Objectives. The primary objective of this study was to assess the effectiveness of two prehospital stroke screens in correctly classifying patients suspected of having a stroke. Secondarily, differences in the sensitivity and specificity of the two screening tools were assessed. Methods. We performed a retrospective assessment of the Cincinnati Prehospital Stroke Scale (CPSS) and the Medic Prehospital Assessment for Code Stroke (Med PACS) between March 1, 2011, and September 30, 2011, in a single emergency medical services (EMS) agency with seven local hospitals all classified as stroke-capable. We obtained data for this analysis from the EMS electronic patient care reports (ePCRs) and the Get With The Guidelines − Stroke (GWTG-S) registries maintained by the two local health care systems by matching on patient identifiers. The Med PACS was developed specifically for the EMS agency under study by a local team of neurologists, emergency physicians, and paramedics. All of the physical assessment elements of the CPSS were included within the Med PACS. Two additional physical assessment items, gaze and leg motor function, were included in the Med PACS. We classified patients as CPSS-positive or -negative and Med PACS-positive or -negative if any one of the physical assessment findings was present. We determined the presence of a hospital discharge diagnosis of stroke from GWTG-S. We calculated sensitivity and specificity with resultant 95% confidence intervals. Results. We enrolled 416 patients in this study, of whom 186 (44.7%) were diagnosed with a stroke and the specificity of the Med PACS was significantly higher compared with the CPSS, with a difference in specificity of 0.086 (95% CI 0.042-0.131), p < 0.001. Conclusion. The two stroke scales under study demonstrated low sensitivity and specificity, with each scale performing marginally better in one of the two metrics assessed.

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01994720.

Background: Stillbirth accounts for over 2 million deaths a year worldwide, and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth.Objectives: To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development.Search strategy: Medline, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019. Selection criteria:We included systematic reviews of association of individual variables with stillbirth without language restriction. Data collection and analysis: Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded. Results:The search identified 1198 citations. 69 systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n=5), BMI (n=6) and maternal diabetes (n=5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension. Conclusion:We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests which were PAPP-A, PlGF and

No abstract

Background and ObjectiveIt is necessary to develop an effective and low-cost screening tool for identifying Chinese people at high risk of stroke. Transcranial Doppler ultrasound (TCD) is a powerful predictor of stroke in the pediatric sickle cell disease population, as demonstrated in the STOP trial. Our study was conducted to determine the prediction value of peak systolic velocities as measured by TCD on subsequent stroke risk in a prospective cohort of the general population from Beijing, China.MethodsIn 2002, a prospective cohort study was conducted among 1392 residents from 11 villages of the Shijingshan district of Beijing, China. The cohort was scheduled for follow up with regard to incident stroke in 2005, 2007, and 2012 by a study team comprised of epidemiologists, nurses, and physicians. Univariate and multivariate Cox proportional hazard regression models were used to determine the factors associated with incident stroke.ResultsParticipants identified by TCD criteria as having intracranial stenosis had a 3.6-fold greater risk of incident stroke (hazard ratio (HR) 3.57, 95% confidence interval (CI) 1.86–6.83, P<0.01) than those without TCD evidence of intracranial stenosis. The association remained significant in multivariate analysis (HR 2.53, 95% CI 1.31–4.87) after adjusting for other risk factors or confounders. Older age, cigarette smoking, hypertension, and diabetes mellitus remained statistically significant as risk factors after controlling for other factors.ConclusionsThe study confirmed the screening value of TCD among the general population in urban China. Increasing the availability of TCD screening may help identify subjects as higher risk for stroke.

ObjectiveTo determine whether young adults (≤40 years old) with acute ischemic stroke are less likely to receive IV tissue plasminogen activator (tPA) and more likely to have longer times to brain imaging and treatment.MethodsWe analyzed data from the Get With The Guidelines–Stroke registry for patients with acute ischemic stroke hospitalized between January 2009 and September 2015. We used multivariable models with generalized estimating equations to evaluate tPA treatment and outcomes between younger (age 18–40 years) and older (age >40 years) patients with acute ischemic stroke.ResultsOf 1,320,965 patients with acute ischemic stroke admitted to 1,983 hospitals, 2.3% (30,448) were 18 to 40 years of age. Among these patients, 12.5% received tPA vs 8.8% of those >40 years of age (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.56–1.71). However, younger patients were less likely to receive brain imaging within 25 minutes (62.5% vs 71.5%, aOR 0.78, 95% CI 0.73–0.84) and to be treated with tPA within 60 minutes of hospital arrival (37.0% vs 42.8%, aOR 0.74, 95% CI 0.68–0.79). Compared to older patients, younger patients treated with tPA had a lower symptomatic intracranial hemorrhage rate (1.7% vs 4.5%, aOR 0.55, 95% CI 0.42–0.72) and lower in-hospital mortality (2.0% vs 4.3%, aOR 0.65, 95% CI 0.52–0.81).ConclusionsIn contrast to our hypothesis, younger patients with acute ischemic stroke were more likely to be treated with tPA than older patients, but they were more likely to experience delay in evaluation and treatment. Compared with older patients, younger patients had better outcomes, including fewer intracranial hemorrhages.

Introduction: The use of mobile electronic care coordination via smartphone technology is a novel approach aimed at increasing efficiency in acute stroke care. One such platform, StopStroke© (Pulsara Inc., Bozeman, MT), serves to coordinate personnel (EMS, nurses, physicians) during stroke codes with real-time digital alerts. This study was designed to examine post-implementation data from multiple medical centers utilizing the StopStroke© application, and to evaluate the effect of method of arrival to ED and time of presentation on these results. Methods: A retrospective analysis of all acute stroke codes using StopStroke© from 3/2013 – 5/2016 at 12 medical centers was performed. Preliminary unadjusted comparison of clinical metrics (door-to-needle time [DTN], door-to-CT time [DTC], and rate of goal DTN) was performed between subgroups based on both method of arrival (EMS vs. other arrival to ED) and time of day. Effects were then adjusted for confounding variables (age, sex, NIHSS score) in multiple linear and logistic regression models. Results: The final dataset included 2589 unique cases. Patients arriving by EMS were older (median age 67 vs. 64, P < 0.0001), had more severe strokes (median NIHSS score 8 vs. 4, P < 0.0001), and were more likely to receive tPA (20% vs. 12%, P < 0.0001) than those arriving to ED via alternative method. After adjustment for age, sex, NIHSS score and case time, patients arriving via EMS had shorter DTC (6.1 min shorter, 95% CI [2, 10.3]) and DTN (12.8 min shorter, 95% CI [4.6, 21]) and were more likely to meet goal DTN (OR 1.83, 95% CI [1.1, 3]). Adjusted analysis also showed longer DTC (7.7 min longer, 95% CI [2.4, 13]) and DTN (21.1 min longer, 95% CI [9.3, 33]), and reduced rate of goal DTN (OR 0.3, 95% CI [0.15, 0.61]) in cases occurring from 1200-1800 when compared to those occurring from 0000-0600. Conclusions: By incorporating real-time pre-hospital data obtained via smartphone technology, this analysis provides unique insight into acute stroke codes. Additionally, mobile electronic stroke care coordination is a promising method for more efficient and efficacious acute stroke care. Furthermore, early activation of a mobile coordination platform in the field appears to promote a more expedited and successful care process.

Introduction: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young. Recent studies reported a low rate of major adverse cardiac events (MACE) in patients with CeAD, with no significant difference between patients randomized to antiplatelet or anticoagulation. Methods: All patients from 2015-2017 consecutively identified by an electronic medical record-based application were enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE (stroke/transient ischemic attack [TIA]/death). Results: The cohort included 111 CeAD patients, (age 53 ±15.9 years, 56% white, 50% female) detected by magnetic resonance (5%), computed tomography (88%) and catheter (7%) angiography. CeAD was noted in the carotid (66%), vertebral (42%) and basilar (2%) arteries, with 83% of them being extracranial. CeAD was classified as grade 1, 2, 3 and 4 in 16%, 33%, 19%, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%), including 21% violent sneezing, 19% carrying heavy load, 11% sports/recreation activity, 9% chiropractic manipulation, 9% abrupt/prolonged rotation of head, and 9% prolonged phone use. At presentation, 41% had stroke, 39% had headache, 5% had TIA, and 15% were asymptomatic. Favorable outcome defined as modified Rankin score of 0-2 was noted in 68% at 3 months and 71% at 12 months. Rate of MACE was 14%, with more events observed in patients not on antiplatelet/anticoagulant therapy due to contraindications (p=0.008, Fig 1). Conclusions: We report diagnostic characteristics and short- and long-term outcomes of CeAD. A high MACE rate was observed within the first week of CeAD diagnosis, especially in patients not initiated on antiplatelet/anticoagulant therapy.