Considerations for the Implementation of a Telestroke Network: A Systematic Review.

The application of telestroke has matured considerably since its inception in 1999. The use of telestroke is now recommended in several published guidelines. Consequently, jurisdictions without a telestroke service are seeking practical information on the best approach to implement telestroke. French et al. (2013) reviewed the challenges of implementing a telestroke network including studies between 2000 and 2010. At the time, telestroke networks were largely limited to the UK, USA, Canada and Europe and only one process evaluation had been conducted. Given the prolific expansion of telestroke services since 2010, we conducted a systematic review to determine factors associated with successful establishment, management, and sustainability of a contemporary telestroke services. A comprehensive search of telestroke studies was conducted in July 2021. Empirical studies published between 2010 and 2021 were included if they contained descriptive, evaluation or operational data on the implementation of a telestroke network. Studies were subsequently evaluated using the Consolidated Framework for Implementation Research (CFIR). The initial literature search revealed a total of 7415 potential studies; 38 of which met the inclusion criteria. The past decade of process evaluation studies has enabled a more nuanced investigations into how to implement and sustain a telestroke network. Pre-implementation planning is crucial to ensure clear telestroke processes, governance structures and stakeholder engagement. Sustainability of networks relies on securing long-term investment, providing adequate resources, and maintaining staff motivation and willingness. Recommendations are provided to overcome commonly identified barriers related to technology, staffing, planning and standardisation of processes, evaluation, and sustainability and scale-up. Further research needs to explore how new advancements in stroke care such as endovascular clot retrieval (EVT) and advanced brain imaging can be considered and planned for during the implementation of a new telestroke service.

Satisfactory immune response following anaphylaxis to PCECV facilitated by the use of steroids and antihistamines.

INTRODUCTION: Rabies is fatal and can cause almost certain mortality in animals and humans. Effective post-exposure prophylaxis (PEP) using the rabies vaccine remains the cornerstone for preventing disease in humans. We present the first reported case of supporting the live purified-chick-embryo-cell rabies vaccine(PCECV) administration with prophylactic high-dose corticosteroids. CASE: A 39-year-old female was at high-risk of developing rabies-like disease following a bat bite. She was commenced on PEP using PCECV. Our patient developed an anaphylactic reaction with bronchospasm and a rash following her 2nd PCECV dose. Consequently, she received 2 days of loratadine and high-dose prednisolone prior to her final vaccination. During this administration in the emergency department, our patient completed the final PCECV dose. At a two-week follow-up, our patient had no evidence of rabies and had adequate viral neutralizing antibody levels detectable on serology. DISCUSSION: Type 1 hypersensitivity reactions to PCECV are rare. Only 20 anaphylactic cases have been reported from a total of 1.1million administered doses over 8 years. Individuals at higher risk of anaphylaxis include those with a prior history of allergy to either egg white, gelatin, milk, penicillin, bee venom, or beef products. Administering high dose prophylactic corticosteroids prior to vaccination can potentially induce immune tolerance and minimize subsequent risks of hypersensitivity reactions. However, data relating to its use is extremely limited to only animal and limited human case-report data from other vaccines. CONCLUSION: We propose an alternative option which will require further research to manage vaccine-related anaphylaxis where immunization is an essential prophylactic requirement with the support of an immunologist and careful monitoring in an appropriate environment.