Prehospital Delay Research Articles

Impact of summer season on pre-hospital time delays in women and men undergoing primary percutaneous coronary intervention

BackgroundPre-hospital delays have been associated with poor outcomes in patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). It is currently unknown how environmental variables affect treatment delays in these patients. Methods and resultsThe association between environmental variables, time to treatment including transportation times and adverse in-hospital events was assessed in 1828 consecutive patients with STEMI undergoing primary PCI between 2010 and 2014 in the Montreal metropolitan area. Median[Q1;Q3] total ischemia time was significantly longer during summer season (April–September) as compared to winter season (October–March, 201[140;305] min vs 187[126;266] min, p = 0.022). This difference between seasons was due to a significant increase in median decision time to seek treatment for symptoms during summer (90[46;185] min vs 78[40;156], p = 0.004). The former peaked during July and August and was most pronounced in men. Hence, outside temperature and summer season were identified as strong predictors of prolonged decision time in patients with STEMI (p < 0.001 and p = 0.002, respectively). Transportation times slightly increased during winter season and snow fall, this difference, however, was not significant (p = 0.46). A significant increase in in-hospital adverse outcomes following primary PCI was observed during summer season as compared to winter season (7.2% vs 4.8%, p = 0.032). Accordingly, multivariate logistic regression models adjusted for baseline variables identified summer season as a strong predictor of periprocedural adverse events (OR 1.83, 95% CI 1.2–3.11, p = 0.037). ConclusionContrary to our initial hypothesis, pre-hospital delays in patients with STEMI are considerably longer and associated with adverse in-hospital outcomes during summer season. Considering the consequences of global warming, it is imperative that educational efforts targeting patients' perception are implemented to counter treatment delays.

Factors influencing prehospital delay in patients presenting with ST-elevation myocardial infarction and the impact of prehospital electrocardiogram

BackgroundIn ST-elevation myocardial infarction (STEMI), prehospital delay is a significant factor, decreasing likelihood of revascularization and increasing mortality. Prehospital delays are substantive in Indian patients with STEMI. Our study aimed to investigate factors associated with prehospital delay in patients with STEMI. MethodsA multicentric prospective analysis was conducted at five major cardiac care referral centers in Punjab including a tertiary care teaching hospital over a period of 1 year from January 2015 to December 2015. Patients presenting with STEMI were included in the study. A structured questionnaire was used to gather patient characteristics and factors responsible for prehospital delay. ResultsOf the 619 patients included in the study, 42% presented with more than 6 h of prehospital delay. On univariate analysis, delay was significantly higher among elderly (p = 0.01), illiterate patients (p = 0.02), and patients residing in rural areas (p = 0.04). Recognizing symptoms as cardiac in origin (p < 0.001), hospital as initial medical contact, and availability of prehospital electrocardiogram (ECG) (p = 0.001) were associated with shorter delays. On multivariate analysis, prehospital delay was significant in elderly patients, initial point of care as outpatient clinic, and patients without access to prehospital ECG. ConclusionOur study concludes that demographic and socioeconomic barriers exist that impede rapid care seeking and highlights the need for utilization of prehospital ECG to decrease prehospital delay. Possibilities include, educating the public on the importance of early emergency medical services contact or creating emergency stations in rural areas with ECG capabilities. Our study also invites further research, regarding role of telemedicine to triage patients derived from prehospital ECGs to decrease prehospital delay. Keywords: STEMI, Pre-hospital ECG, Pre-hospital delay, Factors, Telemedicine.

Factors influencing pre-hospital delay in patients presenting with acute myocardial infarction: A prospective study

Factors influencing pre-hospital delay in patients presenting with acute myocardial infarction: A prospective study

Use of emergency medical transport and impact on time to care in patients with ischaemic stroke

IntroductionAccording to numerous studies, using emergency medical services (EMS) to transport stroke patients to hospitals decreases diagnostic and treatment delays. ObjectivesTo determine the frequency of use of EMS by stroke patients in Bizkaia (Spain), analyse the factors associated with using EMS, and study the impact of EMS on time to care. MethodsWe gathered data from 545 patients hospitalised for acute ischaemic stroke and recruited consecutively. Data were obtained from the patients’ medical histories and interviews with the patients themselves or their companions. We studied the following variables: previous health status, stroke symptoms and severity (NIHSS), type of transport, and time to medical care. Univariate and multivariate analyses were performed to identify factors associated with use of EMS and care delays. ResultsPatients transported to hospital by the EMS accounted for 47.2% of the total. Greater stroke severity, arriving at the hospital at night, and poor functional status at baseline were found to be independently associated with use of EMS. Use of EMS was linked to earlier arrival at the hospital. Door-to-imaging times were shorter in the EMS group; however, this association disappeared after adjusting for stroke severity. Revascularisation was more frequent among patients transported by the EMS. ConclusionsEMS transport was associated with shorter prehospital delays. Effective health education programmes should be developed to promote EMS transport for patients with stroke symptoms. In-hospital stroke management should also be improved to reduce time to medical care.

Disability Adjusted Life Years due to Ischaemic Stroke Preventable by Real-Time Stroke Detection-A Cost-Utility Analysis of Hypothetical Stroke Detection Devices.

Background: Ischaemic stroke remains a significant contributor to permanent disability world-wide. Therapeutic interventions for acute ischaemic stroke (AIS) are available, but need to be administered early after symptom onset in order to be effective. Currently, one of the main factors responsible for poor clinical outcome is an unnecessary long time between symptom onset and arrival at a hospital (pre-hospital delay). In the future, technological devices with the capability of real-time detection of AIS may become available. The health economic implications of such devices have not been explored.Methods: We developed a novel probabilistic model to estimate the maximally allowable annual costs of different hypothetical real-time AIS detection devices in different populations given currently accepted willingness-to-pay thresholds. Distributions of model parameters were extracted from the literature. Effectiveness of the intervention was quantified as reduction in disability-adjusted life-years associated with faster access to thrombolysis and mechanical thrombectomy. Incremental costs were calculated from a societal perspective including acute treatment costs and long-term costs for nursing care, home help, and loss of production. The impact of individual model parameters was explored in one-way and multi-way sensitivity analyses.Results: The model yields significantly shorter prehospital delays and a higher proportion of acute ischaemic patients that fulfill the time-based eligibility criteria for thrombolysis or mechanical thrombectomy in the scenario with a real-time stroke detection device as compared to the control scenario. Depending on the sociodemographic and geographic characteristics of the study population and operating characteristics of the device, the maximally allowable annual cost for the device to operate in a cost-effective manner assuming a willingness-to-pay threshold of GBP 30.000 ranges from GBP 22.00 to GBP 9,952.00. Considering the results of multiway sensitivity analyses, the upper bound increases to GBP 29,449.10 in the subgroup of young patients with a very high annual risk of ischaemic stroke (50 years/20% annual risk).Conclusion: Data from probabilistic modeling suggest that real-time AIS detection devices can be expected to be cost-effective only for a small group of highly selected individuals.

Delay of emergency surgical interventions in Ethiopia: Patient and health system factors

Background: The objectives of this study were to evaluate outcomes among patients with acute abdomen and abdominal trauma who presented at either of 2 referral hospitals in Addis Ababa, Ethiopia, and to determine the factors associated with delay as well as the effects of prehospital and in-hospital delay on outcome. Methods: We conducted a 1-year prospective cross-sectional study, which included all cases of surgically treated acute abdomen and abdominal trauma admitted to St Paul General Specialized Hospital, Addis Ababa, Ethiopia and Gondar University Hospital, Gondar, Ethiopia. Standardized data collection forms were completed for all cases from 1 May 2008 to 30 April 2009. Data were analyzed using Epi Info version 6 and SPSS version 13. Results: A total of 504 patients were studied. Diagnoses were: intestinal obstruction (34.6 %), appendicitis (33 %), and perforated peptic ulcer (3.6 %). Sixty-six percent of patients over 45 years of age, 60% of females, and 61% of intestinal obstruction cases were operated on within 3 days of illness onset. The 35% of patients who were operated on more than 3 days after the development of symptoms had a mortality of 67%. Fifty-four percent of the cases with a total prehospital and in-hospital time of more than 3 days had initially visited other health institutions. Conclusions: Delay of surgical intervention of more than 3 days for acute abdomen or abdominal trauma adversely affected outcomes. Women, patients older than 45 years of age, patients with intestinal obstruction, and those who were referred from other health facilities were delayed and had adverse outcomes. Keywords: delay in surgery; acute abdomen; abdominal trauma; surgical systems improvement

Factors associated with pre-hospital delay before reperfusion therapy in patients with ST-segment elevation myocardial infarction

Introduction: Cardiovascular disease remains the main cause of death in the world, and myocardial infarction represents the main contributor to this mortality. Timely restoration of myocardial blood flow with reperfusion therapy is crucial. Pre-hospital delay is a major obstacle for early reperfusion therapy and has negative impact on mortality and left ventricle function.&#x0D; Methods: A prospective study was carried in cardiology unit of a medical college from August 2013 to December 2017. Cases of acute ST segment elevation myocardial infarction that have undergone thrombolysis were recruited.&#x0D; Results: Out of 450 patients with ST Elevation Myocardial Infection (STEMI), delayed presentation was seen in 288 (64%) for &gt;6 hrs and 108 (24%) patients for &gt;12 hrs. The duration from onset of symptoms to the presentation in the emergency room (pre-hospital delay) was 12.66 hrs (SD=14.19, range = 30 min to 72 hrs). The door to needle time was 54 min (SD=24) The major factors for pre-hospital delay were misinterpretation of symptoms (59%) and transportation problems (31%).&#x0D; Conclusion: Misinterpretation of symptoms remain the most common cause of delayed presentation. Health education for public awareness can reduce the delay. Extension of thrombolytic therapy to district hospital and primary health center level after basic training for medical officer with checklist and collaboration in form of telemedicine with referral cardiac center may have major impact on morbidity and mortality reduction in acute STEMI patients with early reperfusion therapy.

Pre-hospital system delay and its effect on in-hospital mortality of STEMI patients

Pre-hospital system delay and its effect on in-hospital mortality of STEMI patients

Patient-reported symptoms improve prediction of acute coronary syndrome in the emergency department.

Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.

Impact of Reducing Pre-Hospital Delay in Response to Heart Attack Symptoms in Australia

This research estimates the broader socioeconomic impacts of reducing pre-hospital delay times across Australia in patients with heart attack symptoms. A cost benefit analysis (CBA) was undertaken to demonstrate the costs and benefits of a public awareness/education campaign to reduce pre-hospital delay time from 5.2hours (Base Case) to 4.1hours (Scenario 1) and 2.0hours (Scenario 2). All assumptions underlying the CBA are supported by academic literature. Financial impacts considered include campaign/public education costs, direct inpatient costs and long-term health care costs. Socioeconomic impacts considered include burden of disease, productivity losses, informal care costs and net deadweight loss. The campaign is expected to generate an additional net benefit of $41.2-139.1 million in comparison to the Base Case, resulting in a benefit cost ratio (BCR) of 3.23-5.06. Disability Adjusted Life Years (DALYs) reduced by 6,046-7,575 years. This research illustrates that an investment in public awareness/education campaign can generate considerable benefits, more than offsetting the costs associated with the campaign and keeping people living longer such as ongoing health care costs. However, significant effort, supplementary strategies and sustained investment will be required to ensure the impact and benefit is sustained over the long term.

Sex differences in symptoms experienced, knowledge about symptoms, symptom attribution, and perceived urgency for treatment seeking among acute coronary syndrome patients in Karachi Pakistan

BackgroundPatients’ experience of acute coronary syndrome (ACS) symptoms is important in determining their prehospital delay. ObjectiveTo explore gender differences in acute symptoms of ACS, knowledge about the symptoms, their attribution, and perception of urgency, among Pakistani ACS patients. MethodsComparative, cross-sectional study design with 249 ACS patients. ResultsThe most commonly reported symptoms were ghabrahat (fidgetiness), chest pain, and chest heaviness. Most atypical symptoms were experienced more by women, such as nausea/vomiting (p < 0.001), backache (p < 0.001), palpitations (p = 0.004), and epigastric pain (p = 0.005). Chest pain and palpitations were the symptoms most commonly attributed to cardiac causes, whereas epigastric pain was most commonly attributed to non-cardiac causes by both men and women. Significantly more women than men perceived dyspnea (p = 0.026), nausea/vomiting (p = 0.027), sweating (p = 0.014), and palpitations (p = 0.01) as symptoms not at all urgent for treatment. ConclusionsGender disparity in symptom experience along with the women's perception of non-urgency for their symptoms, could lead to delayed care seeking.

Trends and predictors of prehospital delay in patients undergoing primary coronary intervention.

Delay in seeking medical care following symptom onset in patients with acute ST-elevation myocardial infarction (STEMI) is related to increased morbidity and mortality. Actual trends of prehospital delays in patients hospitalized with STEMI have not been well characterized. We evaluated trends in the length of time that had elapsed from symptom onset to hospital presentation among STEMI patients admitted to our hospital. We retrospectively studied 2203 consecutive patients hospitalized for acute STEMI who underwent primary percutaneous coronary intervention (PCI) between January 2008 and December 2016. Information on the delay in time from symptom onset to presentation at hospital was extracted from the patients' medical records. Over the 9-year study period, the median duration of prehospital delay for patients undergoing primary PCI showed significant variations, being maximal between the years 2013 and 2014 (150 vs. 90 min, respectively, P<0.001). A significant increase was found in the proportion of patients with prehospital delay less than 2 h, being maximal between the years 2011 and 2013 (64 vs. 47%, P=0.001). An opposite trend was found for decrease in patients with prehospital delay more than 6 h, being maximal between 2008 and 2015 (32 vs. 23%, P=0.001). Multivariate logistic regression model showed that older age, diabetes, female sex, and first STEMI were associated independently with prehospital delay more than 2 h. Prehospital delay periods for patients undergoing primary PCI showed variations over time. More efforts are needed to educate at-risk populations about seeking early medical assistance.

P5432First medical contact in the pre-hospital phase of a myocardial infarction, the interaction between callers and tele-nurses impacts action and level of care

Background: Pre-hospital delay in myocardial infarction (MI) patients' is of great concern. The total ischemic time, i.e., between symptom onset and reperfusion therapy is the most important factor ...

The Effect of Media Campaigns, Patient Characteristics, and Presenting Symptoms on Prehospital Delay in Myocardial Infarction Patients: A Prospective Cohort Study

Delays in reperfusion therapy for myocardial infarction (MI) are associated with increased mortality and morbidity, and most of this delay is due to delay in patients initiating contact with emergency services. This study assesses the impact of the Australian National Heart Foundation media campaign and identifies patient characteristics and presenting symptoms that may contribute to delay. This prospective cohort study identified patients with a diagnosis of MI admitted to a single tertiary metropolitan hospital in Perth, Western Australia from July 2013 to January 2014. Patients were interviewed and responses were categorised to determine their reasons for delaying treatment and the impact of mass media campaigns. Delay times were analysed using multivariable linear regression models for the Whole Cohort (all patients admitted to the tertiary hospital, including patients from rural and peripheral hospitals) and the Direct Admission Cohort (patients admitted directly to the tertiary hospital). Of 376 patients, 255 patients provided consent, and symptom onset-time was available for 175 patients. While almost two thirds of the cohort was aware of media campaigns, awareness was not associated with decreased prehospital delay. Median delay was 3.9hours for the Whole Cohort and 3.5hours for the Direct Admission Cohort. Delay was associated with being widowed, symptom onset on a weekday compared with weekend, past medical history of MI and coronary artery bypass graft, private compared with ambulance transport to hospital, and lack of symptoms of sweating and weakness. In addition, for the Direct Admission Cohort, age and income were also associated with delay. This study did not find an association between awareness of media campaigns and delay. This study identified important characteristics and presenting symptoms that are associated with delay, and possibly relevant to future media campaigns.

Assessment of gender related differences in management of stroke: Evaluation of clinical practices in a French registry

Introduction The management of stroke is a public health priority in France. Patients require emergency medical care and rapid implementation of reperfusion strategies to improve prognosis and reduce disability. Stroke is the leading cause of death in women, the third in men. We aimed to compare the management of stroke and outcome among women and men, in a cohort of acute ischaemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (tPA). Methods We analysed data from a prospective AIS thrombolysis registry approved by ethical authorities. They are collected in standardized medical records and consistency is checked by clinical research associates. Data concern pre-hospital management, therapeutical decisions, management delays, complications, status at final discharge and follow-up at three months. A total of 2790 patients received tPA between 2010 and in the six stroke units of the RESUVal network (Rhone Valley, France); 1275 women (45.7%) and 15,152,016 men (54.3%). Results Women were older than men at admission time (median age: respectively 77 [66; 84] vs. 71 [61; 80] years old, P Conclusions Since the last years, the increasing use of technical reperfusion strategies - such as thrombectomy - and an organized access to the right pathway of care have tended to standardize treatment of AIS. Despite a later pre-hospital management and more severe presentation at admission, the comparison of the main key management of stroke does not differ among women and men and does not lead to excess mortality among women. For further investigation, we need to analyze the relationship between the pre-hospital delays and behavioral disparities.

Acute coronary syndrome in elderly – risk factors and in-hospital outcome

Background: Elderly patients constitute a majority subset of population developing acute coronary syndrome. But specific risk factors and in-hospital outcome have not been well-studied. Objectives: To study the risk factors and in-hospital outcome of people aged >60 years with acute coronary syndrome. Materials and Methods: 220 patients aged >60 years admitted with acute coronary syndrome under Department of General Medicine (during a time period from 1st January 2015 to 31st December 2015) were studied between admission and death/discharge. All patients who opted for primary PCI and who left treatment before completion were excluded. Patients were grouped into STEMI, NSTEMI and unstable angina. Various factors affecting mortality were studied. Results: After exclusion, 212 patients were included in the study. The mean age of men was 68±6 years while that of women was 71±7 years) (p=0.01). Modifiable risk factors were present in 84.9 % (n=180), most common risk factor observed was past history of systemic hypertension. (52.36%) (n=111). Hypertension was found to have significant association with mortality. (p value=0.05). Chest pain was the most common symptom. Atypical features were found to be higher in those aged above 80 years. (p value = 0.04). Thrombolysis was not done in 15.7 % (16) patients with STEMI, reason being they were out of window period for thrombolysis Women were found to have more pre-hospital delay (p value= 0.026) High Killip class and also hypotension during admission was found to be associated with increased mortality (p value<0.001). Conclusion: Hypertension still remains as an important modifiable risk factor for coronary artery disease in the elderly population. Hence regular monitoring of blood pressure and proper management has to be followed in this age group also. The delay to reach the hospital should be avoided, because thrombolytic therapy is very effective in elderly patients

Stroke 112: A Universal Stroke Awareness Program to Reduce Language and Response Barriers.

To improve stroke awareness and reduce life-threatening prehospital delays worldwide, a universal stroke educational program is needed. To meet this unmet need, we developed a universal program without language barriers and tested its acceptance in Taiwan, where Chinese is the native language. Stroke 112 was developed using the universal emergency phone number, 112. The numbers imply an emergency and correspond to the 3 stroke recognition signs used in FAST (Face, Arm, Speech, and Time): 1 uneven face (crooked mouth); 1 weak arm (arm weakness); 2 incoherent lips (slurred speech). An online survey was used to determine the acceptance of the Stroke 112 program compared with that of FAST in Chinese. The surveys were delivered using SurveyMonkey (http://www.surveymonkey.com) on 2 separate occasions in Taiwan; in August 2017 for an initial estimation of the acceptance of Stroke 112 and in March 2018, 2 weeks after the official release of Stroke 112 in Taiwan, including a special introductory lecture for neurologists hosted by the STARS-Taiwan (Stroke Treatment and Research Society-Taiwan). The initial survey with 465 survey responders, 54.6% thought that Stroke 112 was easier to remember for people in Taiwan compared with FAST (41.2%). After Stroke 112's official release in Taiwan, 610 individuals completed the survey, and the majority (66.4%) thought that Stroke 112 was easier to remember, a significant increase compared with the initial survey (P=0.0001). Among the 130 neurologists who attended the Stroke 112 introductory lecture, 55 completed the online survey. A greater acceptance of Stroke 112 (74.6%) compared with FAST (16.4%) was observed among these 55 neurologists (P=0.0001). Stroke 112, a universal stroke educational program without language barriers was developed. It could potentially be implemented worldwide, especially where 112 is used as an emergency phone number.

Sex-Related Differences in Short- and Long-Term Outcome among Young and Middle-Aged Patients for ST-Segment Elevation Myocardial Infarction Underwent Percutaneous Coronary Intervention.

Background:Females with ST-segment elevation myocardial infarction (STEMI) have higher in-hospital and short-term mortality rates compared with males in China, suggesting that a sex disparity exists. The age of onset of STEMI is ahead of time and tends to be younger. However, there are relatively little data on the significance of sex on prognosis for long-term outcomes for adult patients with STEMI after percutaneous coronary intervention (PCI) in China. This study sought to analyze the sex differences in 30-day, 1-year, and long-term net adverse clinical events (NACEs) in Chinese adult patients with STEMI after PCI.Methods:This study retrospectively analyzed 1920 consecutive STEMI patients (age ≤60 years) treated with PCI from January 01, 2006, to December 31, 2012. A propensity score analysis between males and females was performed to adjust for differences in baseline characteristics and comorbidities. The primary endpoint was the incidence of 3-year NACE. Survival curves were constructed with Kaplan-Meier estimates and compared by log-rank tests between the two groups. Multivariate analysis was performed using a Cox proportional hazards model for 3-year NACE.Results:Compared with males, females had higher risk profiles associated with old age, longer prehospital delay at the onset of STEMI, hypertension, diabetes mellitus, and chronic kidney disease, and a higher Killip class (≥3), with more multivessel diseases (P < 0.05). The female group had a higher levels of low-density lipoprotein (2.72 [2.27, 3.29] vs. 2.53 [2.12, 3.00], P < 0.001), high-density lipoprotein (1.43 [1.23, 1.71] vs. 1.36 [1.11, 1.63], P = 0.003), total cholesterol (4.98 ± 1.10 vs. 4.70 ± 1.15, t = −3.508, P < 0.001), and estimated glomerular filtration rate (103.12 ± 22.22 vs. 87.55 ± 18.03, t = −11.834, P < 0.001) than the male group. In the propensity-matched analysis, being female was associated with a higher risk for 3-year NACE and major adverse cardiac or cerebral events compared with males. In the multivariate model, female gender (hazard ratio [HR]: 2.557, 95% confidence interval [CI]: 1.415–4.620, P = 0.002), hypertension (HR: 2.017, 95% CI: 1.138–3.576, P = 0.016), and family history of coronary heart disease (HR: 2.256, 95% CI: 1.115–4.566, P = 0.024) were independent risk factors for NACE. The number of stents (HR: 0.625, 95% CI: 0.437–0.894, P = 0.010) was independent protective factors of NACE.Conclusions:Females with STEMI undergoing PCI have a significantly higher risk for 3-year NACE compared with males in this population. Sex differences appear to be a risk factor and present diagnostic challenges for clinicians.

The factors associated with pre-hospital delays in patients requiring treatment for ischemic stroke

Cerebral ischemic stroke is the leading cause of death and adulthood disability in developed countries such as the UK and USA. The only pharmacological treatment available is intravenous thrombolytic therapy, which is most effective and beneficial to patients when administrated within a relatively short time window following stroke onset. However, a large number of patients are ineligible for thrombolysis treatment due to delays in receiving treatment. In this review we discuss those factors which are associated with treatment delay. Understanding such factors that contribute to treatment delays, especially in different regions of the world, may help to improve the time at which treatment can be delivered to stroke patients and reduce the detrimental effects of stroke.

Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis.

The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.