Pre-hospital transdermal glyceryl trinitrate in patients with stroke mimics: data from the RIGHT-2 randomised-controlled ambulance trial

Background: Prehospital stroke trials will inevitably recruit patients with non-stroke conditions, so called stroke mimics. We undertook a pre-specified analysis to determine outcomes in patients with mimics in the second Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial (RIGHT-2). Methods: RIGHT-2 was a prospective, multicentre, paramedic-delivered, ambulance-based, sham-controlled, participant-and outcome-blinded, randomised-controlled trial of transdermal glyceryl trinitrate (GTN) in adults with ultra-acute presumed stroke in the UK. Final diagnosis (intracerebral haemorrhage, ischaemic stroke, transient ischaemic attack, mimic) was determined by the hospital investigator. This pre-specified subgroup analysis assessed the safety and efficacy of transdermal GTN (5 mg daily for 4 days) versus sham patch among stroke mimic patients. The primary outcome was the 7-level modified Rankin Scale (mRS) at 90 days. Results: Among 1149 participants in RIGHT-2, 297 (26%) had a final diagnosis of mimic (GTN 134, sham 163). The mimic group were younger, mean age 67 (SD: 18) vs 75 (SD: 13) years, had a longer interval from symptom onset to randomisation, median 75 [95% CI: 47,126] vs 70 [95% CI:45,108] minutes, less atrial fibrillation and a lower systolic blood pressure and Face-Arm-Speech-Time tool score than the stroke group. The three most common mimic diagnoses were seizure (17%), migraine or primary headache disorder (17%) and functional disorders (14%). At 90 days, the GTN group had a better mRS score as compared to the sham group (adjusted common odds ratio 0.54; 95% confidence intervals 0.34, 0.85; p = 0.008), a difference that persisted at 365 days. There was no difference in the proportion of patients who died in hospital, were discharged to a residential care facility, or suffered a serious adverse event. Conclusions: One-quarter of patients suspected by paramedics to have an ultra-acute stroke were subsequently diagnosed with a non-stroke condition. GTN was associated with unexplained improved functional outcome observed at 90 days and one year, a finding that may represent an undetected baseline imbalance, chance, or real efficacy. GTN was not associated with harm. Trial registration: This trial is registered with International Standard Randomised Controlled Trials Number ISRCTN 26986053

Pre-hospital Transdermal Glyceryl Trinitrate in Patients With Stroke Mimics: Data From the Right-2 Randomised-controlled Ambulance Trial

Background: Prehospital stroke trials will inevitably recruit patients with non-stroke conditions, so called stroke mimics. We undertook a pre-specified analysis to determine outcomes in patients with mimics in the second Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial (RIGHT-2). Methods: RIGHT-2 was a prospective, multicentre, paramedic-delivered, ambulance-based, sham-controlled, participant-and outcome-blinded, randomised-controlled trial of transdermal glyceryl trinitrate (GTN) in adults with ultra-acute presumed stroke in the UK. Final diagnosis (intracerebral haemorrhage, ischaemic stroke, transient ischaemic attack, mimic) was determined by the hospital investigator. This pre-specified subgroup analysis assessed the safety and efficacy of transdermal GTN (5 mg daily for 4 days) versus sham patch among stroke mimic patients. The primary outcome was the 7-level modified Rankin Scale (mRS) at 90 days. Results Among 1149 participants in RIGHT-2, 297 (26%) had a final diagnosis of mimic (GTN 134, sham 163). The mimic group were younger, mean age 67 (SD: 18) vs 75 (SD: 13) years, had a longer interval from symptom onset to randomisation, median 75 [95% CI: 47,126] vs 70 [95% CI:45,108] minutes, less atrial fibrillation and a lower systolic blood pressure and Face-Arm-Speech-Time tool score than the stroke group. The three most common mimic diagnoses were seizure (17%), migraine or primary headache disorder (17%) and functional disorders (14%). At 90 days, the GTN group had a better mRS score as compared to the sham group (adjusted common odds ratio 0.54; 95% confidence intervals 0.34, 0.85; p = 0.008), a difference that persisted at 365 days. There was no difference in the proportion of patients who died in hospital, were discharged to a residential care facility, or suffered a serious adverse event. Conclusions One-quarter of patients suspected by paramedics to have an ultra-acute stroke were subsequently diagnosed with a non-stroke condition. GTN was associated with unexplained improved functional outcome observed at 90 days and one year, a finding that may represent an undetected baseline imbalance, chance, or real efficacy. GTN was not associated with harm

Paramedic Response to Acute Stroke/TIA: A Population-based Study of Current Practice and Outcomes

Stroke is a major cause of death and disability. Recent changes in the treatment and care of stroke and transient ischaemic attack (TIA) patients have improved survival and quality of life. However, these therapies are strictly time-dependent, with improved outcomes for early-arriving patients, while late-arriving patients are excluded from some forms of treatment. The overarching aim of this thesis is to explore the paramedic care of acute stroke/TIA patients, through an investigation of the utilisation of the emergency medical services (EMS) as the first medical contact, current EMS practice and patient-focused outcomes. This population-based study links clinical and operational data from the EMS, with patient data from hospital medical records, to explore whether there is a relationship between paramedic care and patient outcomes in acute stroke/TIA. The observational study adopts a quantitative approach and includes records from 2,524 stroke/TIA cases. Sixty-four percent of patients in this study, had their first medical contact with a paramedic rather than with a primary care doctor or Emergency Department staff. Four factors were associated with initial contact with an EMS paramedic: increasing patient age, the presence of signs at onset that were recognisable with a FAST test, a final diagnosis of intracerebral haemorrhage compared to TIA and other sub-classifications compared to lacunar circulation infarct. Paramedics recognised 70 percent of stroke/TIA cases. Six factors were associated with non-recognition of stroke/TIA by paramedics. These factors were: a dispatch code other than stroke, absence of a patient or familial history of stroke/TIA, severity described as minor compared to more severe presentations, absence of a documented FAST assessment, a final diagnosis of intracerebral haemorrhage or ischaemic stroke compared to TIA and a classification of posterior compared to lacunar circulation infarction. Among ischaemic stroke patients, first medical contact with an EMS paramedic was associated with a shorter onset-to-door delay compared to initial contact with a primary care doctor. Thrombolysis rates were higher among ischaemic stroke patients when the paramedic recognised the event. Mortality was higher, and functional independence and quality of life scores were lower among EMS patients than those using other prehospital pathways. These poorer patient outcomes were associated with greater dependency prior to stroke onset or a more severe stroke among this group of patients. However, despite greater severity at baseline in the EMS group, there was no difference between the two groups in the proportion who improved to achieve independent functioning at 28 days. This study identifies a need for increased public awareness of the importance of contacting the EMS in cases of suspected stroke/TIA and of the risk of stroke among younger age groups. Paramedics need to be educated about atypical stroke symptoms and the necessity of screening a wider range of patients in order to improve recognition of stroke/TIA cases. The importance of arriving at a stroke centre as early as possible to maximise the benefits of treatment, rather than within four hours, should be emphasised. Finally, paramedicine as a nascent healthcare profession, should be actively engaged in research collaborations that support evidence-based practice. Files will be made publicly available from 2019-12-1

Changes in demand for emergency ambulances during a nationwide lockdown that resulted in elimination of COVID-19: an observational study from New Zealand

Objective To examine the impact of a 5-week national lockdown on ambulance service demand during the COVID-19 pandemic in New Zealand.Design A descriptive cross-sectional, observational study.Setting High-quality data from ambulance electronic clinical records, New Zealand.Participants Ambulance records were obtained from 588 690 attendances during pre-lockdown (prior to 17 February 2020) and from 36 238 records during the lockdown period (23 March to 26 April 2020).Main outcome measures Ambulance service utilisation during lockdown was compared with pre-lockdown: (a) descriptive analyses of ambulance events and proportions of event types for each period, (b) absolute rates of ambulance attendance (event types/week) for each period.Results During lockdown, ambulance patients were more likely to be attended at home and less likely to be aged between 16 and 25 years. There was a significant increase in the proportion of lower acuity patients (Status 3 and Status 4) attended (p<0.001) and a corresponding increase in patients not transported from scene (p<0.001). Road traffic crashes (p<0.001) and alcohol-related incidents (p<0.001) significantly decreased. There was a decrease in the absolute number of weekly ambulance attendances (ratio (95% CI), 0.89 (0.87 to 0.91), p<0.001), attendances to respiratory conditions (0.74 (0.61 to 0.86), p=0.01), and trauma (0.81 (0.77 to 0.85), p<0.001). However, there was a significant increase in ambulance attendances for mental health conditions (1.37 (1.22 to 1.51), p=0.005).Conclusions Despite the relative absence of COVID-19 in the community during the 5-week nationwide lockdown, there were significant differences in ambulance utilisation during this period. The lockdown was associated with an increase in ambulance attendances for mental health conditions and is of concern. In considering future lockdowns, the potential implications on a population’s mental well-being will need to be seriously considered against the benefits of elimination of virus transmission