The RACE scale is a simple tool that can accurately assess stroke severity and identify patients with acute stroke with large artery occlusion at prehospital setting by medical emergency technicians.

on behalf of the catalan stroke code and reperfusion consortium (cat-scr) Ischemic Stroke To cite: carrera D, gorchs M, Querol M, et al. J NeuroIntervent Surg epub ahead of print: [please include Day Month Year].AbSTrACT background and purpose Our aim was to revalidate the race scale, a prehospital tool that aims to identify patients with large vessel occlusion (lVO), after its region-wide implementation in catalonia, and to analyze geographical differences in access to endovascular treatment (eVT). Methods We used data from the prospective cicaT registry (stroke code catalan registry) that includes all stroke code activations. The race score evaluated by emergency medical services, time metrics, final diagnosis, presence of lVO, and type of revascularization treatment were registered. sensitivity, specificity, and area under the curve (aUc) for the race cut-off value ≥5 for identification of both lVO and eligibility for eVT were calculated. We compared the rate of eVT and time to eVT of patients transferred from referral centers compared with those directly presenting to comprehensive stroke centers (csc). results The race scale was evaluated in the field in 1822 patients, showing a strong correlation with the subsequent in-hospital evaluation of the national institute of health stroke scale evaluated at hospital (r=0.74, P<0.001). a race score ≥5 detected lVO with a sensitivity 0.79 and specificity 0.62 (aUc 0.76). Patients with race ≥5 harbored a lVO and received eVT more frequently than race <5 patients (lVO 35% vs 6%; eVT 20% vs 6%; all P<0.001). Direct admission at a csc was independently associated with higher odds of receiving eVT compared with admission at a referral center (Or 2.40; 95% ci 1.66 to 3.46), and symtoms onset to groin puncture was 133 min shorter. Conclusions This large validation study confirms race accuracy to identify stroke patients eligible for eVT, and provides evidence of geographical imbalances in the access to eVT to the detriment of patients located in remote areas. MeThodS Study setting

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BackgroundStudies have highlighted the effects the use of the WHO Surgical Safety Checklist can have on lowering mortality and surgical complications. Implementation of the checklist is not easy and several barriers have been identified. Few studies have addressed personnel’s acceptance and attitudes toward the WHO Surgical Safety Checklist. Determining personnel’s acceptance might reflect their intention to use the checklist while their awareness and knowledge of the checklist might assess the effectiveness of the training process.MethodsThrough an anonymous self- responded questionnaire, general characteristics of the respondents (age, gender, profession and years spent studying or working at the hospital), knowledge of the WHO Surgical Safety Checklist (awareness of existence, knowledge of objectives, knowledge of correct use), acceptance of the checklist and its implementation (including personal belief of benefits of using the checklist), current use, teamwork and safety climate appreciation were determined.ResultsOf the 147 surgical personnel who answered the questionnaire, 93.8% were aware of the existence of the WHO Surgical Safety Checklist and 88.8% of them reported knowing its objectives. More nurses than other personnel knew the checklist had to be used before the induction of anesthesia, skin incision, and before the patient leaves the operating room. Most personnel thought using the WHO Surgical Safety Checklist is beneficial and that its implementation was a good decision. Between 73.7% and 100% of nurses in public and private hospitals, respectively, reported the checklist had been used either always or almost always in the general elective surgeries they had participated in during the current year.ConclusionsDespite high acceptance of the checklist among personnel, gaps in knowledge about when the checklist should be used still exist. This can jeopardize effective implementation and correct use of the checklist in hospitals in Guatemala City. Efforts should aim to universal awareness and complete knowledge on why and how the checklist should be used.

In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. OBJECTIVE To determine whether, in nonurban areas, direct transport to a thrombectomycapable center is beneficial compared with transport to the closest local stroke center. DESIGN, SETTING, AND PARTICIPANTS Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. INTERVENTIONS Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). MAIN OUTCOMES AND MEASURESThe primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 [no symptoms] to 6 [death]) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. RESULTSEnrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 [IQR,[65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83] years; median National Institutes of Health Stroke Scale score, 17 [IQR,[11][12][13][14][15][16][17][18][19][20][21]); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio [OR], 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 [47.5%] vs 282/467 [60.4%]; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 [48.8%] vs 184/467 [39.4%]; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 [27.3%] vs 194/713 [27.2%]; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). CONCLUSIONS AND RELEVANCEIn nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings.

Rationale Optimal pre-hospital delivery pathways for acute stroke patients suspected to harbor a large vessel occlusion have not been assessed in randomized trials. Aim To establish whether stroke subjects with rapid arterial occlusion evaluation scale based suspicion of large vessel occlusion evaluated by emergency medical services in the field have higher rates of favorable outcome when transferred directly to an endovascular center (endovascular treatment stroke center), as compared to the standard transfer to the closest local stroke center (local-SC). Design Multicenter, superiority, cluster randomized within a cohort trial with blinded endpoint assessment. Procedure Eligible patients must be 18 or older, have acute stroke symptoms and not have an immediate life threatening condition requiring emergent medical intervention. They must be suspected to have intracranial large vessel occlusion based on a pre-hospital rapid arterial occlusion evaluation scale of ≥5, be located in geographical areas where the default health authority assigned referral stroke center is a non-thrombectomy capable hospital, and estimated arrival at a thrombectomy capable stroke hospital in less than 7 h from time last seen well. Cluster randomization is performed according to a pre-established temporal sequence (temporal cluster design) with three strata: day/night, distance to the endovascular treatment stroke center, and week/week-end day. Study outcome The primary endpoint is the modified Rankin Scale score at 90 days. The primary safety outcome is mortality at 90 days. Analysis The primary endpoint based on the modified intention-to-treat population is the distribution of modified Rankin Scale scores at 90 days analyzed under a sequential triangular design. The maximum sample size is 1754 patients, with two planned interim analyses when 701 (40%) and 1227 patients have completed follow-up. Hypothesized common odds ratio is 1.35.

No single biomarker successfully differentiates PNES from ES; in fact, PNES is only diagnosed via the negation of ES. Clinical assessment and rigorous investigation of psychosocial variables specific to PNES remain critical, and subtyping of PNES is warranted. Future investigational and clinical imperatives are discussed.

Background: