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EASY

Essential Acute Stroke care in low resource settings: a pilot studY

An investigator-initiated, evaluator-blinded, prospective, multicentre, before-and-after, effectiveness-implementation hybrid design study to assess the feasibility of essential acute stroke care in low resource settings.

The EASY team

Carlos Abanto

His interest in the study of cerebrovascular diseases started when he was a medical student in his native city of Trujillo, in the northern part of Peru. After his graduation from Medical School, he decided to do his Residency in Neurology at Universidad Nacional Mayor de San Marcos at the National Institute of Neurological Sciences in Lima, Peru, where he currently works. In 2006 with a group of colleagues, they founded Peru Stroke Group, an organization dedicated to stroke training and prevention, of which he was president twice. In 2012, he founded The Cerebrovascular Diseases Research Center at his hospital, The National Institute of Neurological Science, and now he is working on generating and implementing a program of Vascular Neurology Fellowship.

Cheryl Carcel

Dr Carcel is a clinician-researcher with 10 years’ clinical experience in neurology specializing in general neurology, stroke, and electrophysiology. Her main research topics include women’s’ health in stroke, headache, stroke and acute stroke imaging. She has been actively involved in several international clinical trials at The George Institute for Global Health.

Hasan Farhan

Dr Hasan Al-Farhan is a consultant interventional cardiologist, assistant professor in cardiology, and medical educationalist. He is the president of the Iraqi Scientific Council of Cardiology, head of the Scientific Committee in the Cardiology Department, head of Cardio-Maternal Unit at Baghdad Teaching Hospital. Since 2014 – present, annually the ESC including Dr Al-Farhan among the ESC Congress abstract graders, and he is the national coordinator of the EURObservational Research Programme (including PPCM with its Biomarker study, ROPAC, ACS-STEMI) in Iraq since 2015 – present. He is a fellow of many cardiology organizations including, FACC, FRCPE, FESC, FHFA, FSCAI, FICMS Cardiol, in addition to being a member of the stroke council/ESC, European Association of Preventive Cardiology/ESC, Ministerial Research Ethical Committee, and Ministerial Committee of Protocols.

Saima Hilal

Upon finishing her medical school in Karachi, Pakistan (2006) and completing her house-man ship in Medicine and Surgery in 2007, she started working in the Neurology department in Civil Hospital Karachi from 2008-2009. In 2010, she moved to Singapore to work as a research assistant in Memory Aging and Cognition Center. In 2011, she took up a Master’s Degree in Public Health with a specialization in Clinical Epidemiology. Her Ph.D. thesis focused on the identification of novel markers of cardiovascular and cerebrovascular diseases using blood-based samples and MRI. She has become one of the pioneers in identifying a new marker of cardiovascular and cerebrovascular diseases, i.e. cortical cerebral microinfarcts (CMIs) on 3 Tesla MRI scans. Based on her expertise, she was offered a Postdoctoral Fellowship at Erasmus MC, where she is studying plasma-based amyloid-beta levels as biomarkers for cerebrovascular disease, dementia, and stroke.

Lily Song

She is a senior research fellow working at The George Institute for Global Health at Peking University Health Science Center (GI China), a professional institute focus on clinical trials with its head office in Sydney. She has also worked as a neurologist for the past 13 years. During her career, she led her hospital to attend several large clinical trials initiated by the George Institute, and she worked as site principal investigator, medical monitor, end-point adjudicator and the leader of the central follow-up team for several large trials like ENCHANTED, SAVE, HEADPOST and BEYOND 7. July last year, she decided to devote herself to clinical studies in the stroke field and joined GI China to be a full-time research fellow. She currently manages a large implementation study- an international multicentre cluster clinical trial – INTERACT3 – as the main research fellow and project leader.

Yi Sui

He is currently practising stroke neurology in Shenyang, a northeast metro city in China. He obtained his MBBS degree in China and a PhD degree in Melbourne, Australia. He has designed and developed the Shenyang City Acute Stroke Care Map, which integrates 9 evidence-based strategies to improve stroke care quality in the region. Stroke is the most leading cause of mortality and disability in China. Globally, it also imposes a tremendous threat to public health. Therefore, he would love to spare no effects to work with other Leaders to reach the target 25by25.

Kolawole Wahab

Dr Wahab is an Associate Professor of Medicine at the University of Ilorin, a first-rate Nigerian public university and an Honorary Consultant Neurologist to the University of Ilorin Teaching Hospital (UITH). He has a background in Internal Medicine, Neurology and Public Health with further training in stroke care at the University College London Institute of Neurology, Queen Square, London. Through a collaborative agreement between the Nigerian Society of Neurological Sciences and Florida Society of Neurology, he was at the Miller School of Medicine, the University of Miami and Jackson Memorial Hospital, Miami in 2012 as a Clinical Observer in Stroke Medicine. The robust training he had was harnessed with his colleagues at UITH to establish the first stroke unit in Nigeria in 2012 – they were able to achieve a 50% reduction in the case fatality rate of stroke within a period of two years. He is currently the University of Ilorin Site Principal Investigator in the H3Africa/NIH-funded “Stroke Investigative Research and Education Network (SIREN)” project which has an overall goal of deciphering the traditional, novel and genetic risk factors for stroke in black Africans.

Background

Stroke is a leading cause of disability worldwide and is the second most common cause of mortality. Although stroke incidence decreased by 42% in High-Income Countries (HICs) in the last four and a half decades, it has increased by >100% in Low- and Middle-Income Countries (LMICs) during the same period. Data from sub-Saharan Africa (SSA) suggest an annual stroke incidence rate of up to 316 per 100,000, a prevalence rate of up to 315 per 100,000, and a 3-year fatality rate of up to 84%.

In Peru, stroke is the fifth most common cause of mortality and 60% of stroke patients have an unfavourable outcome at discharge, as measured by a modified Rankin scale score of 3-6 points. Death from stroke in the LMICs accounts for 85.5% worldwide stroke mortality while the disability-adjusted life years (DALYs) lost in these countries is almost seven times those lost in HIC.

Specific aims

Primary aim: To determine the feasibility of an essential acute care management plan for a low resource setting in patients with acute stroke.

Secondary (implementation) aims:

    • To investigate if the essential acute stroke care management plan was delivered as intended
    • To explore, in process evaluation, the implementation barriers, and facilitators of an essential acute care management plan for a low resource setting in patients with acute stroke

Methodology

Patients will be recruited from 2 sites each in Nigeria and Peru. Hospitals will be selected if they are in low resource settings without established acute stroke care protocols for the management of acute stroke patients. An example of a low resource setting hospital would be a secondary level hospital which is highly differentiated by function with 5 to 10 clinical specialties; size ranging from 200 to 800 beds; often referred to as a provincial hospital. It may also be a tertiary level hospital where services such as stroke care are present but without adequate human and material resources for evidence-based management of cases.