Background: We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020. Methods: We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am –8:59 pm ) and nighttime (9:00 pm –7:59 am ). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated. Results: We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020–2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680–1.163]; P interaction =0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548–1.072]; nighttime, acOR, 1.785 [95% CI, 1.024–3.112] ; P interaction <0.01); no heterogeneity was observed for other stroke subtypes ( P interaction >0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers. Conclusions: Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02795962.

Background: We aim to compare the outcome of patients from urban areas, where the referral center is able to perform thrombectomy, with patients from nonurban areas enrolled in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion). Methods: Patients with suspected large vessel occlusion stroke, as evaluated by a Rapid Arterial Occlusion Evaluation score of ≥5, from urban catchment areas of thrombectomy-capable centers during RACECAT trial enrollment period were included in the Stroke Code Registry of Catalonia. Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with an ischemic stroke. Secondary outcomes included mortality at 90 days, rate of thrombolysis and thrombectomy, time from onset to thrombolysis, and thrombectomy initiation. Propensity score matching was used to assemble a cohort of patients with similar characteristics. Results: The analysis included 1369 patients from nonurban areas and 2502 patients from urban areas. We matched 920 patients with an ischemic stroke from urban areas and nonurban areas based on their propensity scores. Patients with ischemic stroke from nonurban areas had higher degrees of disability at 90 days (median [interquartle range] modified Rankin Scale score, 3 [2–5] versus 3 [1–5], common odds ratio, 1.25 [95% CI, 1.06–1.48]); the observed average effect was only significant in patients with large vessel stroke (common odds ratio, 1.36 [95% CI, 1.08–1.65]). Mortality rate was similar between groups(odds ratio, 1.02 [95% CI, 0.81–1.28]). Patients from nonurban areas had higher odds of receiving thrombolysis (odds ratio, 1.36 [95% CI, 1.16–1.67]), lower odds of receiving thrombectomy(odds ratio, 0.61 [95% CI, 0.51–0.75]), and longer time from stroke onset to thrombolysis (mean difference 38 minutes [95% CI, 25–52]) and thrombectomy(mean difference 66 minutes [95% CI, 37–95]). Conclusions: In Catalonia, Spain, patients with large vessel occlusion stroke triaged in nonurban areas had worse neurological outcomes than patients from urban areas, where the referral center was able to perform thrombectomy. Interventions aimed at improving organizational practices and the development of thrombectomy capabilities in centers located in remote areas should be pursued. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02795962.

RESUMENLas interacciones bióticas y abióticas entre el río y la zona de ribera determinan procesos hidrológicos relevantes del balance hídrico y ejercen control de los tipos de vegetación característicos del corredor de ribera y laderas aledañas; las plantas responden y se adaptan a las condiciones del medio y, a su vez, controlan el ciclo hidrológico de estos ecosistemas. En las regiones semiáridas, la disponibilidad hídrica ejerce uno de los principales controles para el crecimiento y desarrollo de la vegetación, pues en el continuo suelo-planta-atmósfera son fundamentales la fluctuación de los contenidos de humedad del suelo y la profundidad del sistema de raíces; en estas condiciones, la cercanía con el río genera un gradiente de humedad que determina con mucha claridad el límite entre la ribera de vegetación exuberante y la ladera semiárida colindante.Para enfatizar dichas condiciones y procesos ecohidrológicos, se ha diseñado y aplicado un modelo matemático de la interacción entre la vegetación de ribera y el régimen hídrico del río, denominado "Modelo de agua y vegetación de ribera RibAV", que recoge los principales avances de modelación del ecosistema a nivel mundial y que enriquece su conceptualización con base en la experiencia de campo. Esta herramienta tecnológica es de utilidad para determinar el crecimiento y respuestas de la vegetación ante condiciones variables de disponibilidad de agua de las zonas saturada y no saturada, proveniente de un balance hídrico diario controlado por el régimen del río y por los mecanismos diferenciados de adaptación al medio de los diversos tipos de vegetación presentes.En el modelo, el régimen hídrico del río determina las fluctuaciones del nivel freático en la zona de ribera mediante una aproximación simple. La hidrología de la zona se modela mediante un balance hídrico conceptual que incluye el almacenamiento estático del suelo y los principales movimientos de agua de la ribera (lluvia, evapotranspiración, excedentes y ascenso capilar desde el nivel freático) a los que se ha añadido el del ascenso hidráulico radicular de las plantas como innovación de los modelos a escala de ribera.Se aplicó la clasificación de la vegetación por tipos funcionales propuesta para riberas semiáridas, fortaleciendo el análisis mediante ordenación taxonómica vegetal. A partir de esta zonificación se establecieron los parámetros biofísicos característicos de la zona a modelar: bosques de ribera poco perturbados y bosques secos caducifolios de las laderas aledañas del Valle semiárido del Motagua, Guatemala. La implementación del modelo RibAV ha permitido evaluar las respuestas de los tipos de vegetación frente al régimen hídrico permanente de dos tramos de río provenientes de la Reserva de Biosfera "Sierra de las Minas" (Teculután y Uyús), cuya hidrología a escala de cuenca se determinó con modelación hidrológica distribuida.El modelo genera las tasas de evapotranspiración de los distintos tipos de vegetación a partir de mecanismos diferenciados de respuesta y adaptación a la disponibilid...