Background and Purpose— We designed and validated a simple prehospital stroke scale to identify emergent large vessel occlusion (ELVO) in patients with acute ischemic stroke and compared the scale to other published scales for prediction of ELVO. Methods— A national historical test cohort of 3127 patients with information on intracranial vessel status (angiography) before reperfusion therapy was identified. National Institutes of Health Stroke Scale (NIHSS) items with the highest predictive value of occlusion of a large intracranial artery were identified, and the most optimal combination meeting predefined criteria to ensure usefulness in the prehospital phase was determined. The predictive performance of Prehospital Acute Stroke Severity (PASS) scale was compared with other published scales for ELVO. Results— The PASS scale was composed of 3 NIHSS scores: level of consciousness (month/age), gaze palsy/deviation, and arm weakness. In derivation of PASS 2/3 of the test cohort was used and showed accuracy (area under the curve) of 0.76 for detecting large arterial occlusion. Optimal cut point ≥2 abnormal scores showed: sensitivity=0.66 (95% CI, 0.62–0.69), specificity=0.83 (0.81–0.85), and area under the curve=0.74 (0.72–0.76). Validation on 1/3 of the test cohort showed similar performance. Patients with a large artery occlusion on angiography with PASS ≥2 had a median NIHSS score of 17 (interquartile range=6) as opposed to PASS <2 with a median NIHSS score of 6 (interquartile range=5). The PASS scale showed equal performance although more simple when compared with other scales predicting ELVO. Conclusions— The PASS scale is simple and has promising accuracy for prediction of ELVO in the field.

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Objective: In large-vessel occlusion, endovascular therapy is superior to medical management alone in achieving recanalisation. Reducing time delays to revascularisation in patients with large-vessel occlusion is important to improving outcome. Patients and methods: A campaign was implemented in the Central Denmark Region targeting the identification of patients with large-vessel occlusion for direct transport to a comprehensive stroke centre. Time delays and outcomes before and after the intervention were assessed. Results: A total of 476 patients (153 pre-intervention and 323 post-intervention) were included. They were treated with either intravenous tissue plasminogen activator or endovascular treatment (alone or in combination with intravenous tissue plasminogen activator). Endovascular therapy patients' median system delay was reduced from 234 to 185 min (adjusted relative risk delay 0.79 (95% confidence interval: 0.67-0.93)). The in-hospital delay was the main driver with an adjusted relative risk delay of 0.76 (confidence interval: 0.62-0.94), while pre-hospital delay was almost significantly reduced with an adjusted relative delay of 0.86 (confidence interval: 0.71-1.04). This was achieved without increasing the intravenous tissue plasminogen activator-treated patients' delay. Significantly more patients treated with endovascular therapy in the post-interventional period achieved functional independence (62% versus 43%), corresponding to an adjusted odds ratio of 3.08 (95% confidence interval: 1.08-8.78). Conclusion: Direct transfer of patients with suspected large-vessel occlusion to a comprehensive stroke centre leads to shorter treatment times for endovascular therapy patients and is, in turn, associated with an increase in functional independence. We recorded no adverse effects on intravenous tissue plasminogen activator treatment times or outcome.

ObjectiveTo investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR).MethodsThe CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective “before-and-after” cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014.ResultsCentralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38–0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark.ConclusionsCentralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.

ABSTRACT:We previously showed different effects of tobacco and nicotine on fracture healing, but due to pump reservoir limits, maximum exposure period was 4 weeks. To allow flexibility in pre-and post-fracture exposure periods, the objective of this study was to compare a new oral administration route for nicotine to the established pump method. Four groups were studied: (1) pump saline, (2) pump saline þ oral tobacco, (3) pump saline/nicotine þ oral tobacco, and (4) pump saline þ oral nicotine/tobacco. Sprague-Dawley rats (n ¼ 84) received a transverse femoral fracture stabilized with an intramedullary pin 1 week after initiating dosing. After 3 weeks, no difference was found in torsional strength or stiffness between oral nicotine/tobacco or pump nicotine þ tobacco, while energy absorption with oral nicotine/tobacco was greater than pump nicotine þ tobacco (p < 0.05). Compared to saline control, strength for oral nicotine/tobacco was higher than control (p < 0.05), and stiffnesses for pump nicotine þ tobacco and oral nicotine/tobacco were higher than control (p < 0.05). No differences in energy were found for either nicotine-tobacco group compared to saline control. Mean serum cotinine (stable nicotine metabolite) was different between pump and oral nicotine at 1 and 4 weeks, but all groups were in the range of 1-2 pack/day smokers. In summary, relevant serum cotinine levels can be reached in rats with oral nicotine, and, in the presence of tobacco, nicotine can influence mechanical aspects of fracture healing, dependent on administration method. Caution should be exercised when comparing results of fracture healing studies using different methods of nicotine administration. Fractures and spinal fusions in smokers heal more slowly and result in more nonunions than in nonsmokers. Although the increased prevalence of smoking affects both males and females, women are at higher risk for osteoporosis and related fractures, and smoking may exacerbate this risk.Our previous work using a rat fracture model showed that tobacco extract (with or without pump nicotine administered at 3 mg/kg/day) was associated with a decrease in fracture healing strength, 1 using a 1-week pre-fracture exposure period and a 3-week post-fracture observation period. Focusing on fracture healing response to three doses of pump nicotine (0, 3, 6, 12 mg/ kg/day) delivered at the same intervals showed that the two highest levels of exposure were associated with increased healing strength. 1,2Clinical studies of smoking on fracture healing are invaluable, but do not readily allow determination of mechanisms of interaction. Experimental studies of the relationship of smoking to fracture healing generally conclude that nicotine or tobacco is associated with higher risk of nonunion and slower fracture repair. Animal models facilitate understanding of mechanism by allowing controlled dosing of tobacco and nicotine, specified route of administration, and observation period. However, inconsistent doses and regimens of nicotine and different follow-up ...