Pre- and in-hospital delays in the use of thrombolytic therapy for patients with acute ischemic stroke in rural and urban Egypt

BackgroundReducing pre- and in-hospital delays plays an important role in increasing the rate of intravenous thrombolysis (IVT) in patients with acute ischemic stroke. In Egypt, the IVT rate has increased steadily but is still far away from an ideal rate.AimThe study aimed to investigate the factors associated with pre- and in-hospital delays of IVT among patients with acute ischemic stroke coming from urban and rural communities.MethodsThis prospective, multicenter, observational cohort study was conducted from January 2018 to January 2019. Patients with acute ischemic stroke, who did not receive IVT, were included in the study. Patients were recruited from three large university stroke centers in Egypt, Assiut (south of Egypt), Tanta (north of Egypt), both serving urban and rural patients, and the University Hospital in Cairo (capital city), only serving an urban community. All participants underwent the National Institutes of Health Stroke Scale and full neurological assessment, urgent laboratory investigations, and computed tomography or magnetic resonance imaging to confirm the stroke diagnosis. The patients were subjected to a structured questionnaire that was designed to determine the parameters and time metrics for the pre- and in-hospital delays among patients from rural and urban regions.ResultsA total of 618 patients were included in the study, of which 364 patients (58.9%) lived in rural regions and 254 (41.1%) in urban regions. General demographic characteristics were similar between both groups. Approximately 73.3% of patients who arrived within the therapeutic time window were urban patients. The time from symptom onset till hospital arrival (onset to door time, ODT) was significantly longer among rural patients (738 ± 690 min) than urban patients (360 ± 342 min). Delayed onset to alarm time (OAT), initial misdiagnosis, and presentation to non-stroke-ready hospitals were the most common causes of pre-hospital delay and were significantly higher in rural patients. For patients arriving within the time window, the most common causes of in-hospital delays were prolonged laboratory investigations and imaging duration.ConclusionThe limited availability of stroke-ready hospitals in rural Egypt leads to delays in stroke management, with subsequent treatment inequality of rural patients with acute stroke

Azza A Ghali and Enaas A Kolkaila Migrainous Vertigo: Clinical and Vestibular Evoked Myogenic Potential (VEMP) Findings

ABSTRACT Migrainous vertigo (MV) is one of the most common cause of episodic vertigo and is increasingly recognize

Circadian and circannual patterns of stroke

Abstract Background Cerebrovascular event peaks occur in the morning (≈ 9:00 am) with another one peak in the evening (≈ 8:00 pm) and a trough at night. Knowledge about circadian influences on mechanisms involved in cerebrovascular events is important for optimising the timing of therapy, preventing behavioural triggers at potentially risky circadian phases and selecting the timing of diagnostic procedures. This work aims to evaluate circadian and circannual patterns of stroke onset, and variation in pattern of stroke onset in the month of Ramadan. Patients and methods The study was conducted on 98 stroke patients and 98 age- and sex-matched normal subjects. All patients had a documented time of stroke symptom onset. End-tidal carbon dioxide and core body temperature were served as measures of endogenous circadian phase. Cerebral blood flow velocity was measured using transcranial colour-coded duplex. Circadian rhythm of blood pressure and heart rate variability were also assessed. Results Both ischaemic and haemorrhagic stroke showed a circadian variation regarding their onset, with the peak in the morning and the nadir during night-time. We found a pathologically reduced or abolished circadian blood pressure variation after stroke. Conclusion Stroke was more frequent in the morning; also, it was less likely to occur during the summer and autumn than the winter or spring. Stroke prevention with therapies that target the morning rise in risk factors could be advantageous in reducing the overall risk of stroke

Evaluating pain management practices for cancer patients among health professionals: a global survey

Background: Cancer incidence in the world is predicted to increase in the next decade. While progress has been in diagnosis and treatment, much still remains to be done to improve cancer pain therapy, mainly in underserved communities in low-income countries. Objective: To determine knowledge, beliefs, and barriers regarding pain management in both high- and low-income countries (according to the WHO classification); and to learn about ways to improve the current state of affairs. Design: Descriptive survey. Setting/Subjects: Fifty-six countries worldwide; convenience sample of 1639 consisted of 36.8% physicians; 45.1% nurses, and 4.5% pharmacists employed in varied settings. Results: Improved pain management services are key elements. Top barriers include religion factors, lack of appropriate education and training at all levels, nonadherence to guidelines, patients' reluctance to report on pains, over regulation associated with prescribing and access to opioid analgesics, fear of addiction to opioids, and lack of discussions around prognosis and treatment planning. Conclusion: The majority of patients with cancer in low-income countries are undertreated for their pain. Promoting cancer pain accredited program of training and education on pain management for physicians and nurses is crucial, as well as advocating policymakers and the public at large. Keywords: cancer; global; management; opioids; pain