***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 
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    Input: BACKGROUND AND PURPOSE Telemedicine can disseminate vascular neurology expertise and optimize recombinant tissue plasminogen activator ( rt-PA ) use for acute ischemic stroke in rural underserved communities . The purpose of this study was to prospect ively assess whether telemedicine or telephone was superior for decision-making . METHODS The study design is a pooled analysis of two identically design ed r and omized controlled trials conducted in a multistate hub and spoke telestroke network setting with acute stroke syndrome patients , comparing telemedicine versus telephone-only consultations . From each trial , common data elements were pooled to assess , principally , for correctness of thrombolysis decision-making . Secondary outcomes included rt-PA use rate , 90-day functional outcome , post-thrombolysis intracranial hemorrhage , and data completeness . RESULTS Two hundred seventy-six pooled patients were evaluated .  Correct thrombolysis eligibility decisions were made more often with telemedicine ( 96 % telemedicine , 83 % telephone ; odds ratio [ OR ] 4.2 ; 95 % confidence interval [ CI ] 1.69 - 10.46 ; p=0.002 ) . Intravenous rt-PA usage was 26 % ( 29 % telemedicine , 24 % telephone ; OR 1.27 ; 95 % CI 0.71 - 2.25 ; p=0.41 ) . Ninety-day outcomes were not different for Barthel Index , modified Rankin Scale , or mortality . There was no difference in post-thrombolysis intracranial hemorrhage ( 8 % telemedicine , 6 % telephone ; p>0.999 ) . CONCLUSIONS This pooled analysis supports the hypothesis that stroke telemedicine consultations , compared with telephone-only , result in more accurate decision-making . Together with high rt-PA utilization rate , low post-rt-PA intracranial hemorrhage rate , and acceptable patient outcome , the results confirm that telemedicine is a viable consultative tool for acute stroke . The replication of the hub and spoke network infrastructure supports the generalizability of telemedicine when used in broader setting Background and Purpose — Telemedicine techniques can be used to address the rural – metropolitan disparity in acute stroke care . The Stroke Team Remote Evaluation Using a Digital Observation Camera ( STRokE DOC ) trial reported more accurate decision making for telemedicine consultations compared with telephone-only and that the California-based research network facilitated a high rate of thrombolysis use , improved data collection , low risk of complications , low technical complications , and favorable assessment times . The main objective of the STRokE DOC Arizona TIME ( The Initial Mayo Clinic Experience ) trial was to determine the feasibility of establishing , de novo , a single-hub , multirural spoke hospital telestroke research network across a large geographical area in Arizona by replicating the STRokE DOC protocol . Methods — Methods included prospect i ve , single-hub , 2-spoke , r and omized , blinded , controlled trial of a 2-way , site-independent , audiovisual telemedicine system design ed for remote examination of adult patients with acute stroke versus telephone consultation to assess eligibility for treatment with intravenous thrombolysis .  The primary outcome measure was whether the decision to give thrombolysis was correct . Secondary outcomes were rate of thrombolytic use , 90-day functional outcomes , incidence of intracerebral hemorrhages , and technical observations . Results — From December 2007 to October 2008 , 54 patients were assessed , 27 of whom were r and omized to each arm . Mean National Institutes of Health Stroke Scale score at presentation was 7.3 ( SD 6.2 ) points . No consultations were aborted ; however , technical problems ( 74 % ) were prevalent in the telemedicine arm . Overall , the correct treatment decision was established in 87 % of the consultations . Both modalities , telephone ( 89 % correct ) and telemedicine ( 85 % correct ) , performed well . Intravenous thrombolytic treatment was used in 30 % of the telemedicine and telephone consultations . Good functional outcomes at 90 days were not significantly different . There were no statistically significant differences in mortality ( 4 % in telemedicine and 11 % in telephone ) or rates of intracerebral hemorrhage ( 4 % in telemedicine and 0 % in telephone ) . Conclusions — It is feasible to extend the original STRokE DOC trial protocol to a new state and establish an operational single-hub , multispoke rural hospital telestroke research network in Arizona . The trial was not design ed to have sufficient power to detect a difference between the 2 consultative modes : telemedicine and telephone-only . Whether by telemedicine or telephone consultative modalities , there were appropriate treatment decisions , high rates of thrombolysis use , improved data collection , low rates of intracerebral hemorrhage , and equally favorable time requirements . The learning curve was steep for the hub and spoke personnel of the new telestroke network , as reflected by frequent technical problems . Overall , the results support the effectiveness of highly organized and structured stroke telemedicine networks for extending expert stroke care into rural remote communities lacking sufficient neurological expertise Background and Purpose — Despite Food and Drug Administration approval of tissue-type plasminogen activator for stroke , obstacles in the US healthcare system prevent its widespread use . The Remote Evaluation for Acute Ischemic Stroke ( REACH ) program was developed to address these issues in rural setting s. A key component of stroke assessment in the REACH system is the National Institutes of Health Stroke Scale ( NIHSS ) evaluation . We sought to determine whether , using the REACH system , NIHSS values of bedside and remote evaluators would correspond . Methods — Twenty patients were recruited . On obtaining consent , a neurologist performed a bedside NIHSS evaluation  on each patient . Within 1 hour , using any broadb and -connected workstation — either office or home personal computer and a l and line phone to speak with the patient — a second neurologist remotely evaluated the patient through the REACH system . Paired t tests and Pearson correlation coefficients were used to examine NIHSS reliability performed bedside and remotely . Results — NIHSS ranged from 1 to 24 . Correlations between bedside and remote locations ( r = 0.9552 , P = 0.0001 ) were very strong , and t tests indicate that the means were not different . Conclusions — The NIHSS can be reliably performed over the REACH system . This supports our endeavor to bring stroke expertise to rural community hospitals OBJECTIVE Patients with ischemic stroke treated with tissue plasminogen activator ( rt-PA ) have better outcomes when treated closer to the time of symptom onset and within the 3-hour window . We previously demonstrated the clinical use of TeleBAT , a mobile telemedicine system for stroke . We tested the impact of that system on time to treatment for patients with acute stroke . METHODS Validity and reliability were tested by comparing neurologic examination scores obtained using our wireless system , which transmits video of a patient from a moving ambulance to desktop computers , with those obtained using the National Institute of Neurological Disorders and Stroke training videotape . TeleBAT validity and good interrater reliability were defined a priori as a kappa statistic of r > 0.5 . We compared the average time to treatment for our TeleBAT-evaluated intervention group with that for our control group . The intervention group consisted of two actor patients with stroke mimicking 12 stroke scenarios and evaluated using  TeleBAT . The control group consisted of patients with stroke evaluated and treated with rt-PA on arrival to the emergency department . Data were analyzed using st and ard t test . RESULTS National Institutes of Health Stroke Scale items calculated by the neurologists suggest TeleBAT is valid for assessing patients with stroke remotely . Interrater reliability was high : the neurologists gleaned the same information from TeleBAT transmissions . Kappa values for both validity and reliability exceeded 0.5 . The mean time to treatment for patients assessed by TeleBAT was 17 + /- 4 minutes compared with 33 + /- 17 minutes for our control group ( P = .0033 ) . CONCLUSION TeleBAT seems to be a valid and reliable means of evaluating stroke neurologic deficits . Time to treatment was shortened using ambulance transport time to evaluate patients as c and i date s for thrombolytic therapy . Future studies should use a r and omized design with patients with acute stroke BACKGROUND Thrombolytic therapy for acute ischemic stroke has been approached cautiously because there were high rates of intracerebral hemorrhage in early clinical trials . We performed a r and omized , double-blind trial of intravenous recombinant tissue plasminogen activator ( t-PA ) for ischemic stroke after recent pilot studies suggested that t-PA was beneficial when treatment was begun within three hours of the onset of stroke . METHODS The trial had two parts . Part 1 ( in which 291 patients were enrolled ) tested whether t-PA had clinical activity , as indicated by an improvement of 4 points over base-line values in the score of the National Institutes of Health stroke scale ( NIHSS ) or the resolution of the neurologic deficit within 24 hours of the onset of stroke . Part 2 ( in which 333 patients were enrolled ) used a global test statistic to assess clinical outcome at three months , according to scores on the Barthel index , modified Rankin scale , Glasgow outcome scale , and NIHSS : RESULTS In part 1 , there was no significant difference between the group given t-PA and that given placebo in the percentages of patients with neurologic improvement at 24 hours , although a benefit was observed for the t-PA group at three months for all four outcome measures . In part 2 , the long-term clinical benefit of t-PA predicted by the results of part 1 was confirmed ( global odds ratio for a favorable outcome , 1.7 ; 95 percent confidence interval , 1.2 to 2.6 ) . As compared with patients given placebo , patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales . Symptomatic intracerebral hemorrhage within 36 hours after the onset of stroke occurred in 6.4 percent of patients given t-PA but only 0.6 percent of patients given placebo ( P < 0.001 ) . Mortality at three months was 17 percent in the t-PA group and 21 percent in the placebo group ( P = 0.30 ) . CONCLUSIONS Despite an increased incidence of symptomatic intracerebral hemorrhage , treatment with intravenous t-PA within three hours of the onset of ischemic stroke improved clinical outcome at three months Objective : VA Stroke Study ( VASt ) data were analyzed to determine whether neurologist management affected the process and outcome of care of patients with ischemic stroke . Methods : VASt prospect ively identified patients with stroke admitted to nine VA hospitals ( April 1995 to March 1997 ) .  Demographics , stroke severity ( Canadian Neurologic Score ) , stroke subtype ( Trial of ORG 10172 in Acute Stroke Treatment [ TOAST ] classification ) , tests/ procedures , and discharge status ( independent , Rankin ≤ 2 , vs dead or dependent , Rankin 3 through 5 ) were compared between patients who were or were not cared for by a neurologist . Results : Of 1,073 enrolled patients , 775 ( neurologist care , n = 614 ; non-neurologist , n = 161 ) with ischemic stroke were admitted from home . Stroke severity ( Canadian Neurologic Score 8.7 ± 0.1 vs 8.4 ± 0.2 ; p = 0.44 ) , TOAST subtype ( p = 0.55 ) , and patient age ( 71.4 ± 0.4 vs 72.4 ± 0.7 ; p = 0.23 ) were similar for neurologists and non-neurologists . Neurologists more frequently obtained MRI ( 44 % vs 16 % ; p < 0.001 ) , transesophageal echocardiograms ( 12 % vs 2 % ; p < 0.001 ) , carotid ultrasounds ( 65 % vs 57 % ; p = 0.05 ) , cerebral angiography ( 8 % vs 1 % ; p = 0.001 ) , speech ( 35 % vs 18 % ; p < 0.001 ) , and occupational therapy ( 46 % vs 33 % ; p = 0.005 ) evaluations . Brain CT , transthoracic echocardiogram , 24-hour ambulatory ECG use , and hospitalization duration s ( 18.2 ± 0.8 vs 19.7 ± 4.1 days ; p = 0.725 ) were similar . Neurologists ’ patients were less likely to be dead ( 5.6 % vs 13.5 % ; OR = 0.38 ; 95 % CI 0.22 , 0.68 ; p = 0.001 ) and less likely to be dead or dependent ( 46.1 % vs 57.1 % ; OR = 0.64 ; 95 % CI 0.45 , 0.92 ; p = 0.019 ) at the time of discharge . The benefit remained after controlling for stroke severity and comorbidity ( OR = 0.63 ; 95 % CI 0.42 , 0.94 ; p = 0.025 ) . Conclusion : Neurologist care was associated with more extensive testing , but similar lengths of hospitalization and improved outcomes BACKGROUND To increase the 
    Output:
    
Telestroke technology is now part of mainstream clinical stroke practice in North America and internationally .