***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 and Purpose — Thrombolysis with intravenous recombinant tissue plasminogen activator is an effective treatment for acute ischemic stroke , but the number of treatable patients is limited . The PRomoting ACute Thrombolysis in Ischemic StrokE ( PRACTISE ) trial evaluated the effectiveness of a multidimensional implementation strategy for thrombolysis with intravenous recombinant tissue plasminogen activator in acute ischemic stroke . Methods — The PRACTISE trial was a national multicenter cluster-r and omized controlled trial with r and omization after pairwise matching . Twelve hospitals , both urban and community , academic and nonacademic , in the Netherl and s participated . All patients admitted with stroke within 24 hours from onset of symptoms were registered . The intervention included 5 implementation meetings based on the Breakthrough Series model . The primary outcome was treatment with thrombolysis . Secondary outcomes were admission within 4 hours after onset of symptoms , death or disability at 3 months , and quality of life . Results — Overall 5515 patients were included in the study ' 308 patients ( 12.2 % ) in the control centers and 393 patients ( 13.1 % ) in the intervention centers were treated with thrombolysis ( adjusted OR , 1.25 ; 95 % CI , 0.93 to 1.68 ) . Among the 1657 patients with ischemic stroke admitted within 4 hours from onset , 391 ( 44.5 % ) of 880 in the intervention centers were treated with thrombolysis and 305 ( 39.3 % ) of 777 in the control centers ; the adjusted OR for treatment with thrombolysis was 1.58 ( 95 % CI , 1.11 to 2.27 ) . Conclusions — An intensive implementation strategy increases the proportion of patients with acute stroke treated with thrombolysis in real-life setting s. An apparently pivotal factor in the improvement of the treatment rate is better application of contraindications for thrombolysis Background and Purpose — An educational campaign by mass media has been associated with great increases in the knowledge about early symptoms of stroke . However , few studies were conducted with a controlled community intervention study . Methods — To clarify the effects of a 1-year television campaign for the whole population on improvement of knowledge about stroke symptoms in 2 cities , a campaign area and a control area in Japan were selected . Before and after the campaign , 1960 r and omly selected residents aged 40 to 74 years answered a telephone survey regarding knowledge of early stroke symptoms . We calculated the percentage and 95 % CIs of participants who correctly chose all 5 early symptoms of stroke in each area and in each year . Results — Before the campaign , 53 % of participants ( 95 % CI , 50%–55 % ) in the campaign area and 46 % ( 95 % CI , 44%–49 % ) in the control area correctly chose 5 early symptoms . After the 1-year television campaign , knowledge was significantly improved only in the campaign area ( campaign area , 63 % ; 95 % CI , 60%–66 % ; control area , 51 % ; 95 % CI , 48%–54 % ) . After sex stratification , only women showed improved knowledge of early symptoms . The audience rate for the campaign television programs was found to be higher in women than in men . Conclusions – A 1-year stroke educational television campaign effectively improved knowledge about early stroke symptoms among Japanese women aged 40 to 74 years . No impact was found among men in this age group . Future studies should examine the impact of this approach on stroke knowledge among younger individuals and whether there are any behavioral changes that contribute to earlier presentation for treatment BACKGROUND Many critical appraisal tools ( CATs ) exist for which there is little or no information on development of the CAT , evaluation of validity , or testing reliability . The proposed CAT was developed based on a number of other CATs , general research methods theory , and reporting guidelines but requires further study to determine its effectiveness . OBJECTIVES To establish a scoring system and to evaluate the construct validity of the proposed critical appraisal tool before undertaking reliability testing . METHODS Data obtained from this exploratory study along with information on the design of the proposed CAT were combined to evaluate construct validity using the St and ards for educational and psychological testing which consist of five types of evidence : test content , response process , internal structure , relations to other variables , and consequences of testing . To obtain data for internal structure and relations to other variables , the proposed CAT was analysed against five alternative CATs . A r and om sample of 10 papers from six different research design s across the range of health related research were selected , giving a total sample size of 60 papers . RESULTS In all research design s , the proposed CAT had significant ( p<0.05 , two-tailed ) weak to moderate positive correlations ( Kendall 's τ 0.33 - 0.55 ) with the alternative CATs , except in the Preamble category . There were significant moderate to strong positive correlations in the quasi-experimental ( τ 0.70 - 1.00 ) , descriptive/exploratory/observational ( τ 0.72 - 1.00 ) , qualitative ( τ 0.74 - 0.81 ) , and systematic review ( τ 0.62 - 0.82 ) design s and to a lesser extent in the true experimental ( τ 0.68 - 0.70 ) design . There were no significant correlations in the single system research design s. CONCLUSIONS Based on the results obtained , the theory on which the proposed CAT was design ed , and the objective of the proposed CAT there was enough evidence to show that inferences made from scores obtained from the proposed CAT should be sound OBJECTIVE Prolonged prehospital delay in persons experiencing acute coronary syndrome ( ACS ) remains a problem . Underst and ing which patients respond best to particular interventions design ed to decrease delay time would provide mechanistic insights into the process by which interventions work . METHODS In the PROMOTION trial , 3522 at-risk patients were enrolled from 5 sites in the United States ( 56.4 % ) , Australia and New Zeal and ; 490 ( N=272 intervention , N=218 control ) had an acute event within 2 years . Focusing on these 490 , we ( 1 ) identified predictors of a rapid response to symptoms , ( 2 ) identified intervention group subjects with a change in these predictors over 3 months of follow-up , and ( 3 ) compared intervention group participants with and without the favorable response pattern . Hypothesized predictors of rapid response were increased perceived control and decreased anxiety . Knowledge , attitudes , and beliefs were hypothesized to differ between responders and non-responders . RESULTS Contrary to hypothesis , responders had low anxiety and low perceived control . Only 73 ( 26.8 % ) subjects showed this pattern 3 months following the intervention . No differences in ACS knowledge , attitudes , or beliefs were found . CONCLUSION The results of this study challenge existing beliefs . PRACTICE IMPLICATION S New intervention approaches that focus on a realistic decrease in anxiety and perceived control are needed Background and Purpose — Only a small minority of acute stroke patients receive approved acute stroke therapy . We performed a community and professional behavioral intervention project to increase the proportion of stroke patients treated with approved acute stroke therapy .  Methods — This study used a quasi-experimental design .  Intervention and comparison communities were compared at baseline and during educational intervention .  The communities were based in 5 nonurban East Texas counties . The multilevel intervention worked with hospitals and community physicians while changing the stroke identification skills , outcome expectations , and social norms of community residents . The primary goal was to increase the proportion of patients treated with intravenous recombinant tissue plasminogen activator ( rTPA )  from 1 % to 6 % of all cerebrovascular events in the intervention community . Results — We prospect ively evaluated 1733 patients and vali date d 1189 cerebrovascular events .  Intravenous rTPA treatment increased from 1.38 % to 5.75 % among all cerebrovascular event patients in the intervention community ( P = 0.01 ) compared with a change from 0.49 % to 0.55 % in the comparison community ( P = 1.00 ) . Among the  ischemic stroke patients , an increase from 2.21 % to 8.65 % was noted in the intervention community ( P = 0.02 ) . The comparison group did not appreciably change ( 0.71 % to 0.86 % , P = 1.00 ) . Of eligible intravenous rTPA c and i date s , treatment increased in the intervention community from 14 % to 52 % ( P = 0.003 ) and was unchanged in the comparison community ( 7 % to 6 % , P = 1.00 ) . Conclusions — An aggressive , multilevel stroke educational intervention program can increase delivery of acute stroke therapy . This may have important public health implication s for reducing disability on a national level Background and Purpose — Establishment of stroke centers , combined with accurate paramedic diagnosis and rapid transport , is essential to deliver acute stroke therapy . We wanted to measure and improve paramedic and hospital performance through implementation of the Brain Attack Coalition and American Stroke Association guidelines . Methods — Pre-intervention and active-intervention phases with parallel data measurement points were used . The study involved six hospitals comprising the majority of acute-stroke admissions in Houston , Tex . Hospital , paramedic , and patient data were collected prospect ively pre-intervention and during the active-intervention phase on all suspected acute-stroke patients admitted by Houston Fire Department-Emergency Medical Services . A multilevel educational intervention included paramedic , hospital , and community education . Paramedic diagnostic accuracy , hospital-performance efficiency , and thrombolytic treatment  rates were the main outcome measures of the study . Results — Four hundred forty-six patients ( 74 per month ) were transported in the pre-intervention phase to participating hospitals ( 59.8 % of all suspected stroke patients transported city wide by Houston Fire Department — Emergency Medical Services ) , compared with 1072 patients ( 89 per month , or 68.7 % ) transported in the active-intervention phase ( P<0.001 ) . Accuracy of paramedic diagnosis of stroke increased from 61 % to 79 % . Admission within 2 hours of symptom onset increased from 58 % to 62 % ( P=0.002 ) . Thrombolysis rates increased in 4 of 6 centers , with 1 post- tissue plasminogen activator hemorrhage ( 3.7 % ) reported . Conclusions — A multilevel educational program improves rapid hospitalization and paramedic diagnostic accuracy and increases the number of patients presenting for evaluation within the 3-hour tissue plasminogen activator window . Stroke center development supports safe thrombolytic practice in community setting As part of the recruitment efforts for the National Institutes of Health Tissue Plasminogen Activator Pilot Study , public education and awareness campaigns were conducted to encourage early hospital arrival . We evaluated the change in arrival times during the course of the study for all stroke patients , including those who were not entered into study . Methods Data were gathered on all patients presenting within 24 hours of stroke onset to all of the study hospitals . Coincident with the start of the study , educational and promotional programs , which stressed signs and symptoms of stroke and the need to call 911 , were presented to physicians , paramedical personnel , and the public . The study was divided into four quartiles to analyze differences in time to hospital arrival and use of 911 . Results Of 2099 patients screened , time data were available on 1116 . During the course of the study , the mean time from symptom onset to hospital arrival declined significantly ( 3.2 hours versus 1.5 hours ) . Patients arrived for treatment sooner at community hospitals than at university/teaching hospitals . The use of 911  increased from 39 % in the first quartile of the study to 60 % in the fourth quartile . This was a consistent finding in all study sites . Increased use of 911  was seen almost exclusively in patients with nonhemorrhagic stroke . Conclusions Times from stroke onset to hospital arrival decreased significantly during the course of the National Institutes of Health Tissue Plasminogen Activator Pilot Study . Significantly increased use of 911  was the likely major explanation for the shortened arrival times . The decrease in arrival times may be a consequence of the public and professional education programs conducted at all study sites CONTEXT Poor public knowledge of stroke warning signs and risk factors limits effective stroke intervention and prevention . OBJECTIVE To examine temporal trends in public knowledge of stroke warning signs and risk factors . DESIGN AND SETTING Population -based r and om-digit telephone survey  conducted in July-November 2000 among individuals in the greater Cincinnati , Ohio , region . PARTICIPANTS A total of 2173 survey respondents ( 69 % response rate ) were r and omly identified based on their demographic similarities to the ischemic stroke population with regard to age , race , and sex . MAIN OUTCOME MEASURES Spontaneous recall of at least 1 important stroke warning sign and 1 established stroke risk factor in comparison with findings from the same survey in 1995 . RESULTS In 2000 , 70 % of respondents correctly named at least 1 established stroke warning sign vs 57 % in 1995 ( P<.001 ) , and 72 % correctly named at least 1 established stroke risk factor vs 68 % in 1995 . Groups of individuals with the highest risk and incidence of stroke , such as persons at least 75 years old , blacks , and men , were the least knowledgeable about warning signs and risk factors . Television was the most frequently cited source of knowledge , 32 % in 2000 vs 24 % in 1995 ( P<.001 ) . CONCLUSIONS Public knowledge of stroke warning signs within the greater Cincinnati region has significantly improved from 1995 to 2000 , although knowledge 
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Reporting of specific intervention design was suboptimal and impeded the identification of key intervention components for reducing patient delay .
The parallel delivery of public and professional interventions further limited the identification of successful intervention components .
The potential clinical benefits of public interventions are far-reaching , and the challenge remains in translating knowledge improvements and correct behavioral intentions to appropriate behavior when stroke occurs