***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 Improving access to thrombolytic therapy for patients with ischemic stroke is challenging . We assessed a prehospital process based on firemen rescuers under strict medical direction , aim ed at facilitating thrombolysis of eligible patients . METHODS This was a prospect i ve observational study conducted over 4 months in Paris , France . Prehospital patients with suspected stroke were included after telephone consultation with a physician . If the time since the onset of symptoms was less than 6 hours , patients were transported directly to a neurovascular unit ( NVU ) ; if symptom onset was more than 6 hours ago , they were transported to an emergency department ( ED ) . Confirmation of stroke diagnosis , the rate of thrombolysis , and the time intervals between the call and hospital arrival and imaging were assessed . Comparison used Fisher exact test . RESULTS Of the 271 patients transported to an NVU , 218 were diagnosed with a stroke ( 166 with ischemic stroke ) , 69 received thrombolytic therapy , and the mean stroke-thrombolysis interval was 150 minutes . Of 64 patients admitted to the ED , 36 patients had a stroke ( ischemic , 24 ) . None were thrombolysed . Globally , 36 % of ischemic strokes were thrombolysed ( 27 % of all strokes diagnosed ) . The mean interval call-hospital was 65 minutes ( ED vs NVU , P = .61 ) . The interval call-imaging was 202 minutes ( interquartile range , 105.5 - 254.5 ) for ED and 92 minutes ( interquartile range , 77 - 116 ) for NVU ( P < .001 ) . CONCLUSIONS The prehospital management of stroke by rescuers , under strict medical direction , seemed to be feasible and effective for selection of patients with stroke in an urban environment and may improve the access to thrombolysis Background Stroke recognition tools have been shown to improve diagnostic accuracy in adults . Development of a similar tool in children is needed to reduce lag time to diagnosis . A critical first step is to determine whether adult stoke scales can be applied in childhood stroke . Our objective was to assess the applicability of adult stroke scales in childhood arterial ischemic stroke ( AIS ) Methods Children aged 1 month to < 18 years with radiologically confirmed acute AIS who presented to a tertiary emergency department ( ED ) ( 2003 to 2008 ) were identified retrospectively . Signs , symptoms , risk factors and initial management were extracted . Two adult stroke recognition tools ; ROSIER ( Recognition of Stroke in the Emergency Room ) and FAST ( Face Arm Speech Test ) scales were applied retrospectively to all patients to determine test sensitivity . Results 47 children with AIS were identified . 34 had anterior , 12 had posterior and 1 child had anterior and posterior circulation infa rcts . Median age was 9 years and 51 % were male . Median time from symptom onset to ED presentation was 21 hours but one third of children presented within 6 hours . The most common presenting stroke symptoms were arm ( 63 % ) , face ( 62 % ) , leg weakness ( 57 % ) , speech disturbance ( 46 % ) and headache ( 46 % ) . The most common signs were arm ( 61 % ) , face ( 70 % ) or leg weakness ( 57 % ) and dysarthria ( 34 % ) . 36 ( 78 % ) of children had at least one positive variable on FAST and 38 ( 81 % ) had a positive score of ≥1 on the ROSIER scale . Positive scores were less likely in children with posterior circulation stroke . Conclusion The presenting features of pediatric stroke appear similar to adult strokes . Two adult stroke recognition tools have fair to good sensitivity in radiologically confirmed childhood AIS but require further development and modification . Specificity of the tools also needs to be determined in a prospect i ve cohort of children with stroke and non-stroke brain attacks Abstract We prospect ively verified whether an ad-hoc question naire administered by phone supports pre-hospital suspicion of stroke in the order to reduce the time before care is given . Form June 1996 to May 1997 , physicians of the Emergency Medical Service in the area of Bergamo , Italy asked all people calling for a patient with symptoms and signs suggesting a cerebral vascular injury to immediately answer some questions on common symptoms and signs of stroke . The medical records of the patients hospitalized at Ospedali Riuniti of Bergamo were review ed at the end of the study by a single neurologist , skilled in stroke management and blinded to the question naires . Sensitivity and specificity , in addition to positive and negative predictive values , of single questions versus final diagnosis were assessed . Logistic regression analysis was also performed to identify those questions useful to suspect strokes . We collected 143 valid question naires , related to 63 men and 80 women , aged 34–99 years ( mean , 71.8 years ) . The question concerning headache had the lowest sensitivity and specificity , respectively 57.1 % and 36.5 % , and teh question concerning leg palsy had the highest sensitivity and specificity , respectively 82.0 % and 52.4 % . Multivariate analysis identified questions on facial and leg palsy as independent predictors of a final diagnosis of stroke . A few questions on motor deficits proposed by emergency medical service operators may be useful in the pre-hospital identification of stroke patients . Concordance of any questions versus final diagnosis of stroke was , however , far to be satisfying . Thus , our experience supports the need for an educational program to improve the efficiency of a pre-hospital diagnosis of stroke IMPORTANCE R and omized clinical trials suggest the benefit of intravenous tissue-type plasminogen activator ( tPA ) in acute ischemic stroke is time dependent . However , modest sample sizes have limited characterization of the extent to which onset to treatment ( OTT ) time influences outcome ; and the generalizability of findings to clinical practice is uncertain . OBJECTIVE To evaluate the degree to which OTT time is associated with outcome among patients with acute ischemic stroke treated with intraveneous tPA . DESIGN , SETTING , AND PATIENTS Data were analyzed from 58,353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset in 1395 hospitals participating in the Get With The Guidelines -Stroke Program , April 2003 to March 2012 . MAIN OUTCOMES AND MEASURES Relationship between OTT time and in-hospital mortality , symptomatic intracranial hemorrhage , ambulatory status at discharge , and discharge destination . RESULTS Among the 58,353 tPA-treated patients , median age was 72 years , 50.3 % were women , median OTT time was 144 minutes ( interquartile range , 115 - 170 ) , 9.3 % ( 5404 ) had OTT time of 0 to 90 minutes , 77.2 % ( 45,029 ) had OTT time of 91 to 180 minutes , and 13.6 % ( 7920 ) had OTT time of 181 to 270 minutes . Median pretreatment National Institutes of Health Stroke Scale documented in 87.7 % of patients was 11 ( interquartile range , 6 - 17 ) . Patient factors most strongly associated with shorter OTT included greater stroke severity ( odds ratio [ OR ] , 2.8 ; 95 % CI , 2.5 - 3.1 per 5-point increase ) , arrival by ambulance ( OR , 5.9 ; 95 % CI , 4.5 - 7.3 ) , and arrival during regular hours ( OR , 4.6 ; 95 % CI , 3.8 - 5.4 ) . Overall , there were 5142 ( 8.8 % ) in-hospital deaths , 2873 ( 4.9 % ) patients had intracranial hemorrhage , 19,491 ( 33.4 % ) patients achieved independent ambulation at hospital discharge , and 22,541 ( 38.6 % ) patients were discharged to home . Faster OTT , in 15-minute increments , was associated with reduced in-hospital mortality ( OR , 0.96 ; 95 % CI , 0.95 - 0.98 ; P < .001 ) , reduced symptomatic intracranial hemorrhage ( OR , 0.96 ; 95 % CI , 0.95 - 0.98 ; P < .001 ) , increased achievement of independent ambulation at discharge ( OR , 1.04 ; 95 % CI , 1.03 - 1.05 ; P < .001 ) , and increased discharge to home ( OR , 1.03 ; 95 % CI , 1.02 - 1.04 ; P < .001 ) . CONCLUSIONS AND RELEVANCE In a registry representing US clinical practice , earlier thrombolytic treatment was associated with reduced mortality and symptomatic intracranial hemorrhage , and higher rates of independent ambulation at discharge and discharge to home following acute ischemic stroke . These findings support intensive efforts to accelerate hospital presentation and thrombolytic treatment in patients with stroke Background Stroke is a major cause of death and leading cause of disability in the United States . To maximize a stroke patient 's chances of receiving thrombolytic treatment for acute ischemic stroke , it is important to improve prehospital recognition of stroke . However , it is known from published reports that emergency medical dispatchers ( EMDs ) using Card 28 of the Medical Priority Dispatch System protocol s recognize stroke poorly . Therefore , to improve EMD 's recognition of stroke , the National Association of Emergency Medical Dispatchers recently design ed a new diagnostic stroke tool ( Cincinnati Stroke Scale -CSS ) to be used with Card 28 . The objective of this study is to determine whether the addition of CSS improves diagnostic accuracy of stroke triage . Methods / Design This prospect i ve experimental study will be conducted during a one-year period in the 911 call center of Santa Clara County , CA . We will include callers aged ≥ 18 years with a chief complaint suggestive of stroke and second party callers ( by-st and er or family who are in close proximity to the patient and can administer the tool ) ≥ 18 years of age . Life threatening calls will be excluded from the study . Card 28 questions will be administered to subjects who meet study criteria . After completion of Card 28 , CSS tool will be administered to all calls . EMDs will record their initial assessment of a cerebro-vascular accident ( stroke ) after completion of Card 28 and their final assessment after completion of CSS . These assessment s will be compared with the hospital discharge diagnosis ( ICD-9 codes ) recorded in the Office of Statewide Health Planning and Development ( OSHPD ) data base after linking the EMD data base and OSHPD data base using probabilistic linkage . The primary analysis will compare the sensitivity of the two stroke protocol s using logistic regression and generalizing estimating equations to account for clustering by EMDs . To detect a 15 % difference in sensitivity between the two groups with 80 % power , we will enroll a total of 370 subjects in this trial . Discussion A three week pilot study was performed which demonstrated the feasibility of implementation of the study protocol Background s : Our aim was to confirm the utility of paramedics using the  Kurashiki Prehospital Stroke Scale ( KPSS ) , with a maximum score of 13 , for patients who may be eligible for administration of intravenous tissue plasminogen activator ( IV t-PA ) .  Methods : The subjects comprised acute stroke and transient ischemic attack ( TIA ) patients transferred to our hospital by paramedics . We analyzed correlations between KPSS and the National Institutes of Health Stroke Scale ( NIHSS ) .  Patients admitted within 3 h of onset were categorized into 2 groups : KPSS ≧4 and KPSS < 4 . We compared the proportion of patients receiving IV t-PA  between the groups . Results : Among 430 consecutive patients ( mean age = 73 years ; 266 men ) , paramedics recorded KPSS for 256 patients ( 59.5 % ) . Excellent correlation was observed between KPSS and NIHSS in all 256 patients ( R = 0.766 ; p < 0.001 ) and in 94 patients ( ischemic stroke and TIA with symptoms on admission ) admitted within 3 h of onset ( R = 0.706 ; p < 0.001 ) . Among these 94 patients , IV t-PA  was more frequently given in the KPSS ≧4 group ( 30 of 58 patients , 51.7 % ) than in the KPSS < 4 group ( 5 of 36 patients , 13.9 % ; p < 0.001 ) . Arterial occlusion was more frequently observed in the KPSS ≧4 group ( 57.9 vs. 31.4 % , p = 0.018 ) . KPSS ≧4 was independently associated with administration of IV t-PA  ( odds ratio = 4.7 ; 95 % confidence interval = 1.5–14.6 , p = 0.008 ) . Conclusion : Reliable concordance between KPSS and NIHSS was found in acute stroke and TIA patients . KPSS ≧4 represents a good score to indicate prospect i ve t-PA patients among those admitted within 3 h of stroke onset Background and Purpose — Recent innovations such as CT installation in ambulances may lead to earlier start of stroke-specific treatments . However , such technically complex mobile facilities require effective methods of correctly identifying patients before deployment . We aim ed to develop and vali date a new dispatcher identification algorithm for stroke emergencies . Methods — Dispatcher identification algorithm for stroke emergencies was informed 
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In the field , CPSS was more sensitive than MedPACS and LAPSS , but had similar sensitivity to that of MASS ; and MASS was more sensitive than LAPSS .
In the field , CPSS had consistently the highest sensitivity and , therefore , should be preferred to other scales .
In the ER , ROSIER should be the test of choice , as it was evaluated in more studies than FAST and showed consistently high sensitivity .