Akuuttivaiheen verinäytteitä ja äärimmäisen herkkää määritysmenetelmää hyödyntäen tutkimme kahden verestä mitattavan merkkiaineen, aivojen tukikudoksen tähtisolujen säikeisen happaman proteiinin (GFAP) ja taun varhaista dynamiikkaa aivohalvauspotilailla. Osoitimme ensimmäistä kertaa, että GFAP:n varhaisen vapautumisnopeuden seurantaa sarjanäytteistä voidaan hyödyntää parantamaan tämän merkkiaineen erottelukykyä iskeemisen ja hemorragisen aivokudosvaurion varhaisdiagnostiikassa. Tulokset viittaavat siihen, että GFAP merkkiaine voisi olla jatkossa kehitettävissä ambulansseissa hyödynnettäväksi pikaverikokeeksi, joka auttaisi aivohalvauksen eri muotojen varhaisessa erottelussa. Päivystysdiagnostiikkaan keskittyvässä osatyössä osoitimme ensimmäistä kertaa suuressa aineistossa, että sairaanhoitopiirissämme vuosia optimoitu erittäin nopea vastaanottoarviointi (liuotushoidon mediaaniviive alle 20 minuuttia sisältäen pään kuvauksen) ei vaaranna aivohalvauspotilaiden diagnostiikan tarkkuutta ja hoidon turvallisuutta. Tässä väitöskirjatyössä esitetyt kehityskohteet ja menetelmät auttavat tämän erittäin tärkeän diagnostisen alan tulevassa kehitystyössä. Työssä kuvatut tulokset sisältävät uraauurtavia havaintoja verestä mitattavan GFAP merkkiaineen kinetiikan käytöstä aivohalvauksen varhaisdiagnostiikassa ja tukevat sairaalapäivystysarvion diagnostista tarkkuutta HYKS:n tunnetusti erittäin nopeassa liuotushoitoketjussa

Association of Intravenous Thrombolysis with Delayed Reperfusion After Incomplete Mechanical Thrombectomy.

PURPOSE Treatment of distal vessel occlusions causing incomplete reperfusion after mechanical thrombectomy (MT) is debated. We hypothesized that pretreatment with intravenous thrombolysis (IVT) may facilitate delayed reperfusion (DR) of residual vessel occlusions causing incomplete reperfusion after MT. METHODS Retrospective analysis of patients with incomplete reperfusion after MT, defined as extended thrombolysis in cerebral infarction (eTICI) 2a-2c, and available perfusion follow-up imaging at 24 ± 12 h after MT. DR was defined as absence of any perfusion deficit on time-sensitive perfusion maps, indicating the absence of any residual occlusion. The association of IVT with the occurrence of DR was evaluated using a logistic regression analysis adjusted for confounders. Sensitivity analyses based on IVT timing (time between IVT start and the occurrence incomplete reperfusion following MT) were performed. RESULTS In 368 included patients (median age 73.7 years, 51.1% female), DR occurred in 225 (61.1%). Atrial fibrillation, higher eTICI grade, better collateral status and longer intervention-to-follow-up time were all associated with DR. IVT did not show an association with the occurrence of DR (aOR 0.80, 95% CI 0.44-1.46, even in time-sensitive strata, aOR 2.28 [95% CI 0.65-9.23] and aOR 1.53 [95% CI 0.52-4.73] for IVT to incomplete reperfusion following MT timing <80 and <100 min, respectively). CONCLUSION A DR occurred in 60% of patients with incomplete MT at ~24 h and did not seem to occur more often in patients receiving pretreatment IVT. Further research on potential associations of IVT and DR after MT is required

Thrombolysis ImPlementation in Stroke (TIPS): Evaluating the effectiveness of a strategy to increase the adoption of best evidence practice - protocol for a cluster randomised controlled trial in acute stroke care

Background: Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke.Objectives: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months.Methods and design: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mR

Application of Artificial Intelligence in Modern Healthcare System

Artificial intelligence (AI) has the potential of detecting significant interactions in a dataset and also it is widely used in several clinical conditions to expect the results, treat, and diagnose. Artificial intelligence (AI) is being used or trialed for a variety of healthcare and research purposes, including detection of disease, management of chronic conditions, delivery of health services, and drug discovery. In this chapter, we will discuss the application of artificial intelligence (AI) in modern healthcare system and the challenges of this system in detail. Different types of artificial intelligence devices are described in this chapter with the help of working mechanism discussion. Alginate, a naturally available polymer found in the cell wall of the brown algae, is used in tissue engineering because of its biocompatibility, low cost, and easy gelation. It is composed of α-L-guluronic and β-D-manuronic acid. To improve the cell-material interaction and erratic degradation, alginate is blended with other polymers. Here, we discuss the relationship of artificial intelligence with alginate in tissue engineering fields

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care

BACKGROUND Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke. OBJECTIVES To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months. METHODS AND DESIGN A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks. DISCUSSION TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12613000939796

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care

BACKGROUND: Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke. OBJECTIVES: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months. METHODS AND DESIGN: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks. DISCUSSION: TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN1261300093979