***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background — The effectiveness of specific systems changes to reduce DTN ( door-to-needle ) time has not been fully evaluated . We analyzed the impact of 4 specific  DTN time reduction strategies implemented prospect ively in a staggered fashion . Methods and Results — The HASTE ( Hurry Acute Stroke Treatment and Evaluation ) project was implemented in 3 phases at a single academic medical center . In HASTE I ( June 6 , 2012 to June 5 , 2013 ) , baseline performance was analyzed . In HASTE II ( June 6 , 2013 to January 24 , 2015 ) , 3 changes were implemented : ( 1 ) a STAT stroke protocol to prenotify the stroke team about incoming stroke patients ; ( 2 ) administering alteplase at the computed tomography ( CT ) scanner ; and ( 3 ) registering the patient as unknown to allow immediate order entry . In HASTE III ( January 25 , 2015 to June 29 , 2015 ) , we implemented a process to bring the patient directly to CT on the emergency medical services stretcher . Log-transformed DTN time was modeled . Data from 350 consecutive alteplase-treated patients were analyzed . Multivariable regression showed the following factors to be significant : giving alteplase in the CT ( 32 % decrease in DTN time , 95 % confidence interval [ CI ] 38%–55 % ) , stretcher to CT ( 30 % decrease in DTN time , 95 % CI 16%–42 % ) , patient registered as unknown ( 12 % decrease in DTN time , 95 % CI 3%–20 % ) , STAT stroke protocol ( 11 % decrease in DTN time , 95 % CI 1%–20 % ) , and stroke severity ( National Institutes of Health Stroke Scale score 6–8 : 19 % decrease in DTN time , 95 % CI 6%–31 % ; National Institutes of Health Stroke Scale score > 8 : 27 % decrease in DTN time , 95 % CI 17%–37 % ) . Conclusions — Taking the patient to CT on the emergency medical services stretcher , registering the patient as unknown , STAT stroke protocol , and administering alteplase in CT are associated with lower DTN time Background and Purpose Use of thrombolysis and acute treatments for cerebral infa rct ion may require that acute stroke be treated as a medical emergency . To assess the factors influencing the time to admission in acute stroke , we conducted a prospect i ve study of all such patients admitted to the hospitals in Leicester , UK , over a 12-month period . Methods Factors assessed were age , sex , time of stroke onset , stroke severity , home circumstances , and routes of admission . Initial between-group comparisons were made with the Mann-Whitney U test . The individual contribution of each of these variables was assessed with multiple linear regression analysis . Results An accurate time of stroke onset was identified in 374 ( 70 % ) of 535 registered patients ( median age 77 [ range , 29–98 ] years ; 332 men , 203 women ) .  Median time from onset to admission was 6 hours , with 25 % of the patients arriving in less than 2.5 hours and 75 % in less than 11.5 hours . Multiple regression confirmed that only admission through the bed allocation bureau ( p<0.001 ) , living alone ( p<0.001 ) , and nocturnal onset ( p=0.003 ) prolonged delay time . Despite patients over 70 years of age taking a median of 7 hours from onset to admission compared with 4 hours for those under age 70 ( p<0.001 ) , the effect of age appeared to be dependent on these three factors . Age , sex , level of consciousness , rural domicile , and place of admission did not influence the delay time independently . Conclusions We have identified some of the factors affecting the hospital admission delay time for stroke . With the possible advent of effective early treatments for stroke , these factors will need to be addressed Background and Purpose — Faster treatment with intravenous tissue-type plasminogen activator ( tPA ) is likely to improve outcomes . Optimizing prehospital triage by mobile stroke units ( MSUs ) may speed treatment times . The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit ( BEST-MSU ) study was launched in May 2014 using the first MSU in the United States to compare stroke management using an MSU versus st and ard management ( SM ) . Herein , we describe the results of the prespecified , nonr and omized run-in phase design ed to obtain preliminary data on study logistics . Methods — The run-in phase consisted of 8 MSU weeks when all-patient care occurred on the MSU and 2 SM weeks when the MSU nurse met personnel on scene or at the emergency department to ensure comparability with MSU patients . Telemedicine was independently performed in 9 MSU cases . Results — Of 130 alerts , 24 MSU and 2 SM patients were enrolled . Twelve of 24 MSU patients received tPA on board ; 4 were treated within 60 minutes of last seen normal , and 4 went on to endovascular treatment . There were no hemorrhagic complications . Four had primary intracerebral hemorrhage . Agreement on tPA eligibility between the onsite and telemedicine physician was 90 % . Conclusions — The run-in phase provided a tPA treatment rate of 1.5 patients per week , assured us that treatment within 60 minutes of onset is possible , and enabled enrollment of patients on SM weeks . We also recognized the opportunity to assess the effect of the MSU on endovascular treatment and intracerebral hemorrhage . Challenges include the need to control biased patient selection on MSU versus SM weeks and establish inter-rater agreement for tPA treatment using telemedicine Background and Purpose — Enrollment in acute stroke trials at a stroke center with multiple study protocol s may delay the initiation of intravenous thrombolytics in patients who present within 3 hours of symptom onset . Methods — We studied all patients presenting with acute ischemic stroke over the past 3.5 years who qualified for thrombolysis within 3 hours of symptom onset . We collected demographics , baseline National Institutes of Health Stroke Scale scores , CT findings , and arrival-to-treatment times and compared patients treated with intravenous thrombolytics in a clinical trial with patients who received st and ard of care intravenous tissue plasminogen activator .  Results — Of 290 treated patients , 19 were enrolled in prelytic studies , 46 were enrolled in postlytic studies , and 225 were treated with st and ard intravenous tissue plasminogen activator .  There was no significant difference in age , gender , National Institutes of Health Stroke Scale score , admission glucose , or changes on CT . There was no difference in onset-to-arrival time or arrival-to-treatment time between patients enrolled in clinical studies and those who received st and ard treatment . However , among study patients , prelytic r and omization led to a significantly longer arrival-to-treatment time by 13 minutes ( P=0.028 ) . Conclusion — We found that trials requiring prethrombolytic r and omization can lead to a delay in the initiation of treatment . Future studies are needed to determine if such a delay is clinical ly significant and can be shortened by improved enrollment strategies Background and Purpose — Thrombolysis for treatment of acute ischemic stroke should be administered as fast as possible after symptom onset . The aim of this study was to examine , in our tertiary care center , the time intervals preceding intra-arterial thrombolysis in order to accelerate and optimize the management of acute strokes . Methods — Between January 1 , 2000 , and April 30 , 2002 , 597 patients with acute stroke were admitted to our stroke center . One hundred forty-eight patients underwent diagnostic arteriography  , and 100 ( 16.8 % ) received intra-arterial thrombolysis . For all patients , we prospect ively recorded and analyzed the time of symptom onset , admission , CT and /or MRI scan , diagnostic arteriography , and , if performed , intra-arterial thrombolysis .  Results — The mean time to arrival in the emergency department was 99 minutes for patients who were admitted directly ( Bern patients ) , 127 minutes for those who were referred from community hospitals without a CT scanner ( non-Bern/−CT patients ) , and 210 minutes for patients from hospitals with imaging facilities ( non-Bern/+CT patients ) . The mean delay from symptom onset to treatment was 234 minutes for Bern patients , 269 minutes for non-Bern/−CT patients , and 302 minutes for non-Bern/+CT patients . The patients from the last group needed longer to receive intra-arterial thrombolysis than did patients who were admitted directly ( P = 0.002 ) or who were transferred from a hospital without a CT scanner ( P = 0.03 ) . Conclusions — This prospect i ve study indicates that direct referral without prior imaging at community hospitals shortens the time until intra-arterial thrombolysis . In addition , our in-hospital delay preceding intra-arterial thrombolysis is longer than the delays reported for intravenous thrombolysis and indicates potential for improvement Background Intravenous thrombolysis ( IVT ) with ( recombinant ) tissue plasminogen activator is an effective treatment in acute ischemic stroke . However , IVT is contraindicated when blood pressure is above 185/110 mmHg , because of an increased risk on symptomatic intracranial hemorrhage . In current Dutch clinical practice , two distinct strategies are used in this situation . The active strategy comprises lowering blood pressure with antihypertensive agents below these thresholds to allow start of IVT . In the conservative strategy , IVT is administered only when blood pressure drops spontaneously below protocol led thresholds . A retrospective analysis in two recent stroke trials showed a non-significant signal towards better functional outcome in the active group ; robust evidence for either strategy , however , is lacking . We hypothesize that ( I ) the active strategy leads to a better functional outcome three months after acute ischemic stroke . Secondary hypotheses are that this effect occurs despite ( II ) increasing the number of symptomatic intracranial hemorrhages , and could be attributable to ( III ) a higher rate of IVT treatments and ( IV ) a shorter door-to-needle time . Methods and design The TRUTH is a prospect i ve , observational , cluster-based , parallel group follow-up study ; in which participating centers continue their current local treatment guidelines . Outcomes of patients admitted to centers with an active will be compared to those admitted to centers with a conservative strategy . The primary outcome is functional outcome on the modified Rankin Scale at three months . Secondary outcomes are symptomatic intracranial hemorrhage , IVT treatment and door-to-needle time . We based our sample size estimate on an ordinal analysis of the mRS with the “ proportional odds ” model . With the aforementioned signal observed in a recent retrospective study in these patients as an estimate of the effect size and with alpha 0 · 05 , this analysis would have an 80 % power with a total number of 600 patients . Corrections for expected imbalance in group size and clustering effects result ed in a sample size of 1235 patients . Discussion The TRUTH is the first large prospect i ve study specifically study ing IVT-c and i date s with elevated blood pressure , and has the potential to change clinical practice and optimize acute stroke care in these patients BACKGROUND The time from symptom onset to seeking medical assistance ( decision delay ) accounts for a proportion of prehospital delay in acute stroke . The aims of this study were to identify factors related to decision delay and calling the emergency medical services ( EMS ) as the first medical contact . METHODS Data were prospect ively collected from 350 patients with acute stroke or transient ischemic attack . Data on decision delay , prehospital delay , types of first medical contact , and previous stroke knowledge were recorded . Multivariable logistic regression analyses were conducted to identify factors related to  decision delay  of 1 hour or less and calling the EMS as the first medical contact . RESULTS The median decision delay was 2.0 hours . Decision delay accounted for 62.3 % of prehospital delay ( median value ) . Moderate ( National Institutes of Health Stroke Scale [ NIHSS ] score 8 - 16 ; odds ratio [ OR ] 4.16 [ 95 % confidence interval 1.86 - 9.30 ] ) or severe symptoms ( NIHSS score ≥ 17 ; OR 10.38 [ 2.70 - 39.90 ] ) and living together ( OR 1.84 [ 1.02 - 3.43 ] ) were associated with decision delay of 1 hour or less . Moderate ( OR 6.31 [ 2.79 - 14.29 ] ) or severe symptoms ( OR 8.44 [ 2.64 - 26.98 ] ) were associated with calling the EMS as the first medical contact . Previous stroke knowledge did not affect an early decision or EMS use . CONCLUSIONS The decision to seek medical assistance in acute stroke accounts for more than half of the prehospital delay . Severity of symptoms and living together are related to an early decision ( ≤1 hour ) . Previous stroke knowledge does not affect decision delay or EMS use Rationale Mobile stroke units speed treatment for acute ischemic stroke , thereby possibly improving outcomes . Aim To compare mobile stroke unit and st and ard management clinical outcomes , healthcare utilization , and cost-effectiveness in tissue plasminogen activator-eligible acute ischemic stroke patients calling 911 . Sample size 693 . Eighty percent power with 0.05 type I error rate to detect a difference of 0.09 in mean utility-weighted modified Rankin scale between groups . 
    Output:
    
In-hospital factors relating to assessment , imaging and thrombolysis administration also contributed .