RAPIDO: Promoting stroke awareness among Spanish speakers.

ABSTRACT: The mnemonic BE-FAST (Balance, Eyes, Face, Arm, Speech, Time) has been developed for the public to better remember and identify the warning signs of stroke. However, discrepancies may arise when translating stroke educational materials from English to Spanish. This article discusses the use of a culturally tailored tool, RAPIDO, to raise stroke awareness in Spanish-speaking populations.

Agreement Among Stroke Faculty and Fellows in Treating Ischemic Stroke Patients With Tissue-Type Plasminogen Activator and Thrombectomy.

BACKGROUND AND PURPOSE: The aim of this study is to determine agreement among vascular neurology fellows and faculty in treating patients with acute ischemic stroke with intravenous tissue-type plasminogen activator and intra-arterial thrombectomy (IAT). METHODS: Patients were evaluated simultaneously by at least 2 vascular neurology. Agreement was determined using kappa (κ) and intraclass correlation coefficients. RESULTS: In 60 patients, agreement was substantial for tissue-type plasminogen activator (κ=0.75 [95% confidence interval, 0.57-0.92]) and IAT (κ=0.63 [95% confidence interval, 0.30-0.96]), with no difference between fellow-fellow versus fellow-faculty. Intraclass correlation coefficient for National Institutes of Health Stroke Scale was 0.94 (95% confidence interval, 0.90-0.97) and κ for Alberta Stroke Program Early CT Score was 0.53 (95% confidence interval, 0.20-0.78). Rapidly improving or mild deficits caused disagreement for both tissue-type plasminogen activator and IAT, whereas interpretation of computed tomographic perfusion led to disagreement for IAT. CONCLUSIONS: We found substantial agreement between vascular neurology fellows and faculty in treating with tissue-type plasminogen activator or IAT. Areas for improvement include recognition of stroke mimics, consensus on treating less severe strokes, and use/interpretation of imaging.

A Cross-sectional Survey of Comprehension and Satisfaction of Spanish-Reading Adults Regarding RÁPIDO as a Stroke Awareness Acronym.

ABSTRACT: BACKGROUND: Delay time to hospital arrival may be influenced by lack of recognition of stroke signs and the necessity to seek emergency medical, which in turn is influenced by language barriers to, a modifiable risk factor, stroke awareness education. The objective was to determine the comprehension and satisfaction of a Spanish stroke awareness acronym, RÁPIDO, among community-living, Hispanic and Latino, Spanish-reading adults. METHODS: A 33-item survey was completed by 166 adults. Data on sociodemographics, language preferences, stroke education, and comprehension and satisfaction with RÁPIDO were collected. Descriptive characteristics were calculated. Fisher exact tests were performed to determine whether reading language (group 1, only or predominantly reads in Spanish; group 2, reads in Spanish and English equally or reads predominately in English) influenced survey responses. Responses to open-ended questions were categorized. RESULTS: Sixty-nine percent of the participants were born outside of the United States, 82% currently resided in the United States, 34% read only or predominately in Spanish, and 7% had a stroke. Most participants thought RÁPIDO was informative, eye-catching, and easily remembered. Significant differences were found between reading language preference groups for correctly identifying RÁPIDO images for facial drooping (group 1, 80%; group 2, 95%; P ≤ .001) and dizziness/loss of balance (group 1, 54%; group 2, 73%; P = .027). Eighty percent or more of all participants were able to correctly interpret RÁPIDO images for facial drooping, blurry vision, impaired speech, and call emergency services. Adding "911" to the RÁPIDO image of the clock was a common suggestion. CONCLUSIONS: RÁPIDO was well received among the participants. Modifications to RÁPIDO images representing dizziness/loss of balance and arm weakness, and the addition of "911" may improve its usefulness. Obtaining more extensive feedback across the United States and testing the effect of RÁPIDO on increasing knowledge of stroke signs and retention of that knowledge are necessary next steps.

Inequities in Telemedicine Use Among Patients With Stroke and Cerebrovascular Diseases: A Tricenter Cross-sectional Study.

Background and Objectives: In response to the COVID-19 pandemic, outpatient stroke care delivery was rapidly transformed to outpatient evaluation through video (VTM) and telephone (TPH) telemedicine (TM) visits around the world. We sought to evaluate the sociodemographic differences in outpatient TM use among stroke patients. Methods: We conducted a retrospective chart review of outpatients evaluated at 3 tertiary stroke centers in the early period of the pandemic, 3/16/2020 through 7/31/2020. We compared the use of TM by patient characteristics including age, sex, race/ethnicity, insurance status, stroke type, patient type, and site. The association between TM use and patient characteristics was measured using the relative risk (RR) from a modified Poisson regression, and site-specific effects were controlled using a multilevel analysis. Results: A total of 2,024 visits were included from UTHealth (n = 878), MedStar Health (n = 269), and Columbia (n = 877). The median age was 64 [IQR 52-74] years, and 53% were female. Approximately half of the patients had private insurance, 36% had Medicare, and 15% had Medicaid. Two-thirds of the visits were established patients. TM accounted for 90% of total visits, and the use of TM over office visits was primarily associated with site, not patient characteristics. TM utilization was associated with Asian and other/unknown race. Among TM users, older age, Black race, Hispanic ethnicity, and Medicaid insurance were associated with lower VTM use. Black (aRR 0.88, 95% CI 0.86-0.91, p < 0.001) and Hispanic patients (aRR 0.92, 95% CI 0.87-0.98, p = 0.005) had approximately 10% lower VTM use, while Asian patients (aRR 0.98, 95% CI 0.89-1.07, p = 0.59) had similar VTM use compared with White patients. Patients with Medicaid were less likely to use VTM compared with those with private insurance (aRR 0.86, 95% CI 0.81-0.91, p < 0.001). Discussion: In our diverse cohort across 3 centers, we found differences in TM visit type by race and insurance early during the COVID-19 pandemic. These findings suggest disparities in VTM access across different stroke populations. As VTM remains an integral part of outpatient neurology practice, steps to ensure equitable access are essential.

An Intervention Mapping Approach to Developing a Stroke Literacy Video for Recent Stroke Survivors: Development and Usability Study.

BACKGROUND: Most vascular events after stroke may be prevented by modifying vascular risk factors through medical and behavioral interventions. Stroke literacy-an understanding of stroke symptoms, risk factors, and treatment-likely contributes to vascular risk factor control and in turn stroke recurrence risk. Stroke literacy is the lowest among adults belonging to racial and ethnic minority populations in the United States. Video-based interventions targeting stroke literacy may help acute stroke survivors understand stroke and subsequently reduce the risk of stroke recurrence. However, the failure of prior stroke literacy interventions may be due in part to the fact that the interventions were not theory-driven. Intervention mapping (IM) provides a framework for use in the development, implementation, and evaluation of evidence-informed, health-related interventions. OBJECTIVE: We aimed to develop a video-based educational intervention to improve stroke literacy in hospitalized patients with acute stroke. METHODS: The 6-step iterative process of IM was used to develop a video-based educational intervention and related implementation and evaluation plans. The six steps included a needs assessment, the identification of outcomes and change objectives, the selection of theory- and video-based intervention methods and practical applications, the development of a video-based stroke educational intervention, plans for implementation, and evaluation strategies. RESULTS: A 5-minute video-based educational intervention was developed. The IM approach led to successful intervention development by emphasizing stakeholder involvement, generation and adoption, and information retainment in the planning phase of the intervention. A planned approach to video adoption, implementation, and evaluation was also developed. CONCLUSIONS: An IM approach guided the development of a 5-minute video-based educational intervention to promote stroke literacy among acute stroke survivors. Future studies are needed to assess the use of technology and digital media to support widespread access and participation in video-based health literacy interventions for populations with acute and chronic stroke. Studies are needed to assess the impact of video-based educational interventions that are paired with stroke systems of care optimization to reduce the risk of stroke recurrence. Furthermore, studies on culturally and linguistically sensitive video-based stroke literacy interventions are needed to address known racial and ethnic disparities in stroke literacy. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1371/journal.pone.0171952.

Transitions of Care Coordination Intervention Identifies Barriers to Discharge in Hospitalized Stroke Patients.

Background: Prolonged hospital lengths of stay increase costs, delay rehabilitation, and expose acute ischemic stroke patients to hospital-acquired infections. We designed and implemented a nurse-driven transitions of care coordinator (TOCC) program to facilitate the transition of care from the acute care hospital setting to rehabilitation centers and home. Methods: This was a single-blinded, prospective, randomized pilot study of 40 participants to evaluate the feasibility of implementing a TOCC program led by a stroke nurse navigator in hospitalized acute ischemic stroke patients. The intervention consisted of a stroke nurse navigator completing eight specific tasks, including meeting with stroke patients and their families, facilitating communication between team members at multi-disciplinary rounds, assisting with referrals to rehabilitation facilities, providing stroke education, and arranging stroke clinic follow-up appointments, which were confirmed to be completed by independent study personnel. The primary outcome was to assess the feasibility of the program. The secondary outcomes included comparing hospital length of stay (LOS) and patient satisfaction between the TOCC and usual care groups. We also explored the association between patient-level variables and LOS. Results: The TOCC program was feasible with all pre-specified components completed in 84.2% (95% CI: 60.4-96.6%) and was not significantly different from the assumed completion rate of 75% (p = 0.438). There was no significant difference in median LOS between the two groups [TOCC 5.95 days (4.02, 9.57) vs. usual care 4.01 days (2.00, 10.45), false discovery rate (FDR)-adjusted p = 0.138]. There was a trend toward higher patient median satisfaction in the TOCC group [TOCC 35.00 (33.00, 35.00) vs. usual care 30 (26.00, 35.00), FDR-adjusted p = 0.1] as assessed by a questionnaire at 30 days after discharge. The TOCC study allowed us to identify patient variables (gender, insurance, stroke severity, and discharge disposition) that were significantly associated with longer hospital LOS. Conclusion: A TOCC program is feasible and can serve as a guide for future allocation of resources to facilitate transitions of care and avoid prolonged hospital stays.

Does care in a specialised stroke prevention clinic improve poststroke blood pressure control: a protocol for a randomised comparative effectiveness study.

INTRODUCTION: Hypertension is a major risk factor for recurrent stroke, and blood pressure (BP) reduction is associated with decreased risk of stroke recurrence. However, many stroke survivors have poorly controlled BP after their initial stroke. The Stroke Transitions Education and Prevention (STEP) Clinic was established to provide a comprehensive approach to stroke risk factor reduction. METHODS AND ANALYSIS: This randomised comparative effectiveness study was designed to assess the impact of care in the STEP clinic versus usual care on poststroke BP reduction. Eligible hospitalised patients with ischaemic stroke, haemorrhagic stroke or transient ischaemic attack are scheduled for a clinic screening visit within 4 weeks of discharge if they meet baseline inclusion criteria. At the clinic visit, patients who have uncontrolled BP, defined as automated office BP ≥135/85 mm Hg are randomised (1:1) to either the STEP clinic or usual care for management. STEP clinic patients receive instructions to self-monitor, a BP monitor, sleep apnoea screening, dietary counselling, review of BP monitoring records and adjustment of medications. Patients are followed by a neurologist and a stroke-trained nurse practitioner. Usual care participants are seen by a neurologist and recommendations for secondary prevention are sent to primary care providers. The primary outcome is the difference in mean daytime ambulatory systolic BP at 6 months, assessed using linear regression analysis. Secondary outcomes include 24 hours ambulatory BP, medication adherence and medication self-efficacy, and composite cardiovascular events. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Boards at the McGovern Medical School at the University of Texas Health Sciences Center and the Georgetown University School of Medicine. Uninsured and Spanish-speaking patients are included in the study. TRIAL REGISTRATION NUMBER: NCT02591394; Pre-results.

Video-based educational intervention associated with improved stroke literacy, self-efficacy, and patient satisfaction.

BACKGROUND AND PURPOSE: Interventions are needed to improve stroke literacy among recent stroke survivors. We developed an educational video for patients hospitalized with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). METHODS: A 5-minute stroke education video was shown to our AIS and ICH patients admitted from March to June 2015. Demographics and a 5-minute protocol Montreal Cognitive Assessment were also collected. Questions related to stroke knowledge, self-efficacy, and patient satisfaction were answered before, immediately after, and 30 days after the video. RESULTS: Among 250 screened, 102 patients consented, and 93 completed the video intervention. There was a significant difference between pre-video median knowledge score of 6 (IQR 4-7) and the post-video score of 7 (IQR 6-8; p<0.001) and between pre-video and the 30 day score of 7 (IQR 5-8; p = 0.04). There was a significant difference between the proportion of patients who were very certain in recognizing symptoms of a stroke pre- and post-video, which was maintained at 30-days (35.5% vs. 53.5%, p = 0.01; 35.5% vs. 54.4%, p = 0.02). The proportion who were "very satisfied" with their education post-video (74.2%) was significantly higher than pre-video (49.5%, p<0.01), and this was maintained at 30 days (75.4%, p<0.01). There was no association between MoCA scores and stroke knowledge acquisition or retention. There was no association between stroke knowledge acquisition and rates of home blood pressure monitoring or primary care provider follow-up. CONCLUSIONS: An educational video was associated with improved stroke knowledge, self-efficacy in recognizing stroke symptoms, and satisfaction with education in hospitalized stroke patients, which was maintained at 30 days after discharge.

Human African Trypanosomiasis Encephalitis in the United States: Serial Magnetic Resonance Imaging.

It is important to recognize the signs and symptoms of human African trypanosomiasis (HAT) in order to facilitate early diagnosis and treatment. A 36-year-old man developed encephalitis caused by HAT. This encephalitis can appear many years after well-tolerated systemic infection. The neurologic manifestations developed 7 years after he had emigrated from Cameroon to the United States. We demonstrate the magnetic resonance imaging before, during, and after his treatment with intravenous eflornithine. Clinical signs and symptoms of HAT can be nonspecific and precede abnormalities on magnetic resonance imaging. Human African trypanosomiasis should be considered in the differential diagnosis of patients who have lived in sub-Saharan Africa and have a clinical presentation of subacute encephalitis.