Prehospital Stroke Care. Paramedic Training Needs, and Hospital-Directed Feedback in Lithuania

Background: Emergency medical services (EMS) are the first health care contact for the majority of stroke patients. However, there is a lack of data on the current paramedics’ hospital-directed feedback and training needs across different health care settings. We aimed to evaluate paramedics’ prehospital stroke care knowledge, training needs, and current status of feedback on suspected stroke patients. Methods: We surveyed paramedics from the Vilnius region from September to November 2019 and compared the answers between the city and the district agencies. The questionnaire content included questions on paramedics’ demographic characteristics, prehospital stroke care self-assessment, knowledge on stroke mimics, stroke training needs, and the importance of hospital-directed feedback on suspected stroke patients. Results: A total number of 161 paramedics (or 49.4% of all paramedics from our stroke care network) were surveyed, with more district paramedics rating their prehospital stroke care knowledge as inadequate (44.8% (95% confidence interval (CI) 32.8–57.6) vs. 28.1% (95% CI 20.1–27.8), p = 0.028). In addition, more district paramedics indicated a need for additional stroke training (83.1% (95% CI 71.5–90.5) vs. 69.8% (60.0–78.1), p = 0.043). However, respondents reported being the most confident while dealing with stroke (71.3%, 95% CI 63.8–77.7) compared to other time-critical conditions (p < 0.001). Vertigo (60.8%, 95% CI 53.0–68.0), brain tumors (56.3%, 95% CI 48.5–63.8), and seizures (54.4%, 95% CI 46.7–62.0) were indicated as the most common stroke mimics. Only 6.2% (95% CI 3.4–11.1) of respondents received formal feedback on the outcome of suspected stroke patients brought to the emergency department. Conclusions: A high proportion of paramedics self-perceive having inadequate stroke knowledge and an urgent need for further stroke training. The EMS staff indicate receiving insufficient feedback on suspected stroke patients, even though its usefulness is perceived as paramount.publishersversionPeer reviewe

Stroke care indicators in the Republic of Moldova – the RES-Q registry

Introducere. Până la aderarea Moldovei in anul 2016 la platforma internațională RES-Q (Registry of Stroke Care Quality) - Registrul Calității Îngrijirii Accidentului Vascular Cerebral (AVC), nu au existat date privind indicatorii de calitate intraspitalicești ai ictusului. Scopul acestei lucrări a fost de a evalua calitatea asistenței medicale acordată pacienților cu AVC în Moldova în baza datelor registrului RES-Q. Material și metode. Au fost analizate datele tuturor pacienților cu ictus ischemic și hemoragic acut din registrul RES-Q din 15 spitale din Moldova. Datele au fost colectate timp de o lună pe an pe parcurs a 3 ani (2017-2019). Analiza datelor între spitale s-a realizat din considerentul accesului acestora la computer tomografia cerebrală. Adițional, datele din Moldova au fost comparate cu cele din trei țări ale proiectului ESO-EAST (European Stroke Organization Enhancing and Accelerating Stroke Treatment): România, Lituania și Georgia. Rezultate. Studiul a inclus un număr total de 1660 pacienți, cu vârsta medie de 68 ani (49% - bărbați). Moldova a înregistrat rezultate mai slabe la numărul de CT efectuate (81% [95% CI 79-84%]), la evaluarea disfagiei (29% [95% CI 27-32%]), efectuarea trombolizei intravenoase (3% [95% CI 2-4%]), administrarea de anticoagulante (44% [95% CI 39-49%]) și statine (42% [95% CI 39-45%]) la externare, la mortalitatea intraspitalicească prin AVC (17% [95% CI 15- 19%]). În interiorul Moldovei calitatea asistenței prin AVC s-a comparat reieșind din accesul la CT. Concluzii. Studiul nostru a identificat lacune serioase ale performanțelor asistenței intraspitalicești în ictus, cum ar fi lipsa scanărilor prin CT în multe spitale publice, absența unei rețele naționale centralizate în domeniul AVC, acces extrem de scăzut la tratamentul prin tromboliză și implementarea nesatisfăcătoare a tratamentului de profilaxie secundară a ictusului.Introduction. There were no data on in-hospital stroke care indicators until Moldova’s accession to the international Registry of Stroke Care Quality (RES-Q) platform in 2016. The aim of this paper was to assess the acute stroke care quality in Moldova based on the data of the RES-Q registry. Material and methods. We analyzed the data of all patients with acute ischemic and hemorrhagic stroke of the RES-Q from 15 Moldovan hospitals. Data were collected for one month each year, during a 3-year period (2017-2019). Data analysis was performed between hospitals according to their access to a brain CT facility for Moldovan participating hospitals. Additionally, Moldovan data were compared with other three ESO-EAST (European Stroke Organization Enhancing and Accelerating Stroke Treatment) project countries: Romania, Lithuania, and Georgia. Results. A total of 1660 patients were recruited in the study, mean age of 68 years (49% men). Moldova registered poorer results in number of brain CT performed (81% [95% CI 79-84%]), dysphagia screening (29% [95% CI 27-32%]), IV thrombolysis performed (3% [95% CI 2-4%]), administration of anticoagulants (44% [95% CI 39-49%]) and statins (42% [95% CI 39-45%]) at discharge, in-hospital stroke mortality (17% [95% CI 15- 19%]). Within Moldova the stroke care quality was driven by the access to CT scan. Conclusions. Our study highlighted some serious gaps of in-hospital stroke care performance in Moldova, such as the lack of CT scans in many public hospitals, the absence of a national stroke center network, extremely low accessibility of IV thrombolysis and unsatisfactory implementation of secondary stroke prevention treatment

Interactive Training of the Emergency Medical Services Improved Prehospital Stroke Recognition and Transport Time

Funding Information: This study received funding from Boehringer Ingelheim GmbH & Co KG Lithuania. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit for publication. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding Information: We greatly acknowledge the EMS staff for taking part in the training. LS was supported by the Swiss National Science Foundation postdoctoral scholarship (P2GEP3_191584). This article/publication is based on work from the IRENE COST Action—Implementation Research Network in Stroke Care Quality (CA18118), supported by COST (European Cooperation in Science and Technology; www.cost.eu ). Publisher Copyright: Copyright © 2022 Sveikata, Melaika, Wiśniewski, Vilionskis, Petrikonis, Stankevičius, Jurjans, Ekkert, Jatužis and Masiliūnas.Background and Purpose: Acute stroke treatment outcomes are predicated on reperfusion timeliness which can be improved by better prehospital stroke identification. We aimed to assess the effect of interactive emergency medical services (EMS) training on stroke recognition and prehospital care performance in a very high-risk cardiovascular risk population in Lithuania. Methods: We conducted a single-center interrupted time-series study between March 1, 2019 and March 15, 2020. Two-hour small-group interactive stroke training sessions were organized for 166 paramedics serving our stroke network. We evaluated positive predictive value (PPV) and sensitivity for stroke including transient ischemic attack identification, onset-to-door time, and hospital-based outcomes during 6-months prior and 3.5 months after the training. The study outcomes were compared between EMS providers in urban and suburban areas. Results: In total, 677 suspected stroke cases and 239 stroke chameleons (median age 75 years, 54.8% women) were transported by EMS. After the training, we observed improved PPV for stroke recognition (79.8% vs. 71.8%, p = 0.017) and a trend of decreased in-hospital mortality (7.8% vs. 12.3, p = 0.070). Multivariable logistic regression models adjusted for age, gender, EMS location, and stroke subtype showed an association between EMS stroke training and improved odds of stroke identification (adjusted odds ratio [aOR] 1.6 [1.1–2.3]) and onset-to-door ≤ 90 min (aOR 1.6 [1.1–2.5]). The improvement of PPV was observed in urban EMS (84.9% vs. 71.2%, p = 0.003), but not in the suburban group (75.0% vs. 72.6%, p = 0.621). Conclusions: The interactive EMS training was associated with a robust improvement of stroke recognition, onset to hospital transport time, and a trend of decreased in-hospital mortality. Adapted training strategies may be needed for EMS providers in suburban areas. Future studies should evaluate the long-term effects of the EMS training and identify optimal retraining intervals.publishersversionPeer reviewe

Predicting outcome of intravenous thrombolysis for acute ischenic stroke

The integrated analysis of safety and efficacy of intravenous thrombolysis for acute ischemic stroke patients in Lithuania the first time is presented in this doctoral dissertation. The acceptance of current prognostic models of outcome of ischemic stroke after intravenous thrombolysis for our community is investigated as well. The original prognostic model for our community according to established prognostic factors is done and proposed. 206 patients with acute ischemic stroke and treated with intravenous thrombolysis in Republican Vilnius University hospital and Vilnius University hospital Santariskiu Clinics 2010 – 2013 y. were included in this study. The relation of baseline demographical, clinical and imaging data and the relation with early and late outcome of stroke is analyzed. The results of treatment (efficacy and safety profile) of all patients are presented. The additional analysis for different subgroup analysis is done as well. The independent predictors of good outcome and significant early neurological improvement are identified. The unclear questions, that needs further studies is discussed in this doctoral dissertation. The next steps of scientific research in acute ischemic stroke field are proposed as well. The four practical recommendations are proposed. The results of this study could be helpful for all doctors, who is interesting in treatment of acute stroke patients

Ūminio išeminio insulto gydymo intravenine trombolize baigties prognozavimas

The integrated analysis of safety and efficacy of intravenous thrombolysis for acute ischemic stroke patients in Lithuania the first time is presented in this doctoral dissertation. The acceptance of current prognostic models of outcome of ischemic stroke after intravenous thrombolysis for our community is investigated as well. The original prognostic model for our community according to established prognostic factors is done and proposed. 206 patients with acute ischemic stroke and treated with intravenous thrombolysis in Republican Vilnius University hospital and Vilnius University hospital Santariskiu Clinics 2010 – 2013 y. were included in this study. The relation of baseline demographical, clinical and imaging data and the relation with early and late outcome of stroke is analyzed. The results of treatment (efficacy and safety profile) of all patients are presented. The additional analysis for different subgroup analysis is done as well. The independent predictors of good outcome and significant early neurological improvement are identified. The unclear questions, that needs further studies is discussed in this doctoral dissertation. The next steps of scientific research in acute ischemic stroke field are proposed as well. The four practical recommendations are proposed. The results of this study could be helpful for all doctors, who is interesting in treatment of acute stroke patients

Relevance of anaesthesia type on early neurological outcome in acute ischemic stroke patients undergoing mechanical thrombectomy

Background. Conscious sedation (CS) and general anaesthesia (GA) are types of anaesthesia used during mechanical thrombectomy (MTE). Currently, there are no guidelines on which type of anaesthesia to choose during MTE. Retrospective studies suggest that GA is associated with worse clinical outcomes, while latest clinical studies show no such difference. Materials and methods. Acute stroke patients treated in two Vilnius hospitals and undergoing MTE were included. Patients were divided into two groups according to the type of anaesthesia: general anaesthesia (GA) and conscious sedation (CS). Demographic, clinical and logistic data were evaluated. Primary end point was good outcome 24 hrs after MTE. Safety of the procedure (7-day mortality and symptomatic intracerebral haemorrhage (sICH)) was also evaluated. Results. 248 patients were included in the analysis. 105 patients (42.3%) received GA and 143 (57.7%) – CS. Baseline data was similar in both groups, except for atrial fibrillation (55.9% in CS vs 37.1% in GA, p=0.003) and bridging therapy (66.4% in CS vs 46.7% in GA group, p=0.003). Good outcome 24 hrs after MTE was achieved in 51.4% (n=54) patients in GA group and 58.7% (n=84) patients in CS group (p=0.252). There was no difference in 7-day mortality and sICH between the study groups. Periprocedural arterial blood pressure levels were significantly lower in GA group (p<0.05). Binary logistic regression analysis revealed that independent factors of good outcome were time from arrival to the hospital to recanalization and successful recanalization. Conclusions. Type of anaesthesia does not influence early clinical outcome or safety of mechanical thrombectomy. Further studies are needed to evaluate the relevance of anaesthesia type and to determine the prognostic factors of clinical outcome after MTE

The Problems of migraine headache treatment

The acute treatment and prophylaxis of migraine headache are discussed in this article. The medications for acute treatment, their doses, indications, contraindications and adverse effects are compared. The special attention for migraine headache prophylaxis is paid. The migraine diagnostic criteria and triggers of migraine headache are noted

Efficacy and safety of intravenous thrombolysis for acute ischemic stroke within 3–4.5 hours in Lithuania

Background. Intravenous thrombolysis has been shown as an appropriate treatment for stroke patients within 3–4.5 hours from the onset of stroke in randomized and observational studies, yet extended therapeutic window remains off-label in routine clinical setting. The aim of our study was to evaluate the efficacy and safety of intravenous thrombolysis within 3–4.5 hours for acute stroke patients in Lithuania. Methods. In this pair-matched case control study stroke patients treated by intravenous thrombolysis during January 2002 – May 2010 were included. The patients were divided into two groups according to onsetto- needle time (0–180 min. (group I), and 181–270 min. (group II)), and were pair-matched 1 : 1 according to age and stroke severity. The primary end-point was good functional status after 3 months. Mortality and rates of life-threatening bleeding and symptomatic intracranial hemorrhage were used for analysis of safety profile. Results. 28 pairs were included in the final analysis. The mean onsetto- needle time was significantly higher in group II. There was no difference between the groups according to baseline variables. 32.1% of patients in group I and 39.3% of patients in group II had good functional status (p = 0.58) after 3 months. No significant differences were found between the groups in the safety profile, however, the rate of symptomatic intracerebral hemorrhage was higher in group I. Conclusions. Intravenous thrombolysis within 3–4.5 h after the onset of stroke is acceptable and effective treatment for acute ischemic stroke in our routine clinical setting. Further studies are needed to assess the reasons of higher rates of symptomatic intracerebral hemorrhage

Intraveninės trombolizės efektyvumas bei saugumas ligoniams Lietuvoje, susirgusiems ūminiu išeminiu insultu, praėjus 3-4,5 val. nuo ligos pradžios

Background. Intravenous thrombolysis has been shown as an appropriate treatment for stroke patients within 3–4.5 hours from the onset of stroke in randomized and observational studies, yet extended therapeutic window remains off-label in routine clinical setting. The aim of our study was to evaluate the efficacy and safety of intravenous thrombolysis within 3–4.5 hours for acute stroke patients in Lithuania. Methods. In this pair-matched case control study stroke patients treated by intravenous thrombolysis during January 2002 – May 2010 were included. The patients were divided into two groups according to onsetto- needle time (0–180 min. (group I), and 181–270 min. (group II)), and were pair-matched 1 : 1 according to age and stroke severity. The primary end-point was good functional status after 3 months. Mortality and rates of life-threatening bleeding and symptomatic intracranial hemorrhage were used for analysis of safety profile. Results. 28 pairs were included in the final analysis. The mean onsetto- needle time was significantly higher in group II. There was no difference between the groups according to baseline variables. 32.1% of patients in group I and 39.3% of patients in group II had good functional status (p = 0.58) after 3 months. No significant differences were found between the groups in the safety profile, however, the rate of symptomatic intracerebral hemorrhage was higher in group I. Conclusions. Intravenous thrombolysis within 3–4.5 h after the onset of stroke is acceptable and effective treatment for acute ischemic stroke in our routine clinical setting. Further studies are needed to assess the reasons of higher rates of symptomatic intracerebral hemorrhage